I
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PRINCIPLES OF DIAGNOSIS. X'
BY MARSHALL HALL, M .D



      F.R.S. L. AND E. ETC.
SECOND AMERICAN EDITION,



      WITH notes



   BY JOHN A. SWETT, M.D.

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D. APPLETON & CO., 200, BROADWAY
1839. 
W73p
1639
H. LUDWIG, PRINTER, 72, VESEY-STREET, 
PREFACE
TO   THE   SECOND   AMERICAN   EDITION.

  Four  years ago the Editor,  convinced of the great practical
value of the "Principles or Diagnosis," recommended its publi.
cation in this city.  The increasing demand for the work render-
ing a new  edition necessary, has  suggested  the idea of some
additions, which  will be  found  introduced in the form of notes.
Every one, who  has perused the text, must have been surprised at
the extent of practical  knowledge the author has acquired, but, at
the same time,  it must be admitted, that  no individual mind,
however studious and attentive, can grasp the  whole of practical
medicine.   Many of the chapters, particularly those on Irritation,
Exhaustion, the Puerperal Diseases, &c, are treated in a manner
so complete and experienced, that it would be presumptuous to alter
or add to even their minute details.   But in other chapters, for the
reason above  stated, the same accurate and practical  acquaintance
with the subjects is not so manifest, and it has been the aim of the
Editor to add to  these, in the form of notes, such results of repeated
and personal experience, on subjects that have occupied a large share
of his attention, as may serve to  illustrate, and occasionally, though
with  much deference,  to refute the  opinions expressed in the text.
These remarks apply particularly to the chapters on the Diseases of
the Thoracic Viscera.  The Editor  takes this occasion to add, that
he is indebted for the additions to the chapter on Cutaneous Diseases,
a subject with which the Author has evidently but little practical 
IV
PREFACE.
acquaintance, to his friend Dr.  H. D. Bulkley, of this city, a
gentleman whose ample experience, in this department of pathology,
renders his opinions worthy of great confidence.
   It is certainly to be hoped that the "Principles of Diagnosis,"
will continue to roceive the recommendation of those who have the
direction of medical studies in  this country.  The great practical
error of considering the whole art of medicine to consist in the treat-
ment of diseases, prevails nowhere more extensively than among our-
selves.  While no one will deny that the ultimate  object of the medi-
cal art is to cure disease, yet nothing can be more true than that the
only sure way to reach this point is by the previous study of the natu-
ral history of diseases, and by a thorough practical acquaintance with
the art of Diagnosis.  It has been  thought presumptuous  in  the
great Sydenham to have said that there was no disease which, if
perfectly made  known to him, the resources of his art would  not
enable him to cure;  yet this assertion, vain as it may appear, must
stand as an  evidence how well this  great master understood  the
fundamental principles of the science he so long  and so honourably
cultivated.
                                                   J. A. S.
   New-York, Jan. 1839. 
CONTENTS.
       THE SOURCES OF  DIAGNOSIS.     25


                  SECTION   FIRST.

             THE HISTORY OF DISEASES   .    .   38
       1. The causes.
       2. The course.


                SECTION  SECOND.

            THE SYMPTOMS OF  DISEASES.

                         CHAPTER  I.

The Morbid Appearances  of the  Countenance     .     42
       1. The cuticular surface.
       2. The cutaneous circulation.
       3. The cellular substance.
       4. The muscular system.
       5. Some particular features.
       6. The general expression.

                      CHAPTER II.

On the Morbid Conditions of the Attitude    .     .   56
       1. The postures and motions of the body.
       2. The state of muscular debility, power, contraction, and motion.
       3. Some particular actions.
       4. The general manner of the patient.

                      CHAPTER III.

On the Morbid Appearances of the  Tongue,  &c.  .     66
       1. Its surface, form, papilte, color.
       2. Its mode of being protruded.
       3. The teeth, gums, and internal part of  the cheeks.
       4. The taste.
       5. The breath, &c.


                      CHAPTER IV.

On the Morbid Conditions of the  general Surface     73
       1. The temperature.
       2. The state of dryness or moisture, of tumidity or shrinking,
          or of roughness or smoothness, of the skin.
       3. The color.
       4. The occurrence of emaciation, or of oedema and anasarca.
       5. The conditions of the hands and feet. 
vi                      contents.
                        CHAPTER V.

On some Morbid  Conditions of  the  general  System
       1. The state of Fever.
       2.--------of Irritation.
       3.--------of Exhaustion.
       4. ----.----of Erethismus.
       5.--------of Sinking.


                        CHAPTER  VI.

On the Morbid States of  the Functions of the
     Nervous System    .....••   91
       1. Its energies in general.
       2. The sleep.
       3. The mental faculties and the temper.
       4. The senses and sensations.
       5. The motions—vpluntary, functional, and sphincter.


                       CHAPTER  VII.

On the Morbid Affections of the Function of  Re-
     spiration     .....•••    97
        1. The kinds of dyspnoea.
       2.----------of cough and expectoration. _
       3. The effects of a full inspiration and expiration.
       4. The affections of the voice, articulation, &c.


                       CHAPTER VIII.

On the Morbid Affections of the Circulation      .   109
        1. The pulse.
        2. The pulsations of the heart, of the carotids and abdominal
             aorta, and of the jugular vein.
        4. The state of the capillary or extreme vessels.


                         CHAPTER IX.

The Physical  Conditions of the Thorax  .     .     .117
        I.  By external inspection.
       II.  By percussion.
      III.  By auscultation.
            1. The respiration—vesicular, bronchial, cavernous.
            2. The various rattles—vesicular, bronchial, cavernous.
            3. The voice—bronchophony, pectoriloquism, aegophony.
            4. Cough—tubal, cavernous.
            5. The beat of the heart—its diffusion, impulse, sounds, rhythm.


                         CHAPTER X.

Of  the Functional Affections of the  Alimentary
     Canal........127
        1.  The pharynx and oesophagus.
        2.  The stomach and bowels.
        3.  The sphincter ani. 
contents.
Vll
                    CHAPTER XI.
Of the Functional Affections of the Urinary Organs 132
      1. The secretion, excretion, and condition of the urine.
      2. The substances which are apt to be expelled with the urine.
                    CHAPTER XII.
Of the Functional Changes in the Uterine System    136
                    CHAPTER XIII.
The  Physical Conditions of the Abdomen    .    .    138
      1. External examination.
      2. Examinations per vaginam.
      3. ■------per rectum.
      4.------------with the sound.

                 SECTION  THIRD.
          THE  EFFECTS OF REMEDIES.
The  Effects of Blood-Letting .....    141

               SECTION FOURTH.
            THE MORBID  ANATOMY     .    .    148 
THE PRACTICE  OF DIAGNOSIS.
                  INTRODUCTION.

Of  the objects of  diagnosis,  and of the diagnostic
      arrangement     ....•••   151
           SECTION FIRST.

THE DIAGNOSIS OF THE DISEASES  OF
                 SYSTEMS.
                     CHAPTER I.

THE DIAGNOSIS OF FEVERS  .......165

    I.  Continued Fevers    ...*••  165

          i.  Synochus    .    .     .    •     ■    •     166
             1. The Acute Form.......167
             2. The Typhoid Form......168
             3. The Protracted Form......168

         n.  Typhus      .    .     .    .     .    •     169
             1. The Milder Form.......169
             2. The Severe Form......170
             3. The Sinking Form.......174

    II.  Periodic Fevers......175

          Intermittent     .    .     .    .     .     .175
             1. The Gluotidian........176
             2. The Tertian........176
             2. The auartan.......176
             4. The Reduplicated.......176
             5. The Remittent, Forms.....176

                     CHAPTER H.

 THE DIAGNOSIS OF ERUPTIVE FEVERS     .   .    .    .179

     I.  Rubeola     ......    .     181
             1. Vulgaris........131
             2. Sine Catarrho.......183
             3. Nigra   .          ......184 
                       CONTENTS.                     IX


         II.   Scarlatina    .     .     .     .     <     .184
              1. Simplex.........184
              2. Anginosa........185
              3. Maligna.........185
        III.   Variola.......187
              1. Discreta  ....<....  187
              2. Confluens........189

        IV.   Erysipelas......191
              1. Phlegmonodes........191
              2. CEdematodes.......192
              3. Gangrenosum......i       192


                       CHAPTER III.

THE DIAGNOSIS OF IRRITATION, EXHAUSTION, ETC.   .  194

          I.   Intestinal Irritation    .     .     .     .195
         II.   Exhaustion from Loss  of Blood     .     199
           I. Immediate.........199
           II. Remote  . .. .            .....200
              1. Re-action........201
              2. Sinking........203
        III.   Delirium tremens  .....   204
        IV.   ErethisMus mercurialis    .    .    .     205


                       CHAPTER  IV.

     THE DIAGNOSIS OF DYSPEPSIA, CHLOROSIS, ETC.   209
          I.   Dyspepsia      ......   211
              1. The Acute.......:  211
              2. The Protracted.......213
              3. The Chronic, Forms    ......  214
         II.   Chlorosis      ......   215
              1. Incipient             i.....216
              2. Confirmed........217
              3. Inveterate     ........  218

        III.   Hysteria......220
              1. Mild.........220
              2. Severe.........221
              3. Inveterate........222


                       CHAPTER  V.

     THE DIAGNOSIS OF EPILEPSY, TETANUS, ETC.  .   224

         I.  Chorea.......225
              1. Incipient.........225
              2. Confirmed........225
              3. Inveterate.......    .  226
        II.  Epilepsy......     .   226
           I.  Idiopathic.........226
              1. The Mild........226
              2. The Severe......        .  226
              3. The Inveterate.......227
          II.  Symptomatic........228
                   2 
X
contents.
   III.  Hydrophobia......22^
         1. Rabiosa.........229
         2. Sine Rabie.......ZM
   IV.  Tetanus.......231
      I.  Traumatic.........^31
     II.  Idiopathic.........Zil


                 CHAPTER VI.

THE DIAGNOSIS OF INFLAMMATION, ETC.   .    .    233
    1.  Inflammation  ......  234
      I.  Serous..........234
     II.  Mucous.........234
    III.  Parenchymatous........235

   II.   Rheumatism    ......  235
      I.  Acute..........235
         1. External........235
         2. Internal.........236
     II.  Chronic.........237
   III.  Arthritis      ......  237
      I.  Acute..........238
         1. External........238
         2. Internal  .........238
     II.  Chronic.........239

   IV.  Nodosity.......239
                 CHAPTER  VII.

THE DIAGNOSIS OF TUBERCLES, SCIRRHUS, ETC.    241
    I.  Tubercles     ......  243
         1. In the Head  ........243
         2. In the Thorax.......243
         3. In the Abdomen.......245
    II.  Melanosis......246
   III.  Encephalosis     .....     247
   IV.  Scirrhus.......248
                 CHAPTER VIII.

THE DIAGNOSIS OF THE HEMORRHAGES    .    .   249
    I.  Topical H.emorrhagy    ....   251
         1. From obstructed return of the Venous Blood.
         2. From excessive impulse of the Arterial Blood.
         3. From disease of the Minute, or Capillary, Vessels.

   II.   Dyspeptic H^emorrhagy  .    .     .     .251
         1. Epistaxis.
         3. Haematemesis.
         3. Melaena, &c.

   III.  General H.emorrhagy   ....   251
         1. Cysts of Blood in several Organs, or several parts of
              the same Organ. 
                 contents.                     xi

   IV.   Purpura.......252
         1. Simplex.........252
         2. Hemorrhagica.......253
    V.   Scorbutus      ......   254


                 CHAPTER IX.

THE DIAGNOSIS OF THE DROPSIES  ....   256
    I.   Inflammatory  Dropsy    ....   257
    II.   Exanthematous  Dropsy     .     .     .     257
   III.   Dropsy from Exhaustion     .     .     .   257
   IV.   Dropsy from Debility  ....     258
   V.   Dropsy from Obstruction of  the Venous
          Blood.......258
   VI.   Dropsy from Disease of the Kidney  .     258
                SECTION   SECOND.

THE  DIAGNOSIS  OF THE DISEASES OF ORGANS.
                       CHAPTER  I.

THE DIAGNOSIS OF THE DISEASES  OF THE BRAIN AND
    SPINAL MARROW.........261

                      I. THE SUDDEN.
    Apoplexy  and Paralysis     .....  265
           1. From Congestion:
              1. Arterial.........265
             2. Venous........266
          2. From Rupture, with Haemorrhagy; and
          3. From Destruction of Texture......266
      L  Of the Tuber Annulare.......267
      IL  Of the Cerebrum.........267
          1. Extensive:
             1. Over the Surface.
             2. In the Substance of the Hemisphere.
                 1. Circumscribed ;
                 2. Extending into the Ventricles.
          2. Topical:
             1. In the Radiations of the Corpus Striatum.
             2. In the Radiations of the Thalamus.
             3. In the Corpora Gluadrigemina.
             4. At the Roots of various Nerves.
     III.  Of the Cerebellum........268
             1. Of the Middle Lobe......268
             2. Of the Lateral Lobes......268
     IV.  Of the Medulla Oblongata......268
      V.  Of the  Medulla Spinalis........269 
Xll
CONTENTS.
            1. Diffused:
                1. Of the Cervical Portion.
                2. Of the Dorsal Portion.
            2. Encysted:
                1. Of the Lateral Column.
                2. Of the Anterior Column, or Nerves.
                3. Of the Posterior Column, or Nerves.

                        II.  THE ACUTE.

  Inflammation.
     I.  Of the Cerebrum........270—271
        1. Diffused : 1.  Of the Arachnoid.
                       1. Effusion of Lymph.
                       2. Effusion of Serum.
                       3. Effusion of Pus.
                   2.  Of the Cortical, or
                   3.  Of the Medullary Substance;
                       1. Injection.
                       2. Softening; Induration.
                       3. Suppuration.
        2. Topical.  (See I. II. 2.).......272
     II.  Of the Cerebellum.  (I. III.)......272
     III.  Of the Medulla Oblongata.......273
     IV.  Of the Medulla Spinalis.  (I. V.).....273

                      HI.  THE INSIDIOUS.

  I. Inflammation.

  II. Tubercles ; Encephalosis ; etc.
     I.  Of the Cerebrum.........274
         Effusion; 1.  Over the Surface ;
                  2. At the Base ;
                  3. In the Ventricles.
     II.  Of the Medulla Spinalis.......275

                       IV.   THE CHRONIC.
     I.  Of the Cerebrum.........275
      Inflammation?    .......   275
         1. Mania..........276
         2. Melancholia.........276
         3. Dementia..........277
         4. Lethargy.........277
         5. Epilepsy.........,277
     II.  Of the Medulla Spinalis ?
         1. Paralysis Agitans........277
         2. Tremor Mercurialis  ........  278


                         CHAPTER II.

THE DIAGNOSIS OF THE DISEASES OF THE ORGANS  OF
    RESPIRATION..........280

                         I.  THE ACUTE.

     I.  Laryngitis and Tracheitis    ....   282
            1. Injection.  2.  Tumidity. 3. Exudation.

    II.  Bronchitis......           283
         1. Redness.   2.  Slight thickening.
         3. Augmented and altered Secretion. 
CONTENTS.
xiii
  HI.   Pneumonia     ,......285
        1. Diffused.
        2. Lobular.
        3. Central.
            1. Congestion.
            2. Hepatization.
            3. Purulent Infiltration,
            4. Abscess.
            5. CEdema.
  IV.   H^imorrhagy.
     I.  Bronchial Haemorrhagy     ,......286
    II.  Pulmonary Haemorrhagy or Apoplexy    ....   287
   V.   Pleuritis........287
        1. Of One Pleura.
        2. Of Both Pleuree.
        3. Partial.
        4. Pleuro-pneumonia.
            1. False Membranes.
            2. Serous, Puriform, Haemorrhagic, Effusion.

  VI.   Gangrene  (diffused).....290

                     II.   THE CHRONIC.

   I.   Laryngitis and Tracheitis ....    290

   II.   Bronchitis.......  291
          1. Mucous; Dilatation of the Bronchia.
          2. Pituitous.
          3. Dry ; Emphysema ; Asthma.
          4. Symptomatic.
  III.   Pneumonia.......292

  IV.   Pleuritis........293
          1. Serous,  floculent, or puriform Effusion.
          2. Effusion, with Dilatation of the Chest.
          3. Absorption, with Contraction of the Chest.
          4. Displacement of the Heart.
   V.   Gangrene  (circumscribed)   ....    293

  VI.   Emphysema    .     .     .     .     .     .     .294
          1. Vesicular. 2. Interlobular.
 VII.   Asthma.......295
VIII.   (Edema........296
  IX.   Hydrothorax      ......    297

          1. Idiopathic.  2. Symptomatic.
   X.  Pneumothorax.......297

                    III.   THE INSIDIOUS.

   I.  Ulceration of  the  Larynx, Trach^e, or
          Bronchia .......    298

   II.   Tubercles.......298
       I.  1. Of the Lungs.
          2. Of the Pleura.
      II.  Complications.

  III.   Melanosis.......301 
XIV
contents.
   IV.   Encephalosis.......£"*
    V.   Scirrhus.......301
   VI.   Cysts, Hydatids, etc.    .                       jrj^:
   VII.   Symptomatic  Affections    .


                       CHAPTER III.

THE DIAGNOSIS OF THE DISEASES OF THE HEART AND
    LARGE ARTERIES.........6V6
    I.   Disease of the  Heart  in general     .     •  304

    II.   Hypertrophy     ....••    307
           1. Of the Left Ventricle.
           2. Of the Right Ventricle.
   III.   Dilatation.......307
           1. Of the Left Ventricle.
           2. Of the Right Ventricle.

   IV.   Hypertrophy with Dilatation  .     .     •     308
           1 Of the Ventricles.
           2. Hypertrophy of One Ventricle and Dilatation of the Other.
           3. Of the Auricles.
    V.   Disease of the Valves   .                       309
           1. Of the Aortic Valves.
           2. Of the Mitral Valve.
   VI.   Pericarditis.......310

   VII.   Hydropericarditis  ...•••  310

  VIII.   Aneurysm    .    .     .     •     •     •     •     311
           1. Of the Aorta.
           2. Of other Arteries within the Thorax.
           3. Of the Arteries in the Abdomen.
   IX.   Symptomatic Affections  .....  312
           1. Deficient Action of the Heart......312
           2. Palpitation.  Bruit de Soufflet.....312
           3. Angina Pectoris........312
           4. Pulsation in the Epigastrium.....314


                       CHAPTER IV.

THE  DIAGNOSIS  OF THE DISEASES  OF  THE  ALIMEN-
    TARY CANAL..........315

                  I.  THE ACUTE DISEASES.

    I.   Peritonitis    .......   318
           1. Diffused..........318
           2. Partial.........319
    II.   EsO-GASTRITIS  .     .     .     .     .     .     .319
   III.   The Effects of Corrosive  Poison    .     .     320
   IV.   Enteritis   .......     320

    V.   Obstructions  of the  Intestines    .     .     .  320
           1. Hernia, External and Internal.
           2. Compression ; Internal Obstruction.
           3. Intus-susceptio. 
CONTENTS.
XV
  VI.  Ileus ;  Colic.......322
 VII.  Colica Pictonum......322
VIII.  Irritation    .     .     .     .     .     ...  324

  IX.  Cholera.......324
         I. Europaea.
         2. Indica.

  X.   Eso.enteritis.......325
         1. Membranous.
         2. Glandular.

  XI.   Dysenteria  .......    326
 XII.  H^MORRHAGY.......326

XIII.  Perforation      ......    327
         1. Of the Stomach.
         2. Of the Intestine, etc.

XIV.  Suppuration  of  the  Appendages  of the
            Uterus   .......  327
 XV.   Inflammation of  the Appendix C^eci .     .    327

    II.  THE INSIDIOUS AND PROTRACTED DISEASES.
   I.   Peritonitis.......328

  II.   Tubercles.......329
         1. Of the Peritonaeum.
         2. Of the Intestines.
         3. Of the Mesenteric Glands.

  III.   Eso-gastritis  .......  329
  IV.   Eso-enteritis......330

  V.   Scirrhus.......330—333
      I. Of the Stomach :
         1. Of the Cardia,
         2. Of the Stomach,
         3. Of the Pylorus.
      II.  Of the Intestine:
         1. Of the Ileum,
         2. Of the Colon,
         3. Of the Rectum, contrasted with other diseases of this
            intestine.

  VI.   Encephalosis, etc.     .....    333

              III.  THE CHRONIC DISEASES.

   I.   Dyspepsia ........  334
  II.   Intestinorum Torpor  .....     334
  III.   Vermes........  334

         IV. THE SYMPTOMATIC AFFECTIONS.

   I.   Arthritis   .......     335
  II.   Hysteria......    .    .  335 
XVI
CONTENTS.
                        CHAPTER V.

THE DIAGNOSIS OF THE DISEASES OF THE LIVER, PAN-
    CREAS, AND SPLEEN........336

                 I.  DISEASES  OF THE LIVER.  ...    339

    I.   Inflammation  .     .     .     .     .     •     .339
           1. Injection.........340
           2. Softening.......             340
           3. Induration.........340
           4. Enlargement........340
           5. Abscess..........340
              1. Solitary.   This may open
                  1. Externally.
                  2. Into the Gall-Bladder or Ducts.
                  3. Into the Stomach or Intestines.
                  4. Into the Bronchia.
                  5. Into the Abdomen.
                  6. Into the Pleura.
                  7. Into the Pericardium.....340
              2. Numerous........340

    II.   Congestion     .......   341
        I.  Venous..........341
           1. Causes.
           2. Effects.
       II.  Bilious..........341
           1. Causes.
           2. Effects.

   III.   Encephalosis     ......     341
           1. Solitary.
           2. Diffused.
   IV.   Scirrhus........342
           1. Solitary.
           2. Diffused.

    V.  Tubercles   .......     342

   VI.   Hydatids.  These may escape
           1. Through the Abdominal Parietes.
           2. Through the Stomach or Intestine.
           3. Through the Bronchia.
           4. Into the Peritonaeum.
           5. Into the Pleura    .    .    .    .  ' .    .   .    .  342

  VII.  Fatty  Liver  .......  343

 VIII.   Cirrhosis.......343

          II.  DISEASES  OF THE BILIARY DUCTS   .    .  343
         Obstruction   .......  343
           1. By  Inflammation........343
          2. By  Calculi.........343
          3. By  External Pressure  •...,..    344

            III.   DISEASES OF THE PANCREAS   ...  344

            IV.   DISEASES OF THE SPLEEN   .    .        344 
CONTENTS.
xvi
                         CHAPTER  VI.

THE DIAGNOSIS OF THE DISEASES OF THE URINARY
    ORGANS............346
      I.  THE DISEASES OF  THE KIDNEY AND URETER.
                        I.  THE ORGANIC.
     I.  Inflammation.......349
            1. Injection.
            2. Enlargement.
            3. Softening; Induration.
            4. Suppuration.
                1. Abscess.
                2. Purulent Infiltration.

    II.  Gravel and  Calculus   ....   351—353
      I. The Diathesis and kinds  of Deposit and Gravel.
        1. The Lithic.
            1. With Yellow, Red, or Lateritious or Pink Deposits of
                Lithate of Ammonia.
            2. With the formation of Red Gravel, or Crystals of Uric
                or Lithic Acid.
        2. The Phosphatic.
            1. With  the formation of White Gravel,  or Crystals of
                Phosphate of Magnesia and Ammonia.
            2.  With the White Sediment of the mixed Phosphates of
                Magnesia and Ammonia, and of Lime.
     II. The different kinds of Calculus.
        1. The Lithic or Uric Acid ; or the Light-brown.
        2. The Triple Phosphate of Magnesia and Ammonia ;  or the
            White.
        3. The Mixed Phosphates of Magnesia and Ammonia, and of
            Lime ; or the Fusible.
        4. The Oxalate of Lime;  or the Mulberry.
        5. The Alternating.

   III.  Granulated Kidney.....353
                Effects:
                   1. Albuminous Urine.
                   2. Dropsy;  &c.
   IV.  Organic Diseases      .....     353
                   1. Cysts.
                   2. Encephalosis.
                   3.  Tubercles.
                  4.  Hydatids.
                   5.  Matiere Colloide.

                     II.  THE FUNCTIONAL.
     I.   Suppression of Urine     .....   354
                   1.  Causes.
                  2. Effects.

    II.  Diabetes      .......      354

   III.  Morbid Secretions ......   355
                   1.  Albumen.
                  2. Excess of Urea.
   IV.  Morbid  Admixtures    .....      356
                   1.  Mucus.
                   2.  Pus.
                   3. Blood.
                             3 
XV11I
contents.
 II.  THE DISEASES OF THE BLADDER,  PROSTATE, AND
                        URETHRA.

                      I. OF THE BLADDER.
     1.  Inflammation  .......  357
                   1. Injection.
                   2. Ulceration.
    II.  Calculus.......357

    III.  Nervous Affections.....359
                   1. Irritability.......359
                       1. Immediate.
                       2. Sympathetic.
                   2. Paralysis.......360
    IV.  Retention of Urine   .....     360

                    II.  OF THE PROSTATE.
     I.   Inflammation   .     .     .      .     .     .     .360
                   1. Tenderness.
                   2. Enlargement.
                   3. Abscess.
    II.  Calculus.......362

                   III.  OF THE URETHRA.
     I.   Stricture      .......   362
                   Effects.
    II.   Spasmodic Stricture   .....     362


                        CHAPTER VII.

THE DIAGNOSIS  OF  THE DISEASES  OF THE  UTERINE
     ORGANS.     ......                     sea
             I.  THE  DISEASES OF THE  UTERUS.
                      I.  THE ORGANIC.
    I.  Inflammation .....              357
           I.  Peritonaeal......               ogy
           II.  Parenchymatous.....'           357
              1. Injection
              2. Softening.
              3. Induration.
              4. Enlargement.
              5. Suppuration.
                  1. Abscess.
                  2. Infiltration of Pus.
                  3. In the  Uterine Cavity.
                  4. In the  Veins.
          III.  Of the Mucous Membrane.....       3go
              1. Amenorrhcea.
              2. Dysmenorrhcea.
              3. Formation of a False Membrane.
              4. Obliteration of the Uterine Orifices.
              5. Leucorrhrea.
         IV.  Of the Cervix Uteri.....        368
   II.   The Irritable Uterus     ...          3*39
  III.   Fibrous Tumors     ....             359
              1. Under the Peritonaeum.
              2. In the Substance of the Uterus.
             3.  Under the Mucous Membrane. 
CONTENTS.
xix
IV.  Cysts  or Encysted Tumors      .    .    .     370
 V.  Scirrhus—Cancer  ......  370
           l. In the Cervix Uteri.
          2. Involving the Cervix Uteri and the Rectum,  or
              the Bladder.
VI.  Corroding Ulcer     .    .    .    .     .     371
          1. Of the Cervix Uteri.
2. Involving the Cervix and the Rectum, or the Bladder.
VII.	**. xiirvi.iug LUG VC1 VIA. UUU 111C XCC^LUIU, Ul LI1C J3itlUU« Encephalosis—Cauliflower Excrescence	371
VIII.	Polypus .......	372
IX.	Inversion ........	373
X.	Prolapsus .......	373
XI.	Elongated Cervix ......	373
XII.	Hydatids, &c. distinguished from Pregnancy and	
	its Complications .....	374
XIII.	Anteversion .......	374
XIV.	Retroversion ......	375
XV.	Pregnancy .......	375
XVI.	Pelvic Tumors, &c. .. .	376
                II.  THE FUNCTIONAL.
 I.  Amenorrhea   .......  377
 II.  Dysmenorrhea  ......    377
III.  Menorrhagia.......378
IV.  Leucorrhea .......    378
          III.  THE DISEASES OF THE OVARIA.
  I.  Inflammation  .......  379
            1. Injection.
            2. Suppuration.
  II.  Cysts or Encysted Tumor,  distinguished from
         Ascites   .......     379
 III.  Fibrous  and other Tumors   ....  379
 IV.  Encephalosis     ......     379

         IV.  THE DISEASES OF THE MAMMA.
  I.  Inflammation......380—381
            1. Tenderness and Tumor.
            2. Abscess.
               1. Several.
               2. Deep-seated.
               3. Lacteal.
               4. Chronic
 II.  Tuberculous Swelling.....381
 HI.  The  Irritable Mamma.....382
            1. With Tumor.....•    ... 382
            2. With Ecchymosis......382
 IV.  Chronic  Mammary Tumor    ....  382
  V.  Encysted, Hydatid, and  other  Tumors   .     383
 VI.  Encephalosis.......384
VII.  Scirrhus—Carcinoma.....384
            1. Of the Mammary Gland.
            2. Of the Nipple.
            3. Of the Skin. 
XX
contents.
             4. Of the adjacent Lymphatic Glands.
             5. Ulceration; Cancer.

                     CHAPTER VIII.
THE DIAGNOSIS OF THE DISEASES OF THE GENITAL
   ORGANS...........385
                  I.  IN THE MALE SEX.
                    I.  OF THE PENIS.
    I.   Gonorrhea     .    .    .    .     .     .    •  386
   II.   Excoriation      ......    387
   III.   Superficial Ulcer ....         .  387
   IV.   Phagedenic   .......    388
   V.   Sloughing Ulcer   ......  388
   VI.   Syphilitic Ulcer      .....    389
  VII.   Herpes  Pr.epltialis     .....  390
  VIII.   Scirrhus—Carcinoma  .....    390

                   II.  OF THE TESTIS.
    1.   Inflammation  .......  390
             1. Of the Epididymis.
             2.  Of the Body of the Testis.
                 1. Enlargement.
                 2. Suppuration.
                 3. Sloughing.
    II.  Tubercles   .......    391
   III.   Fibrous Tumor......391
   IV.   Encephalosis    ......    391
    V.   Scirrhus........391
   VI.   Hydrocele.......392
  VII.   Varicocele.......392
  VIII.  Hernia.......392
                 II.   IN THE FEMALE SEX.
                   I.  OF THE PUDENDA.
     I.   Inflammation  .......  392
             1. Enlargement.
             2. Abscess.
    II.   Prurigo.......392
   III.  Vasculur Tumor of the  Meatus  .     .     .  393
   IV.  Varicocele  of the  Urethra    .    .     .     393
    V.  Affections  of the Anus  .....  393

                   II.  OF THE VAGINA.
     I.  Inflammation    ......    393
    II.  Tumors........393

                      CHAPTER  IX.

 THE DIAGNOSIS OF  PUERPERAL DISEASES    ...   395
     I.  Inflammation of the  Peritoneum    .     .    398
              1. Of the Uterine Peritonaeum,
              2. Of the Uterine Appendages. 
                   contents.                   xxi

           3. Of the Pelvic Peritonaeum.
           4. Of the Diffused Peritonaeum.
  II.  Intestinal Irritation   .     .     .     .     .399
           1. With Affection of the Abdomen    .    .   .    .399
           2. With Affection of the Head    ....   400
III.  Exhaustion from Loss of Blood .     ,    .    400
           1. With Re-action.......400
           2. With Sinking    .   .   .   .    .'.'.'  401
 IV.  Mixed Cases......'      401
           Puerperal Mania, &c......       401
  V.  Softening  of the Uterus    ....  402
 VI.  Inflammation of the  Lymphatics     .    .    402
           1. Usually with Peritonitis.
           2. Without Peritonitis.
           3. With Pleuritis.
VII.  Inflammation of the  Veins  ....  402
           1. Adhesive.
               I. Uterine.
               2. Crural.
           2. Suppurative.
               1. Usually without Peritonitis.
               2. With Abscesses of the Brain, Lungs, Liver,
                  Spleen, &c. the Joints, Cellular Membrane,
                  Eye, &c. &c.
                SECTION THIRD.

THE DIAGNOSIS OF  SOME TOPICAL DISEASES.
                      CHAPTER  I.
THE DIAGNOSIS OF SOME DISEASES OF THE FACE   .    404
    I.   Erythema  Nasi    .....       405
   II.   Acne  Rosacea    .....         405
   III.   Porrigo Favosa    ......  406
   IV.   Lupus........4qq
   V.   Scrofula      .     .....       497
   VI.   Carcinoma  ......         4^7
  VII.   Sycosis Menti      .....       408
 VIII.   Ozjena  .......         408
   IX.   Parotid Fistula    ......  409
   X.   Gangrene   .......    409
   XL   Disease of the Antrum      ....  409

                     CHAPTER II.
THE DIAGNOSIS OF THE DISEASES OF THE MOUTH,
   THROAT, AND OESOPHAGUS.....410
             I.  THE DISEASES OF THE GUMS.
    I.   Tumidity.......4H 
XX11
CONTENTS.
 II.
III.
IV.
  I.
 II.
III.
IV.
  II.
 III.
 IV.
  V.
 VI.
 VII.
VIII.
 I.
 II.
III.
IV.
 V.
Shrinking.....
Circular  Ulcer  .    .     .    • ,
Canker   ......
    II.  THE DISEASES OF THE TONGUE.
Ranula     ....••
Tumor, with Slow Suppuration
Ulcer, from Irritation
Scirrhus; Carcinoma
    III. THE DISEASES OF THE FAUCES.
Inflammation     .....
      1. Of the Velum.
      2. Of the Tonsils.
      3. Of the Pharynx.
     4. Of the Posterior Nares.
Elongated Uvula  ....
Enlarged Tonsils     ....
Dyspeptic Sore Throat  .
Scarlatina  ......
Herpes    .
Aphthae     .     .     .     .    •
Ulceration     .....
      1. Syphilitic.
      2. Pseudo-Syphilitic.
      3. Mercurial; &c.
    IV.  DISEASES OF THE CESOPHAGUS.
Inflammation     .....
Stricture      .....
Scirrhus, etc.    .....
Internal  Tumors, etc.
External Tumors, etc.
411
411
412
412
412
412
413
413
413
413
413
414
414
414
414
 415
415
415
415
415
415
                     CHAPTER III.
THE DIAGNOSIS OF THE CUTANEOUS DISEASES
    I.   Roseola
   II.   Scarlet Rash
   HI.   Urticaria
   IV.   Erythema
   V.   Lichen .
   VI.   Prurigo
  VII.   Miliaria
 VIII.   Herpes
   IX.   Eczema
    X.   Impetigo .
   XL   Scabies
  XII.   Porrigo
 XIII.   Srcosis
 XIV.   Acne
 416
417
418
419
420
420
422
423
423
424
426
426
427
428
429 
CONTENTS.
xxiii
  XV.  Ecthyma.......429
 XVI.  Rupia    .......       430
 XVII.  Pemphigus   .......    430
XVIII.  Pompholyx    .     .     .     .     .     .     .431
  XIX.  Lepra  ........    431
   XX.  Psoriasis ........  432
  XXI.  Pityriasis   .......    432
 XXII.  Icthyosis ........  433

                      CHAPTER  IV.
THE DIAGNOSIS OF VARIOLOID DISEASES      .    .     434
    I.  Perfect Vaccinia......435
    II.  Imperfect Vaccinia.....436
              1. The Vaccine Pustule.
              2. Ulceration.
              3. Irregular Vesicles.
   III.  Varicella  .......     ±  437
              1. Varicella lenticularis.
              2. Varicella.
              3. Varicella globata.
   IV.  Variola      .......440
           I.  In the Unprotected  ......   440
              1. The Mild vesicular  .....     440
              2. The vesiculo-pustular   .....   440
          II.  In the Protected .    .    .    .     .     .     441
              Modified Variola   .     .    .    .     .     .441

                     CHAPTER V.
THE DIAGNOSIS OF SOME DISEASES SUBJACENT TO
    THE SKIN.........443
                     I. OF THE LIMBS.
    I.  Phlebitis.......444
    II.  Inflammation of  the Absorbents  .    .     .  445

                    II. OF THE NECK.
    I.  Inflammation of  the Lymphatic  Glands    .    445
    II.   Cynanche Parotide a.....445
  HI.  Bronchocele     .    .     .    .          .     446
   IV.  Tumors  .....    ...  446
    V.  Aneurysm    .......    446
                    HI. OF THE GROIN.
    I.   Inflamed Glands......446
    II.  Hernia.......447
  III.   The Pointing of  Lumbar Abscess  .     .     .  447
   IV.  Tumors.......447
    V.  Aneurysm     .......  447

        IV.  OF  THE LUMBAR AND ILIAC REGIONS.
    I.   Disease of  the Spine  .....     447
    II.  Aneurysm of the Aorta  .....  448
  III.   Lumbar Abscess......448 
XXIV
CONTENTS.
   IV.  Disease of the Kidney.....449
    V.  Disease of the Hip-joint   ....    449

                     CHAPTER VI.
THE DIAGNOSIS OF PAINFUL, SPASMODIC, AND PARA-
   LYTIC DISEASES.........450
               I.  THE PAINFUL DISEASES.
                    I.  OF THE FACE.
    I.  Odontalgia.......452
   II.  Rheumatism.....•    •    452
  III.  Face Ague.......452
  IV.  Tic Douloureux......453
   V.  Inflamed  Antrum Maxillare  ....  453

                   II.  OF THE LIMBS.
    I.  Rheumatic    .......    453
1   II.  Syphilitic  .     .......  453
  III.  Cachectic, Pains......453
  IV.  Sympathetic Pains in Carcinoma   .     .     .  453
   V.  Tic  Douloureux......454
   VI.  Painful Subcutaneous Tubercle  . .     •     •  454
            II. THE SPASMODIC AFFECTIONS.
                    I.  OF THE FACE.
    1.  Trismus........454
   II.  Trismus Hystericus......454
  III.  Permanent Spasm of  the Face   .    .    .    455
  IV.   Tics,  or  Spasmodic  Affections  of various
      Muscles........455
   V.  Chorea; Tremor; Stammering   .    .    .    455
  VI.  Strabismus     ....     ...  455
  VII.  Wry-neck.......455

                   II.  OF THE LIMBS.
    I.  Cramps    ........   456
  II.  Hysteric Spasms of the Hands, Feet, etc.   .     456

           III.  THE PARALYTIC AFFECTIONS.
                   1.  OF THE FACE.
   I.  Cerebral Paralysis......456
   II.  Paralysis  from Affection of the Fifth Pair
      of  Nerves.......456
  III.  Paralysis from Affection of the  Portio Dura
      of  the Seventh.......457
                   II. OF THE LIMBS.
   I.  Paralysis  from Colica Pictonum .    .     .     457
   II.  Wasting of the Muscles of the Shoulder    .   457
  III.  Paralysis from
             1. Epilepsy,
             2. Hysteria,
             3. Rheumatism, &c.   •••...   458 
THE
SOURCES  OF  DIAGNOSIS.
   1. The Diagnosis of Diseases constitutes the first part of the
office of the physician in his actual visits to the sick.
   2. The Sources of Diagnosis are, the History, the Symptoms,
or changes in function, the Effects  of  Remedies, and the Mor-
bid Anatomy, or changes  in structure.
   3. The History teaches  much of the probable progress of the
disease, and of its  effect in inducing changes in structure and
devastations of the powers of the general system.   The Symp-
toms designate the organ  principally affected.  The Effects of
Remedies, carefully considered, throw an important ray of light
upon the  nature and force of the disease, and upon  the condi-
tion  and  energies of the system.   The examination of  the
changes of structure  affords an  invaluable  confirmation or cor-
rection of our previous opinions.
  4.  The study of the history of the disease greatly aids the di-
agnosis.   The constitutional causes, which involve  the heredi-
tary  predisposition, previous attacks, (fee.; the external  causes,
which embrace those circumstances which induce and  modify
the disease; the duration, the past course of the  morbid affec-
tion, &c,  are all events which greatly assist us in  forming  the
diagnosis, and in determining the particular condition of phe or-
gan  principally affected, and of the general system, in the indi-
vidual case.
  5. But the symptoms doubtless constitute the  chief source of
the diagnosis.   The form and  violence  of the symptoms, the
                             3 
26
THE SOURCES
particular order in which they appear, the particular manner in
which they are conjoined, constitute additional means of diag-
nosis.
  6. One of the sources of diagnosis enumerated,  constitutes
a department of knowledge  which may be termed new ; it is
that of the effect of remedies, and especially of blood-letting, as
a diagnostic of diseases, and as a criterion of the general powers
of the system.   In cases in which it is doubtful whether the pain
or other local affection be the effect  of inflammation or of irrita-
tion, the question is immediately  determined by placing the pa-
tient upright and bleeding to incipient syncope:  in  inflamma-
tion much blood flows; in irritation, very little.   The  violence
of the disease, the powers of the  system, and the due measures
of the remedy, are determined at the same time.  There is, in
my opinion, no single fact in physic of equal importance
and value, in the diagnosis of acute diseases and  the use of
an  important remedy.
  7. But it  must be  acknowledged that it is to the study of
morbid anatomy that we are principally indebted for  the recent
progress, and, indeed, for almost all that is solid in medical sci-
ence.  It is by the investigation  of morbid anatomy that we are
principally enabled to establish correct species  of disease ; but it
is equally true, that all the advantages which spring from our
knowledge of changes of structure, must flow through that of the
history and symptoms, as the channel to our individual patients.
The progress of medicine as a science—might  we  not say, as an
abstract science ?—may be considered as greatly dependent on
that of our knowledge of morbid anatomy;  but  the advance-
ment of physic, as a practical art, is intimately linked with our
knowledge of the history, symptoms, and the effects of remedies
—with the diagnosis of the disease in the living patient.
  8. The Sources of Diagnosis may be arranged in the follow-
ing manner:
     I.  The History.
    II.  The Symptoms, or Changes of  Function.
  III.  The Effects of Remedies.
    IV.  The Morbid Anatomy, or Changes of  Struc-
            ture. 
of  diagnosis.
27
  I.   The History of Diseases comprises

  i.   The Causes, which are
      1. Constitutional.
      2. External.

  ii.   The Course,  which is
      1. Acute.
     2.  Chronic.
     3.  Insidious.
      4. Sudden. <$*c.

 II.   The Symptoms, or Changes  of  Function, are ob-
        served in
      1. The Countenance.
     2.  The Attitude.
      3. The Tongue.
     4. The General Surface.
      5. The General System.
     6. The Functions of the Brain, the Spinal Marrow,
         and the Nerves.
      7) The Respiration.
      8. The Circulation.
      9. The Slethoscopic Signs.
    10. The Functions of the Alimentary Canal.
    11.  The Functions of the Urinary Organs.
    12.  The Functions of the Uterine System.
    13. Examinations,
          1. Of the  Abdomen,
         2. Of the Rectum,
         3. Of the  Vagina, fyc.

III.  The Effects of Remedies are

   i.  Immediate.
   ii.  Remote.
  iii.   Curative.
  iv.   Morbid. 
28                  THE SOURCES

  They are principally seen in the administration of
         1. Blood-letting.
         2. Purgatives.
         3. Opiates.
         4. Mercury.
         5. Digitalis.
         6. Alcohol.
         7. Quinine,  fyc.
  It is the immediate effects of blood-letting which are chiefly
valuable in a diagnostic point of view.

IV.   The Changes of Structure are
          1. Febrile.
         2. Eruptive.
          3. Inflammatory.
          4.  Congestive.
          5. Arthritic.
          6.  Rheumatic
          7. Scrofulous— Tubercxdous.
          8. Scirrhous.
          9. Encephaloid.
         10. Melanotic.
         11. Dropsical.
         12. Hemorrhagic. $*c.
   9.  The observation of the history, symptoms, and  effects of
 remedies, is strictly clitiical, and can alone be beneficial to our
 immediate patient.   The examination of the morbid anatomy
 may be viewed as the proper corrective of our clinical opinions,
 whilst  it contributes, more than any other species of investiga-
 tion, to the advancement and exactness of the  science of medi-
 cine.
   10. The true value and importance of the history and symp-
 toms of diseases, and of morbid anatomy,  depend alike on a due
 and correct association.  The most perfect knowledge of symp-
 toms would be utterly useless,  unless considered as signs and in-
 dices of the internal disease; and the most perfect knowledge of 
OF DI AGN OS IS.
29
morbid anatomy would be inefficient, unless we were enabled by
the symptoms to ascertain its existence in the living body.  Our
object, in both those studies, ought, therefore, to be to make them
useful by the establishment of distinct associations of the symp-
tom or the sign, and of the morbid state as the thing signified.
It is in this manner only that the diagnosis and identification of
diseases in the actual practice of physic will  become  more and
more correct and complete.
   11. The objects embraced  in the  history  and  symptoms of
diseases are certainly more transitory and less palpable, and  re-
quire more caution and reserve in the association as  effects of
diseases, than those of morbid anatomy.    But,  from the obser-
vation just made, that  it is only by  association of  the morbid
anatomy with symptoms indicative of the morbid change, that
even this becomes cognizable  in the  living body and  useful in
the practice of medicine, it is plain that the same difficulties  ap-
ply in fact to both.
   12. The study of the history and symptoms  of diseases em-
braces an object unconnected with morbid anatomy, viz : such
instances of morbid affection as consist in derangement of func-
tion and  leave no  trace under the scalpel of the anatomist.* (')
And it is one of the objects of  the history of  diseases especially,
to trace the transitions,  in mixed cases, of deranged  function
into deranged  structure, the  extensions of diseases of structure
from one organ or part to another, and the super inductions,
from  accident or natural consequence, of one disease upon an-
other.   It is a point of great importance, but of great difficulty,
in the study of the history and symptoms of diseases, to deter-
mine the times of these transitions  and extensions of disease.
  * See Baillie's Morbid Anatomy, Pref. p. 1.
   (1.)  The progress of  pathological anatomy  during  the present century,
has not only improved our previous knowledge of the morbid  changes in the
structure of organs, but has, so to speak, created new diseases by proving
that changes formerly regarded  as functional are, in fact, actual changes of
structure.—Indeed it is probable that every disorder of function is accompanied
by a change of structure in the organ affected—so transient or minute often as
to escape the observation of the anatomist.                         "• 
30
the sources
   13. It is an object of the history and symptoms of diseases to
ascertain, in the coincidence of different morbid affections, whe-
ther their co-existence be accidental, or the result of their mutual
relation as cause and effect.
   14. Such is an imperfect sketch of the objects and relations
of this department of medical  science.   It would be wrong to
argue against the importance of the study of the history and
symptoms of diseases from the imperfect manner in which they
have heretofore been treated ; whilst  to  consider perfection  in
this study to be unattainable would be to suppose that medi-
cine cannot exist as a safe and  useful art.   It  would  be wiser
and truer to say, that, hitherto, we have been too apt to form and
to state our opinions,  and to regulate our practice, on insufficient
evidence;  and then to turn our attention to the  real nature of
the evidence for facts in medical science, and especially in clini-
cal medicine, and to inquire whether its sources may not be mul-
tiplied, and its results rendered more sure and conclusive.
   15. It is in this way alone that we can hope to  remove from
the practice of medicine the reproach of  vacillation and uncer-
tainty, and  contradiction.  The  first step is clearly to distin-
guish and to identify the disease;  the second, to appropriate
the remedy, in  its purity and simplicity, and with a due atten-
tion to the strength and  constitution of the patient.  When ex-
periments have thus been carefully instituted, and the results
collected by an  assiduous  observation, we may  expect to be-
come acquainted with the real effects of those agents which  we
consider as remedies,—both good and  bad.  An  investigation
conducted  in this spirit would, I  feel convinced, lead to some
important results.  We still want an essay on the  morbid ef-
fects of remedies,—1. when misapplied,  2. when even  appro-
priately, but perhaps injudiciously,  administered, and 3. from
idiosyncracy.  I may instance  blood-letting, and  purging, and
opium, as productive of  morbific effects of the most serious char-
racter, to which my attention has been particularly directed: it
is needless to add to  the list, mercury, digitalis, cantharides, &c,
with which every practitioner has learnt to associate certain mor-
bid conditions of the system.   But this subject will be more par- 
OF diagnosis.
31
ticularly noticed in the succeeding volume of this work.    I
shall now proceed briefly to notice the advantages which result
from each of the departments of the present volume more dis-
tinctly.
   16.  The principal circumstances more particularly embraced
by the  history of  diseases, are,  the cause,—the progress, the
stage,—the effect of remedies,—the season of the year, the pre-
valency of  epidemics,—the  constitution, and habits, and pre-
vious diseases of the patient, &c.
   17.  The principal subject in the history of diseases, in a diag-
nostic point of view, is its congruity or incongruity with the sup-
posed disease.   We frequently  arrive at a  negative result, es-
pecially, by observing such  incongruity in  the history, and in
this  manner,  by  excluding certain  diseases, we -jsliiow  the
sphere of our inquiries, and have our  attention upon a less nu-
merous class of objects.
   18.  In the study of the symptoms, every circumstance which
can become the subject of observation, and which is at all char-
acteristic, must  be considered as  important.  It is  with this
view that I have carefully examined the countenance  and the
attitude of  patients, as well as those other points which are
more usually considered amongst the class of symptoms.  The
attempt to analyze, distinguish, and describe all the external
appearances of disease, cannot fail to assist the clenical student
and the young practitioner, whilst it  serves only to recall to the
mind of the experienced, those sources of evidence on which his
judgments  have  been  ever, though perhaps  unconsciously,
founded.  For  without having undertaken any distinct ana-
lysis of the general appearances in disease, the experienced phy-
sician has, notwithstanding, been struck with them in the coup-
d'ceil he has taken of these appearances, and of the  general
manner of the patient.  By these means he has recognized and
identified the affection, when he may have been almost uncon-
scious of the sources from which his discrimination flowed.
   19.  The countenance of the patient, although a source of in-
formation too much neglected by writers on  medicine, is very
peculiar and highly characteristic in many diseases, and affords 
32
the sources
 to the physician of experience and  observation  an important
 means of diagnosis.   The kind, the stage, the changes, the mi-
 tigation, and the progress of many morbid affections, are accom-
 panied and denoted by corresponding states of the countenance.
 Let us recall to mind the varied and  distinctive  appearances  in
 the different kinds and stages of fever, in affections of the head,
 of the thorax, and of the  heart; in inflammation in the abdo-
 men, and  in  colic, and  other affections accompanied by  spas-
 modic pain ;  in icterus and in chlorosis, and that class of morbid
 affections which, originating in derangements of  the digestion,
 are accompanied by changes of complexion so  characteristic of
 the original disorder.   It is impossible not to  be impressed
 with the importance of changes in the countenance  so observa-
 ble, so diversified, and so diagnostic, with a view to  every prac-
 tical purpose in the art of medicine.
   20. Hippocrates,* and  Celsus,t and other ancient  writers,
 have, in their  great attention to  the study of  symptoms, paid
 particular regard to the appearances of the countenance.  Celsus
 observes, "  medicus neque in tenebris, neque a capite segri debet
 residere: sed  illustri loco  adversus eum, ut  omnes notas, ex
 vultu quoque cubantis, perspiciat. "J
  21.  These observations are equally applicable to  the subject
of the attitude and motions of the  body in  general,  in different
 diseases ; for,  although the attitude, in certain diseases, is so re-
markable as  absolutely to  have challenged observation, yet,  in
general, this point has been too little noticed, and its indications
too  little explored.   Hippocrates § and Celsus II have particularly
noticed the  attitude  of patients.
  22.  It is  useful to examine the state  of the hands midfeet
of the patient,  in connection with that of the general surface.
But it is not my  intention to  enumerate all the subjects of the
following pages in this place.  I proceed, therefore, to notice  in
 a cursory manner some points rather connected with the inves-
     * Vide llfoyvaTTUMv.          f Lib. 2, cap. 2, 6.
| Lib. 3, cap. 6.    § Vide llpoyvceorMov.    || Lib. 2, cap, 3, 4, 6. 
OF  DIAGNOSIS.
33
tigation of the symptoms  of diseases, than forming a  part of
them.
  23. It is proposed, in the first place, to make each particular
symptom the object of distinct and separate inquiry, and,  consid-
ering it as a general  phenomenon occurring under numerous
and different  circumstances  of disease,  to investigate, distin-
guish, and arrange its varieties,  modifications, and peculi-
arities, in each.
  24. It is insufficient to give to a particular symptom a parti-
cular name,  and notice  its occurrence in  particular diseases;
it is necessary to describe each symptom in general,and to dis-
tinguish each  modification and peculiarity of it in particular.
Dyspnoea is noticed as a symptom of inflammation within the
chest, of hydrothorax, of asthma ; but how widely different is
the dyspnoea of pneumonia from that of asthma—how distinct
the difficulty of breathing in  asthma from  the dyspnoea of hy-
drothorax,  and from that of the numerous other affections in
which this symptom is observed !   How desirable,  then, must
it be to  seize and  describe these  distinctions,  and make the
application of them to the discrimination of diseases !
  25. It can seldom be said that  any particular symptoms of
disease are truly pathognomonic;  but the kind  and character
of the symptom  are  frequently so.   To  ascertain, therefore,
the  form of each  symptom  as  peculiar  to different diseases,
would be to establish  that  system  of pathognomonics so much
desired by the more ancient physicians.*
  26. The varieties and modifications in the form of symptoms
must be  traced too,  in immediate reference to particular in-
stances of disease.  Much has been written  on the different
states of the pulse; and  numerous artificial divisions  of this
symptom have been formed ; but in general this has been done
in too abstract a manner.  To study the pulse to any practical
purpose, it should  be constantly considered in relation to some
individual  disease,  its character  noticed,  its  changes  traced.
* Cullen, Nosologia Method ica, p. vii.
             4 
34
THE   SOURCES
and its indications  ascertained.   Every thing must be as httle
general and as little abstract as possible.
   27.  A proper and full arrangement of the symptoms and
their varieties must be of great importance in the investigation
and identification of diseases.   Some symptoms have been con-
sidered as real diseases,  and it must be absolutely necessary to
draw just distinctions between them with a view to their  cure.
A similar arrangement and discrimination of the varieties of
each symptom are of essential importance to the diagnosis, and
of greater moment  in this place, because the investigation has
been hitherto pursued in a very partial and inadequate degree.
Dyspnoea,  icterus,  hydrops,  &c.  must be  distinguished,  as
symptoms merely, from real diseases, and each form, and va-
riety of these affections must  be carefully distinguished  from
the rest,  and accurately associated with its particular cause.
   28.  There are also some other  circumstances which claim
our attention.   The particular combination of symptoms,  and
the influence of one symptom  in inducing and modifying the
others, are  observed  to  be  characteristic  of certain affections
and stages of disease.
   29.  In our  clinical  visits, we  naturally resort  to the princi-
ples of analysis and synthesis, in order,  first, to seize some
particular points, such as several  prominent  and important
symptoms,  from which we proceed,  in the second place,  to col-
lect such other symptoms as usually concur and complete the
character of the disease we  have in view.  We are thus con-
firmed or corrected in our opinions by the congruity or incon-
gruity of  the  several parts ;  we perceive that the disease is
simple or that it  is complicated; and we trace its  progress in
itself, or its extension, and involution  of other diseases,  or of
parts of the system not originally affected.   It is, indeed, com-
paratively easy to observe and describe symptom,  or  appear-
ances in morbid anatomy, abstractedly ; the  task of difficulty,
as well as of utility, is the proper and just association of them
as signs and diseases.
   30.  Some symptoms are not only incongruous  but incom-
patible,  and by a careful and  patient observation we often 
OF  DIAGNOSIS.
35
 satisfy ourselves on a point which we could not decide by any
 inquiries.   When a patient has complained of pain of the side
 for instance, and it has been  doubtful  whether the pain were
 inflammatory,  a spontaneous  sigh  has decided the  question.
 In the same manner writhing of the  body is unusual if not
 incompatible with inflammation.  At least, although, as Celsus
 observes, "vix  ulla perpetua prsecepta  medicinalis  ars recepit,"
 these  circumstances afford great assistance in the investigation
 of diseases.  We  are thus frequently  enabled to circumscribe
 our inquiries by ascertaining what the disease is not, before we
 have actually discovered what  it is.
   31. But without entering so minutely and carefully into this
 subject, there is something in  the coup-d'ceil, or general sum
 of appearances, which is of great utility to  the  experienced
 physician.  There is in  practical medicine a circumstance of
 the first importance, the recognition of a disease.   The gene-
 ral appearance of  the patient, the  peculiar  modification,  the
 particular combination, and the mutual influence of the  symp-
 toms, give a general character to the  whole disease, which is
 recognised and felt by the physician of experience and obser-
 vation.
   32. Accurately to discriminate the symptoms of diseases, and
 their various forms, is to apply  to the objects of clinical medicine
 the  principle of analysis; and accurately to describe  them,
 will  be to render the knowledge of them and of medical expe-
dience in general more communicable  to others.  It has long
 been remarked and regretted that practical knowledge  in medi-
 cine is peculiar in  this respect,—that it cannot be taught, and
that the precious fruits of experience necessarily die with their
possessors.*  How unfortunately true this remark is to a certain
 extent, must be universally acknowledged.   And from  this ad-
 mission,  the importance  of devising the  means of rendering
 medical knowledge more capable of being imparted from one
 person to another, is sufficiently manifest.  Now it has appeared

  * See Pearson on Cancer, Pre/, p. vi.  Own ti^vh, own <roqtn h^iktov, u /ux /u.*9n
T«.  AHMOKPAT. *U020*. 
36
THE   SOURCES
to me that the difficulty in effecting this object may be in some
degree obviated.   On considering the nature of experience in
medicine, it is plain that  it consists,  in a great measure, in an
acquired capacity for receiving and  acting  on general impres-
sions induced in the mind by the repeated contemplation of dis-
ease.  The inexperienced practitioner is incapable of receiving
these general impressions; the experienced  are, in general,  in-
capable of explaining them.   Is  it not, however, probable that,
by presenting to the young clinical student an analysis of those
general impressions which constitute the object of experience, he
may be very  materially assisted, and that  experience  may not
only thus become more communicable, but that the young prac-
titioner may thus also  sooner become experienced, and earlier
capable of acting on similar general impressions 1  If this be true,
such an analysis of the general impressions of experience must
prove highly useful.  But such an  analysis implies the obser-
vation and detail of every particular constituting the general sum
of morbid  appearances,—the enumeration and description of
every phenomenon which can be presented to  the observation
of the physician.
   33. It is true this general view of disease is inadequate to
the purposes  of practice ; it is, however, of  great assistance and
utility;  and  the most  experienced must not  rest satisfied with
his general knowledge, but must make the most particular
inquiries, in the case of each  individual  patient;  " etiam ve-
tustissimus auctor Hippocrates  dixit, mederi oportere et com-
 munia et  propria intuentem."*  The  general impression in
question is chiefly useful by contracting  the circle of our in-
 quiries, and by leading us nearer that centre which  consists in
 the individual case before us.  It  is especially  useful in Dis-
 pensary practice, in which many patients must be  seen in a
 short time, and in which there is  not, consequently, sufficient
 opportunity for entering fully into particulars.
   34.  In  conclusion, I may remark, that the objects of the his-
 tory and  symptoms  of  diseases may be  divided into those of
* Celsi, rratf. lib. i. 
OF  DIAGNOSIS.
37
observation and those of inquiry on the part of the physician:
the former are the more satisfactory ; the results of inquiries are
apt to partake of the vagueness and incorrectness of the answers
of the patient.  In conducting these inquiries, we  ought to be
careful not to put leading questions, and not to receive the
replies implicitly,  but to try their truth by ascertaining their
congruity or incongruity with the character and history.
   35. I  must  now  revert briefly to that source of diagnosis
which is afforded us in the effects of remedies.   It chiefly refers
to the effects of blood-letting, and consists in  the fact, that in-
flammatory affections of the serous membranes and parenchy-
matous substance of organs induce great tolerance of loss of
blood, in the perfectly erect pobition.   The institution of blood-
letting in this position affords therefore a diagnosis of acute dis-
eases of the utmost moment.  But the  subject will  come to be
noticed more at length in its proper place.
   36.  The morbid anatomy will also come to be briefly treated
of at the conclusion of the present volume.
   37.  I  may  remark, finally, that the matter of the second
volume  is of so much  more practical interest than that of the
present one, which may be viewed as merely preliminary, that I
 have curtailed this in order that I might give fuller details upon
 subjects  of greater moment and more immediate value in actual
 practice.   I wish,  however, the  characteristic of  my  work
throughout to be brevity in statement,  with  fulness  in the col-
lection and arrangement of facts  useful to the practitioner. 
SECTION   I.
THE   HISTORY   OF  DISEASES.
  38. The principal objects in the history of diseases, are, their
causes and their course.  I do not propose to enter into details
upon these subjects, which will be found in the second volume,
but,  supposing them known, to point out some of their practical
applications.
  39. It is of the utmost importance  to  observe  the causes of
prevailing epidemics,—as contagion,—season of the  year,—
state of the weather, &c,—and of endemics, as marsh effluvia,
peculiarity of situation,—prevailing occupations, &c.  It is  im-
portant to know what we may expect, in our visits  to the sick.
  40.  The  influence of local situation  in  inducing Typhus,
Intermittent Fever, Dysentery, Phthisis Pulmonalis, Bron-
chocele,  Calculus, fyc, is now well  understood; the effect of
sedentary occupations is to  lead  to the different forms  of  the
Dyspepsice.  Typhus  is frequently observed in new-comers
into  crowded cities ;* and Intermittents, in the visitants or in-
habitants of marshy districts.  There  seems to be good reason
for  supposing that where intermittents prevail,  Phthisis is
less frequent in its occurrence.!   Calculus is less observed in
sailors than in persons residing on shore.J  It cannot be doubted
that the careful observation of these external causes, and of their

  * Louis, Recherches sur la Gastro-enterite; t. ii, p. 452.  Andral,  Clinique
Medicale; ed. 2, t. iii, p. 448.
  + Trans, for the Improvement of Med. and Surg. Knowledge ; vol. iii, p. 471.
  1 Medico-Chirurgical Transactions. 
            HISTORY   OF  DISEASES.        39

effects, must contribute materially to a knowledge of the diagno-
sis of diseases and of their various forms.
  41.  The next class of causes, which  I shall briefly notice,
are those  of the habits and of the constitution of the patient.
The habits of the patient relate chiefly to his occupation, and
are sedentary or active, and to his mode of living with regard
to diet,  wine, &c.  It has already been observed that sedentary
persons are subject to the Dyspepsia};  those who eat and
drink freely are, of course,  exposed to diseases of fulness,  as
Apoplexy; whilst  the spirit-drinker is exposed, on one hand,
to attacks of the Delirium tremens, or, on the other, to the
slower inroads of Organic Disease of the Liver, Dropsies,
Purpura, fyc.
  42. The constitutional causes are chiefly those of the form,
and of hereditary tendency  or  taint.   The tendency to Apo-
plexy, to  Phthisis, to  Gout, and even to  Calculus and Gall-
stones,  is  sufficient to illustrate the present subject.   Nor can
it be doubted that a careful inquiry into these  points must ma-
terially conduce  both to the prognosis and to  the diagnosis of
these morbid affections.
  43. In  some diseases, however, both the character and prog-
nosis are apt to be modified by complication, or by changes in
the original affection.   Typhus and other fevers are apt, from
a simple  form, to become  complicated  by some  local organic
affection.   The  Dyspepsia, are particularly apt to have their
most prominent symptoms removed from one organ to another.
  44. It is a  point of great  interest and  importance to study
the early history of insidious diseases,  in order to  prevent
errors in the diagnosis  and prognosis.  It  is of still higher im-
portance to trace with accuracy the previous history of sudden
and impending  diseases, in  order that we may, if possible,
prevent them.
  45. In  other diseases, as Inflammation, and especially Or-
ganic Diseases, the course is comparatively more regular and
uniform.
  46. The course of Mesenteric Disease is perhaps the slow- 
40
THE   HISTORY
est, and most regular progressive, of all  diseases  eventually
fatal;  it usually occupies a space of from three to five years.
  47.  In many diseases it is necessary  to watch the course or
extension  of the  primary disease, as it involves different or-
gans.   It is a point,  perhaps, of still greater interest, to trace
the gradual superinduction of organic disease in cases origin-
ally consisting  in derangement of function.   True Asthma
may lead to disease of the heart.  Protracted Dyspepsia is,
after  excess  in  spirits,  the most frequent cause of hepatic
disease.
  48.  There is a  point in  the  history  of diseases which still
requires attention ;  viz. what has been termed the metastasis
or conversion of diseases.   This event has occurred in  Gout,
Rheumatism,  Erysipelas,  Cynanche  Parotidea, some Cu-
taneous Affections, Suppressed Haemorrhoids? fyc.  But I think
some of the events of the morbid affections which accompany
the Dyspepsise, have been mistaken for metastases of diseases;
and some of the effects of the treatment, as will be noticed im-
mediately,  are  very apt to be mistaken for changes or  conse-
quences of  the disease.
  49.   Various  diseases are apt to succeed to each  other from
originating in one common cause: Phthisis is  apt to  follow
Fistula ani;{') syphilitic  and syphiloid  affections variously
succeed to each  other.
  50.  The study of the history of diseases  is of essential  ser-
vice in Dispensary practice, in  which, from  the considerable
number  of patients seen  in  a limited time,  a  prompt diagnosis
is required.  The following rides will  be found  extremely
useful to the young  physician  on such occasions.   It is only
however, as an  approximation to the diagnosis, that such rules
can be attempted.   It will still be necessary to inquire into the
particulars of  the individual case.
   51. The first question to be  asked of the  patient is, < how
            * See the Edinburgh Journal, vol. xv, p. 106.
  (1.) In several hundred cases of Phthisis not more than two presented this
complication.                                               S. 
OF  DISEASE.
41
 long he  has been ill.'   The reply  resolves the case into the
 Class  of Acute,  or of Chronic Affections.  The former are
 principally Fevers, the Acute Dyspepsia, or Acute Inflamma-
 tions ;  the latter  are the Chronic  Dyspepsice, the Insidious
 Organic Diseases, or the Insidious forms of Inflammation,
 especially of the Brain, the Pleura, and the Peritoneum.
   52.  Having  thus  ascertained the class of the disease, we
 must proceed, in the case of the Acute, to investigate the indi-
 vidual nature of the case.   In Chronic affections we may ask—
   53.  In the second place, 'whether  there be a material and
 progressive loss  of flesh.'
   54.  The reply to this inquiry divides the cases into such as
 may subsist without influencing the  nutrition,  and such as
 gradually reduce  the  patient.  The former cases are  chiefly
 the chronic and protracted forms of  Dyspepsia,  or diseases of
 such organs  as are not  engaged in the process of assimilation.
 The latter  are  Marasmus, Phthisis, Mesenteric  Disease,
 Chronic  Inflammation of the Peritoneum, and, in general,
 diseases of the ' organs of supply.'
   55.  A third inquiry is into the state of the pulse.   Increased
 frequency of the pulse is the usual attendant on  the  Insidious
forms of Organic Disease, whilst it is not observed  in the less
 serious cases of the Chronic Dyspepsia}.
   56.  Other questions are, l what is the seat of pain or unea-
 siness V—'what are the functions disordered V
   57. It is needless to enter more minutely into the subject, as
 it  would  be only  repeating  the observations, to be detailed
 forthwith, on the general aspect of the patient, and the general
character and course of the disease.
                             6 
SECTION  II.
THE SYMPTOMS  OF  DISEASES.
                     CHAPTER  I.

   THE MORBID APPEARANCES OF  THE COUNTENANCE.

   58.  The particular circumstances embraced  in an  examina-
tion of the morbid states of the countenance, are the changes in-
duced  in the cuticular surface, the cutaneous circulation, the
cellular substance,  the muscular system, some particular
features^ and the general expression.
   59.  The cuticular surface is morbidly affected in some long-
continued disorders,  chiefly of the digestion,  especially round
the eye and  the mouth, giving a peculiar appearance  to the
complexion.
   60.  But the complexion, as well as the surface  of the coun-
tenance, is principally affected by the condition of the  cutaneous
circulation ; on this  depend chiefly the state of pallor or  flush-
ing, and of the sallow and icterode hues of the complexion ob-
served in some disorders,—the state of  tumidity or shrinking,—
of heat or coldness,—of dryness or moisture, or cutaneous exu-
dation.
   61. The state of  emaciation, so important to  observe and
trace in  chronic diseases, depends  on the loss of  cellular and
muscular substance,  and must  be  always  distinguished from
mere  vascular shrinking.
   62. The muscular system is  principally affected by diseases
attended with pain, languor, or paralysis.
   63. Amongst the particular  features, it is of moment  to ob-
 serve  the eye, the prolabia,—the brow, the nostrils, the lips, &c. 
          MORBID  APPEARANCES,  ETC.        43

The eye, in particular, affords the opportunity of judging of the
degree in which the serum is loaded with bile, in cases of icte-
rus, and of distinguishing that disease from those morbid  affec-
tions in which the complexion becomes sallow and icterode from
the state of the cuticle and cutaneous circulation.  The state of
the prolabia affords an index of other states of the blood,—as of
a too serous condition, or of a defective arterialization.  The nos-
trils, carefully observed, denote the condition of the respiration.
  64. Of the general  expression  of  the  countenance I shall
rarely venture to speak.  It affords an important and essential
source of information in Dispensary practice,  §50, and assists
the experienced  physician in discerning the nature of the disease
where the superficial observer sees only the general look of indis-
position.
   65.  The morbid condition of the cuticular surface,  §59, and
of the cutaneous  circulation, § 60, are accompanied with pecu-
liar affections of the hands, and of the general surface, and of
the tongue.  These associations  it  will be  my object to trace in
the subsequent  pages.   I  now proceed to describe the  appear-
ances of the countenance in reference to particular diseases; I
have already stated, § 26, that it is with such reference  alone
that the knowledge of symptoms  becomes of practical  utility.
   66. In the Acute Synochus there is a diffused, vivid flushing
of the countenance, frequently with considerable turgidity, espe-
cially in the young and sanguineous, the tunica albuginea is apt
to be suffused, and  there is  great  febrile heat.  There  are also
general anxiety,—tremor of the lips in speaking,—and a rapid
movement of the nostrils from hurry in the respiration.   The tu-
midity diminishes as the fever runs its course, and either declines
or assumes the slow and protracted  character.
   67. In  the Acute  Inflammation,  especially  of  the serous
membranes, or parenchymatous substance,  the countenance has
a very  different aspect, which it is important to  observe, especi-
ally in a diagnostic point  of  view.  The heat, turgidity, and
flushing, the suffusion of the eyes, the tremor of the lips, and the
hurried movement of the nostrils, are absent,  whilst the surface 
44         THE  MORBID APPEARANCES

is frequently affected with perspiration.  There is also usually
an appearance peculiar to the primary disease.
  68.  From the state of countenance described, § 66, the tran-
sition is often imperceptible to that observed in the Protracted
Synochus; sometimes, on the contrary, the appearances of this
febrile  affection come on insensibly from similiar causes, with-
out being preceded by the acute form.   Instead of tumidity and
suffusion, there are  shrinking, partial flushing  of the cheeks
only, emaciation, and frequently a  pallid and sallow hue ; the
cheeks become fallen, and the malse, maxillse, and other bony
parts, appear prominent;  the surface  becomes dry, and rough ;
the lips, like the tongue, are dry and tremulous, and not moved
with the usual freedom in articulation;  the teeth are frequently
somewhat affected with sordes or mucus.
  69.  In Chronic Inflammation the appearances are peculiar.
There is a characteristic expression of disease which strikes the
common observer, and, still more, the experienced physician ; the
surface and complexion are cool and pale, or affected with  tran-
sient or partial heat and flushing, usually without sallowness, fre-
quently with slight lividity, sometimes with cool moisture: there
are emaciation and  shrinking, the cheeks falling in, the action
of the  muscles becoming  apparent, and the skin forming into
greater or smaller folds.  These appearances of the countenance
are, however, greatly modified by  the nature and seat of  the
original disease, as will be particularly noticed hereafter.
   70.  In the milder form of Typhus the countenance is equal-
ly unattended by deep flushing and tumidity, or with shrink-
ing ; but it is highly characterized by an expression of languor,
feebleness, anxiety, and indisposition, and by tremor observed in
the lips and on speaking ; the eyes are  frequently suffused ; the
 cheeks slightly flushed ; the surface affected with a moderate de-
 gree of warmth,*
   71.  In the severe forms of Typhus the countenance is mark-
  *See Currie's Medical Reports, vol. 1, p. 12 ; Bateman on Contagious Fever,
p. 28, &c 
OF THE  COUNTENANCE.
45
ed by great debility  and tremulousness of the muscles, and by
great shrinking ; the bones are more prominent, the intervening
spaces more sunk and depressed than natural; the surface  is
sometimes slightly flushed, and sometimes cool and clammy.—
The eye lids are frequently partly closed, and the eyes suffused,
dull, and covered with a film of mucus ; the mouth is apt to be
partly open, the teeth and lips affected  with dark-colored glutin-
ous sordes; the articulation is difficult and imperfect, and attend-
ed with great effort, and with tremor and an inadequate action
of the lips and of the tongue, which is put out with tremor and
difficulty.   There is often superadded the appearance of delirium,
—or of coma,—of congestion,— or of collapse or sinking.
   72.  The countenance in Continued Fevers is  liable to re-
ceive a modification from their complication with a morbid affec-
tion of the head, the viscera of the thorax, or of the abdomen, the
detection of which is amongst the most important objects in the
study of these diseases.
   73. The different stages of Intermittent  Fever are attended
by peculiar states of the countenance, and especially of the cuta-
neous circulation.  In  the cold stage there are shrinking and
paleness,—pale lividity of the prolabia,—trembling of the lips and
maxillae : in the hot stage there are heat, flushing, and tumidity,
and suffusion of the eyes, and the features are restored from their
collapsed condition :  in the sweating  stage, the surface, com-
plexion, and heat, become more natural, whilst there is  greater
or less perspiration.   In the interval  there  are, at first, languor
and slight paleness,—after a time, paleness, shrinking, and ema-
ciation.
   74.  The different Fevers are so. varied in themselves,  and so
various in  their  different stages, and in different  individuals,
ages, and habits, that the countenance, together with the symp-
 toms of the disease, must necessarily be much diversified.  But
of all the diagnostics of the different Fevers, and of all the  indica-
tions of their progress, stages, and changes, none is more dis-
 tinctive and characteristic than  the appearance ef the counte-
nance.   From this source the diagnosis and prognosis of Fevers
 equally flow,  and it cannot,  therefore, be  too strongly recom- 
46        THE MORBID  APPEARANCES

mended to the attention of the clinical student and young prac-
titioner.
  75. The same remark may be extended to some of the Erup-
tive Fevers, in which there is, exclusively of the rash, a charac-
teristic modification of the features.
  76. In  Rubeola the eye-lids are frequently red and swollen,
and  the  eyes  injected, before the appearance of the rash, and
there is usually catarrhal affection; the rash begins in spots on
the face ;  and there are sneezing, intolerance of light, &c.
  77. In  Scarlatina the rash becomes more general and less
interrupted, and  it is  accompanied with more general tumidity
and fulness; there is frequently an appearance of fulness about
the throat, and the voice is affected;  but the  symptoms  of
catarrh are usually absent.
  78. I now proceed to notice some morbid appearances, chiefly
of the complexion, which appear to  me not  to  have  obtained
hitherto the degree of attention which they deserve.
  79. The appearances to which I allude occur in the very va-
ried forms of disorder of the digestion, or Dyspepsia, of which 1
have treated in another work, the especial object of which was
accurately to trace their distinctive characters, as seen in the
countenance, the tongue, the hand, &c.
  80. The most severe or Acute form of this affection is accom-
panied with some paleness and  sallowness, and a dark  hue
about the  eye ; the cutaneous vessels exude a little oily perspira-
tion ;  the prolabia are slightly pale and livid ; the muscles of the
face, and especially of the chin and lips, are affected with a de-
gree of tremor, particularly on any hurry or surprise, or on speak-
ing.   With this state of the countenance there are conjoined
peculiar morbid states of the tongue, and of the hands,  which
will be described in their proper place.
  81. A state  of sallowness of complexion, unaccompanied with
the appearances  just described; usually attends the more Chro-
nic form of this affection, denominated Dyspepsia.
  82. The next variety of this morbid affection is  that which is
usually denominated Chlorosis, of which I have described three
stages.  The incipient stage is denoted by paleness of the com- 
OP THE  COUNTENANCE.
47
plexion, an exanguious  state of the prolabia, a slight appear-
ance of tumidity of the countenance in general, and of puffiness
of the eye-lids, especially the upper one.  There is sometimes
superadded a tinge of green, or yellow, or of lead-color, and fre-
quently darkness of the  eye-lids.  In the confirmed stage the
countenance is still more pallid, the prolabia and the gums ex-
anguious, or  the  prolabia, and especially the upper one, have a
slight  lilac hue, and the integuments in general are puffy and
tumid.   In the inveterate stage these appearances are gradual-
ly modified by the supervention of emaciation, or oedema.   With
each of these stages is associated a peculiar state of the tongue
and general surface.  These appearances in the different stages
of Chlorosis seem  to depend partly on the state of the cutaneous
capillary vessels,  and partly on  the state of the blood itself;  at
least, this fluid has become, in some instances, so serous as scarce-
ly to tinge the linen as it has dropped from the nose.
   83. In the more  chronic form of this  morbid affection, to
 which the epithet decolor is very applicable, there is a state of
 sallowness, of yellowish or icterode hue, of darkness or of lead-
 color, of a squalid or sordid  paleness of  complexion, or a ring ©f
 darkness occupying the  eye-lids, and extending a little, perhaps,
 towards the temples and cheeks, and sometimes encircling the
 mouth.   There is, in this form of the affection,little or no tumi-
 dity,  pallidness of the prolabia, or tendency to oedema; and the
 tunica albuginea of the eye is free from the tinge of icterus.
 This morbid state of the complexion appears,  indeed, to depend
 principally on the condition of the cutaneous surface of the
 countenance.  The tongue is apt to be affected chiefly  in the
form of its surface only, in a peculiar manner, to be described
 hereafter ; and the general  surface of the body is apt  to be more
 or less affected in the same manner as that  of the countenance.
    84.  From this icterode  appearance of the complexion it  is
 important to distinguish the different shades of Icterus itself:
  in this disease the tunica albuginea are tinged proportionately to
  the general surface; and it is in this manner that these two mor-
  bid affections are discriminated.   The term Icterus is merely
 expressive of a symptom of disease, although it is daily named, 
  48        THE  MORBIDAPPEARANCES

  and has long been arranged as  a distinct disease.  The  shade
  varies from yellow to green or blackish.  But the  most impor-
  tant and only practical distinction with regard to Icterus, is that
  of its causes, or of the primary disease ; the principal of these
  are—1. constipation, or  loaded  bowels ; 2. acute  diso' der
  ofthe digestive functions ; 3.  diseases of the liver ; 4. gall-
 stones ; 5. hydatids  in the gall-ducts; 6. organic tumors
 in the abdomen,  situated near  the  biliary  ducts;  7. the
 pregnant uterus; 8. diseases  of the right  kidney; 9.  or
 even of the right lung, or cavity of the pleura.
   85. Besides the morbid affections of  the complexion already
 mentioned, there are others consisting  in different  shades of li-
 vidity, and depending principally on a languid circulation,  on
 a defective arterialization, or on a  venous fulness of the  blood.
   86. In some  cases of Acute Dyspepsia,  § 81, there is  a  re-
 markable  tendency  to  a livid hue  of  the  prolabia, nose, and
 cheeks, as well as of the hands, accompanied with coldness and
 apparently dependent on languor in  the cutaneous circulation.
   87. A similar state of lividity, but frequently much greater  in
 degree, is observed in cases of Tuberculous Disease of the Me-
 sentery, attended with great tendency to coldness and  great
 sensibility to external cold.
   88. A degree of lividity in the prolabia is frequently, though
 not universally, observed in Phthisis Pulmonalis.   This ap-
 pearance seems to depend on the part and on the extent of the
 pulmonary structure involved in the tuberculous disease, and on
 a defective  arterialization, as well as a languid cutaneous circu-
 lation of the blood.
   89.  Besides the  diseases  attended with lividity of the coun-
 tenance already mentioned, this appearance occurs for  the most
 part together with  tumidity, in cases in which  the brain, the
lungs, and  the heart, are severally  oppressed, in Apoplexy, in
 Pneumonia, and in some diseases of the principal  organ of the
circulation.  The appearances in these diseases will be noticed
immediately.
   90. In the attack of Apoplexy there is usually,  at first, gene-
ral tumidity, flushing  and lividity  of   the countenance;  the 
OP THE COUNTENANCE.
49
pupils are contracted, then dilated and often unequal; the features
frequently lose their symmetry, those of one side of the face be-
ing unusually acute, while those of the other are relaxed ;  and
the whole countenance is drawn, or the expression lost in coma.
At a subsequent period, the countenance becomes  pale, fallen,
cold, and often  variously distorted.   Heberden observes, "  apo-
plectici, qui prope absunt a morte, in spirando ambas buccas in
flare solent; " and indeed the oppressed state of  the respiration
always adds a characteristic appearance to the countenance : the
pupils are dilated, perhaps unequal, or irregular in form ; the eye
dull and flaccid ; the jaw frequently  falls, the saliva flows, the
lips are pale, and the mouth is foul.  A similar state of the coun-
tenance to that last described sometimes exists  from the begin-
ning in cases of what has been termed the  serous  and nervous
forms o f apoplexy.
  91. Paralysis is a usual concomitant or consequence of Apo-
plexy. The effects of cerebral Paralysis on the countenance are
very various : the muscles of one side of the face fall into a state
of relaxation, whilst those of the  opposite side are  unusually
contracted from want of power  in  their antagonists ; the  fore-
head is often unequally affected by wrinkles, the eye-brow of one
side falls down, the eye-lids do  not open or close so readily as
usual, or the eyes are not converged on the same object;  one
nostril, one angle of the mouth, and one cheek  fall, whilst the
others are unusually drawn, especially on speaking ;  the tongue
is frequently protruded awry, and with difficulty ; the articula-
tion is indistinct, and some  particular  letters, especially the labi-
als, as borp, cannot be pronounced.   Deglutition is also some-
times affected, and there is a danger  of choaking ;  frequently
mastication is impeded by the collection of the bolus of food into
one side of the mouth ;  sometimes the saliva flows out of that
angle of the  mouth which is now become the lower one.  There
is frequently a difficulty in shaving, from the torpor of the skin,
and  the loss of power in the muscles which in  health put it
upon the stretch.
   92. The countenance in Epileptic Coma has sometimes the
deep suffusion observed in apoplexy, but it preserves its symme- 
 50       THE  MORBID  APPEARANCES

 try ; the lip or tongue is liable to be bitten  and wounded,  and
 there is then frequently a bloody foam in the mouth, a point of
 great importance in the diagnosis.
   93.  The countenance in Deep Intoxication is at first bloated
 and suffused, then pallid and sunk ; the muscular power  is  de-
 fective, the  expression lost, the articulation indistinct, and the
 saliva  flows from the mouth ;  the sensibility is impaired or lost;
 the breath tainted with the intoxicating liquor.
   94.  Hysteric Stupor is distinguished by the absence of the
 suffusion, distortion, and loss of character, observed in apoplexy.
   95.  Syncope is characterized by pallor, coldness, cold  perspi-
 ration, pale lividity, shrinking, and collapse of the  integuments
 and features,—appearances which  do but concur in the com-
 mencement of any other morbid affection.
   96.  In Inflammation of the Brain there is at first an  ex-
 pression of pain or uneasiness manifested usually by  knitting of
 the eye-brows,—with delirium or coma ; afterwards the  pupils,
 from being contracted, become  dilated; there are  strabismus,
 grinding of the teeth, spasms or distortions of  the muscles of
 the face, &c. with profound coma, and without the appearances
 observed in idiopathic fever.
   97.  In Pleuritis the degree of the pain is marked by a pro-
portionate contraction of the features  in general, and by acute-
ness and elevation of the alae nasi;  the nostrils are  moved  and
dilated by the  alternate acts  of the respiration ; there is some-
times a  degree  of vivid  flushing,  terminating abruptly  and
bounded by whiteness towards the nose ; the heat is inconsider-
able, and there is  frequently perspiration.
   98.  In Pneumonia there is  less contraction of the features,
but there is greater appearance of dyspnoea, very important to
be observed in this disease, and the nostrils are widely dilated be-
fore each inspiration ; there is little heat, but frequently a  de-
gree of perspiration.
   99.  In Inflammation of the Chest with  clogged Bronchia
or Air-cells, there is  usually a general and deep suffusion of the
countenance, sometimes amounting to great lividity, conjoined
with turgidity ; there is great anxiety and  dyspnoea,  the nos- 
OF THE  COUNTENANCE.
51
 nils are widely dilated  on inspiration, and drawn in above the
 lobes ;  during inspiration the pomum adami, and even the  chin,
 are sometimes drawn downwards; the surface is cool and some-
 times damp.
   100.  The dawn  of Phthisis Pulmonalis is  marked by a
 delicate  and  often  waxy  paleness, alternated with  transient
 gentle flushing, slight lividity of the  prolabia on exposure to
 cold, an appearance of indisposition, frequently motion of the
 nostrils from the respiration, and frequently a quivering of the
 chin and lips on speaking.   Its progress is denoted chiefly by
 gradual emaciation, in addition to an  aggravated state of the
 other morbid appearances just mentioned.
   10L In Hemoptysis there  is usually a florid state of the
 complexion, and frequently the effects  of dyspnoea are observed
 in an acuteness and movement of the nostrils.   If the heemor-
 rhagy has been  very  great, there  may be paleness, lividity,
 coldness, and a clammy perspiration, with great anxiety.
   102. In Hematemesis,  on the contrary, the complexion is
 generally pale and sallow, and  frequently affected as  described
 4§ 81—84 ; there is less anxiety and  an absence of the move-
 ments of the nostrils.
   103. In Organic Diseases of the Heart the expression and
 complexion are frequently much  affected.*  In those cases in
 which  the pulmonary  circulation is  not impeded, the com-
 plexion simply becomes unusually vivid and florid.  But when
 the nature of the disease affords an obstacle to the  freedom of
 the pulmonary circulation, this  vivid color  passes into a  livid
or violet color, especially in the prolabia, cheeks and nose ;(')
  * M. Corvisart observes, ''la figure, la physionomie, le fades propria enfin,
sont, pour le practicien exerce, le guide le plus sur, a mon avis, pour arriver au
diagnostic d'un assez grand nombre de maladies tant aigues que chroniques;
mais c'est sur-tout dans les cas de maladies du coeur qu'il importe de considerer
attentivement ce signe, qui, je  le repete,  peut seul, dans bien des cas, les faire
reconnaitre."—Essai sur les Maladies du Coeur, ed. 2d, p. 371.
  (1.) This change of color will be found on examination to be dependent in part
upon the dilatation of the cutaneous veins. A condition, however, not peculiar
to organic disease of the heart,  but found, also, in those chronic diseases of the 
52         THE MORBID APPEARANCES
and there is superadded more or less of turgidity, and frequently
of coldness.   There is great anxiety  on mental emotion and
bodily exertion, with an increase of the appearances just enume-
rated, and the  head,  the  ends of the  patient's cravat, &c, are
frequently moved by the violence of the beating of  the heart.
During the  progress  of the disease, these appearances  become
aggravated, the complexion is still more livid,  the turgidity of
the countenance  passes into  oedema, the eyes at length start,
and the head is often moved about, denoting great distress and
iuquietude.
   104. In the paroxysm  of true Asthma, there is the  most ur-
gent anxiety of expression, and a great and rapid movement of
the nostrils, usually without lividity;  the  breath is generally
tainted, the  tongue much affected, and there are frequent eruc-
tations.
   105. In Inflammation of the Abdomen with  severe Pain
there is a continued state of contraction of the muscles of the face,
inducing an unnatural  acuteness of the features ;  the forehead
wrinkled and the brows knit; the nostrils are acute, drawn  up-
wards, and  moved by the alternate and irregular acts of the  res-
piration ;  the wrinkles which pass from the nostrils obliquely
downwards are deeply marked; the upper  lip is  drawn up-
wards,* and the under one, perhaps, downwards, exposing the
teeth; the chin  is often  marked with dimples.  This state of
the features is aggravated on any increase of pain,  from change
of position,  muscular effort, or external pressure.   Indeed, in
cases of abdominal affection, it is better to press on the abdomen,
or beg to the patient to  raise  the head and  shoulders, and
watch the effect on the expression of the  countenance whilst
the patient's mind  is occupied with  some other subject, than to

lungs which produce obstruction in  the pulmonary circulation, particularly in
Emphysema. I would here notice an important fact.  In cases of obstruction to
the circulation from chronic disease, it is common to find  the  cutaneous veins
remarkably distinct over the seat of the obstruction; over the anterior portion
of the chest when the heart or lungs are diseased ; over the abdomen when the
 liver is affected.                                            S.
                 ♦See Laennec, ed. 1, t. i. pp. 90 ;  398. 
               OF  THE  COUNTENANCE.           53

ask  the direct  question whether  pressure induces pain,  as is
usually done ;  for patients naturally suppose that every pain-
ful part must also be tender, and are therefore apt to answer in
the  affirmative, although incorrectly.
   106. In cases  attended with Spasmodic Abdominal  Pain
the  contractions  of the muscles of the countenance  are more
violent, but less permanent; during  the paroxysms,  the distor-
tions of the countenance  take place in a  degree  scarcely ob-
served ; in  the interval, the countenance recovers a calm, unu-
sual, if not incompatible, with inflammation.  The transition of
spasmodic into inflammatory pain may often  be traced with
great  distinctness,  by carefully observing  these changes  and
modifications in the expression of the countenance.
   107. The degree,  increase, or diminution of the disease
may also be observed  and ascertained by the  concomitant in-
crease or diminution of the acuteness and contraction of the fea-
 tures.
   108. The transition of inflammation into the state of Sink-
 ing, or the supervention of Gangrene, is denoted by a fallen
 state of the features, the muscles becoming relaxed, the surface
 cold, with  cold  perspiration,  shrinking, and pale lividity, the
 cheeks sunk, the malse prominent, the nostrils, &c. affected by
 a labored respiration.
   109. The appearance of the countenance affords a valuable
 source of distinction between the Chronic Dyspepsia and In-
 sidious  Organic  Disease.  In the former, the appearances
 are as described  §§ 80,-84; in the latter, there is a characteris-
 tic,  early, and progressive loss of flesh, with paleness, perhaps
 slight flushing, but without sallowness, the bony and muscular
 parts  become  exposed, the integuments are drawn into  deep
 wrinkles, and  there is often coldness and perhaps lividity.
    110. Such  a state of the countenance, with  an expression of
 pain, uneasiness, or anxiety, often leads to the detection of  slow
 and Insidious  Pleuritis or Peritonitis, as well as of other
 diseases which would long remain hidden, from being unattend-
 ed  with acute pain. 
54         THE  MORBID  APPEARANCES
    111. Scirrhus and. Cancer we apt to induce  sallowness (')
 and emaciation—a circumstance  by which they  are sometimes
 distinguishable from other tumors or ulcers.
    112. Polysarcia is distinguished from Anasarca in the face
 by observing that  in the former  the  tumor is deposited with  a
 certain regularity, so that in general the symmetry of the  coun-
 tenance is not destroyed, nor the features much disfigured.
   113. In Anasarca, on the contrary, an inelastic tumor is dis-
 persed unequally over the face,  the  features are obscured,  the
 symmetry of the countenance is  destroyed, the expression lost,
 and the person is scarcely recognised; the posture of the patient
 during sleep influences the  distribution of the swelling, and often
 occasions  one  side of the face to be  more affected than  the
 other ; but the  eye-lids, the lips, and  the cheeks, and in general
 the parts of loosest cellular texture, are most distended.
   114. In general it may be observed that the brow is  contract-
 ed by pain within the head, the nostrils are drawn acutely up-
 wards  by pain of the chest, and the upper lip  is raised and
 stretched over the gums or teeth in painful  affections of the ab-
 domen.
   115.  Alternate  dilatations and contractions  of the nostrils
 arise from any  effort in respiration, and are observed in great
 debility, in the  synochus and typhus fever,  in acute inflamma-
 tions of the  chest  or abdomen, in organic  disease within the
 thorax, &c.
   116. Extreme pallor of the prolabia is observed in excessive
 haemorrhagy, purpura,  chlorosis, &c; deep lividity denotes a
defective  arterialization of the  blood, and occurs  in disease of
the heart, &c.; pale lividity occurs  in cases in  which the cir-
culation at the surface is languid and imperfect.
   117.  One of  the most  important  points  embraced  in the
  (1.) M". Louis, a great authority on the subject of diagnosis, attaches much
importance to the straw color of the complexion, jaunepaille, in the diagnosis of
Cancer. But in the cases I have collected this symptom was frequently absent.
I have also noticed it in a marked degree, in other organic diseases attended by
repeated haemorrhage, as in fibrous tumors of the uterus-               s. 
OF THE  COUNTENANCE.
55
 symptoms of diseases, and one particularly observed in the coun-
 tenance, is the circumstance of emaciation.   It may be said to
 be the surest index to the detection of those diseases which are
 characterized at  once by their insidious character and serious
 and dangerous tendency.
   118. It may be observed, in conclusion, that to  notice every
 morbid appearance of the countenance would be almost impossi-
 ble, and even useless.  The  object of such  an attempt as the
 present, is rather to lead to observation;  the remarks which
 have been made are  sufficient, I trust, to point out  the impor-
 tance of the inquiry.  Many of the morbid  appearances of the
 countenance, like the  morbid states of  the pulse, respiration, &c.
 are, after all, to be observed and felt, and scarcely admit of des-
 cription.
   119. My object has therefore  been  to select a few instances
of morbid affections particularly distinguished  by the state of
 the countenance, in order to invite the attention of the medical
student more particularly to  a source of judgment and informa-
tion applicable also to those fainter shades of diversity  and
change, the perception of which so much distinguishes the  phy-
sician of observation from the mere practitioner.
   120. Sufficient  has been done, however, to  prove that the
countenance, in its various morbid conditions, affords character-
istics of many diseases, and denotes, in a remarkable degree, the
state, course, increase, or decline of nearly all.  The prognosis
is greatly prompted by the condition of the countenance, as  may
still be learnt from the writings of Hippocrates and Celsus. 
CHAPTER  II.
     ON THE MORBID CONDITIONS OF  THE ATTITUDE.

   121. I  employ the term attitude in a rather  comprehensive
sense, intending to embrace, under this head, the consideration
of the postures and motions of the body, the state of muscu-
lar debility, poiver, contraction, and  motion, some particu-
lar actions, and the general manner of the patient.
   122. In general, the supine position, and tremulous motions
of the body, denote muscular  debility,* and distinguish, in an
early stage, the acute  forms of Idiopathic from Symptomatic
Fever.
   123. Augmented power and action of the muscular system
with quick  and forcible changes of position,  denote a state of
delirium, of spasmodic pain, of internal suffering, or of inquie-
tude.
   124. Certain positions adopted  and retained with  caution,
and restrained  movements of the body, are the usual  effects of
inflammatory pain:  other fixed positions  depend on the state of
the respiration,  and of the circulation through the heart.
   125. Certain movements of  the head,  certain actions of  the
hand,  and certain peculiarities of the general manner, also occur
as characteristic of particular diseases, and will be noticed here-
after.
   126. The morbid states  of the attitude will  appear more dis-
tinctly  marked, by  being  contrasted with the more usual and
natural positions of the body.

  ■ I restrict, in this place, the application of the term debility by the epithet
muscular, because  it is now well known  that this species of weakness is fre-
quently the  effect of oppression and the associate of increased vascular action •
just as a throbbing pulse may accompany the state of exhaustion. 
        THE  MORBID  CONDITIONS,   ETC.     57

   127.  In healthy and undisturbed sleep, the usual posture is
that on one side, the body being frequently inclined rather to the
prone than to the supine position ; the head and shoulders are
generally somewhat  raised, and, together  with the thorax, bent
gently forward; the  thighs and legs are  in  a state of easy
flexion.   The position is apt to be changed from time to time,
the person lying on one or other side alternately.
   128.  I now proceed to notice the different morbid states of
the attitude:—
   129.  In Acute Synochus, one of the earliest  and most char-
acteristic symptoms is a deep sense of debility, with tremor, and
an incapability of supporting the erect position ; this  posture, if
assumed, induces also the feelings of vertigo and faintness.
   130.  In Acute Inflammation there is  comparatively little or
no tremor or  muscular debility, or tendency to vertigo or faint-
ness ; the patient  is  capable of moving, and even of walking,
even in a late stage of the disease.
   131.  In Protracted Synochus there is, in some cases, for a
considerable time, a  supine position, with scarcely the ability to
change or support the  position on the side; there  is  tremor,
consisting of less rapid but more  considerable movements  than
those observed in the  acute form;  the  knees  are  apt to be
raised.
   132.  In the milder form of  Typhus Fever the patient some-
times gets up or continues  out of bed, but  appears feeble and
trembling, and  as if incapable of such  a degree of exertion,
whilst he draws near the fire from  susceptibility to cold.   In
cases in which, however,  the patient  cannot get out of bed,  he
experiences vertigo,  and perhaps faintness, on being requested
to sit up in bed for a minute or two.
   133.  In the  severe forms of Typhus  Fever the position of
the patient becomes gradually more and  more supine, and the
actions more and more tremulous : from being able to retain
 the posture on the side, perhaps, the patient falls upon his back,
with  the lower extremities  extended, and  sometimes  with a
tendency to sink towards the bottom of the bed ;  the hands and
arms are moved with effort  and tremor, and at length there is
                             8 
58           THE  MORBID  CONDITIONS
constant subsultus  tendinum.   To this state,  picking of the
bed-clothes, or of flocci  volitantes, delirium, or  coma, is super-
added.
   134.  Hippocrates* and Celsust  have accurately described the
posture of Fever.   Celsus observes, " ubi vero febris aliquem oc-
cupavit, scire licet non periclitari si in latus aut dextrum aut sin-
istrum, ut  ipsi visum est, cubat, cruribus paulum reductis; qui
fere sani quoque jacentis  habitus  est; si facile convertitur, &c.
Contra gravis morbi periculum  est, ubi supinus seger jacet, por-
rectis manibus et  cruribus," "ubi  deorsum  ad pedes subinde de-
labitur ; ubi brachia et crura nudat et inaequaliter dispergit."
   135. As this position is occasioned  by extreme debility, any
change of posture is of favorable  omen,  as denoting a return  of
strength.   The patient perhaps  raises  the  knees,  or puts the
arms out of bed, or places them above his head.   These move-
ments are amongst the first symptoms of recovery.   At length
the patient is capable of  supporting the position  on the side—a
certain mark of returning muscular strength, and an indication
of a favorable change in  the disease.!
   136. Tremor  is  amongst the first  and most characteristic
symptoms of Continued  Fevers; but it occurs also in some
 other morbid affections, united with less muscular debility.
   137. It forms so  remarkable a symptom in  the Delirium
 Tremens, as to  have been adopted  as part of  its designation.
In one instance the tremor had preceded  the delirium several
days, and I  was enabled to predict the  occurrence of delirium :
  * Upoyvcea-riKov.               f Lib. ii, cap. 3, 4,6.
  X There are two points in the treatment of Typhus Fever, connected with
the attitude, of the utmost importance :—sometimes the supine  position is re-
tained so long, that ulceration takes place on the compressed parts, especially
about the sacrum or pelvis.  Dr. Arnott's very  ingenious  proposal of the hy-
drostatic bed seems admirably adapted to obviate this calamity.  The second
point is cautiously to guard against the effects of muscular exertion during the
period of convalescence.  I know, by experience, that by far the greater num-
ber of relapses are occasioned by early and undue exertion and fatigue: the ef-
fect is speedy, or gradual, sinking of the powers; the inference is obvious and
of the utmost consequence. 
OF  THE  ATTITUDE.
59
 in  another case, the effect  of drinking, the  affection consisted
 in great tremor, and, being cut short, delirium never occurred.—
 It is scarcely necessary to advert to the more constant  state of
 tremor observed in hard drinkers.
   138. Tremor on holding  out the hand, in writing, in carry-
 ing a  cup to  the  mouth, in walking, and in  articulation, is a
 usual symptom of Acute Dyspepsia; it is generally conjoined
 with an appearance of nervousness and of susceptibility to hurry
 and agitation.
   139. Tremor is far less and later observed in cases  of local
 inflammation or organic disease;  it does, however, occur  in
 Phthisis  Pulmonalis, and in  cases  in which the  general
 strength suffers.
   140. The form of  tremor  which I have described seems to
 depend on muscular debility, and perhaps on a morbid condition
 of the brain and nervous system.   There is a kind of tremor of
 a more spasmodic character, which occurs from various causes,
 and which I shall notice towards the conclusion of the present
 chapter.
   141.  The effect of particular postures is of importance to be
 noticed as distinctive of Affections of the Head.  In  the idio-
 pathic  affections, as in  the  state of threatening  of apoplexy,
 vertigo  and other  morbid feelings are apt to be experienced  on
stooping: in the symptomatic affections, as in fever, acute dys-
pepsia,  intestinal irritation, exhaustion,  (fee.  vertigo  is  usually
experienced on assuming the erect position.
  142.  An attention to the posture  of the patient is also of im-
portance in the treatment: the recumbent position is as injurious
in the case of apoplexy, as it is beneficial in that of syncope.
  143.  It is scarcely necessary to point  out the effect of hemi-
plegia,  paraplegia,  or partial paralysis, on  the attitude.   In
 Hemiplegia the patient is apt to  lie or  fall more or less upon
the paralyzed side, and especially upon the paralytic arm.   In
 Paraplegia the posture in sitting is manifestly marked by the
defective muscular  power, the patient being constantly apt to
slide off the chair or sofa.  In the Partial Paralysis it is found
that the hand cannot be moved so freely or clasped so firmly, 
60         THE  MORBID  CONDITIONS
or the foot and toes are lifted  imperfectly from the ground m
walking.
   144.  The attitude is peculiar in the different forms of Inflam-
mation of the Chest.   In Pleuritis the patient usually reposes
on the affected side, which is  thus kept free from  movement.
In  Pneumonia  the  patient almost invariably assumes and
retains the posture on the back.   In those cases which are at-
tended wirh much dyspnoea, the patient is  frequently obliged
to have the head  and shoulders raised, and even to assume the
erect position.   I have observed, in some cases attended with
great dyspnoea, that the patient has lain on the side, with the
arm of the other side placed  upright before the chest, the hand
pressing forcibly  on  the bed:  in  this manner the shoulder be-
came fixed,  and  afforded a firm attachment from which the
pectoral muscles acted to expand the chest.
   145.  In Phthisis Pulmonalis the posture is various.   Fre-
quently, however, one  particular  position is chosen and  pre-
served—pain,  cough, dyspnoea, or oppression, being induced in
any other:  this is usually on the side most diseased, as that in
which pleuritic  pain  is most apt to exist, early in the disease,
or cavities, in its later stages.
   146.  In extreme Hydrothorax, the position of the patient is
frequently highly characteristic;  it  is  less so, probably, accord-
ing as the effusion has taken place more gradually and slowly.
In the  less severe form, the patient,  when in bed,  usually lies
with the head, shoulders, and chest gently raised by additional
pillows; when out of bed, he is often observed to sit up, with the
arms placed along the side, and the hands fixed  and pressing
forcibly on the chair, or sofa, on  which he sits: in  other cases
he leans a little  backwards, still  supported  by the arms  and
hands, which are placed behind the back.  This kind of posture
is often constant, or immediately resumed if any accident occa-
sions it to be changed: it  gives  rise to an elevation  of the
shoulders, from which the body  is supported,  or  as it were
suspended.  In the severer forms, the attitude varies with the
degree and progress of the disease:  at first, the patient lies with
the head and shoulders greatly raised;  afterwards the posture 
OF  THE  ATTITUDE.
61
 becomes more and more erect; at a still more advanced period,
 and in a  more aggravated form  of the disease, the  patient is
 sometimes incapable of remaining in  bed, and  is obliged to sit
 up, with the legs  hanging  down; sometimes an arm-chair is
 obtained, on each arm of which the patient presses and supports
 the hands or elbows,  thus suspending the  shoulders;  some-
 times  a second  chair is  required, on the back of which  the
 patient reposes the forehead, or both hands and  forehead, press-
 ing with considerable force, thus fixing the upper attachments
 of the sterno-mastoid muscles.
   147. This aggravated state of the  attitude is certainly most
 frequently observed in cases  of hydrothorax complicated with
 organic diseases of the heart or lungs, or  of  the liver or other
 organ situated in the abdomen.  In some cases of hydrothorax,
 in its simpler forms, the patient has retained a  nearly horizon-
 tal position;  in cases of complicated hydrothorax, he has even
 expired out of bed,  supported by his friends.
   148. In Organic Diseases of the  Heart, the attitude—at
 first the effects of bodily exertion,  and  afterwards the particular
 posture of the patient—is very characteristic.   In incipient and
 dubious cases, the  diagnosis  is assisted  by  observing the effect
 of muscular  effort, especially such  as involves much change of
 position and  general motion  of the body: let  the patient be re-
 quested to run up stairs, the symptoms are invariably produced
 in cases in which they would be  quiescent in  a  state of repose,
 or aggravated  if permanent.  In a more advanced  stage of
the disease, the sufferings of the patient become more acute  and
permanent; a certain restlessness, anxiety, and dyspnoea, aggra-
vated extremely by every muscular effort or motion, take place,
and distinguish  the case from simple  hydrothorax, in which
 muscular  motion induces  far  less inconvenience.   In a  still
more  aggravated  form of the disease, the patient requires to
be raised in bed more and more, until the erect posture, or even
 a posture inclined upon the thighs, becomes necessary ; and at
length there  is an  inability  to sit erect even, while the lower
 extremities are  placed horizontally, and  the patient is obliged,
 perhaps, to sit on the side  of the  bed,  with the legs  hanging 
62         THE  MORBID   CONDITIONS
 down  and the feet on the floor; the night, as well as  day,  is
 sometimes spent sitting  up in a chair near the fire, sometimes
 with the  head  supported  on the back of a chair, and the body
 leaning considerably forwards: in this stage  of the  complaint
 there are an  inexpressible restlessness  and anxiety.   At any
 period of disease of the heart, a sudden change of posture from
 the horizontal to the erect frequently becomes necessary, from
 the aggravation  of the symptoms and general agitation induced
 by a turbulent or terrific dream; frequently too the  patient is
 obliged to  get out  of bed  and repair to the window to respire
 the open air.*
   149. In the paroxysm  of Asthma, by which  term I desig-
 nate the cases of sudden attack of dyspnoea  arising,  at first,
 from a disordered state  of the  digestive  organs, the erect posi-
 tion  is  usually  necessary; and there are great anxiety and
 urgency of suffering, frequently with active restlessness.
   150. In  Inflammation in the Abdomen with Acute  Pain,
 a certain position of the  body is chosen and retained, and all
 muscular exertion,  motion, or change of position,  is carefully
 avoided:—the patient lies on  the back with the thighs raised,
 or he is supported in a somewhat elevated  posture by means of
 pillows  placed under the head and  shoulders, or he lies on the
 side, with the thorax and the thighs in a state  of gentle flexion
 on the abdomen ; if he be desired to raise the head by muscular
 effort, an expression of aggravated  pain is  immediately visible
 in the countenance; the hands, and perhaps the bed-clothes are
 carefully removed from pressing on the abdomen ;  the arms are
 put out, and the  knees raised or depressed with great caution;
 the manner is soft, and the voice low and plaintive, with moan-
ing, and a suppressed kind of complaining.
  * It need scarcely be  observed how important an attention to the attitude
becomes, in the treatment  of diseases of the heart.  In the incipient  stage  the
patient ought to vegetate as it were, and carefully to avoid every kind of exertion
as well as of emotion: in this manner, life and a comfortable state of existence
may frequently be long insured.  In the later stages, every attention should be
paid to enable the patient to support with ease the position which affords the
greatest relief. 
OF  THE  ATTITUDE.
63
   151.  In Spasmodic Pain of the Stomach, or in Colic, the
reverse of this state of general attitude is observed :  the patient
usually  writhes to and fro, and constantly changes  his position
or mode of lying, instead of observing the  cautious stillness of
Inflammation; he often lies  on the abdomen, or in the supine
position, pressing violently on the bowels,  or even grasping a
portion of the abdominal parietes with the hands ;  or he sits in
bed, bending  forcibly  forwards on the  thighs; he cries  out
during the paroxysm of pain, and speaks  in a  loud  and irri-
tated tone of voice.  All this violence,  both  in general manner
and posture, forms a remarkable contrast with the subdued mo-
tions of Inflammation.
   152.  After the Paroxysm of pain in Colic,  the patient re-
sumes an easy position; in the absence of an  aggravation of
pain in Inflammation,  the same cautious posture and manner
are still observed as before.
   153.  The transition from Spasm or Colic into Inflammation,
may be easily traced by cautiously observing the characters of
these different affections.
   154.   The  termination  of Inflammation in   Gangrene,  or
Sinking, is marked by the fallen and supine position, and ex-
treme debility;  the  patient lies extended on the back without
the flexion  and precaution previously observed  in the stage of
Inflammation; the manner of the patient still remains soft and
plaintive.
   155.  In Strangulated  Hernia  the posture  is  at  first, per-
haps, attended with writhing, but soon becomes the same as in
Inflammation,  especially with the  precaution of  bending the
thighs on the abdomen.
   156.  In Inflammation of the Kidney the patient, when up,
often inclines somewhat to  the side  affected, and a little for-
ward, especially in walking; and, in  a painful  state of the af-
fection, he walks with unusual precaution.
   157. In Inflammation of the Bladder the patient frequent-
ly bends forwards on the pelvis, evidently with the view of giv-
ing protection and relief to the parts contained in  it, and of using
as little as possible those muscles whose action might give pain; 
64         THE  MORBID  CONDITIONS
he walks cautiously, and often bends forward still  more, during
this action of the muscles.
  158.  Retention of Urine, as a symptom in acute diseases, is
often  denoted  by a state of  constant  elevation of  the knees,
which is inexplicable until the cause is discovered.
  159.  In  Organic Disease in general,  the  patient soon be-
comes affected with a serious, continued, and  unvaried  debility,
stoops in walking, and moves with slowness and caution.   And
deep-seated  pain or  uneasiness is often experienced from the
succussion induced by  sitting down or making a false step in
walking, especially when there is a state of tenderness from in-
flammation.
  160.  In the appearance of the Hand it  is often easy to read
a state of pain, anxiety, or other suffering  :—it is closed or ex-
panded, or variously moved.  I do not, however, deem it neces-
sary to  enter into any detail respecting points  so  perfectly ob-
vious.
  161.  There  is another symptom of importance to be noticed
—viz: the state of jactitation and inquietude; it occurs in dif-
ferent states of  the system and in some diseases, but principally
in cases of irritation,  exhaustion,  and sinking,  and in  Dis-
eases of the Heart*   I reserve the consideration of these sub-
jects for a subsequent  part of this work.
  162.  Besides the morbid states of the general attitude already
described, there are some other more partial affections, chiefly of
muscular action, which deserve to be noticed ;  these are princi-
pally  spasmodic tremor, paralysis,  and contraction.   And
there are some  more general  affections of a similar kind consti-
tuting convulsion and rigidity. It may be sufficient to enu-
merate the principal cases of these morbid  affections, observing
that the subject still presents ample  scope for resumed inquiry.
  163.  Spasmodic tremor occurs in a remarkable  degree in the
 * In all cases of this kind, as well as in the Erethismus Mercurialis, sudden death
sometimes occurs from suddenly assuming the erect position, or from other mus-
■cular effort or exertion.
■cular effort or exertion 
OF  THE  ATTITUDE.
65
Shaking  Palsy*  in Chorea, as an  effect of the Poison of
Mercury,} of drinking Spirits, fyc.
   164. Paralysis, the usual consequence of disease of the brain,
the spinal marrow, or the nerves, is observed as an effect of the
Poison of Lead, of exposure to cold, &c.
   165. Contraction, of the hand for instance, is a rather remote
effect  of Paralysis, Epilepsy,  Chorea, Hysteria, of the va-
rious  morbid affections termed Fits, &c. and  is usually observ-
ed on one side of the body only.
   166. A  singular  state of contraction of  the hand  occurs in
children, and is described by Dr. Kellie,*
   167. General Convulsion occurs in cases of Diseases of the
Brain, especially of the parts about its base,  Epilepsy, Puer-
peral, Convulsion,  Hysteria, Hooping Cough, &c.   The ef-
fect of convulsive action on the circulation within the head has
not hitherto been sufficiently attended  to by physicians.  Hys-
teric convulsion assumes, from long and frequent repetition, an
epileptic character;  epileptic convulsion often induces  an apo-
plectic coma ; and pertussis, from the violence of coughing, fre-
quently leads  to fits, and even to hydrencephalus, &c.
   168. General rigidity occurs in Tetanus, a,nd in some cases
of Epilepsy  and Hysteria.
 *See Mr. Parkinson's interesting pamphleton this subject.
  fBateman's Reports of the Diseases in London, p. 192.
.J Edinburgh Medical and Surgical Journal, vol. xii, p. 448.
                     9 
CHAPTER  III.
  ON  THE MORBID APPEARANCES OF THE TONGUE,  ETC.

   169. The circumstances to be noticed in an examination of
 the morbid conditions of the Tongue, and in immediate connec-
 tion with them, are, its surface, form, papilla,  color ; its
 mode of being protruded; the teeth, gums, and internal
 parts of the cheeks ;  the taste ; the breath, fyc.
   170. The surface is  apt to  be affected with whiteness, load,
fur, dryness, blackness, chaps, fyc.
   171. The form of the tongue is frequently modified by its be-
 coming stvollen, indented, fissured, and lobulated.
   172. The papillae are,  in some cases, morbidly prominent
 and enlarged,  and in others  almost  obliterated,  leaving  a
 smooth and perhaps tender surface.
   173. The tongue is  protruded with  difficulty, from dryness,
 tremor, or paralysis, and is left protruded in cases of imperfect
 sensibility.
   174. The internal mouth,  the breath, and the taste, are apt
 to be affected, conjointly with the tongue, especially  when the
 latter is swollen and indented.
   175. In the Acute Synochus, the  tongue is usually extreme-
 ly white and loaded, with much thirst,  an impaired  taste, and
 sometimes a tainted breath, but usually without dryness.
   176. In Acute Inflammation  the tongue is not necessarily
 much  affected ; in some cases it has preserved nearly its natu-
ral state: it is,  however, frequently whitish  or furred;  it is fre-
quently moist, and free from indentation, unless it be modified
by the conjunction of a disordered state of the alimentary canal.
  177. In the Protracted Synochus,  the  tongue  is  at  first
white and perhaps loaded; afterwards it is apt to become clean. 
          MORBID  APPEARANCES,  ETC.        67

red, and dry, and sometimes unnaturally smooth, and perhaps
tender; the  teeth become a little affected with mucous sordes.
   178. In  Chronic Inflammation the tongue, mouth,  taste,
and breath, are frequently unaffected : in the latter stages, there
are  frequently  apthee  and  soreness  of the tongue, internal
mouth, and fauces.
   179. In the  milder  form of  Typhus Fever the  tongue is
white and rather loaded, with a tendency to dryness : it  is ge-
nerally protruded with tremor.
   180. In the severer  forms of  Typhus Fever the tongue be-
comes dry, parched, and tender,  and dark brown or black; it is
often protruded  with great difficulty, from its  state of dryness
and of tremor; the internal mouth is also dry and foul; the teeth
are affected with brown mucous  sordes; the breath has a pecu-
liar  odor.   The state of dryness is increased during sleep, the
mouth being then usually open.   It is important to remark whe-
ther, with a given state of the tongue, the tendency is to an
augmentation or diminution of its morbid character.
   181. In Intermittent Fevers the condition of the tongue va-
ries  greatly  in the different  stages and in the interval.   In the
cold sta^e it becomes dryish and clammy ; in the hot stage the
tendency to dryness is still greater ; in the sweating stage and
in the interval  the tongue approaches more to  its natural state,
 remaining only  whitish and rather loaded.
   132. It may be justly remarked that the tongue affords one of
the best diagnostics of the different kinds and degrees of idiopa-
thic fevers,  of idiopathic from symptomatic fevers,  and of their
complications.   And its changes and tendencies  denote, in a par-
 ticular manner,  those of the fever itself.
   183. Scarlatina is frequently distinguished from Rubeola by
 numerous, elongated, florid  pipillse, which portrude through the
  white load.
   184. In  Varioia, pustules sometimes appear on the  tongue
 and in the  internal mouth.   The occurrence of salivation,  and
 of tumefaction  of the countenance, followed by swelling  of the
 hands and feet, is familiar to all.
   185. I now  propose  to  give a description  of those morbid 
68         THE MORBID APPEARANCES

states of the tongue which occur in the varied forms of the Dys-
pepsia :
  186. The most ordinary effect of an occasional or accidental
derangement in the stomach and bowels, is a loaded state of the
tongue, the superior surface of this organ becoming covered with
a layer of  whitish, soft, mucous  substance, admitting of being
partially  removed by  the  tongue-scraper;   the  whole internal
mouth is, at the  same time, more or less disagreeable and clam-
my, the taste depraved, and the breath offensive; and frequent-
ly the substance  of the tongue is a little swollen, cedematous,
and marked by its pressure against the contiguous teeth.
  187. In the Acute  Dyspepsia noticed above, §80, the state
of the tongue already described is  observed, with  some modifi-
cations : the tongue is in general loaded, the mouth clammy, the
taste bitter or nauseous, the  breath foetid, whilst the surface  of
the face  is  frequently  oily.   In some severe cases, the load has
been very thick, and  has eventually pealed  off, leaving the
tongue red, smooth, and tender:  the substance of the tongue is
generally swollen, cedematous, and impressed by the contiguous
teeth: the gums are often red, tumid, and  somewhat separated
from the teeth by tartar, and are easily made to bleed ;  the  in-
side of the cheeks, also, frequently partakes of  the oedema, and
receives,  like the tongue,  impressions from  the adjacent teeth;
sometimes the cheeks  and the gums of the posterior part of the
mouth have been so swollen as to portrude a little over the teeth,
and are either ulcerated by the pressure, or wounded by being
bitten—circumstances which are apt to be induced or aggravat-
ed by cold.   Through the load on the tongue the red papilla are
frequently seen,  either over its whole surface or at its point prin-
cipally ;  frequently the tongue is not only indented, but formed
into creases or folds ; sometimes deeper and more numerous sulei
are formed, the edges of which are sharp, and the sides in con-
tact, requiring to be separated by the two fingers, or by protrud-
ing the tongue further; in some cases the tongue is less loaded
and indented, and its edges are red  and even.
   188. In cases  of the Acute Dyspepsia, I have seen the tongue
affected with deep, foul ulcers, resulting from the slow suppura- 
               OF  THE  TONGUE,  ETC.            69

tion of hardnesses about the size of a horse bean or nut, situated
just under the surface of the tongue, which is loaded, swollen,
and foul, with a copious flow of saliva, and a foetid breath.
   189.  In Chronic Dyspepsia the tongue is sometimes affected
in  a  slighter degree, in the manner just described, being some-
what tumid, indented, and sulcated ; it is in general, however,
less pasty and cedematous ; it is frequently covered with a sort
of viscid mucus; sometimes it is slightly white,  from numerous
minute white points crowded over its surface; it is also frequently
affected, with fur, consisting of short fibres resembling those of
coarse velvet, and admitting of being separated  by the  finger.
In this affection  the tongue is frequently rather dry ; and I have
seen it, in several instances, sulcated longitudinally.
   190. In  very protracted cases, the tongue assumes several
remarkable modifications of form and surface.   In the first case
there is a universal enlargement of the papilla over its surface,
which is now generally clean ;  in two instances the papillae at
the most posterior part of the tongue became particularly enlarg-
ed, causing pain on swallowing, and some alarm to the patients  ;
in the second modification the surface of the tongue is formed into
lobules, sometimes  deeply  intersected  and resembling in form
those of the base of the cerebellum, at other times, of less regular
form, and,  lastly, assuming the  form of squares; in the third
variety the tongue acquires an absolute and morbid smoothness
of surface, which appears as if glazed, and is tense and unyield-
ing.  In all these cases the tongue is morbidly clean—the mouth,
taste, and breath  being nearly natural—and its color, although
perhaps rather paler, frequently little changed; the complexion
is usually rather pale and sallow, but the surface of the face is
free from oiliness, and the integuments from tumidity.
   191. The condition of the tongue in Chlorosis is very char-
acteristic : in the beginning,  the tongue becomes rather pallid
and tumid,  and  has frequently enlarged papillae over its surface;
it is somewhat loaded,  indented, and  sulcated ;  the gums and
prolabia  are pallid,  and the breath is somewhat tainted.  At a
more advanced period, the tongue  becomes cleaner,  smoother,
still more exanguious, and acquiring a peculiar semi-transpa- 
70        THE  MORBID  APPEARANCES

rency, and a very pale lilac hue; it remains a little swollen and
indented, but the papillae disappear and give place to a morbid
smoothness; the complexion, prolabia, gums, and  tongue are
alike exanguious, and perhaps a little tumid ; the breath is still
less tainted,  and even acquires an odor of new milk ; and the
mouth becomes less clammy and disagreeable.
  192. It has already been observed that a particular state of
the tongue accompanies a particular condition of the complexion
and general surface, and that, by observing the latter,  the state
of the former  may frequently  be anticipated:  the loaded and
swollen tongue is usually  associated with an oily and  swarthy
state of the surface and complexion ; the pale, tumid, and clean
tongue, in Chlorosis, is accompanied by a tendency to tumidity
of the integuments in general and oedema of the ankles ;  and
the  clean, papulated,  lobulated,  fissured, or morbidly  smooth
tongue is united with a nearly natural state of the general sur-
face.  The morbid secretions of the mucous membrane of the
tongue and internal mouth are thus connected with a morbid
secretion of the skin ; the  exanguious and tumid  state of the
tongue, with a similar condition of the integuments,  both appa-
rently originating in the same state of the capillary circulation ;
the  nearly clean tongue accompanies the icterode complexion
without tumidity or extreme pallor; and  the morbidly clean
tongue is  attended with little change of the complexion  and
general surface.
  193. The appearance of the tongue in these cases denotes, in
a particular  manner, their duration :—the  mere load is often
soon induced and soon removed ; a swollen tongue has required
a longer time  for its formation, and demands  a  longer use of
remedies;  the  state of tongue  in  Chlorosis,  §191, are of still
slower formation and removal; and those described  §  190, are
often the effect of years of disorder, and  are probably never
totally remedied.  By  an  accurate knowledge of the different
morbid states  of the tongue and of their concomitant morbid
affections,  the physician is  frequently enabled to  speak to his
patients in a manner which excites their surprise, by indicating 
OF  THK  TONGUE,  ETC.           71
his distinct  and accurate  information respecting their diseases,
especially in respect to the history and symptoms.
   194.  In true Asthma the tongue has, at first, the appear-
ances observed in the Acute Dyspepsia.
   195.  In long-continued cases,  both of disorders and of dis-
eases, it is not unusual  for  Aptha to occur,  and  they are
occasionally seen  in acute  affections.  The tongue, inside of
the cheeks,  posterior  part of  the mouth,  and the fauces, are
covered with  white, minute, tender vesicles, which are apt to
be recurrent, soon assume the form of white exfoliations, and
leave the subjacent parts smooth,  red, sore, and  tender.  Some-
times the oesophagus,  stomach, and alimentary canal appear
affected, and obstinate sickness and  diarrhoea occur, with a sense
of burning.   The affections in which apthae are most apt to
occur, are protracted cases of the more  serious  forms of  Dys-
pepsia, Phthisis, Mesenteric Disease, and  Chronic Pleu-
ritis or Peritonitis.
   196.  As an effect of cold, and especially in conjunction with
disorder of the digestive organs, there is frequently an eruption
of one, two, four, or more Aptha, or small circular  ulcers, of
from one to three or four  lines in diameter, on the inside of the
lip or cheek, on the point or near the  root of the  tongue,  &c;
there is great  tenderness,  and  a minute slough, surrounded by
an  inflammatory  border;  the state of tenderness  continues
several days,  and the whole course  of this affection, like the one
about to be mentioned, occupies from six to ten days.
   197. With or  without the last-noticed  affection,  and from
similar causes,  there is frequently an eruption of Herpes, or
of a cluster of small vesicles, occupying some part of  the  prola-
bium or the angle of the  mouth.   It generally denotes that the
patient has taken cold.
   198. There is a chronic affection of the Prolabium and im-
mediately adjoining skin, which I  have not seen described:—
it consists of a repeated dry, splitting, and exfoliation of the cutis
of these parts, and occupies a ring, of about one-fourth  of an
inch across, all round  the mouth; it  varies in severity at differ-
ent times  and  in  different  cases; it is long continued, and 
72    THE  MORBID  APPEARANCES.  ETC.

appears to result from a protracted state of disorder of digestion;
it occurs chiefly in early youth.
  199.  Fur, with a tendency to dryness of the tongue, usually
denotes great local irritation,—such as violent inflammation,—
from  an accident,—of a joint,  &c.  This appearance is  also
common in cases of intestinal irritation.  It occurs in some forms
of the Dyspepsia, especially the chronic and cachectic.  The
state  of fur of the tongue appears to arise from very different
causes from that of load; its indications are therefore very dif-
ferent too ; it is also in general more difficult of removal.
  200.  In Diseases of the Heart with  great lividity of the
prolabium  and  countenance, the tongue  and internal mouth
frequently participate in  the general discoloration.
  201.  There are sometimes great peculiarities in the odor  of
the breath.  I have mentioned the fetid odor observed  in
Acute Dyspepsia, and in some very protracted cases of Chlo-
rosis; I have observed an odor of the breath resembling that of
new milk; in some morbid affections of the Lungs, the breath
has an extremely offensive taint;  and  there is occasionally in
some  diseases, and I may particularize Dysentery, a cadaver-
ous odor, affording a most unfavorable prognosis.
  202.  An attention to the odor of the breath is of great use in
detecting the case of intoxication,—and even of some cases of
poisoning.
  203.  The mode  of protruding and of withdrawing the
tongue, is often worthy of notice.   I  have already named the
tremor of idiopathic as  distinguished  from symptomatic fever.
In cases of stupor from  fever, or from disease of the brain, the
tongue  is  sometimes protruded imperfectly, and not  immedi-
atelv,—and sometimes it is left out until the patient is told in a
loud voice to draw it again within the mouth.
  204.  In cases of Paralysis the tongue is often protruded  to
one side, and frequently the saliva flows from the angle of the
mouth.
  205.  The tongue is frequently severely bitten during the  fit
of Epilepsy. 
CHAPTER  IV.
 ON THE MORBID CONDITIONS OF THE GENERAL SURFACE.

   206.  The objects comprised in this chapter are the tempera-
ture, the state of dryness or moisture, of tumidity or shrink-
ing, or of roughness or smoothness of  the skin, the color,
the occurrence of emaciation, or of edema or anasarca, and
the condition of the hands and feet.
   207.  The temperature of the general  surface and of the
hands  and  feet is greatly  modified by  febrile, functional, and
organic affections, and has been found, in some affections of the
heart, to form a striking contrast with that of the internal mouth
or of the rectum.*
   208.  The state of heat, tumidity,  dryness, and  roughness,
seems to characterize the idiopathic fevers and  to  distinguish
them from the symptomatic, in which an opposite state of the
surface  is more usual.
   209.  The color is  modified by the condition of the cutane-
ous circulation,  of the blood itself, and of the cuticular surface.
   210.  It is of  the utmost moment to remark the occurrence of
emaciation or of oedema,  as important sources of the diagnosis
of functional and organic morbid affections.
   211.  The condition of the Hands and Feet, and the appear-
ance of the Nails especially, vary with  the state of the  blood,
and of the circulation, of which they afford  a  sort  of index, and,
in some protracted cases, with that of the cuticular and cutane-
ous surface.
   212.  The Acute  Synochus is characterized  by  a tumid,
smooth, soft, and dry state of the surface, with a sense of glow-
* Farre's Essay on Malformations of the Heart, p. 32, et seqq.
                      10 
74
THE  MORBID  CONDITIONS
ing heat and  a florid  color: this state is apt, however, to be
modified by the occurrence of rigor, or of perspiration.
   213. In Acute Inflammation the surface is, on the contrary,
frequently nearly natural, of moderate heat,  and  inclined to
perspiration.
   214. Profuse perspirations have been particularly observed in
the acute fever symptomatic of Rheumatism,, Inflammation
of the Mamma, and in some affections of the Kidney.
   215. In the Protracted Synochus the  surface gradually
becomes dry, rough, and  harsh,  the cellular  substance shrinks,
the skin communicates a sense of acrid heat, and the cuticle i3
often  in a state of exfoliation,  and sometimes  raised on the neck
and breast, into miliary vesicles.( )
   216. In Chronic  Symptomatic Fever there is usually an
absence of this state of the surface, copious perspirations being
opposed to the  constant dryness, and a natural warmth or even
coldness to the acrid  heat; the perspirations are apt to be pecu-
liarly profuse in the last or early morning sleep; the coldness,
often joined  with lividity, is sometimes constant, at  other times
the consequence of the least exposure to cold.
   217. The  chronic symptomatic fever  is,  however, much
modified by the nature of the primary disease : in  Tubercu-
lous Phthisis there is often  the alternation from chilliness to
hectic heat and perspiration during sleep  ; in  Strumous Dis-
ease of the Mesentery there are greater chilliness and sensibility
to cold, and cold lividity, with early morning perspirations; and
in organic Disease of the Liver  there  is  frequently little or
none  of these symptoms.
   218. In Typhus Fever the state of the general surface is
various, and  usually less  distinctly characterized than  in  the
  (1.)  A very important diagnostic symptom of continued Fever is the ap-
pearance of rose  colored lenticular spots over the abdomen and  anterior
portion of the thorax.  These spots are sometimes so  numerous as to attract
attention, at other times, only a few are noticed  after a careful  examination.
They commonly appear during the second week of the disease, sometimes
earlier.  They may be  easily distinguished from the bites of insects by their
wanting a central point.                                       g. 
           OF  THE  GENERAL  SURFACE.        75

morbid affections already mentioned.  In the milder form the
temperature is moderately augmented, especially in the young
or plethoric;  but there is rarely great heat or dryness.  In the
severer form the surface is sometimes a little parched  and the
cheek flushed ;  sometimes cool and  affected  with clammy per-
spiration ;  sometimes there is an eruption of miliaria with a dry
skin; and sometimes there are petechia.   In the state of sink-
ing a  cold  and  clammy perspiration affects the nose, cheeks,
hands,  and general surface.   In the  fever  described by Dr.
Currie, "the temperature  rose, in one case,  to 105° Faht.; but
was in general from 101° to 103°, and towards the latter end of
the disease scarcely  above that of health."*  Dr.  Bateman ob-
serves,  "the heat seldom exceeded 99° or 100°."r
   219. The three stages of Intermittent Fevers are highly
characterized by the state of the general surface: in  the cold
stage there is great shrinking, and the skm becomes pale, cold,
and rough,  and in the state  termed cutis anserina,  and the
temperature has been  observed as low as 74°; in the hot stage
the  integuments become  tumid, and injected, and the skin is
hot  and  dry, and the temperature has sometimes been as high
as 105°;  in the last  stage  the tumidity, heat, and  injection
cease and yield  to a general perspiration.
   220. It is in the Scarlatina  Anghiisa  that  the greatest

   * Medical Reports, vol. i. p. Jl.  Dr. -Currie observes, with regard to cok-
tinued fever, that " one exarerbaiion, and one remission in the twenty-four hours
seem generally observable.  The exacerbation usually occurs  in the afternoon
or evening, the remission towards morning.   These exacerbations are marked
by increased flushing, thirst, and restlessness. If the heat of the patient be, at
such times, taken by the thermometer, it will be found to have risen one or two
degrees in the central parts of the body above the average heat of ihe fever, and
still more on the extremities."—Dr. Currie adds, "the safest and most advan-
tageous  lime for using the aspersion or affusion of cold water, is when  the
exacerbation or fever is at its height, or immediately after  its declination is
begun;  and this has led me almost always to direct it to be employed from six
to nine in the evening;  but it may be safely used at any time of the day, when
there, is no sense of chilliness present, when the heat of the surface is steadily above
what is natural, and when there is no general or profuse sensible perspiration.—These
particulars are of the utmost importance."
   f On Contagious Fever, p.  36. 
76         THE  MORBID  CONDITIONS

degree of tumidity, injection, and temperature is observed ; the
rash is continuous and imparts a deep red hue, and the surface
in general is turgid, hot, smooth, soft, and dry—a state which
is succeeded, on the decline of the fever, by dryness, roughness,
and exfoliation.   There is much diversity in the  degree  of
these appearances, as in that of the fever itself;  but in  severe
cases the heat and tumidity are greater than in any other febrile
affection of this climate; the thermometer applied to the surface
of the body rises to 105°  and 106° even in mild cases, and in
the more violent  cases  to  1083,  109°,  110°, and even 112°—
the  greatest heat  ever observed  in  the human  body  by Dr.
Currie.*
   221.   In the  Scarlatina  Maligna  there  is  frequently an
entire absence of tumidity, injection, and heat  of the  surface;
sometimes there are shrinking, cold moisture, and  a pale or livid
rash.  It is of the greatest importance to attend to the state of
the surface, in a curative as well as a diagnostic point of view.t
   222.  After the decline of the tumidity and rash of Scarlatina,
an anasarcous swelling of some  parts of the  surface  is occa-
sionally  observed;  it usually affects the  extremities  and face;
and sometimes the sole of the foot has been  raised into one
entire blister.
   223.  In Rubeola there  is comparatively little  tumidity, in-
jection, and  increased temperature of the general surface; the
face,  and especially the eyes  and  eye-lids are,  however, often
  * Medical Reports, vol. ii, p. 46.
  t Dr. Currie observes, " before I conclude the subject of Scarlatina, I must
again enforce the superior advantage of using the affusion early in this disease;
and the propriety of ascertaining that the skin is dry, and the heat of the patient
greater than natural, in all cases, especially in such as are advanced, and where,
of course, the strength is considerably impaired.  It has come to my knowledge,
that in two cases of Scarlatina, of the most malignant nature, the patients have
been taken out of bed, under the low delirium, with the skin cool and moist, and
the pulse scarcely perceptible. In this state, supported by the attendants, several
gallons of perfectly cold water were madly poured over them, on the supposed
authority of this work!  I need scarcely add, that the effects were almost im-
mediately fatal."—Vol. ii, p. 76. 
          OF  THE  GENERAL  SURFACE.       77

considerably tumid;  the heat of the skin is in this disease, and
in the Influenza,  from  99° to 101° and 102°.*
   224.  In the  Variola Discreta except  in  its  mildest forms,
there are considerable general tumidity and  heat, frequently a
warm perspiration, a full state of the pustules, and a soft condi-
tion of the intervening portions of skin.
   225.  In the  Variola Confluens the surface  is shrunk and
flaccid, the temperature little or not at all  augmented,  and the
skin is frequently  affected with  a clammy perspiration, whilst
the pustules are flat and flaccid,  participating apparently in the
state of the cutaneous circulation.
   226.  In the  course of Variola, and usually about the eighth
day, there is frequently a state  of tumefaction of the  face and
eye-lids, with a flow of saliva ; this state recedes, and about the
eleventh day the tumefaction affects the hands and feet.
   227.  In the  morbid affections already  noticed,  the tempera-
ture of the surface is,  for the  most part, augmented.  There are
some diseases, however, in which there is  a tendency to dimin-
ished temperature and frequently great sensibility to cold.
   228.  There  is  a certain degree of this tendency in Acute
Dyspepsia,  § 86, and  perspiration  is  excited by the  slightest
hurry or fatigue.
   229.  In some cases of Protracted Dyspepsia, the nose is
livid and  cold, and the feet habitually cold.   The case  is distin-
guished from that  to be next noticed by the absence of frequency
of pulse, and of progressive emaciation.
   230.  But the case  in which this peculiarity is most  observed
is the Tuberculous  Disease of the Mesentery.  In this dis-
ease the patient is highly sensitive to external cold,  and to the
least draught of air, and, in  cold weather especially, constantly
draws near  or hangs over the  fire,  sometimes until the hands
and legs assume a brown  color from the influence of  its  heat.
With this sensibility to cold, there is also frequently a  great
tendency to early morning  perspirations, which appear to  be
* Medical Reports, vol. ii, p. 78. 
78         THE  MORBID   CONDITIONS

induced by sleep, and to be in part avoided by keeping awake,
which is often done purposely.
   231. A slighter degree of chilliness is observed in Phthisis
Pulmonalis, and in  other organic  diseases, together with a
greater or less tendency to perspiration.
   232. Decided shivering  occurs in  the commencement  of
febrile and inflammatory diseases in general; (')  in the begin-
ning of each  paroxysm in Intermittents.   This symptom also
occurs in cases of Intestinal Irritation, and in a more marked
degree than in Inflammation.  It is an attendant upon suppu-
ration ;  and then, being repeated, frequently excites  the idea of
Intermittent.
   233.  There is no point of deeper interest, in a practical point
of view, than that of the loss or return of flesh.  The continued
loss of flesh adds, in obscure cases, to the fear of organic disease ;
whereas the least return of  flesh determines the question favor-
ably. (2)
   234.  In Acute Dyspepsia it is highly interesting to watch
the gradual return of flesh under judicious treatment.
   235.  In Tuberculous Disease, on the other hand, there is
a daily loss of flesh, however slow.
   236.  In Hepatic Disease, the case is favorable or unfavorable,
according as the patient continues to lose or begins to regain
flesh.
   237.  In doubtful cases,  the patient's weight may  be regis-
tered, and the result will frequently be contemplated with anxious
feelings.
   238.  In the  study of all, but  especially of chronic diseases,
there  is, indeed, no  point of greater importance  than that of
  (1.) M. Chomel considers a chill at the  commencement of inflammation as
dependent, to a certain extent, on the exposure of the patient at the time of the
attack.  Being, for example, more rare if the patient is attacked while in bed.
                                                          S.
  (2.) The truth of the general fact, that progressive emaciation is a most valu-
able indication of organic disease is not to be questioned.   But, at the same time,
it is important to remember that, in cases where the local disease is checked for
a time in its progress, the patient may regain a portion of his lost flesh.    S. 
          OF  THE  GENERAL  SURFACE.         79

 Emaciation.   Much might certainly be learned by a constant
 attention to this subject.
   239. The degree of emaciation which takes place in patients,
 depends in part on the nature of the disease, and in part on the
 nature and office of the organ affected.
   240. Emaciation is more observed, in a given space of time,
 in Fevers than in Inflammations.
   241. Loss of flesh takes place in the Acute Dyspepsia, but
 is scarcely observed in the Chronic forms of that disorder—a
 circumstance  by which they are therefore distinguishable, from
 Insidious Organic Diseases or Protracted Inflammations.
   212. Emaciation is the usual  effect of  Tuberculous and
 Scirrhous affections of any organ ; it is less early observed in
 some other diseases, as in the encephalosis,* &c.
   213. Emaciation  is little observed  in  diseases  of the  Head,
 Heart, and even the Lungs, compared with  those of the Me-
 senteric  Glands,  the  Stomach,  and Bowels,  the  Liver, the
 Pancreas, &c.
   244. In Diseased  Mesentery  the emaciation  and loss  of
 strength are nearly, if not absolutely,  although very slowly,
 progressive.   In Disease of the Liter there may be, for some
 time, even for years, a degree of recovery ;  and  weakness and
 loss  of flesh, and even icterus and anasarca occasionally disap-
 pear.
   245. There are some highly interesting remarks on this sub-
ject,  in Dr. Pemberlon's interesting work on the Diseases of the
Abdominal Viscera.t  He observes  that, in the organic diseases
of the Liver, the Pancreas; the Mesenteric Glands, the Stomach,
the Small Intestines, and the Spleen, as il glands of supply,"
there is considerable emaciation ; whereas in the  diseases of the
Kidneys, of the Breast,  and of the  Large Intestines, which are
uglan Is of ivxsle," the loss of flesh is less, and less rapid.
  246.  Next to emaciation, as  a consequence  of disease, it  is
Laennec de l'Auscultation, t. ii, p. 62.   t Chapter vi. 
 80         THE  MORBID  CONDITIONS

 important to remark the occurrence of (Edema, or of its aggra-
 vated form of Anasarca.
   247.  The principal causes of this affection are Organic Dis-
 ease  of the Heart, or Lungs,  Enlargement of the Liver,
 Phthisis Pulmonalis, Organic  Tumors in the Abdomen,
 Pregnancy, &c.
   248.  Anasarca is frequently observed  in the late stages of
 Chlorosis.  It is often,  indeed, an effect of debility merely, and
 occurs, consequently, in the last stages of  chronic diseases in
 general,—from want of nourishment,—and in old age,—and
 as an effect of profuse  haemorrhagy or purging.  Anasarca  is
 also occasionally the effect of long exposure to cold and wet.
   249.  The causes of anasarca sometimes induce other kinds of
 dropsy,  as Hydrothorax, Ascites, &c. which are, indeed,  like
 anasarca itself, far more frequently effects of diseases, than pri-
 mary diseases themselves.  It is important  to trace the succes-
 sion of  links in this chain of causes and  effects;  but it is to be
 observed that  these morbid states come at  length to constitute
 diseases in themselves, and produce, in their turn, their peculiar
 effects and symptoms.
   250.  The appearances of the general surface  in cases of
 Cachexia  are peculiar;  but  they do not  appear to require
 description in this place.
   251.  There is a singular morbid affection of the surface, which
has not, I think,  been noticed by any practical writer:  the face,
 and some parts of the surface of the body, become suddenly
 and remarkably puffed and swollen ; this affection appears
 to be occasioned by the presence of some indigestible substance
in the stomach, and generally yields to the operation of an emetic
and purge.
   252.  I now  proceed to notice some morbid states observed
chiefly in the Hands and Feet,  although partly too over  the
general  surface.  The nails, like the  prolabia,  § 63, afford an
opportunity of observing the state of the  blood; the hand, in
 general, often denotes, by the condition of its surface, the degree
 of force or feebleness of the circulation, at least in the capillary 
OF THE  GENERAL  SURFACE.        81
 vessels, and by its steady or tremulous movements, the strength)
 or weakness of the muscular system.
   253.  Continued Fevers and Inflammations in general, are
 distinctly characterized by the  morbid affection of the surface,
 and by the state of tremor, so generally observed in the former,
 and so little, comparatively, in the latter.
   254.  In the Acute Synochus there is generally considerable
 tremor and burning heat; in Acute Inflammation these affec-
 tions are usually absent.
   255.  In the Slow Synochus the hand is still more tremulous,
 and its surface  becomes dry,  parched, and exfoliating;  in.
 Chronic Inflammations the surface is generally totally differ-
 ent, and there is only the tremor of weakness.
   256. In Typhus Fever the  tremor  frequently assumes the
 aggravated character of subsultus tendinum.  It is scarcely neces-
 sary to make any allusion to the circumstance  of the picking
 of the bed-clothes, flocci volitantes, &c.
   257. There is one morbid affection in which tremor  is so
 characteristic  as to have been  chosen for its  denomination,—
 the Delirium Tremens.  From the occurrence of this symptom
 in a remarkable degree, I was enabled, in one case, to  foretell
 that delirium would follow.
   258. In Acute Dyspepsia, a degree of tremor is observed on
 desiring the patient to extend  the hand  and arm ;  the surface
of the  hand is apt to be cold and clammy, and the  nails to
assume a lilac hue,, and their tips to  become white and  opaque.
These  appearances are, in some instances, very long continued,
and they are always very characteristic.
  259.  In Chlorosis, the hands, fingers, and  nails,  become
characteristically pale and  exanguious;—the skin is frequently
opaque and  puffy, and  usually dry;—there is a tendency to
cedema, and, at length, to anasarca.
  260. In very protracted cases of  Dyspepsia,  the skin be-
comes gradually dry, branny, and sallow, or  brownish, and the
nails become brittle, break  off in lamellae—so that the  patient
is  incapable of taking a pin out of her dress,—and sink in
                          11 
 82     THE  MORBID  CONDITIONS,  ETC.

 irregularly in their middle part.   This state  of the nails is by
 no means unfrequent.
   261. In common Dyspepsia even, the  hands and  feet are
 apt to be cold.
   262. In Organic Diseases of the Heart, the hands, like the
 nose and cheeks, frequently become deeply livid and very cold,
 —whilst the  heat within the rectum and  under  the tongue is
 sometimes even higher than natural;*  in  young subjects  the
 finger-ends become expanded, especially laterally.
   263. The finger-ends are swollen, and perhaps affected with
 a sense of tingling, especially in young subjects, in some cases
 of Organic Disease of the Liver, and sometimes in Tuber-
 cular  Phthisis Pulmonalis; and in the latter disease they
 become adunque.
   264. In Inflammation of the Bowels, and in Cholera, and
 Dysentery, there is a characteristic tendency to a cold, clammy,
 and livid state of the surface of the hands,  and feet, and of
 the nose, whilst the pulse is frequent and small.
  265. I have already mentioned the tendency to coldness and
 lividity of the extremities in  Tuberculous Disease of the Me-
 sentery;  sometimes the skin is burnt until it becomes brown
 from the patient's sitting near the fire.
  266. There is  a loss of temperature  in  cases of Paralysis,
 sometimes with lividity and shrinking.
  267. In the action of the hand and fingers we may frequently
observe the expression of pain, of anxiety, or of suffering;—but
this subject properly belongs to a subsequent chapter.
* See Dr. Fane's Essay on Malformations of the Heart, pp. 32—34. 
CHAPTER V.
  ON SOME MORBID  CONDITIONS OF THE GENERAL SYSTEM.

    268.  Before  I  proceed  to notice the symptoms of disease
  referrible to the functions of the Encephalon, and of the Viscera
  of the Thorax, and  Abdomen, I wish to call the attention of the
  reader to some morbid affections of the system at large.
    269.  In the first place,  I shall just refer to  those  various
 morbid  states of the general system denominated Fever.  But
 I shall principally, though briefly, notice some other conditions
 of the system, which have not  hitherto obtained  the degree of
 attention they demand, and which may be denominated the
 states of Irritation, of Exhaustion, of Erethismus, and  of
 Sinking.
   270. All these morbid states are  characterized by affecting
 many or all of the organs and functions of the  body at once ;
 although one particular organ frequently  suffers much more
 than the rest.
   271. Continued Fever is particularly distinguished from In-
flammation by the  characteristic just mentioned,  § 270.  The
 contrast has already  been drawn between the states of the coun-
 tenance,  of  the attitude—including the muscular system,—of
 the tongue, and of the general  surface, in these different affec-
 tions ; and differences not less marked will  be observed in the
 functions of the encephalon, and of the organs of the thorax
 and abdomen.
   272. A similar remark also applies to the dissimilar but char-
 acteristic  effects of local Irritation and Inflammation on the
 general system.  These effects, although in general sufficiently
distinct, are frequently confounded.  How often have I known
that symptom stated  as evidence of the existence of inflamma- 
84         SOME  MORBID  CONDITIONS
tory action, which, in fact, was  connected  with irritation, and
with nothing so remotely as inflammation!
  273.  It is, perhaps, of still  greater moment to observe that
some affections of the system in general, resembling, and often
mistaken  for, local inflammation  and effects symptomatic of
inflammation, are, in fact, effects of Exhaustion !   The mis-
take,  in both these cases, is full  of danger;  the investigation of
the diagnosis is therefore of the utmost importance.
  271.  It is also a remarkable circumstance, as I shall observe
hereafter,  that the phenomena and  effects of Exhaustion are
extremely similar to those of Erethismus, and  especially of
the Erethismus  Mercurialis.
  275.  Lastly, there is a state of constitutional affection which
may be termed the state of Sinking, which occurs in various
diseases, and is characterized frequently  by inducing false ap-
pearances of amendment, dissolving as it  were the series of
morbid actions, and, in a certain sense, curing the disease;  but
subsequently leading to sudden,  or at least early, dissolution.
  276.  Ishall now proceed to sketch the principal phenomena
observed in these stales of the constitution.  It would require
too great a space  to enter into their detail;  and it  is unneces-
sary,  because I  have attempted this, in some measure, in the
second volume of this work.
  277.  The principal sources  of  Irritation to which I shall
allude here, are, the presence of indigestible substances in the
stomach,  and especially Intestinal  Disorder or Load.   The
effects of these sources of  irritation are either gradual or sud-
den.  The gradual effects are, those observed in the Dyspep-
sia, in Chloros's, &c.   It is the  more sudden effects of intestinal
irritation to which I wish to direct the attention in this place.
  278.  The more sudden effects of Intestinal Load  and Irri-
tation are, acute  pain of the head, of the side, of the loins, of
the iliac region, or of some other part of  the abdomen ; attacks
of vertigo, of dyspnoea, of palpitation,  fainting or feeling of
dissolution, of vomiting, and of hickup; there are often anxiety
and  distress; and  there are severe rigors, followed by great
febrile heat, jactitation, and flushing.  The attack is apt to be 
X)F  THE  "GENERAL  SYSTEM.        85
■mistaken for a disease  of [the  organ principally affected, and
bleeding is injuriously prescribed when enemata and purgative
medicines are the only remedies.  The effects of intestinal irri-
tation are  particularly apt to occur after any exertion or agita-
tion,  after the pain  and  fatigue of delivery—and especially
when this cause is conjoined with any cause of exhaustion, as
^misapplied or undue  bloodletting, haemorrhagy, or  purging,__
and in the course of diseases;  and I am persuaded that their
influence in these circumstances is still only half apprehended.
   279.  The principal sources of  Exhaustion are  undue blood-
letting,  and  uterine  hsemorrhagy, especially when  they occur
with intestinal irritation,—hypercatharsis, and diarrhoea.  The
effects of exhaustion may be referred to the head, heart, the vis-
cera of the thorax and of the abdomen, and the muscular sys-
tem.   The symptoms which affect the head are—severe pain;
beating and throbbing; rushing, or cracking noises ;  vertigo, or
turning round of the room; especially on raising the  head, or
assuming the erect position; intolerance of light, and of sound;
wakefulness; starting  during  sleep; awaking  hurried and
alarmed, with faintness, palpitation, feeling of sinking, of im-
pending dissolution, &c;  being overcome by noise, disturbance,
•or thinking even; and delirium.  The heart is,  in  different
cases, affected with palpitation,  fluttering, irregular  and feeble
action; there are beating  and throbbing of the carotids, and
sometimes  even of the abdominal aorta; a  frequent bounding,
and sometimes irregular pulse; faintishness or fainting, urgent
demand for the smelling-bottle, fresh air, fanning, bathing of the
temples; feeling of impending dissolution ; incapability of bear-
ing the erect position, and sometimes early fainting from the use
of the lancet.   The  respiration is affected in different cases,
with panting, hurry, sighing, great  heaving, gasping, blowing,
moaning, catching, &c. and, as has been stated, with  urgent de-
jxiand for fresh air.   There is sometimes a sense of  great and
alarming oppression  about the chest.  There is in some cases,
an Irritative Cough,—in violent fits,—or in the  form of con-
tinual hacking ; this cough appears to originate in the larynx
or trachea.   The stomach is liable to become affected with irri- 
86         SOME  MORBID  CONDITIONS
 tability,  sickness,  retching, vomiting,  hickup,  and eructation;
 the bowels with constipation, or diarrhoea, pain, flatus, disten-
 sion, &c.  There are very frequently urgent restlessness, tossing
 about, and jactitation.   In some cases, various  Spasmodic Af-
fections have occurred.  We have often to combat the effects
 of exhaustion in  the puerperal state, and in cases in which
 blood-letting has been  improperly employed for diseases not in-
 flammatory, or too lavishly in cases of inflammation.
   280. There is an extraordinary similarity, as I have already
 observed, between the  effects of exhaustion, as just noticed, and
 the symptoms of the disease termed Erethismus Mercurialis,
 so well  described  by  Mr.  J.  Pearson,*  and so painfully ex-
 perienced, and so  amply and accurately detailed, by the late Dr.
 Bateman.t  The descriptions of these authors do not, however,
 enumerate the affections of the head; otherwise they would be
 almost identical with that of exhaustion just given : disturbed
 sleep, hurried wakings, palpitation, languor, fainting, feeling of
 impending dissolution, want of air,  fits of coughing,  and of
 retching, &c. occur in  both of these morbid states, and sudden
 and unexpected death from muscular effort has alike termina-
 ted the patient's sufferings.
  281. The morbid effects of digitalis, and of some other vege-
 table remedies, are also not  dissimilar from those of Exhaustion
 and Erethismus.
  282. The  constitutional symptoms in  some cases of  local
 disease, as in the Phagedenic and Sloughing Ulcers, appear
also to partake of the characters of Erethismus.
  283. The state of Sinking occurs  under very different cir-
cumstances, and  accordingly  presents  very dissimilar  pheno-
mena.  It occurs sometimes as a gradual and simple feebleness of
the brain, decline and  cessation of the functions of circulation,
and of respiration,  as  in cases of dissolution in very advanced
age: at other times it takes place with the  more active symp-
 * Observations on Lues Venerea, 2d. ed. chap. xiL
f The Medico-Chirurgical Transactions, vol. ix, p. 220. 
OF  THE GENERAL  SYSTEM.        87
toms of inquietude and jactitation, catching respiration, hickup,
&c.: sometimes  it has the remarkable effect  of  dissolving the
chain  of morbid actions and sensations constituting  the disease
under which the patient has labored, and  of presenting  to
his  friends, and perhaps  to his unwary physician, the appear-
ance of amendment, when life is soon to terminate in an unex-
pected dissolution : lastly, the  appearances of sinking quickly
follow the accession of gangrene.
   284. The gradual decline of the powers and functions of the
heart and of the  respiration scarcely  requires  any description:
there are dozing, and insensibility to  external impressions; the
breathing becomes irregular ; there is a collection of phlegm in
the trachea or larynx, with cough, rattling, and hoarseness; the
powers of the bladder are often impaired, with retention of
urine; the pulse becomes small and feeble, and the extremities,
and the  nose and  cheeks, cold.
   285. In the second form of sinking, § 283, there are constant
restlessness, with throwing about  of the arms, and throwing off
of the bed-clothes, delirium or  incoherency of mind, catching,
sighing,  or gasping breathing; a frequent, small, and perhaps
intermittent  pulse;  hickup; an  indescribable feeling of ap-
proaching dissolution;  a constant necessity for the windows to
be opened, and for the fan, and sal  volatile, &c.; the counte-
nance  becomes pallid and sunk, and, with the extremities, cold,
clammy, and perhaps livid—especially the prolabia.
  286. In the third case, § 383, the pain and symptoms of the
disease often cease, and the patient has even got up or enjoyed
sleep, and yet dissolution has been at  hand,—the pulse perhaps
suddenly becoming very frequent and  the extremities cold, pale,
livid, and clammy.  This phenomenon is,  I think, most  fre-
quently observed in cases of Inflammation  and other Dis-
eases of the  Intestines, as I had remarked long ago.*  It also
occurs  in  other states of the  disease;—delirium, cough, and
  * See the former edition of the Diagnosis, Part I, p. 47.  See also Dr. Aber-
crorabie's paper in the Ed. Journal, vol. ivi, p. 22—185. 
88        SOME  MORBID  CONDITIONS

pain have ceased,  and suppression of urine ha* yielded, under
the influence of the state of sinking.
   287.  That extraordinary man, Mr. J. Hunter, had: accurately-
observed the state of sinking,  and has described it under the
term  dissolution.*  " The first symptoms," he observes, "are
those of the stomach, which produce shivering:  vomiting imme-
diately follows, if not an  immediate  attendant;  there is great
oppression  and anxiety, the persons conceiving they must die.
There is a small quick pulse, with every sign of dissolution in
the countenance:  as it arises with  the  symptoms of death, its
termination is pretty quick."   " I have seen dying people whose
pulse was full and strong as usual on the day previous to their
death, but it has  sunk almost at once, and then become ex-
tremely quick, with a thrill: on such occasions  it shall  rise
again, making a strong effort, and, after a short  time, a mois-
ture shall probably come on the skin, which shall in  this state
of pulse be warm;  but, upon the sinking of the pulse, shall be-
come cold  and clammy: breathing shall  become very imper-
fect, almost like short catchings, and the person shall soon die."
" It would appear in many cases, that disease has produced such
weakness at last as to destroy itself: we  shall  even see the
symptoms, or consequences of  disease, get well before death."
Sir Henry  Halford has also noticed this subject in a late paper
published in the Transactions of the  College of Physicians,! and
has applied it to the Prognosis of diseases.
   288.  The symptoms of sinking in cases.of Gangrene are fa-
miliar to every observer.
   289.  From the preceding  observations  it  will  appear; that
there is a similarity in the symptoms attending intestinal irritat-
tion, exhaustion from loss of blood,  the erethismus mercurialise
the morbific effects ©f digitalis and  other poisonous vegetables^,
sinking,  and  dissolution, which is  really remarkable.   It is  a
question of great importance  how far the  existence of one of
these states tends to  the superinduction of another :—the effects
* Hunter on Inflammation, Part II, chap, ir, sect..3.     f VoLvi, Art. 15. 
OF THE  GENERAL  SYSTEM.         89
  of exhaustion are certainly very apt to supervene in cases of in-
  testinal irritation, and are far less liable to occur, from the same
  application of its causes, during the existence of internal inflam-
  mation ;  a given degree of intestinal irritation, on  the other
  hand, produces  unusual effects in cases  of exhaustion.  I do
  not know whether the same relation exists between irritation or
  exhaustion, and the erethismus of mercury or of digitalis.
    290. The symptoms of Irritation  or of Exhaustion are not
  only particularly apt to supervene when the cause of the other
  state respectively co-exists,  but it appears to  me that the causes
  of one state are also apt to induce those of the other.   Thus
  the state  of intestinal disorder and irritation, at least,  is very
  liable to steal on in cases of exhaustion from loss of blood; and
  when it exists primarily, it is extremely apt to induce diarrhoea,
  and even some kinds of haemorrhagy, as epistaxis,—hasmateme-
  sis, and melaena,—and even uterine haemorrhagy or discharge.
   291.  When the state of Exhaustion terminates fatally, it is
 either by  sudden death, or by more or less gradually passing
 into that of Sinking.  Sudden death is  apt to occur from any
 muscular or bodily effort in a change of the position; one patient
 rose up to make water, sank down  and soon afterwards ex-
 pired.   The transition of the state of exhaustion  into  that of
 sinking, I have an opportunity of witnessing at the moment of
 writing these  lines:—great pain  of  the  head, with  beating,
 throbbing  of the  carotids,  agitation  from sudden  noises,  as
 knocks at the door, violent palpitation of the heart, with fulness
 and bounding of the pulse, alarm and hurry on awaking, &c.
 have gradually subsided  and passed into a tendency to doze
 first with snoring, then with blowing-up of the cheeks and lips,
 and moaning; slight rattling or crepitus heard in the trachea
 and bronchia during  respiration, becoming gradually augment-
 ed;—slight, catching, laryngal cough,  especially when asleep,
 gradually increasing  and becoming painful and  almost  inces-
 sant, but afterwards almost ceasing;  oppression in breathing,
 with blowing through the mouth and lips, the  nostrils  being
very acute,  and dilated  below and drawn in above the lobes;
much flatulency;—at length  the fasces are  passed at  each 
90    SOME  MORBID  CONDITIONS,  ETC.

attempt to void urine, of which there may be retention or invo-
luntary flow,  conjointly  or separately.  The  countenance is
pallid and sunk, the features acute, there is much inquietude,
sometimes jactitation, and delirium, especially on awaking, and
to employ the patient's own expression, * such a dying feeV
  292.  The subjects sketched in this chapter, I do not hesitate
to say, are of an importance  quite stupendous.   I should not,
however, have used so strong  a term, or have devoted so much
space to them, did I not consider it an imperative  duty to call
the attention of the profession to them in the most earnest man-
ner of which I am capable. 
CHAPTER  VI.
ON THE MORBID STATES OF THE FUNCTIONS OF THE BRAIN.

   293.  The  considerations  of the  morbid affections of the
functions of the Brain embraces a view of the derangements
observed in its energies in general, the sleep, the mental fa-
culties and the temper, the senses and sensations, and the
motions—voluntary, functional, and sphincter.
   294.  It is extraordinary that the energies of the brain should
.become affected in a very similar manner from the two opposite
states of undue action or fulness, and of depletion  of that
organ.   Stupor and morbid obtuseness of the nerves and senses,
an one hand, and delirium, and morbid sensibility, on the  other,
occur alike, varied only in form  and degree, in each  of these
states of the  encephalon;  and the  remark equally applies  to
the function of respiration as influenced  by these different and
opposite conditions of  the  brain; indeed, the affections of the
respiration just described as obtaining in the state of sinking
from exhaustion, 5 291, bore the most marked  resemblance to
those observed in apoplexy, the difference being chiefly observed
in the state of the countenance, general surface, and pulse, and
in the degree of the mental stupor.*
   295.  Augmented energy  of the brain, denoted  by delirium
and  augmented sensibilities,  occurs in cases of  Fever, and  of
Irritation, and in the opposite states of  this organ observed  in
Inflammation and Exhaustion.
  * A similar remark is made by Dr. Percival in relation to the opposite states
of congestion and collapse of the brain, in his interesting Essay on Typhus
Fever.  He observes, •• in truth, the state of congestion and the state of collapse,
which resemble each other both in vascular and sensorial appearance?, deserve a
fuller companion than has yet been made of their common character."—p. 69. 
92
THE  MORBID  STATES
   296. Diminished energy of the  brain, on the other hand,
 occurs in Apoplexy and in the state of Sinking from exhaus-
 tion ; in both cases there are  stupor or dozing, rattling  in the
 breathing from  defective absorption of the mucus of the bron-
 chia, oppressed and labored respiration, snoring, blowing-up of
 the cheeks and lips, defective power of the sphincters, &c.
   297.  In  regard  to  Sleep we observe, in different morbid
 affections, the opposite states of lethargy and wakefulness, the
 occurrence of frightful  dreams and hurried wakings, and
 various effects on the functions of the skin, of the heart, &c.
   298. The return of sleep must, in general, be deemed a good
 sign; but a longer sleep than usual is frequently an effect of
 exhaustion, and the patient awakes from it  < overcome ;' dozing
 and sleep again are frequently observed in the state of sinking,
 and then only give rise to a false hope of amendment.
   299.  Drowsiness  is  frequently  an antecedent sign of Apo-
plexy;  it may forebode Icterus,  and it  may arise from  a
disordered state of the stomach.   It is, in other cases, and espe-
cially in the diseases of children,  one of the  first symptoms to
awake alarm and fear of disease within the head.
   300.  Profound sleep, which has received  various names, as
somnolentia, coma,  lethargy, veternus, cataphora,  carus, &c.
according to its degree, usually denotes a state of oppression of
the brain from vascular fulness, effusion upon the membranes,
&c. and occurs as a symptom in Apoplexy and  Organic Dis-
ease of the  Brain in general;—as a complication in Typhus
and other Fevers;—as an effect of the  convulsive efforts in
Epilepsy, Puerperal Convulsion, Fits, Hysteria, the Hoop-
ing  Cough, fyc.
   301.  Heaviness  for  sleep  also  occurs, as has been stated
already, in a state of the brain  the opposite to fulness, and is
observed in  some cases of exhaustion, in the state of sinking,
and in syncope.
   302.  Wakefulness  and  restlessness occur in Mania, in
Puerperal Delirium, in the Delirium Tremens, &c. in con-
nexion  with  delirium,  as their names import;  but they also
arise, independently of delirium,  in  cases of great irritation 
     OF  THE  FUNCTIONS  OF  THE  BRAIN.   93

 or exhaustion, especially intestinal irritation  and exhaustion
 from loss of blood; the same observation applies to the Erethis-
 mus Mercurialis* which,  as I have had occasion to remark
 before, resembles, in so many particulars,  the morbid  effects of
 the causes just mentioned.
   303. But, perhaps,  the most extraordinary  phenomena be-
 longing alike to these three morbid affections, in connexion with
 sleep, are frightful dreams and hurried wakings ; these cir-
 cumstances sometimes occur in the form of incubus, sometimes
 with great palpitation of the heart and  hurry, and sometimes
 with the feeling of impending dissolution.
   304. There is  often much startling in the sleep in  cases of
 indigestion;  and children frequently start, get up in bed or even
 out of bed, or perhaps scream violently and are affected with
 fright or temporary delirium, from this cause.
   305.  Hurried wakings, with a sense of  suffocation, or of im-
 pending dissolution, also occur  in Organic Disease of the
 Heart; the patient, agitated and  alarmed, hastens to the open
 window for air.
   306.  Sleep would appear  to exercise a peculiar influence over
 the circulation: many children perspire profusely during  sleep,
 especially in  a  state of weakness; sleep often induces  flushing
 during the progress of  febrile complaints;  and in cases  of Hec-
 tic, or Tubercles, the last morning sleep, as 1 have already ob-
 served, § 230, is particularly  apt to be attended with profuse per-
 spiration, to prevent which many patients purposely keep them-
 selves awake.
   307.  The  Mental Faculties are affected in various ways,—
by delirium, stupor, imbecility, unfounded hope  or despon-
 dency,  &c.
   308.  Delirium  occurs in Fevers, in most violentaffections,
general and local; and in Inflammation,  or Disease of the
 Brain.  In the former cases, delirium is often long continued;
in the latter,  it usually earlier or later passes into stupor, as in-
+ See Dr. Bateman's case, Med. Chir. Trans, vol. ix, p. 223. 
94
THE  MORBID  STATES
creased action induces effusion.   Delirium is also observed in
some cases of Exhaustion with re-action; and, in its low and
muttering form, it occurs in the state of sinking.
  309. Not only fever, and any severe derangement of the gen-
eral health, but a violent accident, a severe operation, the occur-
rence of gangrene, &c. are generally attended with delirium.
  310. It is scarcely  necessary to allude to  the occurrence of
this symptom as a  frequent puerperal  affection, and as the ef-
fect of habits of drinking spirits.  In  the former  case it is fre-
quently an effect of the loss of blood.
  311. Stupor also occurs in Fevers, but especially in Apoplexy,
and towards the termination of all affections of the brain indu-
cing compression of that organ.
  312. Imbecility of mind, with talkativeness, or with lethargy,
is not often unfrequent in old age.  In these cases there is often
a state of chronic inflammation of the substance or of the mem-
branes of the brain.  Paralysis is apt to be  superadded to the
other symptoms.
  313. After attacks  of Apoplexy, a state of mental imbecility
often  remains, with  loss  of memory,  unmeaning  laughter,
proneness to tears, &c.
  314. The temper of the patient is singularly modified by dif-
ferent disorders and diseases.   The state of despondency in cases
of  indigestion forms a remarkable contrast with that of hopeful-
ness in phthisis pulmonalis and other serious organic diseases.
   315. Despondency on the part of the  patient may, however,
excite a  well-founded alarm in cases of great debility and in-
quietude.
   316. In cases  of serious and fatal disease, and  especially, I
think, in diseases of the intestines,  the  patient frequently ex-
presses his conviction of an approaching dissolution—" tanquam
conscia foret natura, vitam ad finem properare."
   317. The  Senses and Sensations become preternaturally
 acute or defective :—
    318.  Acuteness of hearing and of sight,  and intolerance
of  sound and of light, are  usual symptoms in the dawn of In-
flammation of the Brain, and frequently occur in Idiopathic 
     OF  THE  FUNCTIONS  OF THE  BRAIN.   95

Fevers; but they occur in the most remarkable degree as effects
of Intestinal Irritation and of Exhaustion.
  319.  The  physician is often called to cases in the following
circumstances :—Straw is spread before the door, the knocker
is tied,  the lights are screened, or the room is darkened, and
every source of noise or disturbance is carefully avoided.  The
cases in which  these precautions are  necessary are principally
those of Intestinal Irritation and Exhaustion ; but they are
also frequently necessary in the Acute Synochus, and in some
forms of Puerperal Affection; and the precautions  respecting
noise and disturbance are  sometimes  requisite in Diseases of
the Heart, not from increased susceptibility of the nervous sys-
tem, but of the action of the  heart itself.
  320.  The sense of hearing becomes defective and obtuse in
some cases of Typhus Fever ;  defective vision is a usual occur-
rence in Diseases of the Brain ; and torpor, or defective touch,
is a usual precursor or consequence of Apoplexy or Paralysis,
and occurs in some instances of Hysteria.  I need scarcely al-
 'ude to the flocci volitantes, tinnitus, the epileptic aura, &c.
   321.  Under the head of deranged Sensations may be no-
ticed pain and  vertigo.  Pain of the head  in the recumbent,
 and vertigo in the erect posture, are usual and early symptoms
 in  Typhus Fever and Acute  Synochus,—in cases of Intesti-
 nal Irritation, and of Exhaustion,—and in the Dyspepsia ;
 —and they are frequently precursory and admonitory signs of
 Apoplexy or Paralysis.
   322. Pain of the head, alone, is usually amongst the first
symptoms of Inflammation of the Brain.   Severe pain of the
head occurs in the Dyspepsia, and especially in Chlorosis ; it
 is then attended by the other symptoms cf those affections; but
 it is frequently  so severe as to lead to  the erroneous employment
 of  the lancet.
    323. I need  scarcely  advert to the frequent occurrence of
 headache and  vertigo in  Hysteria,  Hypochondriasis, Asthe-
 nia, Syncope, &c.   It is important, however, to remark, that
 they rarely occur in local or organic diseases, except those of the
 head itself. 
96         THE  MORBID  STATES,  ETC.

  324. Intermittent headache constitutes a peculiar affection,
and is removed by the arsenic.
  325. The sense of an iron finger on some part of the head, or
of an iron hoop round the head, is an effect of exhaustion from
loss of blood. 
CHAPTER  VII.
   ON  THE MORBID AFFECTIONS  OF THE  FUNCTION  OF
                       RESPIRATION.

   326.  In treating of the morbid affections of the function of
 respiration, I shall attempt a description of the different kinds of
 dyspnoea, of cough and expectoration, of the effects of full
 inspiration and expiration, of the affections of the voice
 and articulation, &c.
   327. Healthy  Respiration is performed with ease and free-
 dom, and without the aid of the auxiliary muscles, in  any of
 the  usual positions of the body.  It is effected by a nearly equal
 elevation of the ribs and depression of the diaphragm, except in
 females, in whom the thorax is observed to move more than in
 men; each side of the thorax moves also in an equal degree ; and
 inspiration and expiration occupy nearly equal spaces of time.
   328.  The kinds of Dyspnaa, and the other morbid affec-
 tions of the act of respiration, are so numerous, that it would
 be difficult to  discuss them fully.   In treating the subject, I
 shall proceed on the practical principle pointed out § 26, and
 describe the different modifications of the respiration in reference
 to particular  diseases.
  329.  In the Acute Synochus there is generally a little hurry
 in breathing, and  sometimes a degree of anxiety and of panting.
  330.  The respiration in Typhus Fever is generally anxious
 and  tremulous; when the fever is complicated  with stupor, the
respiration becomes still more affected—frequently deep and sibi-
lous, irregular and unequal, still more tremulous, and sometimes
each inspiration is begun by the diaphragm and completed  by
                            13 
98        THE MORBID  AFFECTIONS  OF

the thorax; in the other complications of this fever the respiration
is variously affected according to their seat and nature.
   331.  In Apoplexy  the respiration becomes irregular, slow,
deep, frequently suspended, and sighing, with rattling or stertor,
or blowing of the cheeks and lips, or with catching in the larynx.
M. Serres observes that, when there is Paralysis, the two sides
of the thorax are moved unequally, the muscles of the paralytic
side  having lost their power.*
   332.  I  have already noticed the similarity which  obtains
between the breathing in apoplexy and that observed in the state
of Sinking, § 294.
   333.  In other Diseases  of the Head with congestion or
compression, as Inflammation or Hydrencephalus, the breath-
ing gradually  becomes irregular  and  unequal,  with alternate
suspension and sighing"; the durationoi the interruption appears
sometimes to be commensurate with the degree of  oppression
of the brain.
   334.  In Inflammation of the Chest, with acute  Pain, the
respiration is sometimes performed exclusively by the diaphragm,
the chest or part  affected being quite motionless ; the alternate
movements of the respiration  are also short, cautious and sup-
pressed.  This peculiarity of the breathing is proportionate to,
and varies with, the degree of acuteness of the pain.
   335.  The part affected is sometimes carefully kept unmoved,
the rest of the thorax or abdomen being moved as usual.  This
is observed in ordinary respiration, still more in a deep inspira-
tion : the patient can draw a deep breath without causing pain;
but if this be done incautiously, pain  is immediately induced.
The patient is  frequently awoke from sleep by this cause : the
caution ceases, perhaps a deep sigh is drawn, and  acute pain
being induced, the patient starts and awakes.
   336.  In Inflammation within the Abdomen, with  acute
Pain, the respiration is, on the contrary, performed principally
and often exclusively, by the chest, the abdomen remaining un-
moved.  This  peculiarity of the  breathing  may  be distinctly
" Annuaire Medico-Chirurgical, 1819. 
       THE   FUNCTION  OF  RESPIRATION.    99

 observed by looking on the chest and binding the bed-clothes
 tight over the abdomen.  The  respiration has sometimes the
 appearance  of heaving of  the chest: every  movement of the
 diaphragm is cautiously avoided.   In this disease the patient is
 also frequently observed to rest, for a few seconds, on a full breath.
 The abdomen begins to move as the pain diminishes, whether
 from  a mitigation of  the disease, from sinking, or  from
 gangrene.
   337. By an attentive observation of the modifications of the
 respiration, inflammation of the pleura is distinguished  from
 inflammation of the peritonaeum covering  the  liver, &c.  The
 very part inflamed is  frequently ascertainable by a simple but
 careful inspection.   Nothing is more interesting than this exer-
 cise of the faculty of pure observation.   The thorax and abdo-
 men should be exposed and  watched.
   338. Inflammatory pain within the abdomen is, in the same
 manner, distinguished  from  spasm or colic, in which there is a
 state of breathing  altogether incompatible with inflammation
 attended with acute pain and tenderness.
   339. In Inflammation of the Lungs the respiration is char-
 acterized  by labor, and by crepitus heard on applying the ear
 to the  chest: these peculiarities are augmented as congestion
 and hepatization take place ', and when much mucus is secreted,
 bronchial rattle is superadded. (')   In chronic cases of Pleuro-
pneumonia the shoulders are elevated, the pomum adami  drawn
downwards, and the lower part of the sternum retracted towards
the spine, on each inspiration—the  abdomen being, at the mo-
ment suddenly protruded, and the upper part of the chest  raised.
  340.  In Tuberculous Phthisis Pulmonalis  an effort  is
  (1.) The difference in the movements of the thoracic parief.es, in acute Pneu-
monia and Pleuritis, is very striking.  In the former, the act of inspiration, from
the effort to admit as much air as possible, elevates the chest to a point above the
©rdinary level; while,  in the act of expiration, from the obstruction and even
distention of a certain number of the air-cells by a solid substance, the chest can-
not  contract  as much as in  health.  The respiration is accordingly high. In
acute Pleuritis, on the  contrary, the stich in the side interrupts only the free
expansion of theparietes of the thorax ;—the respiration is accordingly low. S. 
 100      THE  MORBID  AFFECTIONS  OF

early  visible  in the respiration, and its effect seen  in a move-
ment of the alee nasi; the breathing is also early observed to be
short on any muscular exertion, especially on going  up stairs; at
a late period of the disease there are generally constant labor and
shortness  of breathing,  and  sometimes attacks of suffocative
dyspnoea.
   341. On examining the chest in a recumbent position, it will
frequently be found that its motions are not free, and that respi-
ration is more than usually performed by the diaphragm.  Some-
times one side of the chest moves more than the other.
   342  In the later stages of Hydrothorax there is, in connexion
with the peculiar state  of the attitude,  § 146, a characteristic
affection of the respiration :—the acts of respiration are performed
with very unusual  degrees  of labor;  inspiration is often quick
and sudden, effected with great effort, principally or exclusively
by an elevation of the thorax, and  afterwards by a forcible con-
traction of the auxiliary muscles of respiration; in expiration
these movements are reversed, the chest appears to fall sponta-
neously and without effort; the action of the auxiliary muscles
—the sterno-mastoids, the pectorals, &c. is seen or may be felt on
applying the finger ; the head is often moved, and the chest has,
in protracted cases, the appearance  of being unusually high.
   343. A state of the respiration,  not dissimilar from that just
described,  is observed in cases of  complicated  disease in  the
thorax and in the abdomen—the latter giving origin to what may
be termed the thoracic breathing,  and to a suppression of the
action of the diaphragm.  A painful affection of the upper poi tion
of the peritonaeum would be apt to induce the state  of breathing
observed in Hydrothorax ; whilst the latter affection, by pressing
the diaphragm downwards, has often been mistaken for Disease
of the Liver*
   344. In Diseases of the Heart the dyspnoea  is generally
first experienced, and is ever  particularly aggravated by any
particular muscular exertion or mental emotion, and especially
on going up stairs :  it appears, therefore, to be particularly liable
+ See Portal's Memoires sur plusieurs Maladies. 
      THE  FUNCTION  OF  RESPIRATION.   101

to recur in  paroxysms, and  it is thus distinguished, in some
degree, from  the dyspnoea of hydrothorax, which increases pro-
gressively perhaps, but more uniformly and slowly.
   345.  Besides the kinds of dyspnoea already described, there
are others which require  to  be  accurately distinguished from
them:—
   346.  In the Acute Dyspepsia, and in the more accidental
cases of indigestion, a paroxysm of dyspnoea  often takes place
and appears to me to constitute, in  the greater number of in-
stances, the flrst attack of true Asthma.
   347.  The dyspnoea of Asthma is extremely peculiar :—there
are great anxiety and almost gasping; the inspiration is quick,
the expiration longer, labored and wheezing.  In extreme cases,
the chest is raised, the scrobiculus cordis retracted, and the ab-
domen protruded,  with abruptness,  on inspiration: expiration
reverses these movements, and is attended with labor and wheez-
ing.  In protracted  cases a state of  constant dyspnoea is ob-
served, denoted by labor and wheezing, with a peculiar  cough.
At length, organic disease of the heart  and of the lungs  is
superadded to the primary state of disorder of function.
   348.  In the other forms of Dyspepsia, and especially in
Chlorosis, paroxysms of Hysteric  dyspnoea are observed, fre-
quently attended with pain and tenderness of the  chest or of the
abdomen; it combines a degree of hurry and heaving in the
respiration altogether incompatible with inflammatory pain.
With this state  of the respiration there is  often a total  loss of
voice, and occasionally the cough and  crowing of Croup.
   349.  In the cases of Intestinal Irritation, and in those of
Exhaustion from loss of blood, or other causes, the respiration
becomes affected with hurry, panting, sighing, heaving,  moan-
ing, labor, and gasping, and there is an urgent demand  for the
fan and the fresh  air.
   350. As these  states pass into that of Sinking, gasping,
catching, laryngal cough,  snoring, blowing, slight rattling in
the larynx or trachea, &c.  supervene and  increase as the ener-
gies of the brain, heart, and lungs decline.  There are three
symptoms connected  with  the Exhaustion, which  denote the 
 102     THE  MORBID AFFECTIONS  OF

 Sinking state, and which are consequently of  the most unfa-
 vorable omen :—the^rs^ is an audible, hurried breathing;  the
 second  gasping, however slight, with descent of the  pomum
 adami;  the  third, a slight crepitus heard in the breathing,
 with, or even without the stethoscope.
   351. A similar state of catching in the respiration occurs, as
 a. fatal symptom, towards the termination of many diseases.
   352. Rattle occurs  not only in Apoplexy, Bronchitis, &c.
 but also in the last and fatal stages of debility and sinking,
 and of many diseases.
   353.  The different modifications of  the  breathing, which
 have been described, might be designated and distinguished by
 some epithet chosen from their most prominent character.  But
 I  have avoided this from the fear of fixing the  attention too
 exclusively on one point, which, however prominent, still only
 obtains in common and in connection with  others little less
 remarkable.
   354. There is one remark respecting  the  respiration which
 I think important.  In some instances of  Chronic Inflamma-
 tion of the  Larynx or Trachea, I have observed  that the
 patient is incapable of performing the action of  snufling-up the
 nostrils so as to draw in the alee nasi ;* this was not observed in
 some cases of  Ulcer of the Larynx.   The remark may not
 only enable us to determine  the degree,  but the diagnosis of
 the morbid effects of Laryngitis.
   355.  The  respiration is  tracheal or croupy in Inflammation
 of the  Larynx, and in cases in which a tumor, as Aneurysm
or Scirrhus,  presses upon the larynx.   The latter case is often
distinguishable by the addition of dysphagia^') to the dys-
pnoea, or the  tumor may be obvious to the eye or touch.
  356. In Ulcer of the larynx the sound of respiration is rather
hoarse  and husky than croupy.
  357. 1 now proceed to notice some of the more remarkable
varieties of Cough:
                 * See Medico-Chir. Trans, vol. x.
  (1.) The observations of M. Louis have established the) fact  that dysphagia
is a frequent symptom of ulceration of the epiglottis.                S. 
      THE  FUNCTION  OF  RESPIRATION.   103

  358.  This symptom is modified  by the seat, and nature, of
the disease, and, in the same disease, by the state of pain, or
of expectoration, and by the strength of the patient.
  359.  The laryngal cough often occurs in fits, with hoarse-
ness and incapability of speaking, and is sometimes so violent
as to induce vomiting even.   The tracheal cough is lower, less
violent, and without hoarseness.  The bronchial is  deeper still.
  360.  By observing the kind of effort, and the particular char-
acter of  the cough, the  seat of  irritation or disease is often
distinctly observed to be in the larynx, in the trachea, in the
bronchia, or in the cellular structure of the lungs.
  361.  Not only the seat, but the  nature of the  disease, is fre-
quently ascertained by an attention to the peculiarity of sound
of the cough.   Ulcer in the larynx induces a very different
sound from that of inflammation of the same part, the former
being  hoarse, the  latter croupy;  the sound of the cough in
 Tuberculous Phthisis is very different from that of Catarrh,
or of some forms of Bronchitis;  the cough in Asthma has a
very peculiar dull sound;  and  the sound  of  the cough, or
rather the resounding of the chest on coughing, frequently serves
to indicate a healthy state of the lungs and thorax  in general,
and to distinguish it  from various  morbid  conditions.  The
presence of mucus or of pus in the  bronchial passages also gives
a characteristic sound to the cough.
   362. The effort of coughing is sometimes repressed.   This
occurs in Acute Inflammations of the  Pleura, of  the Perito-
naum, &c. in Rheumatic and Hysteric affections of the mus-
cles about the thorax ; &c.
   363.  Sometimes the cough assumes a spasmodic character.
This occurs in Pertussis, Hysteria, in cases of Intestinal Irri-
tation,  or of irritation about the larynx or trachea; &c/*
   364.  In other cases the coughing is continued, but not suffi-
ciently  violent to be termed spasmodic.  Cough of this char-
acter is observed  in some cases of less  severe irritation in the

  * " Hujus generis tusses, ut et illoe quae a distillatione nascuntur, vehementiores
sunt, et magis sonone, quam quae fiunt ex tabe, sive incipiente, seu deplorata."—
Heb. Com. cap. xcii. 
  104       THE  MORBID AFFECTIONS  OF

  intestinal canal, or in the larynx or trachea; it occurs also from
  circumstances  of  Exhaustion  and  Sinking, and  appears to
  originate in the larynx; it is observed in some instances of Bron-
  chitis, and of Asthma, and  frequently when the strength of the
  patient is too much reduced  to enable him to expectorate.
    365. In Catarrh the cough is often violent, and there is an
  abundant resonance of the thorax : in Tuberculous Phthisis
 the cough  is less  frequently violent; but when it is, the sound
 is flattened, and as it were tearing.*  The cough is generally
 violent with a thin and scanty expectoration, and becomes easier
 as the expectoration becomes more viscid and copious.
   366.  Cough may be said to be a symptom in all cases.  But
 it by no means always  denotes an affection of the organs of re-
 spiration originally.   Perhaps no  circumstance, however, illus-
 trates better  the  transition  of a  sympathetic  and  functional
 affection into one of real disease.  In some instances, a  disor-
 dered state  of the stomach and digestive organs  induces  cough:
 this state of things, if neglected,  leads to a copious secretion
 from the mucous surface of the air passages, and  ultimately to
 actual disease.
   367. In some instances, a state of inanition of the stomach,
 like other circumstances  of exhaustion, induces cough.   One
 patient termed  such a cough a  "want cough,"  and always
 removed it  by  eating.   I have  already alluded,  § 367,  to the
 catching, laryngeal cough observed in the state of Sinking.
  368. Every one must have remarked the peculiarity of the
cough which affects very old  persons, and  especially  old  asth-
matics. (')
  369.  With the consideration of the different kinds of cough
                   * Heberdeni Com. cap. xcii.
  (1.) It may perhaps strike the reader that too much refinement has been in-
troduced in the above description of the cough in different diseases. There is
one point, however, in this connexion worthy of particular notice, which is, the
importance of the cough in the diagnosis of acute Bronchitis, from Pneumonia
and Pleurisy in young  children.  In the former case the cough is loud and free,
in the latter it is repressed or smothered.                          g# 
      THE  FUNCTION  OF  RESPIRATION.   105

is naturally conjoined that of the varieties observed in the Ex-
pectoration :
   370. Mucous  expectoration appears  to arise  from various
sources of inflammation and irritation of the bronchial mem-
brane.   It occurs in Bronchitis,  frequently from  the effects  of
intestinal irritation long continued, or from the irritation of a
diseased Liver, or of Tubercles in the Lungs in a quiescent
state, or of other  sources of irritation,  near or remote.   Slight
mucous expectoration is frequently  observed in  protracted cases
of  Exhaustion, combined, of course, with  cough, and with
rattle,
   371. IB. some instances 1 have  observed a copious mucous
 expectoration  alternate with one  more puriform, on different
days,—even in Tuberculous Phthisis.
   372. It frequently happens that large globules of puriform ex-
pectoration are  observed  to  float amidst a fluid of a  more
aqueous or mucous appearance,—especially in  Tuberculous
Phthisis.
   373. In all these cases an expectoration of blood is frequently
observed.  In  many, especially in Bronchitis, this  appearance
gradually declines without serious consequence.  Il is generally,
however, of a most unfavorable augury,* even when it appears
merely in dots or streaks;(')  and  the more so, I  think, as the
previous disease is more protracted.   The expectoration of blood
is also very  alarming  when it occurs without  previous  symp-
toms, and without muscular effort.
   374. Besides the  mucous,  puriform, and bloody  expectora-
tion, there is an appearance, occasionally observed, of a serious
nature : it is that of a scanty, and, if the term may be allowed,
                  * Heberdeni Com. chap, lxxxiv.
  (1.) This statement appears to me erroneous.  Nothing is more common in
 severe acute Bronchitis than for the expectoration to be thus dotted or streaked
 with blood, and yet the augury is most favorable.  The expectoration, how-
 ever, of a considerable quantity,  (two or three ounces of pure blood,) during the
 twenty-four hours, especially when it occurs under the circumstances mentioned
 in the next sentence, is very alarming, inasmuch as it is then commonly the first
symptom of tubercles in the lungs.                               S
                             14 
106      THE  MORBID  AFFECTIONS  OF

friable,  and  whitish matter, easily  divided with  a probe, and
sinking  in water:  it  occurs  in some cases  of  Tuberculous
Phthisis.^)
   375.  The  expectoration in  Pneumonia is  frequently quite
distinctive and pathognomonic of this  disease: it consists of a
transparent fluid, reddish from the intimate admixture of blood,
sometimes so tenacious as to  admit of turning the vessel, in
which it is received, upside down, without  flowing out:  at first
there may be the expectoration of a little  mucus ;  afterwards,
the degree of tenacity and red color frequently denotes the de-
gree of violence of the  disease.(2)
   376.  There is an interesting experiment proposed by the late
Dr. Young  as distinctive of pus  from mucus, which has not
sufficiently arrested the attention of the profession.   It is  an ex-
periment of the simplest kind,  and may  have many useful ap-
plications in practice.
   377.  If a  minute drop of any fluid, containing globules, be
placed between  two  portions of plate glass,  and  if  we look
through it, placed near the eye, at a distant candle,  we observe
the most distinct and  interesting  phenomena  of circles colored
like the rainbow.   Blood and pus present this phenomenon;
mucus  does  not.   We have,  therefore,  a diagnostic  between
mere laryngitis and bronchitis and mucous discharges from the
stomach, rectum, kidney,  bladder, or uterus, and Ulcer in these
several  organs:  and it  remains, perhaps,  to be  determined
whether  tuberculous,  and encephaloid, and melanous  matter,
  (1.) The expectoration in Tuberculous Phthisis, when once established, is a
very valuable diagnostic sign. It consists of distinct sputa more or less opaque,
with ragged edges, frequently rolled up, pelotonnt, streaked or dotted with sof-
tened tuberculous matter and floating in a transparent serous  liquid.  I once,
however, heard M. Chomel remark, that he had observed the same kind of ex-
pectoration in Rubeola.                                         S.
  (2.) There is a distinction between the expectoration in Pneumonia and acute
Bronchitis that is worth noticing for  the light it throws on  the explanation of
the crepitant and mucous rattles.  In the former case, the bubbles of air contain-
ed in tbe Sputa are minute, equal in size, and equally distributed.  In  the latter
case, the precise contrary to this is true.                            S. 
      THE  FUNCTION  OF  RESPIRATION.   107

possess globules, and present the phenomenon dependent  upon
them.
  378.  Let the experiment be performed with a minute drop of
blood, diluted with  water, and  placed  between two portions  of
glass ; it may lead to an  inquiry of great interest and impor-
tance.
  379. I proceed to make a few  remarks on the effects of a Full
Inspiration and Expiration on the part of the patient.
  380.  The former is useful in  the detection of slight attacks  of
Inflammation of the Pleura,  or of the Peritonaeum, and  in
determining,  by comparison at different periods, its  increase  or
decline.
   381. A  deep inspiration is apt to induce  cough, when the
structure of the lungs is affected with inflammation or disease.
But this morbid state is more distinctly ascertained by an  atten-
tion to the effects of a. full expiration.
   382. In many cases of morbid affection of the lungs, indeed,
in which a deep inspiration induces neither cough nor other in-
convenience,  a full expiration not only occasions cough, but other
effects which vary according to the nature of the pulmonary
disease.  In Inflammation of the Bronchia, or of the Lungs,
in  Tuberculous  Phthisis, &c. cough and rattle  are induced.
These effects are also observed in some cases of  chronic affec-
tions of the bronchia, arising either from slight but protracted in-
flammation, or  from disorder of the digestive organs : in cases of
Asthma too, in which the ordinary  breathing, or a deep inspira-
tion even, is  unattended with  any peculiarity,  a full expiration
excites both cough and the wheezing sound so  characteristic of
this affection.
   383. It is  particularly useful to watch the effects of a full ex-
piration in the slighter affections of the pulmonary structure,
and in the decline of pulmonary disease.
   384. The modifications of the Voice and Articulation,  as
symptoms in diseases, maybe considered as denoting—1, the
state of strength, debility, or  sinking ; 2, the existence and
the kind oipain in the chest, abdomen, &c; 3, some affections
of the mouth, palate, throat, nose, &c. 
108    THE  MORBID  AFFECTIONS,  ETC.

  385. The voice is also modified in some cases of Typhus Fe-
ver, Cholera Morbus, and Dysentery, in which it is apt to be-
come feeble and husky ; in Phthisis and Diseases of the La-
rynx and Trachea, in which it frequently becomes extremely
hoarse ; and in  Hysteria, in which it  is often suddenly and
sometimes long lost and inaudible.
  386. The articulation is affected by Paralysis  and  Spas-
modic Diseases, and, like the voice, in cases of great debility.
  387. These hints  may assist in  an examination of the sub-
ject, and the reader will find an account of some other affections
of the voice in the works of M. Portal.*
  ♦Memoirs sur plusieurs Maladies-, tome i,p. 273; ii, p. 109; iii, 159,165.
Anatomie Medicale, tome iv. 
CHAPTER  VIII.
   ON THE MORBID  AFFECTIONS  OF THE CIRCULATION.

   388. The morbid affections of the function of the Circulation
 are observed in the pulse, in the pulsations of the heart, and
 of the carotids acd abdominal aorta, and, sometimes, of the
jugular vein, and in the capillary or extreme vessels.
   389. The varieties in the Pulse have formed the subject of
 many and even voluminous works.  Iu the present place, I shall
 pursue my accustomed  plan of noting down those varieties of
 the pulse which have struck  me as being of most practical im-
 portance.
   390. The first point to be noticed in this place is the frequency
 of the pulse :—*
   391. I have generally observed that the pulse is much  more
 frequent in the early periods of Fever than of Inflammation.
   392. In Fever  with  congestion of the brain there is fre-
 quently an unnatural slowness of the pulse.
   393. In Fever complicated with inflammatory affections, the
 pulse is, on the contrary, more frequent than in the simpler cases
 of fever.
   394. In  Acute  Inflammatory  Diseases, in general, the
 pulse is usually  slightly frequent  and hard ; but it is modified
by various circumstances, of which the principal are the part af-
fected, the stage of the disease, and the treatment.
   395. In Diseases  of the Brain the  pulse is  often very pe-
 culiar and characteristic.  In the first stage of Inflammation  of
 this  organ, the  pulse is frequent, and  sometimes of unequal
frequency ; as  effusion and compression take place, the  pulse
 becomes slow, and it attains a still greater frequency than before
• See the Trans, of the Col. of Phys. vol. ii, p. 18. 
110     ON  THE  MORBID  AFFECTIONS

towards the conclusion of the disease.   In Apoplexy the pulse is
slow, and often irregular in the beginning, and more frequent in
the later periods.
   396.  In  Inflammation of the Bowels I have known the
pulse to remain of nearly its natural frequency until the stage of
sinking has taken  place;  so that the pulse must be regarded as
a very unsafe guide in this morbid affection ; it is more usually,
however, of increased but variable frequency, and small and
feeble.
   397.  In  Pleuritis  and Peritonitis, and most other inflam-
matory diseases, the pulse is generally somewhat increased in
frequency.
   398.  The pulse  is generally more frequent as the disease  is
more advanced, unless  its violence  has  been subdued.  The
peculiarities in the cases of Encephalitis and Enteritis have
been already noticed.   In  the later stages of inflammatory dis-
ease the pulse is also apt  to become or to remain unnaturally
frequent, as an effect of the loss of blood  from repeated venae-
section ;  it  is therefore important to observe every symptom, not
to be misled by a continued frequency of the pulse.
   399.  It is not unusual to observe that, in various diseases the
frequency of the pulse remains when the morbid actions have
apparently  subsided: in such a case it is necessary to continue
our attention, and watch and wait for the diminution of the fre-
quency  of  the pulse;  and, if this event do not take place in a
moderate space of time, to ascertain  whether the disease be in
fact subsided, or only mitigated  and pursuing its course in an
insidious form.  This watching  is  particularly  necessary  in
cases of  Pleuritis and Peritonitis.   Frequency of the pulse  is
apt to be observed as an effect of Intestinal Irritation: in that
case, as in  Erethismus and in Exhaustion with re-action,
there is also perceptible palpitation of the heart.  This affords,
indeed, a criterion by which such a state of frequency of pulse is
distinguished from that observed in Phthisis and other organic
diseases.
   400.  Frequency of the pulse is the effect of repeated blood-
letting.  The first effect  of a copious blood-letting is a state of 
              OF THE  CIRCULATION.           Ill

syncope with slowness and feebleness of the pulse ;  the cumu-
lative effect of repeated bleeding, when there is re-action of the
system, is a frequent,  full, and throbbing or bounding pulse ;-
but if the powers  of the system be broken, the pulse is frequent
and feeble,  with  the  other symptoms of the state  of sinking
already repeatedly noticed.  In the case of sinking, the pulse very
often retains its frequency until five or ten minutes before the
patient expires, when it suddenly falters and soon ceases altoge-
ther.   It is of the utmost importance to appreciate the effects  of
loss of blood, and distinguish  them from those of the disease,  in
the course of inflammations.   In a case of peritonitis, the  pain
became mitigated, but the pulse increased from 120  or 130  to
145 or 150.   What was  the  cause of this increase of pulse 7
The carotids and afterwards  the aorta were observed  to beat,
and there was a beating movement of the chest  during expira-
tion.  I was of opinion that these were the effects of loss of blood;
and so it proved : the number of the pulse diminished, but the
throb continued for several days longer.
   401. I now proceed to remark the degree of frequency of the
pulse in morbid affections of a more chronic character :—
   402. The frequency of the pulse affords an important diagnos-
tic mark of Disorder of Function  from  Organic Disease,
and of different organic diseases from each other.
   403. In all  the chronic forms of the Dyspepsia, the pulse,  in
general, retains its natural frequency; it is apt,  however, to  be
frequent in the Acute  Dyspepsia ; and it is apt to become fre-
quent in the later stages of the Chronic, when the affection
leads to great loss of  flesh, to  dropsical affections, or to organic
changes; and the case may be  considered as assuming an
alarming character  as the pulse thus becomes  unnaturally fre-
quent.
   404. Some Organic Diseases induce an early and charac-
teristic frequency of the pulse, especially Tuberculous Phthisis,
 Tuberculous  Disease of the Mesentery, and Chronic In-
flammation of the Pleura and of the Peritonaum.
   405. Others often  proceed with  very little frequency of the 
112      ON  THE  MORBID   AFFECTIONS

pulse, as some Organic Diseases of the  Liver, and especially
of the Ovarium, &c.
   406.  There is a variety of the pulse which may properly be
termed  the nervous ; it consists in  great frequency on the first
arrival of  the physician,  which  generally subsides during his
stay.   It is often of importance to observe this peculiarity of the
pulse; and, with this  view, to wait and count its beats several
times during the visit.  It is indeed to this state of things that
the elegant observation of Celsus particularly apply :  he observes,
" venis enim maxime credimus, fallacissimse rei; quia seepe istee
leniores celerioresve sunt, et setate, et sexu, et corporum natura:
seepe eas concitat et resolvit sol, et balneum, et exercitatio, et rae-
tus, et ira, et quilibet alius animi affectus :  adeo ut, cum primum
medicus venit, solicitudo eegri dubitantis quomodo illi se habere
videatur, eas moveat.   Ob  quam causam  periti medici est non
protinus ut venit, apprehendere manu brachium:  sed  primum
residere hilari vultu, percontarique, quemadmodum se habeat; et
si quis ejus metus est, eum probabili sermone lenire ; turn deinde
ejus corpori manum admovere.  Q,uas venas autem conspectus
medici movet, quam facile mille res turbant! "*
   407.  The frequency of  the pulse in Phthisis,  Mesenteric
Disease,  &c. is, on the other hand, permanent, neither easily
augmented, nor becoming diminished.   I have, indeed, frequent-
ly observed nervous excitement to lower the number of the  pulse
of Phthisis for a short space of time.
   408.  The next peculiarity of the pulse is its state of irregula-
rity :—
   409.  This affection of the pulse occurs  principally from  .Dis-
ease within the Head, Disease of the Heart, and Disorders
of the Digestion,  and from various diseases affecting the  respi-
ration, as  Hydrothorax.
   410. In Inflammation  of the Brain the pulse is  often of
unequal frequency ;t in cases of compression, it is frequently
irregular.
                      * Lib. iii, cap. vi.
t See Dr. Abercrombie's excellent paper, Ed. Med. Journal, vol. xiv, p. 267. 
OF  THE  CIRCULATION.           113
   411. Irregularity of the pulse is very usual in Diseases of the
Heart, and especially of its  Valves : it is sometimes merely in-
termittent, and sometimes extremely irregular in its beats, and
in its size and force.   In these diseases the  peculiarity of the
pulse is generally permanent.
   412. Nothing is more common than occasional intermittence
and irregularity of the pulse from Indigestion, and from the va-
rious disorders of the bowels, as Diarrhoea, &c.
   413. Dyspnoea, in general, is frequently attended with inter-
missions in the pulse, probably from its mechanical effect upon
the action of the heart.  A very  deep inspiration and a full ex-
piration have, in some persons, the effect of arresting the action
of the heart in a temporary manner.  The pulse is, probably
from a similar cause, frequently irregular in cases of Asthma, or
Hydrothorax, and in very corpulent persons, an interruption be-
ing often observed on  inspiration.
   414. Irregularity of the pulse is apt to occur in cases of Ery-
sipelas, Gangrene, &c.  in the state of sinking, and in the last
stages of many diseases.
   415. The next peculiarity in  the  pulse, which I shall notice
very briefly, is its state of fulness or smallness :—
   416. The pulse is frequently very full on the attack of Apo-
plexy, but gradually loses this character as it becomes more fre-
quent.
   417. In Organic Disease of the Heart the pulse is  either
full or small,  according to the nature of the affection.  Enlarge-
ment of the heart, with hickening of its parietes, sometimes in-
duces a full and strong pulse;  whilst mere dilatation of the heart
is attended with  a  soft and  feebler  pulse; and, in some other
diseases of this organ, especially of its valves, the pulse becomes
very small, and sometimes almost imperceptible.
   418. The next morbid  affection in which the size of the pulse
is peculiar, is Inflammation of the Intestines, in which there is
a characteristic smallness of the pulse.*

   * This disease is sometimes fatal in twenty-four  hours.  This must be by
exerting a baneful and depressing influence on the vital powers, independently
of the mere interruption of the intestinal functions.
                              15 
114        THE  MORBID  AFFECTIONS

  419.  In cases of Exhaustion with re-action of the system, I
have already stated that the pulse is large and bounding: this
characteristic ceases as the re-action subsides and the state of
Sinking occurs.
  420.  The smallness of the pulse has, in some instances, been
so remarkable as to have  given origin to the terms " thready
or " wiry."
  421.  The subject of pulsation of the heart, carotids, abdomi-
nal aorta, &c. requires to be noticed in connexion with Diseases
of the Heart, with  the state of Exhaustion  with re-action,
with Intestinal Irritation, and, perhaps, with  some morbid
affections of the head.
   422.  In Enlargement of the Heart with thickening of its
parietes, the pulsation of the heart is forcible and circumscribed,
and attended with pulsation of the carotids and other large arte-
ries.  In the case of Dilatations of the Heart, with diminished
thickness of its parietes, the heart beats more freely, but its pul-
sations  are heard over a greater extent of surface ; the carotids
are free from  pulsation.
   423.  But the most extraordinary degree of palpitation and of
pulsation of the carotids, and even of the abdominal aorta, is ob-
served in some cases of Exhaustion from reiterated loss of
 blood.
   424. Palpitation is a common symptom in cases of Hysteria
and other nervous disorders ; a still more frequent symptom is a
 feeling of fluttering' at the heart,  and in the region of the
 stomach, and throbbing of the temples.
   425. In similar cases there is sometimes a preternatural pul-
 sation in the epigastric region; Dr. Baillie observes, "it is
 perhaps difficult to ascertain, in many  instances, the cause of
 this increased pulsation  of the aorta in the epigastric region;
 but in  most cases it will be found to  be connected with an im-
 perfect digestion, and an irritable constitution."
   426.  A similar pulsation is sometimes  the effect  of Aneu-
 rysm of the Aorta, or of a tumor situated over the aorta.   In
 this case the general health is unimpaired. 
OF THE  CIRCULATION.
115
   427.  Pulsation of the Jugular Veins has been observed in Hy-
 pertrophy of the Right  Ventricle.^])
   428.  In the capillary circulation we are enabled to observe
 a characteristic symptom of certain diseases, and to ascertain, in
 some degree, the powers of the circulation and the  state of
 the blood.(2)  We are presented with an opportunity of observ-
 ing the condition of the capillary circulation  by examining the
 condition of the extremities—the nose, the cheeks, the ears, and
 the hands and feet, the prolabia and the finger-nails.
   429. Some  diseases have a peculiar influence over the capil,
 lary circulation, inducing coldness and lividity of the  extremi-
 ties.   This is particularly observed in some cases of  Enteritis,
 of Cholera Morbus, and of Dysentery—in the Acute Dys-
 pepsia, in  Tuberculous Disease,  &c.
   430. In  other diseases, the same tendency to coldness of the
 extreme parts  denotes a failure in the general strength of  the
 system, and should be carefully watched.   It is to be observed,
 however, that flushing and heat sometimes occur during a state
 bordering on that of Sinking.
   431. In some old persons I have observed a remarkable ten-
 dency to lividity of the finger-nails.
   432. It  appears  to me to  be from defective powers of the ca-
 pillary circulation that cold is so difficultly borne by infants and
 very old persons.
   433.  Whilst a  livid hue of the prolabia and  nails  denotes
 feebleness of the  circulation, an exanguious paleness is the fre-
 quent attendant on an aqueous state of the blood, or the effect
 of some morbid affections, as Chlorosis, Purpura, &c. or of
 considerable loss  of blood.
   434.  There is, in the capillary circulation, a peculiarity which
 may be denominated the tendency to hamorrhagy.  This
 state is sometimes the effect of intestinal disorder and irritation,
 and then it leads to epistaxis,  hamatemesis, melana, me-

  (1.) In three cases where the jugular pulse was noticed, there was  dilatation
of the right auriculo-ventricular orifice—in one of these, there was insufficiency
of the tricuspid valve.—In two of the cases the right ventricle was in  a state of
Hypertrophy  and Dilatation—in the third it was natural.             S.
   (2.) See note, page 51.                                    S. 
 116     THE  MORBID  AFFECTIONS,  ETC.

 norrhagia, and even hamaturia*  In other cases the state of
 exanguious paleness precedes and forebodes the haemorrhagy, as
 in some instances of Purpura, in which the tendency to extra-
 vasation of blood is more general, and occurs, in different cases,
 in all or each of the cutaneous and mucous textures, together or
 singly.
   435.  Another effect of an enfeebled capillary circulation is
 oedema or anasarca.  This is a frequent occurrence in protrac-
 ted cases of Chlorosis,  of repeated blood-letting or protracted
 haemorrhagy, and of  the failure of the vital powers in disease,
and in old age.
* See an instance of this in Bateman's Reports of the Diseases in London, p. 123. 
CHAPTER  IX.
       THE PHYSICAL  CONDITIONS OF  THE THORAX.

   436. The physical conditions of the Thorax are determined
 by a careful External Inspection, by Percussion, and by the
 Stethoscope.
   437. There is  nothing, to me, more interesting than to lay
 bare the thorax and to watch its movements.
   438. In Inflammation, and in Disease,  the  movements of
 the thorax are observed to be variously modified, and  its form
 changed.
   439. In Pleuritis, the thorax, or a part of the thorax, is kept
 unmoved, according as the disease is diffused or partial, and the
 respiration is performed by the diaphragm alone, or by one side
 or several parts of the thorax only.
   440. In Peritonitis, the  breathing is,  on  the  contrary,  tho-
 racic—the diaphragm being motionless.
  441. These modifications of the respiration are,amongst  the
 best diagnostics of Pleuritis and Hepatitis.
  442. In more Chronic Pleuritis, the thorax is not only kept
immoveable, but is absolutely deformed, one side or one part/be-
ing drawn and fixed inwards, the shoulder depressed and fixed,
and the spine distorted.   This phenomenon is occasioned  by
the deposit of a thick layer of lymph, with the effusion of serum,
and the subsequent absorption of tm? latter.
  443. In excessive Hydrothorax, on the other hand, the tho-
rax, or the side of the thorax, is more rounded than usual, whilst
the diaphragm is weighed down.  The breathing is thoracic
and high ;  the liver is frequently felt, carried downwards.
  444. The thorax may be actually measured in these cases;
but an inspection is generally sufficient, and  even more satis- 
 118       THE  PHYSICAL  CONDITIONS

 factory.   The posterior  part of the chest should  be viewed  as
 well as the anterior.
   445. It is scarcely necessary to mention  that  Aneurysm is
 eventually visible externally in some cases.  .
   446.  But a far more important source of the diagnosis is
 Percussion, as first  particularly noticed  by Avenbrugger, and
 then by Corvisart.   The operation requires a little use.   A disc
 of ivory, or a half-crown piece, or the fingers, may be laid flat
 upon the chest, or the shirt may be drawn tight over it;  or the
 fingers may be covered with  a glove;  percussion is then to be
 gently but briskly made with the very ends of the fingers,  or
 the  stethoscope.   The next rule is  to  make a precisely com-
 parative percussion of each side,  and  corresponding parts,  of
 the thorax, extending the muscles.   The fore part of the thorax
 is thrown forwards by sitting  perfectly erect, the head  raised,
 and the  elbows carried  backwards; the  back, by  bending a
 little, holding the head down, and bringing the arms forwards.
 It is useful, in obscure cases,  to pass to the other side  of the
 patient and repeat the operation.
   447.  The natural sound of the thorax is clear, on  percussing
 the middle and sternal end of the clavicle; a little less so just
 below; a  little less so still, between the fourth and eighth ribs,
 or in the mammary region.  The sound is  obscure over the
 liver, loud over the  stomach.
   448. Under the sternum the sound on percussion is clear.
   449.  In the axilla, and  immediately  below, the sound  is
 clear: between the fourth and eighth ribs, laterally, the sound
 is clear, on the left side ;  but  sometimes obscure on  the  right ■
 denoting undue elevation of  the liver.   Below the eighth rib
 the left side is sonorous, the right side dull.
   450.  The interscapulary space gives  an  obscure  sound, on
 account ,of the depth of the muscles.  The  space  immediately
below the scapula  is obscure  on the right  side, over the liver,
 and sonorous on the left,  over the stomach.
   451. When the sound of the thorax  is unnaturally dull, the
 subjacent  space,  instead  of containing  the lung  permeable  to
 air, is occupied by the lung  in a state of congestion or hepa- 
OF  THE  THORAX.
119
tization,  by serous effusion, by a tumor, &c.   It  is  thus that
Pneumonia, Hydrothorax, Hydro-pericarditis,  Tumor, Hy-
pertrophy of the Heart,  Aneurysm, &c. induce dulness of
soimd.(  .)
   452. But percussion alone is rarely sufficient for  the diagno-
sis : for this  purpose  it must  be conjoined with the  most im-
portant sign of physical change of all, viz.  Auscultation.
   453. The Stethoscope  should  be accurately applied to the
chest, and all extraneous noises must be carefully removed : the
positions of the patient are similar to those adopted in  the use
of percussion, § 446 ;  inclined backwards,  forwards, or to oppo-
site sides, according  as the fore part, the back, or the side, is to
be examined.
   454. The  point to be first noticed, in treating  of the use of
the stethoscope, is that of the murmur or noise of Respiration.
This  is  divided  by  Laennec into—1, the vesicular; 2, the
bronchial; to which  he  adds—3, the cavernous.
   455.  The vesicular respiration is heard in every part under
which the lungs are subjacent;  it  is loudest  in the axilla and
above the clavicle; but it  is distinct in all the  anterio-superior,
lateral, and posterio-inferior parts of the thorax.
  (1.) The artificial  division of the thorax into regions introduced in many of
the treatises on auscultation appears to me of no great use.  The student should
remember that the principal causes  which modify the sound on percussing  the
healthy chest are, first, the size, situation and character of the viscera which
are contained by, or in close connexion with, the parietes of the thorax—second-
ly, the relative thickness of fat or muscle to  which may be added the degree of
muscular tension.  A minute knowledge of the anatomy of these parts is, there-
fore, indispensable, and the position of the patient a point of great importance.
In cases that will admit of the liberty the chest should be perfectly exposed and
the patient be placed  standing against a wall, with his heels together, when the
anterior portion is being percussed—crossing the arms over the breast and inclining
a little forward when the posterior portion is to be examined.  I may remark
here, that the fore finger of the left hand and the fore and middle fingers of the
right hand are all we need in percussion.  The superiority of the finger over
every other form of pleximeter  is chiefly this, that we gain a more correct idea
of the  elasticity of the parts beneath it.  In conclusion, I will add, that a minute
knowledge of the art of percussion is much more difficult to be acquired  than is
commonly supposed.                                             S. 
 120      THE  PHYSICAL   CONDITIONS

   456.  The vesicular respiration  is louder in infancy than in
 adult age : in cases of hurried respiration, and in cases in which,
 from disease, the patient breathes with only a part of the lungs,
 the  respiration approaches its  puerile  state.   The vesicular re-
 spiration is not always puerile in the cases of dyspnoea in which
 the  breathing is loud  to the ear: the sound,  in such cases, is
 usually formed in the fauces and posterior nares.
   457. The presence of the  vesicular respiration denotes that
 of lung permeable to air;  its absence,  the absence  or imper-
 meability of the lung.
   458. Bronchial respiration is  that  heard on applying the
 stethoscope over the larynx, trachea, and large bronchia at the
 root of the lungs.  It is free from the slight crepitus which
 distinguishes the vesicular respiration, and gives the idea of air
 passing  into or along  larger spaces.(')   It is  heard in almost
 every part of the  neck.   It is not distinguishable where the
 vesicular respiration is equally heard.
   459. But in cases in which the lung is  compressed by effu-
 sion, or condensed,  as in pneumonia or haemoptysis, and the
 vesicular  respiration is impaired or annihilated, the bronchial
 respiration is heard  in its place.(2)  The bronchial respiration
 is frequently heard at  the root and summit of the lungs.
  460.  It is important  to  learn to distinguish these two kinds
 of respiration:  for,  whilst  the vesicular is the sign of  health,
 the bronchial is amongst the first symptoms of pneumonia and
 of tubercles.
  461.  The cavernous respiration  is that heard  over a cavity
in the lung.  It occurs in vomica, abscess, and dilated bronchia.
  462.  To these forms of respiration Laennec has further added,
 the "souffle," or blowing.  When the patient speaks, or coughs,
the air seems actually drawn  from or propelled into the  ear.
  (1.)  The employment of this term to express a characteristic mark of the
vesicular respiration appears to me at least ill-judged.  My own ear has never
detected any .crepitus in the healthy respiration.  It distinguishes one of the
rattles heard in disease.                                        g
  (2.) This statement is in part erroneous.  When there is compression of the
lung from effusion, the respiration becomes first feeble and then annihilated. S. 
OF  THE  THORAX.
121
 This sign indicates a cavity, or  enlarged bronchia, surrounded
 by condensed lung, near the parietes of the thorax.
   463. The souffle is sometimes modified by the sensation as
 of a  veil interposed  between a cavity and the ear—"souffle
 voile."   This  phenomenon is  observed in  cases  in  which  a
 vomica has its parietes thin, yet unequally so, and  unadherent,
 or an abscess  has its  parietes of unequal induration, or a large
 bronchi is surrounded by  lung  partly condensed  and  partly
 natural, or nearly so.
   464.  The phenomena to  be next  noticed  are  the various
 Rattles.  One of these is heard at a distance from  the patient:
 it is that of  mucus in  the trachea, in cases of catarrh and of
 dying persons, and of blood, in haemoptysis.  There is a second
 which is also audible without the stethoscope: it  is  mentioned,
 §  § 351, &c.
   465.  The rattles heard  by means of the stethoscope,  are—
 1, the vesicular, or crepitating, moist  and  dry; 2, the  bron-
 chial,  which  is  mucous, sonorous, or  sibilant;  and  3,  the
 cavernous.
   466.  The moist  vesicular or crepitating rattle, which re-
 sembles the noise  of salt thrown upon the fire,  is  the pathog-
 nomonic sign of the first degree of Pneumonia.  It disappears
 as hepatization takes  place,  and  re-appears with the progress
 of resolution.   It also occurs in Q^dema(1) and in Pulmonary
 Apoplexy.
   467. The dry vesicular or crepitant rattle resembles the noise
 made by  distending  a dry bladder, and is the pathognomonic
 sign of Emphysema of the Lung.[2)

   (1.)  Such was the opinion of Laennec—but the best auscultators of the pre-
sent day, I believe, entertain quite a different opinion.  (Edema of the lung is an
 effusion of serum into the cellular tissue of the organ and not into the air cells—
consequently, no air bubbles exist to produce a rattle.  This fact is easily verified
by making a section of an (Edematous lung and observing the fluid as it escapes.
                                                          S.
   (2.)  The dry crepitous rattle with large bubbles, considered  by Laennec as a
diagnostic sign  of emphysema does not, I think, occur in the true or vesicular
form of the disease. In the interlobular emphysema, a very rare form, it is, pro-
bably, sometimes noticed.                                      S.
                              16 
122       THE  PHYSICAL  CONDITIONS
  468.  The mucous bronchial rattle is that of Bronchitis, or
of softened  Tubercles, and, in the trachea, that of dying per-
sons.   It differs with the quality and the  degree of consistency
of the bronchial fluid, and the consequent size  and number of
the bubbles which form and burst.  It  exists principally  in
Catarrh, in Hamoptysis, and in Pneumonia and  Phthisis.
In the two former it is seated in the bronchia ; in the latter, in
the bronchia  or in cavities.  In the last case  it is designated
cavernous,  and especially heard during the act of coughing.{l)
  469.  The sonorous rattle seems to take place in the bronchia,
compressed  or dilated, or in pulmonary fistula.
  470.  The sibilant rattle has its  seat in the  small  bronchia,
partially obstructed by mucus.(2)
  471.  The phenomena to be next  described are  those  of the
Voice, and  are denominated bronchophony, pectoriloquism,
and agophony.
  472.  The first of these is bronchophony.   The resonance of
the voice, on applying the ear or stethoscope over the healthy
lung, is a little different  from the feeling conveyed  to the hand ;
but that over  the  larynx or trachea, and a great part of the
neck, traverses the tube and is very similar to pectoriloquism,
whilst that  over the sternal part of the trachea, however forcible,
does not penetrate the instrument.
  473.  The  resonance of  the voice over the large bronchia,
situated in  the interscapulary region, is  obscurer, though  still
very distinct,  and  in  thin  persons it resembles laryngophony;
in other parts  of the chest the resonance of the  voice is  nearly
  (1.) The diagnosis of the crepitant from the mucous rattle requires some atten-
tion, yet when once fairly recognised it cannot easily be mistaken.  The former
is equal and very fine, heard only during inspiration and bursting out, if I may
use the expression, from a circumscribed portion of the lung by a sort of explosion.
The mucous rattle is just the reverse  of all this.  It is unequal, heard both
during inspiration and expiration, passing and repassing the ear with each
movement of the chest.                                        S.
  (2.) The sonorous and sibilant  rhonchi are probably produced by the same
causes—the former having its seat in the larger bronchi, the latter in those of a
smaller size.                                                 S. 
OF  THE  THORAX.              123
absent—the bronchia being  small, little  firm  in texture,  and
surrounded by pulmonary tissue, a non-conductor of sound.
   474. If the surrounding lung becomes the seat of hepatization,
of apoplexy, or of tubercles, it conducts the sound of the voice
and gives origin to bronchophony.  This  is especially observed
near the root of the lung, in cases of Pneumonia.^l)
   475. Bronchophony is also produced by  dilatation  of the
bronchia, with  condensation of the  surrounding  pulmonary
tissue.
   476. The next phenomenon of the voice is that termed  pec-
toriloquism ; it is distinguished from  bronchophony by its ca-
vernous and circumscribed character ; and it occurs in all cases
of cavities, resulting from  softened tubercles, abscess, &c.  It is
perfect or imperfect.
  477. Pectoriloquism is perfect when the voice passes through
the stethoscope, from a space accurately circumscribed, and the
cough, rattle, and respiration  combine  to distinguish the  phe-
nomenon from bronchophony.   It  is imperfect when some  of
these phenomena  are wanting, and especially the transmission
of the  voice through  the  tube.   Perfect pectoriloquism  denotes
an ample  and empty cavity, situated near  the  surface, with
dense parietes, and in communication with one or more bronchia
of considerable size, unobstructed by sputa.
   478. With  pectoriloquism, and  especially bronchophony,
agophony  may  easily be confounded,  without great care.   It
consists in a peculiar resonance of the voice, which accompanies
or follows articulation; it seems as if an echo  of the voice, of an
acute,  harsh, and silvery character, were heard at the surface of
the lung, rarely entering, and scarcely ever traversing, the tube.
It resembles the bleating of the goat, whence its name.   In the
vicinity of a large  bronchi, bronchophony  is  frequently  super-
added.

  (1.) The value of the resonance of the voice in cases where there is but slight
condensation of the pulmonary tissue, as in the early stage of tubercles, is not
very great, because the natural resonance varies so much in different persons.
It is important, however, to know that the voice resounds more at the summit of
the right lung, than at the same point on the opposite side—this fact is easily
explained by dissection.                                       S. 
124       THE  PHYSICAL  CONDITIONS

  479. In order to hear the segophony well, the stethoscope must
be firmly  pressed upon the chest, and the ear  must be applied
lightly.    The  phenomenon exists—1, in  cases  of pleuritis,
acute or chronic, with a moderate effusion ;  2, in hydrothorax.
In these cases the sound on percussion is, at the same time, dull,
and the  respiratory  murmur absent.  The segophony ceases
when the fluid is either absorbed, or so augmented in  quantity
as to induce enlargement of that side of the thorax.
   480. iEgophony is always heard over a certain space,  and
often between the scapula and spine, and across the thorax to the
mamma, and not, like pectoriloquism, in one part only—evident-
ly occupying the superior border of the effusion, where it exists
as a thin  layer of fluid, moderately compressing  the bronchial
tubes.   The seat of aegophony is, consequently,  modified by the
quantity of effusion,  and by pleuritic adhesions ;  and changed
by the posture of the  patient.
   481. iEgophony and  bronchophony are united in pleuro-
pneumonia^ )  and pectoriloquism may be conjoined with them
in the case in which abscess is superadded.
   482.  The next phenomenon in connexion  with our present
subject, is that of Cough.  If the stethoscope be applied over the
thorax in general, nothing  is perceived but the concussion indu-
ced  by  coughing; but over the larynx  and the trachea, and
over the bronchia at the root of the lung, especially in the case of
Pneumonia, of pleuritic effusion,  and  of dilatation of the bron-
chia, there is the obvious sensation of an internal cavity or ca-
nal ; the cough is tubal.   In the case of vomica or abscess, the
cough is cavernous,  and  attended by cavernous rattle.
   483.  Cough  is sometimes also  attended with  the  metallic
tinkling, in cases in which this is inaudible in the respiration or
the voice.  The same observation applies to the different rattles •
and it frequently reveals pectoriloquism, crepitus, and respiratory
murmur, which the presence of matters  in the bronchia had sus-
pended.
(1.) Not commonly, because serous effusion is rare in Pleuro-pneumonia. S. 
OF  THE  THORAX.
125
  484.  The sound of the metallic tinkling is precisely that of
a glass struck by a pin.  It is heard in respiration, but especially
when the patient speaks or coughs ;  it exists in two cases: 1, in
that of effusion into the pleura with pneumo-thorax, and a com-
munication with the bronchia;  2, in that of a vast cavity in the
lung partially filled only, with thin pus.   This sign is more dis-
tinct, as, in the former case, the fistula is larger, and the quantity
 of air greater.
   485. Sometimes the sound is like that heard on blowing into a
decanter.  It is then termed amphoric resonance.
   486. There is another sound heard by the stethoscope in the
 case of inter lobular Emphysema : it is that occasioned by the
 ascent and descent of the affected part of the lung against the
 pleura costalis.   A similar phenomenon may exists in Pleuritis
 with moderate effusion. (')
   487.  The next application of the stethoscope is to ascertain the
 condition of the heart and large vessels.  The beat of the heart
 must be examined in regard—1, to its diffusion over the thorax;
 2, to its impulse ; 3, to its sounds;  and 4, to its rhythm.
   488. In the healthy state, the sound of the  heart is more or
 less confined to the space between the  cartilages of the fourth
 and fifth ribs of the left side, and at the bottom of the sternum;
 in which points the left and right sides of the heart are heard re-
 spectively.    In  thin persons and children it is heard under the
 clavicles.
   489. When the extent of the beats of the heart is augmented,
 they are heard in the following spaces:—1, along the left side of
 the chest from the axilla downwards ;  2, along the right side ;
 3,  along the back of the  left side; 4, along the back of the
  right side.
    490. The degree of diffusion of  the beat of the heart is pro-
  portionate to the thinness of its parietes, the feebleness of its con-
  tractions, and to the size of the organ.
  (1.) It is certainly sometimes heard in the advanced stage of Pleuritis, but only
when the effusion is formed by rough and comparatively firm deposits of coagu-
lable lymph.                                              S. 
 126  THE  PHYSICAL CONDITIONS,  ETC.

    491  The  impulse of the heart is inversely as the diffusion
 of its beat, and directly as the thickness of the organ.  Augmen-
 ted impulse is therefore the sign of Hypertrophy ; diffusion of
 the sound, with the absence of impulse, the sign of Dilatation.
    492.  The sound of the  heart is double, consisting of a first,
 dull and prolonged, coinciding with the contraction of the ventri-
 cle, and a second, short and distinct, coinciding with their dila-
 tation.
    493.  The degree of sound is inversely as the impulse, and di-
 rectly as the diffusion, of the beats of the heart: it is, consequent-
 ly, dull in Hypertrophy, loud in Dilatation.
   494.  The following is the healthy rhythm of the heart:—the
 first sound is synchronous with the impulse and the beat of the
 pulse; the  second speedily succeeds;  and after a rather longer
 interval, the first is repeated.*
   395. In Hypertrophy  the first sound is still more obscure and
 prolonged; in Dilatation the first sound is louder, more like the
 second.
   496.  The  next  subject to be noticed  is that of unnatural
 sounds of the  heart.   These  are two: the bellows'  sound  and
 the catfs purr.(')
   497. These sounds vary exceedingly, as do also the morbid
conditions in which they  exist.  These are, contraction of the
valves; hysteric and nervous affections;  the  state  of  inaction
from loss of blood;f &c.
  * Laennec viewed the first sound as owing to the contraction of the ventricles,
the second to that of the auricles.  Dr. Turner, of Edinburgh, considers the first
sound to arise from contraction of the ventricles; but the second not to be syn-
chronous with, therefore not dependent upon, that of the auricles.
  (1.) This is a very imperfect, and I will venture to add, incorrect statement.
The cat's-purr, fremissement catairre, is not distinguished by the ear but by the
touch.  The diagnostic value of the different morbid sounds of the heart will be
more particularly noticed in the second part..                        g,
  f See a Paper in the Med. Chir.  Trans, vol. xvii. 
CHAPTER  X.
  ON THE FUNCTIONAL AFFECTIONS OF THE ALIMENTARY
                          CANAL.

   498.  In this chapter I shall briefly notice the symptoms which
may be taken from the morbid affections of the pharynx and
oesophagus, the stomach and bowels, and the sphincter ani.
   499.  The act of deglutition is performed by the pharynx and
oesophagus, with the aid of the cheeks, fauces, &c.   Sometimes
this act is liable to be interrupted by diseases of some part of the
canal itself, or of the adjacent organs.
   500.  By observing the  kind of effort  made by the patient,
we may often ascertain pretty nearly what is the situation of the
causes of obstruction. If the fauces be defective, the substance
attempted to  be swallowed is often forced through the nostrils;
if thecardia be obstructed, the patient frequently regurgitates a
large quantity of food apparently swallowed.
   501.  In cases of tumors, as Scirrhus,  Aneurysm, &c. the
trachea is often compressed, and a croupy dyspnoea and cough
are apt to be conjoined with dysphagia.
   502. There is much diffiulty of swallowing in the very last
stages of Typhus Fever, and in the state of Sinking in gene-
ral ;  the attempt is not unusually attended with painful choak-
ing, coughing, and catching of the larynx.
   503. The deglutition has been impaired in some cases of Pa-
ralysis.
   504.  Dysphagia is occasionally observed as a symptom in
Hysteria, and other nervous and spasmodic  disorders.
   505. I now proceed to notice the principal morbid affections
of the functions of the Stomach and Bowels: 
 128    THE  FUNCTIONAL   AFFECTIONS

    506.  The functions of the alimentary canal are generally
 much more deranged in Fevers than in Inflammations, except
 those of the mucous  membranes.   Of the former, anorexia is
 often the first, and constipation almost a constant symptom, and
 the alvine  evacuations are dark and foetid; in a  late stage of
 protracted  Fever, aphthae, diarrhoea,  melaena, or a tympanitic
 affection, not (infrequently supervenes: in Inflammations the
 stomach and bowels are not essentially, and often not at all, af-
 fected, except indeed in the colliquative stage, when aphtha? and
 diarrhoea are not uncommon.
   507. A  similar remark applies to the class of Disorders as
 distinguished from Diseases: in the former there is much, in
 the latter frequently very little, stomachal or intestinal disorder.
   508. The stomach and bowels are apt to be much affected in
 Diseases of the Head :  concussion frequently induces vomit-
 ing  as its first symptom; vomiting is often a precursory
 symptom of Apoplexy ;  in cases of compression  the stomach
 and bowels are apt to be torpid,  and are  with  difficulty acted
 upon by medicine.
   509. In  Inflammation and other Diseases of the Thorax
 the stomach and bowels are often little affected.
   510. Inflammation of the Stomach is attended by irritabil-
 ity and frequent vomiting.  In Enteritis  the bowels are apt to
 be obstinately costive.—and there is at length,  in many cases
 much tenderness and  tympanitic affection; the latter symptom
 is also observed in Dysentery.
   511. Vomiting, hickup, the ineffective operation  of purgative
 medicine, distension,  &c. occur in  some  cases of Enteritis
 Strangulated Hernia, lntus susceptio, and the last stages of
 many diseases.
   512.  Hickup, rumination, and vomiting, are  frequent symp-
 toms in the Dyspepsia.   Vomiting occurs of course in the Cho-
 lera Morbus, and in many cases of Poisoning— and frequent-
 ly as a symptom of Gall-stones, and of Renal Calculus or In-
flammation.
   513.  In some Chronic Diseases of the  Bowels the convolu-
 tions of the intestines are apt to be distended and raised in the 
          OF  THE  ALIMENTARY  CANAL.     129

form of a transient, painful,  spasmodic,  and flatulent tumor;
and the passing of the food, or the evacuation of the bowels, is
attended with much pain.
   514.  The substances  rejected by  vomiting  are principally
food, mucus, bile, faeces, pus, and blood.
   515.  The morbid appearances observed in the alvine evacua-
tions are chiefly diarrhoea, scybalse, mucus, pus, and blood ;  the
motions themselves may be  scanty or copious, dark-colored or
light-colored, and disordered and offensive in different degrees;
the appearance of the mucus and of the blood are also various.
   516.  It has already been observed, § 506, that the alvine eva-
cuation is generally much more offensive and disordered in Fe-
vers than in Inflammations, and  in the class of Disorders
than in that of Organic  Diseases.
   517.  In  some protracted Diseases, however, the alvine eva-
cuations are very morbid, especially in Diseases of the Liver,
and of the Mesentery.   In those cases of disease of the liver at-
tended with Icterus, as in all other cases of jaundice, the motions
are clay-colored, and deprived of the  yellow tinge  imparted by
the bile.
s)  518.  In  some cases, both of disease of the liver and of the
mesentery, but especially the latter, the appetite has been  great,
the food has passed off quickly, and the motions have been copi-
ous, foetid, and light-colored.
   519.  The motions are generally pale and foetid when the food
passes through the alimentary canal rapidly, as  in Lientery.
   520.  The alvine evacuations are generally very offensive in
all cases attended with rapid loss of flesh, but in  none more than
in those in  which the powers of life are, at the same time, in a
state of decline—as in the decay of old age, in cases of slow fe-
vers, &c.
   521.  Mucous evacuations are the effect of irritation or inflam-
mation of the mucous membrane of some part of the intestinal
canal, especially the rectum and colon. They occur in Dysen-
tery, as the effect of Corrosive Poison, and in  cases in which
the rectum is irritated by impacted and  scybalous  fseces ; they
are often mixed  with  blood: in the last  case there are  often
                            17 
 130     THE  FUNCTIONAL  AFFECTIONS

 severe attacks of pain in the seat of the sigmoid flexure of the
 colon, and copious discharges of blood—effects which are reliev-
 ed by evacuating the rectum by enemata.
   522. Sometimes an exudation takes place from the  internal
 surface of the intestines, which resembles membrane or taenia,
 and is discharged per anum, exciting much needless alarm in the
 patient.
   523. Discharges of Blood occur from indigestion and intes-
 tinal irritation ; hamatemesis and melana are often conjoined,
 from these causes, in the different forms of the Dyspepsia.
   524. That stale  of things which gives origin to Purpura,
 frequently conjoins  other hemorrhages, as well as the petechial
 rash and vibices,  with the vomiting and dejection of blood.  I
 have already mentioned the  occurrence of melaena as a formida-
 ble symptom in Fevers.
   525. Discharges  of blood  from Hamorrhoids should be dis-
 tinguished from the more serious case of melasna.
   526. The Rectum and Sphincter Ani are apt to be affected
 with  Tenesmus, Obstruction, and Paralysis :—
   527. Tenesmus accompanies some of the diseases of parts in
 the neighborhood of the rectum, as  Calculus, Scirrhus of the
 Prostate Gland, Diseases  of'the Uterus, &c. as well as those
 of the Rectum itself.   It is almost unnecessary  to state how
 painful a symptom it is in most cases of Dysentery, of diseases
 ot the mucous membrane of the colon and rectum, of impacted
 Scybala, &c.
   528.  Obstruction in the rectum is the effect  of disease of the
 part itself, generally  Stricture or Scirrhus, of the pressure of the
 uterus in Reiroversio Uteri, of Organic Tumors affecting ad-
jacent parts, <fcc.
  529. In  every case in which symptoms of this kind occur, an
examination per rectum should be instituted.  By this means
many  cases, which would  otherwise  go  unrelieved, will  be
detected, and the  proper remedies will be applied.  I speak of
the introduction of the finger  ; that of the bougie requires great
care not to mistake the obstruction offered by a fold of the intes-
tine, or the promontory of the sacrum, for disease.  See Chap. 
          OF  THE  ALIMENTARY  CANAL.      131

 IV. The Diagnosis of the Diseases of the Alimentary Canal,
 § 743.
   530. A paralytic state of the rectum and involuntary evac-
 uations occur in the last stages of Apoplexy and other Diseases
 of the Brain, and in Diseases of the Spine.
   531. Involuntary motions  are the frequent  effect of the ex-
 treme debility observed in Typhus Fever and in the state of
 Sinking in general.
   532.  I need scarcely allude to the case of lacerated perinasum
 and rectum, and  the consequent loss of power to retain the
alvine contents. 
CHAPTER  XI.
   ON  THE FUNCTIONAL  AFFECTIONS  OF THE URINARY
                          ORGANS.

   533. The symptoms to be drawn from the morbid affections
 of the  functions of the Urinary Organs, relate to the secretion,
 excretion, and condition of the urine, and to the substances
 which are apt to be mixed and expelled with this fluid.
   534. The secretion of urine is either too copious, scanty, or
 suppressed.
   535. A too copious  secretion of  urine takes  place in  the
 disease termed  Diabetes, and a very rapid secretion of limpid
 urine is sometimes observed in  cases of  Hysteria and  other
 nervous disorders.
   536. The  urine is apt to be  unnaturally scanty in  the
 Dropsies.
   537. The case of total suppression of urine is generally a
 very serious affection—leading to coma and a fatal termination.*
   538. The excretion of urine is apt to be morbidly affected by
 strangury, dysury, retention, and  enuresis.
   539. Strangury occurs from the application or administra-
 tion of Cantharides, in some cases of Hysteria, Dysentery,
 and  Calculus, and other morbid affections of the bladder and
adjacent parts.
  540. Retention of urine is  more frequently a  symptom of
disease.  It is observed  in  the late stages of Typhus Fever,
and  is  of very unfavorable augury; it occurs in  Diseases of
  * See an interesting paper by Dr. Abercrombie, Ed. Med. Journ. vol.
210. 
    THE  FUNCTIONAL  AFFECTIONS,  ETC.  133

the Brain and of the Spine ; it is observed as an effect of de-
bility and of insensibility in general; in the state of sinking, in
extreme old age, &c; it is not unusual after delivery;  it is some-
times induced by the action of cantharides; and it is a symptom
in Retroversio  Uteri, and  in other cases in which the neck
of the  bladder is subjected to compression  from the state of the
viscera situated in the pelvis.   In the cases attended  by insen-
sibility, I have  observed  a constant elevation of the  knees as
the effect of the retention of  urine,  and of the  distended and
tender state of the bladder.
   541.  Enuresis,  or  the involuntary flow of urine, is also a
symptom observed in Typhus Fever, and in Diseases of the
Brain and of the Spinal  Marrow.  It occurs in the former
case from  great debility  and insensibility; in the latter from
insensibility or paralysis.   It is sometimes  even a rather early
symptom of Chronic Inflammation of the Brain.
   542.  Enuresis is an effect in some Diseases of the Blad-
der, and  it  arises  sometimes  from  injury  sustained  during
delivery.
   543.  I have once or twice  met with cases in which the urine
was expelled by involuntary gushes, occasioned by sudden con-
traction of the bladder; they have  appeared to be of a hysteric
or nervous nature.  They have occurred in pregnancy, exciting
the fear of abortion.
   544.  The  appearances of the urine, and the nature of its
deposits, are subject to great variety, and still afford  scope for
observation and experiment:—
   545.  We are still in want of a series of careful observations
on the appearances and  other  obvious characters of the urine
in the different kinds, stages, and circumstances of Fevers and
Inflammations, and of Disorders  and Diseases in  general.
   546.  In some cases the urine is copious  and limpid, and
remains, on cooling, free  from sediment; this is particularly ob-
served in  hysteric and nervous affections.
   547. In other cases the urine is so charged with matters in
solution, that there is not only  a  sediment on cooling, but a
pellicle on its surface from  evaporation or exposure to the air; 
  134     THE  FUNCTIONAL  AFFECTIONS

  this has particularly occurred in some instances of derangement
  of the digestive functions.
    548. More frequently there is simply a copious sediment on
  cooling.  These sediments are of different kinds.  To avoid
  repetition, I refer my readers to Chapter VI. on the Diagnosis of
  the  Diseases  of the Urinary Organs, § § 807—820.  I shall
  merely briefly state, in  this place, the points which most call for
  attention from the mere practitioner:—
    549. The first is to  determine whether the urine  be acid or
  alkaline: this is readily done by using a little paper tinged with
  the tincture of litmus,  or so tinged  and reddened  by a weak
  acid ; acidity turns the  blue paper red, and alkali restores to the
  reddened paper its blue tint.
    550. If acidity prevail, we look for deposits of the urate or
 lithate ammonia, which is pulverulent or amorphous; or of  the
 uric or lithic acid, which is crystallized,  constituting  the  red
 gravel;
    551.  If the urine be alkaline, which is observed more rarely,
 and later, we expect a white pulverulent sediment of the mixed
 phosphates; or white  crystals of phosphate of magnesia and am-
 monia, or the white gravel;
   552. Excess of Urea is detected by the deposit of crystals on
 the addition of nitric acid ;
   553. Albumen, by exposure to an elevated temperature;
   554. Mucus, Pus, and Blood, by the test mentioned, $ 377.
   555. I strongly advise every young clinical student to famil-
iarize himself with these simple but useful experiments.
   556. Besides the tendency to deposits on cooling, the urine
is sometimes charged  with albuminous matters coagulable by
heat, especially in certain cases of Dropsy and Diseases of the
Kidney.  It is almost  unnecessary to notice the bilious tinge
of the urine  in the different cases of  Icterus, and its saccharine
impregnation in Diabetes.
  557.  Discharges  of mucus with  the  urine attend  Chronic
Inflammation  of the  Bladder, Diseases of the  Prostate
 Gland, Calculus, &c.  Pus and blood are sometimes observed
as the effects of Calculus and Ulcers of the Bladder or Kid- 
           OF  THE  URINARY  ORGANS.       135

ney.  These discharges should  be carefully considered.   See
§377.
  558.  Copious discharges of blood occur in some instances of
Intestinal Irritation and of Purpura.
  559.  I once had  a patient who  discharged a quantity of
dark-colored blood on any exposure to severe  cold; the affec-
tion yielded to the genial influence of a warm bed. 
CHAPTER XII.
 ON THE FUNCTIONAL CHANGES IN THE  UTERINE SYSTEM.

   560. The  morbid changes in the function of the Uterine
 System relate principally to the suppression, the too copious
flow, or the unnatural state of the discharges.
   561. The retention or suppression of the catamenia occurs
 in the second stage of Chlorosis: in general, but by no means
 always, the flow loses its color and diminishes in quantity very
 gradually, as the effect of this disorder.
   562. In many organic diseases—in Phthisis  Pulmonalis,
 in Mesenteric Disease,  &c. and in cases attended by great
 debility and emaciation—the catamenia are very apt to become
 suppressed, and  that at once, without the changes in their ap-
 pearance just noticed.
   563. Exposure to cold, fear,  and other  causes, are apt to
induce suppression of the catamenia.  Much  purgative medicine
and fever  will sometimes induce  the same effect;  but fever,
sometimes, on the contrary, seems to occasion a flow of  the
catamenia before the proper period.
   564. The catamenia are usually suppressed during lactation.
   565. Menorrhagia is less frequent than  suppression of  the
catamenia; I have known it induced by Intestinal Irritation;
it is frequently an effect of Fibrous Tumor of the uterus.
  566. The Fluor  Albus is an effect of many states of disor-
der, of great weakness, of frequent miscarriages, &c.  It is often
a source of great debility too, and of the inefficiency of medicine
to remove a series of nervous affections.
  567. Morbid discharges from the  vagina take place in
cases of Polypus, Scirrhus,  Ulcers, and other diseases of  the 
          OF  THE UTERINE  SYSTEM.       137

 Vagina or Uterus: the character of the discharges conduces
very much to the diagnosis; when protracted, they ought al-
ways to lead to a careful examination ; § 377.
  568.  Discharges of blood frequently depend on the existence
of Polypus: such  discharges may, however, be the result of
Menorrhagia ; or, during  pregnancy, of a partial detachment
of the placenta.
  569. All such symptoms should suggest the expediency of a
careful examination per vaginam.  Much unnecessary pain
and suffering are entailed upon the female sex by the ignorance
and inattention of physicians in regard to this important point.
18 
CHAPTER  XIII.
     THE PHYSICAL  CONDITIONS OF THE  ABDOMEN.

  570. The physical conditions of the abdomen are ascertained
by an External Examination,  and by Examinations per
vaginam and per rectum, and with the Sound.
  571. The abdomen  may be divided into the epigastric and
the two  hypochondriac regions;  the umbilical and  the two
chondiliac ; the hyper gastric and two iliac.  The Anatomy
must guide us  in determining the situation of the  viscera  in
each of those regions.
  572. The External Examination consists, at first, in apply-
ing gentle pressurer to ascertion whether the abdomen, or any
part of it, be the seat of an enlarged viscus, of a tumor, of
effusion, of tympanitis, of pulsation, &c.
  573. The Liver  may be felt  lower in  the hypochondrium
than usual from Hydrothorax ; or it may be  enlarged in itself.
The latter case will be distinguished by tenderness and other
symptoms of hepatic disease.^)
  574. The Stomach, and especially the Pylorus, when dis-
eased, may  descend  below  its natural situation,  and be found
in the umbilical, and  even in the hypogastric,  region.   The
symptoms  give the  diagnosis.
   575. It is only necessary to add, in this place, a list of the
principal Viscera and Tumors which may present partial  in-
durations on examination of the abdomen :
   576. The former are—1,  the Liver; 2, the Spleen; 3, the
  (1.) The superior bellies of the recti muscles are, I believe, sometimes mis-
taken for an enlarged liver.                                  S. 
OF  THE  ABDOMEN.
139
 Stomach ;4, the Intestines; 5, the Mesentery; 6, the Kid-
 ney; 7,  the  Bladder;  8, the  Uterus; 9, its Appendages.
 These various organs should be traced  on  every examination
 of the abdomen.
    577. The latter are—1,  Abscess ; 2,  Effusion of Lymph;
 3, Aneurysm ; 4, Intestinal Calculi, indurated Faces, &c.
 These and other sources of tumor should also pass through the
 mind in every examination of the abdomen.
    578. In many cases it is important to  place the patient in the
 prone position, and to examine the regions along  the spine, by
 the hand, and by the stethoscope.
    579. The abdomen may be generally enlarged—1, by Poly-
 sarcia ; 2, by Anasarca;  3. by Ascites ; 4, by Dropsy of the
 Ovarium ; 5,  Tympanitis ; &c.  The two former are readily
 distinguished by comparing the elasticity of the one with the
 opposite characteristic of the other.
   580. Ascites is ascertained by the sense of fluctuation con-
 veyed by percussion.  Early in the disease, the prominent part
 of the abdomen is also sonorous;  the sides without sound.   It is
 frequently necessary to press through ascites, in order to arrive
 at an enlarged viscus, or a tumor.
   581. Dropsy of the Ovarium, on the contrary,  frequently
 presents a total absence of sound in its most prominent part,
 whilst the sides of the abdomen are sonorous.
   582.  In  Tympanitis the whole of the abdomen is tumid,
 tense, and sonorous.
   583.  There can be no doubt that the stethoscope might be
 used with some advantage in Ascites,  Tympanitis, Diseases
 of the Intestines, &c. as well as  in Aneurysm.
   584.  The  Examination per  Vaginam  is essential to  the
 diagnosis of Diseases of the Uterus and its Appendages, of
 Pregnancy,  &c.   Whilst the finger of the right hand is intro-
 duced into the vagina, the left should press upon the hypogas-
 trium.  The state of the os uteri, the size  and weight of the
 uterus  itself,  the existence  of adjacent tumors, &c. are thus
determined; the diminution of the cervix uteri, the enlarged 
140  THE  PHYSICAL  CONDITIONS,  ETC.

state of the uterus, and the repercussion of the foetus, ascertained
by this examination, determine the fact of pregnancy.
  585. To ascertain the condition of the vagina and of the os
uteri, a speculum, consisting of a cylinder of glass of a proper
form, is highly useful.( >)
   586. Examination  per Rectum  frequently  confirms  the
diagnosis  made by that per vaginam, and  determines that of
Diseases of this Intestine itself.   It consists in introducing the
finger, a bougie, or the speculum.   See § 529.
   587. 1  need say nothing of the use of the sound, except that
it should always be conjoined with that of the stethoscope.
  (1.) It appears to me that there is no subject to which the attention of prac-
titioners in this country can be  called with more propriety  than to the impor-
tance of the touch  and the speculum in the diagnosis of uterine diseases,—to the
former mode of examination especially, as being less liable  to objection on the
part of patients.  Much experience is necessary to derive the full advantage
from its use.  The  touch, like the other senses, is capable of infinite improve-
ment by practice,—a fact which ought constantly to be remembered by the per-
severing student as  an  encouragement in the study of the physical signs of dis-
ease.  As to the speculum, the best form of the instrument with which I am ac-
quainted, is the bivalve speculum of M. Ricord.                      S. 
SECTION  III.
THE   EFFECTS  OF  REMEDIES.
            THE EFFECTS  OF BLOOD-LETTING.

  588.  The Effects  of Blood-letting are  those which are most
appropriately introduced in this place, as diagnostic of diseases.
  589.  It is one of the most remarkable facts in physic, that if
several patients of similar strength and constitution, but affected
by dissimilar diseases, be respectively placed in the erect position
and. bled to deUquium, they  will be found to have lost very va-
rious quantities of blood.  I  have known a patient,  not appar-
ently very  feeble, faint on losing four ounces of blood;  and I
have known patients bear to lose fifty, sixty,  and even seventy
ounces of blood without syncope.
  590.  This fact, plain and simple as it is,  with its rationale
and practical applications, has, I think, been greatly overlooked,
   591.  Its rationale is to be found,  I believe, in connection with
an equally interesting fact, that different  diseases induce  in the
constitution different powers or susceptibilities in regard to the
effects of loss of blood.  Each disease appears, indeed, to possess
its own peculiar and  intrinsic virtue in this respect.   This is de-
termined by placing  the patient perfectly erect,  and bleeding to
incipient syncope; the quantity of blood  which  flows  is the 
142      THE  EFFECTS  OF  REMEDIES.
 measure of the protective influence of the disease in one class of
 cases, and of its influence in superinducing a susceptibility to
 the effects of loss of blood in the other.
   592.  An  interesting scale of diseases may be formed  repre-
 senting  these properties.   It would begin with congestion  of the
 head, or tendency to Apoplexy ; Inflammation of the serous
 membranes, and of the parenchymatous substance of various
 organs, would follow; and, lastly, Inflammation  of the mu-
 cous membranes.  This part of the scale would be divided from
 the  next by the condition of the  system in health.   Below this
 would be arranged fever, the effects  of Intestinal Irritation,
 some cases of delirium, re-action from loss of blood, and dis-
 orders of the  same class with Hysteria, Dyspepsia,  Chlorosis,
 and Cholera morbus.
   593  Persons in health and of moderate strength will gene-
 rally faint, if bled in the  erect posture, on  taking fifteen ounces
 of blood.  I have known seventy ounces to be taken in the sit-
 ting posture,  in the tendency to apoplexy, without syncope ; but
 the case  is an extreme one.  Patients with Pleuritis ox Pneu-
 monia frequently lose thirty-five  ounces of blood without faint-
 ing.   In Bronchitis  little  more is borne to be lost than in
 health.  A stout person in Fever will frequently faint oii losing
 ten, twelve, or fourteen ounces of  blood.   In Intestinal Irrita-
 tion, with urgent symptoms even, the abstraction of nine er ten
 ounces of blood will generally induce deliquium.  In Delirium
 Tremens, or Puerperal Delirium, the  patient soon faints
 from loss of blood.   The same thing is still more observed in
 those cases of violent re-action which arise from loss of blood it-
 self.   In Dyspepsia, Hysteria,  and Chlorosis, the suscepti-
 bility to  syncope from loss of blood is very great:  and  I have
known a patient, of good  strength, affected with Cholera, faint
on taking four ounces of blood, although she had shortly before
borne to lose  nearly twenty ounces without faintishness, under
the influence  of inflamed Mamma.
  594. The practical application  of these facts consists chiefly
in its affording a rule for blood-letting in all cases in which this
measure is required to be fully instituted;  a guard against undue 
          THE  EFFECTS  OF  REMEDIES.      143

blood-letting, both in this and some other cases;  and a source of
Diagnosis.
  595.  The rule is suited also to the degree and the duration
of the disease;  for,  with each of these, its influence in inducing
tolerance  or intolerance of loss of blood is respectively aug-
mented.
  596.  It is not less adapted  to those most frequent of all events,
mixed cases.   Inflammation and irritation may be conjoined:
for example, there may be mere nephralgia, or absolute nephri-
tis, from calculus, or a mixed case involving both.   There may
be mingled  intestinal irritation and inflammation.  In each of
these circumstances, the  rule for blood-letting  which  I have
proposed adapts itself accurately  to the demands of these various
morbid  affections, and to  the actual strength and condition of
the general  system.
  597.  It is difficult to say whether more injury has been done
by an undue or by an inefficient use of the  lancet.   In inflam-
mation  we must bleed fully.   In irritation we must  bleed cau-
tiously.   Inefficient blood-letting,  in  the former disease, and
undue  blood-letting, in the latter,  are alike dangerous or even
fatal to  the  patient; from  both extremes we  are guarded by the
rule which I propose.   By directing the patient to be placed in
the  erect position, and bled  to  deliquium, we often take much
more blood  than we should  have ventured  to prescribe, in in-
flammation, and very much  less than we might be disposed to
direct, in irritation; and in both  these cases the rule  conducts us
to the only safe mode of treatment.
  598.  If much blood has  flowed,  then,  before syncope has
occurred,  we must suspect  inflammation;  if little, we must
suspect  that, however similar the symptoms, the case is in fact
of a different nature—perhaps irritation, perhaps exhaustion.
   599.  I have also found that,  in every case in which early
syncope occurs from blood-letting, the more remote effects of loss
of blood, as reaction, or sinking, are also very liable to occur;
and it is in  these cases that sudden  dissolution has followed the
use of the lancet.   There is,  in every point of view, intolerance
of loss  of blood.  The reverse of all  this obtains in inflamma- 
144      THE  EFFECTS  OF  REMEDIES.

tion, which seems to be  incompatible,  to a certain degree, with
the effects of loss of blood, which are, however, very apt to super-
vene as the inflammatory action subsides.
   600.  And here I would solicit the co-operation of my medical
friends in the  further investigation  of the subject of which I
have briefly treated.   It  is by the multitude of facts alone, that
the propositions which have  been stated  can be established or
corrected.  With the view of obtaining these facts, I would pro-
pose that, in every case  in which full  blood-letting is to be in-
stituted, the patient should be placed perfectly erect in a chair,
or in bed, and  bled to the very first appearance of deliquium;
the quantity of blood  taken is then to be noted, and accurately
registered in  a table.   The same thing  is  to  be observed on
each repetition of the blood-letting.
   601.  And that nothing may  be  left unattended  to, which
may throw additional light on the subject, to this point I would
add—1. the appearances of the blood, and 2, the effects of its
abstraction upon the disease.
   602.  These  various facts I propose  to register in the follow-
ing manner:
Age and strength of the patient.	Disease, its stage and complica-tions.	Quantity of blood taken.	Effects on the patient and disease.	Appear-suices of the blood.	Repetitions ot the " blooo-let-ting.	Effects.
						
  603. It is obvious that none but the most unequivocal cases
should be thus registered.  Cases, the diagnosis of which was
not perfectly clear, would only add  their own obscurity to the
investigation.
  604. It is equally obvious that the investigation proposed can
only add useful facts,  which  will in their turn become useful
guides to the physician.   It  is still true,  as  Celsus has ob-
served,—" nulla perpetua precapta medicina recipit."  To 
           THE  EFFECTS   OF  REMEDIES.      145

 the young practitioner, however, I think the practice proposed
 will prove of great assistance :  and if it preserve one from the
 bitter reflection, which some have experienced, of having done
 too much or too  little, I shall  not esteem that my exertions in
 introducing it have been in vain.
    605.  I  would observe, in conclusion, that I do not think it
 safe, in  any case, to bleed to actual deliquium, in the recumbent
 posture.   But there are few cases, if any, in which, if it be pro-
 per to bleed fully at all, danger can accrue from bleeding to the
 most incipient syncope,  in the  perfectly upright position.  Be-
 sides, the  remedy is at hand.  It consists simply in laying the
 patient  recumbent, and if  necessary, raising the feet and de-
 pressing the head.
   606. It  may become a question, v/hether the patient may, in
 a little time, be again placed erect, so as to reproduce a state of
 slight deliquium, and thus to add to the power  of the previous
 blood-letting in subduing the  disease.  But I do not think  a
 state of  continued syncope free from danger.   I  have  known
 it lead to delirium.
   607. On the other hand, the influence of an opposite position,
 the head being placed extremely low, and the lower part of the
 body being very much raised, has not  been  sufficiently traced
 in the various cases of the immediate or remoter effects  of loss
 of blood.
   608. Amongst  the  other objects of  this  " proposal," is that
 of collecting any modifications or exceptions,  in regard  to the
 rule which I  have laid down.   It cannot be  imagined  that it
 should be  without exceptions.   It is as important that  these
 should be pointed out, as that the rule itself should be established.
 There are  two exceptions to the  rule which I have proposed,
 which I would briefly mention.   In some cases of fever requir-
 ing blood-letting, the patient cannot support the erect position:
 in such a case, the arm must be first prepared, and then the
 patient should be  gently raised  and supported  in the upright
 position,  carefully avoiding all muscular effort; the vein should
 then be  promptly opened.  On  the other hand, in the case of
congestion  of the brain from exhaustion, there is not such early
                            19 
146      THE   EFFECTS  OF  REMEDIES.
syncope from blood-letting  as  might be expected; and yet it is
obvious that the system cannot bear the loss of blood: I have
known this to obtain in exhaustion from undue lactation.
   609. It will also be an interesting question whether this rule,
in its repetitions, besides excluding  undue blood-letting on one
hand, and  inefficient blood-letting on the other, does not secure
the cure of the disease, with  the  least possible expenditure of
the vital fluid.
   610. The  appearances of the blood, the effects of its abstrac-
tion upon the disease, and many other questions, will naturally
come to be included  in the farther prosecution of the inquiry
into the effects of blood-letting.
   611. There is a totally different point of view in which  the
Effects of Blood-letting may prove diagnostic: it is when, instead
of effectually removing the disease, it only relieves a symptom
which speedily returns, perhaps with augmented violence.
   612. This effect is seen in cases of Chlorosis, in which  the
pain of the head, or the pain of the side, has led to the re-
peated but mistaken use of the lancet.  I have  known patients
terribly worn  and shattered by this proceeding, the health re-
maining feeble  for years.  In such a case the  very number of
leeches and blisters which have  been applied  becomes a diag-
nostic of the disease!
   613. Another case is that in which one of the remote effects
of loss of blood  itself, as pain of the head, or throbbing of  the
temples,  has suggested the further use of blood-letting.  The
eyes of the  practitioner are  at length opened to the folly and
imprudence of the measure by a state of debility not entirely
free from alarm.*
   614. This effect has been observed kin cases in which  it was
consequent upon blood letting, perhaps properly instituted.  Mr.
Brodie has  observed it in cases of Injury of the Head.t  It is
♦ Researches on the Effects of Loss of Blood.
   t Med. Chir. Trans., vol. xir, p. 381. 
          THE  EFFECTS  OF  REMEDIES.      147

the common consequence of blood-letting  carried beyond the
limit which the  disease requires, or, what is  the same thing,
beyond what the system can bear.
  615. Similar observations might be extended to other reme-
dies, and especially  to mercury, digitalis, purgative medi-
cines, &c. 
SECTION   IV.
THE  MORBID  ANATOMY.
  616. Nothing has contributed so much to establish the va-
lidity of the History,  Symptoms,  and the Effects of Reme-
dies, as signs of disease,—to raise Medicine from its condition
of a conjectural Art, to the rank of a Science, as the investiga-
tions into the Morbid Anatomy.
  617. The presence of morbid changes of structure affords the
evidence of previous morbid actions, their absence affords the
proof that such morbid actions have not existed.
  618. I would observe, however, that the mere student of Mor-
bid  Anatomy is  not a good practical physician.   There  is so
much to be considered in the condition of the general system, in
the sympathies with the organ, or organs, principally affected, in
the effects  of remedies, &c. that he who has an eye to the mere
disease, the morbid change of structure, alone, is not in posses-
sion of the  knowledge required to treat the patient.
  619. In pursuing the post-mortem  examination, a certain
order should be observed : all the cavities, all the organs should
be inspected, and  not those only in which disease is suspected ;
the Head, the Thorax, the  Abdomen, and the various  parts
and organs contained in them, must be examined, must be open-
ed, in succession.
  620. In each of these cavities we must notice the state of each
organ, and in each organ we must examine the different tex-
tures, but especially 
             THE  MORBID  ANATOMY.         149

           1. The Serous Membranes.
           2. The Parenchymatous Substance.
           3. The Mucous Membranes.

  621. In each of these  textures, again, we endeavor to trace
the condition of the circulation, the degree of cohesion, the in-
terstitial deposits, the aggregated deposits, &c.
  622. In the Serous Membranes we observe

           1.  Injection.
           2.  The effusion of Serum.
           «*•-----------Lymph.
           4.------------Blood.
           5.-------------Pus.

  623. In the Parenchyma we trace

           1. Injection.
           2. Induration.
           3.  Softening.
           4. Hypertrophy.
           5. Atrophy.
           6. Suppuration;
               1. Abscess.
              2. Infiltration.
          7. Apoplexy, &c.

 624. In the Mucous Membranes we observe

          1.  Softening.
          2.  Ulceration.
          3. Hypertrophy, &c.

 625. In all we look for

          1.  Tubercles.
          2.  Scirrhus.
          3. Encephalosis. 
160         THE  MORBID  ANATOMY.
           4.  The " Mature Colloide?
           5.  Melanosis.
           6.  Fibrous  Tumors.
           7.  Cysts, <fcc.

  626. Each of the organs has its peculiar alterations, a  List
of which will be furnished in the Table of Contents, to which
I would, therefore, especially direct the attention of the student,
as his guide, when about to proceed to the post-mortem examina-
tion of any case which may have fallen under his notice.
  627. I have thus sketched the principal Sources of the Diag-
nosis of Diseases.   I now proceed to treat of Diagnosis still more
practically.  In doing so, my principal object is to furnish the
young student with a concise view of the objects which will pre-
sent themselves to his notice in his  actual visits to the wards of
his Hospital, or the chambers of the sick. 
THE
PRACTICE   OF  DIAGNOSIS.
                INTRODUCTION.

OF THE  OBJECTS  OF DIAGNOSIS,  AND  OF THE DIAGNOSTIC
                     ARRANGEMENT.

  1. The Diagnosis of diseases, as I have already stated, con-
stitutes the first part  of the office of the physician, in his actual
visits to the sick.
  2. With the diagnosis must be associated correct views of the
nature of the disease, or the pathology, and a just appreciation
of the powers and condition of the patient, or, to use a neglected
phrase of great practical value, the " constitution."   It is in this
manner alone that we can be led  to the ultimate object of the
physician, the correct appropriation and adaptation of the reme-
dies, or the therapeutics.
   3. Having distinguished the disease from all others,  the phy-
sician has still many arduous duties to perform: the nature, the
stage, and the extent of the disease must be determined ;  the or-
ganic changes it may have induced;  the  effects it may have
had on the vital functions and actions ;  the devastations it may
 have occasioned in the powers of the general system.
   4. These points must be reconsidered at each visit.  The pe-
 culiar actions of the disease, the effects induced on the structure
 of the part principally affected, and on the functions and powers
 of the system, vary from day to day.   They must be accurately
 and assiduously watched and traced.
   5. But even this is a simple view of the subject compared with
 what actually occurs in practice.   Very few cases of disease are
 simple.   Generally more than one organ is  affected,  and the 
  152                 THE   OBJECTS

 principal  disease is,  either  from the  commencement,  or the
 course of the  affection, complicated with others, seated more or
 less remotely.   I am quite of the opinion of M. Louis :  " II n'ar-
 rive probablement jamais  que des individus qui meurent d'une
 maladie dont le  siege est  bien determine, n'offrent de lesions
 que dans l'organe primitivement affecte."*  Having detected the
 principal  disease, we  have, therefore, continually, daily,  to in-
 quire what others, what complications, there may be.
   6. The  complications may  consist either in functional  or
 structural changes induced in an organ or organs not originally
 affected, or in the condition  of the general system, its various
 combined functions, and its powers.
   7. One source of complication, which operates in the course of
 the  disease, is that  arising from the very remedies employed.
 We have continually to inquire whether a given phenomenon
 is the effect of the disease or of the mode of treatment,—whether
 it be the effect of the morbid actions or of  the remedial agents.
   8. Besides the actual complications of the  disease, there is a
 further interesting inquiry into  its remoter consequences,  or the
 sequela.   These are  frequently little less important than the
 original disease, and its earlier complications.
   9. Complicated as this  view of the diagnosis and of practice
 may be, it is rendered  easy and familiar to the student by pro-
 per arrangements, and to  the practitioner  by  the force of habit.
 It will  be  one particular object of the present work  to offer such
 arrangements of the sources and objects of diagnosis as may be
 useful  to the young  and inexperienced, for whom it is entirely
 destined.
   10.  The disease,  the complications,  and the sequelae, may
consist in  mere functional, or  structural changes.
   11.  The morbid changes of function  constitute the symptoms
 of the disease, and sometimes, doubtless, the entire disease.
   12.  Morbid changes of function, and occasionally of structure,
are not unfrequentiy the effects of remedies employed.   I have
* Rdcherchcsde Gastro-ente>ite, tome i, p. 419. 
OF  DIAGNOSIS.
153
 treated of such effects as undue  blood-letting at great length, in
 works recently published.*
   13. The morbid effects of some remedies, as  forcibly illustrat-
 ed in the cases of excessive loss of blood, of the erethismus mer-
 curialis, &c. afford, indeed, new examples of states which must
 be early distinguished and identified, if we would save our pa-
 tient from the imminent danger of a repetition or continuation of
 the remedy.   Mr. Brodie observes, in reference to the treatment
 of injuries of the head :t—" Where bleeding has been carried to a
 great extent,  symptoms  frequently occur which in reality arise
 from the loss of blood, but which a superficial observer will be led
 to attribute to the injury itself, and concerning which indeed it is
 sometimes difficult,  even for the most experienced  surgeon, to
 pronounce in the first instance to which of these two causes they
 are to be referred."   Dr.  BatemanJ remarks  on that effect  of
 mercury, termed erethismus  mercurialis, in  his  own case:—"It
 is evident that  the features  of the malady are not sufficiently
 known, even to the most enlightened members of the profession ;
 for the failure on the part of the medical advisers, in the instance
 about to be related, to recognize its first symptoms, and the con-
 sequent repetition of the dose of the poison,  after its commence-
 ment, had nearly proved  fatal."  I shall never  forget a tragical
 instance of the effects of digitalis, under precisely parallel circum-
 stances.   Other  instances of the morbid effects of remedies are
 afforded by purgatives, opium, quinine, &c.  It is thus, as I have
 already slated, frequently an interesting question, as  involving
the safety of the patient, whether a given symptom belong to the
disease or to the remedy,-5—whether the former be unsubdued, or
the latter be already given in excess.
   14. The study of morbid  changes of structure must be pur-
 sued in a new manner, before it can reflect all the advantages
 which it may do upon  the practice of physic—that is, in con-
  * See Researches on the Morbid and Curative Effects of Loss of Blood.  See
also the Medico-Chirurgical Transactions, vol. xiii, and xvii.
  t Medico-Chirurgical Transactions, vol. xiv, p. 3S2.
  I Medico-Chirurgical Transactions, vol. ix, p. 220.
                             20 
154
THE  OBJECTS
nexion with  the previous morbid actions ;  otherwise, how can
they be anticipated—prevented ?  The very nomenclature must
be changed.  Certain morbid structures are found in febrile, in
eruptive,  in  inflammatory,  in  scrofulous,  in  haemorrhagic,
diseases ;  all  have alike been designated as inflammatory, and
there have been interminable disputes whether they be causes or
effects.  The true mode of pursuing this subject is, to associate
the morbid change with the previous disease,  and, as much as
possible,  with its symptoms, its periods, its degrees of severity,
&c. just as, during our attendance on the sick, we should each
day inquire—what is, at this precise period, the probable state of
the structures'.*—of the constitutional powers 1
   15.  This  is  the more essential, because any  given  morbid
change of structure is seldom or never met with in patients, as in
books, distinct and isolated.   It seems probable, indeed, that the
solids, the fluids, and the nervous system, are variously but sim-
ultaneously involved in all diseases.  The morbid change is sel-
dom confined  to a part—an  organ.  Certain morbid appear-
ances, and certain associations of morbid appearances, are met
with in fevers,  in the eruptive diseases,  in  inflammations, in
scrofulous or tuberculous affections, in dropsies, in haemorrhages,
&c. to which  my attention has  been forcibly drawn,  and to
which I wish  to draw the  attention of the  profession.   Such
forms and such associations of morbid changes constitute the
disease.   Each of such  forms  is peculiar.   The same change
of structure observed in different diseases, according to our usual
phraseology, is not, in fact,  the same.   The inflammatory  af-
fections of the skin, which occur in scarlatina, in  rubeola, in  va-
riola,  are  not  the same.  In  like manner morbid changes of
structure, observed in febrile, inflammatory, and  other diseases,
although designated by the same term, are not in truth the same.
It is on this  account that 1 have rather  chosen to speak of mor-
 bid changes as febrile, exanthematous, inflammatory, &c. for in
 this manner alone do we identify  such morbid changes, and as-
 sociate them with the individual disease.   I  have no doubt, too,
 that by a diligent and careful scrutiny, such changes of internal
 structure will,  like the appearance on the skin,  be found to be 
OF  DIAGNOSIS.
155
 peculiar in each disease.  We should not be satisfied in speak-
 ing of the cutaneous affection in variola, rubeola, and scarlatina,
 as mere inflammation.   On the contrary, we carefully preserve
 the idea of difference, of peculiarity.   The same  observation
 applies to the internal changes of structure.   The situation,
 as well as the character of these affections, is peculiar.  In typhus,
 we look for an affection of Peyer's glands ; in rubeola, for bron-
 chitis ;  in scarlatina, for affections of the throat, &c.  But  it
 still remains to be shown, that  in each and every disease, the
 very morbid change of structure itself is peculiar.
   16.  There is  another view  of this subject.  Such changes
 may occur in a given series, or  with a given course of the dis-
 ease ; and this series may flow  from the original causes, as suc-
 cessive local causes and effects, as the effects of remedies, or from
 the condition of the system : some are even cadaveric.  In fever,
 we may  first have ulcerations  of the intestines,  then haemor-
 rhage, as a consequence; then, as further  consequences,  the
 sinking state, and its effects upon various organs;  or we may
 have the sudden perforation of the intestine, or the slow develop-
 ment of tubercles.  Of what value is abstract morbid anatomy,
 undetected during life, unassociated with the history, the symp-
 toms, and the effects of remedies, untraced  to the  individual
 disease and its various periods 'I
   17. Diseases do not, like the objects of natural history, admit
 of being divided into species, which are continually reproduced
 in nature.   They consist, on the  contrary, of mere  varieties or
 individuals, which never recur in precisely the same form.  They
 do not even admit of being viewed in this degree of  simplicity;
 they are,  on the contrary, not  only continually varying, but
 they are continually more or less  complicated with each other, in
 combinations still  more varied.   The  varieties  of diseases  be-
 come yet more numerous by the  conjunction of the same or dif-
 ferent diseases concurring in several parts.  And, lastly, every
case partakes of a peculiar and individual character,  impressed
upon it  by the peculiarities of the constitution,  age, and sex of
the patient;  the season  of the  year, the state  of the atmos-
 phere, &c. 
156
the  objects
  18. The investigation into the state of the "constitution" of
the patient, is one which has been greatly neglected, and which
must be studied anew.   It is to this department of knowledge
that Celsus alludes in the following paragraph :—"Ob queecon-
jicio, eum qui propria non novit, communia tantum intueri  de-
bere ; eumque qui propria nosse potest, ea quidem  non oportere
negligere, sed his quoque insislere.  Ideoque, cum par scientia
sit, utiliorem tamen medicum esse amicum, quam extraneum."*
It is to this department of medical knowledge that  I would par-
ticularly call the renewed attention of the profession.  Every
physician feels how much easier it is to prescribe for a patient for
whom he has frequently prescribed before, than for a stranger.
The habit of such a patient in regard to the kind and severity of
the disease, and in regard to the power of supporting  important
remedies, is familiarly known to him.   There is in every one a
certain  idiosyncracy, to which it is highly important to attend
with scrupulous care.  This notion is become ant iquated of late ;
it is nevertheless founded in truth, and will meet with acceptance,
as an old friend, by all practical physicians.
   19. With all these sources of variety in disease, it is essential
that the physician  should be familiar; it is therefore necessary
that this extensive subject should be simplified for the sake of the
student and the young practitioner, who must be led through its
elementary portals to view the complicated structure of the tem-
ple of medical  science within ; or,  to employ simpler terms,  we
must first treat of diseases viewed  simply and distinctly, before
we  proceed to detail the circumstances of multiplicity and com-
plication under which they occur in nature.  We must then lead
the student on to contemplate diseases  as they actually occur •
as almost universally complicated ;  as involving the general sys-
tem and  its  various parts; or as affecting one particular organ
principally, but the rest also consecutively.
   20. Each disease must be investigated with a  particular re-
ference to
      I.  The Changes  of Structure.
     II.  The State of the System.
"Piasf. 
OF   DIAGNOSIS.                157
   III.  The Effects of Remedies.
  21. Each disease must be further traced in its complications
and sequela, which, in their turns, consist in
     I.  Effects of the disease itself.
    II.  Morbid Effects of Remedies.
    III.  The Development of New Diseases.
  22.  Each of these  complications and sequelae  manifests
itself in
    I.  Changes of Function and
    II.  Changes of Structure.
  23.  In pursuing the diagnosis, I purpose, after every enume-
ration of a disease, to add some of these terms.   The paragraph
will then be continued by the further addition of what is known
on  that topic, in regard to that disease.  How many blanks
there will be I  need not say; but, whenever such a blank does
occur, a note of interrogation will at once express that fact, and
suggest a subject of investigation for new inquirers.
   24.  As a first  example, I  will  adduce the case of Fever.
 This term, derived from ferveo, merely means heat of the ge-
 neral surface.   Such a condition occurs in many diseases;  but
 the term fever has been  restricted  by  physicians, ancient and
 modern, to denote certain diseases, practically and really distinct
 from all others.
   25.  In every case of fever, we have,  first, carefully to inquire
 into the changes of structure, the condition of  the  general  sys-
 tem, the immediate effect of remedies;  in the next place,  we
 have to mark  the remoter effects of the disease, the effects of the
 remedies, and  the development of new  diseases.  Each of these
 may consist in functional or structural  changes.
    26.  It rarely happens that fever consists in mere febrile move-
 ments of the  system.  There are usually complications with
 the general febrile state, of affections of the head, chest, and ab-
 domen;  and it has been  long  disputed whether these  affections
 be primary causes or secondary effects  of the fever; and much
  that is just has been argued on both sides of the question.  It is
  singular  that  no such dispute has  been raised in regard  to a
  class of fevers which I shall designate the eruptive.  Yet it ap-
  pears to me that the rash and the sore throat  of scarlatina,  and 
158
the  objects
 the rash and the catarrh of rubeola, and the ot her complications
 of these and of other febrile diseases, occupy the very same rank
 as the various local affections, whether of function or of anatomy,
 which we observe so constantly in other fevers.   They occur
 alike in the course of these several diseases, and  doubtless oc-
 cupy the place both of effects and of causes in the entire disease.
 The object of greatest moment  in  regard  to the  dispute, is to
 lead the young practitioner to observe accurately, and to watch
 carefully, in order that he may early detect these complications
 in their varied form and extent,  and promptly apply the appro-
 priate remedy.
   27. This concluding remark may be applied to the Eruptive
 Fevers.   In the first days they cannot always be distinguished
 from other forms of fever, and during  their course, and after
 their  more wonted course,  the same watchful observation is
 necessary  to detect topical complications.  This  is especially
 true  of variola, and  scarcely less so of  rubeola, of scarlatina,
 of erysipelas, &c.  The complications of the eruptive febrile
 diseases are principally two:  a  peculiar  inflammation and its
 consequences; and tubercles.  The former  are acute at first,
 the latter insidious.
   28. Similar remarks apply to the  next class of diseases to be
 mentioned, viz. Inflammations.   Inflammation is apt, although
 far less so than fever, to be complicated.   We frequently on dis-
 section find inflammation of more organs, of more cavities, than
 one.   This is particularly true of  protracted inflammation.
   29. I regard the view of fever and of inflammation which I
 am endeavoring to sketch, as applicable to all derangements of
 the system without exception, in  various  degrees, and as one
 of the most important, and least cultivated, to which the atten-
 tion can be  directed.  The actions of the system  cannot  be
 deranged in  any way without the danger, daily increasing, of
topical disease, in one  or more organs.  Most observed in fever,
least in inflammation, this tendency obtains in all diseases, and
in all  disturbances of the system, only in varied degrees, and
in various  modifications.   To this important subject I shall
have frequent occasion to recur in  the following pages.
  30.  Arthritis is another disease  which  involves an affection 
OF  DIAGNOSIS.
159
of the general system, and of various organs or parts, with that
principally affected.   How much  has been said, and how little
is really well and truly known on this subject!  Not being a
disease of hospitals, the morbid anatomy has not been well culti-
vated.   No branch of physic is still so much in need of a philo-
sophical investigation as that of Gout.
   31.  Very similar observations apply to another disease, some-
what better known, indeed, but  still involved in  much doubt
and uncertainty, viz. Rheumatism.  The connection of rheuma-
tism and disease of the heart is well  known  to the physicians
of this country;  but the attention of our  neighbors in France
has not been sufficiently  fixed upon this topic.(')  And how
does confusion reign in regard  to the other internal rheumatic
affections !
   32.  There  is a subject  entirely neglected  by the profession,
which I must bring  particularly before the reader in this work.
It is that which I have designated Irritation.   Much confusion
exists in regard to the sense in which this term is to be em-
ployed in medicine.   The French pathologists appear to mean
by it only a lower degree  of inflammation than that  to which
the latter term  is confined.  Now a question of  mere degree
does  not require a  new  designation, but merely an epithet.
Besides, it must appear to all, that from the very signification of
the word, the term irritation ought to be used  in a sense totally
different from that of inflammation.
   33.   Without  entering  further into this discussion, in this
place, I shall  briefly explain the manner in which I purpose to
use this term, and I shall  do so  by an  unequivocal example.
I will  suppose a  calculus  existing in the gall-duct, or in  the
ureter.   It may prove the  source of much suffering,—of pain,
—of sickness.   This is a case of irritation.  The calculus is the
cause; the pain the immediate, the vomiting  the more remote,
effect.   All this  is very simple and intelligible.   There  is an

   (1.) Much has been done to effect this object since the publication of the last
edition of this work.  The student may consult, with great advantage on this
subject, the writings of M. Bouillaud, Traitt Clinique des Maladies du eceur; Essai
sur U Rhcumatisme—also, the Lecons de Clinique Medicate, t. ii, by M. Chomel.
                '                                        S. 
160
the  objects
example of irritation less known, less acknowledged,  but not
less unequivocal.   It consists in a morbid condition of the in-
testinal contents, which proves a source of  varied  suffering,
chiefly in the abdomen or in the head,—and  resembling  acute
inflammation of those parts.*
  34.  Next to irritation, we must consider the case of Exhaus-
tion, or of Inanition, from loss of blood or other causes.   As in
so many other morbid affections, the general system and differ-
ent organs, are  affected  in this disease, but especially the head
and the heart.t   Like irritation, exhaustion has long been mis-
taken, in its effects, for some inflammatory diseases.  Both these
cases  should be constituted,  like fever, inflammation, &c. into
genera or classes  of  disease.  The  former are scarcely  less
frequent or less  important than the latter, and the diagnosis is
one of the utmost moment.
  35.  Nearly allied both to irritation and exhaustion are Acute
Dyspepsia and Chlorosis.  Conjoining a marked  affection of
the general system with equally marked topical affections, they,
like so many  other diseases,  must  be viewed  in  the  light of
classes rather than of individuals.  It  is highly important that
the young  physician should be familiar with both their general
and their local forms.
  36.  The same observation applies to Hysteria.   Consisting
originally in intestinal, or uterine, or, as some say, spinal irrita-
tion, and inducing peculiar effects upon the nervous and muscu-
lar systems, hysteria is not only a class of disease,  but a class
involving almost as many forms as that of inflammation itself.
  37.  In like manner,  Scrofula or  Tubercles are rarely  con-
fined  to one organ.  There is a general affection of the whole
system,—the cause?—the effect? of this  disease, and an affec-
tion of one or various organs.   In our  despair of curing tuber-
cle, we should  not  neglect the study of the disease  in this
peculiar aspect.  Such a study leads to an early diagnosis, and
this always redounds to  the physician's reputation, and  con-
stitutes, indeed, his best, his most just title to it.
• See the "Researches," already quoted, p. 210.
f Ibid, chap, iii, and p. 115. 
OF  DIAGNOSIS.
161
  38. The disease, still so  little known, designated Melanosis,
affects various organs simultaneously.
  39. That disease, known under the designations fungus hae-
matodes, encephaloid tumor, &c. and which I shall denominate
Encephalosis,  as at once the shortest and most distinctive, is,
like so many others, one of the whole system, and apt also to
occur simultaneously in various organs.
  40. Scirrhus, and its consequence, Carcinoma, is also  apt to
occur in different organs, especially organs of the same system,
and it spreads its awful ravages along the absorbent vessels and
glands.  Dr. Farre detailed an interesting case in his Lectures,
from Sir Astley Cooper, of scirrhus occurring simultaneously in
the uterus and the mamma.
  41.  These diseases must next be arranged according as they
affect the different  important  cavities and organs;—the head,
the chest, the abdomen; the brain, the lungs and the heart; the
organs of the digestive, urinary, and generative systems.
  42.  Morbid actions in one organ almost always induce mor-
bid conditions of another or others, by sympathy.  This sub-
ject, if confined to  purely practical views, still affords scope for
most useful and important investigation.  How  often, for in-
stance, is sickness, or torpor of the bowels, disregarded as a trifling
event by the young and inexperienced, when it ought to awake
the most serious alarm for  the state of the brain,—especially in
children.  Headache and vertigo,  on the other hand, are fre-
quently sympathetic affections from derangement of the stomach
and the intestinal  canal.  The terms sick-headache and stom-
ach-cough are not without their foundation.  And it is not im-
probable that one form of epilepsy, and that true asthma,  origi-
nate in derangements of the stomach and bowels.
   43. Besides the  complications and  sequelae to which I have
adverted, as taking place  in  various febrile, eruptive, inflam-
matory, and other diseases, there are others of a different kind,
arising not  so much from morbid  action, as from interrupted
function in one or  more organs:  thus, disease of  the heart,  of
different kinds, is apt to induce such  derangement in the circu-
lation, in the head, the lungs, the liver, the alimentary canal,
                             21 
162
THE  DIAGNOSTIC
 the cellular membrane, &c. as may lead to congestion  rupture,
 or effusion.  Certain diseases of the head  impede the functions
 of the lungs, the stomach, the intestines; certain diseases of
 the liver lead  to dropsy; certain states of the kidney, to coma.
 To this subject I shall have many occasions of reverting in the
 following work.
   44.  There is still another species of complication.  It occurs
 when an internal organ partakes of the condition of the external
 teguments. It is seen in erysipelas affecting the head, and in
 variola and scarlatina.
   45.  Besides the complications and  sequelae, which are apt to
 occur in all diseases, there is an event which only takes place
 in a few.   It is designated  metastasis, or translation.   It con-
 sists in the transfer of the  disease from one part  or  organ to
 another.    It is observed in rheumatism  and gout.  But it is
 seen most of all in the secondary effects of intestinal irritation,
 and  in hysteria, of which, indeed, it constitutes a marked char-
 acteristic.   A part or organ  most affected by the disease to-day,
 may be entirely free from it to-morrow ; whilst another  part or
 organ  previously  unaffected,  becomes subject to the  morbid
 derangement.
  46. Something  allied to  metastasis is said  to be observed in
 cases in which eruptions, whether acute or chronic, are repelled.
 One form of erysipelas is emphatically termed the erratic.
  47. When the objects of  study are so numerous, the mode of
arrangement cannot but be of the utmost moment; and  when
the great difficulty in the study is the due and accurate distinc-
tion of those objects, the best mode of  arrangement is obviously
that by which this end is most readily attained.
  4S. It  has been my wish, in the first place, as  much  as pos-
sible, to arrange and bring  before the young physician every
case which can require his attention in  actual practice.  In
doing this, I have been equally desirous to avoid  surcharging
these sketches with the names and descriptions of diseases which
are more objects of curiosity and over-refinement, than of prac-
 tical utility.  I must be excused for still thinking the terms
 fever, inflammation,  rheumatism,  scirrhus, &c.  useful and 
arrangement.
163
 practical designations of disease, just as rubeola, erysipelas, and
 gout, are so.  They, like  all other  terms  in  all the sciences,
 require first to be accurately defined,—the sense in which they
 are used to be strictly determined; and then I know not that
 the science or the practice of medicine would gain  by an ex-
 change of these terms for others, such as gastro-enterite, hyper-
 emie, &c. &c. &c. terms equally objectionable, as inadequately
 expressing  the nature and phenomena of  fever or of inflamma-
 tion respectively, and not having the sanction of use for their
 employment.
   49. I shall be guided by similar principles in the distinctions
 which I shall attempt to draw  between different diseases.   My
 aim will still be to separate really useful subjects from the curious
 and  the  fanciful,—and this,  although the former may consist
 in changes of function, unattended  by appreciable changes of
 structure, and the latter, sometimes, in actual changes in the
 anatomy: I think the distinction between inflammation  and
 irritation, for instance,  of infinitely greater  vital importance,
 than that between eccentric and concentric  thickening of the
 heart.  I by no means pretend, however, to depreciate the merit
 even of such discoveries;  I only wish to  state my own convic-
 tion of the comparative value  of certain medical  facts and in-
 vestigations, and  to express the principle which has guided me
 in the selection which I have made, and  the comparative im-
 portance which I have attached to them respectively.
  50.  Having in this manner  endeavored to form  a complete
 collection of diseases, the next question has been as to the mode
 of arrangement.   I have  adopted that which has appeared to
 me at once the simplest and the most  practically useful: it has
 been that of classing them together in the order  and manner
 of their external  similarity.  I have  designated this mode of
 arrangement the diagnostic arrangement, as being that which
 immediately suggests the objects and the means of the diagnosis.
 Two or three diseases placed closely together, for that very reason
 require to be distinguished with peculiar care.  A disease placed
 alone, on the other hand, however difficult of cure, presents no
difficulty in the diagnosis.  Having formed a conjecture, rather 
164   the  diagnostic  arrangement.

than an opinion, of a given case, we have but to refer to this classi-
fication, to discover what difficulties in the diagnosis do exist,
what dangers beset our  path—as the mariner learns from his
chart the situation Of rocks and sand banks—and we are im-
mediately led to look for the means of avoiding them.
   51. It is said that there are more than fifteen hundred  dis-
tinct varieties of the rose.   It seems almost impossible that such
a fact should be established; for when the number and simi-
larity of the objects are so great, the distinction,  identification,
and enumeration of them, must be a matter of extreme difficulty.
This difficulty is diminished  almost infinitely by the simple
means  of bringing  such objects together,  and  placing them
vis-avis each  other, so  that they  may  most readily be com-
pared and contrasted.
   52. Such is the plan, such the object,  of the  diagnostic ar-
rangement of diseases.   Diseases which are similar, are, of
course, apt to be confounded ; the diagnosis can only arise from
careful  comparison and contrast: this  is most readily accom-
plished by arranging such diseases, as it were in parallel lines.
   53. The first question which  occurs in regard to the arrange-
ment of diseases, is the distinction between symptoms and real
diseases.  The same affection sometimes occupies both of these
ranks.  For example, how often is dropsy a mere  symptom;
how often is it a distinct disease.  It will frequently happen that
the very same affection will be  found arranged  both amongst
the symptoms and amongst the diseases.
   54. It may also frequently occur  that the same disease, as
inflammation and hysteria, may, in their  different forms, re-
semble different diseases.  In this case, too,  the  same disease
must be placed in  more than one  part of the arrangement;
perfection of classification being made to give way to practical
utility.
   55. The diagnosis and identification of diseases are, in this
manner, greatly facilitated.  This effected, and not otherwise,
our knowledge of the pathology—of the morbid  anatomy, be-
comes available. 
SECTION  I.
THE  DIAGNOSIS OF THE DISEASES OF SYSTEMS.
                    CHAPTER  I.

          THE  DIAGNOSIS  OF  FEVERS.

   56. If it be true that few diseases of an individual organ
exist uncomplicated, it is especially so in regard to Fevers.  In
fact, our task of diagnosis is only half performed, when we have
ascertained the case to be fever—a special form of fever.  The
complications may, mediately or immediately, be the cause of
death.   If these be undetected, or undistinguished, the first
part of the diagnosis will be unavailing.  In the course of fe-
vers, the early detection of a complication is therefore of  the
utmost  moment.   This will appear very obvious on  reading
the subsequent pages.  It will also appear of the greatest im-
portance to cultivate a habit of watching and of renewed exami-
nation, for such complications.
  57.  Before I proceed to the actual diagnosis of fevers, it may
be well to  present the reader with such an arrangement of the
different kinds of fever,  as may conduce to the object we have
in view.

                ARRANGEMENT OF FEVERS.
    I. Continued Fevers.
            i. Synochus.
                1. The Acute Form.
                2. The  Typhoid Form.
                3. The Protracted Form. 
166
THE  DIAGNOSIS
           ii.  Typhus.
                1.  The Milder Form.
                2.  The Severe Form
                3.  The Sinking  Form.

     II. Periodic Fevers.
           Intermittent.
                1.  The  Quotidian,
                2.  The  Tertian,
                3.  The  Quartian,
                4.  The Reduplicated,
                5.  The  Re.niLent,  Forms.

  58. The object of every work like the present, must be to dis-
entangle the subject of which it treats-., from the maze of useless
terms and distinctions, a id to preset t it to the reader in its sim-
plest and  most practical form.   There is no question in  which
this  is so necessary as that of fevers.   There is none in  which
there has always been such discrepancy  of opinion amongst phy-
sicians.  I think all continued fevers may be comprised under the
two designations Synochus  and Typhus, according to the pre-
ceding arrangement; whilst to confound all under the single de-
signation of Typhus, as is done  by the late Dr. Pateman, i^ to
involve the practical and real distinctions of fevers in insuperable
difficulties. I shall now proceed to a detail of the characteristics
of the two kinds of fever which I have enumerated.

                      I. SYNOCHUS.
  59. This term is employed to designate  the common fever
of this climate, as it arises from ordinary causes.   It was used in
this sense by the late Dr. Willan ;* and some term distinctive of
such a form of fever from typhus, m essentially necessary to the
inquiry into the nature of fevers.
  60. Synochus assumes several distinct forms: the most fre-
quent form may be designated the  acute ; in the heat of sum-
mer, it is apt to be complicated with  bilious vomiting and diar-
• S?e Reports on the Diseases of London. 
OF FEVERS.
167
rhoea and yellowness of the conjunctiva ; in the deVcate and in
the aged it frequently becomes typhoid ; and it is not unfre-
quentiy protracted for many weeks in a « slow nervous " form.

                  I.   The  Acute  Form.
   61.   I.  The History.   The morbid affection which  I pro-
pose to  designate by the term  Synochus, occurs from fatigue,
anxiety, and watching, as in unremitted attendance on the sick;
from long exposure to cold or rain, as  in taking long journeys,
or, as I have often seen, in the labors of the harvest;  from ex-
treme errors in  diet, &c.   It usually comes on immediately af-
ter exposure to one of these causes, with chilliness, febrile heat,
flushing, &c.  Its duration is from ten  to one and twenty days.
   62.   II.  The Symptoms  enumerated more fully are  the
following:—Flushing and tumidity of the countenance,  injec-
tion of the conjunctiva ;  heat, softness, and tumidity of th • skin
generally ;  the tongue is loaded, white, generally moist, swollen,
and  indented ;  the breath tainted.  There are aching  pains,
lassitude,  and muscular debility;  headache;  intolerance of
light or sound, and, in the  erect posture, vertigo or faintishness.
The respiration is hurried;  the  pulse frequent, full,  and soft;
there are anorexia and constipation.
   63.  III. The  Complications usually seen in this affection
are,
     I.—1. Herpes Oris,  and
        2. Herpetic Sore Throat ;
but besides these, there is occasionally,
   II.—1.  Encephalic,
        2.  Thoracic, or
        3. Abdominal, Inflammation.
And in summer there are frequently,
   III.—Bilious Vomiting and Diarrhaa.
   64.  IV.  The Effects of Remedies.  The state of the sys-
tem is such as to admit of the flow of a moderate quantity of
blood without syncope,—generally about fifteen ounces.
   65.  V.   The Morbid Anatomy of  the acute form of  Syno-
chus is unknown, such cases seldom or never proving fatal. 
168
THE  DIAGNOSIS
                  H.   The Typhoid  Form.
   66.  I.   The History   The causes of the typhoid Synochus
 are similar to those of the other forms of this fever ; but the sub-
 jects are, usually, the feeble, females, the aged, &c.
   iJ7.  II.  The Symptoms.  In typhoid Synochus, the surface
 is less heated, the tongue becomes brown and dry, and the teeth
 affected with sordes, and there  are delirium,  coma-vigil, or sub-
 sultus;  but there is rarely purpura, or tympanitis.
   68. III.  The Morbid Anatomy.   This is not distinctly as-
 certained.  There  is an absence of the ulcerations of Peyer's
 gland, which appear to constitute the essential anatomical char-
 acter of true typhus.*

                 III.   The Protracted Form.
   69.  I.  The  History.  This form  of Synochus  comes on
 more slowly,  and after  a still more protracted exposure  to the
 causes  already  enumerated ; from  disappointment and grief;
 from want and poverty, &c.  Its duration is frequently protrac-
 ted through six, eight, ten, or even twelve weeks.
   70.  II.   The Symptoms.   The countenance, occasionally
flushed  at first, becomes shrunk, wan,  sallow,  and tremulous;
the general surface  shrunk, dry,  harsh, and exfoliating;  the
  * The reader is referred to an Essay, by the author, published in  the Medical
 Gazette, for September 15, 1832, for a fuller discussion of this question.  The
 conclusions deduced from the whole argument are these :
  1. That there is a form of common fever, or synochus, which arises from har-
 rass, anxiety, and other similar causes,  which is entirely different from true ty-
 phus ; and, consequently, free from the dothincnterite or disease of Peyer's
 glands.
  2. That typhoid symptoms not only  occur in this fever, but in many other
 diseases, as phlebitis, erysipelas, after operations, accidents, &c especially in old
persons.
  3. That when these cases are abstracted, the  remaining typhoid cases are
 principally, but still  probably not entirely, true typhus, in which the dothinen-
 terite may, however, occasionally be absent, as the rash is sometimes absent in
 scarlatina, and the pustules nearly so in small pox.
  4. That the symptoms of true typhus even,  do not arise from the  presence of
 the  dothinente>ite, but rather coincide with  it, both arising from one and the
 same cause;  and very probably from the condition of the circulating blood. 
OF  FEVERS.
169
 hands are rough and harsh; frequently a circle of redness and
 burning is observed extending round the palm ; there are mus-
 cular tremor and debility, then headache or vertigo, delirium or
 coma ;  the  pulse becomes  frequent and small; the  respiration
 and the articulation are tremulous ;  the tongue becomes brown-
 ish and dry in the centre, or morbidly red, smooth, and dry ;
 there is sometimes vomiting or diarrhoea; the  urine usually de-
 posits a copious pinkish sediment.
   71. III.  The Complications most frequently seen in this
 form of the common fever, are,
     I-—Aphtha of the Mouth and Throat.
    II-—Chronic—1.  Cephalic,
                   2.  Thoracic, or
                   3.  Abdominal, Inflammation.
    III.— Tubercles.
   72. IV.  The Morbid Anatomy of protracted Synochus, as
 distinguished from Typhus, is unknown.
                       II.   TYPHUS.
   73. This fever appears under three  forms:  the mild, the se-
 vere, and the sinking.
   74. I.  The History.  Typhus is sometimes epidemic and
 sometimes endemic ; its causes are contagion (?); malaria (?);
 the air of crowded cities; deficient and unwholesome  food.   It
 usually begins rather insidiously, and gradually assumes one or
other of the forms just mentioned and about to be described.  It
attacks the young chiefly.
                   I.  The Mild Form.
  75. I.  The Symptoms.   The mild form of typhus usually
 begins with pallor, languor, and tremor, muscular debility, chil-
 liness,  alternating with febrile heat, and perhaps perspiration.
 There are headache and vertigo ;  the  pulse is  rather frequent;
the tongue is whitish, and apt to  be dry;  there are  anorexia,
and constipated or relaxed  bowels.  This condition may con-
tinue for a fortnight, and gradually subside.
   76. II. The Complications consist of
                1. Cephalic,
                           22 
170
THK  DIAGNOSIS
                2.  Thoracic, or
                3.  Abdominal, Inflammation.
  77. III.  The Effects of Remedies.  There is  early syn-
cope on abstracting blood in the erect sitting posture,—generally
on the flow of less than ten ounces.
  78. IV.  The Morbid Anatomy of this form of typhus, is, I
believe, similar  to that of typhus in its severe form, varying only
in degree.
                 II.  The Severe Form.
  79. I.  The  First  Symptoms of the severe form of typhus
are chilliness and febrile heat, early and peculiar muscular de-
bility, and mental depression; the countenance expresses lan-
guor and anxiety, and is either pallid or slightly flushed ; the ar-
ticulation, the manner of protruding the tongue and of holding
out the hand, and every muscular motion or effort, is attended
with a peculiar tremor; there are headache, vertigo in the erect
posture, delirium, and somnolency ; the temperature of the ge-
neral surface is only slightly augmented, and there are not unfre-
quentiy coldness and moisture.  The tongue is whitish, and apt
to become brown and dry;  there is complete  anorexia, some-
times constipation, sometimes a degree of griping and diarrhoea,
and the alvine evacuations are occasionally mingled  with slight
portions of mucus, or blood.
   80. II. The Subsequent Symptoms are tremor of the coun-
tenance, with dryness of the lips, sordes over the teeth, and suf-
fusion of the eyes.  Every thing in motion and posture denotes
extreme muscular and nervous debility : the articulation  is in-
distinct, the hand is held out tremulously, the tongue is protruded
with effort, and is often not drawn in again,  from mental tor-
por ;  the tremor passes into subsultus, or spasm; the patient
falls into the most prone position, unable to support himself even
on the side, and is perhaps  constantly occupied in picking the
bed-clothes.  There are delirium, or somnolency, or alternations
of these two states, or violent delirium, or deeper stupor.  The
tongue becomes encrusted, deeply fissured, brown, and excessive-
ly  dry; the lips are also frequently fissured, and bleed, and there
is  frequently epistaxis.   The skin is various—sometimes cool 
OF  FEVERS.
171
and moist, sometimes of slightly elevated  temperature, frequent-
ly beset with miliaria, especially over the neck and thorax, and
with petechia; more  generally.   The pulse is  usually frequent,
and  easily  compressible;  there is  frequently a sonorous rattle,
with or without cough  or  mucous expectoration;   there are ge-
nerally intestinal pain and distention, and diarrhoea, with dark,
offensive, flatulent, mucous, bloody, involuntary, or unconscious
evacuations.  The urine is frequently  partly retained  with dis-
tention of the bladder, and  partly passed unconscionsly.   The
integuments over  the  sacrum are apt to be affected  with gan-
grene from pressure and the irritation of discharges, and blister-
ed parts are  apt to slough.*
   * Typhus fever is  somewhat similar to the following diseases, with which,
 therefore, it must be carefully compared and contrasted:
             1. Phlebitis.                    3. Delirium tremens.
             2. Encephalic disease.            4. Muco-Enlerilis.
   The diagnosis of these affections from typhus fever, will be best effected by
 carefully comparing and contrasting their characters respectively in every point.
 This plan will  also avoid  the necessity for much repetition throughout  this
 work, and form one of the most useful exercises in which the student can be en-
 gaged.  I shall, in  this place, only observe that no disease except typhus con-
joins chilliness, febrile heat, early  vertigo, somnolency or delirium, muscular de-
 bility and  tremor, the peculiar state of the tongue, of the skin, of the bowels,
 petechia, tympanitis, &c.
   1. Phlebitis is generally traced to a local wound or injury, except it occurs as
 a puerperal disease.  There are a peculiar violence of rigor, anxiety of'counte-
 nance, appearance of sinking, delirium, frequency of the pulse, hurried respira-
 tion, vomiting, diarrhoea, &c.
  2. In encephalic disease there is generally none of the symptoms really pecu-
 liar to typhus: the muscular strength is  unimpaired; the pulse, the tongue,
 the general surface, the state of the bowels, are comparatively little affected, and
 there are more simply the symptoms of local affection of the brain.
   3. Delirium tremens, notwithstanding the two symptoms implied in its desig-
 nation, is very different from typhus:  the tremor is less accompanied by debili-
 ty, the delirium less attended by stupor ; there is, on the contrary, considerable
 activity and constant wakefulness, the tongue and skin  are moist, the breath
 tainted  by  some spirituous liquor, and the  disease is readily traceable to its
 cause.
  4. In muco-enteritis there is less febrile action, less debility, and more nausea,
 vomiting, and diarrhoea.  This disease occurs in subjects of every age,  frequent-
ly from some known cause: there is none of the peculiar state of mind, muscle,
tongue, skin, intestinal canal, &c. so characteristic of typhus. 
172
THE  DIAGNOSIS
  81.  III.  The Morbid  Anatomy of typhus fever seems  to
consist in  a diminished  cohesion of the particles which consti-
tute the solids and fluids of the body ;  hence we find,
  82.  1st. Softening of the  parenchymatous substance of all
the organs—the brain, the heart, the liver, the spleen, the kid-
ney, &c.
  83.  2dly. Softening, thinness, and ulcerations of the mucous
membranes—of the epiglottis, larynx,  trachea, pharynx, oeso-
phagus, stomach, bowels, &c.
  84.  3dly. Rupture of the textures constituting the skin, and
the serous and mucous membranes, and hence petechise, vibices,
and effusions of blood, of blood serum, &c.
  85.  4thly. Want of cohesion  in the blood itself; the coagu-
lum of which is soft, uncupped, and occasionally covered with a
buff of the consistency of mere jelly.
  86.  5thly. That change of structure which alone is constant,
or nearly so—is inflammation and ulceration of Peyer's glands,
especially occupying that part of  the ileum  situated near  the
caecum, but extending over a considerable part of the intestines.
This point seems to be established  by the labors of Roederer and
Wagler,* Prost,t MM. Petit and Serres,£ M. Louis,^ M. Cruveil-
hier,||  Dr. Bright,!  Dr.  Cars well,** &c.   It has been long dis-
  * De Morbo Mucoso; Goettingae, 1762.
  f M6decine 6clairee par l'Observation et l'Ouverture des Corps; Paris, 1804,
pp. lv. &c.  This is an extraordinary work for the period at which it appeared
The author observes—" M. Bayle m'associa a ses travaux: des-lors j'esp^rai du
succes."
  | Traite" de la Fi^vre Ente>o-M6sent6rique. Paris, 1813.
  § Recherches du Gastro-Ent6rite, 1829;—a work which will constitute an era
in the science of medicine, by introducing numerical precision into its data.
  || Anatomie Pathologique.  Paris,  1830.
  11 Reports of Medical Cases.  London,  1827.
  "* By the liberality of Dr. Carswell, I, as well as many others, have repeated-
ly seen  his incomparable drawings,  amountin g to  nearly two thousand; and I
have as repeatedly  contemplated this gentleman's labors with unmingled admi.
ration.  They will long be the ornament of the London University.   I rejoice to
know that Dr. Carswell is at length engaged in preparing Elements of Morbid
Anatomy, with plates, for publication: this work must infinitely surpass every
thing of the kind published in this kingdom. 
OF  FEVERS.
173
puted whether this affection be the cause, the effect, or a mere
complication of typhus fever.  It cannot.  I  think, be justly
said to be any one of these.  It is a part—an almost essential
part—of this fever, and appears to bear the same relation to the
entire disease which the rash and sore throat do in scarlatina,
and the rash, and the bronchial  affection in rubeola.
  87.  6thly.  These ulcerations  appear under  various forms,
being granular, pustular, fungous, gangrenous, &c.
  88. 7thly.  "With these ulcerations are conjoined enlargement
and softening of the corresponding mesenteric glands.
  89. IV.  The principal Functional Complications are,

     I.—Encephalic :
              1. Stupor;
              2. Delirium;
              3. Subsultus ;
              4. Spasm, fyc.
     II.  Thoracic:
              1. Cough;
              2. Expectoration ;
              3. Rattle, fy"c.

     III. Gastric  and Intestinal :
              1. Pain and Sickness ;
              2. Pain  and Diarrhoea;
              3. Melana ;
              4.  Tympanitis ;
              5. Symptoms  of Perforation of the Intestine,

  90. The symptoms in the complications of typhus are not
always commensurate with the structural changes.   They fre-
quently depend on the  condition of the system at large, of the
nervous system, or  of the blood.
  91. V. The Structural Complications are—
  92.  1.  Encephalic, consisting  of—1, effusion  upon the
arachnoid ; 2, injection  and softening of the cortical and medul-
lary portions of the brain; and, 3, of similar affections of the 
174               THE  DIAGNOSIS
cerebellum.  This complication is slighter  in  degree, and less
frequent in its occurrence, than is supposed.
   93.  2.  Effusions of lymph, and ulcerations of the epiglottis,
the larynx, the trachea, the pharynx, the oesophagus, &c.
   94.  3.  Thoracic, generally slight, and consisting of—1, ad-
hesions, or effusion of bloody  serum into the pleura ;  2,  hepati-
zation, or splenization of the lung;  3, reddish mucus in the
bronchia;  4, a livid red color, thinness, and  softening of the
heart, denoted generally by  irregularity and feebleness of the
pulse.
   95.  4.  Abdominal; these  are—1, softening, thinness, ulcera-
tion, and the mamillated state, of the mucous membrane of the
stomach; 2,  softening of that of the intestines, with constant
ulcerations of the clustered glands of Peyer,  and occasional ulce-
rations of the solitary glands  of Brunner;  3, enlargement and
softening of the mesenteric glands; 4, softening of the substance
of the liver, spleen, kidney, &c.

              5. Perforation of the Intestine.
   96. The symptoms of perforation of the intestine are gene-
rally sudden pain and tenderness diffused over the abdomen,
nausea and vomiting, sunken countenance, smallness and fee-
bleness of the pulse, cold perspirations, with pallor over the whole
surface, and rapid failure and sinking of the powers of life.
   97. 6. The integuments covering  the sacrum are apt to ul-
cerate and slough from pressure, and those of parts covered with
blisters, from irritation,  in a degree which  becomes somewhat
diagnostic.   There is also occasionally erysipelas.
   98. VI.  The Effects of Remedies ; and
   99. VII. The State of the  System. There is, comparatively
with health, and still more comparatively with inflammation,
little tolerance of loss of blood; syncope is early produced on
opening a vein in the erect sitting posture.

                 III.  The Sinking  Form.
   100.  The Symptoms.  In the sinking form of typhus, or
that designated  the  congestive,  a form little seen in hospitals, 
OF  FEVERS.                    175
 there is early coldness of the face and general surface, with a
 feeble pulse, stupor, deep breathing, extreme debility of the mus-
 cular system, so that articulation and  all  attempts to move are
 abortive;  the eye is sunken, the voice husky, the evacuations
 perhaps involuntary.
    101. This form of typhus is noticed in this place, in order  that
 nothing practically useful may be omitted, and that the student
 may be aware of a form of disease not of frequent occurrence.
 It can scarcely be mistaken for any other  disease.
   102. II.  The  Morbid Anatomy; and
   103. III.  The Effects of Remedies appear to be unknown,
 or, rather, involved in  hypothesis.^ >)

                      II. Periodic Fevers.
                         INTERMITTENT.
   104. I.   The History.   The Causes of intermittent fever in

  (1.)  The arrangement of continued Fevers laid down in the preceding pages,
 is in accordance with the most popular and received notions on the subject, and
 will probably be adopted by most readers without difficulty.  But, for myself, I
 must confess, that the more I examine the subject, the more I am inclined to be-
 lieve in the unity of continued Fevers.  The difference in the violence, the dura-
 tion, and even in the character of the symptoms, is not a conclusive argument
 against this view of the subject—for we know very well from  the study of
 diseases purely local, that the same changes of structure maybe accompanied un-
 der different circumstances, by symptoms widely different in their character. Of
 the essential nature of Fever we know nothing—of its causes we are almost in
 ignorance—and  for these reasons, I think, systematic writers have  been  com-
 pelled to classify it by certain external appearances, or symptoms, which are far
 from being the true foundation of correct classification. On the other hand, those
 who have attempted to assign to Fever a ''local habitation,' whether in the brain,
 the mucous membranes of the stomach and  bowels, or in  the glands of Peyer,
 have met with no better success.  The admirable work of M. Louis, ' Sur  1'Af-
 fection Typhoide,' has made us acquainted, with remarkable accuracy, with the
 morbid changes that occur in the Fever of Paris—but the same observations re-
 peated elsewhere would seem to show that a difference in place is accompanied
 frequently at least, by a corresponding difference in the development of changes
 in the structure of organs.  Thus, if it be true, and I am not disposed to doubt
 it, that the glands of Peyer are always diseased in the continued Fever of Paris,
so as to induce some highly gifted minds  to believe that this change is the disease,
yet in the same  Fever as it  prevails in Great Britain, and, I think, also in this
country, this uniformity has not been noticed.                         S. 
176
THE  DIAGNOSIS
its first and subsequent attacks,  are  the  miasmata of marshes,
stagnant water, and humid localities, and the north-easterly
winds.  The disappearance of intermittent fevers from London
and  its neighborhood,  and  from other  places  in which they
formerly prevailed, is ascribed by Dr. Willan, and by Sir Gil-
bert Blane, to the practice of draining, and  other improvements
in agriculture.  The Course is marked by successive distinct,
cold, hot, and  sweating stages ; and these are recurrent, every,
every second, or every third day,  or at  other intervals,  giving
origin to the designations, quotidian, tertian, quartian, &c.
   105.  1. The Quotidian has an interval of twenty-four hours,
a paroxysm of moderate severity, but of long duration, beginning
with a slight cold stage,  generally in the morning.  It is apt to
assume the remittent form.  It occurs  principally  during  the
spring.
   106.  2. The Tertian has an interval of forty-eight hours, a
severer cold stage, a shorter paroxysm, recurrent generally about
noon, and  followed  by much perspiration.   This  is the most
frequent form  of intermittent, and  is observed to be milder in
spring than in autumn.
   107.  3.  The Quartian has an interval of seventy-two hours,
a short  paroxysm, and a long  intermission.  The paroxysms
usually occur after noon, with a long and  severe cold stage, a
gentle hot stage, and slight perspiration.   The quartian inter-
mittent fever occurs chiefly in autumn, is apt to prove obstinate
without having any tendency to assume the remittent form.
   108.  4.  Intermittent fever sometimes assumes the Redupli-
cated, or merely Remittent forms;  and sometimes every kind
of irregularity in form, and in the intensity of its paroxysms,
or of their different stages.
   109.  The recurrence of the paroxysm may not be always so
accurate in point of time and hour,  in different cases, as  I have
mentioned; yet attention to this point,  in the same case,  is a
very important means of diagnosis in obscure cases.  The rigors
in suppuration  and in phthisis have not such sustained regu-
larity of return.
   110. II. The Symptoms.   The paroxysms of intermittent 
OF  FEVERS.
177
  fever begin with yawning and languor, and a sense of creeping
  along the back; the patient then shivers  with cold; the counte-
  nance and general surface are pale, shrunk, and cold; there is
  that state of the skin termed ' cutis anserina,' and  the nails as-
  sume a livid hue;  the respiration is sibilant; the pulse is small
  and frequent, and perhaps irregular; there are anorexia and
  thirst; the tongue is dry and clammy; the urine is limpid.
    111.  The cold stage  gradually subsides, and the countenance
  becomes flushed and tumid, and the eyes injected, whilst the
  general  surface is turgid, hot, smooth, and dry; there are fre-
  quently  acute pains of the head, throbbing of the temporal arte-
  ries, intolerance of light and sound, and delirium; the respiration
  is frequent, but less anxious; the pulse strong, full, and frequent;
  there are urgent thirst, with continued dryness of the tongue •
  the urine becomes high colored.
    112.  In the sweating stage the countenance assumes nearly
 its natural appearance;  the skin loses its tumidity and heat, and
 becomes  covered with perspiration.   The  head is relieved, and
 sleep often supervenes;  the respiration b ecomes free, the pulse
 nearly natural;  the urine deposits a degree of sediment.*
    113. The paroxysm over, the patient is left somewhat pale
 and  languid, and  there are headache and  anorexia.  In the
 commencement of  intermittent  fever, the apyrexia is, however
 sometimes almost free from indisposition.
    114. III. The Complications of intermittent fever are fre-
 quently, like the fever itself, periodic,—intermittent or remittent;
 and  sometimes, without fever, there are similar paroxysms and
 intermissions, or remissions, of local affections.
   115. The principal of these are,
       1.  Hemicrania.
       2.  Pain of the Eye-brow.
       3.  Thoracic Pain.
       4.  Splenic Pain and Tenderness.
       5.  Pain of the Testis.
       6.  Other Topical  Pains.

  * The observations made upon the urine by the older writers  on Intermit-
tents, are confirmed by M. Andral, in the Clinique M^dicale, Ed. 1.1. i, p. 479. 
178           THE  DIAGNOSIS,  E T C .

  116. These affections sometimes assume a more aggravated
form, and there are,
       1. Headache, Delirium, Coma, or Amaurosis.
       2.  Thoracic Pain, Cough,  Asthma, or Syncope.
       3.  Colic, Cholera, or Diarrhoea.
  117. These local affections may precede, accompany, or fol-
low intermittent fever ; or they may exist variously in the inter-
mittent or remittent form, independently of  febrile symptoms.
They will be particularly noticed hereafter.
  118. The principal permanent complications are,
       1.  Enlargement of the Spleen.
       2.  Anasarca.
  119. IV.  The Morbid Anatomy of intermittent fever seems
really to be little known.   The spleen is the  organ chiefly and
most frequently affected;  it becomes enlarged.  This enlarge-
ment is discovered during life by recurrent pain, dulness of sound
on percussion of the false ribs of the left side,  and, at length, on
examining the region of the spleen  by pressure.  The spleen
may remain enlarged, ascend, or descend, and constitute a mode
of ascertaining the existence formerly of intermittent fever, with-
out materially affecting the health.
   120. V.  The Effects  of Remedies.  The influence of the
quinine in intermittent fever, pains; &c. is so marked as to be at
once diagnostic of the disease, and suggested for all cases of a
distinctly intermittent character. 
CHAPTER  II.
          THE DIAGNOSIS  OF ERUPTIVE FEVERS.

   121.  Since the appearance of the classical work of the late
Dr. Willan, and the useful abridgment of Dr. Bateman, nothing
seems wanting to the  description and portraiture of cutaneous
diseases, both acute and chronic.  And if to distinguish these se-
veral diseases from each other were  all that were required, the
diagnosis might be said to be almost complete.   But this is not
all.  The treatment of these  diseases does not depend merely
upon the questions, whether it be rubeola, or scarlatina, or other
eruptive fever; but upon the question whether the disease, be it
what it  may, be complicated with internal  organic changes, or
modified by constitutional circumstances.
   122.  These are the really important points for diagnosis, the
important questions on which recovery or death  depends.  And
I do not hesitate to say, that, in these respects, but especially in
that of the complications, the subject is involved in the most in-
tense  obscurity,  and offers ample  scope for investigation.   If
there be any thing peculiar in these complications, that pecu-
liarity is completely unknown, and must be established by new
examinations.  If such peculiarities of morbid  change  require
peculiarities in the treatment, this too remains to be ascertained
by future inquiries.
   123.  It has not even been ascertained whether the affection of
the mucous membranes be merely inflammatory, or whether it
be specific; that is, whether it  be rubeolus in rubeola, and scar-
latinous in scarlatina, as it is variolus in variola.  But I believe
it is so.   This observation applies not to the eyes, fauces,  larynx,
trachea, and bronchia  only, but  also to the stomach and in-
testines. 
180
THE  DIAGNOSIS  OF
   124.  But the observation is of still greater moment when it is
considered in connection  with the other textures, the morbid af-
fections of which  in  eruptive fevers,  appear scarcely to have
been examined at all.   Yet it is certain that the arachnoid, the
pleura, and  parenchymatous  substance of the lungs, as well as
the mucous membrane of the bronchia  and of the stomach,
undergo morbid changes in rubeola ; that  the arachnoid, as well
as the parenchymatous, serous, and mucous textures of the tho-
rax and abdomen, the subcutaneous cellular tissue, and the
joints, are involved in  the course of scarlatina.  Yet where do
we meet with any satisfactory account of these morbid changes ?
Willan  and Bateman, Rayer and Biett, Laennec and Andral,
are searched in vain for the morbid anatomy of eruptive fevers.
There are merely  scattered opinions or facts.  All is vague, ge-
neral, and unsatisfactory.  A work upon this subject at all com-
parable  to that of M. Louis upon the Gastro-Enterite, would be
an inestimable contribution to medical science.
   125.  But, besides the complications, there is another interest-
ing subject of inquiry, especially in regard to eruptive fevers: it
is the remoter consequences  or sequela.   These are acute and
chronic.   And they affect the head, the chest, and the abdomen.
They are, principally, chronic inflammation  and tubercles.
   126.  The science of medicine is not so simple as it has been
made to appear.   When our books present a faithful portraiture
of nature, we shall discover that,  both  during the course and
after the course of many diseases,  we have still to watch the pa-
tient, if we would early detect diseases which only require to be
overlooked and disregarded in their beginnings, to  be placed be-
yond the reach of remedy.  I expect much will really be effected
in simplifying the subject by the mode  which I have adopted of
placing these arrangements before the student.  The eye, the
mind, will speedily become familiarized with the multitude of
events which occur, and then the principal difficulty  will be
overcome.
   127. In the present chapter I purpose to notice  those objects
of the diagnosis upon which the treatment principally depends:
these are, the condition of the system and of the internal organs. 
ERUPTIVE  FEVERS.
181
 In a subsequent chapter I shall compare and contrast the differ-
 ent rashes, with  the view of determining  the question of the
 subsequent safety or liability of the individual, in regard to the
 different contagious eruptive fevers respectively.

            ARRANGEMENT OF ERUPTIVE FEVERS.
     I.  Rubeola.

            1.  Vulgaris.
            2.  Sine Catarrho.
            3.  Nigra.

    II.  Scarlatina.
            1.  Simplex.
            2,  Anginosa.
            3.  Maligna.

   III.  Variola.

            1.  Discreta.
           2.  Confluens.

   IV.  Erysipelas.

            1.  Phlegmonodes.
           2.  Erraticum.
           3.  (Edematodes.
           4.  Gangranosum.

                      I.   RUBEOLA.

   128. Rubeola, besides its ordinary form of Rubeola vulgaris,
occasionally   occurs unaccompanied by catanhal symptoms,
when it is designated by Dr. Willan  Rubeola sine catarrho ;
at other times the rash which is usually florid becomes  livid,
when it is called Rubeola nigra.

                   I.  Rubeola vulgaris.

   129.  I. The History.  Rubeola is unequivocally contagious.
A latent period of from ten to fourteen days  intervenes between 
182
THE  DIAGNOSIS  OP
exposure and the development of the febrile, symptoms.   The
catarrh  appears on  the  second or third day.  The  rash  first
appears on the face and neck on  the fourth day, and on the
chest and extremities on the fifth; on the sixth it begins to de-
cline on the parts first affected, whilst it is vivid  on the general
surface.   On the seventh, eighth, and ninth  days, the  rash
fades, leaving the cuticle in a state of exfoliation.
   130.  II.  The Symptoms.  Rubeola is early characterized
by the conjunction  of fever, and a sensation of stricture across
the forehead and eyes, with a disposition to sleep; to these symp-
toms are added, on the third and fourth days, redness of the eyes,
and turgidity of the eyelids and nostrils, a copious flow of tears,
and frequent sneezing, a  sense  of soreness about the throat,
hoarseness, a frequent, dry cough, difficulty in breathing, and a
sense of constriction across the chest.   The rash commences
with distinct, red, and  nearly circular  dots; afterwards larger
patches appear, which tend to assume crescent forms.  The sur-
face of the skin is gently raised; the  wrists and hands papilla-
ted ; the color  of the rash deeper and  less vivid  than that of
scarlatina, being of the raspberry  hue;  miliary vesicles are
frequently seen on the neck, breast,  and  arms.  The general
surface is less tumid than in scarlatina.
   131. III.  The Complications of Rubeola are the  following:

     I.—Inflammation of the  Eyes and Nostrils.
     II.—Efflorescence on the Throat.
    III.—Inflammation—1. of the Larynx ;
                        2. of the Trachea and Bronchia;
                        3. of the substance of the  Lungs;
                        4. of the Pleura or Pericardium;
                        5. or of  the Peritonaum.
    IV.—Sudden attacks of Inflammation  of the Brain and
          its Membranes.*—with or without
  ♦The retrocession of the eruption from exposure to cold, or the administration
of purgative?, is said to occasion delirium, restlessness, difficulty of breathing,
pain of the bowels, diarrhoea, and greatly to endanger the patient's life. 
ERUPTIVE FEVERS.
183
   V.—Acute  Inflammation of  the Cellular Membrane,
         with Anasarca.
  132.  IV.  The Sequela are
    I.—Chronic—I.  Cephalic, or
                  2.  Thoracic, Inflammation.
   II.— Tubercles.

  133. This table of complications and sequela? should be vivid-
ly present  to the mind  whenever  we visit a case of Rubeola.
To avoid repetition, I refer the reader to  the several chapters
which treat of cephalic, thoracic diseases, &c. for the  special
diagnosis of these morbid affections, whether they exist  as
simple forms of the disease or as complications.
  134.  V.   The Morbid Anatomy of Rubeola, in its simple
forms, is, in my opinion, unknown; that of its complications
and sequela? are supposed to be perfectly similar to that of affec-
tions of the several parts enumerated in the preceding table, not
rubeolus.   Is it so ?
  135. VI.  The  Effects of Remedies.   Blood-letting is bet-
ter  borne in Rubeola, than in most  other eruptive fevers, at least
when it is complicated with inflammation.

                II.  Rubeola sine Catarrho.
  136. Dr. Willan observes,—"when the measles are epidem-
ical, a few cases occur wherein the eruption goes through its dif-
ferent stages without  any cough, difficulty of breathing, or in
flammation of the eyes ;  without much alteration of the pulse,
or any febrile symptoms." It does not, then, "appear to emanci-
pate the constitution from the power of  the contagion, nor to
prevent the  accession of the Rubeola vulgaris  at a future
period."

                   III. Rubeola nigra.
   137. Dr. Willan observes—"I never saw the Rubeola vul-
garis intermixed at an early period with petechia?: but it some-
times happens, about  the seventh or eighth day, that the rash 
184
THE  DIAGNOSIS OF
 becomes suddenly black, or of a dark purple color, with a mix-
 ture of yellow."  This appearance has continued  ten days, in
 some cases longer, with no other symptoms of fever  than a quick
 pulse and  a slight degree of languor.

                      II. SCARLATINA.
   138.  Scarlatina occurs  under three forms—Scarlatina sim-
 plex, Scarlatina anginosa, and Scarlatina maligna.
                   I.  Scarlatina simplex.
   139. I.  The History.   Scarlatina is eminently contagious.
 The eruption appears after a latent period of five  or six days,
 and on the second day  of  febrile symptoms.   It consists of a
 close scarlet efflorescence, and first occupies the face and  neck,
 and, in the course of another day, is  diffused  over  the general
 surface, the nostrils, the inside of the  eye-lids, cheeks, and lips,
 the tongue, the palate, and  the  fauces.  On the fifth day the
 rash begins to decline;  it disappears on the sixth and seventh,
 leaving the cuticle in  a state of exfoliation.
   140.  II.  The Symptoms.   The Scarlatina  begins with de-
 bility, heaviness, and slight chills, which lead to great heat and
 tumidity of the general surface.  Numerous specks, or minute
 patches, of  a vivid  scarlet, appear about the face and neck on
 the second day.   In the  course  of the third day the  efflores-
 cence becomes almost continuous over the whole surface of the
 body, and of a full scarlet hue, especially on the loins, nates, and
 in the flexures of the joints.  The rash is most vivid in the even-
 ing, and on the third and fourth days.  Some papula? appear.
 On the fifth day it begins to decline, the scarlet hue being less
 vivid, and the interstices between the patches augmented.
   141.  The tongue is white in the middle, of a scarlet redness
 at the edges, and marked by elongated vivid papilla? about the
point.  The face iy tumefied.  The scarlet efflorescence may
sometimes be observed over the tunica  conjunctiva, and  the eye
is bright and humid, but without the  flow of tears observed in
rubeola.*
  ♦Thus—1.  The rash occurs earlier in scarlatina than in rubeola; 2. There is 
ERUPTIVE  FEVERS.             185
                  II. Scarlatina anginosa.
   142. I. The History and Symptoms. In this form of Scar-
 latina the febrile symptoms  are  more severe, the rash appears
 later, as on the third day, and is less diffused, and more in scat-
 tered patches;  it sometimes vanishes and re-appears; its whole
 duration is longer, and  its color deeper, than  that of Scarlatina
 simplex.   To the fever and efflorescence are superadded swelling
 of the  tonsils,  velum pendulum palati, and uvula, with florid
 redness, sloughs, and ulcerations.  The voice is hoarse and the
 deglutition difficult, and  there is cough.
   143. There are frequently headache,  delirium, restlessness;
 great heat, frequent pulse, quick  respiration;  languor and faint-
 ness, nausea and vomiting.
   144. II.  The  Complications in Scarlatina anginosa are,
   I-—Affection of the fauces, pharynx, glottis, and larynx.
   II.—1.  Cephalic,
        2.  Thoracic,
        3.  Abdominal, Inflammation, or Congestion.
  III.—Enlargement and  softening of the parotid,  sub-
          maxillary, and mesenteric glands, the kidneys, fyc.

   145. III.  The Sequela are,
   I.—An Affection of  the Joints, similar to Rheumatism.
  II.—Inflammatory Anasarca.

                 III.  Scarlatina maligna.
  146.  I.  The History.  The rash, in this form of Scarlatina,
appears late,  and is uncertain in its duration : it sometimes dis-
appears ina few hours, and re-appears at the expiration of a week,
greater fever and greater general tumidity of the skin; 3. The efflorescence is
more diffused or in larger patches, and more vivid in color, without assuming
crescent forms, or being attended with roughness and elevation of the skin ; 4.
There is sore throat in scarlatina, whilst there is catarrh in rubeola ; 5. There is
greater tendency to delirium and affection of the head in the former than in the
latter.
24 
186
THE  DIAGNOSIS  OF
continuing two or three  days.   In one  case  Dr. Willan ob-
served its re-appearance, in  numerous patches, a third time, on
the seventh day from the second eruption :  it remained two days.
   147.  II. The Symptoms.  There are dark-red flushings of
the cheeks, fulness and lividity of the neck, and dull redness of
the eyes.  The efflorescence is  usually  faint, except  in a few
irregular patches,  and presently changes to a dark  or livid red
color; it is often intermixed with petechia?.  There are ulcera-
tions of the tonsils and adjoining parts, covered with dark sloughs
and surrounded with  lividity.  The tongue is  tender and  ulce-
rates  on the  slightest injury.  An  acrid discharge takes place
from  the nostrils, with soreness,  chaps, and blisters, about the
nose and lips.  The breath is extremely foetid.  The state of
the whole system is typhoid.
   148.  III. Willi these appearances there are in different in-
stances  the following Complications:

   I.—Deafness, delirium, coma.
   II.—Rattling, laborious respiration, teazing cough.
  111.—Constriction of the jaws and dysphagia.
  IV.— Violent pain of  the bowels, diarrhaa.
   V.—Petechia, vibices, hcernorrhages.
  VI.— Vesications on the hands and feet.
   ] 49.  Many patients sink at an early period, without any ad-
monitory symptoms.
   150.  IV.  There is doubtless a  corresponding condition of ihe
Morbid Anatomy.   Bui, unfortunately, there are few accurate
cases of post-mortem examinations in the Scarlatina maligna
on record.* There arc,
   I.— Ulcerations of the oesophagus, larynx, and trachea.
  II.—Inflammation, or Congestion, in the—
  * The whole subject is open to new inquiry.  The particular condition of the
skin, of the mucous membranes, of the  parenchymatous textures, of the blood,
{tc. isstill unknown. 
ERUPTIVE   FEVERS.
187
                          1. Head,
                          2. Chest, or
                          3. Abdomen.

                          III. VARIOLA.
   151. Variola varies  extremely in severity, and, according to
the abundance and form of  the eruption, is designated the dis-
tinct or the confluent.   There is  also another  form of this dis-
ease, the modified, which occurs after a previous attack or after
vaccination, and of which I propose to treat,  in connexion with
the  Varicella, in  the  Chapter on  the  Diagnosis of the Acute
Cutaneous Diseases.

                     I.  Variola discreta.
   152. I.  The History.  The unique cause of Variola is con-
tagion.  The latent  period is not well ascertained.*  There are
febrile symptoms, on the fourth day of which the eruption usu-
ally appears.
   153.  II.  The  Symptoms.    The  early  symptoms  are
febrile chills, heat, and diffuse perspiration ; languor, pain of the
head and back, and  tenderness of the  epigastrum.   The erup-
tion first appears on the  face, neck, and  breast, and spreads on
the  next day over the general surface of the body, the febrile
symptoms abating.  On the first and second days of the erup-
tion, (the fourth and fifth of fever,) the pustules are small, hard,
and globular, red  and painful, separate  and distinct from  each
other,  with nearly coloiless interstices.   They enlarge gradual-
ly until  the fourth  day, when they contain a Utile yellowish
fluid, and the interstices become red.   From the fourth to the
  * Heberden kobserves, "Parentibus aliquibus visum est, siquidem  unus ex
liberis in variolas incidisset, non amovere reliquos, sed sin2reutornnesuriA mane-
rent in eadem domo, aut etiam in eodem cubiculo. At sexto plerumque  die post-
quam morbus ad a.x.unv pervenerit, sani pueri coeperunt segrotare; undc verisimili
fit, hoc potissimum tempore variolas fieri contagiosas, atquc idem sputium inter-
cedere ante initium reg ota.io lis, ac fieri novimus in plerisquc inoculatis."  He
adds, " Gluotidianum est, ut ii qui, ut videtur, eod^m tempore contagioni obJM" j
fuerint, multum diverso tempore incipiant aegrotare."—Commcntaiii,  pp. 379,
380. 
188              THE  DIAGNOSIS OF

seventh day the pustules expand in breadth, having a depres-
sion in their centre, and  consisting of fine concentric rings  of
different hues,  and being surrounded by  diffused lings of rose-
colored  inflammation, which coalesce when  the eruption  is
crowded.  About the seventh day the central  depression  gives
way, and the pustule assumes a globular form. About the fourth
day there is frequently an increased flow of saliva, and the in-
teguments of the face are apt to become tumid, the eye-lids being
swollen, and sometimes  closed ;  this tumefaction gradually de-
clines, and, about the seventh day, is often replaced by swelling
of the hands and feet, the salivation and perspiration ceasing.
On the seventh day of the rash, the eleventh of the disease, the
pustules are fully distended ;  from this time they begin to break,
the fluid  issues partially, and at length dries and forms a scab,
the cuticle becoming shrivelled, a process  Avhich is completed on
the face about  the eleventh day.  In a few days more the scabs
separate, leaving the subjacent parts of a brownish-red color, and
often pitied.  The  pustules on the arms  and hands become
flaccid.

   154. III. The Complications in the  Variola discreta are,

     I.— Variolous Inflammation of the—
                       1.  Eyes;
                       2.  Mouth;
                       3.  Throat;
                       4.  Epiglottis;  Larynz,  Trachea
                            and Bronchia;
                       5.  Pharynx, Oesophagus, Stomach,
                            and Intestines.
   TI.—Inflammation within the  Head :
                       1.  of the Membranes;
                       2.  of the  substance of the Brain.
   III.—Inflammation within the  Thorax:
                        1.  Pleuritis;
* See Andral, Clinique Mldicale, Ed. 2, tome i, p. 30. 
ERUPTIVE FEVERS.
189
                       2.  Pneumonia;
                       3.  Pericarditis*
  IV.—Inflammation of the Peritonaum.
  155.  IV.  The Morbid Anatomy of Variola is amongst the
most interesting of the subjects still requiring  investigation:  it
consists of,
  156.  1. The pustular form of inflammation of the mucous
membranes: of all the mucous membranes, that  lining the air
passages suffers the  most;  the whole of the alimentary canal
is subject to  variolous inflammation, but chiefly the  appendix
vermiformh  caeci.*
  157.  2. Inflammation of the serous membranes, in regard to
which the peculiarity  of form is  not  either established or re-
futed.
  158.  3. Inflammation of the parenchymatous substance of
organs, as of the brain, the lungs, &c.
  159.  V.  The Effects of Remedies.  There are no facts on
record calculated to elucidate the question of the effects of reme-
dies.

                  II.  Variola confluens.
  160.  I. History and Symptoms.  The early symptoms of
this form of Variola  are  typhoid; there is delirium, or coma,
vomiting, diarrhoea, cool perspiration, labor in breathing, a feeble,
frequent pulse.  The eruption appears early, on the third day,
and induces less and less permanent relief of the febrile symp-
toms, which resume  their violence on the sixth day ; it is pre-
ceded or attended, in many instances, by exanthematous  red-
ness.   The  pustules are more numerous on  the face;  smaller
and less hard and eminent than in the Variola disciela ; during
a slower and less marked progress, their diameters enlarge ; they
do not retain the  circular and orbicular form, but assume an
irregular figure, remain flat, and coalesce, so that frequently the
  *,M. Rostan observes, Cours de  M6decine Clinique, Ed. 2d, tome ii, p. 201,
" J'ai vu un canal alimentaire garni  des ni6mes pustules que celles de la bouche
depuis l'oesophage jusqu'au rectum." 
190
THE DIAGNOSIS OF
face seems covered with one extended and  continuous pustule.
The interstices are pale and flaccid, and without the rose-colored
inflammation observed in the Variola discreta.  The contained
fluid becomes opaque and brownish, and does not assume the
yellow, consistent, and purulent appearance.  The  pustules at
length break, the cuticle shrivels up, the enclosed fluid issues;
dark-brown scabs are formed, separate slowly, and  leave deep
pits.   The tumefaction of the face, and the salivation, take place
earlier, and are more considerable than in Variola discreta; they
abate, and the hands tumefy, about the seventh day.  On the
general surface the pustules are more distinct; but they are less
prominent, and the enclosed matter less consistent, than in the
former variety.
  161. II.  The Functional  Complications  of the  Variola
confluens are,
     I.—Cephalic:
       1. Delirium; 2. Coma; 3. Subsultus; 4. Spasm, fyc.

    II.— Thoracic :
       1.  Cough ; 2. Rattle; 3. Dyspnoea, <S,-c.

   III.—Abdominal:
       1.  Vomiting; 2. Diarrhoea;
       3.  Melana; 4.  Hamaturia; 5, Menorrhagia, fyc.

   IV.—Integumental:
       1.  Petechia; 2.  Vibices ;
       3.  Livid Vesicles; 4.  Gangrenous  Ulcers :
       5.  Anasarca, $'c

  162. III.  The Structural  Complications are,
     I.— Variolous Opthalmia.
   U,_ Ulcerations—-1. of the Mouth, Fauces, fy Pharynx;
                     2. of the Stomach, Intestines, fyc.
  XII.__Ulcerations—1. of the Epiglottis and Glottis;
                     2. of the Larynx and  Trachea.
IV —Cerebral Congestion. 
ERUPTIVE FEVERS.             191
   V.— Thoracic Disease :
                     1. Bronchitis, with bloody mucus;
                     2. Congestion of the Lungs;
                     3. Pleuritic, Serous, Purulent,  or
                          Sanguineous Effusion.
  VI.—Abdominal Congestion.
 VII.— Glandular Swellings.
VIII.—Swelling and Stiffness of the Joints.

                    IV. ERYSIPELAS.
  163. Erysipelas occurs under  four different forms, the phleg-
monode,  the erratic, the cedematous, and the gangrenous.
  164.   The History.   Erysipelas is generally preceded by
marked derangement of the  digestive organs.  It has been sup-
posed to be contagious.   The gangrenous form  has prevailed
in some seasons epidemically. It is preceded two or three days
by shiverings, which alternate with flushes of heat.

              I. Erysipelas phlegmonodes.
  165.  The Symptoms.  This form of erysipelas frequently
affects one side of the head  and face; at other times it appears
upoh one of the limbs.  In the former case there are languor,
drowsiness, and dull aching pains in the head, neck, and back;
the tongue is white, the  breath  tainted, and  the  bowels disor-
dered.  The swelling usually begins on the second or third
day, on the side of the nose, on the cheek, or near the ear; and
extends subsequently to the  scalp, neck, or breast: it is of a dark
red,  smooth, and soft, and attended with heat and tingling.
The face becomes disfigured, and there is frequently delirium
or stupor.  On the fourth  or fifth day  vesications take place,
principally about the central part of the swelling,  of unequal
size, and irregular base,  and containing a fluid at first clear and
watery, afterwards  straw-colored and opaque, or livid.  These
vesicles break about the  fifth or sixth day, when the swelling
begins to subside and assumes a yellowish hue.
   166. Similar appearances take place when the disease affects
a limb. 
192
THE  DIAGNOSIS  OF
   167. The erratic form of erysipelas is only peculiar by its
 milder and wandering character.

               II. Erysipelas adematodes.
   168.  This form of erysipelas is marked by less redness and
 greater tumefaction than  the  former.  There is  also greater
 tendency to delirium  and  coma, and to gangrene.  It is fre-
 quently fatal, with these symptoms, about the eighth day.{')

              III. Erysipelas gangranosum.
   169.  This form of the disease begins sometimes as the phleg-
 monous ; sometimes as the cedematous.   The swelling exhibits
 a dark red hue, inclining to lividity; it is soft and puffy; phlyc-
 ta?na? form upon it, containing a  dark brown or  livid fluid,
 whilst the skin at their bases becomes black and gangrenous.
 On the cheeks and other parts, there are deep ulcerations, with
 livid edges;  a thin purulent fluid is o'un diffused through the
 cellular membra le, and  sinuses, caverns,  and sloughs, are
 formed;  the eye-lid frequently becomes hard and brown, or
 blackish,  and sphacelates.   Delirium and  coma  accompany
 these appearances.  It affects various parts of the body.
   170.11. The Complications.  Dr. Heberden justly remarks
 —" In hac, ut in omni alia febre, oportet vigilare, et quicquid
 mali  oriatur, idoneis remediis succurrere."*   Indeed in every
case of fatal erysipelas it is probable that there is either

       Inflammation, or Congestion, within the—
                    1.  Head,
                    2.  Thorax, or
                     3.  Abdomen.

   171. III.  The Morbid Anatomy.  I need scarcely  repeat
what I have already stated several times,  that the morbid ana-
tomy requires  to be investigated  anew in reference to each of
  (1.) In this form of erysipelas the skin is smooth and shining, and retains for
some time, the impression of the finger.                           B.
                     • Commentarii, p. 148. 
ERUPTIVE  FEVERS.
193
the eruptive fevers; this remark applies to erysipelas,  equally
with scarlatina, variola, &c.
  172.  The four species of disease enumerated in the present
chapter afford an admirable subject and ample scope for original
inquiry  in many points of  view, but  especially in reference  to
the pathology, the complications, and the morbid anatomy.
25 
CHAPTER  III.
    THE DIAGNOSIS OF  IRRITATION, EXHAUSTION,  ETC.

   173. The first two subjects which I now introduce to the no-
tice of my readers, have been almost neglected by the profession.
I have treated of them expressly before,* and it is now only ne-
cessary to detail their diagnosis.
   174. Irritation, the first of these subjects, consists in the pre-
sence and effects of some cause of pain and suffering, or in the
more immediate effects of such a  cause, should it  be removed.
The irritation  of a calculus in the ureter, or in the hepatic duct,
is well known  to occasion severe pain and a remarkable sympa-
thetic affection of the stomach. viz. nausea and vomiting.!  The
introduction of a bougie into the urethra sometimes induces rigor
and a complete  febrile paroxysm,  although it be immediately
withdrawn.  Uterine irritation is not less frequently or unequivo-
cally the cause  of extraordinary effects  upon the system gene-
rally and upon various organs.
   175. But of all the sources of sympathetic morbid affections,
irritation in the stomach and intestines is the most common, the
most  important.    Indigestible  substances taken, and  fseculent
matters too long retained, are the frequent  causes of that com-
  * See the " Researches," &c. pp. 9—92;  201.
  t These two examples of irritation will be noticed more fully hereafter.  It ia
only necessary to state, in this place, that the former is denoted by local pain,
sympathetic sickness and vomiting, and sometimes icterus; whilst to the pain
and sickness, in the latter case, are added a state of urine charged with animal
matter, with a strong smell, high color, and sometimes an admixture of blood
In either, a calculus, or calculi, may be expelled.  Gentle percussion upon the
part is, in these, as in many instances of disease, of the highest value in a diag-
nostic point of view. 
INTESTINAL  IRRITATION.        195
bined affection of the  head and of the stomach, termed sick-
headache, and of other and  more acute sympathetic morbid af-
fections, less recognized by the profession.
  176. Similar remarks may be made respecting the effects of
exhaustion from the loss of blood.  If the more immediate of
these effects be well known, the more remote have been over-
looked, or mistaken for other morbid affections.  Yet to the phy-
sician the symptoms of re-action from loss of blood, so similar to
those of some affections of the head, and of the heart, present
subjects for his observation of the utmost moment in actual prac-
tice.   The diagnosis of these cases is most important;  the prog-
nosis and the treatment alike depend upon it.
  177. With these affections it will be highly useful to contrast
those denominated delirium tremens and erethismus mercurialis.

      ARRANGEMENT  OF  IRRITATION,  EXHAUSTION, ETC.

       I. Intestinal Irritation.
      II. Exhaustion from  loss of Blood.

                  I.  Immediate.
                 II.  Remote.
                       1. Re-action.
                       2. Sinking.
     III. Delirium tremens.
      IV. Erethismus mercurialis.

              i.   intestinal  irritation.
  178. I.  The History.  The most, frequent cause of this af-
fection is a disordered state of the contents of the colon ;  the next
is some indigestible substance taken into the stomach.  But as
the mere presence of a calculus in the ureter is not always suffi-
cient alone to induce  an attack of pain and vomiting, so a de-
ranged condition of the intestinal contents will not, alone, induce
an attack of the morbid affection which I am about to describe ;
in general  some  superadded  cause, some shock sustained, or
some effort made by the system, is necessary to rouse into activity 
196
the  diagnosis  of
the cause of irritation otherwise dormant.  In the same man-
ner, indigestible substances may frequently be taken, with im-
punity, when the  health is  unimpaired;  but if the system be
under the influence of shock, or effort, or of nervous or vascular
excitement, or exhaustion, a cause of disorder  which might have
been inert in other circumstances, proves of frightful activity.
One condition  frequently involves all these causes:  it is the
puerperal state.  Intestinal irritation is, therefore, most frequent-
ly a puerperal disease.  It is also frequently brought into action
by  a fall, or other accident, by serious operations,  &c.
  179.  II. The Symptoms.  The effects of intestinal irritation
generally begin in the manner of a sudden attack.   This attack
is usually ushered in by rigor, indeed  by a more distinct and de-
cided rigor than is observed in many cases of inflammation ; the
rigor  is usually soon followed by  much heat of surface; with
the heat the patient experiences some affection of the head, chest,
or abdomen,  and, indeed, frequently of all; there are vertigo on
raising the head, pain, and some morbid impression on the mind,
panting in the breathing, fluttering about the heart, with general
hurry, irritability,  and restlessness ;  the  tongue is white  and
loaded ; the alvine evacuations are morbid,—dark-colored, foetid,
and scybalous,—or yellow like the yolk of egg,—or of the ap-
pearance of  yeast;  the urine is turbid and frequently deposits a
copious sediment.
  180.  These affections are apt to occur in sudden attacks, and
to recur in paroxysms,—perhaps varying their form,—and ex-
citing great alarm in the patient and his  friends,  who usually
despatch a hurrying message to the medical attendants.
  181.  III.  The Complications  consist of affections resem-
bling
                     1. Arachnitis;
                     2. Pleuritis;
                     3. Carditis;
                     4. Peritonitis.
  182.  1. The affection of the head consists of the most acute
pain, the greatest intolerance of light and sound, and the severest 
intestinal  irritation.        197
form of  vertigo, wakefulness, and distress, and sometimes even
delirium, and the pupils  of  the eyes  are often extremely con-
tracted.
   183. 2.  The affection  of  the chest is denoted  by severe  and
acute local pain, which is apt to vary its situation, passino- from
one side to the other,  or to the back,  or  occupying a situation
higher  up  or lower down: this pain  checks  a deep inspiration,
and even the ordinary breathing, to which it imparts a character
of difficulty and anxiety.
   184. 3.  When the heart is the seat of this affection, there are
violent and terrific attacks of palpitation, and the course of the
carotids  and even of the abdominal aorta, is sometimes the seat
of violent pulsation or throbbing.
   185. 4.  When the abdomen  is affected, there are acute pain,
and great tenderness under pressure, in some part, or more or less
generally diffused.  The attack  and  situation of  the pain are
such, in some instances, that the case is  with difficulty distin-
guished from gall-stones, though  it more  generally resembles
peritonitis.*
  * It maybe well in this note to state the diagnosis more distinctly.
  1. The attack of intestinal  irritation is, in general, more sudden than that of
inflammation, which is  usually  formed somewhat more gradually.  This cir-
cumstance must therefore be cautiously inquired into, and  may assist the diag-
nosis.
  2. I believe, too, that  the seizure in the former case is attended by more dis-
tinct rigor, and afterwards by greater heat, than in the latter.
  3. The case of  irritation  affects, in a marked degree, more organs at once,
whilst that of inflammation is usually confined} at first at least, to one.
  4. The state  of the tongue and the condition of the alvine evacuations are far
more marked by disorder, and the latter are far more offensive, in attacks from
irritation than in cases of inflammation.
  5. The affection of the head, from irritation comes on suddenly, is formed all
at once, and is frequently attended by great restlessness, suffering, and distress,
and there is early  syncope on taking blood : in arachnitis, the disease is usually
formed somewhat more  gradually; the  patient  has been subject to pain of the
head perhaps for some days or even longer; he complains less; or at least there
is less urgent distress,—less distress of a general kind ;  the pain may be very se-
vere, although it is more frequently rather obscure ; the intolerance of light and
sound  is less urgent; the rigor, and  subsequent heaS and the attack in general, 
198                  THE  DIAGNOSIS  OF
   186.  IV.  The Effects of  Remedies.   In this place I must
beg permission to draw the attention of my reader very particu-
larly to that source of diagnosis afforded by the effects of reme-
dies ;  and  particularly to  the  diagnosis  between the class of
complications  of Intestinal Irritation resembling inflammations
from actual Inflammation.   In  the  latter  cases,  thirty,  forty,
and  even  fifty ounces  of blood may flow  before the slightest
deliquium  is observed:  in the former there is frequently the
most perfect syncope on abstracting nine or ten ounces of blood !
   187. A  further diagnosis is  afforded by the condition of the
intestinal  evacuations, as ascertained by the administration of
copious warm-water enemata ;  &c.
   188. V.  The structural changes induced by continued In-
are less marked ; the patient is not so soon relieved by remedies, and the tongue
and alvine evacuations are less morbid, and there is, especially, great tolerance
of loss of blood.  In  the attack of affection of the head from irritation, the pa-
tient is relieved perhaps  completely if the lancet be employed, but the  attack
soon recurs with equal or greater violence : in arachnitis, the relief is seldom so
complete, the interval of ease so long, or  the return so marked ;  the pain is di-
minished, perhaps,  but  gradually resumes  its  former violence,  unless active
measures be interposed.
  6. When the chest is affected from irritation, the pain is severe and acute, and
perhaps increased by a  full  inspiration; if the inspiration be repeated, how-
ever, a second and a third  time, the increase of the pain is less  and less;  the
situation of the pain varies ; there is no cough, no crepitus on making a full ex-
piration.  In all these respects the case differs from inflammation.  The remarks
already made respecting  the relief from remedies, the effect of blood-letting, the
tendency to a sudden recurrence of the pain, &c. in cases of affection of the head,
apply equally here.
  7. I had long remarked that there might be both acute pain and tenderness
under pressure, of the abdomen, without inflammation ; this state of things ia
frequently the result of intestinal irritation.  It is distinguished from  inflamma-
tion by the general symptoms, the mode of attack, the effects of remedies.  In
inflammation the surface  is  usually cool, the head unaffected, the patient remark.
ably quiet: in the case of  irritation, on the contrary, there is generally much
heat after rigor, the head is much affected, and the patient is restless and gene-
rally distressed, the tongue loaded and perhaps swollen, the alvine evacuations
extremely morbid,  and  great relief is obtained by the  free operation of medi-
cine.  I may refer further  to the Clinique M6dicale of M. Andral, ed. 1,  t. i, pp.
51,54. 
EXHAUSTION.                 199
testinal Irritation are unknown; but it is probable that serous
effusion is not unfrequentiy induced and ascribed to other causes.

                     11.  EXHAUSTION.
   189. The History.  The effects of Exhaustion from loss of
blood are readily traced to its cause when they are immediate  •
but the remote effects of Exhaustion are particularly apt, from
their  similarity to inflammatory diseases, and from the  present
relief conferred by the detraction of blood, to deceive  the un-
wary.  It  is highly important, therefore, to bear this distinction
in mind.
       I.   The immediate Effects of Loss of Blood.
   190. I.  The Symptoms.   The most familiar of  the effects
of loss of blood  is syncope.   In  ordinary syncope from loss of
blood, the patient first experiences a degree of vertigo, to which
loss  of consciousness succeeds; the respiration is affected in
proportion  to the degree of insensibility, being suspended until
the painful sensation produced rouses the patient to  draw deep
and repeated sighs,  and then  suspended as  before ; the beat of
the heart and of the pulse is slow and weak; the face and ge-
neral surface become pale, cool, and bedewed with perspiration  ;
the stomach  is apt to be affected with eructation or sickness.
On recovery there is perhaps a momentary delirium, yawning,
and a return of consciousness ;  irregular sighing breathing; and
a gradual  return of the pulse.
  191. In  cases of profuse haemorrhagy the state of the patient
varies: there is at one moment a greater or  less degree of syn-
cope,  then a degree of  recovery.   During the syncope the
countenance is  extremely pallid, there is more or less insensibil-
ity, the respiratory movements of the thorax are at  one period
imperceptible, and then  there are irregular  sighs, the pulse is
slow,  feeble, or not to be distinguished, the extremities are apt to
be cold, and the stomach is frequently affected with sickness.
   192. In cases of fatal haemorrhagy there are no ameliorations.
The symptoms gradually and  progressively assume a more and
more frightful  aspect: the  countenance does not improve, but 
200
THE  DIAGNOSIS  OF
becomes  more  and  more  pale  and sunk ; the consciousness
sometimes remains until at last there  is  some  delirium; but
every thing  denotes an impaired state of the energies of the
brain; the  breathing becomes stertorous and at  length affected
by terrible gasping ; there may be no efforts to vomit;  the pulse
is extremely feeble or even imperceptible ;  the animal heat fails
and the extremities become colder and  colder in  spite of every
kind of external warmth ;  the  voice may be strong, and there
are constant restlessness and jactitation ; at length the strength
fails, and the patient sinks,  gasps, and expires.
   193. Besides syncope there are other immediate effects of loss
of blood.  These are,

                   1.  Convulsions ;
                  2.  Delirium ;
                   3.  Coma;
                   4.  Sudden Dissolution.
   194.  1. Convulsion is, after syncope, the most familiar effect
of loss of blood.  It constitutes one species of puerperal convul-
sion,  and should be accurately distinguished from other forms of
this affection, arising from intestinal or  uterine irritation, and an
immediate disease of the head.
   195.  2. Delirium occurs as an immediate, as mania occurs as
a more remote, effect of loss of blood.
   196.  3. We may be called to  patients so perfectly comatose,
immediately after blood-letting or  haemorrhage, that we may be
in doubt for  a time whether the case be  not apoplexy.   The his-
tory, the state of the countenance, of the  pulse  and of the ex-
tremities, and the other symptoms,  will, after a little watching,
make the case clear to  us.
   197. 4. Sudden  death has occurred from misapplied  blood-
letting.  For an account of the circumstances in which  this is
apt to take place, I must refer to the work already quoted more
than once;  viz. " Researches," &c. pp. 6—23, &c.

      II. The more remote Effects of Loss of Blood.
   198. The more remote effects of loss of blood  are induced by 
EXHAUST HON.
201
repeated detraction of blood or a continued heemorrhagy,  and
consist in,
         I.—Excessive Re-action ; sometimes with
                1. Delirium ;  Mania ; or
                2. Coma ; Amaurosis ; or Deafness.
        II.— The Sinking State.

                 I. Excessive  Re-action.
   199. 1.  The Symptoms.  Excessive re-action is formed gra-
dually, and  consists, at first, in forcible beating of  the pulse, of
the carotids, and of the heart, accompanied by a sense of throb-
bing in the  head, of palpitation of the  heart, and eventually
perhaps of beating or throbbing in the scrobiculus cordis, and in
the course of the aorta.   This state of re-action is augmented
occasionally  by a turbulent dream,  mental agitation,  or bodily
exertion.   At other times it is modified by a temporary faintness
or syncope.  There is also  sometimes irregularity of the  beat
of the heart  and of the pulse.   The respiration is apt to be fre-
 quent and hurried,  and  attended with  alternate  panting and
 sighing;  the movement  of expiration is sometimes  obviously
 and singularly blended with a movement communicated by the
 beat of the  heart;  the patient requires the smelling-bottle, the
 fan, and the fresh air.  The skin is sometimes hot;  and  there
 are frequently general hurry and restlessness.  In this state of
 exhaustion,  sudden dissolution has sometimes been the immedi-
 ate consequence of  muscular effort on the part of the patient,
 or of his being too suddenly raised from the recumbent into the
 erect position.
   200. II. In the more exquisite cases of excessive re-action the
 symptoms are still more strongly marked, and demand a fuller
 description.  They consist in affections resembling,
                     I.  Arachnitis;
                    II.  Carditis.
    201. I. The beating of the temples is at length accompanied
  by a throbbing pain of the head,  and the energies and  sensi-
                             26 
202             THE  DIAGNOSIS  OF
 bilities of the brain  are  morbidly augmented ; sometimes there
 is intolerance of light, but  still more frequently intolerance of
 noise and of disturbance of  any kind, requiring stillness  to be
 strictly enjoined, the  knockers to be tied, and straw to be strewed
 along the  pavement;  the sleep is  agitated and disturbed by
 fearful dreams, and the patient is liable to awake or to be awoke
 in a state of great hurry of mind, sometimes almost approach-
 ing  to delirium; sometimes there is slight delirium, and  occa-
 sionally  even continued  delirium;  more frequently there are
 great noises in the head  as of singing, of crackers, of a storm, or
 of a cataract; in some instances there are flashes of light; some-
 times there is a sense of  great  pressure or tightness in one part
 or round the head, as if  the skull were pressed by an iron nail
 or bound by an  iron hoop.
   202.  II.  The action of the heart and arteries is morbidly in-
 creased, and there are great palpitation, distinct "bruit  de  scie,"
 under the ear or the stethoscope, and visible throbbings of the
 carotids, and sometimes even of the abdominal aorta, augment-
 ed to a still greater degree, by every cause of hurry of the mind
 or exertion of the  body,  by  sudden noises or hurried  dreams or
 wakings;  the patient is often  greatly alarmed and impressed
 with the feeling of approaching dissolution ;  the state of palpi-
 tation and throbbing are apt to be changed, at different  times,
 to a feeling of syncope ;  the effect of sleep  is in some instances
 very  extraordinary—sometimes palpitation, at other  times  a
 degree of syncope, or an  overwhelming feeling of dissolution ;
 the pulse varies from 100 to  120 or 130, and is attended with a
 forcible jerk or bounding  of the artery.
  203. III.  The  Effects of Remedies.   The symptoms of
 exhaustion with re-action have, I am persuaded, frequently been
 mistaken for those of inflammation or other disease of the  head
or of the heart.  Under this  impression recourse has frequently
been had to the further detraction of blood by the lancet.   And
 the effect of this practice is such as greatly  to impose upon the
 inexperienced,—for all the symptoms are  perhaps greatly re-
 lieved by the induction of a state of syncope.
   204. It seems only necessary to  refer to the occurrence of 
EXHAUSTION.                 203
 delirium, mania, coma, and  amaurosis, as effects of exhaus-
 tion from loss of blood.   They are distinguished by being traced
 to these causes.  The first frequently occurs, either as transient
 delirium or as more permanent mania, as a puerperal disease.
 Coma, amaurosis, and deafness, have occurred  from similar
 causes and under similar circumstances.  They must be cau-
 tiously distinguished from similar symptoms resulting from cere-
 bral inflammation or congestion.

                  II.  The Sinking State.
   205. This term is adopted  not to express a state of negative
 weakness merely, which may continue long and issue in even-
 tual recovery,  but to denote a state of positive and progressive
 failure of the vital powers, attended by its peculiar effects, and
 by a set of phenomena very different from those of exhaustion
 with re-action.
  206. I.  The Symptoms.  If in re-action the energies of the
 system are augmented, in sinking the  functions of the brain,
 the lungs, and the heart are singularly impaired.  The sensi-
 bilities of the brain subside,  and the patient is no longer affected
 by noises as before; there  is,  on  the contrary, a tendency to
 dozing, and gradually some  of those  effects on the  muscular
 system which denote a diminished sensibility of the brain super-
 vene, as snoring, stertor, blowing up of the cheeks in breathing,
 &c; instead of the hurry and alarm on awaking as observed in
 the case of excessive re-action, the patient in the state of sinking,
requires a moment to recollect himself and  recover his conscious-
 ness, is perhaps affected with  slight  delirium, and  he is apt to
forget the circumstances of his situation, and, inattentive to the
objects around  him, to fall  again into a state  of dozing.  Not
less remarkable is the  effect of the state  of  exhaustion  with
sinking on the function of the lungs;  indeed the very first indi-
 cation of this state is, I believe,  to be found in the supervention
of a crepitus in the respiration, only to be heard  at  first on the
most attentive  listening, or by means of  the stethoscope; this
crepitus gradually becomes more audible and  passes into slight
rattling,  heard in the situation of the  bronchia and  trachea; 
204             THE  DIAGNOSIS  OF
there is also a  degree  of labor or oppression,  sighing, hurry,
blowing, in the breathing,  inducing acuteness in the nostrils,
which are dilated below and  drawn in above the lobes at each
inspiration;  in  some cases there is besides, a peculiar catching,
laryngal cough, which  is especially apt to come on during sleep,
and  awakes or  imperfectly awakes the patient.  The heart has,
at the same  time, lost its violent beat and  palpitation, and the
pulse and  arteries their  bounding  or throbbing.  The stomach
and  bowels  become  disordered and flatulent, and  tympanitic,
and  the command  over the  sphincters is impaired.   The last
stage of sinking is denoted  by a  pale and sunk countenance,
inquietude, jactitation, delirium, and coldness of the extremities.
   206.  II.  The Morbid Anatomy.  Extreme exhaustion from
loss of blood  leads to

1. Effusion of Serum or of Blood within the Head.
2. (Edema of the Lungs, accumulated bronchial Secretion,
     and serous Effusion from the Pleura.
3. Serous Effusion from the Peritonaum.
4. General QZdema or Anasarca.
5. Tympanitic Distention of the Bowels.

   207.  I have  been  as full, yet as brief, as possible, in this de-
scription of Intestinal Irritation and Exhaustion.  I was anxious
that subjects so little understood should be fairly brought before
the student; yet I was  equally anxious not to devote an undue
degree of space  to them, however important.

                III. DELIRIUM TREMENS.*
   208.  I.  The History.  The cause of delirium tremens con-
sists in the habit of taking alcoholic liquors; the  immediate at-
tack is frequently induced by  some event which has withdrawn
the wonted stimulus.  The disease is very apt to recur after a
  * An affection very similar to the delirium tremens has been described by
M. Dupuytren as occurring after accidents or operations, under the designation
Delirium traamalicuin. 
          ERETHISMUS  MERCURIALIS.      205

first attack.   The first  symptom is  frequently tremor merely,
which is afterwards succeeded by the delirium.
  209.  II. The Symptoms.  The delirium tremens is strongly
characterized  by the state of expression of the countenance.
There is a wild stare; the patient raises himself up to attend to
what is said to him, but it is soon perceived that the mind wavers
is confused, or intent on some particular purpose, as in endea-
vors to seize or avoid particular objects or persons.   The patient
then talks incoherently.  There is at first little muscular debil-
ity, but there is a state of tremulous motion of the limbs.  The
patient  frequently changes  his posture, sits up, and perhaps
wishes  to get  out  of bed.  The  state of the surface  is httle
changed in the commencement, but, at a later period,  a  copious
perspiration occasionally occurs, sometimes with coldness of the
forehead, face,  and extremities.  There are  utter sleeplessness
and delirium, especially during the night; but the patient may
generally be made to collect himself for a time.   The pulse is
rather frequent, but oft jn nearly natural.  The tongue is white
and usually moist.   There is anorexia.  The bowels are regu-
lar.   In an advanced stage the delirium may pass into coma,
the tremor assume the form of subsultus tendinum, and the
evacuations become involuntary.
   210.  III. The Effects of Remedies.  The e is early syn-
cope from blood-letting; and this  measure is often followed  by
sinking of the powers of life.
   211.  IV. The Morbid Anatomy. The patient may sink in
the first attack without any perceptible organic change.  When
there have been more attacks than one, I have found  effusion
into the ventricles of the brain, and under the arachnoid.

               IV. ERETHISMUS MERCURIA.LIS

   212.  This  affection was  first discriminated by the late Mr.
John Pearson.*
  • See Observations on the Cure of Lues V-siiera, Ed. 2d. chap. xii.  Mr.
Pearson obierves—" In the course of two or three years after my appointment 
206
THE  DIAGNOSIS  OF
   213.  Since Mr. Pearson wrote, we have a  case of deep inte-
rest in the  communication of the late  Dr. Bateman, published
in the Medico-Chirurgical Transactions, vol. ix. art. xv.
   214.   I.  The History.   The  erethismus  mercurialis may
come on at an early period of the use of mercurial remedies.  In
Dr. Bateman, the first symptom occurred on  the ninth day  of
mercurial inunction, with languor,  fever, and on the next morn-
ing with violent  and  irregular  beating of the heart.   The in
unctions were continued  umil the thirteenth day !  (§ 13.)
   215.   II.  The Sy vptoms.   Mr. Pearson  observes—" The
gradual approach of this diseased  state, is commonly indicated
by paleness of the countenance, a state of general inquietude,
and frequent sighing:—The respiration becomes more frequent,
sometimes accompanied with a sense of constriction  across the
thorax;  the pulse is small,  frequent, and often intermitting, and
there is a sense of fluttering about the prascordia.   In this early
stage, the farther progress of the mercurial erethismus may be fre-
quently  prevented,  by giving the camphire mixture with large
doses of volatile  alkali, at the same time suspending the use of
mercury."   And further—" the erethismus is  characterized by
to the care of the Lock Hospital, I observed, that in almost every year, one and
sometimes two instances of sudden death occurred among the patients admitted
into that institution ; that these accidents could not be  traced to any evident
cause ; and that the subjects were commonly men who had nearly, and some-
times entirely, completed their mercurial course.  I consulted Mr. Bromfeild and
Mr. Williams upon this interesting subject, but they acknowledged themselves
unable to communicate any satisfactory information : they had  carefully exam-
ined the bodies of many who had died thus  unexpectedly, without being able to
discover  any morbid appearances ; and they confessed .that they were equally
ignorant  of the cause,  the mode of prevention, or  the method of treating, that
state of the system which immediately preceded the fatal termination.
  " As the object of my inquiry was of considerable importance, I gave a con-
stant and minute attention to the operation of mercury on the constitution in ge-
neral, as  well as to its effects on the disease for which it was administered,  and,
after some time had elapsed, I ascertained, that these sinister events are to be as-
cribed to  mercury acting as a poison on the system, quite unconnected with its
agency as a remedy : and that its deleterious qualities were neither in propor-
tion to the inflammation of the mouth, nor to the actual quantity of the mineral
abs-irbed  into the body." 
ERETHISMUS  MERCURIALIS.       207
great depression of strength, a sense of anxiety  about the prse-
cordia, irregular action of the heart, frequent sighing, trembling,
partial or universal, a  small, quick, and sometimes an intermit-
ting pulse, occasional vomiting, a pale contracted countenance, a
sense of coldness; but the tongue is seldom furred, nor  are the
vital or natural functions much disordered.   When these, or the
greater part of these symptoms are present, a sudden and violent
exertion of the animal power will sometimes prove fatal; for in-
stance, walking hastily  across the ward; rising up suddenly in
the bed to  take food or drink;  or slightly struggling with some
of their  fellow  patients, are among the circumstances which
have commonly preceded the sudden  death of  those afflicted
with the mercurial erethismus."*
   216.  In Dr. Bateman's case it was remarked " that the action
of the heart and arteries, which  was extremely feeble as well as
irregular while  awake,  was  so  much  more enfeebled  during
sleep, as to be  in fact almost suspended, and thus to occasion
alarming faintings and  sinkings; so that it became necessary,
notwithstanding the extreme drowsiness which had  succeeded
the  long-continued watchfulness,  to interrupt the sleep at the
expiration  of two minutes, by which time,  or even  sooner, the
  * " To prevent the dangerous consequences of this diseased state, the patient
ought to discontinue the use of mercury;  nor is this rule to be deviated from,
whatever may  be the stage, or extent, or violence of the venereal symptoms.
The impending destruction of the patient, forms an argument paramount to all
others ; it may not be indeed superfluous to add, that a perseverance in the mer-
curial course, under these circumstances, will seldom restrain the progress of the
disease, or be productive of any advantage.  The patient must  be expressly
directed to expose himself freely to a dry and cool air, in such a manner as shall
be attended with the least fatigue. It will  not be sufficient to sit in a room with
the windows open ; he must be taken into a garden, or a field, and live as much
as possible in  the open air, until the  forementioned symptoms be  considerably
abated.  The good effects of this mode of treatment, conjoined with a generous
course of diet, will be soon manifested; and I have frequently seen patients so
far recovered in the space of from ten to fourteen days that they could safely re-
sume the use of mercury ;  and, what may appear remarkable, they can very
often employ that specific  efficiently afterwards, without suffering any incon-
venience." 
208            THE DIAGNOSIS, ETC.
sinking of the pulse and countenance indicated the approaching
languor."*
   217. There is a case  shortly detailed in Sir C. Bell's admira-
ble work on the Nerves,t  which is surely one of Erethismus
Mercurialis  The patient's " medical  friends have sat I y him
and watched him, and have found that when sleep is over-power-
ing him, the breathi ig becomes slower and  weaker,  the heart
and pulse also fall low, and cease to beat as sleep comes on ; and
in a short time  he awakes in tremor."   The patient has taken
" a great deal of calomel."
  * The reader cannot fail to have observed a degree of similarity between the
erethismus mercurialis and the state of exhaustion from loss of blood.  The con-
dition of the heart's action, the  peculiar effect of sleep, and the proneness to a
sudden fatal termination from muscular effort, are the same in both affections.
  The state of things in extreme chlorosis is also not dissimilar, as I  have had
occasion to notice elsewhere.  See " Researches," p. 115,  and " Commentaries
on some Diseases of Females," Ed. ii, p. 82,
  Similar circumstances are observed also in some diseases of the heart itself.
  f 4to. Ed. 1830, p. cxlviii. 
CHAPTER  IV.
      THE  DIAGNOSIS OP DYSPEPSIA,  CHLOROSIS,  ETC.

    218. There is a class of disorders, each of which consists of a
 more general morbid affection, usually combined with some topi-
 cal symptom or symptoms.   The general affection is complex
 and various ; the complications are multiform and changeable,
 and, by their incidental predominance, frequently imitate other
 diseases widely different in their nature.
    219. The complications of these morbid affections are apt to
 be mistaken and mistreated for different Inflammatory and other
 local diseases, and appear to me to constitute a Class of morbid
 affections scarcely less frequent or less  important, and requiring
 to be distinguished with the utmost care.
    220. The object of this Chapter is to establish  this Class  of
 general and local morbid affections more distinctly and exten-
 sively than before,—to collect and embody the system of facts
 which belong to this part of pathology,—to present accurate de-
 scriptions of the different forms, and to trace the diagnosis of the
 numerous complications  of these disorders.
   221. The first part of the  chain of  constitutional causes and
 effects in all those disorders is a loaded state of the large intes-
 tine.  From this loaded state of the bowels, their functions, and
 those of all  the chylopoetic viscera, most probably become de-
 ranged.   The alvine contents become disordered merely by de-
 lay ; and their presence induces,  in its turn, a disordered state of
 the functions,—or actions,—of all the organs contributory to di-
 gestion, and at length of other organs more remotely situated in
 the animal frame.
   222.  The functions of the parts within the mouth become
 obviously disordered.  The  secretions  become morbid;   the
tongue becomes loaded and swollen ; the gums red  and tumid;
                            27 
210
THE  DIAGNOSIS
the breath tainted ;  and the saliva sometimes profuse and offen-
sive.  The complexion and the skin  become morbid, and there
are the appearances observed in the acute dyspepsia or in chlo-
rosis, and  frequently oedema.   This  condition of the complex-
ion and skin varies with the state  of the original disorder,  and
with that  of the tongue and internal  mouth, of which it affords
indeed an index.   With the state of  the mouth and skin,  that
of the secretions and other functions  of the  whole course of the
alimentary canal and the contributory  digestive organs,—the
liver, the pancreas, &c. may be presumed to be all morbidly af-
fected.  Digestion  is  variously deranged;  the contents  of the
bowels become unnatural;  and thus  reciprocally.
   223.  As co-existent or subsequent  links of this chain of sym-
pathies, the functions of the brain, heart, respiration, stomach,
intestines, uterus, bladder, &c.  become variously affected.   The
muscular system and the senses also suffer in different instances.
And  nutrition, absorption, and  secretion are  impeded or im-
paired.
   224.  The disorders  comprised in this Class may be arrang-
ed in the following order:

        ARRANGEMENT OF DYSPEPSIA,  CHLOROSIS, ETC.
               I. Dyspepsia.
                   1.  The Acute,
                   2.  The Protracted,
                   3.  The Chronic,  Forms.

             II. Chlorosis.

                    1.  Incipient,
                    2.  Confirmed,
                   3.  Inveterate.

              III.  Hysteria.

                    1.  Mild,
                    2.  Severe,
                    3.  Inveterate. 
OF  DYSPEPSIA.
211
                       I.  DYSPEPSIA.
   225. This disorder occurs under three forms :  the acute, the
protracted, and the chronic.
                   I.  The Acute Form*
   226. I.  The History.  This affection is  the usual result of
sedentary habits.   It affects literary persons,  and is particularly
apt to be induced during  a residence at college; it is also fre-
quently seen in females and persons of a delicate mode of life ;
it affects tailors and mantua-makers,  and the youthful inhabit-
ants of schools.   It comes on  insidiously, but often first attracts
attention by the suddenness and severity of some one of its com-
plications.
   227. II.  The  Sympto?ns.   The  Acute Dyspepsia is early
and principally characterized and distinguished by the concur-
rence of the following symptoms,—namely, weakness, tremor,
headache, vertigo, fluttering, faintishness, tendency to perspira-
tion, susceptibility to hurry and  agitation, weariness, and  loss
of flesh.  The countenance is rather pale and thin; the lips are
pale,  and, with the chin,  frequently tremulous,  especially on
speaking; the surface of the face is  generally affected with an
appearance of oily, clammy, and swarthy perspiration, especial-
ly near the nose.   The tongue  is  almost invariably loaded:—
sometimes only slightly, whilst its edges are clean and red ;—in
severe cases, a load has formed over the tongue, and has, almost
at once, peeled off, leaving the surface morbidly red, smooth, and
tender;—at other  times it is more  loaded, swollen, and cedema-
tous, formed into  deep sulci or plaits, and marked by pressure
against the contiguous teeth,—the inside of the cheeks  being
also impressed  in the  same manner;  the papillae of  the
tongue are numerous and enlarged; the  gums are red  and
swollen, and occasionally bleed ; the teeth and the mouth are in
general foul, and  the breath loaded and foetid ;  in a fourth in-
  * A careful examination of some of the older writers has led me to think that
the Acute Dyspepsia is described by them under the designation Scorbutus.
See Willis de Cerebro, &c. Tract de Scorbuto; and an Essay by the author in
the Edinb. Med. and S urg. Journ. vol. xvi, p. 204. 
212
THE  DIAGNOSIS
stance, the tongue may, however, be clean, butlobulated, whilst
the internal mouth and breath are little affected.   There is a
tendency to perspiration, on slight exertion, or any surprise, and,
sometimes, in the night or early in the morning; the skin is, in
general, cool, rather moist, and  clammy; in some protracted
cases, it has become dry and  harsh.  The hands and feet are
apt to be very cold, and the nails occasionally assume a lilac hue.
The patient is usually affected with great tremor, observed some-
times in a quivering of the lip, or dimpling of the chin, but
more usually on holding out the hand, or in  carrying a cup of
tea, for instance, to the mouth, on attempting to  stand  erect or
walk, or on being fatigued or hurried.  There is an early and
daily loss of flesh.   The patient experiences headache and ver-
tigo, and he is nervous, and easily hurried  and agitated.   There
is sometimes heaviness for sleep; sometimes great wakefulness
and restlessness; sometimes incubus, rarely delirium ; sometimes
loss of memory and absence  of mind.   There is  almost uni-
versally a peculiar sense of  fluttering about the heart and pit of
the stomach.   And there is frequently an  acute pain  in some
part of the course of the colon.   The bowels are at first consti-
pated ; afterwards constipation and diarrhoea alternate, and some-
times the latter symptom becomes nearly permanent:  the mo-
 tions, during the constipation, are small, during the diarrhoea,
 scanty, extremely foetid, dark  colored,  often  accompanied by
 blood, and frequently attended by tenesmus.*
    228. III.  The Complications.  Besides the symptoms just
 enumerated, there  are  others which prevail more or  less in
 almost every case; but they are, on the whole, less constant and
 more diversified; and of these one sometimes  predominates so
 much over the rest, as to engross the attention of the patient,
 and sometimes of the practitioner, too exclusively.   The secon-
 dary affection is then considered as idiophatic, and the symptom
  * I have, in two localities, witnessed the most marked form of the Acute Dys.
pepsia within the precincts of convents.  The seclusion and inactivity of these
establishments appear to be the causes which slowly induce this disease. 
OF DYSPEPSIA.
213
is apt to be treated as the disease.   It is therefore of the utmost
importance to present the reader with the following distinct enu-
meration of these symptoms:—

 1. Headache;  Vertigo ; Stupor;  $*c.
 2.  One Form of Epilepsy.
 3.  Paroxysms of Oppressive Dyspnaa ;  True Asthma.
 4.  Palpitation of the Heart ; Fluttering; Faintishness;
     Irregularity and Frequency of the Pulse ;  One Form
     of Angina Pectoris.
 5.  Frequent and Violent Hiccough ;  Vomiting.
 6.  Some Convulsive and Spasmodic Affections.
  7.  Pain in the Epigastric,  or  One or Both of the Hypo*
       chondriac, or Chondiliac Regions.
 S.  Constipation ; Diarrhaa ;  Tenesmus.
  9.  Hamaternesis ; Melana.
 10.  Icterus.
 11.  Severe Pains of  some of the Limbs.
 12.  Sudden Tumefaction of the Integuments, especially of
      the Face*

                  II.  The Protracted Form.
   229. I.  The Symptoms.   In  the more  protracted form of
 this affection, the debility, tremor, loss of  flesh, and tendency to
 faintishness and perspiration are less observed, although perhaps
 not altogether absent.   The countenance is rather sallow, and
 its surface is more or less affected as in the severer form described
  * Even where one of these symptoms is particularly marked and severe, seve-
ral concur, and are experienced in a mitigated form, affording a characteristic
feature of this disorder and a principal source of discrimination ; for whilst most
local diseases are denoted by being simple, and definite, this affection is distin-
guished by its multiplicity, and apparently conjoining  many or all disorders in
one,—Ou^ 'EN t< tw **ji&>v psiwrsu, a.xx' i;iv ots IIOAAA, » kai IIANTA.
  This form of Dyspepsia is also  characterized, although less so perhaps than
the more chronic and continued forms of this affection, by being variable,—
better and worse,—with this or that prevailing feeling or symptom,—even during
a general recovery ;—changes chiefly induced bv bodily fatigue, mental agita-
tion, errors in diet, or constipation. 
214
THE  DIAGNOSIS
 above.  The tongue and the internal mouth are  often affected
 in the severer  degree described.   The  patient is incapable of
 pursuing any laborious employment.   He is prone to perspire
 from slight exertion or agitation.  He perhaps experiences some
 loss of flesh.   He is low spirited  and listless.  The appetite is
 sometimes  impaired, but sometimes craving.  And he  suffers
 from the symptoms described, and from the complications enume-
 rated, only in a milder and more protracted form than  the sub-
 ject of the severer cases of  Acute Dyspepsia.
   230. II.  The  Complications.   Besides the symptoms enu-
 merated, the less severe but more continued form of this disease
 is sometimes attended with one of the following affections :—
 1.  Furunculi ; Paronychia ; Hordeola.
 2. Erysipelas of the Nose ; Erethema Nodosum ; Urticaria
     Chronica ;.  Lichen.
 3. Purpura ; Hamorrhages.
4.  Ulcerations and Pustules of the Conjunctiva.
 5. Decay of the Teeth ; a Morbid State of the Gums ; a pe-
     culiar Ulcer of the Tongue; Chronic Sore Throat.
6. Some Affections resembling Syphilis*

                  III.  The Chronic Form.
   231. I. The History. This form of Dyspepsia, the common
Dyspepsia of  authors, is intimately  allied to the less severe and
               * JVote on a Cachetical Form of Dyspepsia.
  This morbid affection has appeared to degenerate in some cases into a state of
Cachexia, and has been complicated not only with the diseases enumerated but
with other morbid affections,—especially of the skin, the mouth and throat, the
periosteum, the absorbent glands, &c.
  In one case, these were conjoined,  or in succession—1. swarthiness of com-
plexion ; 2. feverishness, with parched throat and mouth, and heat of the forehead
and legs; 3. tendency to perspiration; 4. quivering of the chin and lips in speak-
ing, similar to that observed before shedding tears; 5. tremor; 6. fluttering;  7.
loss of flesh; 8. discharge of bloody mucus from the nostrils, with ulceration;  9.
ulceration of the throat;  10. Icterus; 11. discharge of much blood and mucus
from the bowels, preceded and attended by pain of the abdomen, with tenesmus
and forcing; 12. the stools, otherwise,  light-colored; 13. some anasarca;  14.
boils; 15. painful ulcers on the legs. 
OF  CHLOROSIS.
215
more continued forms described, from which it may originate, or
into which it may pass.  But it very frequently begins, and pur-
sues a longer or shorter course, with the character about  to be
given.
   232. II.  The Symptoms.  It  is denoted,  in general, by fits
of despondency and gloom, of invincible disinclination for  ex-
ertion, of pain about the head, sinking at the praecordia, and
heat or fulness of the stomach.  The countenance is liable to
be  rather sallow, and  occasionally  rather  pallid; and there is
often a great  expression of despondency  and lowness.  The
tongue is  whitish and clammy, furred, and often affected with
minute white points.  There are,  at  different times,  and  in
different instances, heart-burn, a sense of heat or burning, acid-
ity, load, distention, inflation,  nausea;  sometimes eructation of
an acid, at other  times,  of a nidorous taste, and sometimes  the
rejection of fluid, or of  food.   The bowels are often constipated,
or there are unsatisfactory evacuations, and the patient feels  a
sense  of load  about the  rectum; sometimes there is consider-
able pain  in the bowels.  The appetite is in some cases mode-
 rate, in others much impaired, and, with the digestion, various
 at different periods and in different instances.   There are  many
 uneasy feelings in different parts of the body, which vary ex-
 ceedingly, but always engross the  patient's attention in a forcible
 manner.(')

                         II.  CHLOROSIS.
   233.  The History.  Chlorosis occurs  principally in female
 youth ;  but frequently in married women, both young and old ;
 and occasionally in  the  young and sedentary of the male  sex,
 and even in men of adult age, from the influence of sedentary
  (1.) I have frequently seen individuals suffering from Chronic Dyspepsia, af-
fected at the same time with a trifling cough, which would be of little consequence
were it not accompanied by the fear of Phthisis on the part of the patient.  The
diagnosis of such cases from true Phthisis is commonly easy, even without the
aid of auscultation.  The despondency of mind, the unaccelerated pulse, the
absence of progressive emaciation and of other symptoms peculiar to Phthisis^
establish a very broad distinction between these diseases,               **• 
*216
THE  DIAGNOSIS
habits and mental anxiety.  The most frequent cause is seden-
tariness.   This   affection  is,  therefore, usually  observed  in
schools, in females of a delicate mode of life, or of a sedentary
occupation or habit.  Parturition ;  too long lactation; frequent
hsemorrhagies; protracted  or  long-continued  habits of menor-
rhagia,—and of leucorrhoea ; anxiety ; fatigue; and loss of rest,
have appeared to induce the Chlorosis of persons more advanced
in years.
   234. Chlorosis  occurs  under three forms—the Incipient, the
Confirmed, and the Inveterate.

                 I. The  Incipient Form.
   235.  The Symptoms.  The incipient form of Chlorosis is
denoted by paleness  of the complexion, an exanguious state of
the prolabia, and a slight appearance of tumidity of the counte-
nance, and  puffiness of the eye-lids, especially the upper one.
There is sometimes a tinge of  green, or yellow, or of lead color,
and frequently darkness of the eye-lids.  There are great pale-
ness of the general surface,  hands,  fingers, and  nails;  an
opaque, white, tumid, and flabby state of the skin ; and a ten-
dency to oedema of the calves  and ankles.   And there is a cer-
tain  loss  of flesh.   The  tongue is white,  and  loaded;  it is
swollen,  marked  by pressure against the  teeth, or  variously
formed into  creases or folds ; its papillae are very numerous and
much enlarged.   The gums and  the inside of the cheeks be-
come tumid, and  the latter as  well as the former are sometimes
impressed by the teeth.   The breath is tainted.  The patient is
generally languid, listless, sedentary,  indisposed  for  exertion,
easily overcome by exercise, nervous, and low-spirited, drowsy,
dizzy, faintish, or breathless.   There is generally severe head-
ache or vertigo ;  the memory and power of attention are apt to
be impaired ; and there is sometimes heaviness for sleep.  There
is, in different instances, pain of one or both sides about the false
ribs, or in the hypochondriac or chondiliac regions.   Sometimes
there is cough, difficulty in breathing, palpitation or irregular
action of the heart, or imperfect syncope, and almost universally
a sense  of fluttering about the preecordia.  The appetite  is 
OF  CHLOROSIS.
217
 generally impaired.   There is frequently a  morbid appetite for
 acids, or  for magnesia.  The  bowels are constipated—a state
 which sometimes leads  to  diarrhoea.  The feces are dark-co-
 loured, foetid, and scanty. The urine is frequently loaded. The
 catamenia become irregular, are preceded and attended by much
 pain of the back and region of the uterus, and sometimes, but
 not always, become slowly defective in quantity, and pale in colour.

                  II.  The  Confirmed Form.
   236.  The Symptoms. In the confirmed stage of this affec-
 tion  the state of the complexion and general surface is  still
 more marked.  The  countenance  is still  more pallid, the  pro-
 labia and the gums  exanguious, or the prolabia,  especially the
 upper one,  have a slight lilac hue, and  the integuments are
 tumid.  The skin is smooth, but becomes preternaturally dry.
 The integuments are puffy, opaque, and pale, or yellowish, and
 there is a tendency to  oedema of the feet.   There is frequently
 scarcely any further loss of  flesh.   Slight exfoliation  of  the
 nails.  The tongue becomes clean and smooth ;  but it is pale,
 with  a slight but  peculiar appearance of transparency,  and of
 a pale lilac hue ; and it remains a  little swollen, and indented.
 The patient  is affected with languor, lassitude, and even serious
 weakness, being at once reluctant and unable to undergo fatigue.
 There are often attacks of severe pain  of the head, or of equally
severe pain  of the side; and  repeated bleeding, leeches, and
blisters, are usually employed, affording a temporary respite from
these  complaints.  There are also, sometimes, fits  of dyspnoea,
of palpitation of the heart, or of fainting,  with  beating of  the
carotids^1)   The pulse  is rather frequent,  often  about 100,
 and easily accelerated  and rendered irregular by mental emo-
  (1.) We sometimes notice a bellows' sound over the region  of the heart in
chlorotic patients, especially when palpitations are present.—But a much more
common occurrence would appear to be that peculiar modification of the bellows'
sound called by the French, bruit du diable, heard chiefly over the carotid and
subclavian arteries, and commonly on one side only.  This sound in aggravated
cases becomes hissing or even musical, and is then frequently accompanied by a
tremor of the artery.  Bouillaud, Mai. du cceur, t i.                  S-
                             28 
218
THE  DIAGNOSIS
tion.  The appetite is sometimes impaired, occasionally greater
than natural, and very frequently depraved, inducing a longing
or constant  desire for  some  indigestible substance, as acids or
pickles,  magnesia, chalk, cinders,*  and  coffee  grounds, tea
leaves, flour, grits, wheat, &c.   The bowels are slow and con-
stipated—a state which sometimes alternates with diarrhoea, and
induces meleena; the stools are dark, foetid, and  scanty.   The
catamenia are attended with  pain, and become paler, and less in
quantity, and often cease altogether.

                III.  The Inveterate  Form.
  237. I. The Symptoms.   In the  inveterate form of Chloro-
sis all the symptoms assume  an aggravated character.  There
is a very slow but progressive loss of flesh.  The languor be-
comes a state of permanent debility.  The oedema  increases
and takes on the aggravated  form of anasarca.   The pulse be-
comes frequent.  There are less of  the appearances of mere
disorder, and more of  the character of disease.   Or those local
affections which existed in a  less continued manner before, now
become either permanent, or are induced by the slightest causes,
and the patient can scarcely bear the most ordinary occurrences
of domestic life, and perhaps remains  always in bed.  Some-
times there is an  almost permanent pain of  the head, perhaps
with  intolerance  of light or noise.  Sometimes there is pain of
the chest, with tenderness,  difficulty in breathing, and cough.
Frequently there are pain and tenderness of the abdomen,  with
sickness  and constipation, or with diarrhoea.   Different symp-
toms  reign in  different instances,—as some  hysteric or spas-
modic affection:  a state of locked jaw, closed hand, contracted
foot, or twisted limbs; palpitation of  the heart; hurried or sus-
pended respiration; long fits  of coughing;  hiccough;  retention
of urine.t
  * In the West Indies a similar disease prevails amongst the Negroes, who are
then termed Dirt-eaters.
  f The Varieties.  Besides the forms of Chlorosis which have been described,
there are some varieties of deranged complexion, which require to be distinctly
noticed.
  1. Sometimes there is lets pallor of the countenance and prolabia, but a ring of 
OF  CHLOROSIS.
219
  238. II.  The Complications.  Such are the usual symptoms
of the different stages of Chlorosis.   But, as in acute  dyspepsia,
some of these symptoms are liable to be much  aggravated, and
to assume the form of serious local disease.   The following list
of these complications possesses therefore great interest:__
         1.  Pain of the Head;
         2.  Cough and Dyspnoea ;
         3.  Palpitation of the Heart;
         4.  Pain and Tenderness of the Side ;
         5.  Pain and Tenderness of the Abdomen ;
         6.  Constipation;
         7.  Diarrhaa ;
         8.  Melana ;
         9.  Menorrhagia;
        10.  Tendency to Hamorrhagy;
        11.  Purpura;
        12.  Leucorrhoea;
        13.  Hysteric Affections;
        14.  (Edema; Anasarca; Erythema Nodosum.
  239. III. The Pathology. There is occasionally a remarka-
ble state apparently of the capillary system,  giving rise  to a
haemorrhagic tendency,—to epistaxis,  melaena, haematemesis,
menorrhagia,  and  even purpura.    Still more generally,  the
blood discharged from the nose, or taken from the arm, and the
tumid darkness round the eye, and perhaps a tumid state of the upper lip.  2.
Sometimes the complexion is of a more yellow or icterode hue.  3. Sometimes the
complexion is of a peculiar lead-color.  4. There is sometimes a peculiar state of
coldness, cold moisture, and lividity of the hands and fingers, and a lilac hue of the
nails, the tips of which often become white and opaque.  5. The state of Chlo-
rosis consequent on haemorrhagy also deserves to be distinctly noticed; there are
paleness and slight yellowness of the complexion, exanguious prolabia, a greater
degree of loss of flesh, and great fluttering and nervousness. There are also
more chronic forms of this affection, in which there is a continued though variable
state of sallowness, of yellowness or icterode hue, of darkness, or of a wan, squalid,
or sordid  paleness of complexion; or a ring of darkness surrounding the eyes, and
extending a little, perhaps, towards the temples and cheeks, and sometimes en-
circling the mouth, without tumidity, without pallidness of the prolabia, and
without much tendency to redema. 
220
THE  DIAGNOSIS
 catamenia, become almost aqueous and colourless ; so that this
 affection presents an instance in which the vital fluid undergoes
 considerable change.   I have seen the blood scarcely tinge the
 sheets, and I have seen it resolve itself almost entirely into serum
 with scarcely any crassamentum.

                       III.  HYSTERIA.
   240. Hysteria generally occurs in cases of the Acute Dyspep-
 sia, or of  Chlorosis.   But it is occasionally induced  by severe
 mental emotions, as excessive joy  or grief; and  a less curable
 form of the affection has been  occasioned by surprise,  but espe-
 cially by fright.   It is almost peculiar to the female sex.
   241. This affection is generally  denoted by combining some
 considerable emotion of the mind, denoted  by sighing, sobbing,
 tears, or laughter,  with  a sense and expression of suffocation,
 and  with  some urgent affection of  the head, heart,  respiration,
 stomach, or muscular system.
   242. Hysteria occurs in three forms: the Mild, the Severe,
 and the Inveterate.

                    I.  The Mild Form.
   243. The Symptoms.   The mild form of Hysteria subsists
 as a  tendency to alternate high and low spirits, to fits of laugh-
 ter, to frequent deep sighing, and to tears.  A fit of laughter, or
 of crying, sometimes takes on an aggravated character; the
 laughing,  or the sobbing, becomes immoderate, convulsive, and
 involuntary, and there is frequently a peculiar spasmodic chuck-
 ing in the throat.  The countenance changes, being alternately
 flushed, and pale, and denoting great anxiety.   There  is fre-
 quently an urgent difficulty in breathing, with   much rapid
heaving of the chest.  Sometimes a dry, spasmodic, and violent
 fit of coughing  occurs.   There is generally a sense,  and ap-
 pearance,  and an  urgent  fear of impending suffocation.   In
 different instances  there is palpitation,  hiccough, retching, or
borborygmus.  The  patient is despondent,  and exaggerates all
 her sufferings. 
OF  CHLOROSIS.
221
                   II. The Severe Form.
   244.  The Symptoms.   The severe form of Hysteria consists
in a various attack, catenation, or 'combination, of the following
symptoms:—The  commencement, course,  or  termination, of
this, and indeed of every, form of Hysteria, is generally marked,
and the case distinguished, by the signs of some inordinate
mental  emotion,—joy, grief, or other  affection,—which consti-
tute the most characteristic symptoms of this disorder, and have
appeared to be literally hysterical.  The attack is frequently
ushered in by an unusual  appearance of the countenance,—a
rapid change of colour, rolling of the eyes, distortion or spasmodic
affection of the face.  The extremities are apt to become very
cold.  A state of general  or partial, of violent or of continued,
convulsion, or of fixed spasmodic contraction, takes place, and
displays every possible variety in mode and form.  The severe
form of  Hysteria sometimes consists chiefly in a  severe, general
or partial pain and throbbing of the  head.   Occasionally this
pain is confined to one particular spot, and is so acute as to have
obtained the appellation of clavus hystericus.  Sometimes there
is intolerance of light and noise.  Sometimes a state of stupor;
sometimes delirium.  The  respiration is  frequently much af-
fected ;—an oppressive and suffocative dyspnoea takes place; or
the breathing is rapid, anxious, and irregular; or variously at-
tended with  sobbing, sighing, much rapid heaving of the chest,
and sometimes with a spasmodic action  of  the  diaphragm in-
ducing a peculiar elevation of the abdomen, or an equally pecu-
liar succussor)'' movement of the trunk in general; sometimes
the respiration appears to be suspended altogether for some time,
the pulse continuing  to beat as before.   A crowing noise, or
screaming, is apt to occur in this affection.  There is occasion-
ally, hoarseness, or  even an entire loss of the voice, continued
for some time. There is sometimes a painful, violent, dry, hoarse
cough, continued, or  recurrent  in paroxysms.   There is occa-
sionally acute pain  of the chest or abdomen.   Palpitation of the
heart and syncope are usual affections in the Hysteria.  The
pulse is otherwise little affected.  There is frequently an urgent 
222
THE  DIAGNOSIS
Bense  of suffocation, accompanied with the feeling of a ball
ascending into the throat: this symptom is so peculiar as to have
obtained the denomination of globus hystericus, and is considered
as diagnostic of this affection.  Hiccough,  and  violent  singul-
tus; retching and vomiting; the sense of a ball rolling within
the abdomen; borborygmus;  a peculiar, great, and sudden tu-
midity of the abdomen, apparently from flatus; constipation, &c.
are usual symptoms in Hysteria, and sometimes occur in parox-
ysms,  and sometimes assume a more continued form.  There is
frequently difficulty or retention  of urine, succeeded by a very
copious flow of limpid urine.

                  III.  The Inveterate Form.
  245.  The Symptoms.  The Inveterate Form of Hysteria—
id enim  vitium quibusdam feminis crebro revertens perpetuum
evadit,—consists sometimes in an almost perpetual  agitation of
some part of the body, the limbs,  the  respiration,  the  throat, or
the stomach ; —and sometimes  in a state of continued contrac-
tion of the hand or foot, or of some other part.   In different in-
stances too, there is a continued state of nervousness or agitation
from the slightest noise or other cause,—of paralytic, epileptic, or
spasmodic disease,—or of imbecility of the mind.*
  246.  The  Varieties of Hysteria are more numerous even
  * The attention has, I think, been too exclusively directed to the paroxysm of
convulsion in this affection.  Some of the other varieties in the attack of the Hys-
teria, are almost equally frequent.  This affection is characterized,  indeed, by
affecting in the same, or in different instances, singly or conjointly, all the several
systems which constitute the human frame:—the organs of animal and of organic
life;—the different sets of muscles, voluntary, involuntary,  mixed, and sphinc-
ter ;—the faculties of the mind, and the emotions of the heart;—the functions of
the head. the heart, the stomach, &c. It is in thus viewing Hysteria, that the diag-
nosis is  often formed between  its different and very various attacks, and other
affections having a different origin, but of which it is the imitator,—for, as Syden-
ham  observes—" nullos fere non cemulatur ex  iis affectibus quibus atteruntur
miseri mortales."
  Heberden  treats at length of the varied forms of Hysteria,  throughout his
classical Commentaries.
  Mr. Brodie has recently described a hysteric affection of the knee. 
OF  CHLOROSIS.
223
than those of the other forms of disorder treated of in this chap-
ter.  They are also more acute,  urgent,  and violent.  The
following list, it is hoped, will be found tolerably complete:

 1. Convulsion.
 2. Pain of the Head.  3. Delirium.   4. Stupor.
 5. Pain of the Chest.  6. Dyspnoea.   7. Violent Cough.
 8. Apparent Suspended Respiration.  9. A Painful Af-
     fection of the Diaphragm.
10. Imitation of Croup; and appearance  of—11. Impend-
      ing Suffocation!
12. Palpitation of the Heart.   13.  Syncope.
14. Dysphagia.  15. Hiccough. 16. Retching and Vomit-
      ing.  17. Pain of the Abdomen.
18. Dysury.  19. Retention of Urine.
20. Apparent Paralysis.
21. Trismus.   22.  Tetanus.   23.  Contracted Hand.
24. Distorted Foot.  25.  Twisted Legs. 
                    CHAPTER  V.

      THE  DIAGNOSIS  OF EPILEPSY, TETANUS, ETC.

   247.  The transition is natural, in a diagnostic point of view,
from Hysteria to Epilepsy, Chorea, Tetanus, &c.   There is
scarcely any of these latter diseases which is not accurately imi-
tated by some form of Hysteria.
   248.  On the other hand, these various diseases have nothing
in common  under any  other aspect.  Hysteria  is of little im-
portance,  except it become inveterate.  Whereas Epilepsy is
amongst the most unmanageable of diseases; and Tetanus is
almost always, and Hydrophobia always, a fatal disease.
  249. In no cases is the pathology so obscure as  in the diseases
of which I am about to trace the diagnosis.   In no cases is the
inquiry into  that pathology beset with such extreme difficulties.

       DIAGNOSTIC ARRANGEMENT OF EPILEPSY, ETC.

    I.  Chorea.
              1. Incipient.
              2. Confirmed.
              3. Inveterate.
   II. Epilepsy.
             I.   Idiopathic.
                1. The Mild.
                2. The Severe.
                3. The Inveterate.
           II.   Symptomatic.

   III. Hydrophobia.
1.  Rabiosa.
2.  Sine Rabie. 
EPILEPSY,
225
     IV.  Tetanus.

              I.   Traumatic.
             II.   Idiopathic.

                        I. CHOREA.

   250.   The History.   Chorea is usually preceded, for weeks
even, by some form of dyspepsia.   It comes on rather insidious-
ly, so that its first symptoms are apt to be ascribed to trick or an
evil habit.  It is rarely fatal;  but often  tedious.  It usually af-
fects the young, between the ages of ten and fifteen ;  but may
occur earlier  or later.  It affects  both boys and girls; but the
latter more frequently than the former.

                    I.    The Incipient.

  251.   The Symptoms.   In  the beginning of  Chorea the
youthful patient cannot articulate, cannot write, so well as before.
His countenance is moved by grimaces; his hands  and feet, by
some singular gesticulations.   These symptoms augment until
they assume,

               II.   The Confirmed Form.

  252.  The Symptoms are now aggravated in every way; the
countenance is continually and oddly contorted; the articulation
becomes a perfect  stammer, and sometimes unintelligible; the
hands and arms, the  legs and feet, are moved about incessantly
and in the strangest manner ; the voluntary motions are uncer-
tain and interrupted, the hands cannot be directed to any object,
and all attempts to walk are unsteady and issue in the most sin-
gular movement, at once painful and ridiculous to witness.  Fre-
quently  one side is more affected than the  other ;  and this in
turns.   With these symptoms there are frequently vertigo, and
disturbed sleep, and the powers of the mind may  become en-
feebled.
  253. The Morbid Anatomy is unknown.   In two cases ex-
                            29 
226
THE  DIAGNOSIS
amined by Dr. Willan, from two to four  ounces of clear lymph
were found in the ventricles of the brain and in the pericardium.

                III.  The Inveterate  Form.
  254.  This form of Chorea is characterized by imbecility of
mind, and an almost paralytic  convulsive state of some  of the
limbs.
                      II.   EPILEPSIA.
  255. The History.   Epilepsy appears, in some cases, to be
hereditary.   It is frequently induced, or its attacks reproduced,
by  circumstances  which derange the stomach or exhaust the
system : imprudencies in diet, a neglected  state of the bowels,
venereal excesses,  have been the immediate cause of Epilepsy.
No age, sex, or circumstance is secure from attacks of this dis-
ease ;  but it is more frequently seen in the  male than in the fe-
male sex.  Its returns and  its duration are alike altogether un-
certain.
   256. Idiopathic  Epilepsy occurs in forms which may be dis-
tinguished as—the Mild; the Severe ; the Inveterate.

                     I.  The Mild Form.
   257. It occasionally happens that, in the midst of some ordi-
 nary occupation, the patient becomes suddenty quiescent, neither
 doing nor seeing what engaged his attention the moment before,
 ceasing to speak or to  listen;  in a minute or  two he recovers,
 and is perhaps unconscious  of having been ill; the  bystanders,
 alone, may have noticed the passing event.*

                    II.   The Severe Form.
    258.  The Symptoms.  The  severe form of Epilepsy  fre-
 quently comes on without the slightest warning ; in other cases,
  * " Animae defectio levis modo antecedit epilepsiam ; modo quasi vicem ejus
implet, dum nihil aliud  aeger sentit praeter oblivium quoddam et delirium adeo
breve, ut fere ad se redeat, priusquam ab adstantibus animadvertatur."—Heber-
deniCommentarii; p. 139. 
OF EPILEPSY.
227
some of the following premonitory symptoms are experienced:
—a peculiar feeling, as of air, passing along the course of one or
more limbs, termed the aura epileptica ;  a sense of torpor in the
arms  and hands; a sense  of vapor, perhaps with the odor of
musk, ascending from the stomach towards the head;  slight de-
lirium ; 4huness of sight;  drowsiness; grinding of  the teeth;
some defect of the articulation ;  difficulty in breathing ; hickup,
or vomiting ; pain of the bowels or  diarrhoea.   There are fur-
ther, sometimes, livid flushing of the face, or coldness of the ex-
tremities.
  259. In the immediate attack, the  patient is frequently seized,
in the most sudden manner, with insensibility and terrible con-
vulsions ;  the countenance is  livid  and distorted, the mouth
foams, perhaps with blood, for the tongue is frequently bitten se-
verely ; the teeth are forcibly clenched; the hands, arms, and
legs, cramped, or thrown forcibly to and fro ; the pupil is fixed,
and unmoved on the approach of light; sometimes the urine, the
alvine evacuation, or the semen, is  expelled.   After the fit, the
patient may recover more  or less perfectly;  in some instances
the memory and consciousness are impaired  ; in others there is
sleep; in  others, continued and deep coma. In some cases there
is an attack of unconsciousness, and some other symptoms, with-
out convulsion.
   260. The attack may  continue from fifteen minutes to a
whole hour, or hours, or even days.   The principal symptoms, in
such protracted attacks, are convulsions, and coma.
   261. It is by carefully comparing and contrasting the charac-
ters of Hysteria and of  Eilepsy, that their diagnosis is effected.
 Sometimes a little acumen and tact are required for this pur-
 pose.

                 III. The Inveterate Form.
   262. In this form of Epilepsy, the mind and the memory are
 impaired, and  the limbs are crippled by paralysis or spasm.
   263. The Morbid  Anatomy of Epilepsy is very obscure.
 The  observations of  MM.  Bouchet  and Cazauvieilh,  made
 under the eye of M. Esquirol, the latest and  the best, lead to 
228
THE  DIAGNOSIS
 the opinion of MM. Delaye and Foville, that whilst the sent
 of mania  is the gray substance, that of epilepsy, is the white
 substance  of the brain ; and that the appearances found are—
                1. Injection, with redness:
                2. Softening ;
                3. Inequalities ;                    *
                4. Induration*
   264.  But it must be acknowledged that much additional in-
 vestigation is required  before the question of the  morbid ana-
 tomy can be said to be determined.  Some facts would lead to
 the idea that the cerebellum is chiefly affected ; others prove that
 a state of exhaustion  is frequently a  cause  of epilepsy.   It is
 well known too that the tumors in the substance of the brain,
 and ossifications of its  membranes, have  been the probable or-
 ganic causes of this sad disease.  And  what  shall  we say of
 hereditary disposition,  the action of fright, of orgasm, and other
 mental causes ?(')

                II. Epilepsia Symptomatica.
   265. There is a peculiar affection which assumes the epilep-
tic form,  and which is symptomatic of the Acute Dyspepsia. In
the course of that disease the patient is sometimes suddenly af-
fected  with  the  following  symptoms: viz.  sickness,  vertigo,
faintishness, and cold perspiration ; with paleness of the counte-
nance, and  coldness of the extremities; and, with  these symp-
                  * De 1' Epilepsie, &c. pp. 43, 45.
  (1.) The most constant organic change  noticed in Epilepsy, I believe to be
Inflammation of the Membranes of the Brain,—yet this is probably a conse-
quence, rather than a cause.  In the letters on the Brain, by Lallemand, Epi-
lepsy is very rarely mentioned in the cases of suppuration or softening of the or-
gan, yet Arachnitis was almost always noticed ; and in all the cases of simple
Arachnitis recorded by Andral, epileptic symptoms did not occur in a single in-
stance. Epilepsy occurs as a symptom of hypertrophy of the Brain--in one of the
cases recorded by Andral, the membranes were perfectly healthy.  It occurs very
frequently, where chronic indurations or ossifications of the brain or its mem-
branes exist; also in cases where exostoses, growing from the internal table of
the cranium, press upon the brain.                                 S. 
OF  HYDRO P-H O B I A .
229
toms, there is a loss of consciousness, and other symptoms of an
epileptic seizure.
   266. It is highly important to distinguish this curable form of
the disease from the more intractable.
   267. The Symptomatic  Epilepsy,  also probably occurs  in
consequence of irregularities of the catamenia.  But this case is
not so distinct from true Epilepsy, as the one which  I have de-
scribed.

                      III. HYDROPHOBIA.
                   I.  Hydrophobia rabiosa.
   268. I. The History.   The symptoms of the Hydrophobia
rabiosa occur generally within four, six, or eight weeks, after the
bite of the rabid animal has been inflicted; but the precise period
is not so defined as to be diagnostic. " The medium duration of
Hydrophobia is forty  eight-hours.
   269. II.  The Symptoms.  The idea of this terrible disease
may  be conveyed in a few words  : it consists in an undue sus-
ceptibility of the nerves passing to  and from the nervous centres.
The  nerves  of the face are acutely impressed by the slightest
breath of air, and  the nerves of motion immediately induce the
most  sad convulsive movements.*
   270. There  are, from the first,  extreme anxiety of the coun-
tenance and inquietude of  manner, and a peculiar aggravation
  * There is a property of the nervous system not hitherto noticed by physiolo-
gists.  It seems to be seated in the sentient  and motor nerves, independently of
sensation  and volition.  It is manifested by-the following experiment: if, after
killing a turtle, in the usual way, the tail and posterior extremities be separated,
and a lighted taper be held underneath each in turns, the tail moves, the extremi-
ties are motionless.  The sentient nerves of the former are connected with the
caudal portion of the spinal marrow, and, through it, with the motor nerves; the
sentient nerves of the latter are separated from any such connection. If the spinal
marrow is withdrawn, the tail also ceases to move.  What is the nature of this
phenomenon?  Sensation and volition are surely out of the question. Whatever
this function may be, it seems to preside over the acts of respiration and the ac-
tion of the sphincters ;  and to be morbidly augmented in hydrophobia and teta-
nus, and in some of the lower animals brought under the influence of opium and
strychnine. 
230                THE DIAGNOSIS

of these appearances, at the sights of fluids, or on feeling a gust
of air pass over the face, and still more on attempting to drink:
by any of these causes, an expression of horror, a sense of suf-
focation, with constriction about the throat, and convulsive move-
ments, are produced, which are terrible to witness and beyond
description.  Independently of these causes, there  are  similar
symptoms, only in a minor degree.   Later in the disease, the
agony of expression and suffering is extreme;  viscid saliva forms
and collects in the  mouth, and is removed with impatience and
horror, and spasm about the throat;  the mind begins to wander
with a terrible delirium;  the limbs are moved with continual
spasm and agitation.  At length the powers  of life and of the
disease sink together.
  271. III.   The  Morbid  Anatomy of Hydrophobia is  un-
known ; the structural complications hitherto noticed are—

Inflammation.—1. of the Meninges and Substance of the
                       Brain and Spinal  Marrow ;
                2. of the Pharynx,  (Esophagus, and Sto-
                       mach ;
                3. of the Trachea, Bronchia, and Lungs.
  272.  The  vesicles which have  been observed  under  the
tongue, have been  ascertained by Mr.  Kiernan to consist in the
sublingual salivary ducts distended with viscid saliva.

          II.  Hydrophobia  absque rabie canina.

  273. It occasionally  happens that we have to discriminate
between a real and imaginary case of Hydrophobia.  Such an
instance is mentioned by the late Dr. Bateman.*
  274.  Dr. Heberden  observes—" Testis  fui  haud mediocris
timoris aquae, vel cujusvis liquoris,  ultra quam dolor devorand^
intulisset,  in aegro,  cujus  fauces inflammatae  erant, et dein sup-
puratae.t
* Reports on the Diseases of London, p. 188.
t Commentarii, chap. 47. 
OF  TESTA N US.
231
                      IV. TETANUS.

                 I. Tetanus  traumaticus.
  275. I. The History.   Tetanus  usually arises from some
apparently trifling wound on  one of the extremities ;  the most
frequent kind of wound is that induced in the foot by treading
on a rusty nail.  The latent  period  and the duration of this
terrible disease are about ten days.
  276. II.  The  Symptoms of Tetanus are rigidity of the
muscles attached  to the jaw, trunk, neck, and limbs,  inducing
trismus, emprosthotonus, opisthotonus, pleurosthotonus.
  277. There is an expression of anxiety, distress, and pain,
and, afterwards,  spasmodic contraction and  distortion of the
countenance.  The tongue is  apt to be wounded by the teeth.
Deglutition  becomes painful and  difficult.   There is  a painful
spasmodic affection about the ensiform cartilage, peculiar to this
affection.  The respiration is difficult and hurried, the abdomi-
nal muscles are rigid, and  the abdomen retracted towards the
spine.   There is occasional delirium.   The voice becomes shrill.
The heart palpitates.  The bowels are constipated in a degree
which is peculiar.  There is  an undue  sensibility; and the
spasms are excited, or  augmented, by every impression upon
this function, as by objects  moving near and about the patient,
and even by walking over the floor about his bed.
  278. The affection is frequently alternately mitigated for a
period and  then  returns with greater, longer continued, more
painful, and more general  spasm.
  279.  III. The Morbid Anatomy is really unknown.   Mor-
bid appearances,  especially effusion of blood, lymph,  or serum,
have been found along the spinal marrow ; the intestines have
been found contracted.    But the subject must be  examined
anew.

               II.  Tetanus absque vulnere.
  280. Such a case is detailed by Dr.  Willan : it occurred in
the beginning of July, 1800.   " There had been no accident or
local injury whatever.  The only previous circumstance, likely 
232           THE  DIAGNOSIS,  ETC.

to have contributed towards the formation of the disease, was dis-
tress of mind.   Besides a  complete locking of the jaw, there
seemed to be a painful rigidity in all the muscles of the neck,
while the head was firmly and permanently retracted.   The pa-
tient was a female, thirty-two years of age, in a debilitated state
of constitution ; her pulse was obscure and irregular;  she had no
desire for nourishment; neither could any  evacuations be pro-
duced from the bowels.  After being exhausted with pain, tre-
mors, watchfulness,  delirium, and strong perspirations, she died
on the eighth day of the disease."*
* Diseases of London, p. 376. 
CHAPTER  VI.
         THE DIAGNOSIS OF  INFLAMMATION, ETC.

  281.  I now bring before my reader a class of diseases very dif-
ferent from those of which 1 have treated in the former chapters.
As those were, generally speaking, diseases of the whole system,
these are more or less of a topical character.   It must not be sup-
posed that this distinction can be rigidly drawn; but it may serve
the useful purpose of a practical classification.   As scarcely any
general disease exists without some special  complication, so there
is no local disease without an affection of the general system.
  282.  Practically, inflammation is nearly allied to rheumatism
and to  arthritis, which, indeed, only differ from it by being still
more, affections of the  general system.   These three diseases
may, therefore, be aptly  treated of together.  In a diagnostic
point of view, this arrangement is still more appropriate.
          ARRANGEMENT OF  INFLAMMATION, ETC.
              I.   Inflammation.
                    I.  Serous.
                    II.  Parenchymatous.
                   III.  Mucous.

             II.   Rheumatism.
                    I.  Acute.
                           1. External.
                          2.  Internal.
                    II.   Chronic.

             III.   Arthritis.
                    I.   Acute.
                         1. External.
                         2. Internal.
                             30 
234
THE  DIAGNOSIS
                   II.   Chronic.

             IV.  Nodosity.

                    I.  INFLAMMATION.
  283.  Inflammation must be noticed only briefly in this place;
separated from its seat, it presents, indeed, but an abstract idea.
Still there are a few practical remarks to be made upon it.

                 I.   Serous Inflammation.
  284.  I.  The  Symptoms  and Effects  of Remedies.  In-
flammation of the serous membranes is distinguished principally
by two  events: 1. the almost entire absence of the heat of sur-
face, debility and tremor of the muscles, the aching pains, the
affection of the head, and the  hurry of breathing, observed in
fever;  and 2. by extreme tolerance of loss of blood.*   There is
generally acute pain.
   285.  II.  The Morbid  Anatomy consists principally of the
effusion of lymph and the effusion of serum.(')

                II.  Mucous Inflammation.
   286.  I.  The  Symptoms and Effects of Remedies.   In
inflammation of the mucous membranes, there is more of febrile
symptoms, less pain, and less tolerance of the loss of blood, than
in serous inflammation ; there is the augmented excretion  of
mucus.
   287.IT. The Morbid  Anatomy.   The mucous membranes
are far  more apt to ulcerate  than the serous;  besides ulceration,
there is usually a morbid secretion of mucus, and frequently the
effusion of blood.
  * The degree of tolerance of loss of blood depends upon two circumstances:
1. the disease must be fully formed ; 2. it must not have induced havoc of the
powers of the system. It must neither be merely incipient nor inveterate.
  (1.) There is a'so partial  redness, caused by the accumulation of red points or
lines, having their seat in the subserous cellular tissue.                S. 
OF  RHE UM AT ISM.
235
           III.   Parenchymatous Inflammation.
  288.  I.  The Symptoms of this form of inflammation are, in
some respects, intermediate between those of serous  and mu-
cous inflammation ; but they approximate far more to the for-
mer than the latter.  There is less pain ; but there is little less
tolerance of loss of blood.
  289.  II. The  Morbid Anatomy consists, generally speak-
ing, in hypertrophy and induration; but other changes are ob-
served, which are peculiar to individual organs.(')

                    II.   RHEUMATISM.
  290.  Rheumatism occurs in  the  Acute,  Chronic, and Inter-
mediate Forms, and is external or internal in its seat.

                  I.  Acute Rheumatism.
  291.  I.  The  History.  The Acute Rheumatism usually
arises from exposure to wet and coldy and affects the young, the
athletic, and the male sex, principally.   Chronic Rheumatism is
moie frequent in females, the  old,  and the infirm ; and it is a
frequent sequela of the acute form of the disease.
  292.  11.  The  Symptoms.   The Acute Rheumatism is de-
noted by a painful affection of several or of most of the limbs,
accompanied by tenderness, and a slight degree of tumor, and of
re.Sness.  The joints, and the course of the muscles, are princi-
pally, and successively, affected ; the pain is comparatively slight
during a state of rest, but rendered excruciating on  muscular
motion or effort.   Acute Rheumatism is further characterized by
a great expression of pain in  the countenance, with excessive
perspiration on the forehead, and a loaded and moist state of the
tongue.  The patient generally lies on his back, and  especially
avoids every motion of the body or limbs; or if he does move, he
experiences an acute aggravation of pain, calls out, and gives a
prompt check to the muscular effort.   There is  little languor or
  (1.) It is very doubtful whether Hypertrophy, in the si nse in which it is now
used by pathologists, is the consequence of inflammation.  Softening might., I
think, be introduced in its place with great propriety.                S. 
236
THE  DIAGNOSIS
debility, little disturbance of the mental faculties.   The  general
surface is usually covered with  perspiration ;  the skin is warm,
pale, and often profusely moist; and a peculiar odor is exhaled.
The pulse is frequent, strong, and  full.   The functions of the
head are unaffected.  The appetite is sometimes little impaired.
The bowels regular.  The urine deposits a sediment, especially
on the decline of the affection.
  293. In some cases there is a degree of soft  swelling,  com-
municating an obscure sense of fluctuation.  This occurs  espe-
cially, or perhaps only, near the joints.   It is often observed on
the outside of the patella, and on the inside of the patella rather
up the thigh.
  294. III. The Complications or Metastases.  The subject
of Internal Rheumatic Affections is one of the very deepest in-
terest, and still demands a renewed and connected investigation.
Rheumatism of the Heart is that form of internal rheumatism
best known.   It was first distinctly pointed out by Dr. Pitcairn ;
afterwards it  was particularly noticed by Dr. Baillie,* Mr. Da-
vid Dundasj and Dr. Wells.*   The head ; the  pleura and the
lungs ; the liver, and some of the other abdominal  viscera,  have
also been supposed to be affected by Rheumatism.   But the ex-
tent and the limits, the history, the diagnosis, and the pathology,
of Internal Rheumatism, are still lobe ascertained.(•)   It may
exist as a complication of external Rheumatism, or may take
its place by metastasis.  It then affects,

        1. The Meninges and Brain.
        2. The Pleura and Lungs.
        3.  The Pericardium and Heart.
        4.  The Pleura and Diaphragm.
        5.  The Peritonaum,  Liver, fyc.
  * See the Morbid Anatomy.
  fThe Med. Chir. Trans, vol. i. p. 31.
  J Trans, of aSoc. for the Improvement of Med. and Surg. Knowledge, vol. iii,
p. 373.
  (1.) See note, par. 31, part ii.                                & 
OF ARTHRITIS.
237
  295.  But, besides this list of Internal Rheumatisms, there is
a series of rheumatic  affections of the  parietes of the cavities,
which it is very essential to distinguish.  These are,

        1. Of the Head ; or hemicrania.
        2. Of the Thorax; or pleurodyne.
        3. Of the Parietes of the Abdomen.
  296.  IV. The Effects of Remedies.  There is, in Rheuma-
tism, as in serous inflammation, an extraordinary and charac-
teristic degree of tolerance of the loss of blood.
  297.  V. The Morbid Anatomy consists principally of thick-
ening of the synovial  membranes, the periosteum, and the arti-
cular ligaments and cartilages, and of effusion into the joints and
bursas.

                II.   Chronic Rheumatism.
  298.  In Chronic Rheumatism  the  pain is more fixed, and
less general, and there is not even the slight tumor, or discolora-
tion, nor  the  tenderness, of the Acute form of  Rheumatism.
But the limbs  gradually  lose their power, their sensibility, and
sometimes their wonted bulk even, and the patient becomes ex-
tremely lame.   Or these affections take place in a slight degree
only.   There  is at the same time  an absence of the febrile
symptoms peculiar to the acute Rheumatism.

                     III.  ARTHRITIS.
  299.  Arthritis, like  Rheumatism, occurs in an Acute or Chro-
nic form,  and is seated externally or internally.
  300.  The History.   Arthritis seldom  occurs  during early
youth.  It is decidedly hereditary.  It generally  recurs in  the
person who has been  once affected ;  sometimes at nearly stated
periods;  occasionally from accidental  causes.   It affects the
same, or different,  and even successive parts, on these occasions;
the pain is then less severe, but the subsequent debility longer
continued.  Arthritis  affects the male sex and the intemperate
principally, but  by no means exclusively.   It is  generally de-
pendent on a deranged state of the system, and especially of the
stomach and bowels;  it frequently attends the Acute or Protrac- 
238
THE   DIAG NOS I S
 ted Dyspepsia ; and it is very apt to lead to cretaceous deposites
 in and about the joints, and to calculous deposites in the kidney
 or bladder.

                     I.  Acute Arthritis.
   301. I.  The Symptoms.   The Acute Arthritis, especially
 on its first accession, generally affects one particular joint alone,
 —most frequently the ball of  the great toe, but occasionally the
 ankle, the knee, the hand, or the elbow.   The attack frequently
 begins without apparent cause ; it is most apt to take place dur-
 ing the night or early in the morning ;  it induces extreme pain,
 tenderness, throbbing, or sense of weight, even whilst the limb re-
 mains unmoved ;  it is  attended with tumor, a vivid redness, and
 an appearance of distention of the skin ; and afterwards with a
 more diffused and cedematous tumidity.  The attack  is often
 preceded by some symptoms of disorder of the digestive organs,
 or of the general health ;  and it is sometimes attended with  fe-
 verishness, heat of the skin, inappetency, a loaded tongue, thirst,
 constipation,  and a  loaded state  of the urine, from which  a
 copious sediment is  deposited.  The  violence  of the  pain fre-
 quently remits during the morning, and again returns in  the
 evening.*
   302.  II.   The  Complications or  Metastases.   Internal
 Arthritis is far more  obscure than Internal Rheumatism even.
 They assume the following forms principally :
     1. Vertigo ;  tinnitus aurium.
     2. Palpitation ; faintishness.

  * The diagnosis between  rheumatism and gout is generally sufficiently ob-
 vious: 1. the former is excited chiefly by external, the Litter by constitutional,
ciuses ; 2. the former affects many, larger joints, the latter  more frequently one
 smaller one: 3. the former  may  suppurate,  the latter seldom or never suppu-
 rates, but, on the contrary, is apt to lead to peculiararticulavdeposites of urate of
soda  and phosphate of lime; 4. the former is characterized by the state of the
perspiration, the  latter by  the peculiarity of the urinary secretion and de-
 posites^ i)
  (1.)  M. Chomel, Clinique Medicale, t. ii., denies that there is any  essential
difference between Gout and Rheumatism,—yet it must be confessed that the
 weight of autho: i*y is on the side of the author.                       S. 
OP  NODOSITY.
239
     3. Nausea: pain at the stomach  or in the bowels.
     4. Calculus., or gravel.
  303. In one case described by M. Cruveilhier, the patient ex-
perienced several attacks of Apoplexy.   Bayle describes the ex-
pectoration of calculi as apt to occur in arthritic patients.

                    II.  Chronic Arthritis.
  304. Chronic Arthritis consists in a permanent pain, tumor,
weakness, and immobility, of the part or parts which  had been
previously affected with Acute Arthritis, especially of the feet and
the  hands.  Eventually, arthritic concretions, and  ulceration,
take place.

                       IV.   NODOSITY.
  305. Besides Rheumatism and Arthritis, there  is another dis-
ease of the joints, less known.   It was first fully described by the
late Dr. Haygarth of Bath.
   306. This affection consists in hard, pale, and painful swell-
ings, about the different articulations, especially those of the fin-
gers, but also successively about any of the other joints.  This
affection  increases gradually, and often induces much suffering
and deformity.  The swellings  are  sometimes tender  under
pressure; they are confined to the immediate  vicinity of the ar-
ticulations, and do not appear to affect the muscles; the motions
of  the joints become much impeded, and sometimes a degree of
dislocation occurs.*
  * Dr. Haygarth observes,  " The nodes appear most nearly to resemble Gout.
Both of them are attended with pain and nodosity of the joints: but they differ
essentially in many distinguishable circumstances.  1. In the gout, the skin and
other integuments arc generally inflamed, with  pain which is often acute, sore-
ness to the touch, redness and swelling of the soft parts, but in no icspects like
the hardness of bone.  2. The gout attacks the patient in paroxysms of a few
days, weeks, or  months, and has complete intermissions at first for years, but
afterwards for shorter periods.  3. The gout attacks men much more  frequently
than women.
  "These nodes are clearly distinguishable from Acute Rheumatism, because
they are not attended with fever.  The tumor of the joints is much harder, more 
240           THE  DIAGNOSIS,  ETC.
   307.  I have seen  this  disease principally in females some-
what  advanced in  years: it attacks the first joint of several
fingers.   I have also seen a similar affection in a youth, which
affected the second joint of several fingers, and not the first, in-
ducing considerable thickening.
durable, and less painful, in the former than in the latter disease.  The nodes
are totally different from Chronic Rheumatism, because the latter chiefly affects
the muscles, and is seldom attended with any swelling of the affected parts." 
CHAPTER  VII.
      THE DIAGNOSIS OF TUBERCLES,  SCIRRHUS, ETC.

   308. The subjects treated of in this chapter have  doubtless
 a constitutional origin or connexion.   They may be isolated, or
 occur in a single organ only;  but they are far more frequently
 observed in considerable numbers and in several organs at once.
 There is, also, very distinctly, a  series of general or constitu-
 tional symptoms, arising  from  the peculiar  influence of the
 disease, independently of its seat, but apparently commensurate
 with its degree of diffusion.  These symptoms are more marked
 in Tubercles than in any other disease of  this class.  It is in
 Tubercles, at least, that I have been most successful in noticing
 them; to my description of the early symptoms of  this disease,
 indeed, I would beg to call the attention of the young clinical
 student in a particular manner.
  309. The constitutional symptoms of  Melanosis are exceed-
 ingly obscure.
  310.  The symptoms of Encephalosis  are also very obscure,
and  the disease is rarely detected until a tumor has made its
 appearance externally.
  311.  A similar remark applies to Scirrhus.
  312.  There is a sort  of general diagnosis between  organic
disease  and  such derangements  of function  as occur in the
 Dyspepsia, which it may be well to sketch in this place:—
  313.  Insidious organic disease in general, is distinguished by
 a regular, slow, progressive, unvaried course,  during which the
patient becomes gradually affected  with paleness, debility, and
emaciation.  The countenance  becomes  pale, thin,  shrunk,
perhaps deeply wrinkled, and expressive of disease.   The mus-
cular strength becomes much, permanently,  and uninterrupt-
                           31 
242               the  diagnosis
edly, impaired.   The general surface and  the  muscular flesh
waste and  shrink, while the  skin remains soft,  and  free from
dryness and exfoliation.   The head is, in general, little affected
with pain or vertigo; the mind is little despondent; the temper
equable.  The respiration is  not affected with  hurry, nor the
heart with palpitation.   The pulse is regular, and perhaps per-
manently frequent.   The tongue is little affected, and the breath
is generally untainted.   The ankles often become cedematous,
and at length the limbs are liable to be affected with anasarca,
and the abdomen with ascites.
  314.  In  chronic functional derangements  there is usually a
train of phenomena of a very different kind.  The complaints
are characteristically variable: one day  the  patient conceives
himself well, another he is as bad as ever; each successive day
renews his old, or adds some new complaint; and the symptoms
are as  manifold as they are variable.   There is often vertigo, or
pain of the head; the mind is despondent; the temper variable,
and apt to  be querulous ; the patient broods over his complaints
in solitude, but perhaps forgets them in society; and  he is ner-
vous in a variety of ways.  The respiration is sometimes hurried;
the beating of the  heart irregular.   The tongue is in general
loaded, more or less swollen, and its papillae are distinguished at
the point;  the  breath is generally tainted.  The  Stomach, ap-
petite,  and bowels, are  more or less disordered.  There is fre-
quently, during the prevalence of these complaints, little or no
permanent paleness, emaciation, or debility; but the complexion
is variable, and  there is occasionally an incapability of mental
or muscular exertion. Disease probably supervenes, before there
is any serious or permanent loss of flesh.

        ARRANGEMENT OF TUBERCLES, SCIRRHUS, ETC.
            I.  Tubercles.
                   1. In the Head.
                   2. In the Thorax.
                   3. In the Abdomen.
II. Melanosis. 
of  tubercles.                243
           III.  Encephalosis.
           IV.  Scirrhus.

                       I. TUBERCLES.         •
   315.  The History.   Nothing can be more insidious than the
formation and progress of Tubercles.   Tuberculous disease in
the abdomen is the most insidious of  all those diseases which
may be considered as necessarily and progressively fatal; I have
repeatedly traced this  tuberculous affection, through a distinct
course of four, five, and six years.  Tubercles are doubtless fre-
quently of hereditary* origin, and sometimes even  congenital.
They  seem to be induced, in the predisposed, by low  diet; the
families  of butchers are said  to enjoy  a comparative immunity
from them.  They are also  induced by exposure to  cold and
damp; yet it seems to have  been ascertained,  by the late Dr.
Wells, that in localities where intermittents abound, phthisis is
proportionably rare.(])

                       I.  In the Head.
   316.  The Symptoms.  Tuberculous affection  of the  ence-
phalon,  can, I  believe, only be  suspected, and distinguished
from  insidious  inflammation or the slow formation  of tumors,
by observing the concurrent existence  of tubercles,  or of some
other strumous affection, in other parts of the body.  Or if there
do exist symptoms which distinguish this morbid affection within
the head, they have not hitherto been noticed with accuracy.

                     II.  In the Thorax.
   317. Before the stethoscope can detect the existence of tu-
bercles in the lungs,  the  constitution of the patient  frequently
  * The very seat of tubercles is apparently determined by hereditary predispo-
sition.  In one family we meet with successive cases of phthisis, in another of
tubercular disease in the abdomen.
  (1.) It may, I think,  be justly questioned whether cold and moisture have
any thing to do with the production of Tubercles.  That  an  exposure to these
conditions of the atmosphere aggravates their symptoms and  hastens their pro-
gress, are facts that rest upon much better authority.                  S. 
244
THE  DIAGNOSIS
takes the alarm, and the functions of the circulation  and of the
respiration become slightly accelerated, or are  easily hurried.   I
have frequently observed that, with a complexion which is  apt
to alternate between the pallid and the vivid, there is a degree of
sensitiveness  to cold, of susceptibility of the effects  of heat, of
breathlessness on moving quick or ascending a hill or stair-case,
and of cough;  this cough is frequently slight; hacking, and dry,
and scarcely or not  at all observed by the  patient or friends.(1)
In other cases, and especially in females,  the countenance is pal-
lid, with the slightest waxen or lemon hue, a tendency  to blue
lividity observed in the lips and at the roots of the finger  nails,
and a disposition to coldness of the  extremity of the nose, the
ears, and the hands and feet.   These changes are frequently so
insidious, that they are apt to be first observed, not by those who
are in the daily habit of seeing the patient, but by some one who
see3 him after a certain interval and is struck by the change.
Even at this early period, I have frequently found, on inquiry,
that the catamenia  have ceased.  And  I would observe, that
this cessation  of the uterine discharges is generally,  or at least
frequently, complete  at once;  unlike the  case of disorder of  the
general health, in which the flow  becomes very slowly paler and
more  scanty, and except in chlorosis, not ceasing altogether, and,
even  in that disorder,  generally very  gradually.  This is  the
more  remarkable, because the condition of the uterus, under the
influence of tuberculous  disease,  is one  of great proneness to
conception, a change which has, in its  turn, a reflex action in
arresting  the  progress  of  the  tuberculous affection.(2)   The
fever which accompanies phthisis, like other symptomatic fevers,
                  (1.) See note II. par. 374, part I.                S.
  (2.) I am disposed to question the correctness of this statement, chiefly on the
authority of M. Louis.—I remember hearing this distinguished observer remark,
that the occurrence of pregnancy tended rather  to render tubercles latent, than
actually to arrest their progress.  Hence we frequently find when the period of
delivery is passed, that the disease hurries on to its fatal termination.  I mention
this view of the question, because its truth appears to me a point of the greatest
importance.  Indeed the common practice of recommending pregnancy to tuber-
culous females, appears to me, in every point of view, the worst possible advice. S. 
OF  TUBERCLES.
245
and unlike all pure and primary fevers, is frequently unattended
by muscular debility, or by affection of the head, or of the diges-
tion.   There is no headache or vertigo, and the patient often
continues to  walk or to ride to  the last.  There is a degree of
feebleness and stooping observed in the gait, very early in the
disease; and this remains little augmented, until  the colliqua-
tive perspiration or diarrhoea bring  with them their own debility
and emaciation.(1)

                   III.  In the Abdomen.
  318. Tuberculous disease in the abdomen, is greatly charac-
terized by three symptoms:—1. great tendency to coldness and
lividity of the extreme parts of the body, 2. a frequent pulse, and
3. slow but progressive emaciation.   The aspect of the counte-
nance is altogether peculiar, especially in cold weather, together
with an  obvious  emaciation and expression of languor and dis-
ease ;  the end of the nose is livid in color, and cold to the touch ;
and there is in general, either paleness or a slight  degree of flush-
ing.   Similar  observations may be made respecting the general
surface.   There is emaciation; the skin  is  soft, and  apt to
become moist, and there are generally perspirations during sleep
especially in the early part of the morning; to prevent this per-
spiration, the patient frequently endeavors to keep awake; there
is an  undue  sensibility to  cold observed on the slightest unex-
pected exposure,—as  the opening of a door,—and the patient
usually creeps over the fire; sometimes I have observed the back
of the hands, and the fore part of the legs,  to assume a peculiar
brown color,  from being burnt by this constant exposure to heat;
the hands and  fingers are apt  to  be extremely  livid and cold.
The  mode of  walking is peculiar, being attended by stooping,
weakness, and caution.   The  pulse is always frequent, and
generally regular.  It is earlier and longer frequent, in  tubercu-
lous affection of  the abdomen,  than in that of any other cavity.
  (1.) These three symptoms, from their constancy, appear to me to possess the
highest value in the diagnosis of incipient Phthisis, viz.—o short dry cough, emacia-
tion and loss of strength.                                       S. 
246
THE  DIAGNOSIS
I have  known the pulse to be between one hundred and one
hundred and twenty for several years. The emaciation in tuber-
culous disease of the abdomen is uniformly but very slowly pro-
gressive.  It is accompanied by a state of unvaried debility ; and
in the  later periods of the  disease, by some  oedema, generally
observed more in one leg than the other. The other symptoms of
this morbid affection are less constant; they are chiefly an aug-
mented appetite for food, copious, pale, alvine evacuations, and
pain and sometimes a perceptible tumor, in some part of the abdo-
men, especially in the iliac or hypogastric regions.  The catame-
nia simply  become scanty, or cease, without undergoing the
changes observed in some cases of disorder of the general health.
There are altogether a peculiar appearance of the countenance, a
peculiar mode of walking, and a peculiar attitude and manner in
general, all  denoting debility  and great disease ; if to these be
added  the peculiar sensibility to cold, and tendency to coldness
and lividity  of the extreme  parts of the body, the very gradual
emaciation,  and the habitual frequency of the pulse, it is scarce-
ly possible to mistake the nature of this disease.
  319.  The following descriptions of the general symptoms in
Melanosis and in Encephalosis  are  taken from the inimitably
beautiful work of Laennec.

                      II. MELANOSIS.
  320.  " Les melanoses, comme toutes les matieres accidentel-
les qui n'ont point d'analogues dans les tissus et les liquides de
Peconomie animale, produisent des effets generaux et des effets
locaux   Parmi les premiers, le plus constant est la diminution
graduelle des forces vitales, et une alteration tres marquee dans
la nutrition, d'ou resultent  un amaigrissement considerable et
l'hydropisie du tissu cellulaire, quelquefois meme celle des mem-
branes sereuses.  Les sujets que j'ai vu mourir par suite du de-
veloppement de melanoses dans un organe quelconque, et ceux
meme chez  lesquels cette matiere occupait une grande partie du
poumon, n'avaient pas  de fievre continue  et bien marquee: les
deux observations de melanoses du poumon sans complication 
OF  ENCEPHALOSIS.
247
contenues dans l'ouvrage de Bayle*  donnent le meme resultat.
Si ce caractere est constant comme je suis tres-porte a  ecroire,
il pourra servir a faire distinguer pendant la vie la consomption
produite par les melanoses du poumon, de la phthisie tubercu-
leuse, qui, comme l'on sait, est constamment accompagnee pen-
dant presque toute sa duree d'une fievre hectique assez ordinaire-
ment caracterisee par deux exacerbations, dont l'une a lieu vers
le milieu du jour et l'autre dans la nuit."t

                    III. ENCEPHALOSIS.
   321.  " Pendant la plus grande partie de l'existence des ence-
phaloides, il n'y a pas de fievre sensible; et, dans beaucoup de
cas meme, la mort arrive sans que le pouls du malade ait jamais
presents d'alteration notable.   Quand il existe  un mouvement
febrile bien marque, il parait ordinairement du a des  circon-
stances accidentelles, plutot qu'au developpement des encepha-
lo'ides en lui-meme.  Ainsi, lorsque ces tumeurs, a raison de leur
position, genent des organes essentiels, ou occasionment une in-
flammation locale plus  ou moins etendue; lorsque l'irritation
produite par leur presence determine un flux abondant  d'un li-
quide quelconque, la fievre se developpe assez souvent,  et peut
meme  devenir continue et tres-forte.  Mais ce  n'est  guere
qu'aux approches de la mort que l'on voit paraitre la fievre, sans
qu'on puisse l'attribuer a autre chose qu'a Paction deletere de la
matiere morbifique sur Peconomie animale.
   322.  "Les encephaloides peuvent exister  pendant longtemps
sans produire un amaigrissement notable.   Mais ce symptome
est constant vers Pepoque de la terminaison de la maladie, et il
marche alors d'une maniere tres-rapide.  Les  seuls cas ou la
mort arrive sans qu'il y ait eu d'amaigrissement sont ceux ou
elle est  determinee par la situation meme des tumeurs  morbi-
fiques, et par la pression qu'elles exercent sur des organes essen-
tiels, comme le cerveau ou le poumon.   Les cas, au contraire,
ou l'amaigrissement commence de bonne heure et presque des
* Voy. Recherches sur la Phthisie pulmonaire, Obs. xx et xxi.
 f De l'Auscultation, par R. T. II. Laennec, t. ii, pp. 30—31. 
248     .      THE  DIAGNOSIS,  ETC.

I'origine de  la  maladie sont ceux ou la matiere  morbifique, a
raison du lieu ou elle s'est developpee, occasionne un flux colli-
quatif, propre par lui-meme a causer l'amaigrissement, comme
il arrive dans les squirrhes  de  la  matrice.  L'hydropisie n'est
point un effet necessaire du  developpement de  la matiere mor-
bifique dont ils'agit; mais  elle survient cependant assez  fre-
quemment aux approches de la mort, surtout lorsque la matiere
cerebriforme s'est developpee dans le foie  ou dans la matrice."*

                      IV. SCIRRHUS.
  323. Scirrhus occurs later in life,  generally speaking, than
encephalosis.  It is  chiefly remarkable  by inducing a pallid,
sallow hue of the  countenance, with emaciation.  The pulse
is not accelerated, at  the first, and there is no hectic.  After-
wards there are, with these symptoms, peculiar pains, resembling
those of rheumatism, and oedema or anasarca,
* De l'Auscultation, par R. T. H. Laennec, t. ii. pp. 62—63. 
CHAPTER  VIII.
         THE  DIAGNOSIS OF THE  HAEMORRHAGES.

  324.  After inflammation and tubercles,  haemorrhagy is
amongst the most frequent and important of diseases, especially
as it occurs in the brain and the lungs, in the substance of other
organs,  and from  the stomach, the intestines,  the kidney and
bladder, the uterus, &c.
  325.  The use of the term  haemorrhagy must be extended
beyond its literal meaning.  The congestion which precedes the
flow of blood cannot be distinguished by the generic term, from
the clot of blood or the flow of blood, when the parietes  of the
vessels have  given way.   They are different stages  of the
same affection, which must be distinguished by an epithet or in
description.
  326.  The different forms of haemorrhagy are very numerous,
and all its forms are probably not yet distinguished.
  227.  The first and simplest form  is that which results from
the interrupted return of the venous blood. In this manner, con-
gestion first, then effusion of blood, occurs in the lungs and in
the brain, and possibly in the substance of some other organs, in
disease of the heart, and especially in contraction of the left auri-
culo-ventricular orifice.  In this manner, congestion and effusion
of blood occur in the course of the intestinal tube, from compres-
sion or obstruction in the course of the vena porta.
   328.  The second  form of haemorrhagy is that which occurs
from too forcible a projection of the blood from the heart.  Thus
effusion into the brain is an effect of hypertrophy of this viscus.
   329.  The  third form of haemorrhagy occurs—in cases in
which the return of the venous blood is not impeded, or the flow
of  the  arterial blood augmented—from disease  of the minute
                             32 
250
THE  diagnosis  of
vessels themselves, as we observe in some cases of haemorrhagy
into the brain or from the  lungs ;  in cases of broken texture,
tubercles;(l) &c.
   330.  A  fourth  form of  haemorrhagy occurs,  far  more fre-
quently than is supposed,  in the Acute and other forms of Dys-
pepsia.   It takes place from the mucous surface, and especially
from these of the  nostrils, the stomach and intestines, constitu-
ting the most frequent forms of haematemesis and melaena.   It
also doubtless takes place from  the mucous  lining of the gall
ducts, the kidney, the uterus,  &c.
   331.  But,  besides these forms  of  haemorrhagy,  there are
others, if possible, still more  formidable:
   332.  In one case, cysts of blood are formed in  the  parenchy-
matous substance of various organs, simultaneously, or in several
parts of the same organ.  M. Cruveilhier observes—" Plusieurs
faits  prouvent manifestement la connexite qui existe entre les
foyers sanguins des differens organes.   Aucun n'est plus remar-
quable que celui qui a ete sounds a la Sociele anatomique par
M. Robert,  Pun de ses membres.    Tous les organes, la peau, le
tissu  cellulaire,  les  muscles, le cerveau,  les poumons, la rate, le
foie,  le pancreas, l'uterus,  etc.  etaient  comme  farcis de foyers
sanguins.   Les  poumons  en contenaient surtout un nombre
considerable.   Malheureusement on n'a pu obtenir aucuns ren-
seignemens positifs sur les symptomes correspondans.   11 existe
des conditions de l'organisme dans lesquelles  des hemorrhagies
spontanees  avec dechirure peuvent se manifester simultanement
  (1.) It is a commonly received opinion by the profession, I believe, that the
most frequent cause of that important symptom of tubercles in the lungs, hamop-
thisis, is the ulceration of the coats of a blood-vessel.  Careful dissection, how-
ever, would seem to show that even the more formidable attacks are only a
simple exhalation from  the minute vessels. The explanation appears to be
this: the morbid deposit, by the local irritation it produces, determines an undue
proportion of blood to the lungs—the smaller vessels, obstructed and overloaded
relieve themselves by pouring out their contents—while in cases where the ob-
struction begins in the larger vessels, the capillaries relieve themselves by pour-
ing out the serous portions of the blood, as in most cases of dropsy.  Ulceration
of a blood-vessel, however, is sometimes a cause of haemorrhage, and ought I
think, to have been mentioned.                                   S. 
               THE  HEMORRHAGES.           251

dans tons  ou presque tous les systemes d'organes.   Ces condi-
tions n'ont ee bien appreciees que pour le scorbut.   Mais dans
ie plus grand nombre des cas, un seul organe est le siege de ces
hemorrhagies."
  333.  In other cases there is less disposition  to haemorrhagy
into the substance of organs, but the blood  is poured out from
the mucous membranes, or immediately underneath the cuticle.
This affection constitutes the Purpura hamorrhagica.
  334.  In the third place must rank  the disease  termed Scor-
butus, a disease totally distinct, I think, from Purpura.  In this
disease effusions of blood are found in the  spleen, the liver,  the
uterus, the heart, (fee*
  335.  Besides the forms of haemorrhagy already enumerated,
I have  witnessed another, which displayed, on dissection, nu-
merous distinct effusions of blood in the substance of  the brain,
together with an obvious admixture of pus or coagulable lymph
with the blood in the large veins : the eyes  had become  affected
with chemosis and ulcerations, and had burst.
  336.  The different  forms  of haemorrhagy  may, then,  be
arranged in the following manner:
          ARRANGEMENT OF  THE HJEMORRHAGiES.
    I. Topical ELemorrhagy.
         1.  From obstructed return of the Venous Blood.
         2.  From excessive impulse of the Arterial Blood.
         3.  From disease of  the  Minute, or  Capillary,
              Vessels.
   II.  Dyspeptic Haemorrhagy.
         1. Epistaxis.
        2. Hamatemesis.
         3. Melana, fyc.
  III. General ILemorrhagy.
         1.  Cysts of Blood  in  several Organs, or several
              parts  of the same Organ.
* Cruveilhier. 
252
the  diagnosis
  IV.  Purpura.

        1. Simplex.
        2. Hamorrhagica.

   V.  Scorbutus.

  337. I. Topical haemorrhagy depends  upon some local dis-
ease,—in  the heart or large veins,—or in the organ which is the
seat of the haemorrhagy itself.   The account of the symptoms
will be found under these Local Diseases respectively.
  338. II. For the general symptoms in the Dyspeptic Haemor-
rhagy, I must refer to Chapter IV., where they are so amply de-
tailed.
  339. III. The history and symptoms of that form of hesmor-
rhagy in which distinct effusions of blood occur in various organs
of the body, § 332, are altogether unknown.
  340. It only remains for me to treat, in this place, of the con-
stitutional symptoms of Purpura, and of Scorbutus, which I pro-
pose to do at  considerable length.

                       iv.   purpura.
  341. Purpura occurs under three forms:—1. Purpura  sim-
plex, 2.  Purpura  haemorrhagica,  and 3. Purpura urticans.  It
is the second which is principally to occupy us in this place.(')

                   I.   Purpura simplex.
  342.  The purpura simplex is characterized by an appearance
of petechiae, or dark red spots, without much disorder of the con-
stitution, but with paleness, languor, debility, and pain of the
limbs.  They are diffused  chiefly over the arms, legs, breast,
and abdomen,  being largest on the legs, though seldom conflu-
  (1.) An important form of Purpura described by Rayer, not included in the
text, is P. febrUis—in which the cutaneous affection is preceded, from three to
six days, by febrile symptoms and sometimes by nausea and vomiting.  This
variety of Purpura is sometimes sporadic, sometimes epidemic,—it may occur
with or without haemorrhage from internal organs—some interesting epidemics of
>t are on record.                                            B. 
of  purpura.                 253
ent.   In some cases, the appearance of the petechiae is preceded,
for a day or two, by a general red efflorescence.

               II.   Purpura hamorrhagica.
  343.  I. The History.  The usual causes of this disease are
a sedentary  mode of life, poor diet, impure air, anxiety of mind,
laborious work.  Of seventeen patients seen by Dr. Willan, two
only were men ; nine were women, of whom four were beyond
the age of fifty, three were boys, and three infants, not more than
a year old.   This  disease is  sometimes preceded by pallor and
lassitude.  Its duration is uncertain, and varies from fourteen
days to as  many months.  It combines haemorrhage, vibices,
and anasarca.
  344.  II.  The Symptoms.  The purple spots appear first on
the legs, and at uncertain periods on the thighs, arms, and trunk
of the body,  the hands and face being generally free from them.
They are numerous on the tonsils, uvula, palate, gums, tongue,
and inside of the cheeks and lips, where they are sometimes raised
and papulated, and discharge blood  on the slightest pressure.
The color of the spots on the surface of the body is at first a
bright red, but  it soon becomes purple or livid; the cuticle over
them is smooth and shining,  but not elevated.   They are near-
ly of a circular form but of different sizes ; sometimes few and
distinct, sometimes numerous  and coherent;  sometimes distribu-
ted uniformly over the surface, sometimes in irregular clusters.
Many of the patches  disappear  in a week or two, while fresh
ones arise in other places.  They are  largest and most vivid in
the evening or night, smaller and of a yellowish hue during
the day.  Generally  they are interspersed with vibices or livid
patches resembling the effects of a bruise.
   345. The haemorrhage takes  place from the  nostrils, fauces,
gums, lips and cheeks, the tongue,  the lungs, the stomach or in-
testines, or from the uterus even, in women of an advanced age.
 It sometimes precedes, sometimes  succeeds, and sometimes ac-
companies the eruption ; it is at first profuse, and cannot be easily
 restrained ;  in  some cases it returns daily at a stated hour; after
 a week or two it becomes  less violent and frequent.   When 
254
THE  DIAGNOSIS
 the  haemorrhage flows from the gums and mouth, the spots on
 the surface of the  body are numerous and smaller than usual,
 and the fauces, gums, and tongue, sometimes appear livid and
 tumefied.  This complaint is attended with extreme debility and
 depression of spirits.  The pulse is generally weak and frequent.
 Febrile paroxysms occur at  intervals.   Sometimes  there are
 shiverings, sometimes heatwithout shiverings.—At a late period,
 anasarca takes place, first about the ankles, and subsequently in
 the thighs, body, arms, cheeks, and eye-lids, with sallowness of
 the complexion, emaciation, and coldness of the extremities.
   346. III.  The Complications may be enumerated thus :

        I. Petechia upon, or
       II.  Hamorrhagy from,
            I. The Mucous Membrane of
                 1. The Nostrils.
                 2. The Gums, the Tongue.
                 3. The Bronchia.
                 4. The Stomach and Intestines.
                5.  The Kidney or Bladder.
                6.  The Uterus.

            II.  The Serous Membranes.
       III.  Parenchymatous Hamorrhagy.
       IV.  The Effects of Hamorrhagy upon
                  1.  The Brain.
                  2.  The Heart, frc.

        V. Anasarca.

                     v.  SCORBUTUS.
  347. I. The History.   Scorbutus is generally induced by a
deficiency of fresh vegetable food.   It is also occasionally referred
to other errors in diet, to the respiration of a crowded or otherwise
impure atmosphere, to excessive fatigue, anxiety, &c.
  348. II. Scorbutus is usually distinguished by a set  of symp-
toms designated by  the term putrescent, such as a  spongy  and 
OF  SCORBUTUS.
255
ulcerated state of the gums, with extreme  fcetor of the breath ;
gangrenous ulcers; a foetid state of the urine, &c.
  349.  The countenance and skin generally become peculiarly
pale, and sallow, or yellowish, and tumid ; there are extreme de-
bility ; a disposition to  somnolency, to syncope, &c.; shortness
of breathing ;  a feeble pulse;  &c.  Petechias and vibices appear
on various parts of the body ; the  gums bleed ; former cicatrices
are dissolved,  and the  ulcerated surfaces bleed  and  perhaps
slough; there is haemorrhagy from the bowels, the kidney, or
bladder, the uterus, &c.; serous effusions take place into the cel-
lular membranes and  the cavities.
   350.  III. The Morbid Anatomy of  Scorbutus consists of
the effusion of blood, or of bloody serum alone, into the various
parenchymatous textures, or serous cavities of the body, or from
the mucous membranes ;  of  an uncoagulable condition of the
blood, and of softening of the  solids.
   351.  It is a question of intense  interest how far the three last
morbid  affections are allied; and the entire subject  of haemor-
rhagy is one of great promise  to the new inquirer.
   352.  The heemorrhagies are not remotely allied to the drop-
sies, of  which I propose next to  treat.  The effusions and the
urine in the dropsies frequently  contain the albuminous,  and
sometimes even the coloring part of the blood ;  and haemorrhagy
within the brain frequently oocurs in these diseases.   Dropsy, on
the other hand,  frequently supervenes in the haemorrhagies. 
CHAPTER  IX.
            THE  DIAGNOSIS OF  THE DROPSIES.

   353. The transition  is easy from the haemorrhagies to the
 Dropsies.
   354. Dropsies differ, like the haemorrhagies, according to their
 causes.   The diagnosis and the treatment are, therefore, princi-
 pally suggested by the history.
   355. I purpose, in this place, to enumerate the principal causes
 of this disease, and to construct an arrangement or tabular view
 of the subject upon this  principle.
   356. The first cause of Dropsy which I shall mention is in-
flammation.   From this cause we have very frequently general
 anasarca, and effusions from the several serous membranes, as
 the arachnoid, the pleura, the  pericardium, the peritonaeum, the
 tunica vaginalis testis,  &c.
   357. The second cause of Dropsy  is some exanthematous
 disease, and especially scarlatina.
   358. A third cause of  Dropsy is exhaustion  from  loss of
 blood.
   359. A fourth cause,  is  debility from chronic disease or other
 causes, as old age, excessive fatigue, anxiety,  &c.
   360. A fifth and frequent cause of Dropsy is obstruction of
 the flow of the venous  blood :  it takes place  in  disease of the
 heart, disease  of the lungs, disease  of the  liver, especially the
 cirrhose, and in disease of the veins themselves.
   361. A sixth source of Dropsy has been pointed out by  Dr.
 Bright, as consisting in disease of the kidney.
   362. These various forms of Dropsy may be thus arranged: 
                of the  dropsies.             257
        diagnostic arrangement of the dropsies.
  1.   Inflammatory Dropsy.
 ii.   exanthematous dropsy.
III.   Dropsy from Exhaustion.
IV.  Dropsy from Debility.
 V.  Dropsy from Obstruction of the Venous Blood.
VI.  Dropsy from Disease of the Kidney.

               i.  inflammatory dropsy.
  363.  I.  The History.   This form of Dropsy generally
takes place rather suddenly, and is to be traced to exposure to
wet and cold.
  364. II.  The Symptoms consist in the appearance of dif-
fuse, tense, anasarca, generally with  dyspnoea, and frequently
with the signs of effusion into the head,  thorax, or abdomen,
and with a coagulable and occasionally a sanguineous condition
of the urine.
  365. III. The Effects of Remedies.  There is a remarka-
ble degree of the tolerance of loss of blood.
  366. IV.  The  Morbid  Anatomy varies according as the
Dropsy is confined to the cellular membrane, or extended to the
serous membranes;  in the latter case there is frequently the ef-
fusion of coagulable lymph, as well as of serum, from the serous
surfaces.  The kidney, in protracted cases, becomes disorganiz-
ed, granular, scabrous, &c.

              II. EXANTHEMATOUS  DROPSY.
  267. I.  The History.  This form of Dropsy succeeds to
some  exanthematous diseases  but by far most frequently to
scarlatina.
  368. II.  The Symptoms are similar to those just detailed as
designating the Inflammatory Dropsy; there is the same dis-
position to effusions into the brain, thorax, and abdomen.

            III. DROPSY  FROM EXHAUSTION.
  369.  The History and Symptoms.  This form of Dropsy
                           33 
258
THE  DIAGNOSIS
is known by being traced to the loss of blood.  It occurs in the
form of anasarca and  of effusion into the cavities.   I do not
know whether the urine be coagulable.
  370.  A similar form of Dropsy is induced in cases of neglect-
ed Chlorosis.

                IV. DROPSY OF DEBILITY.
  371.  The History and Symptoms sufficiently establish and
distinguish this form  of Dropsy.   The patient has frequently
had returns of dropsical affection and has a pale and cachectic
appearance.  The  urine  coagulates  into brownish  flakes by
exposure to heat.*

V.  DROPSY FROM OBSTRUCTION IN THE FLOW OF VENOUS
                          BLOOD.
  372.  This form of Dropsy arises from
     1.  Disease of the Heart, especially of the valves.
     2.  Disease of the Lungs.
     3.  Disease of the Liver, especially the l Cirrhose.^
     4.  Pressure, or Disease, of the Veins themselves.
   373.  The History  and Symptoms.  This kind  of Dropsy
is distinguished by ascertaining the seat and nature  of the ori-
ginal disease.   Like the rest, it assumes the form of anasarca,
and of  effusion into the  serous  cavities,  and into the cellular
membrane of the internal organs, as the lungs, intestines, fyc.
 The urine is not coagulable.}

      VI.  DROPSY FROM DISEASE  OF THE KIDNEY.
   374. For the detection of this  species  of Dropsy, the profes-
sion and mankind are  indebted to Dr. Bright.
   375.  I.  The Symptoms.  It is distinguished by  the coagu-
lable condition of the urine.  The urine is apt sometimes to be
 sanguineous.
* See Dr. Bright's invaluable " Reports," vol. i, p. 3.
f Ibid, vol. i. pp. 1-4 ;  93, llfc 
OF THE  DROPSIES,
259
  376.  II.  The Complications.   There  is,  in  this kind  of
Dropsy, occasionally
     1.  An Attack of Apoplexy;
and frequently
    2.  Inflammation of the Serous  Membranes, and espe-
            cially of the Pleura.
The liver is usually found free from disease.*
  377.  III.  The Morbid Anatomy.  Dr. Bright observes—
" In all the cases in which I have observed the alluminous urine,
it has appeared to me that the kidney has itself acted a more im-
portant part, and has been more deranged both functionally and
organically than has generally  been imagined.  In the latter
class of cases  I have always found the kidney decidedly disor-
ganized.   In  the former, when very recent, I have found the
kidney  gorged with blood.  And in mixed  cases, where the at-
tack was  recent, although apparently the foundation has been
laid for it in a  course of intemperance, I have found the kidney
likewise disorganized."t
   378. Dr. Bright describes  three kinds of this disease of the
kidney.  In the first, the kidney loses its  usual firmness and
becomes of a  yellow mottled appearance externally.   The size
of the  kidney is not  materially altered.  In  the second, the
whole cortical part  is converted into a granulated texture, and
there appears  to be  a copious morbid interstitial  deposite of an
opaque white  substance.   The kidney is generally rather larger
than natural.    In the third,  the kidney is rough and scabrous
externally, and rises in numerous projections not much exceed-
ing a large pin's head,  yellow, red, and purplish ; it is hard and
inclined to be lobulated, and  its texture approaches to a  semi-
cartilaginous  firmness: there appears, in short, a contraction of
every part of  the organ, with less interstitial deposite than in the
last variety.!
   379. I did  not think it necessary to describe anasarca.   For
• Dr. Bright's Reports, vol. i, pp. 1-4 ;  93 ; 113.
f Ibid vol. i, p. 4.
t Ibid, vol. k pp. 67-69, 
260           THE  DIAGNOSIS,  ETC.

the tyro, it  may, however, be proper to state, that this affection
consists in a general swelling of the integuments  most seen in
the most  dependent parts, and  therefore in the legs during the
day, and in the face and upper parts of the body on awaking in
the morning ;  it is colorless and retains the impression left by
the pressure of the finger, being equally distinct from the elastic
swelling  of polysarcia, and  the  crepitating  tumidity  of em-
physema.
   380. It may be proper to add, that the inflammatory anasarca
is more tense and tender under pressure, than that which arises
from debility ;  and that anasarca of the arm is of more fearful
omen even than that of the inferior extremities.
   381. I here terminate what I had to say on the diagnosis of
the  Diseases of  Systems.  I know that my arrangements
will not always bear severe scrutiny by the nosologist;  but I am
also persuaded that they will be  of use to the young clinical stu-
dent, or  practitioner, and this object I esteem of greater value
than the former. 
SECTION  II.
THE DIAGNOSIS OF THE DISEASES OF ORGANS.
                    CHAPTER   I.

THE  DIAGNOSIS OF  THE DISEASES OF  THE BRAIN  AND
                    SPINAL  MARROW.

  382. In passing from the diseases of systems to  the  diseases
of organs,  I come at once to one of the most important of the
human body—the brain and spinal marrow:  for it  is plain that,
however these two portions of the nervous system have  been se-
parated in books, they constitute but one in nature, and it would
be as correct to  separate  the different parts of the  brain  itself.
Such an artificial disjunction of the brain  and spinal  marrow
has  occasioned  great inconvenience, and been the source of
many errors.   One  great disadvantage  has arisen  from the se-
paration of these two parts of the nervous system in our clinical
studies ; whilst the  brain has received its due degree of atten-
tion, the spinal marrow has been, comparatively, neglected.
  383. The diseases of the brain  consist in arterial, or venous
congestion ; or in rupture or other destruction of its substance;
in the varied effects  of that process designated inflammation; in
effusion; in hypertrophy, atrophy; &c.   The first of these oc-
curs from undue  impulse of the arterial blood, as in  hypertrophy
of the heart; the second from an impediment to the  return of the
venous blood, as in disease in the left auriculo-ventricular orifice;
the third ocours from either of  these causes, or from diseases of
the vessels within the brain itself.  The causes of inflammation
are, generally speaking, well known.  Those of effusion, inde- 
262   DIAGNOSIS OF  THE  DISEASES OF

pendent  of inflammation, are more obscure; those of hypertro-
phy and atrophy more obscure still, but are probably associated
with the degree of supply of arterial blood.
   384.  Congestion tends principally to induce stupor; inflam-
mation to induce delirium; irritation occasions convulsions ; the
rupture, or destruction of the substance of the brain, paralysis :
mere pressure also induces coma or paralysis.
   3S5.  Of all the diseases of the human body, those of the brain
and spinal marrow are, in their different forms, the most sudden
the most acute, the  most insidious, and the most  protracted.
Amongst the first is apoplexy ;  auiongst the second is acute in-
flammation, amongst the third, chronic inflammation, tubercles,
tumors;  and amongst the  last, epilepsy, mania, idiotcy.   No
cases require such acumen, such watchfulness, such  decision on
the part of the physician.
   386.  On  the other hand, the most marked symptoms of dis-
ease of the  brain and spinal marrow occur, and in still more
marked forms, in other diseases, in which there is,  in fact, no
dangerous structural disease; as in intestinal irritation,  exhaus-
tion, hysteria, delirium tremens, &c.
   387. The principal  and most important of these cases are pre-
sented in the following tabular form:

ARRANGEMENT  OF THE DISEASES OF THE BRAIN AND SPINAL
                        MARROW.

                     i.  the sudden.
         Apoplexy  and  Paralysis.

         1.  From  Congestion:
             1. Arterial;
             2.  Venous. \
         2.  From Rupture, with Hamorrhagy ;  and
         3.  From Destruction of Texture,

     I. Of the  Tuber Annulare.
II.  Of the Cerebrum, 
THE  BRAINAND SPINAL MARROW.
    1.  Extensive:
         1.  Over the Surface.
         2.  In the Substance of the Hemisphere.
             1. Circumscribed;
             2. Extending into the Ventricles.

     2.  Topical:
         1. In the Radiations of the Corpus Striatum.
         2.  In  the Radiations of the Thalamus.
         3.  In  the Corpora Quadrigemina.
         4.  At the Roots of various Nerves.
III. Of the Cerebellum.
         1.  Of the Middle Lobe.
         2.  Of the Lateral Lobes.
IV. Of the Medulla Oblongata.
 V. Of the Medulla Spinalis.
         1. Diffused:
              1. Of the Cervical Portion.
              2. Of the Dorsal Portion.
              3. Of the Lumbar  Portion.

          2. Encysted:
               1. Of the Lateral Column.
              2. Of the Anterior Column, or Nerves.
              3. Of the Posterior Column, or Nerves.

                  ii. the acute.
    Inflammation.
  I. Of the Cerebrum.
1.  Diffused: 1.  Of the Arachnoid.
                 1. Efusion of Lymph.
                 2. Efusion of Serum.
                 3. Effusion of Pus.
               2. Of the Cortical, or
               3. Of the Medullary Substance; 
264    DIAGNOSIS  OF  THE  DISEASES OF
                      1. Injection.
                      2. Softening; Induration.
                      3. Suppuration.
              2. Topical.   (See I. II. 2.)
    II.  Of the Cerebellum.  (I. III.)
   III.  Of the Medulla Oblongata.
   IV.  Of the Medulla Spinalis.   (I. V.)
                    III. THE INSIDIOUS.
          I. Inflammation.
     I.  Of the Cerebrum.
                Effusion;  1.  Over the Surface;
                          2.  At the Base ;
                          3.  In the Ventricles.
         II.  Tubercles; Encephalosis; etc.
    II.  Of the Medulla Spinalis.

                    IV. THE CHRONIC
     I.  Of the Cerebrum.
           Inflammation?
                      1. Mania.
                      2. Melancholia.
                      3. Dementia.
                      4. Lethargy.
                      5. Epilepsy.
    II.  Of the Medulla Spinalis ?
                      1. Paralysis  Agitans.
                      2. Tremor  Mercurialis.
  388. From these diseases  we are frequently called upon to
distinguish some other morbid affections, very different in their
nature, but similar in their external characters :
  389. From the sudden diseases we must distinguish
         1.  The coma  of hysteria.
         2. Syncope. 
     the  brain  and  spinal  marrow.  265

         3.  Asphyxia.
         4.  Deep Intoxication.
         5.  Torpor from cold. fyc.
  390. From the acute diseases we must distinguish
         1.  Fever.
         2.  Intestinal Irritation.
         3.  Exhaustion.
         4.  The Delirium tremens.
         5.  Hysteric delirium, $*c.
  391.  My  readers will  readily concede that it is difficult to
simplify, without any material omission, such a subject as this.
Yet such is my chief object in this part of the work.
                 I. THE SUDDEN DISEASES.
              I. apoplexy and paralysis.
  392.  I.  The  History.   The causes of Apoplexy and of
Paralysis are  exceedingly numerous.  They may be arranged
in the following  manner:
     1.  Plethora, Repletion.
     2.  Exhaustion, Inanition,  Debility.
     3.  Diseases of the Brain itself.
     4.  Disease of the  Vessels within  the Head, as  Aneu-
            rism.
     5.  Disease of the Heart, especially
                   1.  Hypertrophy.
                   2.  Disease of the Valves.
     6.  Disease of the Lungs, Liver, Kidney, fyc.
     7.   The  Various Hamorrhagies,  Dropsis, fyc.
   393. Persons of short stature,  of a short  neck, and general
 fulness, are certainly most prone to apoplectic attacks ; but the
 tall and spare, and feeble,  are by no means secure from them.
 Excess in  eating; the  recumbent posture;  muscular  efforts;
 straining;  mental emotion ; sleep;  &c. are also causes of this
 terrible disease^1)

   (1.) Among the most frequent causes of Apoplexy should be mentioned Hy-
 pertrophy of the left ventricle of the heart, with freedom of the aortic orifice. S. 
266   DIAGNOSIS OF  THE  DISEASES  OF

   394. It is highly important to be aware of the premonitory
Symptoms.  These are—sudden flushings ; an unwonted, per-
haps transient, headache, vertigo, a sense of pressure, a sense of
confusion, &c. incoherence of mind, delirium, loss of conscious-
ness, of memory, &c, drowsiness; numbness, paralysis,  spasm,
visual spectra,* noises, &c. sickness; faintishness.
   395. II.  The  Symptoms.  In detailing the symptoms,  I
shall endeavor to associate each of their  numerous forms with
their corresponding organic changes of the encephalon.
   396. Now the principal symptoms in Apolexy are—stupor
or coma; paralysis; and  convulsion: these  may vary in
degree, in extent: the first  seems to be associated with com-
pression  of the brain, and therefore occurs in mere congestion
or fulness of the vessels, as well as in haemorrhagy within the
brain; paralysis arises from broken texture, and varies,  in its
seat and extent, with those  of the organic lesion;  convulsion
arises  from irritation, such as that of inflammation, of a
tumor, &c.
   397. The coma and its degree depend upon congestion, or
effusion of blood in the cerebral substance: when it is extreme,
the countenance is either bloated, or sunk, livid, or pale, accord-
ing  to the  period of  the disease and  the vital powers; the  ex-
pression is lost; the cheeks and lips distended during expiration;
the respiration is stertorous;  the pulse is, at first, full and slow,
and  perhaps irregular, afterwards feebler, and more frequent; the
bladder, or the sphincters, may be in a state of paralysis.
   398. The paralysis, with its degree  and seat, depends on
the extent and seat of the organic lesions: these may be arranged
in the  following manner:
  * The celebrated Lord Peterborough, being engaged in -writing, raised his
head and beheld a human figure before him; it shortly disappeared, but returned
after a time, assuming the same attitude as before.  He sent for his medical ad-
viser, was freely bled and purged, and forthwith dismissed the unwelcome in-
truder, and probably was saved from a lit of apoplexy. 
       THE  BRAIN  AND  SPINAL  MARROW.  267

                I.  Of the  Tuber Annulare.
   399. Extensive lesion of the tuber annulare* induces general
 paralysis of the muscles and sensibility of all the limbs, and of
 the  senses.  In  three patients  observed  by M. Serres,t total
 immobility was  induced by destruction  of the tuber annulare.
 In two others the attack was attended by severe pain, and an
 invariable disposition to run forwards.  In two others there were
 more absolute insensibility and  immobility, loss of sight, and of
 hearing, and of the taste and smell.  When the middle portion
 of the tuber was chiefly affected,  there  were movements like
 those  of chorea, then  the incoherence of drunkenness, and,
 lastly, complete paralysis.  The pupils were either contracted or
 immovable.  In cases in which  one side of the tuber was alone
 diseased, the facial nerve of the opposite side was affected, the
 mouth was drawn, and there was a stammering  articulation.

                   II.  Of the Cerebrum.
                       1.  Extensive.
   400. Disease  extensively diffused in the cerebrum induces a
 paralytic state of the mental, sentient, and muscular functions.
   401. Effusion of blood upon the surface of the brain induces
 coma.
   402. If  the effusion into the substance of the brain  be ex-
 treme, and extended into  the ventricles, it induces speedy,  if
 not sudden dissolution ; if  it be  not extreme, yet  extending into
 the ventricles, it is always fatal, though not until some days may
 have elapsed ; if it be confined to the substance, it induces hemi-
 plegia  of the opposite side of the body, or, according to its situa-
 tion, paralysis of the upper  or lower extremity.

                        2.  Topical.
  403. When the effusion  or disease is confined to a particular
 part  of the brain, particular effects have been observed:

  * This part of the brain has been not inappropriately designated nodus ence-
phali, naud vital, &c.
  f Anatomie du Cerveau ; t. ii, p. 634. 
268    DIAGNOSIS OF  THE  DISEASES  OF
  404.  1. Effusion into the space occupied by the radiations of
the corpus striatum, induces paralysis of the inferior extremity
of the opposite side.
  405.  2. Effusion into the thalamus induces paralysis of the
opposite, superior extremity.
  406.  3. Effusion into the tubercula quadrigemina is said, by
M.  Serres,* to induce strange movements, similar to those of
chorea.
  407. 4. In order to detect disease affecting the roots of the
various nerves, it is essential to know their distribution and phy-
siology .t   Some remarks will be made on this subject in a sub-
sequent chapter.   It is  here only necessary to state that, having
clearly  ascertained the  nerve and function paralysed, we  have
only to determine, by careful examination, and inquiry into the
symptoms, whether the  disease be  seated  within or without the
cranium.

                   III.  Of the Cerebellum.
   408. Disease of a lateral lobe of the cerebellum induces para-
 lysis of the opposite side,  and chiefly of the lower extremity.
   409. Disease of the middle lobe of the cerebellum is denoted
 by erection of the  penis.

               IV.  Of the Medulla Oblongata.
   410.  Disease of the  medulla oblongata induces paralysis of
 the respiratory  muscles,  and  consequently,  when  complete,
 instant death.t
  • Anatomie du Cerveau; t. ii, p. 646, &c.
  f See the- account of the most splendid discovery in physiology within the
last century, entitled " The Nervous System;"  by Charles Bell, F. R. S., 1830.
  I Mr. Kiernau has preserved the parts of the brain in a singularly interesting
case : in one hemisphere of the cerebrum, there was a cicatrix denoting an attack
of hemiplegia experienced three years before, from which recovery took place ;
in the fourth ventricle, a clot of blood was found, which, from its pressure on the
upper part of the medulla oblongata, induced instantaneous dissolution. 
      THE  BRAIN  AND SPINAL  MARROW.   269

              V.  Of the Medulla Spinalis.
                       1.  Diffused.
  411. Sudden lesion of the spinal marrow paralyzes all the
parts  situated below that, principally affected.  Disease of the
cervical portion of the spinal marrow induces asphyxia, the more
promptly as it is situated nearer the medulla oblongata.  Disease
of the spinal marrow situated lower down induces paralysis of
the superior and inferior  extremities, of the bladder, and of the
sphincters.  Disease of the  lumbar portion of the spinal marrow
is confined, inks effects, to paralysis of the lower limbs, the blad-
der, and the sphincters.
                       2.  Encysted.
   412. Disease of the spinal  marrow,  when  encysted, and
strictly confined to one or more parts, induces peculiar effects:
   413. That of the  lateral columns induces paralysis of the
same side;
   414. That of the anterior columns, or of the nerves derived
from them, induces paralysis of the movements only;
   415. That of the posterior columns annihilates the sensa-
 tions.
   416. It remains for me briefly to notice the source of convul-
 sions, as a symptom in Apoplexy.  They usually arise from a
 less degree of lesion than that which iuduces paralysis ; they do
 not arise from lesions of the cerebrum or cerebellum, lesion  of
 the first of which is marked by coma and paralysis, of the second
 by paralysis only; but from those of the
           1.  Tuber Annulare.
           2.  Tubercula Quadrigemina.
           3.  Medulla Oblongata.
           4.  Medulla Spinalis.
    417. Lesions of the two former induce  convulsions of the
  muscles of  the opposite side ; those of the two latter, those of
  the same side.*
    » Serres, t. ii, p. 637.   Recherches du Systeme Nerveux ;  par P.  Floirrens,
  Paris, 1624, p. 119. 
 270    DIAGNOSIS OF THE  DISEASES OF

   418. It will be obvious  how  much the occurrence of convul-
 sions must  assist us in our diagnosis of the seat of the morbid
 lesion.
   419. III. The Complications of Apoplexy  are extremely
 numerous.  I have already enumerated, §§ 392, 396, such as
 act as causes, and such as are to be regarded merely as symp-
 toms.  But there  are other  complications which  occur in
 this disease : they are principally affections of
          1. The Heart.         4. The Intestines.
          2. The Lungs.        5. The Bladder.
          3. The Stomach.      6. The Sphincters.
   420.  The beat of the heart becomes slow and irregular.  The
 bronchia  become clogged  with mucus.   There  is sometimes
 vomiting as  a premonitory symptom ; afterwards there is torpor
 of the stomach and of the bowels ; and there is frequently reten-
 tion of urine.  Eventually  the sphincters are relaxed.
  421.  IV.  The Effects of Remedies.  In the stage antece-
 dent to an attack of apoplexy, there is an extraordinary degree
 of tolerance  of the loss of blood.  After  the attack, the loss of
 blood is still  well borne at first, but we have very shortly to sup-
 port the powers.  I have just noticed, § 420, the peculiar torpor
 of the stomach and bowels ; this is observed under the influence
 of antimonials and purgatives.
  422.  V. The Morbid Anatomy of Apoplexy, besides that
 which may be considered  as amongst its causes,  § 392,  con-
 sists of
       1.  Arterial and Venous Congestion.
       2.  Rupture with Hamorrhagy.
       3.  Sudden Changes, in cases  of Effusion,  Soften-
             ing, Abscess, Tumor, fyc

                 II. THE ACUTE DISEASES.
                     INFLAMMATION.
        I. and II.   Of the Brain and Cerebellum.
  423. I.  The History.  The causes of Inflammation of the
Brain  are frequently very obscure:  mechanical  violence ; ex- 
THE  BRAIN AND  SPINAL  MARROW.  271
posure to the sun-beams; excesses in wine or spirits; anxiety
and  distress of mind, are amongst the most obvious; but the
most usual is probably, some constitutional derangement.  Ence-
phalitis is frequently the complication or sequela of some other
disease, and especially of
       1.  Fever;
       2.  Scarlatina; Rubeola;  Erysipelas;
       3.  Rheumatism; Arthritis;
       4.  Disease of the Kidney; Suppression of Urine ;
       5.  Dropsy; $*c.
  424.  II.  The Symptoms.  In detailing the  symptoms it
will be necessary to  attend to the stages, and the seat of the
disease.  The former may be considered as
              1.  That of Excitement;
              2.  That of Oppression.
The latter may be
              1.  The  Arachnoid.
              2.  The Cortical, or
              3.  The  Medullary Part, or
              4.  The  Base, of the Brain.
  425. I. The very incipient stage of encephalitis is frequently
denoted by one symptom only, viz. unwonted pain.  This is
not always of the acute  kind; but sometimes it  is excruciat-
ing (l)
  426.  With this  symptom  there are  an undue sensibility  of
the eye to light, of the ear to sound, and perhaps of the skin to
touch ; spontaneous flashes  of light, and noises in the head;
wakefulness;  moroseness; slight, perhaps transient, delirium;
pains of the limbs ;  vomiting.
  427. There is sometimes  a singular change in the counte-
nance, or  an expression of astonishment; the eyes are intently
  (1.) Young children sometimes express the sense of the pain very significant,
by frequently putting the hand to the head. 
272    DIAGNOSIS  OF  THE  DISEASES  OF

fixed, the conjunctivae are suffused, the cornea of a vivid bright-
ness ; the pupils contracted; and there may be strabismus.  In-
deed there is  no source of diagnosis of such importance  as the
countenance, which is the real index of the state of the mental
functions.  The respiration is sometimes  rather irregular, and
the pulse unequally frequent in various parts of a minute.
  428. 2. The second period, or the stage of oppression reverses
these appearances, and adds others of a very peculiar character :
the morbid  acuteness of the sensations passes  into blindness,
deafness;  the delirium into stupor;  the wakefulness into drow-
siness, and gradually  into coma; convulsive affections are still
more frequent, and various kinds of paralysis supervene.
  429.  The expression of the countenance changes from the
vivid to the dull, vacant, or idiotic; the eye loses its lustre, and
there is an unfixed, unmeaning stare, with dilated  pupils and
strabismus;  the muscles of the face  may be either partially
convulsed, or paralytic; the articulation, both as a muscular and
mental function, may be defective, the deglutition, imperfect;
there are various spasmodic, convulsive, or paralytic affections of
the limbs.   The respiration becomes irregular, suspirious, and
eventually perhaps stertorous; the pulse becomes frequent; the
bladder is often  distended, with, or  without, relaxation  of the
spincters.
   430.  3. In regard to  the seat of encephalitis, it is said that
inflammation of the arachnoid  of the surface, and of the cor-
tical substance, is more marked by delirium ;  and that of the
base of the brain, by coma* and by retraction of the head.  In
regard to affections of the medullary substance, they may be
deduced  from what  has been detailed  §§ 399—410, and need
not  be repeated here.  I shall merely add a short extract from
the admirable  work  of M.  Lallemand :t   " Ainsi, en derniere
analyse, dans l'inflammation de  l'arachnoiide, symptdmes spas-
  • Recherches de PArachnitis;  par Parent-Duchatelet et L. Martinet; 204 :
229; 551.
  f Recherches sur l'Encephale, t. i, p. 278. 
      THE  BRAIN  AND  SPINAL MARROW.  273

modiques  sans paralysie; dans Phemorrhagie, paralysie
subite, sans symptomes spasmodiques ; dans I'inflammation
du  cerveau, symptomes  spasmodiques, paralysie lente  et
progressive, marche inSgale  et intermittenteP
  431. III. The Effects  of Remedies.  Encephalitis, in its
early but fully  formed stage, presents the most remarkable in-
stance of the tolerance of loss of blood ; and this, in its turn, is
the most  remarkable diagnostic of encephalitis.
  432. IV.  The  Morbid Anatomy consists, in arachnitis, of

              1. Injection,
              2. Effusion of Lymph,
              3. Effusion of Serum,
              4. Effusion of Pus ;
in inflammation of the substance of the brain, of

              1. Injecticn,
              2. Softening, Induration,
              3. Abscess.

  III. and IV. Of the Medulla Oblongata and Medulla
                         Spinalis.
  433. I. The History.   This affection  arises principally from
external  violence or injury ;  from exposure to damp and cold,
as in carelessly lying upon the damp grass, and other similar
causes.
  434. II.  The  Symptoms axe—1. pain in the course of the
spine, sometimes severe, sometimes obscure, distinguished by
not  being augmented by  moderate muscular efforts, but by
gentle percussion, performed in the same manner as in the diag-
nosis of thoracic diseases, and by its duration; 2.  opisthotonic
spasm of the muscles of the back, especially observed when the
membranes are the seat of  the disease.
  435.  The further symptoms are paralysis, generally para-
plegia,  without symptoms of encephalic  disease.  This para-
lysis varies with the seat of the inflammation: when the higher
parts of the spinal marrow are affected, the acts of respiration
                           00 
274    DIAGNOSIS OF  THE  DISEASES OP

are impaired, with paralysis  of both upper and lower extremi-
ties ; when the seat of disease is in the dorsal or lumbar portion
of the spinal marrow, the lower extremities alone are paralyzed:
the functions of the stomach and bowels are interrupted ;  and
the secretions of the kidney  and of  the  mucous  membrane of
the bladder are morbid, and the power of the bladder is anni-
hilated :  at first the sensations, or the movements, alone, may
be paralyzed ;  eventually, with general paraplegia, the power of
the sphincters is lost.*
  436. III.   The Morbid  Anatomy consists in arachnitis, of

          Effusion of Serum, Lymph, or Pus ;
and in inflammation of the substance of the spinal marrow, of
              1. Injection.
              2. Softening ; or Induration.
              3. Abscess.
                III. THE INSIDIOUS DISEASES.
              I. INFLAMMATION.
             II. TUBERCLES.
            III. ENCEPHALOSIS, ETC.
            IV. CARIES.

                      I. Of the Brain.
  437.  The History and Symptoms.  All these affections are
so insidious, that with, or without, previous general indisposition,
with, or without, local pain in the head, more or less continued,
there may be sudden convulsion, or  paralysis; stupor, or im-
becility.   These symptoms  are varied  in  character,  seat,  and
intensity, in  different  instances, according  to the  part of the
encephalon principally affected:  the two former belong to ab-
scess,  softening, tubercles, or tumors;  the two latter, to effusion
of serum, into the ventricles, upon the surface, or  at the base
of the brain.

  * Some years ago I attended an interesting case of this kind with Mr. Alcock.
The patient was also seen by Dr. Babington. Cn examination, medulla spinalis
was found in a state of complete and  extensive softening. The patient had been
exposed to  cold in a boat 
      THE  BRAIN  AND  SPINAL  MARROW.  275

   438. In these various  circumstances, the expression  of the
 countenance, the direction of the  eyes, the articulation, the
 deglutition, the limbs, the sphincters ; the senses, the sensations;
 the  different  faculties of the mind; the memory of persons,
 ■things, or words, &c. are equally variously, and  doubtless ap-
 propriately, affected.*

                II.  Of the Spinal Marrow.
   439. The History and Symptoms.   The insidious  is the
 most usual form of inflammation or disease of the spinal mar-
 row.   The symptoms are pain, cramp,  paralytic weakness, be-
 numbed sensation, of the superior or inferior extremities.  These
 symptoms  may occur singly, or combined ; in one limb, or in
 more than one;  they  usually assume  the  paraplegic form.
 Sometimes a  tender part is discovered  in some region of the
 spinal  marrow, by  percussion.   Sometimes  there is a cord-like
 sensation across the epigastrium.   The  bladder,  or the sphinc-
 ters, may lose their power, and  there may be retention of urine
 or involuntary discharges, singly, or combined.  We  should
 be aware that there may be Caries,—and frequently examine
the spine.
               IV. THE CHRONIC  AFFECTIONS.
                   1.  Of the Cerebrum.
              Inflammation 1
                   1.  Mania.
                  2.  Melancholia.
                  3. Dementia.
                  4.  Lethargy.
                  5. Epilepsia.
  440.  The  diseases to  be noticed in this place are amongst
  * In one sadly interesting case, the finest mind became confused, and at length
complete imbecility took place.  The patient was about forty.  Harrassing
cares seemed to have occasioned  his disease.  An immense effusion of serum
distended the ventricles. 
276   DIA GNOSIS  OF  THE  DISEASES  OF

the most afflictive and  obscure to which man is subject.  The
designations are those of symptoms merely; the organic lesions
on which those symptoms depend, are still almost unknown,
but probably consist in a particular condition of the minute and
capillary circulations.   I shall do little more, in this place, than
explain the use of terms, the diagnosis, generally speaking,
being obvious enough.

                        Mania, fyc.
  441.  I.  The History.  The  principal  causes of mania are
mental excitement, and exhaustion, acting in conjunction with
hereditary predisposition.   Mania is frequently the result of the
arduous  duties of  our  prime ministers, and  of the anxieties of
the stock-exchange ; it is also frequently a puerperal disease.
  442.  II. The Symptoms.  Mania consists in aberrations of
mind too numerous and  too various for description : they are
each  distinguished by ideas at variance with obvious truth.
The patient may quietly wander, generally, or upon  some par-
ticular point merely, as in monomania: or he may be furious,
and this independently of fever or other constitutional derange-
ment.   The  eye, and  the  general expression  of the counte-
nance, the general demeanor, the loquacity of the patient,  dis-
tinguish the various forms and shades of this disease.
  443.  That form of mania designated melancholia, is distin-
guished by an opposite condition of the countenance, and  atti-
tude, by taciturnity, and by the peculiar cast of the ideas.   It is
only necessary to glance the eye upon the two patients, to dis-
tinguish these dissimilar mental maladies.
  444.  In one form  of this  sad  affection there is a  monoma-
niacal  disposition  to suicide :* in a second,  there is the same
propensity to destroy others.
  445.  III. The Morbid Anatomy.   According to MM.  De-
laye and Foville, the cortical substance is  principally affected
in mania: there is injection, with a red or deep brown color,
either generally, or here and there, and with softness, so that
portions of the brain are raised with the membranes when these
• Du Suicide et dc PHypcchondrie; par M. Falret. 
     THE  BRAIN  AND SPINAL  MARROW.   277

are detached;  the  membranes are opaque and  covered  with
serum, lymph, or pus;  the bones  are  found, in some cases,
thickened and hardened.
  446. MM. Bouchet and Cazauvieilh* agree with MM. Delaye
and Foville, in their opinion of the organic origin of mania ; and
add the  important  remark,  that, as mania consists in acute or
chronic inflammation seated in the cortical substance, epilepsy
consists of chronic inflammation of the white or medullary part
of the brain.
   447. Dementia  and Lethargy, which offer no difficulty in
the diagnosis, seem  alike to arise from the effects of chronic in-
flammation, and probably differ only in the seat of the morbid
lesion; in the former the effusion  being  chiefly within the ven-
tricles of the brain, in the latter, upon its surface.

               II.  Of the Medulla Spinalis 7
                I. THE PARALYSIS AGITANS.
   448. The Paralysis Agitans has been described by Mr. Par-
kinson under the designation of the ' shaking palsy.'
   449. I. The History.  The first symptoms of this most in-
 sidious disease is weakness and tremor, of the head, for instance,
 of the  hand, &c.  In about a  year, the other hand, or a  lower
 extremity, is affected, or the patient loses  his balance in walking.
 Generally no accident or other cause can be assigned.
   450. II.  The Symptoms.  There is perpetual tremor, even
 when  the part is supported: the  head,  the hand, the leg, are
 moved incessantly; reading and writing  become impossible, and
 the patient cannot guide his hand  to his mouth; at length the
 patient loses  his balance in  walking, and there is  a constant
 tendency to fall forwards, and, in order to avoid this, to run or
 move  with a quicker pace,  and on the toes.
    451.  At a later period the tremor continues during sleep even,
 augmenting until the patient awakes.  There is increased weak-
 ness, the trunk is  bent  forwards,  the upright position can no
 longer be supported.  The articulation becomes indistinct, mas-
 tication and  swallowing imperfect.  The  bowels are all  along
* De rEpilopsie, &c p. 43. 
 278   DIAGNOSIS  OF  THE  DISEASES  OF

 torpid, then obstinate;  at  last the urine and faeces are passed
 involuntarily.   In the last stage of all there is slight delirium or
 lethargy.
   452.  III. The Morbid Anatomy is unknown.   The symp-
 toms have, however, in several particulars, a  marked resem-
 blance to the effects observed by M.  Serres, of diseases of the
 tuber annulare, and of the tubercula quadrigemina*

                 II.   TREMOR  MERCURIALIS.
   453. I.  The History.   This disease affects workers in mer-
 cury, chiefly those occupied in silvering mirrors.
   454. II.  The Symptoms  are,  at first, paralytic  tremor and
 debility, and perhaps ptyalism ;  afterwards convulsive agitation
 of the limbs whenever  they are moved.  The articulation be-
 comes imperfect.  The hands  are so agitated, that a partly filled
 cup  cannot  be conveyed  to  the  moutht  without spilling the
 liquid.   On attempting to  walk, the limbs dance  and perform
 irregular movements.   Whilst sitting still, the patient may re-
 main free from chorea ;  but on every exertion of the volition, and
 on every occasion of mental agitation, the irregular movements
 are  renewed.  The sleep  is  disturbed: the patient  awakes
 alarmed by terrific dreams ; there are nervousness and debility ;
 the bowels are  constipated.
   455. III. The Morbid Anatomy is unknown.   I suspect
 this  and the former affection are connected with the peculiar
 function noticed in the note, p. 229.
  456. I must only briefly  revert to  the subjects  enumerated,
 §§  389, 390, to recommend to my young reader the careful study
 of the forms of those diseases  which  resemble respectively the
 sudden and acute diseases of the encephalon.  From the latter,
and from the chronic diseases,  it  will be necessary to distinguish
the cephalodyne of  Ague,  of Exhaustion, of Chlorosis, of
            * Anatomie du Cerveau, t. ii, p. 634, 642, & seq.
  f In a case detailed in the Philosophical Transactions for 1665, the patient
'»could not with both hands carry a glass half full of wine to his mouth without*
spilling -> '.hough he loved it l°o well to throw it away."' 
THE   BRAIN  AND   SPINAL  MARROW.   279
Hysteria, &c. §§ 115;  200;  238;  246.   From diseases of the
spinal marrow, we  must carefully distinguish those of the kid-
ney and  those  of the lumbar region generally, subjects to be
treated of hereafter.(1)
   (1.) At the conclusion of this chapter I will take the  liberty to caution the
student against too great positiveness in the diagnosis of the diseases of the Brain,
for, notwithstanding the great attention the subject has received from some of
the first minds in the profession, we remain almost in complete ignorance of the
true points of diagnosis.  The quotation  from Lallemand, par. 430, would have
advanced us very far if subsequent observation had  not proved that the excep-
tions to these general conclusions are so numerous that they really possess very
little practical value.  The strongest proof of our ignorance on this subject is,
that patients frequently die after having  presented, for a long time, the symp-
toms of organic disease of the brain, while  the most minute discretion can dis-
cover no perceptible lesion.
  I would further add,  that softening, ramollissment, is placed  among the conse-
quences of inflammation of the brain.  It is very questionable whether, perhaps,
the largest proportion of these cases, especially that form called the white soften-
ing, can be considered the  result of  inflammation.  Lallemand, in his Letters ,
has attempted to prove that it is, but I think that he has failed to do so.  Thus,
the causes of softening are, for the most part, unknown, while  the causes of sup-
puration are often direct.   In twenty-five cases of diffused suppuration  recorded
by Lallemand, seventeen  were referred to a blow upon the head.  We  know,
also, that Caries  of the petrous portion of the temporal bone gives rise to suppu-
ration, and not to softening of the brain.  Finally, in twenty-five cases of Sup-
puration, Meningitis occurred nineteen times,—in thirty-three cases of softening
it is mentioned only four times.
  In cases where this softening  is sudden and extensive, it causes symptoms
similar to those caused  by haemorrhage of the  brain, viz. sudden  insensibility,
paralysis of one or both sides of the body.  But its usual progress is much more
slow, producing a gradual paralysis, first of one arm, afterward, of the leg on the
same side.  United with  this, there is frequently a contraction of the affected
limb, or a stiffness in the joints.   If we except certain cases of induration  of the
brain, combined with atrophy, congenital for the most part, or occurring in very
early life,  chronic in their progress, and almost always marked by idiotcy, the
above  symptoms may be  considered as connected with but two morbid changes
in the  brain, Softening  and Meningitis, and in about the same proportion.  S. 
CHAPTER  II.
THE  DIAGNOSIS  OF  THE  DISEASES  OF  THE  ORGANS OF
                       RESPIRATION.

   457.  The organs of respiration may be naturally divided into
the larynx, the trachea, the bronchia;  the air-cells; the cellular
substance of the lungs; and the pleura.  Their diseases are as
naturally divided into the acute, the chronic, and the insidious.
   458.  In the following views of the diagnosis of these diseases,
I purpose to confine myself, as usual, to questions of practical
value and scientific interest, and shall discard such as are mere
matters of curiosity or over-refinement, of which many instances
might be adduced in regard to our present subject.  It must be
confessed, indeed,  that it is difficult to  include all that is really
useful, and to exclude all that but encumbers the study of this
important class of diseases.
    ARRANGEMENT OF  THE DISEASES  OF THE ORGANS OF
                       RESPIRATION.

                      I.  THE ACUTE.
    I. Laryngitis and Tracheitis.
              1. Injection.  2. Tumidity.  3. Exudation.
    II. Bronchitis.
              1. Redness.  2.  Slight thickening.
              3. Augmented and altered Secretion.
   III. Pneumonia.
              1. Diffused.
              2. Lobular.
              3. Central. 
THE  ORGANS OF  RESPIRATION.    281
              1.  Congestion.
              2. Hepatization.
              3. Purulent Infiltration.
              4. Abscess.
              5. (Edema.
IV.  HAMORRHAGY.
     I. BRONCHIAL HAMORRHAGY.
    II. PULMONARY HAMORRHAGY  OR APOPLEXY.
 V.  Pleuritis.

          1.  Of One Pleura-
          2.  Of Both Pleura.
          3.  Partial.
          4.  Pleuro-pneumonia.
              1. False Membranes.
              2. Serous, Puriform, Hamorrhagic, Ef-
                fusion.
VI.  Gangrene (diffused.)

                II. THE CHRONIC.

 I.  Laryngitis and Tracheitis.
 II. Bronchitis.

            1. Mucous; Dilatation of the Bronchia.
            2. Pituitous.
            3. Dry ; Emphysema ; Asthma.
            4. Symptomatic.
III. Pneumonia.
IV.  Pleuritis.
          1. Serous, floccident, or puriform Effusion.
          2. Effusion,  with  Dilatation of the Chest.
          3.  Absorption, with Contraction of the Chest-
          4.  Displacement of the Heart.
                      36 
282   DIAGNOSIS OF  THE  DISEASES   OF
   V. Gangrene  (circumscribed.)
  VI. Emphysema.
                1. Vesicular.  2. Interlobular,
  VII. Asthma.
 VIII. (Edema.
  IX. Hydrothorax.
              1. Idiopathic.   2.  Symptomatic,
   X. Pneumothorax.
                   III. the INSIDIOUS.
 I. Ulceration of the Larynx, Trachea, or BroN'
         chia,
II. Tubercles.
             I. 1.  Of the Lungs.
               2.  Of the Pleura.
            II. Complications.
III. Melanosis.
 IV. Encephalosis.
  V. Scirrhus.
 VI. Cysts, Hydatids, etc.
VII.  Symptomatic affections.
                 i. the acute diseases.
            i. laryngitis and tracheitis.
  459, The profession is chiefly indebted for the knowledge of
this disease, as it occurs in adults, to the late Dr. Bailhe,* and
to Dr. Farre.t
  460. I. The  History.   This perilous affection comes on
rather insidiously, with the feelings and appearances  of slight
sore-throat, from exposure to wet and cold.
  * See the Transactions of a Society for the Improvement of Med. and Chir.
knowledge, vol. iii, p. 275 ; Works, by Wardrop, vol. ii, p. 54.
  f Med. Chir. Trans, vol. iii, p. 84, and p. 323. 
         THE  ORGANS  OF  RESPIRATION.     283

   461. II. The Symptoms.  With  a blush of inflammation
about the fauces,  there is,  very soon, a sense of stricture about
the  larynx, and a sonorous yet hoarse respiration, and  cough,
the  inspirations being  long and difficult;  and,  after another
short interval, there is increased dyspnoea,  with the imminent
danger of suffocation, restlessness, great distress, starting of the
eyes^ and  perhaps delirium ; with these symptoms, referable to
the  larynx or trachea, there are a small pulse, paleness  of the
face, dilated pupils, and obvious danger of sinking of the powers
of life.  When the disease is seated about the  rima  glottidis,
there is dysphagia;(l) when lower down  in the larynx, there is
still  hoarseness  or loss of voice ; symptoms which are  absent in
Tracheitis, when distinct from  affection of the larynx.   Gen-
erally the patient can lay his finger on the seat of the stricture
and  of dyspnoea.*
   462. III.  The Morbid Anatomy.  There are injection and
tumidity of the  mucous membrane lining the larynx, or trachea,
or both, with  the exudation of puriform mucus, or of coagulable
lymph;  and  the rima  glottidis, the larynx,  or the trachea, is
proportionably obstructed. (2)

                       II.  BRONCHITIS.
   463.  I. The  History.  This disease  usually succeeds to
exposure to damp and cold.   There is generally, at first,  a state
of coryza affecting the eyes and nostrils.
r (1.) The dysphagia in these cases appears rather to be owing to inflammation
of the epiglottis.                                              °*
  * Of the three cases given by Dr. Baillie, two occurred in the persons of emi-
nent physicians, vizi. Dr. David  Pitcairn and Sir John Macnamara Hayes. Dr.
Pitcairn " had an uneasy feeling in the larynx, and wrote on a piece of paper
that his complaint was croup."  Dr. Farrc's patient answered his inquiry res-
pecting the seat of his suffering, " by putting his finger on the superior part of
the thyroid cartilage."
  (2.) The principal cause of death in  these cases appears to be Acute (Edema
of the glottis. A knowledge of the anatomical arrangement of the mucous mem-
brane lining the air passages will explain this—it being attached by very loose
cellular tissue about the fauces,  epiglottis and ventricles of the larynx, while its
union becomes very intimate' below.                               s- 
284    DIAGNOSIS OF  THE  DISEASES  OF

  464.  II.  The Symptoms.  In the mucous form of the dis-
ease, there is a sense of irritation about the larynx and bronchia,
with a dry,  harsh cough ;  afterwards there is considerable ex-
pectoration,  raised by fits of coughing ; this is at first pituitous,
sometimes mingled with black  pulmonary matter; and after-
wards, still more copious, viscid, opaque, yellowish, or greenish,
and perhaps striated with blood ;  there is pain more  or less dif-
fused over the chest.
  465.  The thorax sounds well on percussion.
  466.  The degree and extent of the disease are readily ascer-
tained by the  stethoscope, being denoted  by the kind and diffu-
sion of the bronchial rattles, which pass from the sonorous to the
mucous, and by the temporary diminution or partial  suspension
of the respiratiory murmur,  by the obstruction  of a bronchial
branch.(')
  467.  III.  Varieties.  Besides the  ordinary forms of acute
bronchitis, some writers, in their fondness for  subdivisions, have
enumerated the following varieties:
                  1.  The Pituitous.
                 2.  The Dry.
                 3.  The Suffocating.(2)
   468. The first and second  are observed at the commencement
and termination of ordinary  bronchitis, and are therefore stages
rather  than distinct forms of disease ; and the last occurs from
the great extent  of the  disease  and  the accumulation of the
mucous secretion, especially,  but not exclusively, in infants, and
in old age.
   469. IV. There is far greater susceptibility to the effects of
blood-letting in bronchitis than in laryngitis or the other diseases
of  this subsection.
  (1.) The diagnostic signs of Bronchitis are, clearness on percussion, a mucous
rattle over the posterior and inferior portions of the chest, and on both sides—in
mild cases of simple Bionchitis, however, it  is not common for this rattle to be
heard at all.                                                  S.
  (2.)  These three varieties of Bronchitis, mentioned by  Laennec, commonly
exist as complications—the two former in combination with Tubercles or Emphy-
sema—the latter with Emphysema also, and organic disease of the Heart.  S. 
         THE  ORGANS  OF  RESPIRATION.    285

  470.  V.  The Morbid Anatomy consists in redness, and
slight thickening of the mucous  membrane of the bronchia,
with  accumulation of its altered secretions.

                      III.  PNEUMONIA.
  471.  I.  The History.  The principal cause of  pneumonia,
like  that of laryngitis, bronchitis, &c.  is exposure to wet and
cold.(')   Pneumonia is very obscure in its first stage.
  472.   II.   The  Symptoms are  obtuse,  deep-seated  pain,
labored  or frequent respiration,(2) and cough, and a peculiar
glutinous expectoration,  highly characteristic:  this  expectora-
tion is  frequently such, that the vessel in which it is contained
may be inverted without its falling out;  its color is various, but
frequently that of the rust of iron.
  473.  But the chief sources of the diagnosis are the stethoscope
and percussion : 1. The crepitant rattle is the invariable pathog-
nomonic sign of the  period  of congestion ;  its diffusion marks
that of  the disease;  the respiration is still heard ; the chest still
sounds well;  2. In the stage of  hepatization, there is neither
rattle, nor respiratory murmur ;  there may be broncophony when
the root, or the upper, or any  exterior  portion of the lung is affect-
ed ;  and with this sign there  are  always  bronchial  respiration
and cough ; the sound on percussion  is dull;  3.  A mucous rattle
marks the  flow of pus into the bronchia, in the case of suppu-
ration^3)
  474. III. The  Complications.   The  brain  and  its  mem-
branes are frequently congested in pneumonia ; and there may
be delirium or coma ;  the latter symptom frequently leads to a
fatal termination in persons of advanced age.
   475. IV.  The Morbid Anatomy consists of

  (1.)  The observations of M. Grisolle, late  Chef de Clinique at Hotel Dieu,
Paris, go to prove that these agents operate much more rarely to produce Pneu-
monia, than is commonly supposed.                              S.
  (2.) See note,  par. 339, part 1.                                 &
  (3.) I believe it is now generally admitted, that the existence of the purulent
infiltration ennnot be ascertained  during life, at  least, in a great majority of
cases. The best proof of its existence is when the expectoration resembles the
juice of preserved prunes—a comparison taken from the French.          S. 
 286   DIAGNOSIS  OF  THE  DISEASES  OF

                1. Congestion,
                2. Hepatization.
                3. Purulent Infiltration.
                4. Abscess.
   476.  The disease may be circumscribed or diffused :  it is  fre-
 quently confined to a lobe, to the root of the lung,(J)  &c.
   477.  During  the  resolution of  pneumonia the  symptoms
 cease in an  inverted order:  the sound yielded on  percussion,
 and, first, the crepitant rattle, and then the vesicular respiration,
 return.
   478. If abscess form, which is rare, and this abscess open into
 the  bronchia, there  are pectoriloquism,  cavernous  respiration,
 cough, and rattle, and perhaps the ' souffle voile.'
   479. Sometimes pneumonia does  not terminate by resolution,
 but  gradually yields to a state  of adema.{2)   The symptoms
 are then dyspnoea, obscure respiration, and a subcrepitant rattle.

                      IV. HAEMORRHAGY.
               I.  BRONCHIAL  HAMORRHAGY.
   480. I.  The  History.   The causes of bronchial  haemor-
rhagy are muscular efforts,* especially of the voice,t and of the
respiration; other causes assigned  are the suppression of an ha-
bitual haemorrhagy, of the catamenia,(3) &c.
   481. II. The  Symptoms.  Bronchial haemorrhagy is  de-
noted by the rejection of a  moderate quantity of spumous and
  (1.) In children under 6 years of age, the inflammation attacks distinct lobules
of the lung ;—in adults  it extends over a continuous surface.  In adults
the inflammation  most commonly attacks the  posterior and  inferior  por-
tion of the lung.  In old persons it very frequently attacks the superior portion.
These facts are well established, and are of great value.                S.
  (2.) This is not, I believe, a true oedema—the air-cells, not the cellular tissue,
become infiltrated with serum.                                    S.
  * The convulsions of epilepsy often fill the mouth with bloody froth, one source
of which seems to be the bronchia.
  f It is said that Talma usually experienced a bronchial haemorrhagy after per-
forming "Les Fureurs d'Orestc."
  (3.) By far the most common cause of bronchial haemorrhage, is the existence
of tubercles in the lungs.                                        S. 
       THE  ORGANS  OF  RESPIRATION.    287

sometimes coagulated  blood.   The chest sounds well;  there is
a mucous rattle.
   482.111.  The Morbid Anatomy.   The bronchia are found
to contain more or less of blood, and  to be tinged by its imbi-
bition.

       II. PULMONARY HAEMORRHAGY OR APOPLEXY.
   483.  I.  The History.   The causes of pulmonary haemor-
rhagy are  the  same, generally, as those of bronchial  haemor-
rhagy.   The former is more frequently associated with disease
of the heart; the latter with tubercles in the lungs.   Exposure
to  excessive heat or  cold is a frequent cause of the  immediate
attack.   But  this disease frequently occurs in the most sudden
and unexpected manner^1)
  484. II. The Symptoms are oppression at the chest, cough
with much irritation of the larynx, and the rejection of a con-
siderable, perhaps an enormous, quantity of florid, spumous, or
coagulated blood, with a  frequent vibrating  pulse, and  the
' bruit de soufflet' of the heart and arteries.  The countenance
is  either  flushed, or  pale;  the  skin is natural, the feet may be-
come cold.
   485.  The stethoscope affords two important signs of pulmo-
nary haemorrhagy: the first  is the absence of respiration in
some part of the chest; the second, a crepitant rattle surround-
ing this part.
   486. III. The Morbid Anatomy of pulmonary haemorrhagy
consists in induration of the lung.  This induration is as great
as that  of the hepatization of pneumonia; but it is  usually
more partial  and  more distinctly and  abruptly circumscribed;
and it is uniformly of the deep  hue of venous blood.

                       V.  PLEURITIS.
   487.  I.  The History.   Pleuritis, in its  acute form,  usually
  (1.)  Pulmonary apoplexy is, I believe, a very rare form of disease.  During
an attendance of nearly a year and a half in the hospitals of Paris, and in search,
constantly, for cases of disease of the chest, I did not meet with a single case, or
hear of more than one case.                                    s- 
288   DIAGNOSIS  OF  THE  DISEASES  OF

occurs rather abruptly, from  exposure to wet and  cold.   The
very first symptoms are pain and a checked respiration.
   488. II.  The Symptoms.  The pain of  pleuritis is usually
distinctly fixed to a spot denoting the seat  of the inflamma-
tion (')   It is produced or augmented by a free inspiration; and
it induces modifications in the movements of respiration which
are highly peculiar and  characteristic;  the thorax, the affected
side, or the part, of the thorax, is unmoved, the respiration being
either diaphragmatic or only partially thoracic.*(2)
   489. As the usual speedy effect of pleuritis is effusion, there
is a dulness  or  the entire absence of sound on percussion, and
there is the diminution of respiration  under  the ear  or  stetho-
scope : the degree of effusion is measured by the degree and the
diffusion of these too  physical signs, which are usually greater
than in  pneumonia: there is another stethoscopic sign of effu-
sion, in  aegophony, which is  heard when  the quantity of the
effusion  is moderate, varying  in  its situation with  that of the
upper  thinner layer of  the  fluid, and  consequently with the
position of the patient.(3)
   490. In the  few cases in  which there is  no effusion, these
stethoscopic signs are absent.
   491. III.  The  Varieties.    Pleuritis may  exist
       1.  In one,  or
       2.  In both Pleural Sacs, or
       3.  In one Part only,  as
             1.  Between the Lung and Diaphragm,
             2,  Between the Pulmonary Lobes, dec
       4.  With Pneumonia.

  (1.) The seat of the  pain, trie stitch, in Pleuritis, does not denote at all the
extent of the inflammation—it occurs at the point where the dilatation of the
parietes of the  chest is the greatest, i. c. just below and to the  outside of the
nipple.                                                     S.
  * I have frequently been able to detect the side,  or  the part,  affected, by
watching the movements of the che3t in respiration,  and  especially in a deep
inspiration.
  (2.) The respiration is low.  See note, par. 339, part I.              S.
  (3.) Dilatation of the affected side occurs in both acute and chrcnic Pleuritis
when the serous effusion is great.                                 S. 
         THE  ORGANS  OF  RESPIRATION.     289

   492. When one  side of the chest is  affected, the pain and
other symptoms are confined to that side;  when both sides are
affected, percussion  and the ear discover the want of sound, and
of respiration, equally on both sides.
   493. In partial pleuritis, the seat of the pain and the absence
of  equal  movement in  respiration, combined with dulness of
sound on  percussion  and want of respiration under the ear or
the stethoscope, denote the particular seat of the disease.  Dia-
phragmatic  pleuritis is  denoted  by a thoracic respiration and
augmented pain on  calling the diaphragm into  play.(»)  Par-
tial pleuritis is denoted by absence of sound and respiration, pre-
ceded  by acute pleuritic pain.  Pleuro-pneumonia unites  the
symptoms of pleuritic and pneumonic inflammation.
   494. IV.  In early, yet fully formed, pleuritis,  there is  ex-
treme tolerance of loss of blood.
   495. V.  The Morbid Anatomy consists of the effusion
       1. Of Organizable Lymph.
       2. Of Serous, Puriform, or Sanguineous Fluid.
   496. From pleuritis it is highly important to distinguish the
different forms of pleurodyne: these are
                 1.  Dyspeptic ;
                 2.  Chlorotic;
                 3.  Hysteric;
                4.  Rheumatic, &c.
  497.  The diagnosis is founded upon  the history, and gene-
ral  symptoms of these affections respectively;  and upon the
absence of those of pleuritis, and of its stethoscopic signs.(2)  My
young reader may refer to §§  228 ; 238; 245; 295 ; &c.
  (1.) Diaphragmatic Pleurisy may be suspected when the pain exists along
the edges of the false ribs, and the patient is compelled to sit up with the body
bent forcibly forwards.                                         S,
  (2.) The rheumatic pleurodyne, the most common form, may be distinguished
from  Pleurisy, by the absence of febrile, symptoms, the diffusion and variable
character of the pain much aggravated by turning in bed.              S.
                             37 
290    DIAGNOSIS  OF  THE  DISEASES  OF
                 VI. GANGRENE (DIFFUSED.)
   498. I.  The  History.   Gangrene of the lungs is either dif-
fused, or circumscribed.   In the  former case it is  a disease of
acute form  and rapid  progress.  It is of rare occurrence, and
generally allied to other gangrenous diseases rather than to in-
flammation.
   499. II.   The Symptoms are extreme general debility and
sinking, with great oppression and a frequent feeble pulse ; there
is a crepitant rattle, with a peculiar and  even pathognomonic
expectoration of a gangrenous fcetor and dingy green color;
the rattle rapidly augments, and the  patient dies from accumu-
lation in the bronchia and sinking of the powers.
   500. III.  The Morbid Anatomy.   The  substance of the
lung is congested, easily torn, of the various, greenish, brownish,
or blackish,  hues, and excessive foetor, of other parts in a  state
of gangrene.
                 II.  THE CHRONIC  DISEASES.
              I.  LARYNGITIS OR TRACHEITIS.
   501. I.   The History.  Chronic Laryngitis is  sometimes
insidious, sometimes the sequel of laryngitis in the acute form.(l)
   502. II.  The Symptoms in Chronic Laryngitis are difficult
and hoarse  or sonorous respiration, a croupy cough, and dyspha-
gia ; there is a sense of stricture or of soreness distinctly  referred
to the larynx ; and there is, at  length, the remarkable symptom
of inability of snuffing up the nostrils or of drawing the alee nasi
together by  quick inspiration.*
  (1.) It will assist the student to know the fact, that true Chronic Laryngitis is
almost always, if indeed there beany exception, a symptom of two constitutional
diseases, viz. Syphilis and Tuberculous Phthisis.  There is also a subacute form
of Laryngitis, well described by Mr. Porter in his work, Surgical Pathology of
the Larynx and Trachea, occurring  chiefly in public speakers, who are com-
pelled to a protracted use of  the voice during  the slight laryngeal inflammation
of ordinary bronchitis.                                         S.
  * The rationale of this symptom is given in a paper by the author, published
in the Med. Chir. Trans, part x, p. 166. 
        THE  ORGANS  OF  RESPIRATION.    291

   503.  Tracheitis is distinguished by the absence of dyspha-
gia, and by the seat of stricture and uneasiness.
   504.  III.  The Diagnosis.  It is important to bear in mind
that Chronic Laryngitis or  Tracheitis may be supposed to exist
when, in fact, the case  is Hysteria,  or  the trachea is com-
pressed by
               I. A Tumor,
              2. An Abscess, or
              3. An Aneurysm!
   505.  The young physician being aware of the danger of this
mistake, will seek  the  diagnosis in  the  symptoms peculiar to
these diseases.
   506.  IV. The Morbid  Anatomy  consists in thickening of
the mucous membrane lining the larynx  or trachea, sometimes
with effusion from its surface, or oedema  of the subjacent cellu-
lar substance.  There is frequently increased  bronchial secre-
tion, or  pulmonary oedema.

                     II. BRONCHITIS.
   507.  I.   The  History.   Chronic Bronchitis is  usually  the
consequence or issue of an acute attack of this disease.   It may
long exist, with, or without fever.  It is a frequent disease of
old age; sometimes its simple effect.
   508.  II.  The  Symptoms are those  of ordinary bronchitis
protracted: there is the absence of the pectoriloquism and cavern-
ous  respiration of phthisis ; the sound of the chest and of the
respiration is unimpaired.  There is a degree of pallor, and fre-
quently weakness and emaciation; dyspnoea is easily induced by
exertion, or there may be confirmed dyspnoea.
   509.  The expectoration is very various, in different cases and
at different periods of the  same : generally copious,  it is some-
times so much and so suddenly so as to lead to the erroneous
idea of a ruptured abscess ;  it is frequently opaque, and greenish
from the admixture of black pulmonary  matter ; occasionally it
is foetid, and more of a gangrenous odor; it is sometimes mixed
 with blood. 
292    DIAGNOSIS  OF  THE   DISEASES  OF

  510.  III. The  Varieties.  Besides the common  or mucous
form of Chronic Bronchitis, there are several others to which it
is necessary to advert briefly in this place :  these are
              1. The Pituitous.
              2. The Dry.
              3. That with  Dilated Bronchia.
              4. That with  Dilated Air-cells, or Emphy-
                   sema.
              5. The  Symptomatic.^)
  511.  The first of these  is distinguished by the peculiar ex-
pectoration ; the second by the want of it, with  peculiar sonor-
ous rattles; the third by bronchial  respiration and broncophony ;
the symptoms of emphysema  will be detailed hereafter.
  512.  The sympathetic forms are traceable to other diseases,
of the lungs, of the liver, of the heart, &c.
  513.  Besides  these forms of bronchitis, there are  others still,
which I need but  enumerate  in  this place: they are those at-
tended with

              1. Polypi.
              2. Ulcers.
              3. Diseased Cartilages.
              4. Diseased Bronchial Glands.
  514.  IV.  The Mordid Anatomy is similar  to that  of acute
bronchitis: the bronchia and the air-cells are sometimes dilated.

                      III.  PNEUMONIA.
   515.   The History.  Chronic Pneumonia is rare, and gene-
rally a sequela of the acute formof  the disease, or of pulmonary
haemorrhagy.
   516.   The Symptoms.  It  is marked by the same symptoms
and signs as the acute pneumonia.(2)
  (1.) There is a form of Chronic Bronchitis, the origin oCwhich can be traced to
a previous attack of Pleuritis—this consequence of Pleuritis is, 1 believe, far from
being rare.   I know of no author who has mentioned it, except M. Chomel, Die.
des Sciences Medicaids, and there only in a very cursory manner.       S.
  (2.) Chronic Pneumonia is an exceedingly rare form of disease; M. Chomel, in 
        THE  ORGANS  OF  RESPIRATION.    293

                      IV.  PLEURITIS.
  517.  I.  The History.   Chronic Pleuritis, far more common
than chronic pneumonia, occurs  in feeble or cachectic subjects,
and may possess its chronic  form from the beginning;  or it may
be the sequela of acute pleuritis.
  518.  II.  The Symptoms.  In  Chronic  Pleuritis the symp-
toms are generally  such as denote a profuse effusion:  there is
the want of sound on  percussion and of respiration  under the
ear or stethoscope ; pleuritic pain and aegophony are rare ; but, on
the other hand, an enlargement of the side  of the thorax is not
uncommon.  There are fever,  emaciation, and  cough, with
mucous, or even puriform expectoration.
  519.  III. In the  course of this affection, when it proves fatal,
the following Complications occur :

  1.  Congestion or Effusion within the Head.
  2. Anasarca; especially of the Arm, and  Leg, of the
        side affected.
  520.  IV. Varieties.  In the case which has been described
there is, when the effusion  is very great, dilatation of the tho-
rax ; in other instances, the effusion is slowly absorbed, but the
lung, bound down by strong layers of lymph, does not expand,
the thorax is,  therefore contracted : both these  states are de-
termined by the eye, and by admeasurements.   In a third case,
the heart is pushed or drawn from its natural position.
  521.  V.  The Morbid  Anatomy is similar to  that of acute
pleuritis: the effusion is generally  more  abundant; frequently
flocculent, or puriform ; and sometimes of a slightly disagreeable
odor.   In contraction of the chest,  the lung is bound down by
lymph, and carnified.
             V. GANGRENE  (CIRCUMSCRIBED.)
  522.  I.  The History.   Diffused gangrene is rapid, the cir.
cumscribed very slow in its course.
the vast experience of sixteen years, met with but two cases of it.  I have never
met with more than a single case, which was shown to me by M. Cruveilhier,
at Salpetriere.                                            S. 
294    DIAGNOSIS OF  THE  DISEASES  OF

   523.  II. The Symptoms.  The peculiar greenish or brown-
ish expectoration of gangrenous odor,  is  the  pathognomonic
symptom.  With it  there are, pectoriloquism,  and  cavernous
respiration, rattle, and cough.
   524.  III. The Morbid Anatomy is similar to that of dif-
fused gangrene: it is circumscribed, sometimes affecting a tuber-
culous cavity;  sometimes involving and destroying the pleura,
and opening a communication with its cavity.

                     VI. EMPHYSEMA.
                I.  Vesicular Emphysema.
  525. I. The History. This  disease is  most frequently the
issue of repeated attacks of that form of  bronchitis, termed the
dry ; it also frequently constitutes the disease termed asthma ;
and in its turn, it frequently causes hypertrophy or dilatation of
the heart.
   526.  II.  The Symptoms. Emphysema is the  most fre-
quent of the varied forms of disease to which the designation of
asthma has been given : its principal symptom is, as that name
imports, great  dyspnoea; this dyspnoea recurs in paroxysms
and becomes more and more habitual or permanent;  there is a
dull sounding cough, at first dry, afterwards with expectoration;
the chest is large and elevated ; the complexion  becomes dingy,
the lips, livid.
  527.  These  symptoms may well lead to the suspicion of em-
physema ; the  pathognomonic signs are afforded by percussion
and auscultation: the chest sounds remarkably well; the respira-
tion is scarcely audible; there is sometimes a crepitant  rattle,
not constant, but during short spaces of time, which differs from
that of pneumonia by  communicating the idea of dryness.
  528. Vesicular Emphysema may be extended to both lungs,
or confined to one.
  529. III.  The Morbid Anatomy consists in dilatation of the
air-cells : this is sometimes visible, sometimes invisible, external-
ly ; sometimes the dilated cells are prominent,  and sometimes
even globular, with a narrow attachment only.   Sometimes the 
THE  ORGANS  OF RESPIRATION.     295
textures break  and there is emphysema  of the cellular  mem-
brane, or interlobular emphysema.(»)

                2.  Interlobular Emphysema.
   530.  This form of the disease arises from violent efforts, con-
sists in the ruptured cells of the lobules,  and true i^er-lobular
emphysema, and  is denoted by  the crepitant rattle  " a grosses
bulles," and by the noise of ascending and descending friction
against  the adjacent pleura;  there is  sometimes external  em-
physema.
                       VII.   ASTHMA.
   531. Besides those forms  of dyspnoea consequent upon the dry
bronchitis, and  attendant upon  emphysema (§ 525), there  is a
morbid affection which more distinctly claims  the designation
of Asthma.
   532. I.  The History.   This affection occurs  generally in
the recluse and sedentary :  college and studious habits induce it,
so do the modes of life of tailors, shoemakers, &c.   It is usually
conjoined with symptoms of the acute dyspepsia.
  (1.) The disease now known as Emphysema, and which Laennec maybe said
to have created, although there is a slight mention of it in the Morbid Anatomy
of Dr. Baillie, is next to Tuberculous Phthisis, the most common of all  the chro-
nicdisease of the lungs.   The author has copied the error of Laennec in attribu-
ting the disease to an  antecedent bronchitis.  My attention was first called to
this point by M. Louis, in his wards  at the Hospital of La Pitie\  Paris, where
I satisfied myself, by abundant observation, that the dyspnoea, the characteristic
sign  of Emphysema,  had preceded the cough in a great majority of cases.  In
fact, nothing can be more clear than that the disease is frequently hereditary as
well as congenital, and that it may exist for a long  period  of time, for years,
without symptoms of bronchitis, which will, however, infallibly supervene sooner
or later, and become the principal exciting cause of the paroxysms of dyspnoea.
It is important also to notice that in this disease, when partial, (which commonly
happens,  except, perhaps, when it is congenital,)  the anterior  and  superior
portion of the lung is principally affected, and  it is over this seat that we must
look for those partial dilatations of the parietes which, when accompanied by in-
creased resonance on  percussion, and by a. feeble or dry respiratory murmur, dis-
tinguish this disease from every other.  The above remarks refer entirely to the
true, or vesicular Emphysema.                                     S. 
296     DIAGNOSIS  OF THE  DISEASES  OF

   533. II.  The  Symptoms.   There are attacks of extreme
and urgent dyspnoea,  recurrent at, or soon after, midnight:
strong, brief efforts to inspire are followed by longer, labored, and
wheezing expirations; there is  a dry, sounding  cough, at first
without expectoration;  there is  no  fever,  pain, or  frequency of
the pulse ; but terrible anxiety and distress ;  the breath is taint-
ed, and there  is generally much flatus.*

                       VIII.  (EDEMA.
   534. I.  The History.   (Edema is rarely an idiopathic dis-
ease.   It  is,  on  the  contrary, generally a complication  or
sequela of
            1. Protracted Fevers.
            2. Diseases of the Heart.
            3. Pneumonia.
            4. Bronchitis, especially the Pituitous.
            5.  Other Dropsies,  fyc.
   535. II.  The  Symptoms are  dyspnoea,  slight cough, and
aqueous expectoration.  The stethoscope affords  two  signs of
this disease:  a diminished respiration, and  a sub-crepitant rat-
tle.(')
   536. III.   The Morbid Anatomy.   The  lung is dense, and
at once crepitant and retaining the impression made by the pres-
sure of the finger ;  on making an incision,  there is a copious
flow of limpid fluid.

  * To this brief description, I beg to add that  several  patients have recovered
by  attending to  the general health, and have been for years free from attacks
of Asthma.
  There are probably other forms of Asthma still: one gentleman  experienced
attacks of dyspnoea on inhaling the atmosphere in which a vial of ipecacuanha
had been merely opened.   Another has his  attack, if he attempts to sleep in a
room higher than the ground-floor.
  From Asthma it is  necessary to distinguish Hysteric Dyspnoea. Dr. Heberden
observes, in regard to this affection, " in iis etiam quibus pulmones sunt integer-
rimi, spiritus  fit non minus difhcilis quain in justo asthmate."—Com. p. 196.
The dyspnoea is most urgent and attended with great heaviness of the chest. By
waiting and watching, we soon detect unequivocal symptoms of Hysteria.
   (1.) See note, par. 466, part i.                                 g. 
          THE  ORGANS  OF  RESPIRATION.     297

                     IX.   HYDROTHORAX.
                 I.  Idiopathic Hydrothorax.
    537.  This affection is  extremely rare.   It  usually exists on
 one side alone, and then this side is larger than the other.  The
 symptoms are precisely those detailed in § 489, as denoting effu-
 sion in pleuritis.

               2. Symptomatic  Hydrothorax.
   538.  This affection is as common as the idiopathic is rare. It
 may be  the  effect of all  diseases, towards their close,  acute or
 chronic  ; but it is chiefly so, of
               1. Diseases of the Heart.
               2. Diseases of the Lungs.
               3. Diseases of the Liver, fyc.
   It frequently exists on both sides of the thorax.   Its symptoms
 are similar to those described § 489.

                    X. PNEUMOTHORAX.
   539.  Pneumothorax may exist under the following forms:
       1. The Simple.
       2. Complicated with Pleuritic Effusion.
       3.  Complicated with  a Fistulous  Communication
            with the Bronchia.
       4.  The Double.
   540. I.  The History.   This disease, when simple, most fre-
 quently occurs with  pleuritis, in cases of phthisis. It may be
 simple, or complicated with effusion, or  with a communication
 with the  bronchia by means of a softened tubercle.  It may be
 the result of the effusion and decomposition of blood, or the con-
 sequence of circumscribed gangrene.
   541. II.  The Symptoms.  There is dyspnoea, and the side
 affected is generally enlarged.  But the true diagnostics are de-
 rived from a comparison of the effects of percussion and of aus-
 cultation : one  side of the thorax sounds better than the other,
 whilst the respiration is inaudible, except at the root of the lung,
being audible at the side least sonorous.   When effusion is added
                            38 
 298   DIAGNOSIS  OF  THE  DISEASES OF

 to the pneumothorax, there is dulness of sound on percussion of
 the lower part of the chest, and a fluctuation is heard when the
 patient changes his posture rapidly.  If there be a fistulous com-
 munication with the bronchia, there is metallic tinkling, or am-
 phoric resonance.

                III.  THE  INSIDIOUS DISEASES.
          I.  ULCERATION OF THE LARYNX,  ETC.
   542. I.  The History.  This affection is of the most insidious
 character,  and generally occurs without  any obvious external
 cause.
   543. II.  The Symptoms of Ulceration of the Larynx,  are
 hoarseness, and hoarse cough, with the expectoration of mixed,
 limpid, and puriform mucus,  frequently dotted or streaked with
 blood.   The hoarseness,  cough,  and  expectoration  augment.
 Difficulty or imperfection in swallowing  is added to the  other
 symptoms: the  patient frequently becomes choked in the  act of
 deglutition, or the food is propelled through the nostrils.
  544. Hectic and emaciation eventually take place, frequently
 with all the symptoms of phthisis.
  545. III. The Morbid Anatomy  combines ulcerative  de-
 struction of some parts of the larynx, with tubercles of the  lungs
and frequently of the organs.(')

              II.  TUBERCLES,  OR PHTHISIS.
  546. I. The History.  Phthisis is  usually  very insidious,
 slow, and gradual, in its progress and termination.   In other in-
stances its commencement and progress are more rapid, and its
termination may be sudden and unexpected  in any period  of its
course.   The  exciting causes are sometimes undetected ; in
other instances, exposure to cold, the debility left by some  acute
disease, by mercury, &c. are its obvious causes.   Phthisis is dis-
tinctly an hereditary or family disease; it is also an effect of
scanty or impure nourishment.  (See further § 315.)
  547.11. The Symptoms.   The general symptoms of tuber-
(1.) See note, par. 501, part ii.  S. 
        THE  ORGANS  OF  RESPIRATION.     299

culous diseases have been already fully detailed, §§ 316—318,
and the local symptoms of phthisis, § 317.   The local signs vary
with the stage and state of the pulmonary disease.  This may
subsist in the following forms:
                     1.  Tubercles.
                         1. Crude.
                         2. Softened,
                     2.  Excavation.
  548.  1. In accumulations of the crude tubercles, there is oc-
casionally a perceptible diminution of sound on percussion,  and
diffuse broncophony, especially immediately under  the clavicle
and in the axilla, and especially on the right side.
  549.  2.  As the tubercles soften, a  gurgling  is heard, a  mu-
cous rattle is  gradually established, and the  cough becomes
cavernous.
  550.  3.  As a cavity forms, and becomes emptied, the respira-
tion and rattle become cavernous, and  the broncophony passes
into pectoriloquism, at first imperfect, and then more evident;
and the sound of the chest may sometimes, though but rarely,
become clearer.  Pectoriloquism is a most distinct diagnostic: it
may be perfect, imperfect, or doubtful, intermitting or  perma-
nent.   When the cavity is superficial,  there is sometimes the
sound of cracked  porcelain.
  551.  When the cavity is extremely large,  there is no pecto-
riloquism, but the voice, cough, and  respiration are attended by
the amphoric  resonance, and  sometimes there is  the metallic
tinkling.   The case differs from pneumothorax by the absence
of fluctuation on rapid changes of posture.
  552.  III. The Complications of Phthisis present a most in-
teresting subject  for enumeration: they  may  be divided  into
several classes.  The first is  nearly peculiar  to phthisis,  and
embraces
   1.  Ulcerations of the Epiglottis,  the Larynx, and the
           Trachea;
   2.  Ulcerations of the Clustered and Solitary Glands of
          the Ileum and Colon;
   3.  The Fatty Enlargement of the Liver. 
300    DIAGNOSIS  OF THE  DISEASES  OF

   553.  The second class consists of lesions which are only ex-
tremely frequent, and not peculiar to phthisis;  they are
                     1.  Pleuritis.
                     2. Pneumonia.
   554.  There is a third  class of complications of phthisis, less
frequent;  this consists of
1. Inflammation  of the Arachnoid, or of the Substance of
       the Brain, with Effusion, or Softening.
2. Inflammation  and Softening of the Mucous Membrane
        of the Stomach, or Colon.
   555.  The fourth class consists of
1. Tuberculous Inflammation of the Pleura, Peritonaum,
        fyc.
2. Tuberculous Inflammation of the Lymphatic  Glands,
        especially  the Mesenteric, those of the neck, fyc.
   556.  The fifth  class consists of
     Serous Effusion into 1. The Ventricles.
                          2. The Pleura.
                          3. The Pericardium.
                          4. The Peritonaum.
   557.  To complete the view of this subject, it is necessary to
add  that  the  heart is sometimes softened, and  that the aorta
is found  red in the young and more deeply altered in  older
subjects.
   558.  This  list of the  complications will enable  the  young
physician to anticipate, and to obviate lesions which may, even
amidst  a  disease almost always fatal in itself, fearfully tend to
shorten the patient's few remaining days.
   559.  IV. The Morbid Anatomy of phthisis consists in the
different forms and conditions of tubercles; of the cavities left by
their softening and expectoration ;  and of the adjacent portions
 of the tongue and  pleura (1)

   (1.) The diagnosis of incipient Phthisis is a point of great importance, but
 often of great difficulty. The most important of the rational sign?, a short dry
 cough, progressive emaciation, and loss of strength, I have  mentioned already 
        THE  ORGANS  OF  RESPIRATION.     301

                       III.  MELANOSIS.
   560. The general  Symptoms of Melanosis have been no-
ticed § 320.   Instead of the hectic and emaciation of pulmo-
nary tubercles, there is a disposition to cachexia and anasarca.
   561. The stethoscopic signs are the  same as those of un-
softened tubercles:  § 548; cavities are rarely formed  in Me-
lanosis.
                    IV. ENCEPHALOSIS.
   562. The general Symptoms of this disease have been de-
tailed, § 321.
   563. The local Symptoms are  dyspnoea and cough, some-
times with  expectoration.   This  disease generally occasions
death  by  pressure  and  suffocation, before  any extraordinary
emaciation is  induced.   At  length there are  emaciation and
dropsy.
   564. The case may be mistaken for tracheitis, or bronchitis,
when  the  tumor presses upon the  windpipe, or bronchia, or for
aneurysm, when it is seated  so as to receive an impulse from
an adjacent artery.
   565. When the tumor has attained a certain size, there is the
absence of respiration under the stethoscope, and  of sound on
percussion.
                        V. SCIRRHUS.
   566.  It is only necessary to refer to the  general symptoms of
Scirrhus, given § 323.

              VI. CYSTS, CEPHALOCYSTS,  ETC.
   507.  The Symptoms of Cy3ts, or  Hydatids, are dyspncea

(note, par. 317, part 2). It will be proper to remark in this place that ihe physu
cal signs of tubercles are frequently absent in incipient Phthisis.  The earliest
indications of change are a prolonged expiration, or a  feeble respiratory murmur,
accompanied by slight flatness on percussion, points that can only be satisfacto-
rily settled by the practised  ear, and by a  careful comparison of the opposite
sides of the chest.  The existence of a slight mucous rattle under the clavicle
or above the spine of the scapula, the respiration remaining pure elsewhere, often
marks the first  disposition to the softening of tubercles, and is a very important
diagnostic sign of their existence.                                S. 
302  DIAGNOSIS  OF  THE  DISEASES,  ETC.

and cough; when these bodies are near the surface of the lung,
there is the absence of  sound on percussion, and  of  respiration
under the stethoscope.
               IV.  SYMPTOMATIC AFFECTIONS.
   568.  Before I dismiss the subject of the Diagnosis of Diseases
of the Chest,  I must once more  advert to several  symptomatic
affections which require to be distinguished from them : they are
                1. Hysteric Croup.
                2. Hysteric Pleurodyne.
                3. Chlorotic Pleurodyne.
                4. Dyspeptic Asthma.
   569.  Hysteric  Croup is so similar, in some instances, to
Acute Laryngitis,  and suffocation has been apparently so im-
minent, that  the surgeon has been on the point  of performing
the operation of tracheotomy !   This event is particularly no-
ticed  by Sir  Charles Bell, in  his ' Reports,' which it  is much to
be regretted  that  he has left unfinished.   By  waiting  and
watching, the  case is unveiled  by the occurrence of some une-
quivocal symptoms of hysteria.
   570.  Hysteric Pleurodyne is amongst the most acute pains
of the chest.  The surface of the skin even  is sensitive to the
touch.   It is distinguished by the character of hurry and other
symptoms of Hysteria.  It is only necessary to  put the young
physician on his guard in regard to it.
   571. Chlorotic Pleurodyne is sometimes  so  like Chronic
Pleuritis that I have known patients to be bled  and blistered
for the  twentieth  time, under  this erroneous impression.   In
this case the  history, the general symptoms, and the stethoscope,
with percussion, will enable the attentive practitioner to insti-
tute the due  diagnosis.
   572.  True Asthma arises,  I believe,  generally,  from  dys-
pepsia.  It is distinguished by  the history, and  general symp-
toms, by its peculiar sudden attack,  and by being  unpreceded
 by dry bronchitis,  or  other diseases within the  thorax.  See
 §533. 
CHAPTER   III.
THE  DIAGNOSIS  OF THE  DISEASES OF THE  HEART ANB<
                     LARGE ARTERIES.

   573.  In treating of the Diagnosis of the  Diseases of the Heart
and large Arteries, it will be my object, as usual, to select all the
really important and practical distinctions, whilst I avoid  the
useless minutiae with which this subject has been incumbered.
   574.  The most frequent diseases of the heart, are, dilatation
and hypertrophy  of the ventricles,  single or variously com-
bined.
   575.  The diseases of the heart, next in frequency, are ossifi-
cation, or excrescences, of the valves of the aorta, or of the mi-
tral valve: these  generally induce eventually  hypertrophy or
dilatation of the  ventricles.
   576.  Next follow hypertrophy, or  dilatation of the auricles,
of still more rare occurrence, and usually consecutive to disease
of the valves or ventricles.
   577.  This abstract will enable the young student to form dis-
tinct ideas of the diseases of the heart of most usual occurrence;
pericarditis and  hydropericarditis,  and aneurysm  of  the
aorta and large arteries, must be added, and the list of diseases
of the heart and large vessels is nearly complete.
   578.  These diseases may be thus presented in a  tabular
form:

  ARRANGEMENT OF DISEASES OF THE HEART  AND  LARGE
                         ARTERIES.
    I. Disease of the Heart in General. 
304   DIAGNOSIS  OF  THE  DISEASES  OF
   II. Hypertrophy.
      1. Of the Left Ventricle.
      2. Of the Right Ventricle.
  III. Dilatation.
      1. Of the Left Ventricle.
      2. Of the Right Ventricle.
  IV. Hypertrophy with Dilatation.
      1. Of the Ventricles.
      2. Hypertrophy of One Ventricle with Dilatation of
          the Other.
      3. Of the Auricles.
   V. Disease of the Valves.
      1. Of the Aortic  Valves.
      2. Of the Mitral Valve.
   VI. Pericarditis.
  VII. Hydropericarditis.
 VIII. Aneurysm.
      1. Of the Aorta.
      2. Of other Arteries within the Thorax.
      3. Of the Arteries in the  Abdomen.
  IX. Sympathetic Affections.
      1. Deficient Action of the Heart.
      2. Palpitation.  Bruit de Soufflet.
      3. Angina Pectoris.
      4. Pulsation in the Epigastrium.

        i. disease  of  the heart  in general.
  579. I. The History.  The  most frequent cause of disease
of the heart, is some antecedent disease, attended by dyspnoea,
and consequently most frequently of the lungs.  The principal
of these are
1. Dry Bronchitis.
2. Emphysema. 
     "THE  HEART  AND  LARGE   ARTERIES.   305

               3.  Phthisis.^)
               4.  Chronic Pneumonia.
               5.  Empyema.
   580. To these causes are to be added muscular efforts, men-
 tal emotions, and nervous diseases.   And to these, it is said, the
 congenital disproportion between the size of the heart  and the
 calibre of the  aorta, and the congenital unusual thickness or
 thinness of the ventricles.
   581. There is  still  another  addition to be made to  the list
of causes of disease of the heart of an important kind: it is that of

              The Metastasis of Rheumatism.
   The reader may turn to § 294.
   582. II.  The  Symptom of Disease of the Heart, in its early
stage, is dyspnma, uniformly induced, or aggravated, by muscu-
lar effort or exertion: in its larger stages, various effects of de-
rangement of the capillary circulation are superadded.
   583. 1. Disease of the heart, even in its early stages, is highly
characterized by the invariable aggravation of the dyspnoea; on
making the patient  walk quickly, or  run up stairs: the beat of
the heart becomes violent or tumultuous, and there is  a sense of
great oppression or of suffocation.   The  sleep is disturbed by
frightful dreams.
   584. In the later stages and more aggravated forms  of Dis-
ease of the  Heart, the dyspnoea and oppression are permanent,
perhaps extreme :  not only muscular effort, but  the horizontal
posture becomes insupportable.
   585.  The countenance, at first of a dingy pallor, becomes tu-
mid, and livid, or of a purple hue, especially the lips ; the posture
is raised by successive additions of pillows, until it becomes per-
fectly upright,  and eventually the patient  may require to have
the feet placed low, whilst his head and shoulders are raised, and
  (1.) It is a common error to suppose that Phthisis is apt to lead to enlarge-
ment of the Heart; whereas the direct opposite of this is the truth.  See the Obs.
of M. Bizot, Mem. Med. Soc. d'Observation, Paris, t. i.                S.
                             39 
 306    DIAGNOSIS  OF THE  DISEASES  OF

 the shoulders or elbows are supported.  The dyspnoea and op-
 pression augment, the various Complications to be immediately
 enumerated, with  their  appropriate symptoms, are gradually
 superadded.
   586. The symptoms and signs of each particular disease of
 the heart will be detailed under their respective heads.
   587. III. The Complications  of disease of the heart, form,
 with that disease, and its most frequent causes, a series or chain
 of organic lesions of the most interesting character.   The causes
 have been already  enumerated, § 579 ; the effects are  the fol-
 lowing :
 1.  Cerebral Apoplexy.
 2. Bronchial, and
 3. Pulmonary Hamorrhagy.
 4. Congestion of the Liver, <$fc.
 5. Congestion of the Membrane lining the  Ventricles and
    the Aorta.
 6. Congestion of the
              1. Sub-serous,
              2. Sub-mucous, and
              3. Subcutaneous,  Tissues.
 7. Effusion into the
              1. Ventricles,
             2. Pleura,
              3. Pericardium,
              4. Peritonaum,
             5. Cellular Membrane :
                  1. Of the Lungs; (Edema.
                 2. Of the Intestines.
                 3. Of the Integuments ; Anasarca.
  588. IV.  The Effects of Remedies.  There is a degree of
relief from blood-letting, and  from digitalis, not observed in ner-
vous affections of the heart. 
       THE HEART AND LARGE ARTERIES.   307

                     II. HYPERTROPHY.
            1. Hypertrophy of the Left Ventricle.
    589. I.  The Symptoms of Hypertrophy of the Left Ven-
 tricle of the heart, in addition  to the symptoms of disease of the
 heart  in  general, are a florid  complexion, forcible pulsation of
 the heart, a strong and generally  a  regular pulse; there are
 frequent palpitations.
   590.  II.  But it is to the Signs afforded by the stethoscope
 and percussion, that we must have recourse for the diagnosis of
 the individual diseases of the heart.  The contraction of the
 ventricle is accompanied by  a  strong  impulse,  and a feeble
 sound; it is prolonged in proportion to  the hypertrophy, and
 is felt  and heard over a small space, and principally between the
 cartilages  of the fifth and  sixth ribs, on the left side of the
 chest.   The second sound is brief, and low.
   591. III.  The  Complications.  It is  in this form of disease
 of the heart that Apoplexy most frequently occurs as a compli-
 cation.
   592.  The  Morbid  Anatomy consists in augmented thick-
 ness and firmness of the parietes of the ventricle.

          2.  Hypertrophy  of the  Right Ventricle.
   593.  The Symptoms.   There  is, in  this case, greater dys-
 pnoea ;  and there is  frequently an  obvious pulsation  of the
jugular veins.(')
   594.  II.  The  Signs.   The beat of  the heart is attended
 with great impulse; there is rather less dulness of sound than
in hypertrophy of  the left ventricle ; these signs are  perceived
 under the sternum.
                     III. DILATATION.
            1.  Dilatation of the Left Ventricle.
   595. The History.  This form of disease of the heart occurs
 most frequently in women, who have naturally a heart of thin-
 ner parietes than  men.  Its causes are ossification of the valves,
(1.) See note, par. 427, part 1.
S. 
308   DIAGNOSIS OF  THE  DISEASES  OF

congenital tightness of the aorta, diseases of the lungs, laborious
occupations, &c.
   596.  II. The  Signs.  The only true sign of Dilatation of
the Left Ventricle is a clear  and loud sound, heard under the
ear or stethoscope, chiefly between the cartilages of the fifth and
sixth  ribs.  The extent to which this sound is  diffused is the
measure of the degree of dilatation.

          2. Dilatation  of the Right  Ventricle.
   597.  The  Symptoms.  According to Laennec,  habitual
swelling, without perceptible pulsation, of the jugular veins,
is  the most constant, yet still an equivocal, symptom of dilata-
tion of the left ventricle.
   598. The  only pathognomonic Sign is the loud sound of
the heart under the lower part of the sternum.

          VI. DILATATION  WITH HYPERTROPHY.*
   599. 1. The  Symptoms.  This  disease is attended by vio-
lent palpitations : the head, the limbs, are moved at each con-
traction ; the pulsation of the carotids is visible, and the pulse is
full, strong and vibrating.
   600. II. The Signs afforded by the stethoscope,  or the appli-
cation of the ear, are those of hypertrophy and  of dilatation,
§§  570, 576,  combined:  the contraction of the ventricles are  at-
tended by great impulse and a  notable sound,  the second
sound is loud  ; the ventricular contraction is heard and felt over
a great extent.   The situation, \h 570, 574, in which the con-
tractions of the ventricles are perceived determines whether the
left or the right ventricle alone, or both, be affected.
   601. III. It is in dilatation with hypertrophy that the heart
acquires the  greatest volume,  and in which,  consequently, the
sound on percussion of the region of the heart, is  most obscure.
   602. Sometimes there is dilatation of one ventricle and hyper-
trophy of the other: there  is then the corresponding augmented
  *  The " Active Aneurysm" of Corvisart, a far more common affection than
hypertrophy, or even dilatation, s:ngly. 
       THE  HEART AND LARGE  ARTERIES.   309

 impulse, or sound, between the cartilages of the fifth and sixth
 ribs of the left side, or at the lower part of the sternum, respect-
 ively.
   603. Dilatation and Hypertrophy of the Left Auricle, usually
 the effect of disease of the mitral valve; or of the Right Auricle,
 the effect  of Hypertrophy of the Right Ventricle, are not to be
 distinguisded from those  original diseases; and if they could,
 the distinction would be more curious than useful.*
   604.  IV.  The  Morbid  Anatomy.    The  parietes of  the
 ventricles  are greatly  thickened  and their cavities enlarged ;
 the  heart, in  consequence,  occasionally  attains an enormous
 size^1)
                 V.  DISEASE  OF  THE VALVES.

   605.  The Signs of Disease  or  Constriction of  the Valves
 consist in the " bruit de rape" and the » fremissement cataire :"
 the former resembles the sound of a rasp acting upon wood; the
latter  the  purring of a cat felt under the finger.f   The  pulse
is irregular.   There are many of the general symptoms of dis-
ease of the heart.(2)
   * The signs  of induration of the  heart are those of hypertrophy :  those of
 softening, defective impulse and of sound, occurring simultaneously.
   (1.) The signs mentioned above as diagnostic of the different forms of enlarge-
 ment of the heart, cannot, 1 think, be safely relied upon.  The most important
 fact to remember in this connexion is, that by far the most common form of en-
 largement is that of Hypertrophy and Dilatation  united.  Simple Hypertrophy
 is sometimes met with, but simple Dilatation is very rare.  The most conclusive
 physical signs of enlargement of the heart are first, that the apex strikes higher
 up and further  to the left than natural; secondly, that the flatness over  the
 precordial region is increased, while the respiratory murmur is absent j  thirdly,
 that this region is evidently dilated ; but these signs belong only to the more
 advanced cases, and some of them are found also in cases of pericarditis with
 effusion of serum.  See note, par. 610.                              S.
  f The situation and period of the former of these signs might determine, if it
 were of any moment to do so, the particular valve affected.
  (2.) The signs of valvular disease are involved in much doubt and  obscurity.
 I have not yet had sufficient opportunity to verify the conclusions of Mr. Hope
 on this subject, but it is not improbable that too much refinement has been used
in the diagnosis of these cases.   The best signs of valvular disease appear to be 
 310   DIAGNOSIS  OF  THE   DISEASES   OF

   606.  II.  The Morbid Anatomy.  The mitral valve and the
 sigmoid valves of the aorta become ossified, or assume a cartila-
 ginous hardness : they are then thickened and altered  in form,
 and frequently partially closed, so that the course of the blood is
 impeded.   Such disease occurs  rarely on the right side of the
 heart.( ')
   607. In other cases morbid growths take  place from the sur-
 face or borders of the valves.

    VI--VII.  PERICARDITIS AND HYDROPERICARDITIS.
   608.   I.  The History.   The causes of  Pericarditis are ob-
 scure : a blow,  violent exertion, or mental  affection, have ap-
 peared to be the most frequent.   Men are more subject to this
 disease than females.
   609. II.  The Symptoms of Pericarditis are sudden pains in
 the region of the heart, palpitation, dyspnoea, irregularity of the
 pulse,  the  absence of respiratory murmur under the ear, and of
 sound on percussion.
   610. III. The Signs.   The contractions of the  ventricles
 frequently become stronger and irregular ;  and are attended with
 the creaking sound of new leather, when the surface of the part
is covered with a false membrane.(2)
   611. IV.  The Morbid Anatomy consists of
these,—an irregular pulse and feeble when compared with the action of the heart
—the early occurrence of oedema—a permanent sawing or rasping or filing sound
over the valves of the heart, especially after depletion and rest.           S.
  (1.) An important form of valvular disease, not mentioned in the text, is insuf-
ficiency, insuffisance, when from adhesion or other causes the valves do not per-
fectly close the corresponding orifices, so that the blood regurgitates.      S.
  (2.) The physical signs of Pericarditis, especially of by far the most common
form, the subacute  attended  by serous effusion, are in many respects similar to
those mentioned as accompanying enlargement of the heart (see note, par. 604.)
In both  cases there is flatness, absence of respiration, and dilatation over the
praecordial region;—but in common pericarditis the impulse of the heart cannot
be felt, and the sounds are dull and distant. In pericarditis the physical signs
occur early and suddenly.   In enlargement of,the heart  they are very  slowly
developed.                                                     S. 
    THE  HEART  AND  LARGE  ARTERIES.  311

  1.  The Effusion of Serum, with or without Lymph, Pus,
       or Blood.
  2.  The Formation of a False Membrane over the Surface
       of the Heart or Pericardium.
  3.  Adhesions; sometimes Ossifications.

            VIII.  ANEURYSM OF THE AORTA.
  612.  I.  The History. No disease is more insidious  than
Aneurysm of  the Aorta.   It sometimes exists, and even proves
suddenly fatal,  unsuspected, in persons apparently the  most
healthy ;  and, until it induces some symptom  of the compres-
sion of adjacent parts, it may be indetectible.
  613.  II. The Symptoms. Aneurysm of the Aorta consists
in simple, forcible  pulsations, perceptible over a circumscribed
spot of the anterior parietes  of the thorax, or along the spine,
under the ear, and finger.  These pulsations are more forcible
than those of the left ventricle. It is frequently extremely difficult
to distinguish such aneurysmal pulsations from  those of a tumor
situated over or upon the artery.  In both cases the sound  emit-
ted by percussion is obscure.
  614.  III. The further Symptoms of Aortic Aneurysm are,
in fact, those of its effects upon contiguous parts, or  organs,
which may be arranged in the following manner:

  1. Compression  of the  Trachea, or Bronchia.
  2. Compression  of the  (Esophagus.
  3. Compression of  One of the Subclavian  Arteries.
  4. Protrusion and Wearing of the Ribs or Sternum.
  5. The  Wearing of some Part of the Vertebral Column.
  615.  1.  Compression of trachea or bronchia induces symp-
toms similar to  those of chronic tracheitis, or bronchitis.  The
stethoscope should, therefore,  be carefully, applied in every case
of these latter diseases.
  616. 2.  Compression  of the oesophagus leads to dysphagia.
The case of Aneurysm must be distinguished from that  of other
tumors compressing this organ, or of stricture.
  617. 3.  When Aneurysm compresses  one of the subclavian 
 312    DIAGNOSIS  OF  THE DISEASES OF

 arteries, it leads to dissimilarity in the pulse  of the  two radial
 arteries.
   618. 4. Protrusion and Wearing of the ribs or sternum, will
 be attended by the simple pulsation of the Aneurysm. The case
 must be distinguished from that of a tumor, moved by the sub-
jacent artery.
   619. 5. Wearing of the vertebral column is attended by pains
 described  as resembling those of rheumatism, or as being of a
 gnawing, tearing, or lacerating nature.  The stethoscope  must
 be called in aid of the diagnosis.(')
   620. It ought to be repeated that a tumor, as encephalosis,
 may occasion precisely similar effects.  The reader may revert
 to § 504, and pass on § 636.

           IX.  THE SYMPTOMATIC AFFECTIONS.
   621. The  first of the symptomatic Affections of the Heart are
those in which the action of this organ is too feeble: these are

              1.  The Erethismus Mercurialis.
              2.  The Effects of  the Digitalis.
   622. The Symptoms in the former case have been already
detailed, §§ 214—217.
  623.  The  Symptoms  resulting from the Digitalis are nausea
and vomiting, debility, faintness, and cold perspirations;  the ac-
tion of the heart and the  pulse are feeble and intermitting.
  624.  The second symptomatic affection is the

                    Angina Pectoris.
  625.  I.  The  History.  This affection  consists in attacks
which recur at various intervals, generally from the influence of
muscular effort or  exertion, as in walking quick, up an ascent, or
meeting the wind;  or from mental emotions, especially anger.
This affection occurs principally in men, past fifty.
  626.  II. The Symptoms  are  a sense of  pain, pressure, or
  (1.) For the most complete Summary of the diagnostic signs Aneurysm of the
Aorta, the student may consult the Art. of Mr. Hope, Cyc. Prac. Med.   S. 
THE  HEART AND  LARGE  ARTERIES.  313
constriction in the region of the heart, across the breast, espe-
cially on the left side, and of pains or numbness down the arms,
especially the left.   In females the  mamma is sometimes ex-
tremely sensitive to the touch.  In extreme cases there are pal-
pitation, or syncope, and suffocating dyspnoea, and the apparent
danger of dissolution.   It is sometimes suddenly fatal.
   627. At first the intervals are long and free from indisposition;
afterwards they become shorter, and  the angina is far more
readily excited, if not in some degree constantly present.
   628. III.  The  Morbid Anatomy.  Heberden observes—
<( Inciso cadavere hominis, qui hoc morbo subito perierat, expertis-
simus  anatomicus nullum vitium deprehendere potuit  in corde,
aut valvulis, aut in arteriis, venisve vicinis, preeter exigua rudi-
menta ossea in aorto."  Laennec is of opinion that the Angina
Pectoris, although it  may be accidentally associated with dis-
eases of the heart, does not, as Parry supposed, necessarily de-
pend upon it.(l)
   629. The third  class of  symptomatic  affection of the heart
consists of

              1. Palpitation, and the
              2. Bruit de Scie.(2)
   630. These symptoms are apt to occur  in

              1. Intestinal Irritation.
              2. Reaction from Loss of Blood.
              3. Hysteria.
              4. Chlorosis.
              5. Dyspepsia.
   631. It is only necessary for  me to refer to the descriptions of
these affections, the diagnosis flowing from the general symp-
toms.
   632. Palpitation is more felt by the patient, than the beating
  (1.) The student should consult the Art. Angina Pectoris, by Dr. Forbes, Cyc.
Prac. Med.                                               S.
  (2.) The term Bruit du SoufHet would be more proper in this place.     S.
                               40 
314   DIAGNOSIS  OF  THE  DISEASES,  ETC.

of the heart in hypertrophy ;  and it is, in fact, attended by little
real impulse : scarcely raising the ear or the stethoscope.
  633.  The  < bruit de  scie,'  is,  like  palpitation, a frequent
symptom  in some nervous affections.   It attends the re-action
from loss of blood, and may  be produced in a dog very readily,
as I have  shown  in  a recent Essay.*   I have also observed  it
most distinctly in Chlorosis.
  634.  The last symptomatic affection which I shall notice in
this place, is

            Pulsation in the  Epigastrium,  fyc.
  635.  This affection seems, like palpitation, to  be  dependent
on nervous causes, and is distinguished, like that symptom, by
occurring in paroxysms, in dyspeptic persons, from mental emo
tion, &c.
   636.  Sometimes aneurysm  is imitated  still more accurately
by the  pulsation being communicated to  an apparent  tumor,
formed  by gas pent up, or faeculent matter  detained,  in folds of
the colon .t
   637.  Pulsation, the sense  of purring, the " bruit de souffiet,"
the " bruit de scie,;' occur along the abdominal aorta, in the ca-
rotid, and even in the radial artery, from similar nervous causes.
  * See the Med. Chir. Trnns. vol. xvi.
  \ An interesting case of this kind, in which both Boyle and Laennec were de->
ceived, is detailed by the latter able writer, 
CHAPTER   IV.
 THE DIAGNOSIS  OF THE  DISEASES OF THE ALIMENTARY
                           CANAL.

   638. The alimentary canal comprises the stomach, the duo-
 denum, the jejunum, the  ileum, the colon, and the rectum.
 Each of these portions is liable to its peculiar diseases, and is,
 therefore, of great interest in a medical point of view.
   639. Each division of the alimentary canal may be viewed as
 consisting of a serous and of a mucous membrane, of a muscular
 coat, and of a cellular tissue.  Each of these textures is subject
 to its peculiar morbid actions and lesions.
   640. It may be observed, in general, that inflammatory af-
 fections of the peritonaeum do not necessarily disturb the func-
 tions of the  stomach and intestines ;  those of the muscular coat,
 on the contrary, as enteritis, are apt to be  attended by sickness,
 severe pain, and obstruction ; whilst those of the mucous  mem-
 brane are usually associated with pain of a less severe kind,  and
 diarrhoea.   We may readily judge of the character of the  first
 by what we witness in the familiar example of Peritonitis, of
 that of the second by what occurs in Hernia, and of that  of the
 third by the symptoms observed in Dysenteria.  I would propose
 to characterize the inflammatory affections of the mucous  mem-
 brane by prefixing  the Greek  preposition i<ra  to our present
 terms:  eso-gastritis and eso-enteritis,  would,  in  a very simple
 manner, express inflammation of the mucous membrane  of the
 stomach and of the intestines;  and the further epithets of  mem-
 branous and follicular would distinguish the inflammation  of the
 mere membrane or of the follicles.
   641.  Of affections of a nature different from  inflammation,
some are attended  with  obstruction and distention,  whilst in 
316      DIAGNOSIS  OF  THE  DISEASES

others, to these symptoms are added an inverted or antiperistal-
tic action, and vomiting, perhaps of faeculent matters.
  642. The diseases of the alimentary canal admit of a practi-
cal division, into the Acute, the Chronic, and the Insidious, dis-
tinguishing, by the last mentioned term, those diseases which
are usually progressively, though slowly, fatal.   To this list the
symptomatic affections must  be subjoined.
  643. It is in these  different aspects that the subject is to  be
viewed in this work,  and the diseases of the entire alimentary
canal may be presented in the following tabular form :

ARRANGEMENT OF THE DISEASES OF THE  ALIMENTARY CANAL.
                 I. THE ACUTE DISEASES.

     I. Peritonitis.
                  1.  Diffused  2. Partial.
   II. ESO-GASTRITIS.
   III. The Effects of Corrosive Poison.
   IV. Enteritis.
    V. Obstructions of the Intestines.
           1.  Hernia, External and Internal.
           2.  Compression;  Internal Obstructio?i.
           3.  Intus-susceptio.
   VI. Ileus ; Colic.
  V1L COLICA PlCTONUM.
 VIIL Irritation.
  IX. Cholera.
               1. Europaa.
               2. Indica.
   X. Eso-enteritis.
               1. Membranous.
               2. Glandular.
  XI. Dysenteria.
  XII. HAEMORRHAGY. 
       OF THE  ALIMENTARY CANAL.     317
XIII.  Perforation.
             1. Of the Stomach.
             2.  Of the Intestines, fyc.
 XIV. Suppuration  of  the  Appendages  of  the
          Uterus.
 XV. Inflammation of the Appendix Cjeci.

     II.  THE INSIDIOUS AND PROTRACTED DISEASES.
   I. Peritonitis.
  II.  Tubercles.
             1. Of the Peritonaum.
             2.  Of the Intestines.
             3.  Of the Mesenteric Glands.
 III. ESO-GASTRITIS.
 IV. ESO-ENTERITIS.
  V. Scirrhus.
         I. Of the Stomach ;
             1. Of the Cardia,
             2. Of the Stomach,
             3. Of the Pylorus.
         II. Of the Intestine ;
             1. Of the Ileum,
             2. Of the Colon,
             3. Of the Rectum, contrasted with other
                   Diseases of this Intestine.
 VI. Encephalosis ; &c

             III. THE  CHRONIC  DISEASES.
   I. Dyspepsia.
  II. Intestinorum Torpor.
 III. Vermes. 
 318     diagnosis  of  the  diseases

             iv. the  symptomatic  affections.

     I.  Arthritis.
    II.  Hysteria,

                 I. THE ACUTE DISEASES.

                     I.  PERITONITIS.
                       1. Diffused.
   644.  I. The History.   The attack  of acute Peritonitis is
generally prompt or sudden, after exposure to wet and cold, and
after rigor.
   645.  II.    The Symptoms arise out of acute pain and ten-
derness  in the abdomen : the countenance has  a  peculiar ex-
pression ; the upper lip is  drawn upwards and  bound tightly
over the teeth ; the posture of the patient is not less peculiar; he
generally lies still, upon the back, every motion being attended
by augmented pain; the head cannot be raised from the pillow,
nor the trunk moved, without exciting pain and its expression in
the countenance  and  manner;  the respiration is thoracic, the
diaphragm being kept unmoved; the knees are frequently rais-
ed so as to remove the pressure of the bed-clothes.(l)
   646.  A careful examination of the abdomen should be made,
daily: in this manner  we detect the part which is the principal
seat of inflammation, and even some part of the morbid changes,
as the effusion of serum, and perhaps of lymph, by the pain and
tenderness experienced, and the tension observed on pressure.
   647. The functions of the stomach and bowels are not always
materially affected ;  there may be no vomiting, nor constipation.
   648.  The skin is usually of  very  moderate heat;  the pulse
very moderately quick.
   649.  III.  The Effects of Remedies.  There is, in this, as in
all cases of inflammation of the  serous membranes, great tole-
rance of loss of blood;  and  this fact becomes  a most important
diagnostic and guide in the treatment of the disease.
  (I.) A tympanitic state of the abdomen might be enumerated as a characteris-
tic symptom of Peritonitis.                                   S. 
          OF  THE  ALIMENTARY  CANAL.      319

   650. The Pathology.  The morbid  changes consist princi-
pally of the effusion of serum, mingled, or not, with flakes of
lymph, puriform, or  sanguineous; or of lymph, by  means  of
which adhesions are contracted between the peritoneal surfaces,
or the folds of the intestine.

                  2. Partial Peritonitis.
   651. Peritonitis may be partial.  It may be confined, indeed,
to any part of the peritonaeum, as that which  covers the sto-
mach, the intestines, or any portion of the latter; to the epi-
ploon, to  the hypochondrium, to the mesentery,  to the pel-
vis, &c.
   652. In many of these cases, the symptoms&re pain, tender-
ness, and perhaps hardness and tumidity, of the part affected,
together with some degree of interruption of the function of the
adjacent  organs.(')

                       II. GASTRITIS.
   653. Gastritis, or rather Eso-gastritis, § 640, as an acute dis-
ease, is extremely rare; yet, I believe I have witnessed several
instances  of such an affection.
   654. The  Symptoms  consist  in pain, or  weight, or  drag-
ging, in the region of the stomach, very shortly after eating, and
after taking the mildest medicines, sometimes amounting to a
paroxysm of suffering, and only terminated by vomiting, and
recurring after each repetition of the cause.  With these symp-
toms there are debility and emaciation.
   655. Similar symptoms have appeared  to me to arise in in-
flammation of the duodenum, with the addition of icterus, and
a tender and somewhat enlarged condition of the liver.
   656. II. The Morbid Anatomy of this affection is unknown,
but it probably consists in injection or softening of the mucous
membrane.
  (1.) Everyone in the habit of examining dead bodies must have remarked
how rare it is to find old adhesions denoting the previous existence of perito-
nitis. It is not probable then that many cases which recover, after being called
peritonitis, have been mistaken by practitioners.                    S. 
320      DIAGNOSIS  OF THE  DISEASES

   657. Acute Gastritis occurs in one very unequivocal case, that
of the administration of
                  III. CORROSIVE POISON.
   658. I.  The  History.  As  concealment is frequently  at-
tempted in this case,  it is very important to be  aware of every
possible means of discovering the fact of poison  administered.
   659 II.  The Symptoms which  should excite suspicion, are,
a sudden attack of pain, of vomiting, and, perhaps, of diarrhoea.
The matters rejected,  and passed, should, of course, be carefully
examined.  The history and the acts of the patient, of the per-
sons near or present;  the articles in the room, &c. are so many
sources of diagnosis.
                      IV.  ENTERITIS.(')
   660. I.  The History.  The attack of  Enteritis  is usually
rather sudden, and frequently occasioned  by  exposure to wet
and cold.
   661. II.  The Symptoms are those of peritonitis, § 645, with
the addition of sickness and vomiting, and obstruction or extreme
difficulty of moving, the bowels.  The extremities are frequently
cold and livid, and the pulse small;  the countenance  expressive
of great pain, the upper lip being raised and  bound  over the
teeth ; the movements extremely cautious ;  the respiration tho-
racic ;  the abdomen extremely tender.
   662. Early sinking is apt to take place, without gangrene ;
the countenance  is cold,  livid, and collapsed;  the extremities
livid, cold, and clammy; the pulse thread-like or  quite imper-
ceptible ; the pains perhaps entirely gone.   The patient and by-
standers frequently imagine that the disease is subdued, when it
is, in fact, only yielding to dissolution.   This is particularly the
case in a renewed attack of Enteritis.
   663. III. The Morbid Anatomy in Enteritis consists chiefly
in the deposit of the layers of lymph upon the intestine, leading to
adhesions.
          V.  OBSTRUCTION  OF THE INTESTINES.
   664. In every case  of Enteritis, or of disease similar to Enteri-
(1.) Enteritis might, it appears to me, be properly classed with Peritonitis. S 
          OF  THE  ALIMENTARY  CANAL.      321

tis, the physician should search diligently for some cause of Ob-
struction ; for the symptoms  of the two  affections are almost
identical.
   665.  The different forms of Obstruction are
                 1. External Hernia.
                 2. Internal Hernia.
                 3. Intus-susceptio.
                4. Compression.
                 5. Internal Obstruction.
   666.  The first of these is principally
     1.  Inguinal.  2. Femoral.  3.  Umbilical; fyc.
   667.  The second is hidden, being
1. Diaphragmatic ;
2. Mesenteric; 3. Epiplootic, fyc. or
4. Formed by the Passage of a fold of Intestine between a
     Loop of Intestine adherent after Inflammation.
   668.  Intus-susceptio generally consists of the descent of a
higher portion of intestine into a lower one,—of the ileum into
the colon.  In this case there is sometimes, with the  usual
symptoms of  obstruction, a tumor of an extended form  along
the part affected.
   669.  Compression is the consequence  of a tumor external
to the intestines;  internal obstruction is the effect of  calculus,
or perhaps of  impacted faeces.   In all these  cases a tumor will
be discovered on examination.
   670.  The Symptoms.  There is less tenderness, at first, but
more sickness and vomiting, than in Enteritis, and the obstruc-
tion of the  bowels, under the influence of the purgatives and
enemata, is complete.   Such symptoms should  always lead
to the most attentive search for the source of obstruction.
   671.  There is great anxiety.   The sickness  and vomiting
increase; the abdomen becomes tender and tumid; the obstruc
tion is obstinate, the action of the bowels perhaps antiperistaltic,
so as to lead to stercoraceous vomiting.
   672.  The Morbid Anatomy.  Besides the effects of strangu-
                            41 
322      DIAGNOSIS  OF  THE  DISEASES

lation  upon the part more immediately involved  in it,  as in-
flammation, gangrene, &c, the intestine above this  part is apt
to be distended, to a greater or less  extent, in the whole, or in
parts, of its circumference, according to the acute or more chronic
character of the disease.

                    VI.  ILEUS OR COLIC.
   673.  This disease is very obscure.  It frequently proves fatal
without leaving any traces  of inflammation;  and I confine the
terms to cases unattended,  uncomplicated by other diseases.
   674.  I.  The Symptoms are very similar to those of enteritis
and obstruction : there are pains, generally twisting pains of the
bowels, chiefly round the umbilicus; vomiting; obstinate  con-
stipation ; the pain is sometimes relieved rather than augmented
by pressure; at length tenderness and tympanitis are superadded
to the tormina, perhaps with the inverted action of the intestines
and the vomiting of fseculent matters. There are great anxiety,
little febrile action, sometimes speedy sinking.
   675.  The Pathology.   In some cases a portion of the in-
testine is found much  distended; in others there is the effusion
of lymph; and in others a state of gangrene.
   676.  But, in fact, the  causes and the pathology  of Ileus or
Colic, properly distinguished from all other diseases, are ex-
tremely obscure, and highly deserving of fresh investigation.

                  VII. COLICA PICTONUM.
   677.  I. The History. This affection arises from exposure to
the influence of lead, and  especially, if not exclusively, according
to Dr. A. T. Thomson, to  that of the carbonate.   It is some-
times a very acute, at others a more chronic, disease.
   678.  II. The Symptoms are  extreme pain of the abdomen,
unaugmented, perhaps relieved, by pressure; vomitings, obsti-
nate constipation, retraction of the abdomen towards  the spine;
generally without  fever,—chills, heat, or perspiration,—quick-
ness of  pulse, whiteness of the  tongue, &c. and  frequently
promptly  relieved  by large doses  of emetics and  purgatives.*
* These constitute the 'traitement de la ChariteV 
         OF  THE  ALIMENTARY  CANAL.      323

There are frequently pain of the limbs, especially of the arms,
great distress, sleeplessness, and restlessness.
   679. Sometimes the disease is less  acute, and the pains are
at one period dull, at another extreme.  The attacks may con-
tinue several days, or even a month, pass off, and return after
various intervals.
   680. After a varied  duration of  this disease, there is usually
the accession of pain, and of a peculiar paralysis of the ex-
tensor muscles of the hands, but also of the arms  and some-
times of the legs; the thumb and fingers are frequently forcibly
flexed or distorted.  The  character of this  disease, whether in
the abdomen or in the limbs, seems to be that of paralysis united
with pain.
   681. III.  The  Varieties and Complications of the Colica
Pictonum deserve to be distinctly enumerated.  Heberden,* M.
Louis,t and M. Andral,J mention

                      Sudden Death
as an  event in  this  disease.  The former  speaks  of lead as
" nervis inimicissima."  The other events'or complications of
the colica pictonum are

   1.  Coma; Delirium.
   2. Pain and Paralysis, of the Legs, as well as Arms.
   3. Convulsions.

   682.  The adductor pollicis shrinks, and  sometimes a tumor
of the size of a nut is seen occupying the beginning of the meta-
carpal bone of the middle finger.
   683.  IV.  The Effects of Remedies have been already men-
tioned, § 678.
   684.  V.   The Morbid Anatomy.   The most  recent re-
searches of M. Andral, M. Louis, and others, confirm the opinion
* Commentarii, ed. 1807, p. 330.
f Recherches Anatomico-Pathologiques, pp. 483—491.
J M^decine Clinique, ed. 2, t. iv, p. 153. 
524      DIAGNOSIS   OF  THE  DISEASES

of Heberden, that there is no  morbid appearance peculiar to
this disease.*
   685. The seat of the disease is probably the spinal marrow.
In this organ we must, therefore, look for its morbid appear-
ances which have hitherto escaped detection.

      VIII.  STOMACHAL AND INTESTINAL IRRITATION.
   686. It is only necessary to refer, in this place, to §§ 181, 185,
and to request the reader's attention  to the importance of the
distinction between these diseases, and especially to the diagno-
sis afforded by the effects of the loss of blood.

                        IX.  CHOLERA
                   1. Cholera Europcea.
   687. I.  The History.   This  disease  usually arises rather
suddenly from the influence of heat,  in the autumnal season.
   688. II.  The Symptoms are violent  abdominal pains, with
bilious vomiting and purging.   The  face and  surface are often
cool, the extremities cold  and  perhaps  clammy and  livid, and
the pulse  small.   To these  symptoms are frequently added
severe cramps and sometimes even convulsions.
   689. III.  The Pathology.  There  is frequently not the
slightest trace of morbid change of  structure on examination
after death.  In protracted cases, red, brown, or black patches,
and even  gangrenous points, have been found in some parts of
the intestines, and the  liver  has been much congested.

                     2. Cholera Indica.
   690. I.  The History.  This terrible disease is epidemic or
 sporadic.  In the former  case it is of dreadful fatality.  When
 sporadic, it is less so.   Its causes are  very obscure.
   691. II.  The Symptoms.   The early symptoms are mere
 diarrhoea, perhaps unattended  by pain or spasm; the evacua-
  • "Inciso cadavere hominis hac colica peremti, nullum vitium intusin corpore
deprehensum est, quod ad hunc morbum pertinere,mortemque inferre potuisset."
Heberden. p. 330.
  t Rostan, Cours de M6decine Clinique, ed. 2, t. ii, p. 506. 
         OF  THE  ALIMENTARY  CANAL.     325

tions are copious, liquid, almost inodorous, and usually com-
pared, in appearance, to rice-water.
  692.  Afterwards, the same sort of fluid is rejected by vomit-
ing and passed by  stool, in amazing quantities,  variously at-
tended  by pain, anxiety and cramps,  but speedily followed by
collapse  and sinking,  the  countenance being livid,  cold  and
clammy, the arm livid, cold, clammy, and pulseless, the voice
husky ; there is complete suppression of urine.
  693.  In the worst cases  there are early blueness, pallor, and
collapse of the  countenance; loss of voice, loss of pulse; a cold,
clammy, and livid  state of the extremities; speedy sinking or
asphyxia.
  694.   III.  The  Morbid Anatomy consists  in intestines re-
plete with fluid like rice-water, in a gall-bladder  replete  with
bile;  and in a urinary bladder  empty and  collapsed.   The
mucous  membrane of the intestines is apt to be  injected, and
even gangrened, and the clustered and  isolated glands are fre-
quently enlarged: but none of these appearances are constant.

                    X.  ESO-ENTERITIS.

                      1.  Membranous.
   695. A state of inflammation of the mucous membrane of the
intestine seems to  be  the cause of many forms of Diarrhaa
especially those attended by mucous discharges.
   696. I.  The Symptoms.  There are slight pains or griping,
tenderness on pressure, and sometimes, but not always, frequent
evacuations.  The countenance is pale,  perhaps icterode ;  there
are emaciation, and considerable  debility.   The affection is ex-
tremely apt to  pass into the chronic form.
   697. II.   The Morbid  Anatomy consists in injection, soft-
ening, and ulceration of the mucous membrane.

                2.  Glandular  Eso-enteritis.
   698.  This  term expresses the tumidity and ulceration  of
 Peyer's and Biunner's glands, already mentioned as occurring,
 in the acute form, in Typhus, § 86, and in the chronic form,  in
 Phthisis, § 552. 
 326      DIAGNOSIS  OF  THE   DISEASES

                     XI.  DYSENTERIA.
   699. I.  The History.   I witnessed this disease, in its epi-
 demic  form, in the summer and  autumn of three successive
 years.  It also frequently occurs sporadically.  Is it ever conta-
 gious ?
   700. II.  The  Symptoms are griping, with frequent or in-
 cessant mucous, sanguineous stools, and constant tenesmus.
   701. There is frequently sickness, and pain and tenderness
 of the epigastrium, and over the course of the colon, especially
 in the left ileum.  The " desidendi cupiditas" and the tenesmus
 are quite terrible.  The pain, anxiety, and distress are frequent-
 ly extreme.
   702.  This affection may pass suddenly into the sinking, or
 slowly into the chronic state.
   703.  The Morbid  Anatomy consists of injection, thicken-
 ing, and ulcerations of the mucous membrane of the colon and
 rectum.  In  severe  cases, the morbid  changes are still more
 deeply seated,  and the tumefaction  is such as to thicken thetex-
turey of the intestine whilst  it contracts its calibre; the ulcera-
tions are of irregular forms, but generally, I  think, transverse,
and frighfully deep.

                   XII. HAEMORRHAGY.
  704.  Haemorrhagy may take  place from the surface of the
gastric  and intestinal mucous membrane congested from any
cause, and the blood may be rejected by vomiting or passed per
anum, constituting hamatemesis or melana.  This  event  is
frequently, if not chiefly, induced by the loaded condition of the
bowels observed in Dyspepsia, Chlorosis, &c.  §§ 228 ; 238.
  705.  This affection has been cured in many instances which
I have  witnessed ; but I suppose  it may be attended by that
state of the intestine which has been designated and depicted as
the hsemorrhagic, and then prove less remediable.
  706.  It is  well known that  haemorrhagy from the stomach
and bowels is a consequence in many diseases, as fever, purpura,
ulcers, cancer, &c. and of obstruction of the vena portae. 
         OF  THE ALIMENTARY  CANAL.      327


                   XIII. PERFORATION.
   707.  The History.   This fatal accident may take place in
the Stomach, or Intestines, and occurs principally from the fol-
lowing circumstances :

1. Softening of the Mucous Membrane.
2.  Ulceration of Peyer's or Brunnefs  Glands, in
              1. Typhus;
              2. Phthisis.
3. The Separation of  an Eschar, the effect of poisoning by
       Sulphuric Acid.
4. Gangrene induced by Strangulation.
5.  Ulceration in  Dysentery.
6. Rupture in Cancer and other Diseases.
   708. II.   The Symptoms are those of the most sudden peri-
tonitis or enteritis: violent pains of the abdomen, exceedingly
augmented by pressure; nausea and vomiting ; dreadful change
in the countenance, in the powers, and in  all the  vital func-
tions ; a rapidly sinking  pulse, a cold, clammy state of the face
and of the extremities.

XIV.  SUPPURATION OF  THE APPENDAGES  OF THE  UTERUS.
   709. This event is frequently a sequela  of puerperal peritoni-
tis ; which is apt to terminate in suppuration, and abscess, and
an external opening.  There are, pain, tenderness,  and tumor
in the situation of the uterine appendages.

   XV. INFLAMMATION  OF THE APPENDIX VERMIFORMIS
                           CjECI.
   710. This disease is  generally the result of some substance
received and retained in that singular canal.  In  one case it
was a cherry-stone, in a second a pin, in a third a tooth.  There
are local  pain, tenderness, and tumor.  This disease usually
leads to speedy sinking. 
328      DIAGNOSIS  OF   THE  DISEASES
                 II. THE INSIDIOUS DISEASES.

                      I.  PERITONITIS.
  711.  I.  The  History.  Chronic Peritonitis may originate in
the acute  form, or be chronic from its commencement.   It may
require great attention for its detection.
  712.  II.  The  Symptoms.  There is sometimes little or no
pain, tenderness, or tumor of the abdomen, although a careful
examination generally detects some  degree of one or other of
these symptoms.  There is frequently also some degree of vomit-
ing and diarrhoea.  But the principal symptoms consist of hectic
fever and  emaciation.  See further, §§313, 314.
  713.  In the course of the affection, various  effusions of serum
or lymph  take place,  and the elasticity of the abdomen  is di-
minished, generally or partially, so  as to constitute diffused or
partial hardness or tumor, or even suppuration; or a  state of
ascites is established.
  714.  III.  The  Varieties and  Morbid Anatomy.   This
affection,  frequently obscure in itself, is rendered still more so by
its varied  forms and complications: these arise principally from
the
       1.  Effusion of Serum, when it resembles Ascites.
       2.   The Effusion of coagulable  Lymph, when it as-
              sumes  the form  of  abdominal  Tumor or
               Tumors.
      3.  The Supervention of Inflammation, or Ulceration,
             of the mucous Membrane of the Stomach, or In-
             testines, or the Mucous Glands.
        4. The Deposit of Tubercles.^ ')
  (1.) It is the opinion of M. Louis, the highest authority on this subject, that
Chronic Peritonitis is always tuberculous. In cases that have fallen under my
notice, the abdomen has become enlarged, but without the regular development,
and especially without the tension observed in ascites,—the swelling beinf inelas-
tic and marked by greater prominence  and firmness in some portions than in
others.  It is sometimes possible to feel distinctly the ridges and depressions pro-
duced by the folds of the intestines united to each other by coagulable lymph. 
          OF  THE  ALIMENTARY  CANAL.      329

   715. The last complication of chronic Peritonitis naturally
 leads us to the consideration of

                      II.  TUBERCLES.
   716.  The  History and the general Symptoms have been
 already detailed, § 318.  It only remains to trace, in this place,
 the local Symptoms of this disease.
   717. I.  The History.  Compared with chronic peritonitis,
 Tubercles of the  abdomen form a far  more insidious disease
 still;  and it rarely, if ever, puts on an  acute form at its com-
 mencement, in its progress, or at its termination.
   718. II.  The local Symptoms are at first obscure and deep-
 seated pain  in the abdomen and generally in the right iliac re-
 gion.   This pain is sometimes aggravated for a day or two. At
 a later period, a degree of tension, and finally of tumor, is added
 to the tenderness.  The bowels are uncertain : frequently there
 are copious, white,  alvine evacuations.
   719. III.  The Morbid Anatomy consists in
     1.  Tubercles and Tuberculous Adhesions diffused over
          the  Peritonaum.
     2. Masses of Tubercles and  Interstices inextricably
          matted together.
     3. Ulcerations of Peyer's and Brunner's Glands, and
          Tuberculous  Enlargement  of the  Mesenteric
          Glands.
    4.  Various Tuberculous Masses and Cavities,  espe-
         cially in the right  Iliac  Region, sometimes com-
         municating with the Intestines.   See §§ 552—556.

                   III.  ESO-GASTRITIS.
  720.  I. The History.  Eso-gastritis is far more frequently
an insidious and protracted than an acute disease.
  721.  II. The Symptoms  are such as have  been  detailed
 § 654,  in a protracted, or repeated, form: food and medicine,
even of the mildest kind, are apt alike to disagree,  inducing pain,
sickness, vomiting,  a sense of weight, or of dragging, &c.  The
                            42 
830      DIAGNOSIS -OF  THE  DISEASE3

evacuations are frequently pale and without bile. The strength
and fleshsfail.
  722.  A careful examination of the epigastrium, and a careful
observation of the effects of food and of medicines, the recurrent
nature of the attacks of pain and suffering, the condition of the
bowels, &c. are the chief diagnostics of this disease, which is, I
think, little known.
  723. I have already expressed, § 655, my opinion that icterus
is apt to be formed when  the duodenum is involved in this dis-
ease.   I know, however, that M. Rostan* is incredulous upon
this point.  With the icterus, tenderness and  enlargement of the
liver (from bilious congestion?) are apt to take place, with a dis-
position to anasarca.
  724. III.  Effects of Remedies.  Enemata of warm water
afford great relief, and constitute one of our chief resources in this
disease.
  725. IV.  The Morbid Anatomy consists in softening, thin-
ness,  and perhaps destruction of the mucous  membrane of some
part or parts of the stomach, or this membrane becomes raam-
melated.

                    TV.  ESO-ENTERITIS.
  726. I.  The  History.   This disease, like the  eso-gastritis,
generally occurs in an insidious and protracted form.
  727. II. The Symptoms are intestinal pains and tenderness,
and generally diarrhoea.   The evacuations,  carefully inspected,
frequently display appearances of mucus, or pus, or even blood.
There are slight fever, debility, and wasting of the flesh.
  728. III. The Morbid Anatomy consists of injection, disco-
loration, softening, and perhaps  ulceration of the mucous mem-
brane of the intestine, in various parts of its course.

                      v. SCIRRHUS.

   729. I.  The History.  No disease can be more insidious than
Scirrhus of the Stomach,  unless it be so situated as to interfere
* Cours de M^decine Clinique, tome ii, p. 447. 
          OF  THE  ALIMENTARY  CANAL.     331

 with the ingress or egress of the food.  It usually occurs in the
 middle periods of life, being rarely seen in early youth or ex-
 treme age.   It can seldom be traced to any particular cause.
   730.  II.  The general Symptoms have been slightly sketch-
 ed, § 323.  They consist in a peculiar pale, sallow, worn coun-
 tenance, expressive of suffering, usually with a gradual emacia-
 tion^1)   The contrast of symptoms drawn §J 313. 314, mustbe
 usefully studied in reference to the diagnosis of this affection.
   731. III.  The local Symptoms depend entirely upon the sit-
 uation and mechanical effect of the disease.  Its principal seats
 in the stomach are
                 1.  The Cardia.
                 2.  The Pylorus.
                 3.  The Body of the Stomach.
   732. 1. Scirrhus of the cardia induces pain  and difficulty in
 swallowing, which slowly but daily increase.   The food is apt,
 late in the disease, to accumulate in the lower part of the oesopha-
 gus, and to be rejected, by a peculiar effort,  not dissimilar in  me-
 chanism to  that of vomiting,* without having ever reached the
 cavity of the stomach, together  with much  mucous or glairy
 fluid.
  733.  2. Scirrhus of the pylorus is -denoted by an accession of
 pain, oppression, and other inconvenience, some time after eating,
 which increase gradually until the stomach relieves itself by
 vomiting.  The mornings are comparatively easy, and the even-
 ings full  of suffering from the alternate,  comparative empty, or
 replete, condition of the stomach.
  734.  3.  In Scirrhus of the  body of the stomach,  which is
 usually seated at the small curvature, there  are only the general
symptoms of disease and of scirrhus, §§ 313, 323, with ardor,
gastrodynia, uneasiness, &c. at various periods after eating.
  735. Besides the symptoms already detailed, it is important to
                (1.) See note, par. Ill, parti. S.
  * See a Memoir by the Author, in the Journal of the Royal Institution for
June, J 828. 
332      DIAGNOSIS OF  THE  DISEASES

notice the condition of the matters rejected from the oesophagus
or stomach:  these are mucus, pus, sanies, blood, &c, sometimes
of extremely foetid odor.  It is also important to examine care-
fully and repeatedly for tumor.
  736. After these different parts of the stomach, the following
are the principal seats of Scirrhus in the intestines:
  1. The Ileum.
  2. The Colon, especially the  ascending and descending.
  3. The Rectum.
  737. Rarely seen  in the  first,  much more frequently in the
second, this  disease occurs most frequently in the last of these
situations.
  738. IV.  The local Symptoms vary with the seat of the dis-
ease:
   739. 1. Scirrhus of the ileum is denoted by local pain, tender-
ness, and tumor, augmented sometime after eating, and even-
tually attended by vomiting, paroxysms of pain, and symptoms
of obstruction.   The sufferings are usually augmented after eat-
ing, or towards evening.
   740. 2. Scirrhus of the colon is attended by similar symptoms
and by pains of the kind designated by the term colic ; whilst
the sense and symptoms  of obstruction are more distinct, and
the evacuations are more marked by  mucus, pus, or blood.
The bowels become more  and more  constipated—obstructed.
The symptoms are apt to be aggravated in paroxysms of aug-
mented obstruction.  The course of the colon, and especially the
ascending and descending portion, must be carefully, repeatedly,
examined for tumor.
   741.  3. Scirrhus of the rectum is accompanied  by similar
symptoms, which,  even when alone, should always lead to an
examination per  anum.  There are afterwards  local pains,
great difficulty in passing the faeces, gradually augmented ; dis-
charges at first of mucus and afterwards of foetid sanies, pus,
or blood;  tumors at the verge  of the anus, &c. the occur- 
         OF  THE  ALIMENTARY  CANAL.     333

rence of any one of which  should also lead to an attentive ex-
amination.
  742.  The Morbid Anatomy of Scirrhus consists, according
to M. Andral,  in hypertrophy of the cellular membrane.  The
part affected is indurated, thick, and traversed by hard, white
bands, which separate the muscular fibres.  At length the mu-
cous membrane and the peritonaeum are involved in a change
of structure which was originally confined to the cellular mem-
brane.  Eventually ulceration takes place, and an open cancer
is formed, with rugged  surfaces, fungous growths,  frightful
chasms, &c.
  743.  In this place I must draw the  attention of my young
reader to  other cases of disease of the rectum, which it  will
be  his office to distinguish from Scirrhus.  They  are princi-
pally these:

            1. Common Strictures.
            2. Hamorrhoids*
            3. Fistula.
            4. Impacted Faces.
            5. Biliary or Intestinal Calculus.
They are distinguished by a careful examination.   But I am
sorry to say that it has become necessary to distinguish diseases
of the rectum from no disease of the rectum !  A friend  of
mine—and  I  have heard of  similar  events—had a rectum
bougie passed daily, whilst at Bath,  from suspicion  of stricture
or other disease of the rectum.   I was persuaded that there  was
no  disease.    I took him to Sir Charles Clark, who confirmed
my opinion.   The bougie was omitted,  and all the symptoms
vanished, with much of real distress, and much more of ground-
less and unnecessary apprehension.

                   VI. ENCEPHALOSIS.
  744.  I. The History.   This disease is scarcely attended by
  * Haemorrhoids, as well as varicose veins, frequently arise from the compres-
sion of the gravid uterus, or of a loaded intestine, and other causes. 
 334      DIAGNOSIS  OF  THE  DISEASES

 any  symptoms until it manifests itself by a tumo , perceptible
 on examination, or by its effect upon adjacent organs.   ^ 320,
 620.
   745. II.  The  Symptoms of Encephalosis of the abdomen
 are, therefore, a tumor, less sensible on pressure than inflamma-
 tion,  less marked by general symptoms than tubercles.

                III.  THE CHRONIC DISEASES.
                       I.  DYSPEPSIA.
   746. I propose,  in this place, merely to call the  attention of
 my readers to several prominent forms of dyspepsia.  They are
 principally
                      1.  Gastrodynia.
                     2.  Pyrosis.
   74.7. 1.  Gastrodynia may occur either with an empty sto-
 mach or after eating: in the former case, it is usually conjoined
 with  acidity;  in the  latter it follows almost immediately upon
 taking food.  In both cases it is chronic, and distinguished from
 Eso-gastritis by producing little effect on the general system.
   748.  2. Pyrosis consists in the sudden rejection of a quantity
 of a saltish fluid from the  stomach, accompanied  by ardor, or
 acidity. Like gastrodynia, it is chronic, and induces little effect
 on the system at large.

               II. INTESTINORUM TORPOR.
   749.  By this term I wish to designate  a strange disposition
 in the large intestines  to form scybalae and  to retain them  in
 its cavity,  whilst there may be constipation, or a daily insuffi-
 cient  evacuation of the bowels.   The effect of this disposition
 in inducing a variety of ailments is very imperfectly  understood.

                      III. VERMES.
   750.  There are  no symptoms  which positively indicate the
presence of worms in the adult.   We can only suspect their ex-
istence,—give a cathartic, and examine the evacuations. 
         OF  THE  ALIMENTARY  CANAL.     335

            IV.  THE SYMPTOMATIC AFFECTIONS.
                       I. ARTHRITIS.
  751.  The stomach is frequently the seat of pain and disorder
in suppressed  Gout.    The  case is  distinguished from other
gastric affections only by this point of its History.      \

                       II.  HYSTERIA.
  752.  In  Hysteria, the surface of the abdomen is  frequently
so tender, as to lead to the suspicion of peritonitis.   The case is
distinguished by the history, and by the occurrence of other un-
equivocal symptoms of Hysteria; the pain is  induced by the
slightest touch, but it is not proportionately increased on making
deeper pressure.   If blood be taken, there is early syncope. 
CHAPTER  V.
 THE  DIAGNOSIS OF  THE DISEASES  OF THE  LIVER,  PAN-
                   CREAS, AND SPLEEN.

   753.  Few  diseases require  the  attention of the physician
more than those of the Liver;  the diseases of the Spleen, and
especially  of the  Pancreas,  are too  obscure to possess equal
interest.
   754. The Liver is the central organ of so  many systems,—
the hepatic artery, the vena portae, the biliary ducts, the hepatic
vein,—that its diseases, minutely considered, must be equally
various  and important.  The  profession will  soon possess a
treatise on this subject, of great value and novelty, by Mr. Kier-
nan, who has made many interesting discoveries in the minute
anatomy and pathology of this organ.
   755. It is my object to  place before  my reader, as usual, a
practical view of the diagnosis of hepatic diseases.   The Liver,
like  every other organ, is subject to inflammation.   It is ex-
posed to venous congestion from the interrupted  return and  flow
of blood in diseases of  the heart, § 587-4; and  it is subject to
bilious  congestion from  obstructed gall-ducts.   This organ is
subject to  other diseases which are common to it with several
other viscera, as encephalosis, scirrhus, tubercles, hydatids ;  and
it is exposed  to others, peculiar to itself, viz.  those  termed  the
fatty liver and the cirrhosis, § 372-3.
   756. M. Andral*  correctly observes—II n'est presqu' aucune
des alterations du foie qu'on n'ait designees sous le nom d'he-
patite.   A mon avis,  il n'en est non plus presqu'  aucune qui
ne puisse resulter d'une  irritation qui  a eu pour premier  effet
* Anatomie Pathologique, t i. p. GOG. 
       THE LIVER, PANCREAS,  AND SLEEN.  337

 de determiner une hyperemie du foie.  En veut-on une preuve
 evidente 1 quatre individus eprouvent sur la region meme du
 foie une violence exterieure: chez Pun, un abces se developpe
 dans le  foie; chez le second,  cet  organe devient cancereux •
 chez le  troisieme, il  se remplit d'hydatides; et chez  le qua-
 trieme,  il s'atrophie.  Dans ces quatre  cas  l'irritation a ete
 manifestement le point de depart des alterations du foie.  Mais
 quel a ete son role: elle a derange le mode normal de nutrition
 du foie : la s'est bornee son influence, la predisposition  de l'in-
 dividu a fait le reste.  D'un autre cote,  je  ne sache pas une
 alteration de nutrition ou  de secretion du foie, pas meme une
 collection de pus dans son parenchyme,  qui puisse etre consi-
 dered comme ayant  sa cause necessaire  dans un travail ante-
 cedent d'irritation ;  je n'en connais pas une  de laquelle on
 puisse dire qu'une hyperemie en a necessairement precede la
 formation."
   757. M.  Cruveilhier makes a similar  observation :—" Une
 contusion ou une  commotion du foie a  ete,  dans ce  cas (de
 kystes acephalocystes), la  cause  evidente de la production
 organique :  je ne connais pas de lesion dans 1'organisation qui
 ne puisse reconnaitre une cause semblable.  La  contusion et
 la commotion developpent, dans  les parties qui en sont le siege,
 des modifications de  vitaiite telles, que toutes les formes d'al-
 teration organique, soit aigue, soit chronique, peuvent en etre le
 resultat."*
   758. No organ is so susceptible of changes of size and of form.
 Under the influence of the compression from ascites, the Liver
sometimes shrinks greatly;  and it is sometimes marked by  the
tight lacing of stays.  In case of enlargement, it may encroach
 upon the thorax, the left hypochondriac, or the right iliac, region.
   759. To the preceding list, must be added obstruction of the
 gall-ducts, and it is complete for all practical purposes.
   760. The diseases  of the Pancreas and of the Spleen will
occupy little space, for their diagnostics are almost unknown.
* Anatomie Pathologique, iii. livraison.
             43 
333   DIAGNOSIS  OF THE  DISEASES OF

ARRANGEMENT OF THE  DISEASES OF THE  LIVER, PANCREAS,
                      AND SPLEEN.

                I. DISEASES OF THE LIVER.

   I. Inflammation.
             1.  Injection.
             2.  Softening.
             3.  Induration.
             4.  Enlargement.
             5.  Abscess.
                1. Solitary.  This may open
                   1. Externally.
                   2. Into the  Gall-Bladder or Ducts.
                   3. Into the Stomach or Intestines.
                   4. Into the Bronchia.
                   5. Into the Abdomen.
                   6. Into the  Pleura.
                   7. Into the Pericardium.
                2.  Numerous.
   II. Congestion.
       1.  Venous.
            1. Causes.
            2. Effects.
       II. Bilious.
            1. Causes.
            2. Effects.
   III. Encephalosis.
            1. Solitary.
            2. Diffused.
    IV. Scirrhus.
            1. Solitary.
            2. Diffused.
      V. Tubercles. 
    THE LIVER, PANCREAS, AND  SPLEEN.  339

    VI. Hydatids.   These may escape
              1. Through the Abdominal Parietes.
              2. Through the Stomach or Intestine.
              3. Through the Bronchia.
              4. Into the Peritonaum.
              5. Into the Pleura.
   VII.  Fatty  Liver.
  VIII.  Cirrhosis.

            ii.  diseases of the biliary ducts.
            Obstruction.

                  1. By Inflammation.
                  2. By Calculi.
                  3. By External Pressure.

              III. DISEASES OF THE PANCREAS.

               IV. DISEASES OF  THE SPLEEN.

                 I. DISEASES OF THE LIVER.

                    I.  INFLAMMATION.
   761.  I.  The History.  Inflammation of the Liver  may
arise from ordinary causes,  as exposure to wet and cold •  from
blows or falls;  and from  constitutional causes, as  disease of
some other organs.
   762.  II.  The Symptoms consist in local pain, augmented
by pressure, and by percussion ;  sometimes the border of the
organ is to be felt;  sometimes there is jaundice, ascites, or ana-
sarca.   There may be little febrile action;  pain of the right
shoulder does not belong to hepatitis; but the condition of the
stomach and bowels  is generally deranged, and  there  are
anorexia, nausea, sickness, constipation, and a colorless state of
the faeces, and the urine is frequently high colored.
   763.  III.  There is considerable tolerance of loss of blood, and
this becomes a useful diagnostic. 
340    DIAGNOSIS OF THE  DISEASES  OF

  764. IV.  The Morbid Anatomy consists of
                1.  Injection.
                2.  Softening.
               3.  Induration
               4.  Enlargement.
But, besides these states, there is a fifth which requires particular
notice.  This is
                5.  Abscess.

                   1.  Solitary  Abscess.
  765. The Symptoms of this termination of hepatitis occa-
sionally resemble Intermittent Fever ; but in other cases they
are very obscure, and the  occurrence of suppuration is not sus-
pected until the abscess points or the pus  appears  externally.
The pus may issue by an opening

             1. In the Hepatic Region.
             2. Into  the  Gall Ducts.
             3. Into the Stomach or Intestines.
             4. Into the Bronchia.
  766. This appearance of pus is known to arise from hepatic
abscess, by being associated  with the previous history and symp-
toms.  The abscess sometimes bursts into

             1. The Peritonaum,
             2. Ths Pleura, and
             3. The  Pericardium;
an event which can only be conjectured from the occurrence of
some sensation,  as of rupture, and by the appearance of symp-
toms of inflammation of one or  other of these  several mem
branes.
                2.  Numerous Abscesses.
  767.  This form of hepatic  disease occurs, like similar  ab-
scesses in other parts, in cases of  Phlebitis. 
    THE  LIVER, PANCREAS,  AND SPLEEN.  311

                      II.  CONGESTION.

                        1.  Venous.
   768. Venous Congestion of the Liver usually arises from dis-
 ease of the heart  impeding the flow of blood from the hepatic
 vein.  It leads to enlargement of the Liver, to dropsy, and per-
 haps to icterus.  See § 5S7.

                        2. Bilious.
   769. Bilious Congestion of the Liver arises from obstructed
 gall-ducts, and leads to enlargement of the Liver, to dropsy, and
 emaciation, and is attended by icterus.  See § 723.

                   III.  ENCEPHALOSIS.
   770. I.  The History.   This disease is extremely insidious,
 and ultimately induces symptoms only  by its size and pressure.
   771. II. These Symptoms are uneasiness and oppression in
 the epigastric and  hypochondriac regions, augmented by food,
 relieved by purgatives.   The countenance is pallid  and thin,
 and there is general and progressive emaciation, with ascites
 and anasarca,  and very frequently with icterus.  The enlarge-
 ment of the Liver, and, at  length, even its  irregularities of sur-
 face, are felt on a careful examination.
   772. II. The Symptoms are sometimes  merely those of hy-
pochondriasis.   A  careful examination should be made in every
such case.
   773. III.  The Morbid Anatomy consists in the presence of
Encephaloid Tubera, which may be few in number,  and con-
fined to the Liver,  or, what is more frequent, diffused over this
and various other organs.   These tumors compress, in different
instances, a large blood-vessel, a large gall-duct, the vena portae  ;
inducing, respectively,

              1. Partial Atrophy.
              2. Icterus.
              3. Ascites ; Anasarca.
   774.  The ascites is probably occasioned, in some instances 
342     DIAGNOSIS  OF THE  DISEASES  OF

by  irritation of the portions of the peritonaeum adjacent to the
hepatic tumor or tumors;  and  effusion into the thorax has
arisen in the same manner.   Other diseases, as of the  heart
and of the lungs, are  also occasionally induced  by hepatic en-
cephalosis, besides the occurrence of the same morbid change  in
various  organs.   In fact,  few  diseases,  as I  have observed
already, are single or simple.

                       IV.  SCIRRHUS.
  775.  The Symptoms of Scirrhus of the Liver are similar to
those of Encephalosis of this organ.  The countenance is rather
sallow than pallid, and there is earlier emaciation.

                       V.  TUBERCLES.
  776. Tubercles of the Liver are characterized by no symp-
toms except those of tubercles, and of disease of the Liver,  in
general.

            VI.  HYDATIDS, OR  ACEPHALOCYSTS.
  777. This affection may be suspected when there is enlarge-
ment of the liver, unequally developed, perhaps  circumscribed,
and then perhaps fluctuating;  icterus, ascites, and  anasarca,
may be superadded.*
  778. Hydatids of the liver may be expelled through

               1. The Intestinal Canal,
               3. The Bronchia;
or they may escape into
               1. The Peritonaum,
               2. The Pleura;
and then there is sudden acute inflammation.
  * In this and similar cases a puncture may be made by a minute trocar, in or-
der to ascertain the nature of the contents of the tumor.  This manoeuvre was
recommended, in external tumors, by the late Mr. Hey of Leeds. I believe I
was the first to extend the experiment to  cases of effusion into the thorax,* an
operation which ought to have been noticed, p. 297.
           * See the first edition of the Diagnosis, pp. 803; 204. 
    THE LIVER, PANCREAS, AND SPLEEN. 343

  779.  The Morbid Anatomy consists of the various  distor-
tion and enlargement of the liver by cysts and hydatids.

                VII.  THE  FATTY LIVER.
  780. In this case the liver is enlarged, leaves a  layer of oily
substance on the scalpel, renders  paper  oily and transparent
when warmed, and  burns in  the flame of a candle  when  its
aqueous particles are evaporated;  it sometimes  swims upon
water.  It is unattended by  icterus. It occurs principally in
                    Phthisis.  § 552.

                     VII.  CIRRHOSIS.
  781. This disease consists of diminution and deformity of the
liver, which  is dense, granular, wrinkled, and, as  its name im-
ports, of a  yellow color.  It is  uniformly attended by ascites,
§ 372, but without icterus.

            II.  DISEASES OF THE BILIARY DUCTS.

  782. The only disease of the Biliary Ducts which can be de-
tected during life is

                      OBSTRUCTION ;
and this may arise from a great variety of causes,  as

1. Thickening of the Ducts themselves.
2. Calculi ; or viscid Bile.
3. The Compression of Hepatic  Tumors.
4. The Compression of a Tumor  of some adjacent Organs.
5. Inflammation of the Duodenum.
6. A loaded state of the  Colon.
  783. The Symptom common to all these cases is Icterus;
those peculiar to each have been already detailed, with the ex-
ception of

                    BILIARY CALCULI.
   784. The History  and  Symptoms.   Biliary Calculi in-
duce no symptoms except when they obstruct the hepatic  or 
 344  DIAGNOSIS  OF  THE  DISEASES  OF

 common ducts ; they may long exist in the gall bladder or cys-
 tic duct without symptoms.  In the former case they may in-
 duce sudden paroxysms, or confirmed  suffering, of the kind
 about to be described.
   785. The paroxysm consists of the most excruciating pain,
 and perpetual sickness and vomiting; these are frequently pre-
 ceded by rigor and followed by icterus;  the bowels are con-
 stipated, the fasces pale, and the urine scanty and deep-colored.*
   786. The continued pain is attended by tenderness, extend-
 ing from the region of the gall-bladder over the hepatic region,
 and by icterus;  and eventually the liver itself becomes affected
 with inflammation, bilious congestion, and enlargement.
   787.  There is a fact, a reference to which is essential to the
 completion of the diagnosis of diseases of the liver and its appen-
 dages :  it is that of

              Rupture  of the  Gall-Bladder.
   788.  Such cases are mentioned by many authors, and,  re-
 cently, by M. Cruveilhier and M. Andral, and such a case lately
 occurred in the practice of my friend Mr. Cox.
   789.  The Symptoms are those of the most sudden and
acute Peritonitis:  excruciating pain and tenderness;  sick-
ness; sinking;  &c.  and, in  a word, the  symptoms observed in
perforation of the stomach or intestine ; § 707.

                DISEASES OF THE PANCREAS.
  790. The Pancreas is sometimes found of a redder color, and
denser texture, than natural, or affected by suppuration. It may
be scirrhous or compressed by scirrhus.   But  the Symptoms
are unknown, and, to this day, the diseases of the Pancreas are
of as little moment in a therapeutical point of view, as they are
rare in their occurrence.
  * It is extremely important to remark that precisely similar symptoms have
originated from a disordered and loaded state of the colon. 
  THE  LIVER,  PANCREAS,  AND  S P L E E N.  345

               IV. DISEASES OF THE  SPLEEN.
   791. The diseases of the spleen are exceedingly obscure: they
 may be viewed as only forming a part of a previous disease, as
                   1.  Typhus.
                   2.  Intermittent.
                   3.  Purpura, fyc.
 or as constituting a primary disease, as
      I. Inflammation, inducing
          1.  Changes in volume, consistencyy color;
          2.  Suppuration.
               1. Diffused.
               2. Abscess.
    II.  Organic Disease.
          1.  Tubercles.
         2. Encephalosis.
          3.  Cysts.
         4. Hydatids, 8fc

                   i.   inflammation.
  792. Inflammation of the Spleen is  usually attended by ob-
 scure pain and scarcely any  symptoms.  It has been supposed
 to give origin to phenomena of an aguish or intermittent char-
 acter.  It is principally to be detected by a careful examination :
 there is sometimes tenderness, sometimes a perceptible tumor;
 sometimes without tumor, the sound of the posterior and lowest
 part of the left side of the chest is dull, though the respiration is
 perfect.

                 II. ORGANIC DISEASE.
  793. Organic Disease of the Spleen  is easily detected when
there is enlargement, by which alone, indeed, it seems to affect
the general system.
                           44 
CHAPTER  VI.
  THE  DIAGNOSIS OF THE  DISEASES  OF THE  URINARY
                         ORGANS.

  794.  Few diseases are more frequent, or more practically im-
portant, than those of the Urinary Organs, viewed as primary,
and as secondary;  or as causes, and as effects, of other diseases.
  795.  Organic disease  of the kidney sometimes leads to the
suppression of the secretion, and this to comatose and other dis-
eases ; in  other cases, such disease leads to albuminous  urine
and  to dropsy.
  796.  Derangement of the stomach  equally leads to derange-
ment of the functions  of the kidney, and to the  deposit of va-
rious calculi, and their train of painful and dangerous effects.
  797. In other instances the function of the kidney becomes
deranged independently of previous derangement of other or-
gans, or of organic change in the kidney itself, but probably
from hereditary predisposition, as in Diabetes.
  798. All diseases modify the secretion of the urine, from Fe-
ver to those affections  which must still  be acknowledged, and
which  are  termed Nervous.   The periods  of digestion ;  each
kind of diet, of  beverage, and even of water ; each change of
the temperature and moisture of the atmosphere ;  has its effect
upon the secretion of the kidney.   Bodily exercise and certain
mental emotions, also have an obvious and immediate influence
in diminishing or augmenting the secretion of urine.
   799. It can no longer, therefore, be matter of surprise that ne-
 phritic affections are so frequent; and  we have still to add  to
 the list, those which affect the bladder, the prostate, and the ure-
 thra, and the general mucous lining of the urinary organs. 
OF THE  URINARY  ORGANS.       347
  800. All these are affections of one system, and one with the
general system.
  801. It will be my object, as usual, in this Chapter, to  dis-
encumber the subject of useless, or almost useless, refinements,
and to present to the  young practitioner, as simple and prac-
tical a view of the subject as possible; referring to the incom-
parable treatises of Dr. Prout and Mr. Brodie for further infor-
mation of a minuter kind.

 ARRANGEMENT OF THE DISEASES OF THE URINARF ORGANS.

       I.  THE DISEASES OF THE KIDNEY AND URETER.

                     I. THE ORGANIC.
    I. Inflammation.
              1. Injection.
             2. Enlargement.
              3. Softening; Induration.
              4. Suppuration.
                  1.  Abscess.
                  2.  Purulent Infiltration.

    II. Gravel and Calculus.
I.  The Diatheses  and kinds of Deposit and Gravel.
    1. The Lithic.
          1. With Yellow, Red or Lateritious, or Pink  De-
              posits of Lithate of Ammonia.
         2. With the formation of Red Gravel, or Crystals
              of Uric or Lithic Acid.
    2.  The Phosphatic.
          1. With the formation of White Gravel, or Crys-
              tals of Phosphate  of Magnesia  and Am-
              monia.
          2. With the White Sediment of the mixed Phos-
              phates of Magnesia and Ammonia, and of
              Lime. 
348     DIAGNOSIS OF THE DISEASES
II. The different kinds of Calculus.
    1.  The Lithic or Uric Acid; or the Light-brown.
    2.  The Triple Phosphate of Magnesia and Ammo-
        nia; or the  White.
    3.  The Mixed Phosphates of Magnesia and Ammo-
        nia, and of Lime ; or the Fusible.
    4.  The Oxalate of Lime; or the Mulberry.
    5.  The Alternating.

III. Granulated Kidney.
       Effects :
          1.  Albuminous Urine.
          2.  Dropsy, fyc.

IV. Organic Diseases.
          1.  Cysts.
          2.  Encephalosis.
          3.  Tubercles.
          4.  Hydatids.
          5.  Matiere Colloide.

                 II.  THE FUNCTIONAL.

  I. Suppression of Urine.
          1.  Causes.
          2. Effects.

 II. Diabetes.
III. Morbid Secretions.
           1. Albumen.
           2. Excess of Urea.

IV. Morbid Admixtures.
           1. Mucus.
           2. Pus.
           3. Blood. 
OF  THE URINARY  ORGANS.      349
II. THE DISEASES OF THE BLADDER, PROSTATE, AND URETHRA.

                  I. OF THE BLADDER.

  I. Inflammation,
           1. Injection.
           2. Ulceration.

 II. Calculus.
III. Nervous Affections.
           1. Irritability.
               1. Immediate.
               2. Sympathetic.
           2. Paralysis.

IV. Retention of Urine.

                 ii.  of the prostate.

  I. Inflammation.
           1. Tenderness.
           2. Enlargement.
           3. Abscess.
 IL Calculus.

                 ih. of the urethra.

  I. Stricture.
             Effects.
 II. Sympathetic Stricture.

      I.  THE DISEASES  OF THE KIDNEY AND URETER.

                   I.  THE  ORGANIC.
                  I.   INFLAMMATION.

  802. I.  The  History. The causes  of Nephritis may  be
constitutional, as  gout or rheumatism; seated in the kidney 
350    DIAGNOSIS   OF  THE  DISEASES

itself, as calculus ;  external violence, as a  fall, a blow, violent
riding; or exposure to  wet and cold ;  some  medicines, as tur-
pentine ; &c.  The attack of Nephritis may be acute, insidious,
or chronic; a frequent effect is the formation of a calculus ; and,
through its  medium, gout and calculus are frequently con-
nected.
  803.  II.  The  Symptoms are local pain and  tenderness.
These are felt on pressure, or percussion; or if the patient makes
a quick movement, or experiences a shock, as in making a false
step in walking.
  804.  The examination is best  made by placing the patient
accurately on the back, and pressing the fingers  between the
short ribs and the ilium, the thumb being opposed to them upon
the corresponding  part of the abdomen:  in this manner the
kidney is really between the thumb and fingers, and can be ex-
amined most distinctly, and pain and tumor are readily detect-
ed ; if the patient be not in bed, pain and tenderness are frequent-
ly detected by percussion.
  805.  With these symptoms are usually conjoined, fever;
nausea, and sickness,  retching and  vomiting; colicky pains
constipation  ; pain in the loins, extending into the iliac region,
in fact along the ureter;  symptoms of irritation of the bladder
or cervix ; various  morbid appearances of the urine, as deep
color, foetor, deposits, mucous, puriform,  sanguineous admixtures.
  806. III.  The  Organic  Changes in Inflammation of the
kidney are

              1. Injection ;
              2. Enlargement;
              3. Softening, or Induration ;
              4. Suppuration, assuming the forms of

                   1. Abscess,
                   2. Infiltration.
   807.   The Symptoms of Abscess are rigors, fever, and per-
spiration,  in irregular  paroxysms, resembling Intermittent, or
Hectic.  Mucous  or puriform sediments  are observed in the 
OF THE URINARY  ORGANS.        351
urine, which is frequently deep-colored, and of an ammoniacal
odor; and there is great irritation of the bladder and urethra.
  808.  Nephritic Abscess may point and burst externally;  or
it may penetrate and open into the abdomen, and induce sud-
den, severe,  and fatal peritonitis.
  809.   Nephritis,  however  confined to one kidney at  first,
usually invades both in its course.

                      II.  CALCULUS.
  810. I.   The History.  Calculus  is  frequently  the cause,
and as frequently an effect,  of the disease last noticed; it is the
latter  especially, when  Gout or  Rheumatism is the cause of
Nephritis.
   811. But calculus is apt to be formed in the kidney, in the
circumstances of those constitutional derangements which have
been denominated the calculous diatheses, of which the princi-
pal are

     1.  The Lithic.
          1.  With  Yellow,  Red, or  Lateritious, or Pink
                  Deposits of Lithate of Ammonia.
          2.  With the formation of Red Gravel, or  Crys-
                 tals of Uric or Lithic Acid.
      2.  The  Phosphatic.
          1.  With the formation of White Gravel, or Crys-
               tals  of Phosphate of  Magnesia and Am-
               monia.
          2.  With  the  White Sediment of the mixed Phos-
               phates of Magnesia and Ammonia, and of
               Lime.

    812. 1.  The first  of these is  associated  with  high  living,
 dyspepsia  and gout; and is denoted by an acid state of the
 urine, readily detected by litmus paper, red, lateritious, or pink
 deposits of lithate of ammonia, and  afterwards by the appear-
 ance of crystals of uric or lithic acid, or  the red Gravel.  This
 ■diathesis prevails in childhood, and about the age of forty. 
  352      DIAGNOSIS  OF  THE DISEASES

    813. There is a constant disposition to change from the lithic
  to the phosphatic diathesis: the urine becomes pale; there is a
  disposition, from slight causes of disorder, to deposit mixed lithic
  and phosphatic  sediments, or an iridescent  pellicle of triple
  phosphate forms upon its surface.   At length the urine becomes
  alkaline, and crystals of the triple phosphate of magnesia and
  ammonia are formed, constituting the white  gravel.
    814.  Under the influence  of these two diatheses, the lithic
 acid calculus and the triple phosphate calculus are formed. But,
 besides these, there are two other kinds of diathesis and of cal-
 culus to be briefly noticed in this place:
   815.  1.  The crystals of the  triple  phosphate are apt to be
 changed for a pulverulent deposit of that phosphate mixed with
 the phosphate of lime; and  the same mixture constitutes the
fusible calculus.  The constitutional and nephritic symptoms
 are extremely severe; the urine soon putrefies, with the  evolu-
 tion of ammonia.  A fall upon the back, an injury done  to any
 part of the urinary organs, may excite  this diathesis and its ef-
 fects ; and all the other forms of calculous diathesis tend to pass
 into this.
   816. 2. The other form of diathesis is that in which the
 mulberry calculus, or that consisting of oxalate of lime is
 formed.
   817. II.  The Symptoms of Nephritic Calculus, independent
of Inflammation, are  excruciating pain in the region of the
kidney and along the ureter; incessant nausea, vomiting, and
retching ; pain and  retraction of the testis ;  pain in the  inside
of the thigh;  dysury ; strangury.  The urine is high-colored ;
acid or alkaline;  mixed with mucous, puriform, or sanguineous
deposition.
   818.  The paroxysm  is  of various severity and duration;
gravel or a small calculus may pass, with perfect relief; or there
may be the transition from irritation into inflammation.
   819.  III. The Varieties of Calculus may be thus enumerat-
ed and  arranged for  practical purposes: 
OF THE  URINARY  ORGANS.        353
  1.  The Lithic or Uric Acid; or the Light-brown.
  2.  The Triple Phosphate  of Magnesia and Ammonia;
       or the White.
  3.  The Mixed  Phosphates of Magnesia and Ammonia;
       and of Lime ; or the Fusible.
  4.  The Oxalate of Lime ;  or  the Mulberry."
  5.  The Alternating.
   820.  The last of these is the most interesting in a pathologi-
cal point of view:  the nucleus in such calculi is most frequent-
ly lithic  acid, rarely the phosphates; these, on  the  contrary,
generally form upon some nucleus, and are seldom covered by
other depositions.   Indeed  Dr.  Prout  has deduced, from his
accurate observations, the  following law, upon  this subject:
" that a  decided deposition of  the mixed phosphates  is not fol-
lowed by other depositions."   The tendency, in the diathesis,
in deposits, of gravel, and calculous depositions, is always from
the lithic to the phosphatic.

               III. GRANULATED KIDNEY*
   821. I think it  important to refer, once  more, in this  place,
to the important researches and discoveries of Dr. Bright  on
this disease and its consequences: viz.
            1.  Albuminous Urine.
            2.  Dropsy, $-c.   See §§ 374—398.

                  IV. ORGANIC  DISEASE.
   822» The principal organic diseases of the kidney, are
            1. Encephalosis.
            2.  Scirrhus.
           3.  The Matiere Colloide.
            4.  Cysts.
            5.  Hydatids.
   823.  The Symptoms consist in some degree of tenderness:
in tumor; in various irritative effects upon the bladder and the
acts of micturition; and in deranged appearances of the urine.
                             45 
354      DIAGNOSIS  OF  THE  DISEASES

               II.  THE FUNCTIONAL DISEASES.
                I.  SUPPRESSION OF URINE.
  824.  I.  The History involves that of some antecedent dis-
ease, of which this is, in truth, but a symptom, yet so serious
and  fatal a symptom, as to deserve  peculiar attention.  That
disease may be inflammation, or calculus, with their effects, and
perhaps any form of organic disease of the kidney.
  825.  II.  The Symptoms.  The suppression may be partial
or complete; its  existence, its degree, and its distinction from
retention, are determined, at once, by the catheter.
  826.  From whatever cause it may arise, suppression of urine,
if continued, speedily induces serious symptoms.  There are
fever, thirst, a taste  of urine in the  mouth,  and  the  smell  of
urine in the perspiration ; to these, nausea, vomiting, sometimes
of matters having a urinous odor, and hiccup, succeed ; and  to
these, dyspnoea, delirium, and eventually coma, and convulsions.
  827.  Having ascertained the existence of  suppression, the
next  point in  the diagnosis,  that  which  directs the mode of
treatment, is the identification  of the original disease.   This
is to be done upon the principles detailed in the former part of
this chapter.
  828.  III. The Morbid Anatomy consists in  those morbid
changes which constitute the causes of this affection,  and in  its
effects,  especially in inducing  congestion, or effusion into the
ventricles, of the brain.

                      II.  DIABETES.
  829.  I. The History.  This disease seems to be hereditary.
Its accession is highly insidious,  the first symptom which excites
attention being the augmented secretion of urine.
  830.  II. The Symptoms.   The pathognomonic  symptom
of Diabetes, is a saccharine  state of the urine: the urine itself
has a peculiar sweetish taste and smell; and,  if  dropped  and
dried  upon linen or  paper, it is glutinous and adheres  to the
fingers.   There is urgent thirst, and the appetite for food is
excessive; the mouth is clammy or parched,  the tongue clean; 
OF  THE  URINARY  ORGANS.       355
the skin is harsh and dry, and without perspiration; the bowels
constipated.  There are pain and  weakness across the loins;
frequent micturition; diuresis; irritation of the orifice of the
urethra; anaphrodisia.   There are debility and  emaciation;
oedema; &c.
   831. III. The  Complications.   If these symptoms be  not
checked, there succeed
                   1. Hectic ;
                   2. Phthisis ;
                   3. Dropsy ;
                   4. Apoplexy ;
   832. IV.  The Morbid Anatomy  is still  very imperfectly
known,

                III. MORBID SECRETIONS.
   833. Dr. Prout describes  the albuminous character of the
urine as being  of two  kinds:  the  chylous and serous;  the
former being far more frequent than the latter;  but the mixed,
most frequent of all.
   834. 1.  In the Chylous variety, the albumen is greater after
meals.  There  is  frequent micturition, and increased secretion
or diuresis.   There are craving  for food, and other of the
symptoms of Diabetes.
   835. 2.  The  Serous  variety of this affection seems to be  con-
nected with augmented action in the system : the urine is not
only albuminous, but occasionally mingled with blood itself; it
is, in such cases, frequently associated with dropsy, and  apt to
terminate  in apoplexy.   See §§ 364; 376; &c.

                     Excess of Urea.
   836. For the discovery of this form of disease, we are in-
debted to Dr. Prout.  There is diuresis, and the case has been
termed diabetes insipidus.   The  urine is generally pale and
without sediment, and  is only characterized by the deposit of
crystals of urea on the addition of nitric acid.
   837. There is a constant desire to void urine, both  by night 
356      DIAGNOSIS  OF  THE  DISEASES

and  day ;  there is sometimes dull pain  in the back, at others,
occasional  irritation at the neck of the bladder and along  the
urethra.   There is no affection of the  skin, or pulse, no thirst,
or inordinate appetite, or constipation.  This affection seems, ac-
cording to Dr. Prout, to be allied to those in which the urine is
albuminous, or saccharine, or deposits the phosphates.

                IV. MORBID  ADMIXTURES.
   838.  The Morbid Admixtures with the urine are
                     1.  Mucus,
                     2.  Pus, or
                     3.  Blood.
They must be regarded merely as Symptoms, and denote in^
flammation, or irritation, of the
                     1. Kidney.
                     2.  Bladder, or
                     3.  Prostate.
   839.  The source of these admixtures with the urine is de
termined by the other symptoms in the first two cases, and by
a careful examination in the third.   If the symptoms  be prin-
cipally nephritic, § 804, and the  blood be diffused through the
urine, the kidney is the probable seat of  the morbid secretion or
effusion;  if vesical, § 846, with the discharge of blood only
partially mixed with  the urine, and towards the end of mictu-
rition, the bladder is probably that source.
   840.  But, besides  these cases, Hamaturia occurs  in some
other circumstances: it is frequent, for instance, in
                     1.  Typhus.
                     2.  Purpura.
                     3.  Scorbutus.
   841.  In one case, the patient  discharged large quantities of
dark-colored blood,  perfectly mingled  with the urine, on every
exposure to cold; the flow was as certainly arrested by the genial
influence of warmth. 
           OF  THE  URINARY  ORGANS.        357

  II. DISEASES  OF THE BLADDER, PROSTATE, AND URETHRA.
                   I. OF THE BLADDER.
                    I. INFLAMMATION.
  842. I. Acute Inflammation of the  Bladder is rare.   The
repulsion of gonorrhoea sometimes induces this disease, as, in
other instances,  it excites inflammation of the prostate, or of the
testis.  Chronic Inflammation of the Bladder may arise from
               1.  Stricture of the Urethra.
               2.  Disease of the Prostate.
  843. II. The Symptoms are a frequent desire to void urine,
even when  the bladder is empty,  or strangury; and  pain in
the region of the  bladder, especially  on or after micturition.
There is fever, with a frequent pulse, and a furred tongue   The
urine deposits a mucous sediment, suggesting the designation
catarrhus vesica ; it adheres to the vessel, and is alkaline.
  844. III. The  Morbid Anatomy  consists in redness and
dark-color, and  thickening of the mucous membrane,  sometimes
extending along the ureters and to the pelves of the kidneys,
which are apt to be dilated, and to the substance of these organs,
which are then  enlarged, and perhaps become the seat of abscess
or other  disease.   The internal  membrane of  the  bladder is
sometimes ulcerated.  The bladder is sometimes perforated like
the stomach, and the urine flows into the cavity  of the perito-
naeum, or through a fistula  into the rectum, or by an external
opening.

                        CALCULUS.
   845. I. The History.  Vesical Calculi may be  viewed in
two points of light: that of
                  1.  The Nucleus.
                  2.  The exterior portion.
   The most common nucleus is a nephritic calculus, which has
passed through the ureter.   But any foreign  substance intro-
duced into the bladder may become the nucleus of calculus; thus 
358      DIAGNOSIS  OF  THE  DISEASES

a hazel nut, a portion of a bougie, has formed the centre of calcu-
lous  deposition.  The  exterior portion  is  most frequently the
triple phosphate, or the mixed phosphates.  The phosphates are
frequently deposited by the influence of .the alkaline mucus of
the bladder, when this is  very abundant,  mingling with the
urine.
  846. II.  The Symptoms vary in intensity exceedingly, ac-
cording to
       1.  The Size and Surface of the Calculus ;
       2.  The Condition of the Bladder;
       3.  The Condition  of the Urine.
It is obvious that a small, smooth calculus  must induce less un-
easiness than  one that is rough  and large: the same calculus
will induce very different effects upon a healthy and upon an in-
flamed vesical surface:  acid, and especially alkaline urine, adds
another source of irritation to that of the calculus itself.
  847. 1. In the 'milder forms of this disease,  there is a slightly
increased desire to make water, and this  act is followed by slight
irritation at the cervix or along the  urethra ; the flow of urine is
sometimes suddenly stopped, the calculus  closing the  orifice of
the urethra ; the urine is apt to be bloody after  riding or other
shaking exercise.
  848. 2. In the severe forms  of calculus, the  calls  to make
water become sudden, frequent,  urgent, and irresistible, and lia-
ble to be induced by any change of position.  There is a charac-
teristic sympathetic pain, on voiding urine, at the termination
of the urethra  and glans penis.   There is pain in the region
of the bladder,  groins, &c.
  849. The symptoms are  aggravated  still further, as the cal-
culus enlarges, as the  bladder inflames, and as the urine be-
comes alkaline.  The desire to make water becomes urgent and
incessant; the pains  are extremely augmented, and the urine
becomes  ammoniacal,  mucous, and sanguineous.   There is
sometimes spasmodic stricture of the urethra.
  850. These symptoms, and indeed any one or more of them,
will lead to the use of the sound, by which alone the existence 
           OF  THE  URINARY  ORGANS.       359

of calculus is rendered certain, and its size and character are,
in some degree, ascertained : if the calculus be of recent forma-
tion, and  the urine acid, we have further  reason  to  conclude
that it consists of lithic acid ; if, on the contrary, the symptoms
have  existed long and are severe, and the urine is alkaline, we
may conclude that the phosphates have begun to be deposited.
  851. III.   The Morbid Anatomy of calculus relates  princi-
pally to
             1.  The Bladder itself;
             2.  The Kidney ;
             3.  The Prostate.
  852. 1. There are the usual appearances of inflammation in
the mucous  membrane of the bladder.
  853. 2. The pelvis of the kidney and the ureter are frequent-
ly augmented in size, and  the kidney itself suffers variously
from inflammation and other morbid changes.
  854. 3. The  prostate is sometimes enlarged ; in a few cases
it has become ulcerated, and then the sufferings of the patient
are extreme.

                III. NERVOUS AFFECTIONS.
                      1.   Irritability.
  855. I. In some  cases there is an irritability of the bladder
which is entirely mental: the attention is directed to this orsun
and the necessity for emptying it,  however imaginary,  becomes
imperative ;  it is repeated ;  it becomes  constant.  The patient
cannot travel, cannot visit, on account of this mental irritability
in regard to  the bladder.
  856. In other instances, the  urine becomes acid, or alkaline •
the bladder is unusually stimulated, and becomes irritable.
  857. Irritability of the bladder occurs in nervous patients, and
in old persons, without disease.
  858. Irritability of the bladder is not unfrequentiy a  sympa-
thetic affection in
Disease of the Kidney. 
360     DIAGNOSIS  OF  THE  DISEASES


                       2. Paralysis.
   859.  Paralysis of the bladder occurs  from disease or injury
of the brain and  spinal marrow;  in typhus ; in old age.  It
leads to
                IV. RETENTION  OF URINE.
   860.  When retention occurs from paralysis,  it is very fre-
quently accompanied  by incontinence of urine, the cervix as
well as the body of the bladder being affected.  The region of
the bladder  should be carefully examined, and  the  catheter
should be passed.  Retention may also arise from
             1.  Stricture.
             2.  Disease of the Prostate, fyc.

              II. DISEASES  OF THE  PROSTATE.
                   I.  INFLAMMATION.

             1.  Acute.
                  1. Swelling.
                  2. Abscess.
             2.  Chronic.
   861.  I.  The History.  In the young, the prostate is some-
times the seat of Acute Inflammation, with, or without, the re-
pulsion of gonorrhoea.  In the old, this gland becomes the seat
of Chronic Inflammation.

                      I.  The Acute.
   862. II. The Symptoms of the Acute Inflammation of the
Prostate, are pain and uneasiness, and a sense of fulness, at the
cervix vesicas, in the perinaeum, and in the rectum, frequent de-
sire to void the bladder, with more or less of obstruction,  stran-
gury, and tenesmus.   There is  distinct  tenderness on pressure
by the finger introduced into the rectum, with some enlarge-
ment ; the bougie determines the absence of stricture.
   863. If Abscess forms,  these symptoms continue;  the ten- 
OF  THE  URINARY  ORGANS.        361
derness and swelling increase, and at length the abscess opens
externally, into the urethra, &c.   Meantime the dysury  in-
creases, with perpetual calls to make water, and there are rigors,
fever, quickened pulse, hot skin, furred tongue, &c.  With this
affection there is frequently extensive

            Disorganization of the Kidneys.

                     2.  The Chronic.
   864. III. The  Symptoms in Chronic Enlargement of the
Prostate  are irritability  of the bladder, with  some obstruction
to the passage through  the urethra.  There  are frequent calls
to void urine,  and some difficulty in  doing so,  and it perhaps
dribbles  away, especially during sleep, and is, at best,  but im-
perfectly expelled.   From  various causes, the symptoms may be
aggravated, and the difficulty of passing urine becomes  extreme,
or there  is complete retention.  In extreme cases, the vesical
mucous  membrane may  slough, the powers of life  fail,  the
tongue becomes dry and black, and there is complete, and fatal,
coma.
   865. IV. The following  Complications of this disease  are
apt to take place :
       1. Abscess or Ulceration of the Prostate.
       2. Inflammation of the Bladder.
       3.  The Formation of Vesical Calculi.
       4. Disease of the Kidney.
These affections  seem  to be  sometimes continuous  from, at
others, excited by, the disease of the prostate.   The urine may
be augmented or  diminished in quantity, suppressed or re-
tained* with the usual formidable  or fatal  symptoms,  § 826.
The bladder is very often marked by hypertrophy of the muscu-
lar fibres.
  * Mr. Brodie has treated this subject in the fullest and most able manner, in
his Lectures on the Urinary Organs : Lecture v.
                            46 
362   DIAGNOSIS  OF THE  DISEASES, ETC.

                       II. CALCULI.
  866.  Calculi  of  the  Prostate  produce  similar  symptoms.
They are sometimes detected on  examination with the finger
or sound;  sometimes fragments are discharged,  and they  are
identified by their chemical composition, which consists  princi-
pally of phosphate of lime, with animal matter.

              HI. DISEASES OF THE URETHRA.

                      I. STRICTURE.
  867. Stricture may be suspected whenever there is difficulty
in passing the urine, and this flows in a  diminished,  flattened,
spiral, or split stream;  it is ascertained, with its  situation and
extent, by means of the bougie, &c.
  868. The principal Effects of Stricture are
       1.  Irritability of the Bladder.
       2.  Retention of Urine.
       3.  Abscess in Perinao.
       4.  Dilatation of the  Urethra.
       5.  Disease of the Prostate.
       6.  Inflammation of the Bladder.
       7.  Hypertrophy of the Muscular Coat of the  Blad-
           der.
       8.  Disease in the Kidneys.
       9.  Disease of the Testis  ?

                II.  SPASMODIC STRICTURE.
  869. This affection may take  place from exposure to cold,
excess in wine, &c.  There is difficulty or inability of micturi-
tion.  This comes on suddenly, and sometimes  goes off under
the influence of sudorific  and anodyne remedies.  By repeated
returns, it may lead to permanent stricture. 
CHAPTER  VII.
  THE  DIAGNOSIS OF THE DISEASES  OF THE UTERINE
                         ORGANS.

  870.  As the kidney, the bladder, the prostate, form a series
or system of organs, the diseases of which mutually induce or
aggravate each other;  so do, in an especial manner, the uterus,
the ovarium, the mamma?, &c.   It is still an important inquiry
how far remedies applied to one part of the series may  relieve
disordered actions in  another.   And the  bond of connexion
which binds these several organs amongst each other, and with
the whole system, still  affords a subject of deep interest for  re-
newed  inquiry.  There is  no question  that the head  is fre-
quently affected by the condition of the uterine system.   This
is seen in nymphomania.  On the other hand, phthisis disposes
to conception, and this  frequently checks the progress of phthisis.
And cancer occurs simultaneously in the mamma  and  in the
uterus.   These connexions  are still more readily traced  in the
physiology of the uterine system.
  871.  I shall  take this opportunity of relating a characteristic
anecdote of the late  Dr. Gregory, for which I am indebted to
Dr. Patterson.  Dr. Gregory was consulted, in the town of Ayr,
in the case of a lady who had repeatedly miscarried, with  dread-
ful haemorrhage, in spite of  every remedial means which could
be devised by the first medical authorities  in Scotland.  Dr.
Gregory saw the patient on one of  these occasions:  he prescrib-
ed for the heemorrhagy, and, when this had been arrested, and
the patient had sufficiently recovered, he examined the state of the
mammae, found them distended with  milk, and directed a lusty
infant to be applied, and nursed for nine  months.   The  course
of the uterine blood  was directed into another channel.   The 
364      DIAGNOSIS OF THE  DISEASES

lady became pregnant, the mother of a living child, and ulti-
mately of a numerous family, her labours being unattended by
haemorrhagy!
  872. This history bears the stamp of genius.  The fact itself
is full of interest, and  perhaps of more extensive application
than may appear at first sight.  May not the disposition to ute-
rine haemorrhagy, in other instances, be  prevented by attention
to the due adjustment of the mode and period of lactation ?
  873. I have,  throughout these sketches, called the attention
to one  important  principle—that  diseases are not simple—not
the affections of single organs—but of systems; and I again
take the liberty of repeating this remark in connexion with the
diseases of the uterine organs.

 ARRANGEMENT OF THE DISEASES OF THE UTERINE ORGANS.
             I. THE DISEASES OF THE UTERUS.
                     I. THE ORGANIC.

  I.  Inflammation.
          I. Peritonaal.
         II. Parenchymatous.
                1. Injection.
                2. Softening.
                3. Induration.
                4. Enlargement.
                5. Suppuration.
                    I. Abscess.
                    2. Infiltration of Pus.
                    3. In the Uterine Cavity.
                    4. In the Veins.
         III.   Of the Mucous Membrane.
              1.  Amenorrhaa.
              2.  Dysmenorrhea.
              3.  Formation of a False Membrane.
              4.  Obliteration of the Uterine Orifices.
              5.  Leucorrhoea. 
          of  the  uterine  organs.       365
       IV. Of the Cervix Uteri.
    II. The Irritable Uterus.
   III. Fibrous Tumors.
          1.  Under the Peritonaum.
          2. In the substance of the Uterus.
          3,  Under the Mucous Membranes.
   IV. Cysts or Encysted Tumors.
    V. Scirrhus—Cancer.
          1. In the  Cervix Uteri.
          2. Involving the Cervix Uteri and the Rectum,
                or the Bladder.
   VI. Corroding Ulcer.
          1. Of the Cervix Uteri.
          2. Involving the Cervix and the Rectum, or the
               Bladder.
  VII. Encephalosis—Cauliflower Excrescence.
 VIII. Polypus.
  IX. Inversion.
   X. Prolapsus.
  XI. Elongated Cervix.
 XII.  Anteversion.
XIII.  Retroversion.
XIV. Hydatids, &c. distinguished from Pregnancy and
           its complications.
 XV. Pelvic Tumors, &c.
                 n. THE functional.
   I. Amenorrhcea.
   II.  Dysmenorrhcea.
  III.  Menorrhagia.
  IV. L.EUC0RRH03A. 
366      diagnosis of the diseases

             II. diseases of the ovaria.

    I. Inflammation.
          1. Injection.
          2. Suppuration.
   II. Cysts or Encysted Tumor, distinguished from
            Ascites.
  III. Fibrous and other Tumors.
  IV. Encephalosis.

          HI. THE DISEASES OF THE MAMMA.

   I. Inflammation.
         1.  Tenderness and Tumor.
         2.  Abscess.
             1.  Several.
             2.  Deep-seated.
             3.  Lacteal.
             4.  Chronic.
   II. Tuberculous Swelling.
  III. The Irritable Mamma.
         1.  With Tumor.
         2.  With Ecchymosis.
  IV. Chronic Mammary Tumor.
  V. Encysted, Hydatid, and other Tumors.
 VI.  Encephalosis.
VII,  Scirrhus—Carcinoma.
         1.  Of the Mammary Gland.
         2.  Of the Nipple.
         3.  Of the Skin.
         4.  Of the adjacent Lymphatic Glands.
         5.  Ulceration; Cancer. 
OF THE  UTERINE  ORGANS.
367
             I. THE DISEASES OF THE UTERUS.
                   I. ORGANIC DISEASES.
                    I. INFLAMMATION.
                     1. Peritonaal.
  874. Inflammation of the Peritonseal Coat of the Uterus is
denoted by pain, and tenderness on pressure, and, if it be con-
fined to this texture, by the absence of other symptoms.

                   2. Parenchymatous.
  875. I. The History.  Inflammation of the  Parenchyma-
tous Substance of the Uterus is very apt to be overlooked : it is
sometimes induced by the sudden  repression of the catamenia,
from exposure to fatigue, wet, or cold ; by marriage, &c.
  876. II.  The Symptoms are pain and tenderness in the re-
gion of the uterus, aggravated by pressure, and in  paroxysms,
and at each return of the catamenial period.  There are a sense
of fulness;  perhaps some disposition to bearing down; frequent
calls to make water; some degree of tenesmus, or uneasy feel-
ing about the rectum. There is pain in the back and round the
ilium, augmented by coughing, straining, or walking.   Great
relief is afforded by quiet, and the horizontal position.
  877. III. The Morbid Anatomy.  Besides  these forms of
Inflammation of the Uterus, this organ, in acute cases, under-
goes a change of texture which leads to
                       Softening ;
in more chronic cases, there is
                       Induration ;
and, in other instances, there is
                       Suppuration.
The pus may exist in
                1. A dictinct Abscess ;
                2. The State of Infiltration;
                3. The Cavity of the  Uterus;
                4. The Adjacent  Veins; 
368     DIAGNOSIS  OF  THE  DISEASES

and may escape
                1. Per Vaginam;
                2. Into the Abdomen;  fyc.
             3. Of the Mucous Membrane.
  878. Inflammation of  the Mucous Membrane of the Uterus
assumes several forms, which are respectively denoted by
                1. Amenorrhea;
                2. Dysmenorrhea;
                3. The Formation  and  Expulsion of a
                    False Membrane.
                4. Obliteration of the Uterine Orifices;
                5. Leucorrhea.
  879.  1.  There seems to be no doubt that Amenorrhcea,
which is a symptom in Chlorosis, Tubercle, and so many other
diseases, may arise from  Uterine Inflammation.  The history
and the other symptoms establish the diagnosis.
  880. 2.  Dysmenorrhcea is also, I am persuaded, a frequent
effect of Inflammation of the Mucous Membrane of the Uterus.
  881. 3.  The False Membrane, sometimes periodically formed
and expelled by  the Uterus, can only be compared to that ob-
served in Croup, and in some cases of Eso-enteritis.
  882. 4.  Obliteration of the Uterine Orifices may result from
Inflammation, and prove  the source of sterility.
  883. 5.  Lastly, one form of Leucorrhcea seems also to have
its origin in Inflammation  of the Mucous Membrane of the
Uterus.

       II.  INFLAMMATION OF THE CERVIX UTERI.
  884. I.   The History.  This affection is induced by the
same causes as Inflammation of the Uterus itself.
  885. II.  The  Symptoms consist in an exudation  of white
mucus from the cervix uteri, and tenderness on examination
per  vaginam, without  tumefaction, or  ulceration.  The cata-
menia may be unaffected; or there may be dysmenorrhcea; or
conception may be prevented.   The act of passing  indurated
fasces, the shaking of  riding, give pain.  There may be some 
OF  THE  URINARY  ORGANS.        369
degree of irritation about the rectum, but more especially about
the bladder, and there is frequently pruritus of the pudenda.(')

                III.  THE IRRITABLE UTERUS.
   886. I. The History.  Dr. Gooch has described an interest-
ing  case of Uterine affection under this designation,  neither
inflammatory in its nature, nor tending to disorganization in its
course.*  It seems to arise from  cases similar to  those enume-
rated § 875.  It is very apt to be of a protracted  character.
   887. II. The Symptoms consist in pain in the region of the
uterus, aggravated  by every movement of the body, and re-
lieved by quiet and  the  recumbent position ; and in exquisite
tenderness of the os uteri.  There is irritability of the general
system.
   888. III.  Effects of Remedies.   There is great intolerance
of loss of blood.
   889. IV.  The Mordid Anatomy.  This affection does not
tend to disorganization.   The os uteri is only slightly swollen.

                    III.  FIBROUS TUMORS.
   890.  I.  The History.   The Fibrous Tumor is  generally
slow in its progress, and unattended by constitutional symptoms.
   891. II. The Symptoms are very obscure; but  this disease
is a frequent cause of menorrhagia,\ even when long continued,
a fact important to  be  generally known.   In  the  progress of
  (1.) The fact that Amenorrhea and Dysmenorrhcea are frequently symptoms
of inflammation of the uterus, especially of the cervix uteri, is a point of great
practical importance.  Consult Duparque, Mai. de l'TJterus, for much valuable
information on that much-neglected subject, the pathology of Uterine Diseases.
                                                           S.
  * This affection may be compared to the Irritable Breast, the Hysteric Affection
of the Joints, &c.
  f In one case there was profuse monorrhagia during twelve years of unfruitful
marriage ; the patient then became pregnant;  the tumors were distinctly felt in
the parietes of the distended uterus ; parturition was accomplished well; but the
fibrous tumors became infkmed and suppurated: and this led to a fatal puerperal
disease.
                               47 
370      DIAGNOSIS  OF  THE  DISEASES
the disease the tumors  become detectible on external examina-
tion, or on examination per vaginam, and  per rectum-C)
   892. III.  The Morbid Anatomy.   A fibrous texture some-
times occupies a great  part  of the uterus;  the fibrous tumor
may occur
        1. Immediately under the Peritonaum ;
       2. In the Substance of the Uterus;
       3.  Under the Mucous Membrane.

             IV.  CYSTS OR ENCYSTED TUMORS.
   893. This disease can only be ascertained  when, by its size,
it compresses some adjacent organ, as the intestine, the bladder,
and so leads to a careful examination of the hypogastric region
and per vaginam.  It is unattended by constitutional symptoms.
It is occasionally attended by a sense of fluctuation.

                V.  SCIRRHUS ;  CARCINOMA.
   894.  I.  The History.   This terrible disease usually occurs
after thirty or forty.  It is extremely insidious.
   895. II.   The  Symptoms we lancinating pain, and  local
pains extending round the ilia and to  the  back, and even the
loins;  strangury;  some  vaginal discharge;  perhaps repeated
abortion; and  some obvious inroads made upon the  general
health,—especially the complexion, the  strength, the flesh, &c.
Such circumstances should  invariably lead to a careful exami-
nation per vaginam.(2)
  (1.) Haemorrhage occurs as a symptom of Fibrous Tumors of the Uterus,
only in cases where the tumor is situated either in the substance of the uterus or
beneath the mucous membrane.  Consult G ooch, an account of some of the most
important diseases peculiar to women.                             S.
  (2.) The physical signs of the early stage of Carcinoma Uteri appear to me
to be these—It is a well established fact  that the cervix is the  po.tion first af-
fected.  On examination by the touch this portion of the organ is ? emarkably
firm without being much, if at all, enlarged, and without increased sensibility.
Through the speculum it appears more pale than natural, sometimes even of a
dead while colour.  The nibbled, irregular, condition of the os tincae, which some
have considered as diagnostic of this stagei of Carcinoma, although more marked
in this disease, does not appear to me peculiar to it.                    S. 
            OF  THE  UTERINE  ORGANS.        371

   896.  All the symptoms  become aggravated  daily : the dis-
charge becomes sanious, sanguineous, foetid ;  the pains severer ;
the complexion paler,  yellower;  the loss of flesh and loss of
strength greater; and a  disposition to anasarca, and  pains like
those of rheumatism, supervene.
   897. On examination, the os uteri is found swollen, hard, ir-
regular in form, open and circular; afterwards, it is jagged from
ulceration.   The real state of things is, however, only  to be
correctly known by means of  the speculum.
   898.  The  contiguous parts are  gradually  involved in  the
disease, and a communication may be formed with the rectum
or the b didder.

   VI.  THE CORRODING  ULCER*  OF  THE CERVIX  UTERI.
   899.  This  disease  occurs  unaccompanied by  tumor, hard-
ness, or other appearances of scirrhus.   There is a sensation of
heat or burning.  The catamenia yield to a yellow, or sanguine-
ous, sanies.   There is none of the lancinating pain observed in
scirrhus.  There are  great pallor, debility,  emaciation.  The
state of disease of the cervix is accurately ascertained  only by
the finger and the speculum conjointly.
   900. Like scirrhus and carcinoma, the corroding ulcer some-
times penetrates into the rectum, or the bladder,  affording  an
exit to the fasces, or urine, through the vagina,

    VII.  ENCEPHALOSIS.--CAULIFLOWER EXCRESCENCE.
                         •
   901. This disease may effect the  body or the cervix of  the
uterus.   In the former case, it occasions a tumor, perceptible in
the hypogastric region, which is rather rapid in its progress, and
not unattended by constitutional symptoms.  In the latter case,
it probably  constitutes the disease which has  been  designated
  * Sir C. M. Clarke, Diseases of Females, vol. i, p. 135.  Baillie's Morbid
Anatomy ; Malignant Ulcer ; Ed. by Mr. Wardrop, vol. ii. p. 323.  Andral,
Precis d'Anatomie Pathologique, t. ii, p. 683, &c 
372      DIAGNOSIS  OF  THE  DISEASES
               The Cauliflower Excrescence.
  902.  I. This affection was first noticed by the late Dr. Clarke,
and is described by Sir C. M. Clarke.   It has been recently con-
sidered  more fully by the late  Dr.  Gooch, who considers it as
fungus  haematodes, or Encephalosis.
  903.  II. This disease is the source of a watery discharge, and
of frequent haemorrhagies; it grows from the cervix uteri by a
broad base, has a rough  surface, and is insensible: if tied by
ligature, it returns.  In one case, it was readily removed in por-
tions by the finger, without augmented haemorrhagy.  It destroys
life by its malignant influence upon the constitution, and by the
loss of  blood.   The patient becomes  pallid and  feeble,  and
gradually,  or  suddenly,  sinks.   The  examination with the
finger should  certainly  be aided by that by means of the spe-
culum,
                      VIII. POLYPUS.
  904.  The first Symptom, in Polypus is an alternate discharge
of blood and serum, or a discharge of serum  only, usually mis-
taken for menorrhagia, or leucorrhea, without local pain.
  905.  In all such cases, an examination should be made per
vaginam. In Polypus,  a  round, smooth, firm, insensible tumor
is felt;   and  the  next  object is to ascertain its attachment;
this is
            1. At the Fundus ;
            2. Beyond the Cervix ;
            3.  Upon the  Cervix.
In the first case, the finger may be passed  round the stalk ;  in
the second, it can be passed half round only ;  in the third,  its
origin is distinctly felt.*(')

  * Much of the character and diagnosis of polypus may be learnt by the use of
the speculum—by means of which the operation for its removal has become, in
the hands of my friend Mr. Heming,* of infinitely greater facility  and safety
than before.
  * See the fotthcoming translation of the work of M. Dgges and Mme. Boivin, with
Additions.
  (1.)  The existence of Haemorrhage as a symptom of uterine Polypi, depends
upon the place of their insertion—if within the cavity of the uterus, Haemorrhage
is a constant and often formidable symptom.  Consult Gooch, ut sup.    S, 
          OF  THE  UTERINE ORGANS.         373

                   IX.  INVERSIO  UTERI.
  906.  I. It occured to Dr. W. Hunter, and it has occurred to
others, to apply a ligature to the Inverted Uterus, mistaking it
for Polypus!   It  occured to  Dr. Denman, and it  occurred in
Bartholomew's Hospital, to include a portion of the uterus in the
ligature of a Polypus !
  907.  II.  Inversion of  the Uterus, in its simple  form is dis-
tinguished by its  occurrence immediately after  parturition, and
by its sensibility.
  908.  III.   When  complicated with polypus, it is  still distin-
guished by its sensibility; and if  a ligature should ever give
extreme pain or  induce  vomiting, it  should  immediately be
removed, on the supposition of  its  having involved, or at least
irritated, the uterus itself.

                      x. PROLAPSUS.
  909.  Prolapsus is distinguished by observing that the os uteri
occupies its lowest part; by ascertaining that the tumor is sen-
sible ; and  by the fact that it  may be  returned into its proper
situation.

              XI. THE  ENLONGATED  CERVIX.
   910.  The existence of this form of Uterine Disease  was first
pointed out by Mr. Heming.
   911.  The os  uteri is discovered upon the most  protuberant
part of  the tumor, through which a probe may be passed up six
inches or more into the  uterus.  The  enlongated neck of the
uterus may  be  traced with  the finger.  This form of disease
occurs

            1. In Pregnancy ;
            2. In Hernia of the Bladder ;
            3. In Hernia of the Rectum ;
            4. In Ascites, fyc.
apparently from the influence of mechanical causes. 
 374      DIAGNOSIS  OF  THE  DISEASES

                  XII.  HYDATIDS : ETC.
   912. The cavity of the uterus is sometimes distended by sub-
 stances foreign to it in its natural state : these are
            1. Hydatids.
            2. Aqueous Fluid.
            3. Air.
            4. Calculus.
            5. A Bony Mass.
            6. A Dead Fetus, &c.
            7. Retained Catamenia.
   913.  The Symptoms  of Hydatids may be given, instar om-
 nium.  There is tumor  in the  region of  the  uterus, without
 tenderness, and without regularity in its progress.   At length,
 with contractile uterine pain, a portion of hydatids, or, in other
 cases, of fluid, of air, &c. is expelled, and the disease is made
 manifest.  There  are,  in the mean  time, neither the constitu-
 tional symptoms  of inflammatory, nor those of  malignant dis-
ease : the pulse, the flesh, &c. are unaffected.
   914.  It is chiefly important to notice this disease, in order to
 institute a comparison between it and pregnancy, the subject to
 be shortly noticed.

                  XIII.   ANTEVERSION.
   915.  I. The  History.   Anteversion of the Uterus arise ge-
 nerally  from augmented fulness of  the blood-vessels  in some
forms of Inflammation.   Its exciting cause is frequently fatigue,
effort, &c.
   916.  II. The Symptoms consist in obstruction to the evacu-
ation of the bladder and of the rectum.
   917.  III. On examination,  the os uteri  is  found pressing
backwards upon the intestine, the fundus being thrown for-
wards upon the neck of the bladder.
   918.  Anteversion of the uterus may exist with far less incon-
venience than Retroversion, and has, therefore, been far more
frequently overlooked. 
OF  THE  UTERINE  ORGANS.       375
                   XIV.   RETROVERSION.
   919. I.  The History.  Retroversion most frequently occurs
 from the third to the fourth month of pregnancy.   It may also
 occur from enlargement of the uterus from other causes; as po-
 lypus.  It is frequently induced by effort, blows on the loins,
 &c.  It is generally sudden in its accession.
   920. II.  The  Symptoms are retention of urine, obstruction
 of the intestine, pain in the groins and  loins, diminished hypo-
 gastric  tumor; augmented symptoms of retention  of the urine
 and of the faeces ;  (fee.
   921. III. On examination per vaginam, the finger passed
 upwards anteriorly  can scarcely  reach the os uteri; posteriorly
 its  fundus  is left pressing upon the rectum and sacrum.   On
 passing the finger into  the rectum, the  fundus uteri is felt still
 more distinctly pressing upon the intestine.
   922. To complete the diagnosis, the uterus must be replaced.
 The catheter must be introduced ;  the rectum must, if possible,
 be relieved : the fingers are then to be introduced into the vagina
 or rectum,  and the fundus uteri pressed gently upwards.  The
 symptoms then cease.

                    XV.  PREGNANCY
   923. Is denoted by suppression of the catamenia, by sympa-
 thetic sickness, by gradually increasing  tumor, first in the hypo-
 gastrium, then of the lower part of the abdomen, by a tumid and
 harder condition of the mammae, with  the development of the
 areola and  follicles  round the nipple, and by the movements of
 the foetus.
  924.  It is by this assemblage of symptoms that pregnancy
 is  ascertained : the  sudden suppression of the  catamenia ; the
 sudden attacks of morning sickness; the regularly increasing
 hypogastric tremor; the peculiar change in the mammae and
 areola ; can scarcely occur together without pregnancy.
  925.  When, in addition to these symptoms, a tumor begins to
be felt above the pubes ;  when the umbilicus, from being con-
 cave, becomes convex ; when the  movements of the fcetus are 
376     DIAGNOSIS  OF  THE   DISEASES

distinctly felt, by the hand applied to  the hypogastrium ;  the
existence of pregnancy is certain.
   926. Lastly,  when, on examination per  vaginam, the cervix
uteri  becomes  first less  and  less distinct, and then obliterated ;
when the body of the uterus is felt enlarged ;  when,  the patient
being  in the erect position, the os uteri is  raised quickly by the
finger, and the foetus made to float in the liquid amnii, and its
fall is felt, there  is no  remaining doubt of pregnancy, even
though the other criteria were obscure.
   927. The most proper periods  for making these various ex-
aminations will occur to the mind of every well-educated  practi-
tioner.  But if more information be required than this brief  pa-
ragraph affords, it will be found in the beautiful chapter by  the
late Dr. Gooch upon this subject.(')
   928. The Complications.  It is important to  remark that
Pregnancy may also be complicated with
            1.  Disease of the Uterus;
            2.  Disease  of the  Ovarium;
            3.  Pelvic Tumors.
            4.  Retention of Urine;
            5.  Ascites.
It will require the utmost attention to establish the full diagnosis
in these complicated affections, since the distinction, when they
occur in an isolated form, is not always perfectly easy.

                XVI.  PELVIC TUMORS, ETC.
   929. Tumors may form in any  part of the pelvis, and may
complicate Pregnancy, or any of the preceding or  subsequent
  (1.)  Auscultation has been successfully applied to the diagnosis of Pregnan-
cy.  The sounds of the fnetal heart can certainly be heard through the  walls of
the abdomen, and as early as the third or fourth month, according to the obser-
vations of recent authors.  These sounds, when heard, constitute, of course, an-
infallible sign of pregnancy.  It has also been supposed that the arteries of the
placenta gave rise to a bellows' sound; but this sound has probably its seat in the
large arteries of the pelvis, and may be produced by the pressure of any tumor.
Consult Kennedyr Montgomery, Bricheteau, Clin, de l'H6p. Neckar.      S. 
OF  THE  UTERINE  ORGANS.
377
forms of disease;  in  Pregnancy  itself, the foetus may die and
yet be retained for a time ;  the diagnosis may thus be very ob-
scure ; it can, indeed, only be perfectly established by the most
careful examination, per vaginam, per rectum, <fcc. with the
precaution of previously emptying the bladder by the catheter,
and the rectum by large  enemata.  It would be encumbering
this work to imagine every possible case of such complications,
and to lay down  Rules for the diagnosis of each.   Anatomical
and pathological knowledge, and good sense, must guide us.

               II. THE FUNCTIONAL AFFECTIONS.
   930. The cases which I have enumerated as functional af-
fections, are rather symptoms than real diseases, and ought,
therefore, to be noticed in that relation.   It may not be  amiss,
however,  to state, in this place, under what circumstances they
are most apt to occur.

                    I.  AMENORRHEA.
   931. This affection occurs principally  in
             1. Chlorosis.
             2.  Tuberculous Disease.
             3. Inflammation of the Uterus*
   932. In the first  of these, its  accession is slow and gradual.
 § 235.   In the second, its occurrence is generally sudden and all
at once. § 318.   In the third, its occurrence is also sudden, but
it may be imperfect or irregular.
   933. Amenorrhoea is  also a well known  sudden  effect of ex-
posure to damp or cold, or fo mental  emotions, during the flow
of the catamenia.

                  II.   DYSMEN0RRH03A.

   934. This affection  results principally
        1. From Inflammation of the  Uterus.
        2. From Scybala retained in the Colon and Rec-
              tum.
   935. In the former case, there is occasionally the formation
                             48 
378      DIAGNOSIS   OF THE  DISEASES

and expulsion of a layer of lymph. §881.   The  latter  affec-
tion has been briefly noticed § 749.

                    III.  MENORRHAGIA.

   936. The profuse flow of the catamenia depends chiefly upon
two causes :  the irritation of
        1.  A  Fibrous Tumor of the  Uterus.(')
        2.  Scybala in the  Colon or Rectum.
   937. The  recurrence of  the flow is frequently induced by fa-
tigue or harass, bodily or mental.

                      IV.   LEUC0RRHO3A.
   938. This morbid affection is
                    1. Uterine.
                    2. Vaginal.
   939. The former case depends on
           1.  Uterine Disease.
           2.  Constitutional Debility or Exhaustion.
   940. The  first is  of  various kinds, already noticed.   The
second is frequently induced by fatigue and harass,  but  by no
cause so frequently as undue lactation.   It may be conjoined
with haemorrhcea, or may follow, or be followed  by, sanguineous
discharge.  It frequently alternates with menorrhagia.
  (1.) It was probably the intention of the author to include Polypi in this
class.  Another cause of Menorrhagia is a condition of the uterus the reverse of
that noticed above, (note to par. 885,) as a cause of amenorrhcea and dysmenor-
rhea ; in the first case, the cervix uteri presents a brownish red appearance, is
somewhat enlarged, and has a soft, spongy, feel;  in the latter case,  there  is in-
creased development and tenderness to the touch ; the redness is a rose colour,
and the natural firmness of the parts is not diminished. Consult Duparque,  ut
sup.  Menorrhagia also not unfrequentiy  occurs just before the  cessation  of
the catamenia.  1 would remark here that the distinction between  menorrhagia
and uterine haemorrhage does not seem to be of much practical importance. S. 
OF THE  UTERINE ORGANS.        379
   941.  Vaginal Leucorrhcea may arise from
           1. Inflammation.
           2. Inflammation of the Cervix Uteri. § 885.
           3. Polypus, &c.
           4. Hamorrhoids.
           5. Ascarides.

             III.  THE DISEASES OF THE OVARIUM.
                      I.  INFLAMMATION.
   942. Inflammation of  the  Uterine Appendages has been al-
 ready noticed, § 709.  That of the Ovarium is denoted solely by
 local pain and tenderness, the general system and the functions
 of other organs being scarcely influenced by this affection.

                  II.  ENCEPHALOSIS, ETC.
   943. As inflammation  of the Ovarium  is merely character-
 ized by local pain and tenderness, the present and other morbid
 growths are  denoted by local tumor, detected by a careful ex-
 amination, and  the effects of compression on adjacent organs.

                III.  ENCYSTED TUMOR, ETC.
   944. This case includes
                 1.  One  Cyst;
                 2.  Numerous  Cysts;
                 3.  Hydatids.
   945. It is distinguished  by tumor,  § 943, originating in the
situation of the ovarium, on one side of the abdomen,  gradually
enlarging,  and leading to a tumor with fluctuation, of consi-
derable, and even enormous magnitude.(')
   946. This affection is distinguished from
                          ASCITES
by the following signs:  1. it is generally more tense,  and,
  (1.) I have heard M. Chomel express the opinion that the encysted  ovarian
tumor had its origin in the morbid development of one or more of the ovarian
vesicles.  This is an ingenious and probably a correct idea of its formation.  S. 
 380      DIAGNOSIS  OF  THE  DISEASES

 when of moderate magnitude, more protuberant, more defined;
 2.  the sound is dull on percussion at the prominent part of the
 abdomen,  whereas in Ascites it is sonorous at this part, from
 the floating of the intestines, whilst it is dull nearer the  spine ;
 3. it is less changed  by posture, whilst in Ascites the effusion
 falls to the lowest part of the abdomen  in the erect, and  to  the
 posterior parts in the recumbent, positions.
   947.  Ovarial cysts generally arise  without  any assignable
 cause; but Ascites usually depends upon some preceding organic
 affection, the diagnosis of which  is, in  itself,  important:  the
 principal of these are
              1. Peritonitis;
              2. Disease of the Heart ;
              3. Disease of the Liver ;
              4. Disease of the Kidney, (fee.
              5. The Loss of Blood ;
              6. Inveterate Chlorosis;
              7. The Cachexia, &c.  (fee.
 Of these various primary diseases in Ascites, numerous notices
 are distributed throughout this work, and the subject is treated
 of expressly in Chap. ix. of Sect. I.

             III. THE DISEASES OF THE MAMMA.
                     I. INFLAMMATION.
                      1.  The Acute.
  948. I.  The  History.   Inflammation of the Mamma may
 occur from a blow, or  similar external causes ;  but its most fre-
 quent source is that change which  is  wrought for  the secretion
 of milk,  after parturition, left unrelieved by the  too tardy ap-
 plication  of the infant  to the breast.1
  949.  II.  The Symptoms  consist in swelling, tenderness,
 and pain, sometimes preceded  by rigor and attended by fever.
 These symptoms  may subside, or  become attended by  throb-
 bing and augmented  hardness, and tenderness, and eventually
by glossy redness, and fluctuation,  denoting the occurrence of 
OF  THE  UTERINE  ORGANS.        381
suppuration.  The most tender part at length ulcerates, unless
the pus be allowed to escape through an artificial opening.
   950. III.  The Varieties.  Sometimes there are several suc-
cessive abscesses, with much suffering, fever, and perspiration.
Sometimes an abscess is formed very deeply, burrows, and forms
several sinuses, requiring successive punctures by the lancet.  In
other,  rarer, cases, pus forms in contact with the ribs, leading to
exfoliations of bone.

                    2. Lacteal Abscess.
   951. This affection is not preceded by the symptoms of acute
abscess ; but a sense of tension is experienced, and a fluctuating
tumor is felt extending from the nipple towards the circumfer-
ence of the mamma.  The tumor is confined to this part.   Its
tension is augmented by the rush of milk when the infant is
put to  the breast.   The cutaneous veins are large.  If a punc-
ture be made, several ounces of milk are discharged; and if this
opening be small, the cavity is speedily filled again.  Sometimes
the skin ulcerates, and an opening is made, through which the
milk  flows  during each act of suckling.  This  affection  re-
sembles Ranula in its nature.*

                    3.  Chronic Abscess.
   952. Sometimes pus is formed slowly,  without previous red-
ness, tenderness, pain, heat, rigor, or fever.  In such a case,
the operation for removing the mamma has been begun, and
the pus has been  accidentally evacuated by the scalpel!   A
careful examination may,  in doubtful cases, detect fluctuation,
and a puncture (p. 269) would make the nature of the case per-
fectly obvious.

               II.  TUBERCULOUS SWELLING.
  953. This disease is slow  in its progress, unattended by pain,
distinctly circumscribed, generally, though not always, solitary;
it is usually accompanied by enlarged cervical glands.
* Sir Astley Cooper on the Diseases of the Mamma; p. 16. 
382     DIAGNOSIS  OF  THE  DISEASES

               III.  THE  IRRITABLE MAMMA.
                   ■1.  Without Tumor.
   954. In this case, the mamma, or one or more of its lobules,
becomes exquisitely tender and painful.  The pain is often ex-
tended to the shoulder, axilla, inner side of the elbow, and the
fingers, and sometimes along the side to the hip.  The slightest
handling  augments the pain, which is sometimes  such as to
render the weight  of  the breast or the position on the side af-
fected, equally insupportable.
   955.  This affection is  augmented on the approach,  and
diminished on the recession, of the catamenia, which are gene-
rally irregular, deficient or profuse.
   956.  There is sometimes an alternate sensation  of heat  and
cold, or darting like that  of tic doloureux.   Sometimes both
mammae are  affected.

                     2. With Tumor.
   957.  In some instances the pain and tenderness are situated
in a small, moveable tumor, varying from the size of a  pea to
that of a marble.
   958.  This tumor is solid and semitransparent, interwoven
with fibres.

                  3. With Ecchymosis.
   959.  With exquisite tenderness of the mamma,  and pain
down the inner side of the arm, there is, in this case, a degree of
ecchymosis before and at each catamenial period.  It exists in
one large spot, whilst smaller and less vivid spots appear in other
parts of the mamma.   It declines at various  periods after the
cessation of the catamenia.  It occurs in the young, and fre-
quently in those in whom the mamma is large, and the consti-
tution irritable.

             IV.  CHRONIC  MAMMARY TUMOR.
   960. I.  The History.  This affection, like that last men-
tioned, has a strict connection  with the catamenia, being pro- 
           OF  THE  UTERINE  ORGANS.       383

bably induced, and certainly aggravated, by sympathy with the
uterine organs at the catamenial periods.   It occurs principally
in the young, single or childless.
   961.  II.  The Symptoms.  This tumor grows upon the sur-
face of the mamma, either the anterior or posterior ; it is move-
able over that surface, and lobulated to the touch ;  it begins and
often continues long, without pain ;  but it is sometimes painful,
the  pains extending to the  shoulder, resembling  the aching of
rheumatism ; it is generally, but not always, free from tenderness
to the touch.   Its growth is slow ; its weight usually from one
to four ounces; but it is sometimes larger.
   962.  III.  The Morbid Anatomy.   The  structure of this
tumor is lobular, and it is enveloped in a membrane, both similar
in appearance to the mamma itself.

                V. CYSTS,  HYDATIDS.  ETC.
   963.  These affections are distinguished  by tumors, without
pain or tenderness, but with tension, and, eventually, with fluc-
tuation.  Their accession and progress are slow.   There are no
 constitutional symptoms.  The disease gives no real uneasiness,
 until,  becoming large, it is inconvenient  from  its  bulk and
 weight.  The external veins enlarge.  The tumor is moveable
 upon the ribs and under the integuments.
   964.  Cysts and Hydatids sometimes induce inflammation and
 ulceration.   The system then suffers.
   965.  The most certain criterion of the Encysted or Hydatid
 tumors, is a puncture.  The escape of a limpid fluid satisfies
 the  doubts of the surgeon,  and  allays the fears of the patient.
 Both diseases are local, and free from malignancy.
   966.  Cysts  generally occur  in clusters.  Hydatids are dis-
 tinguished by containing others  produced  by  their internal
 surface.
   967.  The preceding diseases are all free from malignancy in
their character and  tendency.   Those which are next to be
noticed are frightfully malignant and destructive, and arise from,
or lead to, terrific constitutional contaminations. 
 384    DIAGNOSIS  OF  THE  DISEASES

                    VI.  ENCEPHALOSIS.
   968.  I.  The  History.  This disease occurs earlier in life
than the terrific disease next to he noticed.
   969.  II. The Symptoms.  It is  distinguished from  it,  by
its rapid growth, its irregular form, its soft, doughy feel, its ten-
dency to ulceration; the formation of fungus  At first, it is even
and smooth on its surface, free from pain or tenderness, or disco-
loration, but soft and fluctuating.   It soon acquires a fearful size
and aspect; the surface is then uneven and discolored, the feel
quaggy.   The system suffers: the patient has pallid prolabia,
and is feeble and restless.
   970.  The  adjacent lymphatic glands, or some more distant
part, internal  or external,  may be simultaneously affected.

              VII. SCIRRHUS.  CARCINOMA.
  971. I.  The History.   Scirrhus frequently occurs about the
period of the cessation of the catamenia.  It may be apparently
spontaneous:  or it may arise from a blow, or from the change in
form and character, of some other mammary disease.
  972. II. The  Symptoms.   This disease is circumscribed,
at first, little augmented in size, of singular hardness, somewhat
tender, and accompanied by a peculiar lancinating pain.  In its
progress,
  973.  1.  The Nipple frequently becomes fixed and drawn in-
wards ;
  974.  2.  The Skin becomes  adherent and tuberculated  ;
  975.  3.  The adjacent  lymphatic  vessels and glands be-
come enlarged and hard.
  976.  4. Eventually, the skin ulcerates, and presents the ap-
pearance of frightful chasms, and perhaps fungous growths, and
there is  extreme suffering, and extreme acrimony and foetor of
the discharges.
  977. 5.  The whole system is worn, and hectic; the com-
plexion is  " jaune paille,"  and there is  great emaciation. 
CHAPTER  VIII.
  THE DIAGNOSIS OF THE DISEASES OF THE GENITAL
                       ORGANS.
  978. Few diseases require such care in the diagnosis as those
of the genital organs.  In the subsequent paragraphs, I shall, as
usual, attempt a brief, practical view of this subject.
  arrangement of the diseases of the genital organs.
                  i. in the malesex.
                   i. of the penis.
   1.  Gonorrhoea,
  II.  Excoriation.
  III.  Superficial Ulcer.
  IV.  Phagedenic Ulcer.
  V.  Sloughing Ulcer.
  VI.  Syphilitic  Ulcer.
VII. Herpes  Pr-«putialis.
VIII. Scirrhus—Carcinoma.
                  ii.  of the testis.
  1. Inflammation.
        1.  Of the  Epididymis.
        2.  Of the  Body of the Testis.
            1. Enlargement.
            2. Suppuration.
            3. Sloughing.
  II. Tubercles.
  III. Fibrous Tumor.
                            49 
386      diagnosis  of  the  diseases*
 IV. Encephalosis.
  V. Scirrhus.
 VI. Hydrocele.
 VII. Varicocele.
VIII. Hernia.
               II. IN THE FEMALE SEX,
                I. OF THE PUDENDA.
  I. Inflammation.
          1.  Enlargement.
          2.  Abscess.
  II. Prurigo.
 III. Vascular Tumor of the Meatus.
 IV. Varicocele of  the Urethra.
  V. Affections of the Anus.
                  ii.  of the vagina,
  I. Inflammation.
  II. Tumors.
                 I. in the male sex.
              11. diseases of the penis.
                  i.  gonorrhoea.
  979. I. The History.  This disease usually takes place six
or eight or more days after an impure coitus.
  980. II. The Symptoms are a white, opaque, mucous dis-
charge from the urethra, with partial abrasions, with ardor uri-
nse,  and frequently with one or other of the following- Compli-
 cations :
       1. Chordee,
       2. Inflammation of the Testis,
       3. Sympathetic Bubo; 
of the genital  organs         387
^nd it frequently issues in
         1.  Gleet,
         2.  Stricture.(x)

                     II.  EXCORIATION.
   981. This affection has frequently a similar origin, and is de-
noted by superficial redness, the removal of portions of the cuti-
cle, and an  offensive discharge, occupying principally the corona
glandis and the adjacent part of the prepuce, and usually attend-
ed by phymosis and gonorrhoea.

              III.  THE SUPERFICIAL  ULCER.
   982. This affection is divided by  Mr.  Carmichael, in his ex-
-cellent work,* into two kinds :
          1. Without elevated Edges.
          2. With Elevated Edges.
   983. I.  The first  of these, the  most frequent of venereal
ulcers, is characterized by being superficial, and free from indu-
ration, and from elevation of its edges.   In general, it is raised
above the surrounding skin, and exhibits a smooth surface, the
color of a healthy sore ; but it  is without granulations, and has
somewhat a fungous appearance.   Sometimes it is level  with
the surrounding surface, seldom excavated.
   984. These ulcers  vary from the size  of a pea to that of half-
a-crown.  They occur most frequently on the glands penis and
inside of the prepuce, often exciting phymosis; but they also
occur on the external surface of the penis and scrotum : in the
latter situation, they  are frequently raised, and  resemble soft
warts.  In women, they occur on the labia, perinaeum, and  fossa
of the nates.  They are often complicated by gonorrhoea or by a
similar discharge from the mucous membrane of  the glands or
prepuce.
  (1.) Besides the above, there may occur as complications, 1, oedema of the
prepuce: 2, haemorrhage from  the urethra; 3, inflammation of the bladder; 4,
morerarely, inflammation of the prostate gland.                     B.
             • An Essay on Venereal Diseases, 4to. 1814. 
 388     DIAGNOSIS  OF  THE  DISEASES

   985. 2. The second form of superficial ulcer differs from the
 former one by having elevated edges; it displays a  whitish or
 reddish brown surface, without  granulalions.  It is not excavat-
 ed, but may be raised ;  and it is free from induration.
   986. It appears most frequently on the external surface of the
 prepuce, penis, or scrotum, and varies from the size of a pea to
 that of a shilling.  It frequently  occupies the orifice  of the pre-
 puce and causes phymosis.
   987. This ulcer frequently leads to obstinate buboes.
   3b'8. Mr. Carmichael is, of opinion that the same constitu-
 tional Symptoms arise in each  of the three cases which have
 been described, and which he ascribes to the same original poi-
 son.   Those symptoms are " more or less fever, which ushers in
 a papular eruption, inflammation  and soreness of the fauces,
 attended  with  difficulty in swallowing, severe  pains  which
 affect the head and large joints, and sometimes  inflammatory
 swellings over the superficial bones."

                 IV.   PHAGEDENIC  ULCER.
 [f 989. This ulcer, the character  of  which  is obvious at first
 sight,  is usually situated on  the  glans  penis,  more  or less  of
 which it destroys by a more or less gradual or  rapid progress:
 there is no appearance of granulation ; when healed  or nearly
 so, it frequently resumes the phagedenic appearance.

               V.  THE SLOUGHING ULCER.
   990. This ulcer, more terrible  in its devastations  than the
 phagedenic ulcer, is characterized  by the presence of  a slough,
 which is small, circumscribed, and black at first, but afterwards
 more or less extensive and ragged.   "When this slough separates
 it frequently displays an ulcer of a phagedenic character.  There
 is then pain, and the formation  of a fresh slough, and thus the
 penis, the  pudenda, are destroyed, and even the bladder and ute-
 rus themselves.
   991. The constitutional symptoms  are, according to Mr.
 Carfnichael, the same in the phagedenic and in the sloughing
ulcers, and consist of a pustular  eruption on the skin, which 
            OF  THE  GENITAL  ORGANS.        389

degenerates into ulcers covered by crusts ;—in,{a white, slimy
ulceration of the tonsils and pharynx," of the velum and uvulae,
wl.ich it promptly destroys, and of the nares, when it induces a
foetid discharge, with caries ;—and in pain of  the joints, espe-
cially of the knees, wrists, and ankles, but also of the fingers
and toes, which become red and painful.

                 VI.  SYPHILITIC ULCER.
   992.  This ulcer is still  best described by Mr. Hunter, as "a
sore somewhat of a circular form, excavated, without granula-
tions, with matter adhering to the surface, and with a thicken-
ed edge and base.  This hardness or thickness is very circum-
scribed, not diffusing itself gradually and imperceptibly into the
surrounding parts, but teiminating rather abruptly."*
   993.  The constitutional symptoms are, according to Mr.
Carmichael, a scaly  eruption,  which appears on the forehead,
groins, &c. and on the palms of the hands, except when the skin
is in contact with other skin, when it is elevated, moist, flat, and
warty ;—ulcerations of the throat, described by Mr.  Hunter as
" a fair loss of substance, part being dug out, as  it were, from the
body of the tonsil, with a determined edge, commonly found with
while matter  adhering to it,  like  a slough which cannot be
washed away ;"t— nodes, which affect, principally, the superfi-
cial bones,  as the tibia, sternum, clavicle, and  cranium, being
deeply situated in their substance and unattended with discolo-
ration.
   994.  The Effects of Remedies.  Whilst all the other forms
of veneral diseases are  unrelieved, perhaps greatly exasperated,
by the use of mercury, true syphilis undergoes an amelioration
which proceeds, pari passu, with the influence of mercury on
the system.
   995.  I have only to add that these distinctions, and especially
these associations of primary and secondary symptoms, must
not be received implicitly.   The subject is  full of interest  and
* Hunter on the Venereal Disease.        t Ibid. 
890     DIAGNOSIS   OF   THE   DISEASES

importance, and requires fresh examination.  Some  forms of
eruption are omitted, as the tubercular.

                VII.  HERPES  PR.EPUTIALIS.
   996.  This affection consists  in one or two clusters of vesicles,
situated on the praepuce, or on the labia pudendi.  Transparent
at first, these vesicles  become opaque, and then assume a pecu-
liar appearance.   On the internal  surface, these vesicles lead,
on the fourth or fifth day, to a small ulceration ;  on the exter-
nal surface, to a scab, about the sixth.   This affection yields
without remedies.  It is apt to recur.
   997.  Herpes praeputialis is precisely similar to that familiar
form of Herpes seen on the lip, from exposure to cold.

               VIII.  SCIRRHUS--CARCINOMA.
   998.  Cancer of the penis frequently arises from a wart  or
warts, situated on the glans, fraenum, or praepuce.   Long indo-
lent, this local disease, when irritated, may lead to the formation
of Scirrhus, having its usual character of  induration ; and this,
to ulceration or Carcinoma.  The course  of this disease is usu-
ally  slowly progressive:  it  eventually  involves the inguinal
glands, and the integuments of  the pubes, or scrotum.
   999.  Mr. Earle* has made some interesting observations upon
diseases resembling cancer, induced by local irritation ; from
which  I extract the following description  of a disease affecting
the penis:  It occurs in  persons with elongated foreskins from
want  of cleanliness.  The praepuce becomes  excoriated and
cedematous, and the fraenum thickened ; and there is phymosis.
The further irritation of the urine induces ulceration, swelling,
and induration.

       II. THE DISEASES OF THE TESTIS, SCROTUM, ETC.
                     I.  INFLAMMATION.
   1000.  I.  The History. The  testis may  become  inflamed
♦ Medico-Chirurgical Transactions, vol. xii, p. 283. 
OF  THE   GENITAL   ORGANS.        391
from blows or other similar causes;  but the most frequent cause
is gonorrhea.
   1001. II.  The Symptoms are heat, tenderness, and swelling,
affecting, like all the other diseases of this organ,
        1.  The Body of the Testis principally, or
        2.  The Chord and Epididymis.^)
This affection may issue in

               1. Enlargement.
               2. Abscess or Abscesses.
               3. Sloughs of the Cellular  Membrane.

                        II.  TUBERCLES.
   1002.  The Symptoms of the Tuberculous Testis are  those
of slow inflammation.   This  affection usually  arises from go-
norrhoea, affects the epididymis, and yields to remedies.(2)

     III. FIBROUS  TUMOR—ENCEPHALOSIS—SCIRRHUS.
   1003. The Fibrous Tumor is distinguished  by its uniform
shape from  Encephalosis, and by its  want  of extreme indura-
tion, from Scirrhus.   All occupy  the body of the testis chiefly.
The first  is purely local; the others apt to  spread, and apt to
occur in distant parts*
   1004.  A singular disease must be noticed in this place, termed
the
  (1.)  The4" sioelled testicle," from gonorrhoea, commences in the epididymis ;
this form is soon followed by effusion into the tunica viginalis testis, which con-
stitutes the principal bulk of the tumor.  The body of the testicle is not commonly
much enlarged.                                                 S.
  (2.)  The summary contained in this paragraph appears to me every way
incorrect.  Is it not more probable that Tuberculous Testis has its  origin in
constitutional causes; and that the deposit, as in other organs, tends to softening,
and is finally discharged with a more or less complete destruction of the organ,
without being much under the control of remedies ?            '         S.
  * Encephalosis seems to push the textures in which it is situated aside; Scir-
rhus seems to involve them in its extension. 
 392   DIAGNOSIS   OF   THE  DISEASES

             iv. chimney-sweeper's  cancer.
    1005.  I.  The History.   This disease does not  occur in
 children  or  the very young subject.  It is caused by the irrita-
 tion of soot,  within the cuticular folds, chiefly of  the scrotum, in
 those predisposed by middle age, to such diseases.
    1006.  II.  The Symptoms. This disease  is denoted by  a
 warty excrescence, which eventually ulcerates, the edges of the
 ulcer being everted,  and affected by fungous growths ;  the  dis-
 charge is foetid ; and there is much induration.  The disease
 spreads, and eventually  may involve the entire scrotum,  the
 perinseum, the testis, the inguinal glands, &c.

                      V. HYDROCELE.
   1007. Hydrocele is  distinguished, and its extent in compli-
 cated cases traced, by its transparency.

                     VI.  VARICOCELE.
   1008. Varicocele is ascertained by its peculiar, varicose feel;
 and by its disappearing in the recumbent position.

                        VII.  HERNIA.
   1009. Hernia is ascertained by its history, by its being redu-
 cible, by its tympanitic feel and sound, <fec.

                  II. IN THE  FEMALE  SEX.
             I.  THE DISEASES OF THE  PUDENDA.

                    I.  INFLAMMATION.
   1010. Inflammation may affect the  pudenda,  from internal
and external causes, and lead to
                1.  Swelling, and
                2.  Suppuration.

                  n.  pruritus;  etc.
   1011. Herpes  of the pudenda has been  already mentioned
§ 996.  Sometimes,  especially  in diseases of the uterus, there 
           OF  THE   GENITAL   ORGANS.       393

 is extreme pruritus; this symptom alone should always lead
 to  an examination per vaginam.  In  other cases, there is
 excoriation, or apthae, or verrucae, the nature of which is only
 ascertained on inspection.
   1012. The venereal affections  have been  already described
 §§ 981, 992.

         III.  VASCULAR TUMOR  OF THE  MEATUS.
   1013. Sir  C.  M. Clarke has  described a vascular  tumor
 occupying the orifice of the  meatus urinarius.   It is exquisitely
 tender to the  touch ; and attended by a mucous discharge.   It
 is ascertained, at  once,  by  an inspection  of  the  part.   It  is
 cured by a ligature.

        IV.   VARICOSE  VESSELS  OF  THE URETHRA.
   1014. The vessels of the  urethra sometimes become varicose.
 This disease is also described by Sir C. M.  Clarke.   The urine
 is apt to be detained in a posterior  part of the urethra, causing a
 pouch, in which the urine is retained, and inducing a constant
 desire to make water.

              V.  AFFECTIONS OF  THE ANUS.
   1015. With or  without an affection of the pudenda,  there
 may be pruritus, excoriation, verrucae, &c,  of  the  verge  of the
 anus, inducing great distress.  An  inspection alone can establish
 the diagnosis.

             II. THE DISEASES  OF THE VAGINA.
                    I.   INFLAMMATION.
  1016.  Besides gonorrhoea, other forms of inflammation affect
 the vagina, attended by mucous  discharges and constituting
 vaginal leucorrhoea.  Such a complaint may continue during
 pregnancy, in which case uterine leucorrhoea  ceases.   It is
readily cured by the injection of the nitras argenti.

                        II. TUMORS.
  1017. Tumors may form in any part adjacent to the exterior
                             50 
394  DIAGNOSIS  OF  THE DISEASES,  ETC

surface of the  vagina.  Mr. Heming has  described soma in-
teresting cases of this kind.  These tumors may be
             1.  Mere Abscess; or
             2.  Encysted,
             3.  Fibrous,
             4.  Tuberculous,
             5.  Encephaloid, or
             6.  Scirrhous.
  1018. The Diagnosis will depend on the History, Symp-
toms, and a careful Examination. 
CHAPTER   IX.
           THE DIAGNOSIS OF PUERPERAL DISEASES.

   1019. In the early period of pregnancy, we witness the effects
 of a singular  sympathy  between the uterus and the stomach
 —a disease  of irritation—under  the form of  sickness  and
 vomiting.
   1020. In the latter periods of pregnancy, we  have to witness
 the effects of plethora, and of compression upon the abdominal
 viscera and vessels.   The enlarged and gravid uterus occupies
 great space;  and, in  addition to this, the  colon  is  frequently
 somewhat obstructed and  becomes loaded.
   1021. At the latest period of pregnancy and during parturi-
 tion, there is frequently great  fear of an affection of the brain,
 with apoplexy  or convulsions.
   1022. After parturition, we encounter  other circumstances,
 the effects of which are not less  to be feared;—the immediate
 effects of haemorrhagy; sometimes convulsions.
   1023. Nor are we secure, even when the immediate effects of
 parturition have  passed away:  the contracted uterus is more
 vascular than natural, and  augmented in size ;  it is in  a state
 bordering on  inflammation:  it is very apt, with  its peritonaeal
 covering, and its  appendages, to take on actual inflammation:
 its internal surface  is  exposed,  and the veins and lymphatics
 which take their  origin or course from  it may also become in-
 flamed : but, besides these events, we  are frequently, very fre-
 quently, called  to witness others which result from a state of
 intestinal load and irritation :  nor do these complete the list;
 for, although the immediate effects  of haemorrhage may have
ceased, others, later in their period of occurrence,  and of a widely 
396
THE  DIAGNOSIS  OF
different  character, frequently occur and present some very for-
midable cases of puerperal disease.
  1024.  There is, besides,, a series of mixed cases, to which I
would very particularly draw the attention of my young readers.
  1025.  I shall now endeavor to present such an arrangement
of puerperal  diseases, in the order of their importance and fre-
quency, as I have formed  from long attention to the  subject,—
not in hospitals, which present a very unfair view of the subject,
but in actual practice,—not amongst the poor only, but amongst
the middling and higher classes of society.
  1026.  There is still another point to which I must  draw the
attention of my reader:  there are doubtful cases,  as well as
mixed cases ; and there will often  be great difficulty, anxiety,
and danger, in determining the question of general blood-letting.
In every  case in which it is decided that a vein is to be opened,
let it be done in the erect position, the eyes turned to the ceiling
of the room.  In this manner, frequently much  less, and fre-
quently also much more, blood will be taken,  than  it was
previously contemplated to take : for the case will partake more
of the nature of irritation, or  of inflammation, than was sup-
posed !   The physician will derive much information, and the
patient will be preserved  from much danger, by adopting the
plan  which  I have proposed.  I am astonished to see how so
plain, so  simple, and so important a  rule is either disregarded
through  supineness, or attempted to  be  put aside from motives
which I forbear to name.   The plan which I have so often en-
forced is  one of great safety, and replete with diagnosis.
  1027.  But I proceed to the

          ARRANGEMENT OF PUERPERAL DISEASES.
     I. Inflammation of the  Peritonaeum.
           1.  Of the  Uterine  Peritonaum.
           2.  Of the  Uterine Appendages.
           3.  Of the Pelvic Peritonaum.
           4.  Of the Diffused Peritonaum. 
puerperal  diseases.         397
    II. Intestinal Irritation.
           1.  With Affection of the Abdomen.
           2.  With Affection of the Head.

   III. Exhaustion from Loss of Blood.
           1.  With Re-action.
           2.  With Sinking.

   IV. Mixed Cases.

                 Puerperal Mania, fyc.

    V.  Softening of the Uterus.

   VI. Inflammation of the Lymphatics.
           1.  Usually with Peritonitis.
           2.  Without Peritonitis.
           3.  With Pleuritis.

  VII. Inflammation of the Veins.
           1.  Adhesive.
               1. Uterine.
               2. Crural.
           2.  Suppurative.
               1. Usually without Peritonitis.
             ■  2. With Abscesses of the Brain, Lungs,
                   Liver, Spleen, $-c. the Joints, Cellular
                   Membrane, Eye, $*c. fyc.

  1028. Before I  proceed to detail the prominent symptoms of
the morbid  affections which I have thus  enumerated, I would
particularly impress upon my reader the importance of an accu-
rate acquaintance with the

                  PUERPERAL  STATE
when unattended by actual disease. 
398
THE  DIAGNOSIS  OF
  1029. There is frequently a degree of febrile action and of
perspiration ;  yet, in some cases, carefully noted, there was no
frequency of the pulse, no tenderness of the  uterus: a degree
of acceleration of the pulse, however, and a  degree of uterine
tenderness,  may occur, and subsxle; but either of these symp-
toms should lead  us to watcii the patient wTith care, not to say
anxiety.  The physician should also  make himself intimately
acquainted with the ordinary feel of the uterus, and  with the
appearances of the lochia, at various periods  after parturition ;
and  he should  carefully study the  phenomena, constitutional
and local, of the effort to establish the secretion of the milk, and
of the office of lactation.
  1030. I now  proceed to treat of

        I. INFLAMMATION OF THE PERITONAEUM.
                        1.  Acute.
  1031. I.  The History.  Puerperal inflammation within the
abdomen is  usually  introduced by rigor;  but by no means
always; neither are heat of skin, and headache,  essential
symptoms in this disease.
  1032. II.  The Symptoms vary somewhat with the seat and
extent of the inflammation.  This begins and may be nearly
confined to
           1. The Uterine Peritonaum,
           2. The  Uterine Appendages,
           3. The Pelvic Peritonaum,
but it may be diffused over

           4.  The Abdominal Peritonaum.
  1033. These circumstances are only to be  determined  by a
careful examination of the abdomen, and especially of the hy-
pogastric and iliac regions.   With the pain, there is tenderness
on pressure, more or less confined, at first, to the former of  these
regions, and  diffused afterwards, perhaps, over the  ahdomen,
and varying in degree.
  1034. The movements of the body,  and of respiration, are 
PUERPERAL   DISEASES.          399
more or less repressed; and there are frequently sickness and
vomiting.  The pulse quickens and frequently becomes small.
The state of the lochia should  be carefully noticed:  it consti-
tutes the index to the condition  of the uterus : the  lochia be-
come scanty or suppressed, and lose their healthy  color.
   1035. III.  The Effects of Remedies.  We learn much of
the nature of  the  disease, or of the  extent and  degree of the
inflammation, and of the strength of  the patient, by, observing
the effect of blood-letting in the perfectly erect position : in acute
and extensive serous inflammation, much blood flows  before
syncope is induced : in  some other diseases, and in other forms
of inflammation, there  is comparatively great susceptibility to
the effects of loss of blood. ' In no case is this criterion more im-
portant than in puerperal diseases.
   1036. IV.  The Morbid Anatomy consists in the effusion of
serum, lymph, or ]jus, in various quantity, and over a various
extent of surface.

                        2. Chronic.
   1037. The chronic form of Puerperal Peritonitis is usually
confined to the uterine appendages, or to the pelvic peritonaeum.
The former case  has been briefly characterized,  § 709; the
latter may induce a fulness in some part of the pelvis, perceptible
on an examination per vaginam, with compression and inter-
rupted function of the bladder*  and rectum, and  constitutional
fever.
               II.  INTESTINAL IRRITATION.
   1038. I.  The History. This affection, the most common of
puerperal diseases, in its milder or severer forms, is not unfre-
quentiy ushered in by severe rigor: this is followed by febrile
heat, and the  symptoms about to be mentioned.

            1. With Affection of the Abdomen.
   1039. II.  The  Symptoms in this case are diffused pain, and
  • In one case there was a copious deposite of uric acid, frequent desire to void
urine, and a perceptible fulness in the front of the vagina. 
400
THE  DIAGNOSIS  OF
superficial  and  diffused,  but  often  extreme tenderness:  the
uterine region is not  usually more  tender or  painful than the
rest of the abdomen.  There is frequently general tumidity, as
well as tenderness.

              2. With Affection  of the Head.
   1040.  In this case, there is great pain of the head, frequently
with great intolerance of light  and of sound,  throbbing  of the
temples/ and occasionally delirium.
   1041.  These  two affections are not unfrequentiy combined
in the same case, at the same or at subsequent periods.
   1042.  In addition to these principal' affections, there is also,
in some instances, severe pain along the course of the scaleni
muscles ; or of one side of the  thorax, resembling pleuritis.
   1043.  The reader may consult further, § 178.
   1044.  III.  The Effects of Remedies. In this  affection there
is, compared with inflammation of the peritonaeum, a charac-
teristic and  diagnostic susceptibility  to the effects of  loss of
blood, denoted by early syncope on withdrawing blood in the
erect position.
   1045.  I have  only twice  had an  opportunity  of examining
the body after this disease:  there  was no discoverable  morbid
change of structure or effusion.

         III.  EXHAUSTION FROM LOSS OF BLOOD.
   1046.  I.   The History is sufficiently marked by the previous
occurrence  of haemorrhagy.   It is only important to bear  in
mind that the symptoms of Exhaustion do  not always arise
from profuse haemorrhagy, but occasionally, in the susceptible,
from a moderate loss of blood ; and that they do not always form
immediately.
   1047.  II. The Symptoms :

                     1.  Of Re-action.
   1048.  In this  case there are  excessive pain and throbbing of
the head, palpitation of the heart, fulness and throbbing of the
pulse, &c. with a disposition to faintishness. 
PUERPERAL  DISEASES.          401
   1049. The affection of the head is sometimes violent in the
extreme.: there are severe pain, a sense of pressure, intolerance
of sound, perhaps delirium.
   1050. The affection of the heart consists in equally violent
palpitation, perhaps with a disposition to syncope.

                      2.  Of Sinking.
   1051. In this case the violence of the symptoms subsides:
there is frequently delirium ; the breathing becomes  noisy, like
that of a person out of breath—always a fearful  symptom ; a
crepitus is heard in the extreme branches of the  bronchia, on
applying the ear to the chest; the pulse loses its throb, but not
its frequency.
   1052. See further, §§ 205,  206.
   1053. III.  The Effects of Remedies.  There is a disposi-
tion to syncope, even on moving the bowels.
   1054. IV. The Morbid Anatomy.  There is, doubtless, a
disposition to effusion within the head.

                    IV.  MIXED CASES.
   1055. It most frequently happens that Inflammation, Irrita-
tion, and Exhaustion,  are mixed in the same puerperal case.
It becomes  therefore more than ever necessary to adopt any
precautions in the  use  of blood-letting which  can conduce to
the safety of the patient or the diagnosis of the disease.   See
§ 1022.
   1056. But in this place I am particularly anxious to draw the
attention of my reader to the  subject of

                    PUERPERAL MANIA.
   1057. I.  The History,  This disease generally involves
         1. Intestinal Irritation;
         2. Exhaustion, and perhaps
         3. Inflammation;  with
         4.  Uterine Irritation.
Its accession is  usually rather sudden,  perhaps after some  men-
tal excitement.   It  occurs at various periods  after delivery • 
402              THE  DIAGNOSIS OF
sometimes even from protracted  lactation ;  and generally in
those in whom there is an hereditary disposition to mania.
  1058. II.  The Symptom  is some form  of mania, and, in
the case of uterine irritation,  sometimes  that termed nympho-
mania.
  1059. In  every case  of puerperal mania, the slate of the
bowels, the  condition of the system, and especially that of the
uterus and its appendages, should be carefully ascertained.
   1060.  The diseases of which I must next treat, are still more
formidable.   They are principally hospital  cases.  The first
of them is

             V.   SOFTENING  OF  THE  UTERUS.
   1061.  I. The History and Symptoms. When, after rigors,
and fever, and with pain in the hypogastrium, and suppression
of the  lochia, there are symptoms like those of the sinking
state,  softening and destruction of the substance of the uterus
may be suspected; the countenance becomes pallid, cold, and
collapsed; the pulse  extremely frequent  and small; there is a
hurried state of the respiration, anxiety, prostration, and other
typhoid symptoms.
   1062.  II.  The Morbid Anatomy consists  in a softened,
broken texture of the substance of the uterus, with a foetid, sa-
nious exudation from the incisions made into it.

       VI,   INFLAMMATION  OF THE  LYMPHATICS.
   1063.  The general Symptoms in this formidable disease
are typhoid, and very similar to  those just detailed.   There is
usually  peritonitis,  and,  sometimes, pleuritis;  but  there
are not the secondary abscesses, &c. observed in phlebitis.

                     VII.  PHLEBITIS.
   1064.  The important distinction in regard to uterine as  in
the other forms of Phlebitis, is between the
            1.  Adhesive, and
            2.  The Suppurative. 
PUERPERAL  DISEASES.          403
   1065. In  the former, the effects are  localized.   Uterine
Phlebitis of the adhesive character is attended by local pain and
tenderness.  The occurrence of Crural Phlebitis seems to con-
stitute the disease  formerly termed the

                   PHLEGMASIA  DOLENS.*
   1066. This disease is distinguished by pain in the situation
of the iliac and inguinal veins,  with tension and swelling, after-
wards pursuing their course down the thigh.  The femoral vein
is sometimes felt  like a cord, and  the swelling is white, tense,
elastic, painful, and tender.
   1067. The latter is a far  more formidable and fatal disease.
It is denoted  by the occurrence of terrific  typhoid symptoms,
and by external suppurative  inflammation  of the integuments,
or of the eye; whilst abscesses form internally in the brain, the
lobules of the lungs and liver, in the spleen, in the joints, in
the muscular substance, &c.   It is usually unattended by per-
itonitis.
  " For the elucidation of this subject, the profession is deeply indebted to Dr.
D. D. Davis and to Dr. Robert Lee. 
SECTION  III.
THE  DIAGNOSIS OF SOME TOPICAL  DISEASES.
                    CHAPTER   I.

    THE  DIAGNOSIS OF SOME DISEASES OF  THE FACE.

   1068. It is admitted to be impossible strictly to define and se-
parate the objects of physic and surgery.   The same disease
may, at one period,  belong to the former, and, in a subsequent
period, to the latter department of the  healing art.  There is a
province, which both physicians and surgeons should investigate,
and which has been denominated Medical  Surgery.   To
this, most of the subjects to  be treated  of in the present section
belong.
   1069. This remark is especially true in  reference to certain
diseases of the Face, the diagnosis of which  it is my present ob-
ject to bring before my readers.
   1070. These diseases consist chiefly in eruptions, ulcerations,
or changes of texture, in some of the structures constituting the
different parts of the face, having their origin in constitutional
circumstances or local irritations.  It is highly important to be
intimately acquainted with the early appearances of these  affec-
tions, some of which are inexpressibly  terrible.
   1071. One of these diseases, the porrigo  favosa, although  of
a frightful aspect, is nevertheless  superficial,  and often  heals 
DISEASES  OF  THE  FACE.        405
without a scar ;  another assumes a phagedenic character, and
erodes through the part affected;  a third, the lupus, begins with
a tubercle which penetrates deep, and is afterwards itself destroy-
ed by ulceration; a fourth early assumes the appearance of a
cancerous ulcer.
   1072. The forehead, the eye-lids, the cheeks, the nose, the
lips, the chin, are the parts principally affected by these diseases,
which may be thus arranged :
       ARRANGEMENT OF THE DISEASES OF THE FACE.
           I.   Erythema Nasi.
           II.  Acne Rosacea.
          III.   Porrigo Favosa.
          IV.   Lupus.
           V.   Scrofula.
          VI.   Carcinoma.
        VII.   Sycosis  Menti.
        VIII.   OzaENA.
         IX.   Parotid Fistula.
           X.   Gangrene.
          XI.  Disease of  the  Antrum.

                  i.  erythema  nasi.
   1073. There is a peculiar and distressing  recurrent  form of
Erythema or Erysipelas of the  Nose,  dependent on a deranged
state of the digestive organs;  it is readily recognized, and it is
cured by a persevering use of mild, warm, purgative medicines.

                   II.  ACNE ROSACEA.
   1074. I.  The History.  This disease usually occurs after
the age of forty, and is apt to  be induced by long-continued ex-
cess in wine or spirits.
   1075. II. The Symptoms.   It is denoted by extreme red-
ness, first observed upon the end of the nose, and gradually ex-
tending over the sides of the nose  and to the cheeks: these 
406        THE  DIAGNOSIS  OF  SOME
parts are rough, beset with small  suppurating tubercles, and
perhaps even fissured.  The forehead, cheeks, and even  the
chin, may become affected.  The nose sometimes  enlarges and
becomes fiery or deep red;  and the  tubercles, on suppurating,
may ulcerate unfavorably.

                         III.  PORRIGO.
   1076.  The Porrigo favosa, when it affects the nose and face,
assumes  a frightful  aspect.   It  nevertheless  frequently heals
without leaving a scar.  It must be distinguished from  Lupus,
the  disease to be next described, and from the Ecthyma and
Scycosis.
   1077.  This disease is characterized by an eruption of large,
soft,  straw-colored  pustules,  without  previous inflammation:
these pustules are somewhat flat, with an irregular edge. When
seated on the face, they become confluent, discharge a viscid hu-
mor, form scabs, and  are surrounded by inflammation, and per-
haps by other more distinct pustules highly characteristic of this
disease.(*)
                          IV.  LUPUS.
   1078.  This disease originates in tubercles, which enlarge, red-
den, and ulcerate.   The ulcerations coalesce, and gradually de-
stroy the parts upon which it is seated.   These are principally
the nose, the lips, the cheeks, the forehead, the eye-lids ;  but
far most frequently the nose*
  (1.) The author evidently intends by the above the form of Impetigo, vaguely
called when occurringin children, crusta lactea,—which sometimes, besides en-
veloping the forehead, and even the whole head, with a thick mask, (and hence
called I. larvalis) extends also over the nose, and more or less over the face.  It
occasionally: also, occurs on the cheeks and nose of adults.  It seldom leaves a
scar.  There is little danger in confounding  it with Lupus, or Ecthyma, or
Sycosis. It differs essentially from true Porrigo.  For the characteristics of Por-
rigo see note, par. 1167, p. ii.                                     B.
  * The various ulcers which come under the denomination of Lupus, noli me
tangere, &c. have not yet been fully designated and described.  Dr.  Bateman is
in error in thinking  that M. Alibert's plate 21 represents this affection.  I  have 
DISEASES  OF  THE  FACE.          407
   1079. In the last situation, the ulcer is apt to spread, destroy-
ing the  apex, alae, and  septum of the nose, and portions of the
cheeks, and inducing dreadful deformity^1)

                           v.   SCROFULA.
   1080. This  affection of the face consists,  chiefly, in  a tumid
state of the upper lip, frequently with a deep crack and perhaps
ulcer.   There  is also a peculiar, frightful, diseased  ulceration,
which passes over the nose and  cheeks,  which  belongs  to this
disease.   But the whole subject  is in  need  of fresh description
and representation.

                         VI.   CARCINOMA.
   1081. This  disease, when it  attacks the face, is usually seat-
noticed several forms of ulcer, about the nose especially, distinct, but not distin-
guished from Lupus.   One of these is without  redness, and erodes through the
ala nasi.  Another is
                               Syphilitic,
as ascertained by its history, the concurrence of other secondary  symptoms,
and its cure by mercury.
   Representations of the earliest stage of these diseases would constitute a va-
luable addition to the diagnosis.
  (1.)  Lupus may attack, primarily, either the skin or the mucous membrane
of the nostrils.   In the former case, it may commence with a red or violet-red
spot, with little or no elevation, or with  one or more tubercles.  In the latter
case, the soft pulpy texture of the part prevents the formation of tubercle.  The
primary stage may be followed, either by a peculiar destruction of the parts un-
derneath, without ulceration, produced by the skin becoming more and more thin
at the same time that it is red, smooth, and shining, assuming afterwards the ap-
pearance of a cicatrix following a burn,—or, the primary stage may be followed
in other cases, (and this is by far the most common course) by ulceration, or by
hypertrophy, giving rise to a remarkable degree of puffiness.
  Lupus, therefore, admits of a division into two distinct varieties—L. exedens
and L. non-exedens.   A practical subdivision of the  first variety is  into that
which ulcerates upon the surface, and that whose ravages destroy the deep seat-
ed parts*—the one healing in one part and extending in another,—the other con-
fining itself more to one spot and destroying the parts beneath to a considerable
depth,  thus producing great and  permanent deformity.
  It is important to distinguish Lupus from Cancer and  Syphilis, with both of
which it may be  confounded.                                       B. 
408        THE   DIAGNOSIS  OF  SOME
 ed upon  the lower-lip ; but  it may occur upon the forehead,
 the eye-lid, the cheek, &c.
   1082.  It begins obscurely,  frequently without scirrhus, in a
 merely scaly, tubercular, or slightly thickened  condition of the
 skin, which is succeeded by  ulceration, which  spreads progres-
 sively with everted edges,  frightfully destroying and deforming
 the part in which it is seated.   It is, unlike Lupus, without sur-
 rounding redness.   It is atlended with  pain,  and eventually
 with the  pale, sallow hue of the complexion  peculiar to cancer.
 Its progress is very various,—slow, arrested,  or  rapidly progres-
 sive.

                       VII.  SYCOSIS.
   1083.  This disease is peculiar to those parts which are cover-
 ed with hair : it occurs principally upon the bearded part of the
 upper lip and chin, and on the head.  It is almost, but not quite,
 confined to the male sex.

                      Sycosis Menti.
   1084. The Sycosis of the face is distinguished by slowly sup-
 purating tubercles, the centre  of each of which is occupied  by a
 hair.  The part becomes inflamed, indurated, red, tender, en-
 crusted, in distinct  or coalescent spots, matting the beard to-
 gether, and preventing shaving.  Its progress  is very various.
 Itis sometimes long continued.

                       VIII.   OZaENA.
   1085.  This term has been  employed  to denote various  dis-
eases within the nostrils,  attended  by ulcerations,  foetid  dis-
charges, caries, &c.   The  extent of the disease is ascertained by
an examination : its origin, by an attention to the history of the
case.  It is chiefly connected with
              1. Syphilis ; or
              2. Cachexia.
It is distinguished, by a careful inspection, from
                         Polypus. 
            DISEASES  OF  THE  FACE.          409

                  IX.  PAROTID FISTULA.
   1086. This disease is readily distinguished by the flow of
saliva externally through the perforated cheek, which is contin-
ual during the hours of fasting, but greatly augmented during
eating.

                      X.   GANGRENE.
   1087. Gangrene  sometimes  attacks the cheek or  the  jaw
after acute diseases, especially in the young.   I have principal-
ly observed this  disease in infants ; but it occurs occasionally in
adults.
   1088. The part becomes tense and pale: an eschar is discov-
ered occupying  the internal or external part of the cheeks or the
gums.  It frequently destroys a part  of  the  cheek,  or  of the
alveolee.

              XI.  DISEASES  OF THE ANTRUM.
   1089. This disease is denoted by fixed pain in the seat of the
Antrum of Highmore. It can only be suspected, until it is fully
ascertained by the surgeon.
52 
CHAPTER  II.
THE DIAGNOSIS OF THE DISEASES OF THE MOUTH AND THROAT.

  1090. The diseases of the  Mouth and  Throat are highly
interesting both to the Physician and the Surgeon,  and con-
stitute, in some of their forms, an interesting branch of Medical
Surgery.  Inflammation,  Scirrhus, and  Syphilus present ex-
amples  of each of these  points ; but they must be arranged
together, in order that the diagnosis may be made apparent.

ARRANGEMENT OF THE DISEASES OF THE MOUTH AND THROAT.
             I. THE DISEASES OF THE GUMS.,
        I. Tumidity.
       II. Shrinking.
      III. Circular Ulcer.
       IV. Canker.

            II. the diseases of the tongue.
        I. Ranula.
       II. Tumors, with slow Suppuration.
      III. Ulcer, from Irritation.
       IV. Scirrhus ; Carcinoma.

            hi. the diseases of the fauces.
        I. Inflammation.
             1. Of the  Velum.
             2. Of the Tonsils.
             3. Of the Pharynx.
             4. Of the Posterior Nares. 
         OF  THE  MOUTH  AND  THROAT.     411

        II. Elongated Uvula.
       III. Enlarged Tonsils.
        IV. Scarlatina.
        V. Herpes.
       VI. Aphthae.
       VII. Ulceration.
              1.  Syphilitic.
              2.  Pseudo-Syphilitic.
              3.  Mercurial;  fyc.

                I.  DISEASES OF THE GUMS;
                      I. TUMIDITY.
   1091.  Tumidity of the Gums sometimes occurs in so marked
a form as to constitute an actual disease.  The gums  grow up,
in front, between the  teeth, and, in the posterior  part of the
mouth, so as to cover  some of the molares.   This disease is
usually induced by a loaded state of the  colon, and is apt to be
aggravated by taking cold.

                      n. shrinking.
   1092.  Instead of tumidity, the  gums sometimes experience a
degree of shrinking.  The  teeth are left exposed, frequently
become loose,  and fall out, even in the young, without the least
appearance of decay.

                  III.   CIRCULAR  ULCER.
   1093.  The gums, the inside of the lip or cheek, the point or
edge of the tongue, are liable to an affection consisting of one,
two, or more minute  circular spots  of inflammation, which
gradually pass through the stages of sloughing and ulceration,
with extreme  tenderness.  This affection arises from, and  de-
notes a deranged state of the stomach, and occupies a space of
eight or nine days.  It is promptly relieved  by being touched
with the nitrate of silver. 
412      DIAGNOSIS  of  THE  DISEASES'
                        IV.  CANKER.
   1094.  This  peculiar disease occurs principally in children,
 and consists of a diffused, ragged ulceration, with  offensive dis-
 charge, occupying the edge of the gums, and inducing looseness
 and decay of the teeth.  The inside of the cheek is generally
 affected in a similar manner.
   1095. This affection must be distinguished from the ptyalism
 of mercury, scorbutus, aphthae, &c. and  from the disease de-
 scribed § 1087.

                II.  DISEASES OF THE TONGUE.

                        I.  RANULA.

   1096.  This  disease consists of a distended salivary  duct,
 generally of the  submaxillary gland.  It must  be  carefully dis-
 tinguished from
                 1.  A serous Cyst.
                 2.  An Abscess.
                 3.  ^4 Tumor.
                 4.  Calculus.
   1097. These affections have frequently a similar seat at the
 under surface of the tongue.   The distinction is most readily
 made by means of a puncture with a couching needle.

           II. TUMOR, WITH SLOW SUPPURATION.
  1098. This affection, of which I have witnessed several in-
 stances, is usually situated in the upper surface of the tongue.
 It is at first a  hard tumor, slightly tender on pressure;  this
 slowly suppurates; after which it  presents the appearance of a
 deep ulcer.  It usually arises from derangement of the bowels
 and is  cured  by purgative medicines, with the local application
 of the nitrate of silver.

              III. ULCER, FROM  IRRITATION.
  1099.  The principal cause of this affection is a jagged, de-
cayed tooth: it therefore occurs usually at the edge of the tongue. 
OF THE  MOUTH  AND  THROAT.
413
There are hardness, tenderness, and ulceration.   It must be
distinguished from

             IV. SCIRRHUS, AND CARCINOMA.
  1100.  This disease of the tongue has no special seat;  it has
no obvious cause.   It is  denoted, first, by scirrhous hardness,
then by irregular ulceration ; it  is not acutely tender;  but it is
accompanied by lancinating pain, and, in a short time, by pale
sallowness, and emaciation.

              III.  DISEASES OF THE  THROAT.

                    I.   INFLAMMATION.
  1101.  This disease is denoted by redness and tenderness, and
therefore by pain on swallowing.  Its seat is determined by that
of the pain, and by a careful examination, and is usually
             1.  The Velum  Palati.
             2.  The Tonsils.
             3.  The Pharynx.
             4.  The Posterior Nares.
In one form of this  disease, there are  great laryngeal irritation
and violent cough, which are removed by passing the nitrate
of silver along the border  of the  velum.

                 II.  ELONGATED UVULA.
  1102.  By repeated inflammation, the uvula is sometimes left
elongated; and,  descending upon the  posterior  part  of  the
tongue, it frequently excites a  troublesome cough, which is
cured by removing a portion of the elongated organ.

                III.  ENLARGED TONSILS.
  1103.  In other cases, inflammation leaves an enlargement of
the tonsils;  the deglutition and  the speech are somewhat affect-
ed.    The nature and extent of the disease are determined on
examination.

              IV.   DYSPEPTIC SORE THROAT.
  1104.  This form of Sore Throat occurs in the acute or pro- 
414      DIAGNOSIS  OF  THE  DISEASES

tracted dyspepsia.   It is continued, or removed, with  the original
disease.*

                      V. SCARLATINA.
  1105.  This affection is frequently confined to the throat.  It
is distinguished by its peculiar scarlet hue,  and by occurring
during the prevalence of scarlatina in those exposed to its con-
tagion.

                        VI.  HERPES.
  1106.  With, or without a cluster of vesicles, or Herpes, on the
lip,  there is, occasionally, a diffused Herpes  of the velum and
palate, readily detected and discriminated on a careful exami-
nation.

                      VII.  APHTHaE.
  1107.  The velum and palate are frequently beset,  with the
tongue, the inside of the lips and cheeks, and perhaps the pha-
rynx and oesophagus, with diffused  inflammation, partly denud-
ed,  and  partly  covered  with ragged portions of  cuticle,  or
Aphthae.

                   VIII.  ULCERATION.
  1108.  Ulceration of the Throat is seen in the  Tonsils, the
Uvula and Velum, and the Pharynx.   It is
              1.  Syphilitic.
              2.  Pseudo-syphilitic.
              3.  Mercurial;  &c.
  1109.  The different forms of ulcer  of  the throat  have been
described, §§ 998,  991, 992.   The mercurial ulcer is associated
with the exhibition of mercury, and perhaps with ptyalism.
  1110.  The profession is still greatly in need of representa-
tions of  these morbid affections of the Throat.
  *  I have depicted, this affection in the Commentaries on Diseases of Females,
2d edition. 
OF THE  CE S O P H A G U S .
415
             IV. DISEASES OF THE OESOPHAGUS.
  These diseases have, by mistake, been omitted  in the Ar-
rangement, p. 365.   They are principally the following :
    I.  Inflammation
   II.  Stricture.
  III.  Scirrhus,  Encephalosis, etc.
   IV.  Internal  Tumors, Polypi, etc.
    V.  External Tumors, Aneurysm, etc.

                    i. inflammation.
  This disease of the oesophagus is rare, and can only be indi-
cated by pain  and difficulty in swallowing.   It is the source of
thickening and of

                      n. stricture.
  Stricture, in its simple form, usually occupies the superior por-
tions of the oesophagus.  The seat of the disease may be con-
jectured by the quantity of fluid which may be made to disap-
pear before it is regurgitated, being lower as this is greater:  it is
ascertained by the bougie.

                     in. scirrhus,  etc.
  Scirrhus is more frequently than simple stricture found at the
lower parts of the oesophagus, or at the cardia itself.  It is dis-
tinguished by the constitutional affection, by watching the efforts
 o swallow, and by the bougie.  See §§ 323, 732.  I  have seen a
3mall  basinful of cocoa swallowed, retained for a  time in the
oesophagus, and then rejected by an effort precisely like that of
vomiting.

               iv.  internal tumors, etc.
                v.  external  tumors, etc.
   The former of these scarcely admit of diagnosis from stricture
or scirrhus ; the latter are to be discriminated only by a careful
examination.  See  § 616. 
CHAPTER  III.
        the  diagnosis  of cutaneous diseases.

   1111. I have reserved  for this Chapter such of the Cutane-
ous Diseases as do not possess the degree of  importance of the
eruptive fevers, and yet require great care and attention for their
diagnosis and treatment.   My account of them  will be as short
as possible to be useful.
   1112. Cutaneous Diseases gradually pass from the acute into
the chronic forms ; and even the same  cutaneous disease fre-
quently assumes, in its course, both these characters successively.
The arrangement of these morbid affections, which is at once
most natural and best adapted to set forth the diagnosis, is that
which begins with their acute forms and  gradually descends to
the chronic.   Every artificial arrangement,  not excepting  the
elegant classification of Willan, must dissociate similar and asso-
ciate dissimilar diseases:  for example, ecthyma and rupia, al-
though probably different  forms of the same disease, are found
arranged in the distinct orders of Pustulae and Vesiculae.  Many
other equally injurious distributions of  cutaneous diseases in Dr.
Wilkin's classification, might be pointed out.
   1113. In  portraying the diagnosis of Cutaneous Diseases, I
shall  be anxious,  as  usual, to simplify the subject, and not to
admit of subdivisions which are mere refinements, and not mark-
ed by practical utility. 
CUTANEOUS  DISEASES.
417
        ARRANGEMENT OF
   I. Roseola.
  II. Scarlet  Rash.
 III. Urticaria.
  IV. Erythema.
   V. Lichen.
  VI. Prurigo.
 VII. Miliaria.
VIII. Herpes.
  IX. Eczema.
   X.  Impetigo.
  XI.  Scabies.
CUTANEOUS DISEASES.
    XII. Porrigo.
   XIII. Sycosis.
   XIV. Acne.
    XV. Ecthyma-
   XVI. Rupia.
   XVII. Pemphigus.
  XVIII. Pomfholyx.
   XIX. Lepra.
    XX. Psoriasis.
   XXI. Pityriasis.
   XXII. Icthyosis.
                     i.   roseola.
  1114. I. The History.   The Roseola is either induced by in-
clemencies of the atmosphere, or  occurs symptomatically in
other diseases, and principally
           1.  In Synochus and Typhus.
           2.  In Variola and Vaccinia.
           3.  In Gout and Rheumatism.
           4.  With Miliaria.
  1115. II.  The Symptoms consist in a rash, generally figur-
ed, at first red, afterwards more or less of a rose-color, usually
beginning at the extremities and  terminating on the face and
trunk of the body, of several days' duration, and apt  to be re-
current.
  1116. It is important to notice this affection, chiefly with the
view of distinguishing it from Scarlatina, Rubeola,  Erythema,
Urticaria, &c.  The forms of Roseola enumerated by Dr. Wil-
lan are
1.  Roseola estiva.
2.  Roseola autumnalis
3.  Roseola annulata.
4.  Roseola infantilis
5.  Roseola variolosa.
6.  Roseola vaccina.
7.  Roseola miliar is.
53 
418            THE  DIAGNOSIS  OF
 The only forms of this disease requiring notice in this place are

                     1.  Roseola JEstiva.
   1117.  I.  The History.  This form of Roseola occurs chiefly
 in females of irritable constitutions, from exposure to heats and
 chills in summer ; it is sometimes associated with the local com-
 plaints of this season.
   1118.  II.  The Symptoms.   It is preceded by fever and ac-
 companied by itching and tingling.  It is distributed in patches
 of various figure, not crescentiform, larger, more irregular, and
 paler than rubeola;  at  first red, it soon assumes its  peculiar
 roseate hue.  The fauces are affected with a  similar efflores-
 cence.  The rash continues vivid on the second  day, but de-
 clines  on the third,  and has disappeared on  the fifth.  It is
 sometimes partial  and longer continued,  or  it recedes  and re-
 turns.
                     Roseola Annulata.
   1119. This form of Roseola appears on every part of the body,
 in rose-colored rings, with central  areas  of  the natural  color,
 which gradually dilate, from one or two lines, to half an inch in
 diameter.  This affection is either attended with fever and short
 in its duration, or it is without fever and more protracted.
   1120. Roseola is distinguished from Rubeola by the absence of
 all evidence of infection, of catarrhal symptoms, and of the char-
 acteristic appearance of the rash first on the  face, and then on
 the other  parts of the body, with its peculiar crescentic forms.

                     II.  SCARLET RASH.
   1121. A cutaneous disease,  of which I believe I have seen
 several instances, resembling Scarlatina in its appearance, is
 described by  Dr. Maton.* It is highly interesting in a diagnostic
 point of view.
  1122. I.  The  History.  It appears to be contagious.   But
the contagion is latent for a longer period than Scarlatina,  in the
proportion of three weeks to one.
* Trans, of the Royal Col. of Phys. vol.v, p. 143. 
CUTANEOUS  DISEASES.
419
    1123. II. The Symptoms.  There  are rigor, and,  shortly
 afterwards, the appearance  of rash : this is distinguished from
 Scarlatina by much tingling, by the absence of enlarged  papillae
 of the tongue,  and of the degree of sore throat observed in Scar-
 latina, and  of the desquammation of  the cuticle  which fol-
 lows it.*

                       III.   URTICARIA.
   1124. I.  The  History.   Urticaria  is  generally  excited  by
 some improper article of food, or other source of indigestion.  It
 assumes various forms, which are  thus enumerated by Dr. Wil-
 lan :
      1.  Urticaria febrHis.        4.  Urticaria conferta.
     2.  Urticaria evanida.      5. Urticaria subcutanea.
     3.  Urticaria perstans.      6.  Urticaria tuberosa.
 The following  description will be sufficient for the diagnosis.
   1125.  II.  The Symptoms.  Urticaria consists of elevations
 of the skin, of greater or less  circumference, of various forms, flat
 at  their  upper  surface,  and  generally denominated wheals.
 There is no tenderness  or disposition to suppuration; but there
 is excessive itching or tingling.(')
   1126.  In the febrile Urticaria, there is a diffused efflores-
 cence, as well  as  numerous wheals.  The case must be distin-
 guished  from  Scarlatina; but  the diagnosis only requires the
 most ordinary caution.
   1127.  The other forms of Urticaria are sufficiently expressed
by  their several epithets,^ and really present  little difficulty in
 the diagnosis.
  * This rash bears the same similarity to Scarlatina which Roseola does to Ru-
beola ;  the diagnosis is of great importance in determining the question of the
possibility of the recurrence of Scarlatina and Rubeola in the same person.
  (1.) These elevations are sometimes red, and at other  times white surround-
ed by redness more or less diffused, asd are generally very fleeting in their du-
ration.                                                      B.
  t  I have carefully preserved the epithets of Dr. Willan, on account  of their
utility in the diagnosis of their different forms, although they are frequently but
too minute as grounds of subdivision and arrangement. 
420
THE  DIAGNOSIS  OF
                     IV.  ERYTHEMA.
   1128.  I.  The History.   The Erythema is generally symp-
tomatic.
   1129.  II.  The Symptoms.   This affection consists of diffus-
ed patches of efflorescence.   It is frequently seen upon the face,
neck, chest, and arms; and, in conjunction with oedema, upon
the legs.   In the last situation, it may terminate in gangrenous
ulceration.   Dr. Willan  enumerates the following  varieties of
Erythema:

            1.  The Erythema fug ax.
            2.  The Erythema lave.
            3.  The Erythema marginatum.
            4.  The Erythema papulatum.
            5.  The Erythema tuberculatum.
            6.  The Erythema nodosum.
            7.  The Erythema intertrigo.
   1130.  None of these forms require particular notice, except the
sixth.   The Erythema nodosum is common in chlorosis and the
similar affections of younger patients.   It occurs in the  form of
red nodes under the skin,  along  the anterior part  of the leg,
which are slightly tender, but do not suppurate^1)
   1131.  There is another form of Erythema not noticed by Dr.
Willan.  See § 1073.

                        V.  LICHEN.

   1132.  I.  The History.   The  Lichen generally arises from
internal disorders.   It occurs, according to Dr.  Willan  under
the following forms;
  (1.) The dark red, oval elevations of Erythema nodosum, resembling very
much tumors likely to suppurate, may also occur on other parts, as on the arms
and forearms, and on the nates and thighs, though much the most common on the
anterior part of the tibia,  and almost always occurring there when but few in
number.  When  on the long bones, their longest diameter is parallel with the
shaft of the bone on which they are seated.                         g 
CUTANEOUS   DISEASES.
421
     1.  Lichen Simplex.           5. Lichen lividus.
     2.  Lichen pilaris.             6. Lichen tropicus.
     3.  Lichen circumscriptus.    7. Lichen urticatus.
     4.  Lichen agrius.
The principal of these forms are the
                 1. Lichen simplex ; and
                 2. Lichen agrius.
The Lichen pilaris is  only  peculiar from occupying the roots of
the hairs; the Lichen circumscriptus, from the clustered arrange-
ment of the papulae; the  Lichen urticatus from its combining
the characters of Lichen and of Urticaria; and the Lichen livi-
dus from combining those  of Lichen and of Purpura.
   1133.  II. The Symptoms •

                     1.  Lichen simplex.
This affection consists of red, inflamed papulae, first appearing
on the  face and arms, and then on the  trunk and limbs, pre-
ceded by fever, and attended by tingling, especially in the night.
In about a week,  the redness fades and the papulae decline into
scurf, most and  longest  seen at the flexures of the joints.  It
may pass into Psoriasis. (l)

                       2. Lichen agrius.
   1134.  This severer form of Lichen is  ushered in by fever.
The papulae occur in large  patches, of a  high red  color, with
  (1.) Lichen .simplex may be either acute or chronic.  In the acute form the
papulae are red and inflamed—in the chronic form, they are but little, if at all,
inflamed, and are most usually of the color of the skin.  In neither case, is the
appearance of the papulae preceded by fever unless the eruption is quite  abun-
dant, though not uncommonly by some symptoms of gastric or intestinal de-
rangement.  The chronic form is almost always accompanied by thickening of
the skin, and is most frequently seen on the extremities, and especially on the
hands, and almost always on  their dorsal surface, where it constitutes the most
frequent of  the several varieties of cutaneous disease known under the  vague
name of " salt rheum."
  It  never passes into Psoriasis, though occurring in one  form which bears a
strong resemblance to that affection.                               B, 
422             THE  DIAGNOSIS  OF
 diffused inflammation:  there  are much itching, heat, and tin-
 gling, which  are exasperated by  heat, or any irritation, and
 after dinner.   Small vesicles, filled with a straw colored  fluid,
 are occasionally intermixed with the papulae.   If this affection
 be  long continued,  the skin  becomes  harsh, thickened, and
 cracked, and there is exquisite pain if it be rubbed.   After re-
 peated attacks, it may assume the character of Impetigo.(')

                          VI.  PRURIGO.
   1135. This disease is denoted by severe itching, increased
 by exposure to heat,  affecting  either the whole  surface of the
 skin,  or a  part only ; in some instances, without any apparent
 eruption; in  others,  accompanied  by an eruption  of  papulae,
 generally larger than those of  lichen, and nearly of the same
 color with the adjoining cuticle.(2)
   1136.  Dr. Willan describes three forms of Prurigo :
        1. Prurigo mitis.         3.  Prurigo senilis.
        2.  Prurigo formicans.
   1137.  The first of these occurs in the young.   The second
is distinguished  by its obstinacy and  severity,  and its peculiar
sensations of itching, stinging, creeping, &c.    If the  second
form of Prurigo be obstinate, the third is inveterate, and often
destroys the comfort of the patient, by  its incessant itching  and
stinging, for the rest of life.
  (1.) Small ulcerations frequently form on the summits of many of the papulae,
especially when aggravated by any internal or external cause of irritation. The
sero-purulent fluid which these discharge concretes into small, thin, yellowish
scabs, which are  soft, and  but slightly adherent.  Pustules of Impetigo, and
also of Ecthyma, as well as vesicles of Eczema, sometimes complicate the papular
eruption, and it is in this way only that it can ever assume the character of
Impetigo, as asserted by Willan, and mentioned in the text.             B.
  (2.) An important diagnostic mark of Prurigo, though an accidental one, is
the presence of small, dark-colored scabs on the summits of many of the papulae,
produced by the  concretion of minute portions of blood which ooze out when
they are violently rubbed during the intense itching which accompanies the dis-
cas?.   The papulae of Prurigo are also isolated and distinct, and scattered ove;
larger surf ces, instead of tending to form groups as observed in Lich< n.  B. 
CUTANEOUS  DISEASES.
423
                      VII. MILIARIA.
   1138. I.  The History.   The Miliaria is always sympto-
matic.   It may occur in any febrile disorder ;  but it is chiefly
observed when  the skin is excited to profuse  perspiration.   1
have seen it in typhus, rheumatism, &c. and it  was formerly a
frequent attendant on the puerperal state.
   1139. II. The Symptoms.   It consists of an  eruption of
minute, round vesicles, of the size of millet seeds, transparent at
first, afterwards very slightly opaque.   This eruption occurs
upon every part of the surface, but chiefly  on the throat, neck,
and face, diffused, or in patches.
   1140. The Miliaria  can scarcely be confounded with any
other cutaneous  affection.

                       VIII. HERPES.
   1141. 1.  The History.  Herpes is generally the result of ex-
posure to cold under constitutional derangement.  It observes a
regular  course of eruption, scabbing, and  desiccation, which oc-
cupies nine or ten days.
   1142. II.  The Symptoms.   This affection consists of clus-
ters of  vesicles, which vary much in form,  seat,  and  extent,
giving origin to  the following varieties of the disease:

    1. Herpes labialis.          4. Herpes circinatus.
    2. Herpes zoster.           5. Herpes iris.
    3. Herpes phlyctanodes.    6. Herpes praputialis.

                    1.  Herpes labialis.
   1143. This form  of Herpes  has been  already described,
§ 1105.

                     2.  Herpes zoster.
   1144. This form of the disease consists of successive clusters
of vesicles, with surrounding redness, spreading directly or ob- 
424            THE  DIAGNOSIS   OF
liquefy across the waist or thorax, in the manner of a sash or
sword-belt.   Its vulgar designatian is Shingles.(')

                  3.  Herpes phlyctanodes.
   1145.  This kind  of Herpes  consists of similar successive
clusters of vesicles, which observe a similar course, but less regu-
lar form.   It may occur on any part of the body. It is denomi-
nated Nirles by the vulgar.

                   4. Herpes circinatus.
   1146.  This affection is more chronic than the preceding
forms of Herpes, and is popularly designated Ringworm.  Its
vesicular character distinguishes it, at  once, from the pustular
Porrigo.

                   5.  Herpes praputialis.
   1147.  This affection has been already described, § 996.

                        IX.  ECZEMA.
   1148.  The Eczema depends upon the application of external
or internal irritants.  Unlike Herpes, it  is extremely irregular in
its course and decline.  Dr. Willan describes three forms of it:
     1.  Eczema solare.           3.  Eczema rubrum.
     2. Eczema impetiginodes.
The first of these arises in a part which  has been exposed to
the direct  rays  of the sun, chiefly the face and neck.  The
second depends upon the application of a local irritation, and
appears principally on the hands: it constitutes what is desig-
nated, in one  instance, the Grocer's,  in  another  the  Brick-
  (1.) The seat of Herpes zoster is not confined to the " waist or thorax," though
it occurs in those regions in by far the greater number of cases.  It may appear
on the neck, the shoulders, the face, the temples, and even on the hairy scalp, pre-
serving in each situation its peculiar characteristic of never passing the median
Une.  It also sometimes runs parallel with the axis of a limb.           B. 
CUTANEOUS   DISEASES.
425
layer'sitch, according as the exciting cause is sugar, or lime^1)
But the most important variety of Eczema is the

                       Eczema Rubrum.
   1149. I.  The History.   This disease is  generally, but not
universally, excited by the external or internal use of mercury.
Its seat, extent, and duration are  extremely variable.
   1150.  II.  The  Symptoms.   The  first appearance of the
Eczema is a diffused redness,  rather rough  to the touch,  and
distinctly though minutely vesicular on  a careful examination.
It is attended by tingling and  tumefaction.   The vesicles  con-
tain a fluid, transparent  at first,  and, in a few days,  slightly
opaque.  It is most frequently  seen on the upper part and flex-
ures of the thighs; but it is often diffused extensively over the
surface.  The vesicles burst, at length, and pour forth an acrid
ichor, and the parts are painfully excoriated and fissured.
   (1.)  A much more satisfactory division of Eczema is into acute and chronic—
 including under the former, 1. E. simplex; 2. E. rubrum; 3. E. impetiginodes. To
 these should be added a third group, embracing the different local varieties, or
 the modifications depending on peculiarity of seat.   With this arrangement, E.
 solare would be merely a variety of E. simplex arising from a special cause, of
 which there is a great variety, both internal and external, acting to produce this
 affection.
   The  variety of E. impetiginodes caused by local irritation and appearing prin-
 cipally  in the hands, is the least frequent in its occurrence, and by far the least
 important in its character. This species embraces a large number of cases origi-
 nating in different, and indeed opposite states of the system, the greater part
 dependent on internal irritation,  extremely annoying in their nature, and very
 obstinate in their resistance to  remedies,  I have  seen numerous cases of this
 species  of Eczema in  emigrants from Europe, sometimes appearing just before,
 but usually soon after landing, who had been suffering from the combined causes
 of impure air, improper, and perhaps scanty diet, and neglect of cleanliness;
 and daily witness it among children of the lower classes who are so frequently
 exposed to a similar combination of depressing influences.  These cases simulate
 Scabies very much.
   Among the local varieties of Eczema, that affecting the  head in infants, and
 known, among other affections of that part of a character entirely dissimilar,
 nnder the vague name of "tinea' capitis," is one of the most common and the
most troublesome.                                               B.
                                54 
426
THE  DIAGNOSIS  OF
   1151.  The general health is frequently little affected^1)

                         x.  IMPETIGO.
   1152.  The transition is  natural from Eczema to Impetigo,
 although these diseases are distributed in distant parts  of  Dr.
 Willan's arrangement.   That author has divided Impetigo into
 five forms :
     1. Impetigo figurata.       .4.  Impetigo scabida.
     2. Impetigo sparsa.          5. Impetigo rodens.
     3. Impetigo erysipelatodes.
   1153.  The Symptoms.   Impetigo consists in the eruption
 of pustules, which are not very prominent, and which in a few
 days break and discharge their fluid, the surface becoming red,
 excoriated, and shining, and discharging an ichorous fluid; there
 are also great heat, itching,  and smarting.   The discharge con-
 cretes into thin scabs.
   1154. The first variety of Impetigo assumes the form  of
 Ringworm ; the second is more  diffused; the  third appears
upon the surface of a part affected with erysipelatous inflamma-
tion; the fourth is long-continued, the part  being "encased  in
a thick, yellowish, scaly  crust, not unlike the bark of  a tree;"
the fifth variety is said to be allied to cancer.*

                        XI.  SCABIES.
   1155. I.  The History.  Scabies is decidedly contagious.
  (1.) This species of Eczema  occurs more frequently from other causes than
the internal or external use of mercury, especially since the prevalence of the
present more cautious use of this remedy. The cutaneous affection produced by
this article is so distinct in  its cause, aud so different in its progress from the
other forms of Eczema, that it has been thought advisable to separate it from
them, and it has been described under the name of Eczema mercuriale, Erythema
mercuriale, Lepra mercuriale, and more properly under that of Hydrargyria. B.
  * It will be obvious, from this brief description, that Eczema and Impetigo are
nearly allied.  The vesicular and  pustular  eruptions are sometimes  combined
even; and the Bricklayer's and the Grocer's itch, is sometimes an Eczema, some-
times an impetigo.  Impetigo seems also allied to Porrigo.   The subject is in
need of simplification. 
CUTANEOUS  DISEASES.
427
   1156.  II.  The Symptoms.   It  consists of an  eruption of
 papulae, vesicles, or pustules, singly, or intermixed, chiefly seated
 betwixt the fingers and at the bend of the wrists, and of the other
 joints, but  also  on every part of the body except the face, ter-
 minating in  scabs, and accompanied by intolerable itching.(')
   1157.  Dr. Willan divided  this disease into four  distinct
 forms :
      1. Scabies papulifor mis.     3. Scabies purulent a.
      2. Scabies lymphatica.       4.  Scabies cachectica.(2)
   1158.  III.  The Effects  of Remedies.   Scabies generally,
 real Scabies perhaps always, yields to the due application of the
 unguentum sulphuris.

                       XII.  PORRIGO.
   1159. I.  The History.  This disease, like Scabies, is conta-
 gious.
   1160. II.  The  Symptoms.   The Porrigo  consists  of the
 eruption  of straw-colored pustules,  sometimes  circumscribed,
 sometimes diffused, generally  but not always confined  to  the
 head ;  the pustules break and give issue to a fluid which con-
 cretes into yellowish or brownish, thin or thick, crusts or scabs.
   1161. Dr. Willan describes six varieties of Porrigo: L
     1.  Porrigo larvalis.       4. Porrigo scutulata.
     2.  Porrigo furfurans.    5. Porrigo decalvans.
     3.  Porrigo lupinosa.      6. Porrigo favosa.
   1162. The first is  peculiar to infants.
   1163.  The second  consists in  pustules  which successively
issue in thin scabs,  like scurf, the hair becoming thin, and
weak, and lighter in color.
  (1.) The elementary form of scabies is considered by the French writers on
this subject as vesicular ;—the pustules which sometimes appear being regarded
as complications, commonly of Ecthyma.                          B.
  (2.) S. cacheclica has doubtful claims to a place here.  It seems unphilosophi-
cal to attribute a disease to contagion in one case, and to mere cachexia in an-
other. It is probably a mere variety of Eczema.                    B. 
428
THE   DIAGNOSIS  OF
   1164.   The third consists of pustules  which terminate in
small scabs of the  size and appearance of  lupine-seeds,  and
ultimately of the size of a sixpence.
   1165.  The fourth, of pustules leading to thin scabs, which
become thick if neglected, assuming the form of Ringworm,
and ultimately coalescing so as to affect the whole scalp.
   1166.  The fifth  variety,  or the Porrigo  decalvans,  is ob-
scurely, if at  all, pustular, and consists in bald patches of the
scalp.
   1167.  The  Porrigo favosa occurs in  all parts of the  body,
sometimes on the scalp,  sometimes on the face, trunk, or  extre-
mities only, but chiefly on the head  and behind the ears, with
swelling of the cervical glands.(1)

                         XIII.  SYCOSIS.
   1168.  This cutaneous disease, when  it affects the head, must
be  distinguished from Porrigo.    The distinction is  founded on
its tubercular, slowly  suppurating character.   Its tubercles are
inflamed, fleshy, and of a darkish red ; they are apt to coalesce ;
and they pour out a sanious matter, which concretes, and mats
the hair together.   It is distinguished by its seat into the
     1. Sycosis menti.           2.  Sycosis capillitii.
  (1.) There is not a more striking instance of inaccuracy in cutaneous patho-
logy, and that too, intimately connected with practical results, than is exhibited
by Willan in his Genus Porrigo.  Of his six species, P. ZaruaZisJand P. favosa,
which include by far the largest proportion  of cases, are varieties of Impetigo ;
while P. lupinosa and P. scutulata only, are true Porrigo, which Rayer describes
under the generic title of Favus.  In Impetigo, the pustules  are small and acu-
minated, and pour out a viscid, yellow fluid, which concretes into brittle, rough
scabs--of considerable thickness, resembling somewhat dried honey, or the gum
of peach or plum trees.
  In Porrigo, the pustules are minute,  without elevation, enchassies, followed by
scabs of the color of sulphur,  very adherent,  circular, cup-like, and having the
peculiar odor of mice.  Porrigo is farther distinguished from Impetigo by being
contagious, producing baldness, and by being much more intractable.
  The French authors  exclude the two remaining species,  P. furfurans and P.
decalvans, from this genus; while the English writers, and particularly Dick,
still continue to consider them as true Porrigo.                         B, 
CUTANEOUS  DISEASES.
429
  1169.  The former, affecting the bearded part of the lip and
chin, has been noticed § 1083.   The latter is principally seated
upon the margin of the hairy scalp : the tubercles rise in circu-
lar clusters,  are softer and more acuminated than those of the
Sycosis menti, slowly  suppurate,  coalesce, and induce an ele-
vated,  unequal,  ulcerated surface,  which  often appears gra-
nulated, resembling the cut  surface of a fig; whence its name.

                       XIV.  ACNE.
  1170.  It seems quite unnecessary to enter into any minute
description of that eruption  of slowly  or partially suppurating
tubercles, which chiefly beset  the face and the skin upon the
shoulders of young persons.   It has been described under four
forms by Dr. Willan, the  designations of which  sufficiently
express the varieties of its appearance :
    1. Acne simplex.         3. Acne indurata.
    2. Acne punctata.        4. Acne rosacea.
The last of these has been already noticed  § 1074.

                      XV.  ECTHYMA.
  1171.  I.  The History.  The Ecthyma generally follows
some severe indisposition, as fever, scarlatina, rubeola, variola,
dyspepsia acuta, or the effects of anxiety, spirits, &c.   It consti-
tutes certain forms  of venereal eruptions,  § 991;  and it is a
frequent  effect of Cachexia.
  1172.  The Symptoms.  This disease consists of  distinct,
scattered pustules, situated upon  hard, elevated, and  inflamed
bases, and terminating in thick, hard, greenish, or dark-colored
scabs.
  1173.  Dr. Willan describes  four varieties of Ecthyma :
     1. Ecthyma vulgare.    3. Ecthyma luridum.
     2. Ecthyma infantile.   4. Ecthyma cachecticum.
  1174. The first  variety consists of a  partial  eruption  of
small, hard  pustules,  on the neck, shoulders, or extremities,
which is completed in about  three days.   They  enlarge and
inflame, form pus, and then scabs.   These eventually dry, fall 
 430              THE   DIAGNOSIS   OF

 off, and leave no mark behind.  They are chiefly seen in young
 persons whose health has been impaired.
   1175. The  pustules  of the Ecthyma  luridum  are larger,
 more diffused, more repeated, and are fixed upon a hard,  elevated
 base of a  peculiar dark   red  color.   They appear upon every
 part of the body, but least frequently on the face.
   1176.  This form of Ecthyma is principally seen  in  old  per-
 sons  of broken constitutions.   A symptomatic  variety  also
 occurs during the cachexia which succeeds to scarlatina, &c.
   1177. The Ecthyma  cachecticum occurs, as its  name  im-
 ports, during various  forms  of  Cachexia,  and especially that
 which  follows certain venereal taints.   My reader  is once more
 referred to § 991.

                          XVI.  RUP1A.
   1178.  Rupia is described by Dr. Bateman as consisting of an
"eruption of flat, distinct vesicles, with the  base slightly  in-
 flamed, containing a sanious fluid, the scabs accumulating, some-
times in a conical form, easily rubbed off, and soon  reproduced."
The same author enumerates three varieties of the  disease :
     1. Rupia simplex.           3.  Rupia escharotica*
     2. Rupia prominens.

                      XVII.  PEMPHIGUS.
   1179. This disease is described by Dr. Bateman as an  erup-
  * This disease was not noticed by Dr. Willan.  Dr. Bateman confesses that,
for all practical purposes, it might be included with the Ecthyma, appearing
under similar circumstances with the Ecthyma luridum and the Ecthyma cachec*
ticum.  It is altogether a useless refinement^1)
  (J.) This disease, though not noticed by Willan, and though presenting in some points a
strong analogy, both in its causes and progress,^with some.forms of Ecthyma, differs sufficiently
in its scabs and subsequent ulcerations, to entitle it to the rank of a distinct genus, and has
such a place assigned it Ly all the later French and English writers on cutaneous diseases.
Though placed among the vesiculae by Bateman, it is  a bullar, and not a vesicular disease,
being characterized by effusions under the epidermis of serous or sero-purulent, and sometimes
sanious fluid, of a size varying from  two or three,  to  ten or even twelve lines in diameter,
which are followed by thick or prominent dark colored scabs, and by ulcerations of  greater or
Jess depth.                                                       B. 
CUTANEOUS   DISEASES.
431
tion of transparent vesicles, about the  size of a filbert, with a
red, inflamed edge, but without surrounding blush or tumefac-
tion, containing a pellucid fluid, and  disposed  to ulcerate on
breaking.

                    XVIII.   POMPHOLYX.
   1180. This affection consists of an eruption of blebs without
surrounding inflammation, and without fever, which break and
heal without scab or crust.   It appears under the three following
forms:
     1.  Pompholyx benignus.     3.  Pompholyx solitarius.
     2.  Pompholyx diutinus.
   1181. ^he first consists of transparent blebs, which appear in
succession, burst, and soon heal.   They appear  chiefly in boys
in hot weather, on the face, neck, and limbs.
   1182. The second occurs in debilitated or aged persons,  in
the form of successive blebs, which augment from the size of a
pea to that of a walnut, and perhaps burst and lead to excoria-
tion. This disease is sometimes associated with  dropsy or pur-
pura.
   1183. The third form of Pompholyx requires no distinct no-
tice.^)

                        XIX.   LEPRA.
   1184. This disease  consists of circular patches of smooth, la-
minated scales, of different sizes, inflamed at their borders, and
depressed in their centres.
  (1.) This subject is much simplified by studying Pemphigus under the two
leading forms of acute and chronic, and referring to one or the other of these, the
three varieties of disease described  by Willan,  under the name of Pompholyx,
and thus d ispensing with that term.  Under such an arrangement, Pompholyx
benignus would be described as a mild variety of the acute form; while the chro-
nic form would correspond to  Pompholyx diutinus, and also include P. sol-
itarius, which is a very rare form, and receives its specific name from the pre-
sence of a single bulla only at a time, and that of a very large size.       B. 
432
THE DIAGNOSIS  OF
   1185. There are three varieties of Lepra:
     1. Lepra vulgaris.          3.  Lepra nigricans.(x)
     2. Lepra alphoides.
   1186. The first and second do not deserve a distinct notice.
The Lepra is generally seen to occupy the skin over the olecra-
non and patella.
   1187. The third variety is attended by thinner scales ; and,
when  these are removed, the part is frequently tender and apt
to bleed.  It is frequently associated with cachexia.

                      XX.   PSORIASIS.
   1188. Psoriasis differs from the Lepra chiefly in the irregular
form and in the diffusion of the scaly patches, and in the absence
of its inflamed borders, depressed centres, and regular oval or cir-
cular forms.   The subjacent surface is also more tender, more
easily  denuded, and more prone  to become affected by fissures.
Psoriasis has been divided into the following varieties :
     1. Psoriasis guttata.     4. Psoriasis  inveterata.
    2. Psoriasis diffusa.     5. Psoriasis  localis.
     3. Psoriasis gyrata.
   1189. These varieties,  except the last, depend on the differ-
ence of form and duration of the  disease.  The Psoriasis lo-
calis  affects—1, the under lip; 2,  the  wrists and fore-arm in
washerwomen; 3, the palm of the hand, the  eyelids; 4, the
back of the hand in bakers ;  5, the prepuce ; 6, the scrotum.(2)

                     XXI.   PITYRIASIS.
   1190. This affection consists of irregular patches of thin, bran-
like scales, which repeatedly exfoliate and recur, but never form
crusts, or are accompanied  with excoriations.
  (I.) The Lepra nigricans of Willan is evidently a syphilitic affection.   B.
  (2.) In addition to the local varieties enumerated in the text, Psoriasis may af-
fect—1, the hairy scalp ; 2, the face ; 3, the nails, from the extension of the dis-
ease, when the hand is affected.                                  B. 
CUTANEOUS  DISEASES.
433
   1191. Four varieties of Pityriasis have been described:
      1. Pityriasis capitis.    3.  Pityriasis versicolor.
      2. Pityriasis rubra.     4.  Pityriasis nigra.
   1192. The first of these is the dandriff of infants.
   1193. The second occurs in advanced life.
   1194. The third is denoted by  the variegated appearance of
the cuticle.
   1195. The fourth is seen in children born in India.(»)

                       XXII.  ICTHYOSIS.
   1196. This disease consists in an indurated, horny condition
of the skin.   It  is divided into two kinds :
      1.  Icthyosis simplex.      2. Icthyosis cornea.(3)
  (1.) The appearance  of Pityriasis rubra is  not  necessarily confined  to ad-
vanced life. It is a very rare form of disease.
  The color of Pityriasis Versicolor is characteristic, being a more or less decided
shade of yellow, sometimes approaching to that of rhubarb or saffron*
  Biett says that the variety above mentioned, P. nigra, is not a scaly disease,
and describes a form under that name differing entirely from it.          S.
  (2.) An important division of Icthyosis, for practical purposes, is into con-
genital and accidental; for on this depends the chance of cure.            B.
55 
CHAPTER  IV,
        THE DIAGNOSIS  OF VARIOLOID  DISEASES.

  1197. I have thought the subject of the present chapter of suf-
ficient importance to be separated  from that of Cutaneous Dis-
eases generally.   The question of the efficacy of  Vaccination,
and the question so ably agitated by Dr. Thomson, of the iden-
tity of modified Variola and Varicella, are of such moment in the
practice of physic as to require every possible mode of illustration.
  1198. I purpose, therefore, in this place,  to describe the true
Vaccine vesicle and its various imperfect forms ; the several va-
rieties of the Varicella ; the most usual appearance of the modi-
fied Variola ; and the variety of forms which the Variola assumes
in those unprotected from its  power.

        ARRANGEMENT OF THE VARIOLOID DISEASES.

     I. Perfect Vaccinia.

    II. Imperfect  Vaccinia.

              1.  The Vaccine Pustule.
             2.  Ulceration.
             3.  Irregular Vesicles.
   III. Varicella.

              1. Varicella lenticularis.
             2.  Varicella  conoidalis.
             3.  Varicella  globata. 
            the   varioloid  diseases.       435

     2^-  Variola.
         I.  In the  Unprotected..
                1.  The mild vesicular.
                2.  The vesiculo-pustular.
        II.  In the Protected.
                Modified Variola.

                   i.  perfect  vaccinia.

    1199. Vaccinia, when perfect, is denoted by a semi-transpa-
 rent, pearl-colored Vesicle, which, after the ninth  day,  is sur-
 rounded by a red areola, and afterwards terminates in a hard,
 dark-colored scab.   The base is circular, or somewhat oval, with
 a diameter of about four lines, on the tenth  day.   Till the end
 of the eighth toy, its upper surface is uneven, being considerably
 more elaborated at the margin than about the centre, and some-
 times  indented by one or  two concentric furrows ; but  on the
 ninth or tenth day, the surface becomes plane, and, in a very
 few instances, the central part is highest.   The margin is tur-
 gid, firm, shining, and rounded, so as often to extend a little be-
 yond the line of the base.  This  convex,  wheel-shaped margin
 forms  the criterion of a perfect Vesicle.   The Vesicle consists in-
 ternally  of numerous little cells,  filled with clear lymph, and
 communicating with each other.   The  areola which is formed
 round the vesicle is of an intense red color.   Its diameter differs
 in different persons, from a quarter of an inch  to two inches ; and
 it  is usually attended with considerable tumor and  hardness of
 the adjoining cellular membrane.
   1200.  On the eleventh and twelfth day, as the areola de-
 clines, the surface of the vesicle becomes brown at the centre, and
 less  clear at the margin.  The cuticle then begins  to separate,
 and the fluid in the cells gradually concretes into a hard rounded
scab of a reddish brown color.  This scab  becomes at  length
black,  contracted, and dry; but it is not detached till after the
twentieth day from the inoculation.   It leaves a  permanent
cicatrix about five lines in diameter, and a little depressed, the 
436
THE  DIAGNOSIS OF
surface being marked with very minute pits or indentations, de-
noting the number of cells of which the vesicles had been com-
posed.*

                 II. IMPERFECT VACCINIA,
                1,  The  Vaccine Pustule.
                2.  Ulceration.
                3.  Irregular vesicles.
   1.201.  I.  The Histcry.  It has been ascertained  that Vacci-
nation is imperfect or insufficient—1.  When the fluid employed
has lost some of its  properties.   2. When the persons inoculated
are soon afterwards affected with any contagious  or  eruptive
fever.  3. When they are affected at  the same time with some
Cutaneous Disorders,  as Herpes,  Psoriasis, Impetigo, Lichen,
Porrigo; and perhaps Scabies and Prurigo.
   1202.  The Pustule or Ulceration may arise from the use of
effete or altered virus, or from the presence of Chronic  Cutane-
ous eruptions.   The vesicle without an Areola arises when the
patient has previously received  the infection of Small-pox, or is
affected with any other contagious disease.  The other Vesicles
arise from some of the causes enumerated, § 1200.
   1203.  II.   The  Symptoms.  Imperfect Vaccination is de-
noted,  in different  instances,  by the  appearance 'of Pustules,
Ulcerations, or Vesicles of an irregular form :
   1204.  1.  The Vaccine Pustule is  conoidal; it increases ra-
pidly from the second to  the fifth or sixth day, when it is raised
on a hard inflamed base, with a premature diffuse  redness ex-
tending beyond it on the skin.   It is usually broken before the
end of the sixth day, and is soon after succeeded by an irregular
yellowish brown scab.   The redness disappears within a day
or two, and the tumor gradually  subsides.  This  pustule re-
sembles the suppuration induced by the presence of a thorn ;  it
contains a straw-colored opaque matter,
  + " The discovery of Vaccination, as a preventive of Small-pox, is the most
important event which the History of Medicine can furnish," and "has conferred
immortality on the name of Jenner."— Willan. 
THE  VARIOLOID  DISEASES.       437
     1205. 2. The Ulceration probably arises  from the Vaccine
  Pustule, when it is rubbed or scratched off at  an early period.
     1206. 3. The  Irregular  vesicles are of three  kinds.   1. A
  smgle  pearl-colored  vesicle, set on a dark-red base, slightly ele-
  vated.   It is larger and more globate than the Pustule; but it is
  much less than the genuine vesicle, its top is  flattened, or some-
  times a little depressed, but the margin is not  rounded or  promi-
  nent.   The areola is usually diffuse, and of a  dark rose-color.
  2. A vesicle which appears cellular, like the genuine Vaccination,
  but somewhat smaller, more sessile, and having a sharp angu-
  lated edge.   The areola  is  sometimes of a dilute scarlet color,
  radiated, and very extensive, as from the sting of a wasp; some-
  times it  is less  extensive—The areola  appears  round  these
  vesicles on the seventh or eighth  day after  inoculation,  and
  continues more or less vivid  for three days, during which time
 the scab is completely formed; it is smaller and less regular than
 that which succeeds  the genuine Vesicle,  falls  off sooner,  and
 leaves a smaller cicatrix, which is sometimes angulated.  3. The
 third Irregular Vesicle is unattended with an areola.*

                       III. VARICELLA.
                  1.  Varicella  lenticularis,
                  2.  Varicella conoidalis.
                  3.  Varicella globata.
   1207.  I.  The History.  In Varicella the  eruption appears
two or three days after the  commencement of  fever, which
continues  sometimes to the third day after  the appearance of
the eruption.
  * When any deviation from the perfect and genuine Vaccine Vesicle arises,
common prudence, as Dr. Jenner remarks, points out the necessity of reinocula-
tion.  Amongst the improvements in Vaccination, however, none is so important
as the plan of Reinoculation in every case at the end of the fifth or beginning of
the  sixth day, suggested, as the test of Vaccination, by Mr.  Bryce.  In this
case, when the first Inoculation is effective, both Vesicles arrive at maturity, and
exhibit an areola, at the same  time; the latter Vesicle proceeds  more rapidly
through its stages,  and on the ninth or tenth day, is an equal state of forwardness
with the former, but more diminutive. 
438
THE  DIAGNOSIS  OF
   14-08.  The eruption in Varicella usually commences on the
breast and back, appears next on the face and scalp, and, lastly,
on the extremities.  It is  attended, especially in children,  with
tingling and itching, which leads them to scratch off the tops of
the vesicles, so that the characteristics of the disease are often
destroyed at  an early period.  The  vesicles, thus  broken and
irritated, become inflamed and pustular, containing thick yellow
matter.   They continue three or four  days, and finally  leave
pits.   The eruption is usually fullest in the conoidal varicella.
The vesicles are sometimes coherent, but rarely confluent.
  1209.  II.  The Symptoms.  1. The varicella lenticularis,
or the Chicken-pox, exhibits, on the first day of eruption, small
red protuberances, not exactly circular, and having a flat, shining
surface, in the centre of which a minute vesicle is soon  formed.
This, on the  second day, is filled  with  a whitish lymph, and
then  it  somewhat resembles  a miliary vesicle ; but it is less
prominent and tense, and  less regularly circumscribed ;  its  dia-
meter is about the tenth  of an inch.   On the third day, the
lymph becomes  straw-colored.  On  the fourth, many of the
vesicles are broken at their most prominent  part; the rest begin
to shrink, and are puckered at their edges.  Few remain entire
on the fifth day,  but the orifices of several of the broken vesicles
are closed or  adhere to the skin, so as to confine a little opaque
lymph within the puckered margins.   On the sixth  day, small,
thin  brown scabs  are  seen  universally instead of the vesicles,
which, on the seventh or eighth,  become  yellowish, and  gra-
dually dry from the circumference to the centre.  On the ninth
and tenth days,  they fall off, leaving for some time, red marks
on the skin, without depression.   The eruption is generally first
observed  on the  breast and neck;  afterwards on the face  and
extremities.   As fresh vesicles arise during two or three  succes-
sive days, and go through the same stages as the first, the dura-
tion of the disease is sometimes longer than above stated.
  1210.  2. The Varicella conoidalis, or Swine-pox,  exhibits
vesicles which rise suddenly, have a hard, inflamed border, and
are, on the first  day, acuminated, and  contain a bright, trans-
parent lymph.  On the second, they are somewhat more turgid, 
THE  VARIOLOID  DISEASES.        439
surrounded by a more extensive inflammation, and many of
them  contain straw-colored  lymph.    On the third  day,  the
vesicles are shrivelled, and those which have been broken exhibit
at the top slight gummy scabs, formed by the concretion of the
exuding lymph ;  some of the shrivelled vesicles which remain
entire,  but have much surrounding inflammation,  contain a
purulent fluid, and such vesicles leave a durable cicatrix or pit.
On the fourth day, thin, dark brown scabs appear, intermixed
with others, which are rounded, yellowish, and semi-transparent;
they  gradually dry and separate in four or five days.  A fresh
eruption of vesicles takes place on the second  and third  days;
and,  as each  set has a  similar course, the whole duration of the
eruptive stage is  six days; the last-formed scabs are separated
on the eleventh or twelfth day.
   1211. 3. In the Varicella globata, or Hives, the vesicles are
large and obicular, but their base is not exactly circular. There
is a surrounding inflammation, and they contain a transparent
lymph, which, on the  second day of  eruption, resembles milk-
whey.   On the third, the vesicles subside,  and, as in the  two
former species, become puckered or shrivelled ; they also appear
yellowish, a small quantity  of pus being mixed with the lymph.
Some remain in this state till the following morning; but before
the conclusion of the fourth day, the cuticle separates, and thin,
blackish scabs cover the bases of the vesicles.  The scabs dry
and fall off in four or  five  days.   The eruption is usually com-
pleted in three days; but a few fresh vesicles sometimes appear
on the fourth day ;  in  which case, the eruptive stage occupies
eight days.*
  * Dr. Heberden observes, " the principal marks by which the Chicken-pox
may be distinguished from the Small-pox are, 1, The appearance, on the second
or third day from the eruption, of the vesicles full of serum  at the top of the
pock.  The pustules which  are fullest of the yellow liquor  resemble what
the genuine Small-pox are on the fifth or sixth day, especially when there hap-
pens to be a larger space than usual occupied by the extravasated serum.  It
happens to most of them either on the first day that the little vesicle arises, or
on the day after, that its tender cuticle is burst; a thin scab is then formed at
the top of the pock, and the swelling of the other part abates, without its ever 
440
THE   DIAGNOSIS   OF
                           IV.   VARIOLA.*

                     I.   In  the  Unprotected.

   1212. Of Variola, as it occurs in the unprotected, Dr. Thom-
son describes two varieties, besides those termed the distinct and
the confluent, §§ 152, 160, of which I propose to give the char-
acters in this place.   They are
                 1.  The mild vesicular.
                2.   The vesiculopustular.
being turned into pus, as it is in the Small-pox.   2, Slight scabs over the Chick-
en-pox on  the fifth day; at which time the Small-pox are not at the height of
their suppuration.  3, The inflammation round the Chicken-pox is very small,
and the contents of them do not seem to be owing to suppuration, as in the
Small-pox,  but rather to what is extravasated immediately under the cuticle by
the serous vessels of the skin, as in a common blister.  No wonder,  therefore,
that this liquor appears so soon as on the second  day, and that, upon the cuticle
being broken, it is presently succeeded by a thin scab.  Hence, too, as the  true
skin is so little affected, no mark or scar is likely to be left."
  * Dr. Willan  remarks, with regard to the Diagnosis between Varicella  and
Variola," that Variolous pustules, on thefirst and second days of their eruption,
are small, hard, globular, red and painful.  The sensation of them to the touch
on passing the finger over them,  is similar to that which one might conceive to
be excited by the pressure of small round  seeds under the cuticle.   In the Vari-
cella, almost every vesicle has, on the first day, a  hard, inflamed margin ; but
the sensation communicated to the finger in this case is like that from a round
seed  flattened by pressure.  On the third and fourth day, the shrivelled  or
wrinkled state of the vesicles which remain entire, and the radiating furrows  of
others whose ruptured  apices have been closed  by a slight incrustation, fully
characterize the Varicella, and distinguish its eruption from the firm  and durable
pustules of small-pox.   As the vesicles of the  Chicken-pox appear in succession
during three or four days, a partial examination will not always discover the
characteristic here specified.  In order to form a  proper judgment, practitioners
should inspect the eruption on the face,  breast, and limbs, attending more espe-
cially to the places in which it was first observed. If the whole eruption be viewed
on the fifth  or sixth day, every gradation of the progress of the vesicles will ap-
pear at the  same time.   This circumstance may be added to the Diagnostics  of
Varicella, as it cannot take place in the  slow and regidar progress of the Small-
pox.  The  globated vesicles, not  having any  resemblance to variolous pustules,
distinguish  the varicella from Small-pox, whenever they appear; for it is to be
remembered that these large vesicles are occasionally intermixed both with the
lenticular and the conoidal vesicles of the Chicken-pox." 
           THE VARIOLOID  DISEASES.       441

   1213.  I.  The  mild vesicular.  Dr. Thomson observes, in
regard to this form of variola, " The eruption has been almost
always papular in its origin.  In a small number of cases, in
which the eruption has been scanty, the papulae have become
vesicular on the first or second day, have continued such nearly
till their disappearance, which has usually happened before the
end of the fifth or sixth day, and have left behind them only a
slight roughness, or small thin  scales upon the skin.   The
cases  to which I allude  have occurred  in  situations in which
confluent and malignant small-pox existed, and to the contagion
of which they could  be distinctly traced.  Had  it not been for
this circumstance, I should never have  had any  doubt of these
cases  having been examples of genuine chicken-pox.   This va-
riety might be termed mild vesicular small-pox."
   1214.  II. The vesiculo-pustular.  Dr. Thomson observes,
" In other instances,  in  which the  papulae have from the first
appeared vesicular, the vesicles, after continuing pellucid for two
or more days, have become filled with a whitish fluid, sometimes
resembling milk, and sometimes pus, which dried into small
crusts or scabs.   It was impossible, during the vesicular state of
the disease in these cases,  to say  whether the vesicles would be-
come  pustules, whether, when they became pustules, they would
continue prominent, or  become depressed in their centres ; and
whether  they would decay by the sixth or by  the ninth day.
In this variety, though the disease might have been regarded as
chicken-pox in its commencement, it was impossible, by any
characters with which I am acquainted, to  have  distinguished it
from small-pox, in its termination.  This variety  may be termed
vesiculo-pustular small-pox."

                   II. In the Protected.
   1215.  In the Modified variola, "the fever  which  precedes
the eruption is similar in form, and equal in degree, to the fever
usually attending the inoculated Small-pox ;  and the eruption
is either papuliform, or tuberculated, without much surrounding
inflammation ;  it coincides in these  leading circumstances with
the disease produced, when the vaccine  and variolous matter are
                            56 
442             THE  DIAGNOSIS  OF
inoculated  nearly together, and restrain the operation of each
other on the skin,  or when a person exposed to  variolous con-
tagion has been inoculated with vaccine lymph early enough to
mitigate the eruption of the Small-pox, but not wholly to super-
sede it."  " This variolous eruption  consists  of hard, distinct,
shining pustules, which have but little inflammation  surround-
ing them, and which seldom maturate.   Some of these pustules
are tuberculated.  The small quantity of matter contained  in
them soon disappears, leaving the cuticle which confined it horny
and elevated for many days afterward.  The rest of the eruption
is minute and papulous, not suppurating, but desquamating."*
  1216.  Dr. Thomson, after having shown that Variola some-
times assumes, in the unprotected, Varicelloid forms, §§ 1212,
1213, adds that, in other instances, it may assume the distinct
or confluent forms, in those protected by vaccination or pre-
vious small-pox, although far more rarely.
  1217.  Dr. Thomson concludes that it is probable that Varicel-
la, and the Secondary or the Modified Variola, are the same dis-
ease, arising from  the same contagion,  and that, previously to
the discovery of the cow-pock, secondary small pox, being a dis-
ease frequent in  its occurrence, must have  stood in nearly the
same relation to the primary small-pox, that modified small-pox
now does to cow-pock.t
• Willan on Vaccine Inoculation, §§ iv and v.
f See the interesting and valuable work on Varioloid Diseases. 
CHAPTER  V.
THE  DIAGNOSIS  OF SOME DISEASES SUBJACENT  TO THE
                         SKIN.

   1218. I propose, in the present chapter, to sketch the diagno-
sis of those diseases which are seated deeper than the skin.
They will present new instances of affections belonging to the
province of medical surgery rather than that of physic.
   1219. These diseases occur in the course of the limbs, in the
neck, in the groin, and  in the lumbar and iliac regions.  The
diseases of each of these parts form interesting subjects for diag-
nosis, as the reader will perceive on casting his eye over the sub-
joined arrangement.

   ARRANGEMENT OF DISEASES SEATED BENEATH THE SKIN.

                    I.  OF THE LIMBS.

     I. Phlebitis.
    II.  Imflammation of the Absorbents,

                    pi. of the neck.

     I.  Inflammation of the Lymphatic Glands.
    II.  Cynanche Parotidea.
   III.  Bronchocele.
   IV.  Tumors.
     V.  Aneur'ysm. 
444
the diagnosis  of
                   III. OF THE GROIN.

    I.  Inflamed Glands.
   II.  Hernia,
  III.  The Pointing of Lumbar Abscess.
  IV.  Tumors
   V,  Aneurysm.

         IV.  OF THE LUMBAR AND ILIAC REGIONS,

    I.  Disease of  the Spine.
   II.  Aneurysm of the Aorta.
  III.  Lumbar  Abscess.
  IV.  Disease of the Kidney.
    V.  Disease of  the Hip-joint.

               i. diseases of the limbs.

                     i. phlebitis.

  1220. I.  The History.  Inflammation of the vein fre-
quently occurs from an accident or surgical operation :  it is apt
to follow  vensesection, the  ligature of a vein, &c. and  I have
known one  instance  occasioned  by the bite of a horse on the
finger.
  1221. II.  The Symptoms.  Phlebitis is distinguished by a
hard, cord-like, tender line, pursuing the course of a vein or veins,
from an incision or wound.  It is
              Suppurative, and Diffused ;
and attended by typhoid fever, and abscesses;  or
               Suppurative, and Adhesive,
and accompanied by distinct abscesses in the course of the in-
flamed vein, with protracted fever.  See §§ 1064, 1067. 
some  subcutaneous  diseases.
445
        II.  INFLAMMATION OF THE LYMPHATICS.

   1222.  I.  The  History.   This disease usually arises from a
wound or ulcer.
   1223.  The Symptoms consist in a flat line of redness and
tenderness, pursuing its course from this wound or ulcer  along
the lymphatic vessels, and frequently attaining the lymphatic
glands,—in the next, in the axilla, or in the groin,—when the
scalp, the hand or arm, the leg or foot, or the penis, is severally
affected.   The redness and tenderness may subside ; or nume-
rous successive abscesses may form in the course of the lympha-
tic vessels or glands.

                 II.  DISEASES OF THE NECK.

     I.  INFLAMMATION OF THE  LYMPHATIC GLANDS.

   1224.  I.  The  History.   This affection is generally slow in
its progress, and allied to struma or connected with general dis-
order.  It is also a frequent complication of porrigo.
   1225.  II.  The Symptoms.  The tumor obviously consists
of a single lymphatic gland, or of  a chain or cluster of glands;
it is, of course, seated in the  situation of  these glands, and thus
distinguished from the disease to be next  mentioned ; it frequent-
ly passes into slow suppuration.

                 II.  CYNANCHE PAROTIDEA.

   1226.  I.   The History.   The  Cynanche  Parotidea, or
 mumps,  is  a contagious disease, and may  generally  be traced
 to exposure to patients similarly affected.
   1227. II. The Symptoms.  It is distinguished by occupy-
 ing the position of one, or more, of the parotid or submaxillary
 glands.   It  is soft,  puffy, slightly tender,  and not disposed to
 suppurate.  It is subject to metastasis, to the testis in the male,
 and to the mamma in the female subject.  It is attended by
 febrile symptoms. 
446
THE  DIAGNOSIS  OF
                    III.  BRONCHOCELE.

   1228. I, The History.  This singular affection is endemic
 in hilly countries; in Switzerland it is termed the goitre, and is
 apt to be associated with cretinism.
   1229. II. The Symptoms.  Bronchocele is an enlargement
 of the thyroid gland ; its situation will, therefore, be well known
 to many  students  of  anatomy;  it is frequently unequally
 developed on the two sides of the thyroid cartilage; it is soft and
 free from tenderness; and it is  moved upwards in deglutition.
   1230. By degrees it may  increase in magnitude  so as to
 impede the respiration; and it  may become extremely hard and
 even  ossified.
   1231. III.  The Effect of Remedies.  Early in the disease,
 the iodine seems to be almost specific.

                       IV. TUMORS.

   1232. A tumor situated in the neck can only be identified by
 contrasting its form, origin and progress, with those of the affec-
 tions  just described, and by comparing them with those of the
 various kinds of morbid growths.  In this manner, too, is such
 a tumor to be distinguished from

                      V.  ANEURYSM,

 which is further distinguished by its peculiar pulsation, and the
 impulse felt and the sound heard under the ear or stethoscope.

                III.  DISEASES OF THE GROIN.

                  I. INFLAMED GLANDS.

   1233.  This disease is distinguished by its tenderness, and by
 presenting  to the finger  the sensation of several distinct glands
 forming the general tumor.   There are frequently redness of the
skin and an obvious disposition to suppurate. 
       SOME  SUBCUTANEOUS  DISEASES.    447


                  II. INGUINAL  HERNIA.

  1234. This disease, when free from strangulation, consists of an
individual tumor, augmented on coughing, reducible by pressure
in the recumbent posture, and unattended by tenderness, or pain,
or other symptoms.
  1235.  When strangulated, it is attended by its peculiar symp.
toms of sickness, vomiting, and intestinal obstruction and pain ;
and  the  local tumor,  when  examined, is usually found to be
tender under pressure.

                  III.  LUMBAR  ABSCESS.

  1236.  When it points in the groin, is attended by phenomena
precisely  similar to those of hernia  when free from strangulation.
These two  cases are distinguished by the history,  lumbar
abscess being preceded  by its peculiar symptoms.   They are
also distinguished by the state of  the general health, which, in
lumbar abscess, is greatly  impaired.   The stethoscope would
also probably assist the diagnosis.

                     iv. tumors and
                      v.  aneurysm
  1237.  Are to be distinguished by their appropriate course and
symptoms, which need not be repeated in this place.

       IV. DISEASES OF THE LUMBAR AND ILIAC REGIONS.

                I.  DISEASE OF  THE  SPINE.

i  1238.  This  disease,  which is  usually of the most insidious
character is detected by careful examination. Pain and tender-
ness in the course of the  spine, followed by spasmodic or paralytic
symptoms, are the diagnostic marks of this terrific disease.  The
general health also fails, and there are debility and emaciation. 
 448             THE  DIAGNOSIS OF

 In the case of caries, redness and tumor and augmented pain
 and tenderness supervene.

               II. ANEURYSM OF THE AORTA.

   1239. In cases of pain and tenderness in the region of the
 spine, the ear or the  stethoscope will  occasionally detect the
 pulsation of an aortic aneurysm.  In all such cases, this mode of
 examination should, therefore, be adopted.   See §§ 614—620.


               III. RHEUMATISM ;  LUMBAGO.

   1240. This affection is usually sudden in  its attack, attended
 with greatly aggravated pain on throwing the lumbar  muscles
 into action, and frequently with pain in the joints or limbs, and
 unattended  by the symptoms peculiar  to the other diseases of
 this section.

              IV. LUMBAR OR ILIAC ABSCESS.

   1241. I.  The History.  This affection may sometimes be
 traced to a blow or strain,  or to exposure to damp and cold.  It
is exceedingly insidious, and frequently undetected until it be-
gins to point externally.
   1242.  II. The Symptoms are obscure pain of the back, with
little tenderness, but with  a peculiar lameness of  one leg, the
thigh being with difficulty flexed upon the abdomen or rotated
inwards.  There is some  degree of hectic, debility  and emacia-
tion ; in the course of time, a soft tumor appears  in the groin,
near the anus, or  in  the  back, (fee.  which  becomes tense on
coughing, and fluctuates under the finger.  This disease is fre-
quently complicated with

                1. Caries of the Spine, or
                2.  Tuberculous Disease. 
       SOME  SUBCUTANEOUS  DISEASES.   449

It is necessary to distinguish it from

               V. DISEASE OF THE KIDNEY,
  1243.  The diagnostic marks of which are given §§ 202, &c.
and from

                VI.  DISEASE OF  THE HIP,
  1244.  The diagnosis of which is to be found in works treating
professedly of surgery,
57 
CHAPTER  VI.
 THE  DIAGNOSIS OF PAINFUL,  SPASMODIC, AND  PARALYTIC
                      DISEASES.
  1245.  The subject with which I propose to terminate this
volume is one of great interest, as involving the topical Painful,
Spasmodic, and painful Affections.  They may be arranged in
the following order:

ARRANGEMENT OF THE PAINFUL, SPASMODIC, AND PARALYTIC
                      DISEASES.
               I. THE PAINFUL DISEASES.
                   I. OF THE FACE.
        I.  Odontalgia.
      II.  Rheumatism.
      III.  Face Ague.
      IV.  Tic Douloureux.
      V.  Inflamed Antrum Maxillare,

                  ii. of the limbs.
        I.  Rheumatic.
      II.  Syphilitic.
      III.  Cachectic, Pains.
      IV.  Sympathetic Pains  in Carcinoma.
       V.  Tic Douloureux.
      VI.  Painful Subcutaneous Tubercle. 
SPASMODIC AFFECTIONS.
451
       II.  THE SPASMODIC AFFECTIONS.
             I. OF THE FACE.
  I.  Trismus.
  II.  Trismus Hystericus.
 III.  Permanent Spasm of the Face.
 IV.  Tics, or Spasmodic Affections of
      various Muscles.
  V.  Chorea ; Tremor ; Stammering.
 VI.  Strabismus.
VII.  Wry-neck.
             ii. of the limbs.
  I.  Cramps,
  II.  Hysteric Spasms of the Hands, Feet, etc.
       III. THE paralytic affections.
              I. of the face.
  I.  Cerebral Paralysis.
  II.  Paralysis from  Affection of the  Fifth
       Pair of Nerves.
 III.  Paralysis from  Affection of the Portio
       Dura of the Seventh.
             ii. of the limbs.
  I.  Paralysis from Colica Pictonum.
  II.  Wasting of the Muscles of the Shoulder.
 III.  Paralysis from
             1. Epilepsy,
             2. Hysteria.
             3. Rheumatism, fyc. 
452
THE  DIAGNOSIS  OF
                  I. THE PAINFUL DISEASES.

                      I. OF  THE FACE.

                      I.  ODONTALGIA.

    1246.  I.  The History.    Odontalgia is apt to return in pa-
 roxysms ; it is frequently distinctly traceable  to exposure to
 damp or  cold, and to derangement of the  stomach;  there is a
 permanent cause in decay or  other disease of a tooth or of teeth.
   1247. II.  The Symptoms.   This pain is distinguished by
 being traceable, by  examination or pressure, to one or more
 teeth. It is attended by tumefaction of the cheek, and frequently
 by abscess of the gum.

                    II.  RHEUMATISM.
   1248. I.   The History.   Rheumatic pain of the face is
 usually referrible to exposure to damp or cold, and associated with
 other rheumatic affections.
   1249. II.  The Symptoms. It is not referrible to an indivi-
 dual tooth, or even to several  teeth :  it is unattended  by much
 tumefaction, and there is no disposition to suppuration.  It is apt
 to spread along the fibres of the muscles or tendons of the face,
 temples, or occiput, and to be aggravated on calling them into
 action.  It is usually relieved by warmth.

             III.   NEURALGIA,  OR  FACE-AGUE.
   1250. I.  The History.  This singular disease is  apt to oc-
cur and recur in spring or autumn, from exposure to the north-
east wind: it prevails in damp or marshy districts, and it is fre-
quently observed to accompany the epidemic influenza.  It  fre-
quently exists as a

              Complication of Intermittent.

   1251. II.  The Symptoms.  The true Ague occupies  the 
THE  PAINFUL  DISEASES.         453
 brow, the temple, the forehead, the occiput, &c.:  it recurs in pa-
 roxysms frequently of considerable  regularity;  it is often ex-
 cruciating,  occasionally  inducing delirium, and,  still more fre-
 quently, redness of the conjunctiva.   It may recur once or twice
 in the course of the day.
   1252. III. The Effects of Remedies.   This pain is almost
 certainly removed by the quinine or the arsenic.

                  IV.  TIC DOULOUREUX.

   1253.  I.   The History.   The paroxysms of this formidable
 disease are sudden, irregular in their occurrence, frequently more
 or less transient or momentary, induced by the act of eating, or
 talking, or by the contact of external bodies  with  the  acutely
 sentient extremities of the nerves.
   1254. II.  The Symptoms. It is distinguished by that which
 the term  tic means originally; viz. by a sudden contraction of
several muscles, with distortion of the face.  Its seat is various—
in different parts of the  face, of the limbs, and of other parts of the
 surface of the body.

   V.   INFLAMMATION OF THE ANTRUM MAXILLARE.

  1255.  The History and Symptoms.   This disease is dis-
tinguished by its gradually aggravated pain, its steady and con-
tinuous character, and its particular seat.  It is eventually at-
tended by external tumor and redness.   It is usually relieved by
the extraction of a tooth and the puncture of the antrum.

                    II.  OF THE  LIMBS.

                I.  RHEUMATIC,

               II.  SYPHILITIC,
              III.  CACHECTIC, AND
               IV.   CANCEROUS  PAINS. 
454
THE  DIAGNOSIS  OF
   1256. These various pains are distinguished by the History
and the Symptoms.  To avoid repetition, the reader is requested
to turn to §§ 298, 988, 991,  992, 323.

                   V.   TIC DOULOUREUX.

   1257. This has been just noticed, § 1253.  It is again men-
tioned in this place, in order that it may be duly contrasted with
an interesting affection noticed by Mr. Wood* and by myselft
under the designation of the

             VI.   SUBCUTANEOUS TUBERCLE.

   1258. This disease is attended with most acute pain, proceed-
ing from one point, often  extending along the course of  the
nerves, occurring in paroxysms, which take place spontaneously,
or are occasioned by friction or other slight injury of the part, and
which frequently disturb the night's repose.   The case is distin-
guished by an  examination of the part affected, when a small
body, of the magnitude of about half a small pea, is  felt under
the integuments : this part  is generally tender to the  touch, es-
pecially during the  paroxysm; and an acute pain is induced,
and is extended along the nerves, by pressure.

              II.  THE  SPASMODIC AFFECTIONS.

                     I.  OF THE  FACE.

                    I.  II.  TRISMUS.

   1259.  Trismus is frequently the first symptom'in  Tetanus,
\h 27h, 280;  and  it is, frequently a form of  Hysteria, § 246.
It is, in both  instances, distinguished by the History and con-
comitant Symptoms.
* Edinb. Med Journ.
t Ibid. 
THE  SPASMODIC  AFFECTIONS.
455
          III.   PERMANENT SPASM OF THE FACE.
   1260. I.  The History.   I do not think this disease has been
described.   It is induced by exposure to cold.  It is readily dis-
tinguished from

                        PARALYSIS,
which may result from the same cause,* by a careful examina-
tion.   It is  only necessary for me to warn my reader that such
forms of disease exist.
   1261. II.  The Symptoms.  In the spasm,  contraction, in
the paralysis, relaxation, of the muscles, occur on the  affected
side.

                        IV.   TICS.
   1262. There are various forms of  Tic observed in  the face
especially in the  eye-lid and in the cheek.   The muscles are
rapidly, and then perhaps spasmodically, contracted.   The na-
ture of the affection is very obscure.   It would, however, appear
to be related to

        V.   CHOREA ;  TREMOR ; AND  STAMMERING.
and to some forms of
                    VI.   STRABISMUS.
   1263. This class of diseases have their origin variously :
               1. In the Stomach,  or
               2. In the Brain itself.

                   VII.  THE WRY-NECK.

   1264. This disease usually consists in spasmodic contraction
of one of the sterno-mastoideus muscles; the head is drawn, of
course, towards the opposite side.   It is  generally the  result of
exposure to cold.
• Trans. Col. of Phys. vol. v, p. 96. 
456
THE   DIAGNOSIS   OF
                      II. OF THE LIMBS.
                         I.  CRAMPS.
  1265.  This affection is chiefly seated in the sole of the foot,
and calf of the leg.  It occurs from the undue contraction of the
muscles, or it is a symptom of derangement of the  digestion,
and of  diarrhaa, cholera, (fee.

                   II.  HYSTERIC SPASMS
are frequently  permanent,  and distort the hands  and feet.
They  are distinguished by the History  and Symptoms from
other forms of cramps or spasms.

               II. THE PARALYTIC AFFECTIONS.
                       I. OF THE FACE.

                  I. CEREBRAL PARALYSIS.

  1266. In this case the face is frequently accurately divided by
the mesial plane, the muscular power and sensibility  being  im-
paired on one side and perfect on the other:  the eye-brow and
the eye-lid of the affected side, may fall, the nose, and  especially
the mouth and the tongue, may be drawn to the opposite side
—an effect rendered still more obvious on any muscular effort;
the finger passed along the surface of the face, distinctly traces
the paralytic boundary ; the articulation and  the deglutition are
frequently impaired.*

II.  PARALYSIS FROM AFFECTION  OF THE FIFTH  PAIR OF
                          NERVES.

   1267. For a knowledge of this disease we are indebted, first,
  * Cerebral Paralysis denotes, as I have  stated at length, § 402, a disease of
the opposite side of the brain; and when affecting the anterior or posterior
extremities, the opposite portion of that organ, §§404, 405.  All this may be
conceived and remembered by bearing in mind that the facts of pathology seem
to indicate a double crossing of the cerebral fibres, from one side to the other, and
from before backwards, and vice versa. 
THE   PARALYTIC  DISEASES.         457
 to the experiments of M. Majendie, and, secondly, to the obser-
 vations of M. Serres.
    1268.  The  Symptoms  of  this affection are, redness of the
 conjunctiva,  insensibility of the cornea, of the nostrils, and  of
 the tongue, on one side ; dullness  of hearing and a diseased
 state of the gums, similar to that observed in scorbutus.*

 III.  PARALYSIS  FROM AFFECTION  OF THE  PORTIO DURA.

    1269.  For the  detection  and  discrimination of this form  of
 paralysis, we are indebted to  the  splendid  discoveries of Sir
 Charles Bell.
    1270.  This paralysis is distinguished by a permanently open
 state of the eyelids and loss of power in the muscles of expression,
 whilst the voluntary  motions and the sensibility remain.   A
 tumor or injury very often exists in the course of the nerve under
 the ear, ascertainable on examination.

                      II. OF THE LIMBS.

         I.  PARALYSIS IN  THE  COLICA  PICTONUM.

   1271.  I need only remind my reader of the existence of this
 affection,  and refer him to §§ 680, &c.       I

              II.   WASTING OF THE  DELTOID.

   1272.  In this case, the  outline of the scapula, the acromion,
 and the  clavicle,  is more marked and more prominent than
 natural, and  in  the affected than the unaffected side.  The
 muscles of the arm also shrink.   The shoulder falls  a little;
the muscular power of the arm is much impaired ;  and the con-
traction of the muscles is attended with less swell than usual:
  » In one case observed by M. Serres, the right eye and the right nostril were
insensible, the left sensitive, the gums scorbutic.  On examination, the origin of
the fifth pair, on the right side of the tuber annulare, was found diseased.  See
Anatomie Compare du Cerveau, t. ii, pp. 67—87.
                             58 
458            THE  DIAGNOSIS,   ETC.
but  all  the motions of the  arm and shoulder, if assisted, are
complete.*

                    III. PARALYSIS FROM

                    1. Epilepsy,
                    2. Hysteria.
                    3. Rheumatism, (fee.

   1273. I  have  but to remind my reader of the occurrence of
these forms of paralytic affection, and to direct his attention to
those parts of this work  which treat of the original  diseases.
The History determines the diagnosis.
  * The nature of this affection, of which I have seen one marked example, is
very obscure. In the case to which I allude it was supposed to be of a syphilitic
nature ; but the patient had also suffered from rheumatism.  This disease had
escaped observation until I noticed it in the former edition of this work:  it has
recently been noticed by the late Dr. Darwall. 
 
 
 
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