'£r* TREATISE ON THE PRACTICE OF MEDICINE, BY GEORGE B. WOO]), M.D.3 'it PROFESSOR OF THE THEORY AND PRACTICE OF MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA J PRESIDENT OF THE COLLEGE OF PHYSICIANS OF PHILADELPHIA; ONE OF THE PHYSICIANS OF THE PENNSYLVANIA HOSPITAL ; ONE OF THE AUTHORS OF THE DISPENSATORY OF TIIS UNITED STATES OF AMERICA; ETC. ETC. FIFTH EDITION. IN TWO VOLUMES. YOL. I. PHILADELPHIA: J. B. LIPPINCOTT AND CO., Nos. 22 and 24 NORTH FOURTH STREET. 18 58. • « » -r - -N . . * V% 1858 v. I Entered, according to the Act of Congress, in the year 1858, By George B. Wood, M.D., In the Clerk's Office of the District Court of the United States in and for the Eastern District of Pennsylvania. PREFACE TO the FIRST EDITION. In adding another to the many existing Treatises on the Practice of Medicine, the author may be reasonably expected to show upon what grounds he has ventured to advance a new claim to the public attention, already so fully occupied. He has no other excuse to offer than this; that he has written in obedience to impulses which he could not well resist. Having been engaged, for nearly thirty years, in public and private practice, and, during that time, devoted an almost exclusive attention to the study of diseases and their reme- dies, he has accumulated facts, and formed opinions, which have been long soliciting expression, with an urgency to which he has at length yielded, though unfeignedly distrustful of their sufficient value. It will be inferred, from what has been said, that the present work claims to be something more than a mere compilation. In giving it the form of a General Treatise on the Practice of Medicine, it was incumbent upon the author, in order to do justice to his readers, to gather from every attainable source the knowledge which he might deem important; and he has accordingly consulted numerous works upon the different branches of his subject, and made ample use of the materials which they afforded. But these materials have for the most part been maturely considered, have been submitted to the closest scrutiny of which he was capable, and have been re-arranged in accordance with his own best judgment. In relation to facts, which, from having been known for a certain length of time, have become the common property of the profession, he has not deemed it necessary to quote authorities; but, wherever the influence of a name was thought necessary to support a position, or justice to indi- viduals required that they should be noticed in connection with their iii IV PREFACE. discoveries or opinions, he has considered it his duty to make the requisite references in the text. As to those portions of the work which have been drawn from bis own stores, the author does not wish to urge any strong claims to exclusive originality. The sources of our knowledge are so various, we learn so much from books, and hear so much from others, in addi- tion to all that may be derived from our own observation, or result from our own reflection, that it would be extremely difficult for one who has lived long, and sought knowledge wherever it was to be found, to analyze what he may possess, and determine how much, if any, originated entirely with himself. It would be impossible to enumerate, in this place, all the sources to which the author is indebted for the materials of the work. Many of them are mentioned in connection with the subjects, in relation to which they were particularly consulted. He wishes, however, to acknowledge a peculiar obligation to the several contributors to those excellent works, the uDictionnaire de Medecine," the publication of which has been but recently completed in Paris, and "The System of Practical Medicine," arranged and edited by Dr. Alexander Tweedie. It will be seen, from the frequent references in the fol- lowing pages, that he has also derived great aid from the "American Journal of Medical Sciences," edited by Dr. Isaac Hays, which com- prises a body of the progressive medical knowledge of the last twenty years, especially of that contributed by the physicians of this coun- try, which it would be difficult to find elsewhere. Nor would the author be doing justice to his feelings, without acknowledging his indebtedness, for much of his practical information, to two individu- als ; the late Dr. Joseph Parrish, his private preceptor, whose in- timacy it was long his happiness to enjoy, and whose peculiar views and modes of practice were as familiar to him as if they were his own; and Dr. N. Chapman, Professor of the Theory and Practice of Medicine in the University of Pennsylvania, under whose public instruction it was his good fortune to sit thirty years ago, and from whom were undoubtedly imbibed many of the facts and opinions which will be found detailed in the following treatise. In relation to the mode in which the work has been executed, the author has little to say. The reader will draw his own inferences as to its merits, not from what he may find in the preface, but from the book itself. The author claims no indulgence on the score of haste. His leisure has been for several years devoted to the prepa- ration of the work, and there was no urgent necessity for its publi- cation, which could justify him in giving it prematurely to the world. PREFACE. V It may possibly be thought by some that diseases of little import- ance have, in many instances, received an undue share of attention; but the author has proceeded upon the ground, that every disease, which is at all worthy of notice, should be well understood. Nothing more than is necessary to this object should be said of the most important disease; and nothing less of that which is least important. It may not be amiss to state, in addition, that, in using the first person singular, when speaking upon his own authority, the writer has been actuated by no spirit of egotism, but merely by a wish to express the fact, without affectation, in the shortest and simplest mode. The author is sensible of many imperfections in the work. He will undoubtedly discover others, when time shall have in some measure obviated the inevitable partiality of recent authorship. It will be his duty and his pleasure, should the work have the good fortune to reach a second edition, to correct, as far as may lie in his power, these defects, and all others, which a just and candid criti- cism, hereby cordially invited, may point out. Philadelphia, January, 1847. PREFACE FIFTH EDITION. In accordance with the scheme of this Treatise, as presented in the original preface, the author has deemed it incumbent upon him, in each succeeding edition, to make such additions and alterations as were neces- sary to keep the work in due relation to the existing knowledge of the time. By throwing out what appeared to have become effete in the ad- vance of discovery, and studying brevity of expression as far as seemed to him consistent with clearness, he has sought to accomplish this object with as little increase in the size of the volumes as possible. In the pre- sent edition he has followed the same plan ; but, notwithstanding his best efforts, and the omission of the section on "general therapeutic pro- cesses," which he has transferred to his recently published work on " The- rapeutics and Pharmacology," to which it more properly belongs, he has been compelled to extend considerably the number of pages, in order to keep pace with the rapid progress of theoretical and practical medicine in the last three or four years. Besides numerous modifications, inter- spersed here and there throughout the Treatise, copious additions have been made in relation to several diseases, and some new subjects have been introduced, among which may be specified the therapeutics of in- flammation and other constituent forms of disease, milk-sickness sim- ple ulcer of the stomach, the cachexia connected with bronzed skin and disease of the supr.a-renal capsules recently described by Dr. Addison and coagula in the blood considered in reference to their formation trans- fer, and effects. The author would here call attention to a practical point, inadvertently overlooked in the revision. As American leeches draw at most only one-fourth as much blood as the European it is im- portant that, when any particular number of these animals is' ordered the variety to be employed should be designated. In this work wherever reference is made to the number of leeches to be used the' A merman are always intended, unless otherwise specially stated • and if thl V ropean should be preferred by the practitioner in any case he shnnS employ not more than one for every four directed. It is rjo^hl +w in the haste of revision rendered necessary by the entire exha r f the late very large edition, other errors or omissions may have bPP n,° requiring the indulgence of the reader; but the author can trulv* m?w no diligence or care of which he was capable has been spared • a ii? ventures to hope that, upon the whole, the work will be found'n t i worthy of the approval of the profession than hitherto ess Philadelphia, July, 1858. TABLE OF CONTENTS. PART I. GEXERAL PATHOLOGY AND THERAPEUTICS. CHAPTER I. CONSTITUENT FORMS OF DISEASE. Section I. DISEASE OF THE FLUIDS. Section II. DISEASE OF THE SOLIDS. Subsection I. DISEASE FROM MECHANICAL AND CHEMICAL CAUSES. Subsection II. DISEASE FROM INFLUENCES UPON THE VITAL PROPERTIES. -Irritation. -Inflammation. -Depression. -Congestion. -Fever. -Disease with Peculiar Products. 1. Tuberculosis.—2. Melanosis.—3. Organized Non-malignant Pro- ducts.—4. Malignant Growths, including Carcinoma or Cancer, Epithelioma, and Fibro-plastic Tumours. —5. Parasitic Growths, including Parasitic Animals or Entozoa, and Parasitic Plants. Article I.- Article II.- Article III.- Article IV. Article V. Article VI. CHAPTER II. CAUSES OF DISEASE, OR ETIOLOGY. viii TABLE OF CONTENTS. CHAPTER III. SYMPTOMATOLOGY, OR SEMEIOLOGY. Section I SYMPTOMS OR SIGNS OF DISEASE. Section II. COURSE, DURATION, AND TERMINATION OF DISEASE. Section III. DIAGNOSIS. Section IV. PROGNOSIS. CHAPTER IV. GENERAL THERAPEUTICS. Section I. GENERAL INDICATIONS. Section II. TREATMENT OF THE CONSTITUENT FORMS OF DISEASE. Article I.—Treatment of Diseases of the Blood. Article II.__Treatment of the Mechanical and Chemical Affections. Article III.—Treatment of Irritation and Inflammation. Article IV.— Treatment of Depression and Debility. Article V.—Treatment of Diseases with Peculiar Products. 1. Tuberculosis. — 2. Melanosis, Cysts, and Non-malignant Tu- mours.—3. Carcinoma, &c—4. Parasitic Growths. PART II. SPECIAL PATHOLOGY AND THERAPEUTICS. CLASS I. GENERAL DISEASES. Article I.—Irritative Fever. Article II.—Miasmatic Fever. 1. Intermittent fever.—2. Remittent Fever.—8. Pernicious Fever TABLE OF CONTENTS. IX Article III.—Yellow Fever. Article IV.—Enteric, or Typhoid Fever. Article V.—Typhus Fever. Article VI.—Plague. Article VII.—Smallpox, or Variola. Article VIII.—Vaccine Disease. Article IX.—Chickenpox, or Varicella. Article X.—Measles, or Rubeola. Article XL—Scarlet Fever, or Scarlatina. Article XII.—Erysipelas. Article XIII.—Glanders. Article XIV.—Dengue. Article XV.—Milk Sickness. CLASS II CONSTITUTIONAL DISEASES. Article I.—Rheumatism. Article II.—Gout. CLASS III. LOCAL DISEASES. Section I. DISEASES OF THE DIGESTIVE SYSTEM. Subsection I. DISEASES OF THE MOUTH. Article I. —Inflammation of the Mouth, or Stomatitis. 1. Common diffused inflammation.—2. Diffused Inflammation with Curdy Exudation, or Thrush.—3. Follicular Inflammation.— 4. Eruptive or Vesicular Inflammation.—5. Ulcerative Inflam- mation, or Canker.—6. Sore-mouth of Nursing Women.— 7.—Gangrenous Inflammation.—8. Mercurial Inflammation. Article II.—Inflammation of the Tongue, or Glossitis. Article III.—Morbid Dentition. Article IV.—Toothache, or Odontalgia. Article V.—Falling of the Teeth. Subsection II. DISEASES OP THE FAUCES, PHARYNX, AND CESOPHAGUS. Article I.—Inflammation of the Fauces, or Angina. 1. Common Inflammation of the Fauces, or Simple Angina.— 2. Pseudo-membranous Inflammation.—3. Ulcerative Inflam- mation. Article II.—Inflammation of the Tonsils, or Tonsillitis. Article HI.—Inflammation of the Pharynx, or Pharyngitis. Article IV.—Inflammation of the (Esophagus, or Oesophagitis. Article V.—Stricture of the Oesophagus. X TABLE OF CONTENTS. Subsection 111. DISEASES OF THE STOMACH. Article I.—Inflammation of the Stomach, or Gastritis. Article II.—Cancer of the Stomach. Article III.—Irritation of Stomach. 1. Cardialgia.-2. Gastralgia.-3. Pyrosis.-4. Spasm of the Stom- ach.-5. Nausea and Vomiting.—6. Sea-sickness.-7. Sick- headache.—8. Morbid Appetite. Article IV.—Indigestion, or Dyspepsia. Subsection IV. DISEASES OF THE BOWELS. Article I.—Inflammation of the Bowels. 1. Inflammation of the Duodenum.—2. Inflammation of the Small Intestines, or Enteritis.—3. Dysentery. Article II.—Cancer of the Bowels. Article III.—Irritation of the Bowels. 1. Diarrhoea.—2. Colic, including Simple Spasmodic Colic, Bilious Colic, Colic from Obstruction, Rheumatic Colic, and Neuralgic Colic.—3. Lead Colic. Article IV.—Constipation. Article V.—Obstruction of the Bowels. Article VI.—Worms in the Alimentary Canal. Article VII.—Stricture of the Rectum. Article VIII.—Hemorrhoids, or Piles. Article IX.—Fissures of the Anus. Article X.—Prolapsus Ani. Subsection V. ^ DISEASES OF THE STOMACH AND BOWELS CONJOINTLY. Article I.—Cholera Morbus. Article II.—Epidemic Cholera. Article III.—Cholera Infantum. Article IV.—Flatulence. Article V—Peritoneal Inflammation, or Peritonitis. Section II. DISEASES OF THE ABSORBENT SYSTEM. Article /.—Inflammation of the Absorbents. Article //.—Inflammation of the Absorbent Glands. Article ///-Scrofulous Inflammation of the Glands, or External Scroti* Article IV—Disease of the Bronchial Glands. Article V.— Disease of the Mesenteric Glands. Section III. DISEASES OF THE RESPIRATORY SYSTEM. TABLE OF CONTENTS. XI Subsection I. INFLAMMATION OF THE RESPIRATORY PASSAGES. Article I.—Inflammation of the Nostrils. 1. Acute Inflammation of the Nostrils, or Coryza.—2. Chronic In- flammation of the Nostrils, or Ozsena. Article II.—Inflammation of the Larynx, or Laryngitis. 1. Acute Laryngitis, including Mucous Laryngitis, Submucous La- ryngitis, and Pseudo-membranous Laryngitis. — 2. Chronic Laryngitis. Article III.—Inflammation of the Bronchia, or Bronchitis. 1. Acute Bronchitis.—2. Chronic Bronchitis.—3. Catarrh.—4. In- fluenza.—5. Croup, including Catarrhal Croup, and Pseudo- membranous Croup. Subsection II. NERVOUS OR FUNCTIONAL DISEASES OF THE RESPIRATORY PASSAGES. Article I.—Laryngeal Nervous Disease. 1. Infantile Spasm of the Glottis.—2. Spasm of the Glottis in Adults.—3. Suppression of the Voice, or Aphonia.—4. Laryn- geal and Tracheal Pains. Article II.—Hooping-cough, or Pertussis. Article III.—Nervous Cough. Article IV.—Asthma. Subsection III. ORGANIC DISEASES OF THE PULMONARY TISSUE AND PLEURA. Article I.—Inflammation of the Lungs, or Pneumonia. Article II.—Gangrene of the Lungs. Article III.—Inflammation of the Pleura, or Pleurisy. Article IV.—Pneumothorax. Article V.—Emphysema of the Lungs. Article VI.—Bronchial Dilatation. Article VII.— Phthisis. Article VIII.—Various Organic Affections of the Lungs, including Hydatids, Cir- rhosis, &c. Subsection IV. FUNCTIONAL DISEASE OF THE PULMONARY TISSUE. Article I.—Loss of Breath, Apnoea, or Asphyxia. Section IV. DISEASES OF THE CIRCULATORY SYSTEM. Subsection I. DISEASES OF THE HEART. Article I.—Inflammation of the Pericardium, or Pericarditis. Article II.—Inflammation of the Endocardium, or Endocarditis. xii TABLE OF CONTENTS. Article ///.—Inflammation of the Heart, or Carditis. Article IV.—Chronic Valvular Disease. Article V.—Hypertrophy and Dilatation. Article VI.—Various organic Diseases of the Heart. 1. Atrophy.—2. Softening.—3. Degeneration and Abnormal Pro- ducts, including Fatty Degeneration, Tubercles, &c—4. Rup- ture.—5. Polypous Concretions.—6. Malformation with Cya- nosis. Article VII.—Functional or Nervous Diseases of the Heart. 1. Palpitation.—2. Syncope.—3. Neuralgia of the Heart, or An- gina Pectoris. Subsection II. DISEASES OF THE ARTERIES. Article I.—Inflammation of the Arteries, or Arteritis. Article II.—Ossification of the Arteries. Article III.—Aneurism. Article IV.—Arterial Palpitation. Sitbseclion III. DISEASES OF THE VEINS. Article I.—Inflammation of the Veins, or Phlebitis. 1. Phlegmasia Dolens.—2 Metastatic Abscess, or Purulent Infec- tion.—3. Chronic Phlebitis. Article II.—Varicose Veins. Article Article Article Article Article Article Article Article I, Article II, Article III, Article IV, Article V, Article VI, Article VII, Article VIII, Article IX. Article X. Article XI. Article XII. Subsection IV. DISEASES OF THE BLOOD. /—Plethora. //.—Anaemia. ///.—Leucocythaemia. IV.—Supra-renal Cachexia, or Addison's Disease. V.—Coagula in the Blood. VI.—Scurvy, or Scorbutus. VII.—Purpura. Subsection V. DISEASES OF THE BLOOD AND BLOOD-VESSELS CONJOINTLY. -Hemorrhage in General. -Hemorrhage from the Nostrils, or Epistaxis. -Hemorrhage from the Mouth, or Stomatorrhagia. -Hemorrhage from the Lungs, or Haemoptysis. -Hemorrhage from the Stomach, or Haematemesis. -Hemorrhage from the Bowels, or Mclaena. -Hemorrhage from the Rectum, or Bleeding Piles -Hemorrhage from the Urinary Organs, or Hematuria. -Hemorrhage from the Uterus. -Hemorrhage from the Skin. -Hemorrhage from the Serous Membranes. -Hemorrhage from the Cellular and Parenchymatous Tissues. TABLE OF CONTENTS. xm Section V. DISEASES OF THE ORGANS OF SECRETION. Subsection I. DISEASES OF THE SEROUS AND CELLULAR TISSUES. Article I.—Dropsy in general. Article II.—Anasarca. Article III.—Dropsy of the Brain, or Hydrocephalus. Article IV.—Dropsy of the Chest, or Hydrothorax. 1. Pleural Dropsy.—2. Pericardial Dropsy.—3. Pulmonary QMema, or Dropsy of the Lungs. Article V—Abdominal Dropsy. 1. Ascites.—2. Encysted Dropsy. Ovarian Dropsy. Subsection II. DISEASES OF THE SKIN. Article I.—Rashes. 1. Erythema.—2. Scarlet Rash, or Roseola.—3. Nettle-rash, or Urticaria. Article II.—Papulous Diseases, or Pimples. 1. Strophulus.—2. Lichen.—3. Prurigo. Article III.—Vesicular Diseases. 1. Herpes.—2. Eczema.—3. Miliary Eruption.—4. Pemphigus.— 5. Rupia. Article IV.—Pustular Diseases. 1. Ecthyma.—2. Impetigo.—3. Acne.—4. Rosacea, Article V.—Scaly Diseases. ' 1. Psoriasis.—2. Lepra, or Leprosy.—3. Pityriasis.—4. Ichthyosis. Article VI.—Tuberculated Diseases. 1. Elephantiasis of the Greeks.—2. Lupus.—3. Molluscum.— 4. Yaws, or Framboesia.—5. Keloid.—6. Vitiligo and Vitili- goidea. Article VII.—Discolorations, or Maculae. 1. Lentigo, or Freckles.—2. Ephelis.—3. Naevus.—4. Albinism. Article VIII.—Parasitic affections. 1. Animalcular affections, including Scabies.—2. Cryptogamous parasitic affections, including Pityriasis versicolor, Sycosis, Porrigo or Favus, and Trichosis. Article IX.—Unclassified Skin Diseases. 1. Elephantiasis of the Arabians.—2. Pellagra. Subsection III. DISEASES OF THE SALIVARY GLANDS AND PANCREAS. Article I.—Functional Diseases of the Salivary Glands. Article II.—Inflammation of the Salivary Glands. Article III.—Mumps. Article IV.—Diseases of the Pancreas. XIV TABLE OF CONTENTS. Softening.— Subsection IV. DISEASES OF THE LIVER AND ITS APPENDAGES. Article I.—Inflammation of the Liver, or Hepatitis. Article II.—Non-Inflammatory Organic Diseases of the Liver. 1. Hypertrophy.—2. Atrophy.—3. Induration. 5. Cirrhosis.-6. Fatty Liver.-7. Tubercles.—8. Serous Cysts and Hydatids.—9. Malignant Affections. Article III.—Functional Diseases of the Liver. 1. Nervous Disorder.—2. Circulatory Disorder.—3. Secretory Dis- order. Article IV—Diseases of the Biliary Passages, and Gall-bladder. 1. Inflammation ofthe Ducts and Gall-bladder.—2. Biliary Calculi, or Gall-stones.—3. Distension of the GaU-bladder. Article V.—Jaundice. Subsection V. DISEASES OF THE SPLEEN. Article I.—Acute Splenitis. Article II.—Chronic Splenitis. Article III.—Non-inflammatory Diseases of the Spleen. Subsection VI. DISEASES OF THE URINARY ORGANS. -Inflammation of the Kidneys, or Nephritis. -Bright's Disease. -Non-inflammatory Organic Diseases. -Inflammation of the Bladder, or Cystitis. -Diseases of the Prostate. -Functional Disease of the Urinary Organs. 1. Nervous Affections, including Neuralgia, Calculous Nephralgia, Spasm of the Bladder, Irritable Bladder, Paralysis or De- bility of the Bladder, and Strangury.—2. Disorder of Secre- tion and Excretion. -Diuresis. -Diabetes. -Suppression of Urine. -Lithiasis. 1. Uric Acid Lithiasis, or Lithic Gravel.—2. —3. Oxalic Lithiasis. -Retention of Urine. 1. Renal Retention.—2. Vesical Retention. —Incontinence of Urine. Article I. Article II. Article III, Article IV. Article V. Article VI. Article VII, Article VIII, Article IX, Article X, Phosphatic Lithiasis. Article XL- Article XII, Section VI. DISEASES OF THE NERVOUS SYSTEM. Article Subsection I. DISEASES OF THE BRAIN. /.—Inflammation of the Brain and its Membranes. 1. Meningitis.—2. Cerebritis.—3. Tuberculous Meningitis TABLE OF CONTENTS. XV Article Article Article Article Article Article Article II.—Organic Diseases of the Brain. 1. Non-inflammatory Softening.—2. Hypertrophy.—3. Atrophy. —4. Tumours. ///.—Apoplexy. IV.—Functional Disease of the Brain. 1. Nervous Irritation.—2. Vascular Irritation, or Active Conges- tion —3. Depression.—4. Mechanical, or Passive Congestion. —5. Headache, or Cephalalgia.—6. Stupor and Wakefulness. —7. Ecstasy.—8. Somnambulism.—9. Artificial Somnambul- ism.—10. Convulsions.—11. Catalepsy. V.—Insanity. VI.—Delirium Tremens. VII.—Epilepsy. VIII.—Chorea. Subsection II. Article II, Article III, Article IV, Article V DISEASES OF THE SPINAL MARROW Article I.—Inflammation of the Spinal Marrow and its Membranes. 1. Spinal Meningitis.—2. Cerebro-spinal Meningitis.—3. Myelitis. Organic Diseases of the Spinal Marrow. Functional Diseases of axe Spinal Marrow.—Spinal Irritation. -Tetanus. -Hydrophobia. Subsection III. DISEASES OF THE NERVES. Article I.—Inflammation of the Nerves, or Neuritis. Article II.—Neuralgia. Article III.—Cramp. Article IV.—Hiccough, or Singultus. Article Article Subsection IV. DISEASES OF THE NERVOUS SYSTEM IN GENERAL. /.—Palsy, or Paralysis. //.—Hysteria. PRACTICE OF MEDICINE, PAET I. GENERAL PATHOLOGY AND THERAPEUTICS. Prefatory Remarks. ' A Treatise on the Practice of Medicine, as the term is now generally understood, embraces all those branches of medical science, with the excep- tion of Midwifery and Surgery, which have a direct reference to the know- ledge and treatment of disease, and to the preservation of health. That department of the Practice which has for its object the knowledge of disease is called pathology, and is divided into general pathology and special pathology, the former treating of what is common to diseases in general, or to a number of them, the latter of what is peculiar to individual diseases. The second great department of the Practice, or that which concerns the treatment of diseases, is called therapeutics, which is also general or spe- cial, according as it teaches the principles of treatment common to many complaints, or the particular course demanded by each one separately. The third department, which embraces the means of preventing disease, or in other words of preserving health, has received the name of hygiene. But, notwithstanding this scientific arrangement of the different subjects of practical medicine, it has been found that the natural mode of teaching it is the most effective. A stronger impression is made on the mind of the student, and one more available for practical purposes, by presenting him with a vivid picture of each disease in all its bearings, as it must hereafter offer itself to his attention, than by distributing its dissected parts among the various sciences to which they respectively belong, and thus separating what he will afterwards be compelled to put together again in practice. The former plan, therefore, will be followed in the present work. But there are numerous points in relation both to pathology and therapeutics, which are common to many diseases, and which may with great propriety be treated of in general, so as at once to render the subsequent study of particular dis- eases more easy, and to spare the necessity for much and wearisome repeti- tion. Before proceeding, therefore, to an account of individual diseases, I propose to present, in the first part of the work, such principles and facts of universal or extensive applicability, as appear to me to be well established^ avoiding speculation as much as possible, and seldom stopping to discuss the numerous hypotheses which have risen and disappeared, in rapid succession, in this as in other departments of medicine. VOL. I. 1 9 GENERAL PATHOLOGY. [PART I. Definition of Disease.-Disea.se may be defined to be a derangement of the organization, or of one or more of the functions of the body. But this definition is defective, like almost all others referring to natural processes, which so run into one another that a precise line of distinction can seldom be drawn between them. In the performance of every function, and in the condition of everv onran, there is considerable diversity within the limits of health ; and a state of things which, if continued, would constitute disease, may be so fugitive as not to merit the name ; so that, both in point of degree and of duration, it is often impossible to say, of any particular variation from the ordinary condition of the system, whether it is healthy or morbid. For practical purposes, however, perfect accuracy of distinction is unneces- sary. Derangements have usually passed considerably beyond the boundary which separates health and disease, before they are brought to the notice of the physician. Division of the Subject.—la this part of the work I shall treat, first, of the constituent forms of disease, or of thpse derangements which, by their various combination, constitute diseases as we ordinarily see them; secondly, of the causes of disease considered generally, forming the subordi- nate branch of pathological science denominated etiology ; thirdly, of the exploration of disease, in other words, the modes in which diseases may be recognized, one distinguished from another, and the whole course of each traced to its probable termination—a branch of general pathology which may be designated as symptomatology ; and fourthly, of the general prin- ciples of treatment, or general therapeutics. Whatever observations may be necessary on the subject of Hygiene will be most conveniently made in connection with individual diseases. CHAPTER I. CONSTITUENT FORMS OF DISEASE. Prefatory Remarks. Diseases, viewed superficially, appear to be exceedingly numerous and diversified; but, when subjected to analysis, they are found to consist of a comparatively few constituent states of derangement, by the combination of which, in various modes, in relation to number, seat, and decree that great apparent diversity is produced. These constituent morbid" states bear to diseases, in their ordinary forms, the same relation that the proximate prin- ciples of organic bodies be.ar to these bodies as found in nature • the same for example, that sugar, starch, gum, &c, do to the bark or root'eontainine them. That they are themselves necessarily simple or elementary is not maintained. Efforts have been made to reach the elements of dise-v'e • h t not very successfully; because we have not yet learned the essential*nature of the healthy actions, and cannot, therefore, understand their d ments. But, though we cannot push analysis satisfactorily to the a^ntr elements, we are able to appreciate to a great extent their less comnle binations, forming the proximate ingredients of those associations of m C°l™i states or actions usually called diseases. It mav be admitted as ^ evident proposition, that disease has its seat in the fluids or solids* fu body, or in both. ot tne CHAP. I.] DISEASE OF THE FLUIDS. 3 SECTION I. disease of the fluids. In relation to the fluids of the body, our pathological knowledge, though greatly advanced within a few years, is still very deficient. There can be no doubt that all of them are occasionally unhealthy in their condition; and there can be as little doubt that, in this unhealthy condition, many of them may become the sources of serious disease. But the question is, whether the vitiated state of the fluids is original with them, or whether it arises from some disorder of the solids by which they are generated. During the pre- valence of the Humoral Pathology, it was customary to -ascribe most com- plaints to a morbid state of the liquids of the body; and, when this system was overthrown, medical sentiment turned with equal exclusiveness towards the solids. But at present an intermediate opinion prevails; and the truth probably is, that, while the greater number of diseases have their origin in derangements either of the functions or structure of the organs, others con- sist essentially in a disordered state of the liquids, though even these usually find expression in complaints of the fixed structures. As all the fluids, with the exception of the lymph and chyle, are derived from the blood, and as the two former enter directly into the constitution of the latter, and convey into it all the deleterious principles which they may contain, the blood may be considered as the only fluid subject to original morbid changes, or at least the only one to which we are to look as the pri- mary seat of diseases requiring our attention. The numerous liquid secre- tions, if deranged at the time of their formation, must be so in consequence of the diseased condition of the blood from which they are derived, or of the organs by which they are elaborated; if they become deranged after their formation, as sometimes happens with the bile, urine, and some others, it must be owing to their undue detention, or an undue influence of surround- ing parts upon them, in either of which cases the solids are in fault. 1. There can be no doubt that the blood is very frequently the source of diseases, by serving as a vehicle through which noxious substances are enabled to reach the parts upon which they act. Many poisons prove fatal by enter- ing the circulation through the medium of absorption; and the miasmatic and contagious effluvia probably operate on the system through the same channel. The body itself affords sources of a similar deleterious impregna- tion. Thus, the fetid contents of the bowels, if long retained, are often partially taken up by the veins or absorbents; and, in cases of mortification, the putrid results of that process may follow the same course into the circula- tion. Various morbid products, the results of deranged secretion, such as pus and the sanies of unhealthy ulcers, occasionally find an entrance into the blood-vessels ; and it is believed by many that bile and urine, at least some of their characteristic principles, are absorbed in cases of unhealthy retention of these fluids. In all these instances, there can be no doubt that the noxious matters prove injurious to health by coming into contact everywhere with the tissues, and deranging their condition or function. How far they may act also directly on the blood, is a point for subsequent consideration. 2. Another source of vitiation in the blood is the accumulation of certain principles, which, normally existing in that fluid in very small proportion, are usually thrown off by the excretory functions, and, when retained, arc 4 GENERAL PATHOLOGY. [PART I. capable of exercising a highly injurious influence. This accumulation may result from a more rapid production of the principles in question, or from a diminished or suspended action of the organs by wliich they are naturally eliminated. Thus, uric acid is generated in the animal economy in a healthy state, but is thrown off by the kidneys so as not to be readily discovered in the blood. In persons who live chiefly on animal food, and take little exer- cise, the quantity of this acid is sometimes very much increased, so that it is not only secreted in unusual abundance by the kidneys, constituting gravel, but is also deposited in other parts of the body, especially in the joiuts and fibrous tissues. It is not improbable that its accumulation in the blood, under these circumstances, may be the cause of some of those peculiarities which distinguish gouty affections. Again, when the secretion of urine is arrested, the urea, which commonly escapes with this excretion, remains in the blood, and imparts to it highly noxious properties. The same remark may be made of the colouring principle of the bile, which, upon a cessation of the hepatic secretion, becomes redundant in the blood, and, being thrown off by the skin and kidneys, produces jaundice. Black pigmentary matter has also been found in the blood, in the form either of cells or amorphous granules ; and, if in great excess, may readily be supposed to occasion black discoloration of the skin, or melanotic deposit. Bernard has proved that glucose or grape sugar is generated as a normal product in the liver, and is thence carried to the lungs, where he supposes it to be consumed. It is true that, if reliance can be placed on the results of experiments performed by M. Chauveau and Dr. Harley, the glucose disappears not exclusively or even chiefly in the lungs, but in the general circulation ; but this does not affect the inference to be deduced. If too largely generated in the liver, or in- sufficiently consumed in the lungs, or in the course of the circulation, it ac- cumulates abnormally in the latter, and, being eliminated by the kidneys, gives rise to diabetic urine. There is reason to believe that other principles, elaborated by the digestive and absorbent processes, or resulting from the partial disintegration which the blood itself, as well as every other constituent of the body, is perpetually undergoing in the exercise of its functions, exist in the circulation, and prove innocent in health only because they are rapidly carried off with the urinary, cutaneous, pulmonary, or intestinal se- cretion. Hence, probably, one of the sources of the numerous evils which result from the suppression of these secretions. In certain febrile conditions the sour breath and sour perspiration evince the existence of an acid in the blood, which probably aids other causes in sustaining the disease, and the elimination of which may be one of the advantages of diaphoretic medicines in these complaints. 3. Hitherto, we have considered the blood as vitiated in consequence cither of some foreign principle being admitted into it, or of the accumula- tion of some principle which, though naturally entering the circulation is in the healthy state, thrown out as fast as it enters. But it must also' be regarded as in a morbid state, when any one of its ordinary and essential constituents becomes either greatly redundant or greatly deficient Such a redundance or deficiency may result from the peculiar character of the food out of which the blood is elaborated, or from some modification in the f,Z tions concerned in its elaboration, including those which sunnlv it with ma- terials, as digestion and absorption, those which abstract materials fron as secretion and nutrition, and those which contribute to both these PnZ o circulation, respiration, and probably nervous action. Ilealthv hlnnrt ^ • in 1000 parts from 110 to 140 parts of the red corpuscles from ^ tnT? parts of fibrin, and from 65 to 10 parts of pure albumen. Any considerable CHAP. I.] DISEASE OF THE FLUIDS. 5 excess or deficiency of either or all of these ingredients, in reference to the numbers mentioned respectively, must be regarded as morbid.* * It may be useful to present to the student a slight sketch of the constitution of the blood, as now generally admitted. This most important constituent of the system con- sists of a liquid denominated liquor sanguinis, in which float certain minute organized bodies, denominated corpuscles, which only the microscope can render distinctly visible. The liquor sanguinis consists of wafer, holding in solution or intimate admixture fibrin, albumen, extractive and fatty matters, and various salts. The corpuscles are of two kinds, one denominated red corpuscles, to which the blood owes its colour, and the other, in comparatively very small proportion, called white or colourless corpuscles. Besides these ingredients, there is held in solution more or less gaseous matter, which is chiefly oxygen and carbonic acid, the former existing in the arterial, and the latter in the venous blood ; and a volatile principle which, when the blood is drawn, is exhaled with a pe- culiar and characteristic odour. These may be considered as proper constituents. But the blood also contains minute quantities of urea, bilious colouring matter, and prob- ably various other substances, the results of its own disintegration, or that of the solid tissues, which are present in it merely in order that they may escape from the sys- tem, and in fact, in the healthy state, are eliminated as fast as they originate in or enter it. MM. Guillot and Leblanc believe that they have detected casein as a normal con- stituent of the blood. The proportion has not been ascertained; but it appears to be inconstant, though the principle is always present in health. It is peculiarly abundant in the female during lactation. (Archives Generates, 4e se'r. xxiv. 364.) When removed from the body, the blood undergoes a new arrangement of its con- stituents. The fibrin, before held in solution, now spontaneously coagulates, involving the corpuscles, and forming the clot, which at tirst holds the liquid part mechanically entangled in its meshes, but gradually separates from it by a firmer contraction. The liquid thus deprived of the fibrin is called the serum, and contains the albumen, salts, and extractive and fatty matters ofthe liquor sanguinis. The red corpuscles, which are cells containing a red liquid, are not chemically homogenous, but consist of various substances, most of which are identical or analogous with the constituents of the liquor sanguinis, but one at least, denominated hematosin, is quite distinct, being the principle to which the red corpuscles and consequently the blood owe their colour, and having this striking peculiarity, that it contains a definite proportion of iron as one of its elements. M. Le Canu gives the following as the result of his latest researches into the chemical composition of the red corpuscles: 1. hema- tosin or red colouring principle ; 2. albumen, and extractive, fatty, and saline matters, dif- fering in nothing from those of the serum ; 3. globulin, an albuminous substance, but distinguishable from ordinary albumen by its solubility in hot diluted alcohol, and by forming with cold water a solution, which is not troubled by subacetate of lead; and 4. a fibrinous substance constituting the envelope or cell-wall of the red corpuscles, and differing from ordinary fibrin in being insoluble, even at a boiling temperature, in a solution of potassa containing one-tenth of the alkali. (Jour, de I'harm. et de Chim. 3e sir. xxii. 339.) Of the chemical nature of the white corpuscles little is definitively known. They are believed to be identical with the lymph corpuscles, and to enter the circulation with the fluid of the thoracic duct. It lias been rendered highly probable that they consti- tute a stage in the development of the red corpuscles. MM. Donders and Moleschott have inferred from a microscopical examination of the blood of seven persons of differ- ent ages, between two and eighty years, that the average number of the white compared with the red corpuscles is 1 of the former to 373 of the latter: the proportion increasing with the age. They are increased after eating and lessoned after fasting, and are pecu- liarly augmented by food rich in albumen. (Archives Gen., Fev. 1855, p. 200.) Others give the proportion differently. Hirt found in his own blood from 1 in 230 to 1 in 760, the greatest proportion being about two hours after the last meal of the day, the least in the morning before breakfast. The blood of the splenic vein contains a much larger proportion than the corresponding artery; and that of the hepatic vein than of the portal vein, showing that either the white corpuscles are generated, or the red destroyed, in the spleen and liver. Tonics have been found to increase the proportion of white corpuscles. (Brit, and For. Med. Chir. Rev., Am. ed., July, 1856, p. 177.) From the researches of Drs. Leconte and de Goumoens it appears that albumen, fibrin, and globulin, as well as other albuminoid substances, are always composed of two distinct chemical constituents, one soluble and the other insoluble in crystallizable acetic acid. In fibrin, the first of these constituents has when isolated the form of granules, the second retains that of fibrils. As obtained from albumen or globulin, they G GENERAL PATHOLOGY. [PART I. Sometimes, under the influence of a rich diet and vigorous digestion, with a comparative deficiency in the nutritive process, the solid organic principles of the blood increase so much as to constitute a state of disease. The blood is intensely red, and, when taken from the body, affords a larger and firmer coagulum than in health. It is in this state highly stimulating to the organs, and may give rise to a general excitement amounting to fever, or to local inflammation or hemorrhage. cannot be distinguished by the microscope, but still have precisely the same chemical characters as those of fibrin. These are interesting facts, having a strong bearing on the physiological properties of albuminoid substances, and tending to show that fibrin is of a higher grade than the others, in reference to organization. (Archives Generates, Juin 1853, p. 681.) The fact is stated by M. Verdeil, that hematosin has strong analogies with chloro- phylle, or the green colouring matter of plants, when freed from a fatty impurity associ- ated with it as usually obtained. (Chem. Gaz., Feb. 16,1852, p. 74; from Comptes Rendus, Dec. 1851.) In reference to hematosin, another interesting statement, which at present must be looked on rather as a probable conjecture than as a fact, is that the colouring principles of the urine and the bile are merely altered conditions of that principle, re- sulting from the normal disintegration of the red corpuscles after the period of their active life is past. As useful to the reader for reference in the perusal of this work, the following tables of the composition of the blood are given, offering the average of the results obtained by numerous experimentalists. They are taken from Kirkes and Paget's Manual of Physiology. 1. Chief constituents in 1000 parts of the blood. Water......78400 j Fibrin......2-20 Red corpuscles . . . . 131-00 j Extractive and fatty matters, &c. . 6-77 Albumen of the liquor sanguinis . 70-00 | Saline matters . . . .6-03 2. All the constituents in 1000 parts. Water Albumen Fibrin . Red Cor- ( Globulin . tuscles. \ Hematosin ' Cholesterin Fatty Matters. Cerebrin Serolin Oleic and margaric acids, volatile and odorous fatty acid Fat containing phos- phorus . 784-00 70-00 2-20 123-50 7-50 0-08 0-40 0-02 0-80 f Cloride of sodium Chloride of potassium . Tribasic phosphate of soda Inorganic I Carbonate of soda '. Salts. ! Sulphate of soda . Phosphate of lime and magnesia . Oxide and phosphate of iron Extractive matter, salivary matter, urea, biliary colouring matter^ gases, and accidental substances '. 3-60 0-36 0-20 0-84 0-28 0-25 0-50 5-47 The fibrin must be considered as including the white corpuscles, which chemists have yet been unable to examine separately. The proportion of fibrin eiven in the above tab e is below the average generally admitted, which is about 3 in 1000 ™vt« It should be stated that arterial blood differs in the proportion of its constituent from venous; containmg according to Dr. J. Beclard, more of the red corpuscles and somewhat less of the fibrin. From the experiments of the same chvlnltf ,i appear that, while the arterial blood is identical in all parts of tL? syStem fL ™ differs in different situations. Thus, the blood returning from the sXen ^ ! of the red corpuscles and more of the albumen and fibrin than he venous wSl f £" general system; while that of the mesenteric veins varies according tc^ t2°££d o? digestion, having a considerable increase of albumen with diminution of th* J puscles in the early stage of digestive absorption, and precisely the reverbo«a -^ after the absorption has been completed. (Archives Generates* 4e J,™m Ji?AltM£ has been stated in the text that, according to the observations of Ber'n^rl T ' grape sugar is found as a normal constituent in the blood of the liver »nri •' g\ucose or of the circulation thence to the lungs, and, according to M. Chauveau »«5 r? xt r generally associated with, if not de- CHAP. II.] CAUSES OF DISEASE--CONTAGION. 169 pendent on, some parasitic growth, either animal or vegetable. Some dis- eases are contagious exclusively by means of contact or insertion, as syphilis, hydrophobia, and the vaccine disease; others possibly through the air alone, as hooping-cough, scarlatina, and typhus; and others again in both modes, as smallpox, chickenpox, and, as some assert, measles. Indeed, it is by no means certain that all the febrile contagious diseases might not be propa- gated by inoculation, were we acquainted with the proper matter to apply in each case. The contagious matter may be the product of local action in the diseased individual, as in syphilis, scabies, and porrigo, or may be connected with a general contamination of the system, and exhaled from all the free surfaces of the body, as in smallpox, scarlatina, measles, and typhus. It has no sen- sible properties by which its poisonous character might be indicated, nor does it yield any evidence of its nature to chemical investigation. In some diseases, as in smallpox and typhus fever, it is often attended with a dis- agreeable odour; but it is by no means certain that it is the matter of con- tagion itself that smells. In other instances, it is without odour, as in measles and hooping-cough. There is a great difference in the contagious power of the different exhala- tions. In some, it is feeble, and attacks few comparatively of those exposed to it, as in scarlatina; in others, very active, allowing few that are unpro- tected to escape, as in smallpox. Contagion does not usually act at a great distance from its source, though there is considerable difference also in this respect. Thus, typhous contagion seldom extends beyond a few feet in well ventilated apartments; while the variolous will not unfrequently spread through all parts of a house from a single bed, and even from one house to another in the near vicinity. The effluvia are capable, in some instances, of attaching themselves to clothing, merchandise, &c, and may thus be conveyed to great distances. It very rarely happens, however, that the mere entrance into the sick room is sufficient so far to impregnate the clothing, as to enable the wearer to be- come the instrument of spreading the disease. Hence, we scarcely ever hear of a physician conveying the complaint from one person to another. Still, it would be prudent, in a practitioner attending upon very contagious dis- eases, such as bad cases of smallpox, to change his dress before visiting another patient. Instances not unfrequently occur, in which contagion is imparted by the clothes or bedding of a patient, or of persons in constant and close attendance upon him. Disease has thus been carried to very con- siderable distances, and caused to spread in places before uninfected. Fab- rics of wool, silk, and cotton, are especially liable to act as fomites; but those of flax and hemp are not exempt. Hair may also serve as a vehicle. The greatest danger is when boxes, containing clothing thus infected, are first opened. Insects have been suspected of conveying the contagion by alighting successively on the body of the patient, and on that of a suscepti- ble individual. Fomites will often long retain the poison, though it is weak- ened and at length destroyed by time. It is always safest to act upon the supposition, that the period of its activity is indefinite, unless measures are taken to destroy it by chemical agency. The matter of contagion is said to be rendered inert by a heat of 120° F., and consequently by any higher degree. Hence, the boiling or baking of infected clothing should render it harmless. Intense cold is thought also to impair the activity ofthe contagious matter. Nevertheless, diseases of this class occur more abundantly in winter than in summer, owing, no doubt, to the confinement which is necessary, in the former season, to guard against the cold, and the consequent concentration of the morbific agent. Certain 170 GENERAL PATHOLOGY. [PART I. chemical substances have the power of completely decomposing contagious matter, especially chlorine, which is, therefore, much used for the purpose of disinfection. Its activity is also gradually impaired by time. It is said that the virulence of the poison is diminished by transmission through nu- merous individuals; and one contagious affection at least, namely syphilis, would appear to have become milder by time ; but the correctness of the general statement may well be disputed. The time at which a contagious principle begins to show its effects varies from two or three days to several weeks, after exposure. The resulting dis- eases are generally febrile, especially when the contagion is of the kind transmissible through the atmosphere. The effect of certain contagious principles on the system is essentially depressing, as that of typhus; and, in general, their operation is rather debilitating than inflammatory; though this is by no means uniformly the case. The manner in which the disease spreads is peculiar, and often affords the requisite criterion of its contagious nature. Thus, it does not at once seize upon great numbers, as an epidemic, or occur in several separate points within a given space at the same time, like an endemic; but spreads from individual to individual, or from house to house; and, when new cases occur at a distance from the original one, they can often be traced to it by the intervention of persons or fomites. Instead of originally seizing a whole family, or several members of it, at one time, it generally first attacks a single individual, and, from two or three days to two or three weeks afterwards, several others almost simultaneously. The febrile contagious diseases generally run a certain course, having dis- tinct stages at certain intervals, and terminating in a given number of days. This property is not absolute; but is so general as to be characteristic. Another peculiarity of the same set of diseases is, that one attack in gene- ral secures the system against a second. This rule, however, is liable to frequent exceptions, and does not apply to the complaints imparted exclu- sively by contact. There seems to be a certain incompatibility between the several contagious febrile complaints; so that, if an individual has been exposed to the causes of two of them, he will not usually be affected simultaneously with both ; but one will run its course, and, when it begins to decline, the other will appear; or the feebler one, if it have precedence, will be superseded for a time by the more powerful, and will return and finish its course, after the latter has sub- sided. Such is the case with measles and smallpox. Occasionally, however, we see two of these complaints apparently existing together, and modifying each other, as in the cases of measles and scarlet fever. A common character of all contagious diseases, and, indeed, the one that renders them such, is the power of reproducing the same kind of matter as that by which they were brought into existence. Nevertheless, it may be said that this rule is not absolutely universal. Thus, it is very doubtful whether the matter of hydrophobia can be reproduced in the human subject. A sufficient answer would be, that, if it cannot be reproduced, hydrophobia is not a contagious disease .so far as man is concerned. Many, perhaps all, of the contagious diseases may arise from other causes than their own peculiar contagion, and may afterwards propagate themselves in the ordinary mode. This is the case with typhus fever. There is often an epidemic tendency to certain contagious diseases, which, under such circumstances, may, I believe, originate without other influence. Such a tendency, moreover, greatly increases the activity of the contagious cause; and it not unfrequently happens, during its prevalence, that persons before supposed to be sufficiently protected are attacked a second time. CHAP. II.] CAUSES OF DISEASE.—CONTAGION. 171 The contagious affections of inferior animals are sometimes imparted to man, though probably somewhat modified. The vaccine disease, hydropho- bia, the glanders of horses, and perhaps the malignant pustule, are examples of this kind. The nature and mode of action of the contagious principles are points of great interest, which remain yet to be settled. There are two circumstances which serve to distinguish them from other morbific agents; their power of reproduction in the human system, and the immunity which one attack gene- rally gives against their future influence. In this latter circumstance, there is a striking difference between them; for, while most of them obey the gene- ral law just stated, others, such as the contagions of syphilis and gonorrhoea, are capable of affecting the same individual as often as they may be brought into contact with him. Two theories have been advanced to explain the action of these causes. By one they are considered in the light of ferments, which, entering the blood- vessels, occasion chemical changes, that result in a further production of simi- lar contagious matter; as the fermentation of beer developes an additional quantity of the same kind of yeast, by the presence of a little of which it was excited. This explains the reproduction of the morbific agent. An attempt has been made to account for the fact of future exemption by supposing that, in every system there exist, as consequences of the organic processes of growth, peculiar matters, each one of which, through the fermentation ex- cited by the contagious cause, is itself converted into contagion, and elimi- nated ; so that, on any future occasion, though the poison may be absorbed, it will find no material to act on, and will therefore be harmless. An ex- planation so purely hypothetical scarcely requires criticism. The objection naturally suggests itself, that there should be so many distinct unnecessary substances, generated and retained in the system, as if with no other purpose than to await the action of certain special morbific principles, to be received from without. A more plausible explanation of the future exemption is that given by Mr. Paget. Each organized structure has the property of assimi- lating to its own nature, the material presented to it in the nutritive process. Thus the bony tissue converts the organizable material into bone, muscle into muscle, &c. The blood itself is in the same category. Should a structure become diseased, it assimilates the material, not to its original, but to its altered condition. Tumours, upon this principle, retain their character as they increase in size. In like manner the blood, which, under the influence of ab- sorbed contagious matter, undergoes some modification which renders it no longer susceptible to the influence of the contagion, maintains its new condi- tion, and of course a continued insusceptibility, by the principle of assimi- lation. (Lect. on Surg. Pathol., i. 51.) The second theory considers contagion as the influence of certain invisible organic agents, either animal or vegetable, which, fully developed, or in the state of germs, enter the blood-vessels, and there live and propagate to the no little disturbance of the system, which is at length excited into desperate efforts, and throws off the intruders and their whole brood, or perishes in the attempt. In support of this view, the argument has been advanced, that, in certain cutaneous affections, as porrigo, the cause has been proved to exist in microscopic fungi, the sporules or seeds of which become the medium of contagion; and, in the case of psora, the disease is conveyed by animalcules of a peculiar character, which propagate in the skin. But the fact that, in these affections, no future exemption is secured, shows that they are essen- tially distinct in nature, and probably in cause, from the febrile or general contagious diseases; and there is nothing in the animalcular hypothesis, 172 GENERAL PATHOLOGY. [PART I. which affords even a plausible explanation of the immunity, secured by one attack of these latter complaints. * Predispositions. Before leaving the subject of etiology, it is necessary that we should notice certain influences, which, though not always strictly causes, have yet an im- portant agency in the production of disease. I have already spoken, in general terms, of the distinction between predisposing and exciting causes; and have considered somewhat fully such as seemed to require particular attention in a general treatise. At present, my object is to speak of the predisposi- tions, in other words, the states of system which render it especially liable to the assaults of disease. These may be arranged in three divisions. The first includes certain conditions which are not in themselves deviations from * Zymotic Diseases.—The term zymotic, applied to a class of diseases, and sometimes to their cause or causes, has come so extensively into use as to require some explana- tion in a general treatise like the present. It is derived from the Greek word Ci>fin, ferment, and is applied to a certain set of diseases, in which it is supposed that a mor- bific agent, entering the blood, operates upon it as a ferment, as yeast for example operates upon saccharine juices. A minute quantity of the poison sets on foot an action in the blood, by which the whole mass is changed; and the resulting phonomena proceed from the altered state of the blood, and not from the direct agency of the foreign matter admitted into the circulation. Upon this principle it is thought that all those causes operate which are included, in the text, under the names of animal effluvia, miasmata, epidemic influence, and contagion. They would be called, under this theory, zymotic agents; while the diseases produced by them are called zymotic diseases. Of course, under the latter title, are included all miasmatic or malarious fevers, all epi- demics, and all contagious diseases resulting from an absorbed poison. The reader will notice that this view of the operation of certain causes of disease is purely hypo- thetical, being founded altogether on certain analogies which in themselves are not complete, and unsupported by chemical or microscopic observation. The hypothesis is plausible, and to a certain extent may be true, but has not been proved, and should not, therefore, I think, be made the basis of a new classification or new nomenclature of diseases. The effect of such classification and nomenclature, if generally adopted, is to lead the student to receive as admitted fact, what is yet simply conjecture. In the text allusion is made to a mode of explaining the peculiarities of contagious diseases upon the principle here referred to. Liebig teaches that fermentation is owing to a movement of decomposition, excited in one body by the mere presence of another body undergoing decomposition. Yeast is a nitrogenous substance in this condition. Introduced into a pure saccharine solution, it sets on foot a process of decomposition which results in the formation of alcohol and carbonic acid out of the sugar, without further change; but, if along with the sugar and water there be a nitrogenous body, as in the infusion of malt, this body undergoes, through the same agency, chemical changes which convert it into a substance having all the properties of the yeast origi- nally employed. So in contagious diseases, a little of the zymotic agent, itself in a state of chemical change, entering into the blood, and finding there some material sus- ceptible of its influence, sets on foot a process of decomposition in that material which ends in its conversion into a similar zymotic agent, to be thrown out of the system. Dr. Carpenter has ingeniously extended this theory to the explanation of the predis- positions to the epidemic or zymotic diseases, which, as is well known, are apt to attack only a certain number of individuals exposed to their influence, while many escape. In referenced) cholera, for example, it is those who have lived miserably, in confined places, and in a contaminated atmosphere, who are most apt to suffer. He supposes that, in these persons, the blood has become contaminated with absorbed or generated nitrogenous matters, in a state ready to enter into decomposition with great facility upon the application of the ferment. In these, therefore, the absorbed poison excites the movement of decomposition which gives rise to the morbid phenomena; while pure blood, offering no such material for the action of the poison, undergoes no change, and the individual escapes. The reader who is disposed to push this inquiry further is re- ferred to an article on the predisposing causes of epidemics, in the British and Foreign Me- dico-Chirurgical Review, for January, 1853. All these speculations, however, should be looked on as sdggestive merely, prompting to positive experimental research, and should not be received as truths until established by the results of such research. (Note to the fourth edition.) CHAP. II.] CAUSES OF DISEASE.---PREDISPOSITIONS. 173 health, and might with great propriety be denominated, after Chomel, apti- tudes. To the second belong those states of system, not strictly healthy, which predispose to no one peculiar disease exclusively, but rather to some set of diseases, some general mode of derangement, or to almost any disease, according to the nature of the exciting cause. The third embraces what are usually denominated diatheses; that is, tendencies to some one special and peculiar disease, which is apt to appear whenever the body is excited or dis- turbed, no matter by what cause, and will occasionally break forth without any apparent cause whatever. These may indeed be considered, in some instances at least, rather as latent conditions of the peculiar disease, than as mere predispositions. Such are the gouty, the rheumatic, and the scrofulous diatheses. The proper place to treat of these is obviously in connection with the several affections to wdiich they belong. It is only the first two divisions which require particular notice in this place. Among the apti- tudes, we may consider temperaments, idiosyncrasies, sex, and age; among the predispositions, hereditary tendencies, habit, the effects of climate, and the results of occupation and modes of life. 1. Temperaments.—Scarcely an individual, probably, can be found, whose organization is so well constituted, and so nicely balanced, as not to offer an aptitude to some particular disease or mode of derangement, rather than to another. Almost all have some deficient or predominant tissue or organ, some weaker or stronger susceptibility, some inequality of function, or some peculiarity of sympathetic relation, which favours the action, or gives spe- cialty to the direction of some morbific cause. These constitutional peculi- arities, when they are such as affect classes of persons, are called tempera- ments, when confined to individuals, idiosyncrasies. The general rule, in relation to the temperaments as predispositions to disease, is, that a predominance, either of development or function, in any structure, organ, or system of the body, is apt to lead to disease of that part. Thus, the sanguine temperament, in which the circulatory system predomi- nates, predisposes to acute inflammations, hemorrhages, and fevers of a sthenic character; the lymphatic temperament, which is characterized by an excess of the colourless tissues, and deficiency of red blood, to scrofulous and dropsical affections ; the nervous temperament, in which the cerebro- spinal system is in excess, or peculiarly excitable, to neuralgia, and the various forms of nervous disorder; and the bilious temperament, the name of which sufficiently indicates its character, to hepatic and dyspeptic diseases. 2. Idiosyncrasies.—These are highly important. Many persons have pecu- liarities, either confined to themselves, or participated in by very few, which render them susceptible to morbid impressions from causes, wThich in general either produce no effect, or one entirely different. These are not indicated by external signs, and are to be ascertained only by experience. Thus, cer- tain kinds of food, usually very wholesome, may produce violent urticaria. Exhalations, which are quite harmless to the great mass, excite, in certain individuals, excessive irritation of the nostrils, fauces, or respiratory pass- ages. Some very susceptible persons faint at the perception of odours, usually agreeable in their effects. So frequent are these peculiarities, and sometimes so important, especially in relation to the operation of medicines, that the physician should make himself acquainted with the constitution of every new patient, as far as practicable, before prescribing for him, in any serious case. Inferences as to the morbid liabilities of individuals may some- times be drawn from the shape or size of their organs. 3. Sex.—This has great influence in giving peculiar morbid tendencies. Of course, each sex is prone to the diseases belonging to its own organs and functions. But, independently of these, women, in consequence of the greater 174 GENERAL PATHOLOGY. [PART I. excitability of their nervous system, are especially predisposed to nervous complaints; and causes, which in men produce inflammation, will in them give rise to mere functional disorder. Thus, gout and rheumatism, instead of assuming a frank inflammatory character, are apt to lurk in the female system, under the forms of dyspepsia, palpitations, headache, and neuralgia in every shape. From the same cause, women are especially liable to spinal disorder, and to all the protean forms of hysteria. Their sexual peculiari- ties also impress on the general system predispositions, not immediately or necessarily connected with the several organs. Thus, about and soon after the age of puberty, they are strongly prone to chlorosis or anaemia. Child- bearing, though liable to its accidents, is probably on the whole favourable to health, by superseding constitutional morbid tendencies. But, when men- struation has permanently ceased, these tendencies are apt to display them- selves ; and this, consequently, is the most dangerous period in the life of woman. It is now, especially, that cancerous affections occur. But if she escape the dangers of this period, she may reasonably hope to enjoy a long exemption from disease, and to live on to a good old age. Much of the peculiarity, ordinarily observable in the female predispositions, is owing rather to their habits than to any natural cause. Hence, probably, in part, their tendencies to spinal deformity, pulmonary consumption, anemic com- plaints, and dyspepsia. 4. Age.—In consequence of the early development of the brain, and the exposure of the skin to a new and unaccustomed medium, very young infants are peculiarly predisposed to cephalic and cutaneous diseases. The rapid growth of the body, requiring a vigorous exercise of the digestive organs, afterwards makes these also a centre of morbid action. The process of den- tition keeps up, during its continuance, a constant irritation, which, through the fresh and unimpaired sympathies, extends to the various functions, espe- cially those of the skin, alimentary canal, and brain, giving rise to frequent diseases of these parts. Vast numbers of children are carried off by com- plaints of the stomach and bowels, during the period of teething. The almost unremitted excitement of the nervous system, either directly from the source of irritation, or as the instrument of ail the sympathies, renders this system more liable to derangement than at any other period of life; and causes which are ordinarily little felt now frequently produce convulsions. By far the most dangerous period of life is before the close of the third year. There is another source of danger, which continues in operation until after the com- pletion of the second dentition. In the inflammatory affections of children, at this age, there is a strong tendency to the exudation of coagulable lymph, and the consequent formation of false membrane, even upon the mucous surfaces. Perhaps this may be owing to a predominance of fibrin in the blood, consequent upon the wants of the nutritive process; but the explana- tion is altogether conjectural. It is this disposition which renders croup so fatal at the age referred to. After the second dentition, until the age of puberty, is among the healthiest periods of life. Children are now scarcely predisposed to any other occasional affection than epistaxis. They are, how- ever, often exposed to the influence of the aerial contagions, such as measles, scarlatina, and hooping-cough, because they are old enough to be frequently abroad, and have not yet generally acquired the exemption which secures them in later life. The age of puberty is not peculiarly liable to any dis- order in the male; but, in the female, it is not unfrequently accompanied with derangements of the uterine functions, and of the general health, which may continue for years. Chorea, chlorosis, and hysteria, often have their origin at this period. With the exception alluded to, the healthfulness that suc- ceeds the completion of the second dentition, continues onward until near the CHAP. II.] CAUSES OF DISEASE.--PREDISPOSITIONS. 175 age at which rapid growth ceases. At the latter period is another dangerous crisis. There is now a strong predisposition to hemorrhages, pulmonary consumption, and dyspeptic affections. The quantity of blood furnished by the digestive process has not yet become exactly accommodated to the diminished wants of nutrition, and hence is apt to escape by irregular out- lets. Perhaps the peculiar liability to phthisis may be explained by the same necessity for extravasation, which, in persons of the consumptive habit, takes the form of tuberculous deposit. The appetite, or at least the habit of eating, has not learned to adapt itself to the moderated powers of digestion, and the stomach is apt to be overworked. After maturity, when the body has attained its full expansion, and growth has ceased, there is again a period of comparative exemption from morbid tendencies, which continues, with the exception, in females, of a few years about the cessation of the menses, until life begins to decline. The functions are now all well balanced in the healthy individual; no organ is called on for an excess of duty; and none, therefore, is especially liable to derangement. But, when the period of decline has arrived, the balance is again disturbed, one organ fails too rapidly, another retains a disproportionate activity, and the general hardening of the tissues, incident to age, goes on with an unequal, and sometimes a dangerous speed. Hence, predispositions to various organic diseases accrue ; and the brain, the heart, and the urinary and genital organs, are especially prone to suffer. In the degeneration of tissue that takes place, the characteristic properties of the ultimate cells are sometimes perverted or lost; new laws regulate the nutritive process ; and thus morbid growths are apt to be developed, such as scirrhus or cancer, which is especially a disease of advanced life. 5. Hereditary Tendency.—As we often resemble our parents in external form, so also do we inherit their internal peculiarities, and consequently all the morbid tendencies growing out of them. It is not diseases, generally speaking, that are inherited. It is only the peculiarities of structure or con- st itut ion, which serve as predispositions to disease. We are not born with the scrofula, gout, rheumatism, &c, of our parents, but only with that con- dition of system which favours the development of these affections, when other causes operate. The inherited diathesis, however, is often sufficiently strong to lead ultimately to the disease, without other cause. We see this fact constantly illustrated in consumption and gout. Nay, the hereditary disease will often be developed, notwithstanding the most determined mea- sures to prevent it, which sagacity and experience can suggest. The inherit- ance may descend from either parent or both. It has been supposed that the peculiar diseases of the mother are more apt to be found in the son, and those of the father in the daughter; but the accuracy of the opinion may be doubted. When only one parent is affected, it often happens that the off- spring escape entirely, taking after the healthy parent exclusively. But when both are diseased, and in the same way, the chances of escape on the part of the children are greatly diminished. Hence the danger of constant inter- marriages between near connexions, who may be supposed to have the same defects of constitution. The morbid tendencies thus go on accumu- lating, from generation to generation, until families, and even races, become extinct. Sometimes the hereditary malady passes over one generation, to fix upon the next. The child escapes, but the grandchild is affected. This fact admits of easy explanation. It is only the tendency that is received from the parent. This may remain latent, from the absence of causes cal- culated to call it into action; or counteracting circumstances may exist which shall prevent its development. The tendency is, nevertheless, handed down to the next generation, which may be less fortunate in relation to the influences that bear upon it. Occasionally we observe family predisposi- 176 GENERAL PATHOLOGY. [PART I. tions to disease, which have no prototype in the immediate, or even remote ancestors. One child after another falls a victim to the same disease, from some inherent vice of constitution ; and parents, themselves of sound health, may thus be completely stripped of their offspring. This sometimes happens from a vicious system of physical education, and is much more frequent among the rich than the poor. But, in other instances, the defect is received from the parent, and exists from birth. In such cases, however, the disease can- not, in strictness, be said to be hereditary. Complaints dependent on in- herited peculiarities of system, are apt to appear earlier in life than similar complaints of a different origin. 6. Habit.—The influence of this principle is generally salutary. The sys- tem, frequently exposed to morbific causes, may be reconciled to them in the end, and cease to receive further injury. Persons thus become acclimated in unhealthy districts, and sometimes, when brought up in such districts from infancy, are gradually accustomed to the noxious influence, and appear not to suffer. Occasionally, however, habit constitutes a predisposition to dis- ease. Thus, when the system has adapted itself to certain influences, ordi- narily injurious, they may become necessary to health; and an exposure to circumstances, incompatible with their continuance, may lead to disorder. Hence an important practical rule, to withdraw individuals cautiously, and by degrees, from a long accustomed exposure to what may even be deemed injurious agencies, unless immediate danger is apprehended from them, or no other than a sudden breaking up of the dangerous habit can be effectual. Habit may act as a cause, at least of the continuance of disease, by the tendency it produces to a return of any abnormal mode of action, to which the system has been once or oftener exposed. Thus, epilepsy, once established, is probably often maintained by habit, and hence, after a certain duration, becomes extremely difficult of cure. 7. Effects of Climate.—These frequently constitute predispositions to dis- ease. In hot climates, the liver and its appendages are kept in an undue state of excitement, both from the direct stimulant influence of heat upon that organ, and from the additional duty which it has to perform in the elimi- nation of carbonaceous matter. A certain excess of carbon is introduced with the food, which is thrown off partly by the lungs and skin, in the form of carbonic acid, partly by the liver in the form of fatty matter. That part of it which is converted into carbonic acid, answers the additional purpose of affording animal heat; but, as little of this is needed in hot countries, there is less of the acid formed, and a greater proportion of carbon must con- sequently escape by the liver. This organ is, therefore, overburdened with duty, while the lungs are spared. Hence is established a predisposition to biliary and gastro-intestinal diseases ; and those of the lungs are compara- tively rare. In cold climates, the facts of the case are exactly reversed. Ani- mal temperature is here especially wanted, and the carbon consequently finds its chief outlet through the pulmonary organs ; the liver having proportion- ably less duty to perform. Under these circumstances, hepatic affections are rare ; while a strong predisposition exists to diseases of the lungs. In tem- perate latitudes, there is less exclusive tendency of disease to any one organ; but, from the frequent vicissitudes of weather, and the consequent varying conditions of the organs, there is a greater general tendency to inflammatory affections. The vicissitudes are felt more strongly when the climate is damp as well as variable, and the morbid tendency is also consequently stronger. Rheumatism and catarrhal affections are the most frequent results. In warm moist climates, the system is depressed by the sedative influence of the moisture, and a predisposition to low forms of disease is established. A hot dry climate is said to predispose to diseases of the skin. CHAP. III.] SYMPTOMS OF DISEASE. 177 8. Effects of Occupation, Modes of Life, &c.—The predispositions which flow from these causes are numerous. It is, however, impossible, to follow them in all their ramifications. They may generally be estimated by refer- ring to the various causes of disease already enumerated, and ascertaining their bearing in each particular case. A few remarks on the subject of diet, dress, and employments, whether of business or pleasure, will close this essay. The habitual use of animal food in excess produces a superabundance and richness of the blood, which strongly predisposes to inflammatory diseases, especially when a corresponding amount of exercise is not taken. An exclu- sive vegetable diet may, on the contrary, impoverish the blood, and occasion a general debility, predisposing to scrofulous and tuberculous affections, and various nervous derangements. Scanty and unwholesome, or putrid food, vitiates at once the fluids and solids of the body, and predisposes to scurvy and low forms of fever. Stimulating drinks and condiments favour directly the causes of irritation, and, by the relaxation which follows their use, lay the system open to the assaults of morbific causes in general. The predispositions produced by dress resolve themselves into those result- ing from heat, cold, and pressure, according as the clothing is too abundant, too scanty, or too tight. So far as the predispositions resulting from occupations of all kinds, in- cluding the pursuit of pleasure, are concerned, there are two prominent con- siderations to be kept in view; first, that over-exercise of the organs, by ren- dering them the centre of vascular and nervous excitement, strongly disposes them to inflammation from other causes; and, secondly, that the same over- exercise, if continued too long, may exhaust at length the excitability of the organs, and thus impairing their powers, may expose the system to all the morbid consequences of a failure of their functions, as well as, generally, to the influence of morbific causes through the resulting debility. CHAPTER III. SYMPTOMATOLOGY, or SEMEIOLOGY. Symptoms are those effects of disease which are either sensible to the pa- tient, or perceptible by the observer. Signs are the evidences by which dis- ease is made known. All symptoms are necessarily signs ; but there may be signs which are not symptoms. Thus, the age or sex of the patient may serve to lix the character of some particular affection; and the cause of a disease, when known to us, often determines our opinion of its nature. These may, therefore, be signs; but they cannot be considered as symptoms. Symptomatology, or Semeiology, is the science which treats of the symp- toms and signs of disease, in all their relations. The course of a disease, so far as it can be observed, is the peculiar succession of its symptoms ; the diag- nosis is the application of the symptoms and signs to the formation of an opinion as to its nature ; the prognosis is the deduction of inferences from the symptoms as to its future progress or result. The course of disease, there- fore, its diagnosis, and prognosis, come within the province of symptomato- logy. It will be most convenient to treat first of the symptoms and signs; then of the course, which may be considered as including the duration and terminations of disease; next of the diagnosis, under which will be included the methods of exploring disease; and, lastly, of the prognosis. VOL. i. 12 178 GENERAL PATHOLOGY. [PART I. SECTION I. SYMPTOMS AND SIGNS OF DISEASE. A division of symptoms has been made into those connected essentially with derangement of the vital properties, and those which consist in changes of the sensible properties of the system. The former have been variously denominated general, rational, and vital symptoms; the latter, physical signs. A little reflection will show that the distinction is not very philoso- phical. Many of the general, rational, or vital symptoms are appreciable by the senses. Thus, the cries of pain are heard ; the derangements of the pulse are felt; and convulsive movements are seen. On the other hand, many of the signs called physical are clearly symptoms of some vital dis- turbance. Thus, the increased bulk of an organ, the modification of its healthy sounds, and alterations in its colour, are often immediate signs of changes in the vital actions. In these general remarks, therefore, I shall not follow the division alluded to ; but, in the description of individual dis- eases, it will be most convenient, in many instances, to separate from the ordinary symptoms those signs which are elicited by certain processes of com- paratively recent origin, as percussion and auscultation, and which have been distinguished by the designation of physical signs. Such a discrimination is called for by the considerations, that these latter require a peculiar training in the observer, in order to be fully appreciated, that they have not yet re- ceived the universal attention which they merit, and that, if treated of indis- criminately with those better known and understood, they might tend, with many, rather to confuse than to aid the diagnosis. It would be quite out of place, in this preliminary essay, to treat of all the symptoms severally. In the account of each disease, those which belong to that disease must, of necessity, be referred to; and to describe them now would be to render repetition unavoidable. Indeed, many of the phenomena wrhich, under certain circumstances, are symptoms of disease, under others, are themselves diseases, and must, therefore, be fully discussed in the de- partment of special pathology. Our attention here must be directed more especially to those phenomena, which, being common to numerous diseases, require a general description in order to be fully understood, and of which a description now will spare the necessity of much repetition hereafter. It will be necessary, moreover, to explain the nature of certain symptoms, which, not entering into the category of diseases, might otherwise not receive the special notice which they merit. The reader, however, will understand that our notice is to be directed, in this part of the work, to the symptoms themselves ; their relation with the several diseases which they indicate being left for future consideration. In the following remarks, I shall pursue the natural order of the functions, beginning with digestion. 1. Symptoms belonging to the Digestive Function.__Perhaps the most important of these are the symptoms presented by the tongue, which are here described more fully, iu consequence of the great number of diseases in which they afford valuable indications. Tongue.—In drawing inferences from the condition of this organ, it is important to know whether the appearances it may present are the result of local disease in the mouth, or of the relations which connect it with other parts of the system. In general, there is little difficulty in coming to a cor- rect conclusion upon this point; and it is only necessary that the attention should be directed towards it. The following remarks have reference only CHAP. III.] SYMPTOMS OF DISEASE.—THE TONGUE. 179 to the general indications offered by the tongue. This organ seems to have been designed as an index, to the eye as well as to the ear, of the state of the system; so numerous and diversified are the morbid affections which modify its healthy appearance. It not only participates in all general de- rangements of the whole system, serving as one of the surest guides to a correct judgment in relation to the degree, progress, and precise stage of the disease; but especially also sympathizes with the different parts of the digestive tube, at one extremity of which it is placed. The bulk of the tongue may be increased or diminished. Its enlargement, when not so considerable as to be very obvious, may often be known by the appearance of indentations on its sides, made by the pressure of the teeth. This is occasionally one of the first signs of the mercurial influence. Its contraction, when not the mere effect of dryness, is usually the result of a diminished supply of blood, and indicates either a general deficiency of the circulating fluid, or great feebleness of the heart's action. Like every other part naturally moist, it shrinks by drying; and, under such circumstances, no general inference can be deduced from its mere loss of volume. Its colour is often greatly and significantly modified. Morbid floridness of the tongue is the consequence either of the condition of the blood, or of its greater abundance in the organ. In the former case, an unduly arterial- ized state of the mass of the blood is indicated; in the latter, either over- excitement of the circulation generally, or phlogosis of the stomach. Red- ness of the tongue, not the result of local causes exclusively, has been sup- posed by some pathologists to be an almost certain sign of gastric inflamma- tion or irritation. But this is far from being the case. It is often seen when no evidence of gastritis is presented, either by the symptoms or upon dissection, and is not unfrequently absent when that disease exists. Serious practical injury may result from this error. The red tongue can be consi- dered as having special reference to the stomach, only when other symptoms point in the same direction; and, even then, is by no means a certain sign. A livid or purple colour of the tongue is usually dependent upon an insuffi- cient aeration of the blood, and is a valuable sign, in connection with the same colour of the lips. Not unfrequently the tongue is morbidly pale; and this state is a sign of deficiency of the blood in general, or its red cor- puscles in particular, or of great prostration of the circulating forces. Its condition as to dryness and moisture is often highly significant. But caution is necessary not to mistake dryness, from temporary and unimportant causes, for that which results from general disease. In persons who sleep habitually with their mouths open, the tongue is apt to be dry in the morn- ing; and the same cause often produces the same effect in sickness. On visiting a patient, we find the tongue unexpectedly dry, and begin to feel some apprehension, until we learn that the patient has been breathing for some time through the mouth alone. A stoppage of the nostrils often gives rise to this phenomenon. In all doubtful cases, it is only necessary to request the patient to close his mouth, and then move the tongue about so as to moisten it. If he succeed satisfactorily, we may conclude that the dryness was accidental, and of no account. Another caution is requisite; to take care, namely, that a really dry tongue should not be mistaken for a moist one, in consequence of the patient having recently taken a liquid into his mouth. Dryness may exist in different degrees, from mere clamminess to perfect aridity. It depends on a deficiency of saliva, or of mucus, or both, and indi- cates a general tendency to diminished secretion. It not unfrequently occurs, as a sympathetic affection, in ulcerative inflammation of the small intestine. It affords sometimes the most important therapeutical indications, as will be fully shown hereafter. (See Enteric Fever.) 180 GENERAL PATHOLOGY. [PART I. The temperature of the tongue serves as a guide to that of the body gene- rally. When cold, it evinces, for the most part, great prostration of the powers of life. It proves that the process of calorification is failing at the very fountain ; for the breath must be cool, before the tongue can become so in any considerable degree. This coldness of the tongue has been frequently noticed in severe cases of epidemic cholera. But we must take care not to confound coolness from local causes, as from ice in the mouth, or from the patient having slept long with the mouth open in a cold atmosphere, with that proceeding from the state of the system. Heat of the tongue, except when arising from inflammation of the organ, may be considered as a sign of a general elevation of temperature. But the condition usually denominated a furred tongue is, perhaps, the most valuable diagnostic symptom afforded by that very important little member. In this state, the tongue is covered with a morbid coating, which adheres so firmly that it cannot be removed, without removing a portion of the surface along with it. Occasionally deposits take place from the saliva and the mucus of the mouth; but these are easily removable, and must be distinguished from the genuine fur. The latter proceeds from a disordered action of the tongue itself, resulting in an excessive formation of a deranged epithelium, the effete scales of which adhere with great tenacity to each other, and to the parts beneath. When long continued, the fur sometimes becomes mixed with a microscopic fungus, the seeds of which, derived probably from the air, adhere to the surface, and send forth very delicate filaments in great numbers. The fur is almost always confined to the upper surface, where the structure of the membrane is papillary. Though very generally a sign of disease, it is not always so. Some persons have a furred tongue habitu- ally, more especially upon rising in the morning; and, though in the greater number of these there is probably some chronic disorder of digestion, yet in others the health appears to be perfect. A furred tongue almost always accompanies fever, and is one of the most decided characteristics of that affection. Indeed, when considerable in de- gree, and not dependent upon stomatitis of any kind, it may very generally be regarded as a febrile symptom. When the fur is white, thickish, tolerably uniform, and accompanied with moisture, it usually indicates an open, active state of fever, in which, though the obvious symptoms may possibly be vio- lent, there is not apt to be any lurking mischief, nor any malignant tendency. When short, very adhesive, and rather scanty, permitting the redness of the tongue to appear through it, and attended with some disposition to dryness, it is often a sign of a protracted and obstinate form of fever, which is apt to assume a low, nervous, or typhoid form. A yellowish hue of the fur is usu- ally indicative of bilious disorder, being produced either by the vomiting of bile, or, what is probably much more frequent, by direct extravasation from the tongue, consequent upon deficient secretion by the liver, or an excessive production of bilious matter in,the blood. Not unfrequently, this colour of the tongue is accompanied with a bitter taste. It is common in miasmatic fevers, and hepatic diseases. A brown or black tongue is usually indicative of a low state of the system, and an impaired condition of the blood. It is owing to the secretion of a dark matter, apparently identical with that which collects about.the teeth and lips in typhous fevers, and probably consisting of blood modified in its passage out of the vessels. The same action would seem to take place in the tongue as that which, in the stomach and bowels, occasions the black discharges so common in malignant fevers. It may de- pend on an enfeebled state of the secreting tissue, or a diseased state of the blood, or on both united. Very frequently, this darkness of the tongue supervenes upon a previously white coating, and indicates a deteriorated CHAP. III.] SYMPTOMS OF DISEASE.---THE TONGUE. 181 state of the vital forces and probably of the blood. The caution should be observed, not to confound this discoloration with that proceeding from ac- cidental causes, as the chewing of liquorice, tobacco, burnt coffee grains, &c. In many instances, the white fur of the tongue is modified by red points, which are the tops of the swollen and projecting papillae. This appearance is not uncommon in eruptive febrile diseases, especially scarlet fever and measles. When consequent upon a dyspeptic state of the stomach, the fur is most copious in the morning before breakfast. In some persons, emptiness of the stomach is said always to induce this state of the tongue. The manner in which a furred tongue becomes clean affords valuable indi- cations. When the fur slowly recedes from the tip and edges, thinning gra- dually as it retires, it intimates a favourable convalescence. A portion of fur often lingers near the root of the tongue, long after the disease has given way. In another mode of cleaning, the fur loosens and separates in flakes, often beginning at the middle or near the root, sometimes in large patches, or over almost the whole tongue at once, leaving a smooth, red, glossy sur- face, as though the papillary structure had been lost. In such cases, if acute, and if the tongue remains moist, convalescence almost always takes place, though usually tedious, and sometimes very lingering. In threatening fevers, it is very desirable to witness this phenomenon; and, as it is often preceded by a feeling of soreness in the fauces, this may be considered, when it occurs in such cases, as an auspicious circumstance. Much stress was laid upon this as a prognostic symptom by the late Dr. Joseph Parrish, of Philadelphia. Sometimes the fur recurs once and again, before it ultimately disappears; and weeks and even months are occasionally consumed, in the struggling and apparently uncertain advance of the system towards health. In less fa- vourable cases, the tongue, after having commenced the process of cleaning, as just described, or even after completing it, instead of continuing moist, becomes as dry as a chip, with an aggravation of all the symptoms, and no little increase of danger. The indication is still more unfavourable, when, in addition to its dryness, the surface becomes gashed, chapped, or fissured, or exhibits a rough, scaly appearance. This smooth, red, and glossy state ofthe tongue, sometimes with moisture and sometimes with dryness, is not uncommon in chronic diseases, in which it is generally a bad sign, being supposed to indicate serious derangement of the alimentary mucous membrane. Still worse, however, is a condition resembling thrush (see Stomatitis), which is apt to come on in the advanced stages of chronic diseases, and is generally to be received, under these cir- cumstances, as a fatal sign, though of itself, and occurring in ordinary health, it is in no degree alarming. A loss or depravation of taste is not uncommon, and is generally of little consequence, depending upon a mere derangement of the surface which re- ceives the gustatory impressions. But, when of a paralytic nature, it is much more serious, as it generally indicates disease within the encephalon. The only other point requiring consideration refers to the movements of the tongue. When, in acute febrile diseases, these are not under the control of the patient; when, upon being requested to protrude the tongue, he is unable to do so, or the organ trembles much in the attempt, the symptom is exceedingly unfavourable, indicating either great prostration, or dangerous cerebral disease. Of similar unfavourable prognostication, under the same circumstances, is the occurrence of a difficult and hesitating utterance, like stammering. The inclination of the tongue towards one side, when pro- truded, usually indicates palsy, and is a common attendant upon hemiplegia. Deglutition.—This is occasionally difficult, or impossible. The causes are, 1. inability of the muscles concerned in the process to contract properly, either 182 GENERAL PATHOLOGY. [PART I. from a general prostration or derangement of the nervous power, or from spasm, paralysis, or inflammation ofthe muscles themselves or the neighbouring parts; 2. contraction of the passage by stricture, or tumours compressing it from without; 3. too great bulk in the body to be swallowed; and 4. disease of the larynx, preventing an accurate closure of the glottis, and consequently admitting the food or drink to enter that aperture upon every attempt to swallow, as when the epiglottis is ulcerated, or swollen and stiffened by in- flammation. From this view of the causes of difficult deglutition, it is ob- vious that the symptom is of considerable importance, and that care is requisite not to misinterpret it. When the consequence of pure functional nervous disorder, as sometimes happens in hysteria, it is of little account; but, when arising from the other causes mentioned, it often affords just ground for great solicitude. Appetite and Desire for Drink.—The appetite for food may become ex- cessive, deficient, or depraved. The temporary loss of it is one of the most common results of disease, especially of fever, and its return one of the surest evidences of convalescence. So much is this the case, that hunger, during the existence of fever, is considered a bad sign, indicating great derangement of the nervous system. It does not necessarily follow, from the loss of appe- tite, that the stomach must be diseased. The sense of hunger, though referred to the stomach, and often undoubtedly originating in that organ, is probably, in general, the result of impressions conveyed to the sensorium from all parts of the system, and arising from the consumption of the organized tissues everywhere, in the performance of the various vital functions. In disease, these processes may cease, and the sense of hunger must cease along with them. Food would, under these circumstances, burthen the system, and is, therefore, not called for. This is one and probably the most frequent cause of loss of appetite. It may result also from derangement of stomach, without any disease whatever elsewhere. Excess of appetite, or boulimia, as the affection is technically denominated, is much less common than its deficiency. It may arise from a certain amount of irritation of stomach, from excessive consumption of the living tissues or of the blood, or from mere nervous de- rangement. Hence its occurrence in some cases of dyspepsia, in diabetes, and hysteria. Depraved appetite, or a desire for substances ordinarily dis- gusting, or wholly unfit for nutrition, is an occasional result of gastric dis- ease, or of affections in which the nerves are deranged, as in hysteria or pregnancy. It is, however, a rare symptom. The desire for drink is morbidly excessive, even more frequently than the opposite state of the appetite for food. It is, moreover, very often in excess in those very cases in which the desire for food is lost, as in febrile diseases generally. But thirst may arise from two very opposite conditions, which it is important not to confound ; one, a condition of excitement, and the other of depression. Like hunger, the sensation of thirst probably arises from im- pressions transmitted to the sensorium from all parts of the frame, wherever the blood circulates. That it is referred to the fauces, is no proof whatever that it originates there exclusively. Whenever the blood is in a state re- quiring dilution, an impression is received from it by all the tissues which it supplies, which impression, conveyed by the nerves to the lira in, occasions the feeling of thirst. Hence, this sensation is experienced when the blood is hot and stimulating, as in fevers and inflammations; and when it has be- come too much diminished by hemorrhage, or by excessive secretion or exha- lation, as in cholera, colliquative sweats, diabetes, &c. Every one is familiar with the thirst of fever. That of the opposite condition of exhaustion is no less urgent. It is highly important that the distinction should be borne in mind; and that the mere existence of thirst should never be considered as a CHAP. III.] SYMPTOMS OF DISEASE.--DEFECATION. 183 sufficient evidence of sanguineous congestion or excitement. Extreme thirst sometimes attends the lowest states of prostration in malignant diseases. The most pressing want, in some cases of this kind, is of cold water. This has been considered as a sign that the blood is congested in the interior organs, and that depletion is requisite. It is, in fact, only a sign that the capillaries are everywhere nearly empty, and are making an urgent call, through the sensorium, for liquid to fill them. Every one is familiar with the excessive thirst of the wounded, under great loss of blood. Nausea and Vomiting.—These, together with various other derangements of stomach, will receive special notice hereafter. Reference is here made to them only to observe that, when nausea and vomiting are very obstinate, without any obvious cause, without, for example, any apparent disease of the stomach or other abdominal viscus, and without spinal tenderness, there is reason to fear that either an eruptive affection is maturing itself, or that the brain is diseased. Defecation.—In relation to the symptoms afforded by this process, it is only necessary here to allude to their great importance, and to urge upon the student the necessity of attending to them. This is the more necessary, as they are often overlooked. The patient states that his bowels are regular, and the physician is satisfied with the information. But it very often hap- pens that a most erroneous impression is conveyed. The patient, it is true, may have had an evacuation daily; but it may have been scanty, and quite insufficient to prevent large fecal accumulation. Instances even occur, in which there is apparent diarrhoea, but real and dangerous constipation. The physician, therefore, should always assure himself of the true state of the case. But the existence or non-existence of constipation is not all that is to be attended to. The colour of the stools, their consistence, and nature, are often most important guides to the discovery of disease. The habit, there- fore, of inspecting the evacuations of the sick, however disagreeable it may be, is indispensable to a proper performance of the duties of the physician. A false delicacy may, under other circumstances, lead only to inconvenience; in our profession, it is but too frequently fatal. 2. Symptoms belonging to the Respiratory Function.—The absorb- ent system offers no symptoms which merit notice in this place. The same, however, cannot be said of the respiratory system. The symptoms presented by the latter are of the highest importance, as signs not only of disease of the lungs, but of various other organs, and even of the system generally. Thus, respiration may be abnormally frequent or slow, rapid or prolonged, forcible or feeble; it may be irregular, wheezing, stertorous, spasmodic, or convulsive ; it may also be peculiar in the association or suc- cession of its movements, or by attendant phenomena, as in sneezing, cough- ing, laughing, crying, sobbing, sighing, yawning, and hiccough. The tem- perature and odour of the expired air may become signs of disease. The breath is hot in fevers, and cool in certain diseases of great prostration, as in the collapse of cholera, and the last stage of malignant typhus. A sour smell of the breath indicates acid in the circulation; an offensive smell, either gangrene of the lungs, a diseased state of the blood, mercurial action, or local disease in the mouth, fauces, or nostrils. By its peculiar odour, poison- ous substances which have been swallowed, can sometimes be detected, as alcohol, and prussic acid. The matter of expectoration affords other and most valuable signs. The various physical signs made evident by measure- ment, percussion, auscultation, kc, are of incalculable importance. Most of these, however, will be sufficiently considered under diseases of the respi- ratory organs. At present I shall only offer some observations upon dyspnoea and cough. 184 GENERAL PATHOLOGY. [PART I. Dyspnoea.—This literally signifies difficult breathing. The term may be so extended as to embrace all cases of increased frequency or force of respira- tion, attended with obvious effort, and all others in which the sensations of the patient are painful, whether there be augmented movement or not. A patient may be unconscious of a disturbance which is very obvious to others, and very painfully conscious of a difficulty wliich others do not see. The affection, in both cases, is here ranked with dyspnoea. It is a very frequent symptom, dependent on very different pathological conditions, and offering the most opposite practical indications. In all its varieties, however, there must be one thing constant; and that is, an impression of a peculiar kind upon the nervous centre which presides over respiration. This may be trans- mitted to the centre from the various parts interested in the results of the function, or it may be the consequence of disordered action originating in the centre itself. In its higher grades, it constitutes or rather occasions, the sensation of want of breath; and, in all cases in which the efferent nerves are not defective, or the respiratory muscles paralyzed, it gives rise to movements more or less excited of the organs of breathing. The remote cause of dys- pnoea is usually a want of the due arterialization of the blood. From all parts of the system where this want is experienced, and especially, it is probable, from the pulmonary air-cells and bronchia, there goes up, through the affe- rent nerves, to the medulla oblongata, an impression, which occasions the feeling of want of breath, and causes to be transmitted from that centre, through the efferent nerves, a motor impulse to the respiratory muscles. According to the degree of the want, is the strength of the sensation, and the energy of the consequent movements. In bad cases, the distress of the patient for want of breath is extreme; he gasps for air, his chest heaves laboriously, he is compelled to maintain the erect position, he cannot bear the windows or doors shut even in cold weather, and sometimes leans out of a window, as if in search of breath. The necessity of maintaining the erect position, called orthopnoea, is owing to the greater freedom in the expansion of the chest in this position, and the relief it affords from the pressure of the abdominal viscera, in the horizontal posture, upon the diaphragm. In the mildest cases, there may be only a slight feeling of uneasiness, or no uneasi- ness at all; and the only apparent morbid result is an increase in the fre- quency of respiration, of which the patient himself may not be sensible. Between these two extremes there is every grade. Should the efferent nerves, or the muscles of respiration be paralyzed, then the patient may experience the greatest conceivable anxiety and oppression, amounting to a sense of suffocation, without any or with little violence of respiratory movement. Again, should the nervous centre lose its suscepti- bility under the influence of badly aerated blood, as not unfrequently happens, there may be neither sensation nor increased movement; and asphyxia, or a state approaching to it, is produced. It may happen, moreover, that irrita- tion may exist in the nervous centre, independently of any deficiency in the aeration of the blood, as in nervous disease, and especially in hysteria; and this irritation, transmitted to the muscles of the chest, may produce hurried breathing or dyspnoea. The circumstances under which the main condition requisite to dyspnoea, the want of due aeration of the blood, may occur, are very diversified. Thus, the blood may be in a state of disorganization from malignant disease, in which it is unable to undergo the requisite changes in Hie lungs; though, in such cases, the nervous centre is also apt to become unimpressible, and respi- ration languishes or ceases, instead of being excited. Another condition is that in which the blood, from various causes, becomes congested in the pul- monary capillaries, so as to impede the entrance of air into the cells, and at CnAP. III.] SYMPTOMS OF DISEASE.—COUGH. 185 the same time retard the pulmonary circulation. A third condition is afford- ed by different diseases of the lungs, which produce consolidation, compres- sion, or destruction of the pulmonary tissue, or fill the cells with liquid, so as to exclude the air. Inflammation of the lungs, bronchitis, pulmonary hemorrhage, pleuritic effusion, dropsy of the chest and pericardium, tumours of all kinds within the chest, pulmonary consumption, &c, operate, in ex- cluding the air from portions of the lungs, in one of the modes just men- tioned. The portion to wliich the air has access is insufficient properly to arterialize the blood; the condition requisite to dyspnoea is produced ; and respiration is augmented, in order that the sound portion of the lungs may, by performing additional duty, counterbalance the loss of function in the diseased part. A fourth condition consists in the constricting of the air passages by spasm, tumours, kc, so as to impede the free access of air to the cells. An example of this is presented in spasmodic asthma. A fifth condition is that of disease of certain muscles of respiration, either paralytic, rheumatic, or inflammatory, in which they become unable to contract, and thus throw their duty upon the other muscles, which are stimulated to ex- cessive action. Thus, when the diaphragm cannot descend, the ribs move much more in respiration than under ordinary circumstances. Lastly, the fault may be in the air, which may be too much rarefied, or its place supplied by irrespirable gases, so that the blood cannot become duly aerated. From this sketch it will be seen, how various are the circumstances under which dyspnoea may be produced, and yet how important to discriminate between them, as they often require peculiar plans of management. It is usually severest in acute diseases, in which the cause is sudden, and the sensibility of the nervous respiratory centres is yet unimpaired.* Cough.—This is the sound produced by a sudden and forcible expiration, preceded by a temporary closure or resistance ofthe rima glottidis, in order to give additional impulse to the current of air. It is generally succeeded by a fuller than ordinary inspiration, in consequence of the exhaustion of the air in the lungs by the previous act. Occasionally, the rima glottidis is made tense during the inspiration, in which case, this also is attended with sound, as in hooping-cough. Cough, like dyspnoea, depends upon an impression * To judge correctly as to the increased frequency of respiration in any case, it is necessary that there should be some standard of normal frequency with which to make comparison. According to the best authorities, the number of respirations in a minute, in the healthy adult, at rest, is from 15 to 20. M. Marce, upon an examination of Go adult individuals, of whom 41 were men and 24 women, found the average number to be for the males 19, for the females 23, and for both sexes jointly 20. The examination was made in the morning before breakfast, the individuals lying on their backs. (Arch. Gen. Juillet, 1855. The frequency is greater in childhood, and is increased by what- ever accelerates the circulation, without any necessary departure from health. Chomel states the number in the new-born infant at 35. There is a remarkable constancy in the relation between the frequency of the respira- tions and of the pulse. According to Dr. Hooker the relation is about 1 of the former to about 4i of the latter; and any considerable deviation from this proportion may be considered as an evidence of disease. M. Marce, after numerous experiments, has come to a somewhat different conclusion. He has found that the proportionate numbers in the healthy adult, at the normal standard, of both processes, are 1 to 3}; but that this proportion varies somewhat with circumstances; the number of respirations neither increasing nor diminishing in an equal ratio to that of the pulse, when from any cause accelerated or retarded. He also found that, in old age, the frequency of respiration diminishes, even when the pulse remains at the normal standard of the adult. Another interesting deduction from his experiments was that, in disease, the only condition which increases the normal proportion of respirations is pain of the walls of the chest, as in pleurisy, rheumatism of the intercostals, and neuralgia; and the only conditions capable of reducing this proportion are comatose affections, and sudden and large losses of blood. See Archives Generates, Juillet, 185S, pp. SI and 87.) 186 GENERAL PATHOLOGY. [PART I. received by the nervous centre, producing a sensation of tickling, pressure, fulness, or other uneasiness in the respiratory passages, especially the larynx and trachea, which then causes the transmission of motor influence from the centre to the muscles concerned. The object aimed at is obviously the removal of matters in the air-tubes, wliich might interfere with respiration. The source of the impression made upon the sensorium is various. Most frequently it is some irritation of the respiratory mucous membrane, either consequent upon the presence of foreign bodies, such as dust, acrid vapours, &c, admitted with the air, upon certain qualities of the air itself, as coldness and dampness, which operate by reaction, or upon substances extravasated into the passages, as mucus, pus, blood, &c. Inflammation, from whatever cause, acts as a source of uneasiness, both by producing effusion, and by exalting the sensibility of the membrane, whereby the ordinary healthful stimuli are converted into irritants; the air itself being sometimes sufficient, under these circumstances, to excite cough. Certain parts of the air-tubes are much more susceptible to this irritation than others. The glottis is espe- cially sensitive, with the purpose, no doubt, of guarding the entrance of the tube against injurious agents. Another source of the sensorial impression above alluded to, is some disturbance conducted by the afferent nerves of respiration, from parts not directly connected with the air-tubes, as the pa- renchyma of the lungs, the pleurae, the pericardium, the stomach, the liver, the bowels, the peritoneum, &c. It is probably through branches of the par vaguin, directly or indirectly, that impressions from these sources are conveyed to the medulla oblongata, and the brain. A third source of the impression is some unappreciable change in the nervous centre, or the respiratory nerves entering it, such as occurs in hysteria, and sometimes in gouty or rheumatic individuals, producing nervous and spasmodic coughs, without any apparent disease of the thoracic or abdominal viscera. There is great diversity in the character of the cough, which has received names corresponding with its peculiarities. Thus, we have the dry cough without, and the moist cough with expectoration; the short, hacking cough, resulting from slight irritation, and the violent, spasmodic, and convulsive cough, from high degrees, or peculiar modifications of the same cause; the occasional, the incessant, and the paroxysmal cough, from the mode of recur- rence ; the hoarse, wheezing, barking, and shrill coughs, from modifications in the tension or capacity of the rima glottidis, or other portion of the respi- ratory tube; the hollow cough, from its resonance in the enlarged bronchia, or pulmonary excavations; and, finally, the laryngeal or guttural, the pec- toral, the hepatic, the stomachic, the verminous, kc, according to the part from which it may be supposed to proceed, or the cause producing it. Expectoration.—Expectoration is the act of discharging the secretions or fluids of the air-passages. This is usually effected by coughing. Sometimes, however, when the matter in the bronchia is very copious, it is thrown off in a full stream, by a simultaneous contraction of all the muscles of expiration, without any resistance whatever at the glottis. The process resembles vomiting, and it is sometimes difficult to determine whether the substances discharged have proceeded from the lungs, or from the stomach. Chomel calls it pectoral vomiting. It is in this manner that blood is sometimes ex- pectorated in violent attacks of haemoptysis. A third mode of expectora- tion is that in which the liquid rises up gradually, and without any effort on the part of the patient, as far as the glottis or fauces, when it is removed by hawking. The matters expectorated are called sputa. These will be treated of under the special diseases in which they are severally met with. 3. Symptoms belonging to the Circulatory Function.__The heart affords by its action, size, or position, numerous signs very important in CHAP. III.] SYMPTOMS OF DISEASE.—THE PULSE. 187 diagnosis. These will be considered when we reach the diseases of that organ. Upon the pulse, it is necessary to make some preliminary observa- tions, as that phenomenon is constantly referred to throughout the work, and should be early understood. The Pulse.—The evidences of the pulse in disease are probably, on the whole, the most important that we can attain; but they are not without their fallacies, and much caution is often necessary to avoid wrong inferences. The pulse, in the ordinary acceptation of the term, is the beating of the arteries. In each pulsation, the vessel is slightly expanded, and sometimes laterally displaced, and then returns to its original size and position, after which there is an interval of rest. The influences concerned in its production and pecu- liarities, are those of the heart, the arteries themselves, and the blood. The heart gives the impulse by which the expanding wave of blood is carried onward; and the vessel contracts, either by its elasticity alone, or by some additional vital force. It is obvious that the frequency of the pulsations, and the regularity or irregularity of their succession, must depend upon the heart. The pulse at the wrist, when it can be felt, always corresponds with the systole of the ventricles, allowance being made for the very slight inter- val that must elapse, before the wave reaches so distant a part. To the heart's action must also be referred most of the other healthy characters of the pulse;" and for the source of its peculiarities in disease, we must look chiefly to the same organ. But the state of the arteries is not without its influence. These vessels are gifted, like all other living and movable tissues, with a certain degree of vital contractility or tone, upon which their healthy firmness depends. Without this tone, they become relaxed and flaccid, yield- ing readily to the expanding force of the blood, and not rapidly recovering their dimensions when the impulse ceases. It is evident that, in this condi- tion of the vessels, that portion of the heart's impulse which is employed in dilating the arteries, is not restored to the blood duly by the contraction of their coats, and is, therefore, partially lost before it reaches the extremities. Hence, the pulse, in such cases, is not a proper measure of the strength of the cardiac contraction. The latter may be strong, while the former is com- paratively weak. Again, an excessive tension of the arterial coats may occasion a resistance to the finger, which might lead to improper inferences as to the force of the heart. Happily, however, there is a general corres- pondence between the arterial and cardiac pulsations, which renders the for- mer, in the great majority of cases, a tolerably correct measure of the latter. The quantity of the blood also has undoubtedly some influence upon the character of the pulse. When it is in excess, the pulse is likely to be fuller than usual, when deficient, smaller. The rule, however, is not absolute. The pulse may be small, even in a plethoric state of the system, if some obstruction to the pulmonary circulation exist, causing congestion in the lungs and venous system, and preventing a due supply to the left ventricle. It is hardly pro- bable that difference in the quality of the blood can act upon the pulse in any other way, than as it may affect the condition of the heart or the vascu- lar coats. After this view of the causes of the pulse, it will be proper to give an account of its qualities. These may be included under the heads of frequency, quickness, mutual relation of the pulsations, volume, tension, strength, and subordinate movements. Frequency of the pulse has relation to the number of pulsations in a given time. This varies considerably within the limits of health. It differs greatly with the age. The following has been generally considered about the ave- rage frequency in health, at different ages: viz. from 130 to 140 in a minute soon after birth, 100 to 120 in the second year, 90 in the eighth year, 80 at puberty, 65 to 15 in persons of middle age, and 55 to 65 in the old. But 188 GENERAL PATHOLOGY. [PART I. the numbers are given very differently by authors; and the most opposite assertions have been made upon the subject. Thus, according to M. Billard, the pulse of new-born infants is often as slow as that of adults; and MM. Leuret and Mitivie state, as the result of numerous observations, that the pulse of the old is more frequent than that of the young; the mean for the former being 73, and for the latter 65. Dr. Pennock, of Philadelphia, found the average pulse in 170 men, of the mean age of 64 09 years, to be 71'83 in the minute; and in 203 women, ofthe mean age of 7057 years, to be 7802. (Am. Journ. of Med. Sci, N. S., xiv. 70.) Perhaps the pulse of the old has hitherto been thought slower than it really is; but, judging from my own observations, I am inclined to believe that the statement first made, with some allowance for too low an estimate in this respect, is not far from the truth; the individual being supposed to be sitting, wben his pulse is counted. It is certain, however, that very many exceptions will be found; for there are few points in wrhich men differ more, physiologically, than in the frequency of the pulse. Thus, young persons are occasionally met with having a pulse below 60; while in old men it is sometimes above 80; and constitutional idiosyncrasies have occurred, in which it has habitually ex- ceeded 100, or fallen short of 30 or 40, without apparent disease. Sex influences the frequency of the pulse. In women it is said to be ten beats in the minute more frequent than in men. There is certainly some difference; but this, I think, is beyond the reality. Temperament is not with- out effect. The pulse is usually more frequent in the nervous and sanguine, than in the bilious and phlegmatic. It is often more so in thin than in fat persons, and, as it is said, in those under, than in those over the middle size. The frequency is usually greater in the morning than in the evening, after a full meal than before it, in the standing than in the sitting posture, and in the sitting than the lying. Exercise and mental excitement generally in- crease it, and in some persons greatly. The effect of posture referred to may be resolved into that of muscular exertion. Dr. R. B. Todd has ob- served that, in some instances of great debility of the heart, the rule of in- creased frequency in the erect position does not hold, and may even be re- versed. (Lond. Med. Gaz., March, 1851, p. 397.) In the inverted posture of the body, the frequency is diminished, probably from pressure on the brain. During sleep, the pulse is usually considerably slower than in the waking state. In health, whatever exercise of function calls for a consumption of blood, tends, when increased, to excite the heart, and consequently the pulse. In all diseases of excitement, the tendency is to an increased frequency of pulse; but the converse of the proposition is not equally true. In diseases of depression and debility, the pulse is sometimes slower than natural; but very often it is more frequent. This generally arises from the co-existence of some source of irritation. Indeed, it often happens that debility is one cause of extreme frequency of pulse. A certain supply of blood is demanded by the functions, and the heart, being too feeble to act forcibly, is driven to excessive frequency of contraction in order to compensate for its want of strength. It is obvious that an irritant, under these circumstances, must be felt more in the increased frequency, than the increased strength, of the pulse. Even profuse hemorrhage, and exhausting secretions, are often attended with frequency of pulse, especially upon the occasion of any muscular or mental effort. Slowness of pulse is the general result of depressing causes, so long as no source of excitation exists in the system. Even with such a source, it will sometimes occur when the susceptibility ofthe heart has become exhausted; as towards the close of a fatal affection, and when the nervous centres, which are the medium through which stimulation reaches the heart, become iusen- sible by disease, as in cerebritis and apoplexy. CnAP. III.] SYMPTOMS OF DISEASE.—THE PULSE. 189 It follows, from what has been said above, that little satisfactory inference can be drawn, as to the state of the system, from the mere frequency or slow- ness of the pulse, unconnected with its other qualities. It may, however, be admitted as generally true, that extreme frequency indicates irritation com- bined with debility. Quickness of pulse is different from frequency. The latter has reference to the succession of the pulsations, the former to each one separately. A frequent pulse is one in which the number of beats is greater than usual in a given time; a quick pulse, one in which each beat occupies less than the usual time, though the whole number may not be increased. This quality of the pulse is owing to the mode in which the ventricle contracts, and almost always indicates irritation with little strength. The heart makes a quick, short, angry contraction, differing much from the somewhat prolonged and forcible contraction of real energy under excitement. The former is usually a sign of nervous disorder, the latter often of inflammation. The jerking pulse is a modification of that now under consideration. It is characterized by a quick, rather forcible beat, followed by an abrupt cessation, as if the direction of the current had suddenly changed. Dr. Hope considers this pulse as evincing deficiency of the aortic valves, and consequent regurgitation. Something like it may sometimes be observed in nervous affections. The mutual relation of the pulsations may refer to their succession, their comparative duration, or their strength. In all these respects, the pulse is often irregular. It need scarcely be stated that the source of the irregularity is almost invariably in the heart. Occasionally, a pulsation is altogether omitted. This constitutes intermission of the pulse. The intermission may be regular, that is, may occur uniformly at the end of a certain number of pulsations; but much more frequently, it is irregular. But every intermis- sion of the pulse at the wrist does not necessarily imply an intermission of the heart's action; for this may recur regularly, yet at times may be so feeble, that the impulse does not reach the extremities. Hence, intermissions of the pulse are sometimes observed, when the pulsations are regular over the heart. But very frequently, along with intermissions of the pulse, there is irregularity in other respects. Several beats may occur rapidly in succes- sion, and then be followed by others at longer intervals; and these alterna- tions are themselves frequently altogether irregular. A want of uniformity in the strength and duration of the several pulsations is also not unfrequent. One may be strong and another feeble, one quick, another prolonged; and often several run on successively of one character, to be followed by one or more of the other. Sometimes all the irregularities mentioned, or most of them, occur in the same pulse, which may then be called hobbling. Another, but comparatively rare incident, is the interpolation of an additional pulsation between two others, which occur at the regular interval. The affections of the pulse above described are very common in diseases of the heart, and, though they often indicate nothing more than functional or mere nervous disorder of that organ, yet, when constant or very frequent, arc sufficient to justify suspicion of something worse, and should lead to a close examination. Irregularity of pulse is sometimes observed in perfectly healthy individuals, who live to old age without any resulting inconvenience. This is especially the case with mere intermission, which is not uncommon in the old. Habitual intermissions ofthe pulse, in elderly people, sometimes disappear during acute disease, and return when the disease is passed. The volume of the pulse may be greater than usual, in which case it is said to be full, or it may be less than usual, when it is said to be small or contracted. Fulness of the pulse may depend on general plethora, on a pro- longed and forcible contraction of the ventricle, to a certain extent on re- 190 GENERAL PATHOLOGY. [PART I. laxation of the arterial coats, and on obstruction in the capillaries, without diminished power of the heart. It may be associated with strength, or with feebleness of pulsation. In the latter case, the pulse readily yields to the finger, and, in its extreme of debility, is sometimes called a gaseous pulse. It is not unfrequent in cases of watery or impoverished blood. A small pulse may result from general deficiency of blood, from congestion in the venous system or larger interior organs, from feeble action of the heart, from great tonicity of the arterial coats, or from certain constringing agents, as cold and astringents. When very small, it is sometimes said to be thread- like. It may be associated, like fulness, with firmness or weakness. In the former case, the pulse is said to be corded. It often depends on the frequency of the heart's action, whether the pulse shall be large or small. Supposing the amount of blood circulated to be the same, the pulse will generally be small in proportion to its rapidity, and large in proportion to its slowness. Tension is that property of the pulse by which it resists compression. It may be considered as generally synonymous with hardness. There is one condition, however, in which the pulse may be hard without being tense. I allude to instances in which the coats of the artery have become cartilaginous, or ossified. This often happens in the old, and the practitioner must be on his guard not to draw false inferences from it. True tension of the pulse requires a union of considerable strength of action in the heart with tonic contraction of the vascular coats. When very tense, and at the same time small, the pulse is sometimes called wiry. Softness of the pulse is synony- mous with compressibility. It is usually indicative of general weakness, and, when connected with smallness, is often a sign of great prostration. The strength of the pulse depends chiefly upon the force with which the ventricle contracts, but in some measure also upon the tonicity of the artery itself, and the volume of the blood. Into the idea of a strong pulse enter not only vigour of impulse, but a steady resistance to pressure, and a certain degree of fulness. We may have a sharp, forcible beat; but, if not sus- tained by a certain amount of subsequent firmness, we should consider the pulse as indicating rather irritation than real energy. A very contracted pulse, however tense, and however sharp the impulse, can scarcely be called a strong one. Force or momentum is, in the body as well as out of it, the product of velocity and mass. The more voluminous the pulse, the velocity being the same, the greater is its strength. Here then is a combination of all those conditions which indicate a general elevation of vital powers and actions; force in the heart's contractions, a high degree of general tonicity, and a large amount of blood. Hence, a strong pulse is rightly considered as a sign of a sthenic, or vigorous state of system. But it is not invariably so. Hypertrophy of the left ventricle may give strength to the pulse, even though the general powers may be failing. In some persons affected with that disease, the pulse remains strong almost to the very close of life. It is highly important, in judging of the condition of the system from the pulse, to bear in mind this effect of hypertrophy. Weakness is of course the oppo- site of strength of pulse. In this, the impulse is feeble, the tension is slight, and the volume often small. But, in cases of superabundance of an impover- ished blood, or very slow action of the heart, or great relaxation of the arteries, or of all these conditions combined, there may be a full, and at the same time, a feeble pulse. It is important not to confound this character with strength. The feeble pulse may be distinguished by the weakness of the impulse, and by readily yielding to slight pressure. As strength of pulse generally indicates vigour of system, so weakness indicates debility. But, as in the former case, so in this, there are exceptions to the general rule. The heart may from particular causes act feebly, while the energies of the CHAP. III.] SYMPTOMS OF DISEASE.—THE PULSE. 191 system at large are unimpaired. Thus, violent pulmonary congestion, of an active character, may so far impede the passage of blood through the lungs that it cannot reach the heart in due quantity, and the pulse will be neces- sarily feeble. A mistake, in such a case, might be fatal. Inflammation, even of a vigorous character, in the nervous centres which more immediately influence the heart's actions, may so far reduce them as to give weakness to the pulse, and a semblance of weakness to the system. Inflammation of the substance of the heart may have the same effect. Excessive and continued nausea may, for a time, prostrate the circulatory forces; as in severe in- flammation of the stomach or peritoneum. These are examples of depres- sion, but not of debility; depletion may be demanded instead of stimulation; and it is highly important that the young physician should enter upon the practice of his profession, properly guarded upon this point. By the subordinate movements of the pulse, I mean modifications of the regular impulse, other than mere differences in force or duration. Besides the steady, onward motion of the volume of blood, there are often subordinate currents within the stream, which make themselves sensible by communica- ting a vibratory thrill to the coats. Hence the thrilling pulse of aneurism, diseased heart, and anaemia. The cause of this, as well as its indications, will be explained elsewhere. The trembling pulse is another modification. It probably depends upon successive efforts of the heart, in accomplishing one systole, and would indicate debility of the organ. The rebounding p>ulse, on the contrary, may be the result of an excess of energy, inducing a second and subordinate contraction of the ventricle, by which it may be more completely emptied than by the regular systole alone. Some practical rules will close these remarks on the pulse. The physician should always bear in mind the possible individual varieties of the pulse, and make due allowances. Thus, in some persons the arteries are large, in others small; in some thin and distensible, in others thick and rigid; in some again superficial, in others, deep-seated. All these peculiarities have a decided influence on the apparent character of the pulse. Occasionally the arteries deviate from the usual course. This is not unfrequently the case with the radial artery near the wrist, where the pulse is usually examined. Instead of retaining its ordinary position in front of the wrist, it winds, in these cases, round upon the back; and there might sometimes be danger of supposing the patient to be pulseless. A still more probable source of error, is in those cases in which the artery winds around to the back of the wrist, but sends onward a very small branch, which occupies the ordinary position of the main vessel. I have known the pulse, under such circumstances, to be considered as evincing great debility. Great caution should be observed, while examining the pulse of nervous, excitable, or timid persons, to do so quietly and without any display of hurry or eagerness. In individuals of this character, the heart is often excited to increased frequency of action by the slightest causes, and it is impossible, under such circumstances, to draw any correct inferences from the pulse. It is usually best to wait until the first agitation occasioned by the visit has subsided, before attempting to examine the pulse; and the physician may often very advantageously engage his patient in conversation, so as to divert the attention away from disturbing subjects of thought. The pulse cannot be relied on immediately after bodily exercise, or mental emotion of any kind. The patient should generally be in the sitting or lying position. It is best always, in a new ease, to examine both wrists; as the artery of one side is sometimes larger than that of the other. Care should be taken that there be no pressure upon the artery in its course, as by the clothes in the axilla, by very tight sleeves, by tumours, &c. It is usually advisable to 192 GENERAL PATHOLOGY. [PART I. apply three or four fingers at once to the artery; as the larger the surface of contact, the more accurate is the impression received. The fingers should alternately press upon the artery, and relax the pressure so as to appreciate its degree of resistance. Where great accuracy is required, it is best to count by a watch; and the physician will save time, and secure greater pre- cision, by using an instrument with a second hand that makes four circuits in a minute. The pulse should generally be felt more than once at each visit The physician thus becomes acquainted with its diversities, and will often have occasion to correct, if not reverse, upon the second examination, the conclusions he may have formed from the first. When the pulsations are excessively rapid, exceeding, for instance, 150 or 160, so as with difficulty to be enumerated, it may be proper, as suggested by Chomel, to count only as high as ten, and then to go over the same ground again, instead of advancing into the higher numbers, the longer names of which occupy more time in their mental repetition. Should the pulse at the wrist, from any cause, not answer the desired purpose, it may be examined in the arm, in the neck, or at the temples. By examining the pulse while the arm is much elevated, some inference may be drawn as to the strength of the heart's contractions, which must be very great to overcome the effect of gravitation, and sustain a full strong pulse at the wrist. State of the Capillaries.'—The state of the capillary circulation cannot always be correctly inferred from that of the circulation generally, and some- times requires a distinct examination. By pressing the finger upon the skin, and observing the rapidity with which the blood returns into the whitened spot, we may ascertain the rate of the current through the capillaries. The colour also has much value as a symptom. When these vessels are sluggish, the skin is apt to assume a dark-red or purplish hue, which is sometimes very striking, and, when not dependent on the general condition of the blood, may be regarded, in connection with the sign before mentioned, as a mark of debility. A florid colour, on the contrary, with a rapid movement of the blood, may be considered as an evidence of active excitement in these vessels, These signs are sometimes of considerable significance in cutaneous affections. It is occasionally important to be able to decide, whether redness upon the surface is the result of extravasation of blood, or simply of capillary injection. The test of pressure will generally determine this point. If the redness re- main unaffected by the pressure, while the circulation is going on elsewhere, it may be referred to extravasation. Venous Symptoms.—The only sign connected with the veins, requiring notice here, is the occasional occurrence of a venous pulse. This sometimes results from a continuation of the heart's impulse through the capillaries, and may generally, in this case, be considered as an evidence of high excitement of the circulation. In other instances, it is owing to a retrograde current, produced by the contraction of the right ventricle, and indicates an inaccurate closure of the tricuspid valve. This venous pulse is felt especially in the jugular. State of the Blood.—This should always be examined when blood is drawn. From the characters which it offers to the eye, or to chemical or microscopical examination, important inferences may often be deduced as to the nature of the disease, and the previous diagnosis confirmed or corrected. Occasionally, too, affections which had before been lurking unseen are thus clearly revealed. The morbid states of the blood, however, and their indications, are detailed elsewhere. The manner in wliich the blood issues from the opening is not without some value as a sign. An unusually forcible jet, and rapidity of flow, are evidences of energy in the circulatory movement; while the contrary in- ference may be drawn from an escape of the blood, drop by drop, when the opening into the vein is free, and there is no reason to suppose that any merely CHAP. III.] SYMPTOMS OF DISEASE.—THE PULSE. 193 temporary interference with the action of the heart may be the cause of the phenomenon. In the latter case, it not unfrequently happens that the current gradually increases, and at last flows as vigorously as under ordinary circum- stances. The symptoms presented by the blood must be observed incident- ally ; for it can seldom be proper to bleed for this purpose alone. 4. Symptoms belonging to the Functions of Nutrition and Secre- tion.—In relation to the symptoms connected with the former function, all that is necessary will be stated under special diseases. The most prominent of them are emaciation, softness and flaccidity of the tissues, and atrophy, indicating a deficiency of the process; obesity and hypertrophy, indicating its excess, and various organic changes of tissue, indicating its perversion. The symptoms afforded by the secretions are often of the greatest importance, and should always be most carefully investigated. They consist in an increase, diminution, or perversion of the function. Sometimes there is a general defi- ciency of all the secretions, as in certain cases of fever; but a general increase is scarcely possible. Much more frequently, the deficiency, as well as the in- crease, is confined to one or a few organs. When the increase is so great as to be exhausting, the affection is called colliquative. Thus, we say, colliquative sweats, colliquative diarrhoea, and colliquative diuresis. In perversion of the secretory function, the products are sometimes wholly different in character from those in health; being not unfrequently excessively irritant instead of bland, and sometimes yielding evidence to chemical reagents of the presence of new constituents. In some instances, one secretory organ seems to perform the office of another; as where the colouring matter of bile is thrown out by the kidneys, when the liver ceases to secrete. The individual secretions which most require attention are those of the liver, the kidneys, and the skin. The symptoms connected with disordered hepatic secretion are exhibited chiefly in the stools, which are deep-yellow, or clay-coloured, or dark, according as the secretion is too copious, deficient, or deranged. Those connected with the kidneys are seen in the excess, the diminution or suppression, and the altera- tion of the urine, which presents a great diversity of quality and composition, indicative of peculiar and very serious diseases. Independently of its variation in quantity, the perspiration sometimes affords valuable signs by its quality, as when, by its sour smell, it indicates an excess of acid in the circulation, and by its offensiveness, an unhealthy state of the blood. All these symptoms, however, are fully noticed in connection with the diseases they represent; and they are referred to here, only that the student may be impressed with the importance of making a close examination of them, in all serious cases. 5. Symptoms belonging to the Calorific Function.—Though the human system is capable of supporting great extremes of temperature, for a short time, with impunity, yet that of the body itself is never very greatly above or below the mean standard of health, until vitality has ceased, or has been so far reduced, as to have surrendered the body, in great measure, to the action of physical and chemical laws. The mean temperature of the body is about 100° F. Dr. Davy found the greatest deviation from this standard, in the cases of 114 individuals whom he examined, to be in the downward di- rection 96^°, and in the upward 102°. The temperature of the blood in the heart, as determined by M. CI. Bernard, in the dog, is somewhat higher dur- ing digestion than abstinence ; and the same is probably the case with man. (Arch. Gen,, Nov. 1856, p. 626.) In disease, especially in fevers, the heat of the body not unfrequently rises to 106°, and sometimes, as found by Dr. Ben- net Dowlcr in yellow fever, to 109°, and in a case of tetanus, mentioned by Dr. Edwards, 110^°; while in cholera it has been reduced to 66° in some rare cases, and 20° below the average has not been uncommon. It must be recol- lected, however, in estimating the temperature in disease, that in health it is vol. i. 13 194 GENERAL PATHOLOGY. [PART I. higher in the young and vigorous than in the old, in the waking than in the sleeping state, near the heart than at the extremities, within the body than upon the surface, and that it may be increased by active muscular exertion, and ex- posure to a high temperature. To determine accurately the heat of the body, it is necessary to employ the thermometer, the bulb of which should be placed under the tongue; but for ordinary purposes the hand is sufficient. It must be borne in mind that the temperature of the body, and the sensa- tions of heat or cold felt by the patient, are very different things. Generally, they coincide in a greater or less degree ; but not always. Sometimes the patient experiences chilly sensations when his surface feels hot to a bystander, as not unfrequently happens in the earlier stages of fever ; and sometimes, on the other hand, he suffers greatly with a feeling of heat, when the surface of the body is really cold. These deranged seusations must be ascribed to nervous disorder. It is true that the heat, sometimes complained of by patients in malignant diseases when the skin is very cold, has been referred to sanguineous congestion of the internal organs; but the sense of heat is not confined to the interior, in these cases. I have known complaints to be made also of heat of the surface, under the same circumstances. It is, I have no doubt, a perverted sensation, consequent on the derangement of the nervous system, just as light flashes sometimes before the diseased eye in darkness, and roaring sounds are heard in the midst of profound silence. It is, moreover, for the most part, a very unfavourable symptom. The change of temperature may be general or local; and it not unfre- quently happens that one portion of the body is affected in one way, and an- other in another. Thus, the head is often hot, while the extremities are cold. Attempts have been made to designate, by particular names, different modifications of the sensations of heat and cold. Thus, we have the ex- pressions on the one hand of chilliness, coldness, and rigors or shivering; and on the other of warmth, heat, burning, acrid heat, pungent or biting heat (calor mordicans), &c. The shivering, trembling, and shaking which often attend the feeling and reality of cold, sometimes occur as mere nervous phe- nomena, without reference to the existing temperature of the body. 6. Symptoms beloivging to the Sensorial Functions.—These are ex- ceedingly numerous. They embrace all derangements, not only of general and special sensation, as these terms are usually understood, but also of those feelings which proceed from the interior organs and tissues, and by which they make their wants and their sufferings known, such as nausea, hunger, thirst, breathlessness, &c. But these have already been considered, or will be considered hereafter, in connection with the derangements of which they are the expressions. Our attention will at present be confined to the symp- toms afforded by derangements of general sensation, and of the several special senses of sight, hearing, &c. General sensation is deranged in two ways. Either it is, in the first place, defective or altogether wanting, or, secondly, it is disagreeably altered, constituting various kinds of uneasiness, which, for convenience sake, may all be classed together under the head of pain. It is only the latter that requires any general remarks. Bain.—This feeling is quite undefinable, and can be known only by those who have felt it. There can be no doubt that it resides exclusively in the nervous structure. It has various sources. Irritation or excessive excite- ment of the nervous function may produce it, either with or without vascular disease. It is a very frequent attendant upon inflammation, and is ascribed by writers generally to the pressure made upon the nerves in this affection. But, as it very often precedes the inflammation, appearing to be the first obvious step in that process, and as a much greater amount of pressure upon the healthy nerves does not produce it, the probability is, that it is the direct CHAP. III.] SYMPTOMS OF DISEASE.—SENSORIAL FUNCTIONS. 195 result of the irritant cause acting on the nerves. But there appears also to be a modification of the nerves, by which their sensibility is exalted, inde- pendently of any irritant agent, and in which pain is produced by ordinary agents which, in the healthy condition of the nerves, excite no sensation. It is possible, however, that this may be nothing more than an excitement, which, insufficient of itself to occasion uneasiness, may amount to pain when very slightly increased. Still, there are cases, and those by no means unfre- quent, in which pain is attended with no appreciable excitement of any kind, whether nervous or vascular; but, on the contrary, occurs in a state of posi- tive depression and debility, and even seems to be favoured by that state. Thus, a limb benumbed by cold, in which special sensation is almost lost, and vascular action is greatly diminished, often experiences exquisite pain; palsy is not unfrequently attended with the same symptom; and neuralgia is a common result of general debility. It is, therefore, a great error to consider pain as always an evidence of inflammation. It is, indeed, in very many in- stances, most effectually relieved by means calculated most strongly to aggra- vate the latter affection. Nor is inflammation always attended with pain. There is reason to believe that pain is seated in nerves, distinct from those devoted to the special sense of touch. Hence the sensation of pain in parts benumbed by cold ; and hence, too, the complete insensibility to painful impres- sions in some instances of artificial somnambulism, in which the sense of touch, and the other special senses, are acutely alive to impressions. Pain differs exceedingly in its modes of recurrence, degree, and character. Thus, it is fugitive or persistent, wandering or fixed, intermittent, remittent, or continued. In its different grades, it is slight, moderate, severe, violent, intense, excruciating, or agonizing. In character, it is dull or obtuse, sharp or acute, aching, smarting, &c.; and, in its different varieties, has received peculiar names from certain real or supposed analogies, as lancinating, cul- ling, stinging, pungent, boring, tearing or rending, gnawing, &c. When attended with a beating sensation, consequent upon the heart's action, it is called pulsating or throbbing; when with a feeling of tightness, tensive; when with weight, heavy; when with heat, burning. There are also pecu- liar sensations, which, in excess, become positively painful, though they might not be considered so in their slighter degrees. Such are itching, tickling, prickling, tingling, &c. To pain belongs also tenderness, or that property by which a part becomes positively, and sometimes acutely painful, by motion or pressure. Tenderness has been considered as one of the most certain signs of inflammation. But, though it very commonly accompanies that process, it often exists without it. Thus, it is not unfrequent in neuralgia, and generally follows severe spasm, whether of the exterior muscles, or the muscular coat of the stomach and bowels. This fact is of some practical importance ; as the knowledge of it may spare many a patient an unnecessary and perhaps injurious loss of blood. Under pain, finally, we may rank those general and in- definite sensations which are vaguely designated by the terms general uneasi- ness, restlessness or inquietude, anxiety, and oppression ; sensations which in- dicate disorder of the nervous system, and are often useful as signs. It has been stated above that pain is sometimes wandering, and sometimes fixed. Wandering or flying pains are frequently purely nervous or neuralgic, and fixed pains inflammatory; but the distinction is by no means constant. This character, however, may often be employed as a diagnostic symptom. Thus, il may be doubted whether a pain in the side is symptomatic of pleu- ritis or pleurodynia. If fixed, the presumption is that it is the former; if wandering from one point to another, that it is the latter. Pain is different in the different tissues. In the serous and synovial mem- branes, it is often severe, and sharp or acute; in the mucous membranes and 196 GENERAL PATHOLOGY. [PART I. parenchyma of the viscera, dull or obtuse, oppressive, heavy, &c.; in the skin, it is apt to be burning, itching, tingling, &c. It is not always that pain is felt in the spot where the cause of it exists. Thus, in irritation of stomach, it is often referred to the forehead and eyes; in hepatitis, to the shoulder ; in inflamed hip-joint, to the knee; in disorder of a nervous centre, or in the course of the nerve, to the place of distribu- tion ; and in disease of any passage, to its outer extremity, as in the case of stone in the bladder, in which the pain is often felt at the end of the penis. In judging of the degree of pain in any particular case, we must not always be determined by the statements of the patient. Very different meanings are often attached to the same words by different individuals ; and some have the habit of using terms of exaggeration for all their feelings. In such cases, we must be guided more by the expression of the countenance, and the tone of the voice, than by what is said. If a person tell us, with perfectly composed features, and a calm equable tone of voice, that he is suffering excruciating pain, we shall be justified in estimating its severity greatly below the real value of the term. Patients also have very different degrees of sensibility, and feel with differ- ent degrees of acuteness. Some persons are little sensitive to painful impres- sions of any kind, others suffer really and greatly from slight causes. Exter- nal cancer, which, in most individuals, is a source of extreme suffering, appears in some scarcely to produce pain. Special Sensation.—The several senses, sight, hearing, smell, taste, and touch, are liable, like all other functions of the body, to be morbidly exalted, depressed, or perverted. They are very apt to be deranged, not only by direct morbific impressions, but also by irritating impressions proceeding from dis- tant organs, and reflected upon them from their respective nervous centres. Hence the muscse volitantes, and the tinnitus aurium, which so frequently accompany derangement of stomach. 7. Symptoms belonging to the Intellectual and Emotional Func- tions.—These are very numerous, embracing all the phenomena of deranged intellect, defective, augmented, or perverted memory, emotional excitement, whether pleasing or painful, depression of spirits, depraved dispositions and tastes, and every variety of facial expression. Those forms of diminished, suspended, or disordered cerebral action, denominated heaviness, drowsiness, somnolence, stupor, lethargy, coma, vertigo, giddiness, dizziness, faintness, wakefulness, disturbed dreams, somnambulism, &c, may all be included in the same category. All the general remarks that are necessary may be arranged under the two heads of delirium and facial expression. It may, however, be proper to state that some diseases have a remarkable tendency to produce cheerfulness, confidence, or resignation of spirit, as phthisis; while others evince an equally strong tendency to mental dejection and despondency, espe- cially the gastric and hepatic affections. Delirium.—This is an acute and temporary disorder of the intellectual or perceptive faculties. When chronic, it becomes insanity. It occurs much more readily in some persons than in others, under apparently the same cir- cumstances. There are individuals who become delirious with the slightest fever; while there are others who scarcely ever evince signs of mental aberra- tion, in the severest forms of febrile disease. The affection is more frequent in the young than the old, and in nervous persons than in those of a different temperament. It arises from different causes, producing the opposite con- ditions of irritation or depression of the cerebral functions, and especially from causes acting on the hemispheres. Those affecting the base of the brain are more apt to evince themselves by derangements of general sensation, or the motive power. Meningeal affections are usually marked by delirium of CHAP. III.] SYMPTOMS OF DISEASE.—DELIRIUM. 197 the more active character, because the influence they extend into the cortical substance is sufficient to cause irritation, without abolishing function; while original disease ofthe brain itself is apt to produce the latter effect, evinced, according to its degree, by impaired intellect, lethargy, coma, &c. Yery fre- quently, the impressions which ascend to the brain from diseased organs in various parts of the body, especially the stomach, bowels, liver, and uterus, are sufficient to occasion delirium; and this is a more frequent effect of such cau- ses than the abolition of function, because their effects are generally those of mere irritation, and stop short of organic disease. A want of due energy or action in the brain may be the occasion of delirium, as well as its excess. This is usually the result either of the withdrawal of some wonted stimulus, as in delirium tremens; of the languor which follows excessive excitement, as in the advanced stage of active delirium; or ofthe direct action of a sedative agent, as the poison of typhus fever, or the depraved blood of that disease and of the last stages of pectoral affections. Organic cerebral disease may pro- duce one or the other condition of function, according to its degree and extent. If moderate, or in the early stage, it may exaggerate the function, especially of those parts not directly involved in the disease; if extensive, or in the advanced stage, it tends rather to impair power and function together. Delirium may, therefore, be active or passive. The active differs greatly in degree, being sometimes very mild, sometimes violent or furious, and of all intervening grades. The milder grades are usually evinced by some men- tal aberration, with little disposition to action; the higher grades by super- added violence of gesture, voice, and language. In the passive delirium, the brain acts wrongly, because it cannot elevate itself to the point for the due perception of impressions, or the formation of judgments. Of this kind is the low muttering delirium of typhus. It often happens, in passive delirium, that an increase of the proper stimulus restores temporary correctness of thought. Thus, though the patient may be muttering sentences without apparent meaning; yet, if roused, and spoken to in a loud and distinct voice, he will often answer coherently and correctly. Sometimes in delirium there is a complete derangement of mind. The patient recognizes neither the persons nor the things around him. He is very apt to imagine himself in a strange place, and to insist upon returning home. This is often a bad sign. In other instances, the sensations and perceptions are correct, but the judgment is perverted. In others, again, only the perceptions are wrong, while the mind acts rightly upon the per- ception which it forms. Thus, the patient sees objects and hears sounds which do not exist, and acts as if those sights and sounds were real. When the fallacy of the perceptions or sensations is recognized by the patient him- self, he cannot be said to be delirious. Facial Expression.—This is of great importance, and should be carefully studied. It is occasionally almost our sole dependence in diagnosis. Through it, we sometimes recognize the existence of pain, mental anxiety or de- pression, insanity, and even, in a general way, pectoral or abdominal disease, when other signs are either wanting, obscure, or not available. In the cases of children, of the insane, and of persons who may be disposed to deceive us, it is a peculiarly valuable resource. Many diseases are attended with a characteristic aspect of countenance, which will often be recognized by the experienced, so far at least as to suggest the disease to his mind. By a glance, we can often ascertain whether our patient has changed for the better or worse in our absence. But it is only by experience, and close observation, that this power is attained. The modifications and combinations of feature which constitute expression are too numerous, intricate, delicate, and evan- escent, to admit of analysis, at least of profitable description. 198 GENERAL PATHOLOGY. [PART I. There are, however, certain changes in the face of a more tangible charac- ter, connected rather with the organic functions than the action of mind, which can be more accurately appreciated. The colour, shape, temperature, and various movements independent of expression, often yield important in- dications. Thus, a bright-red colour signifies one thing, a dark-red, purple, or violet colour another. In the former case, the blood is duly arterialized, and probably sent up vigorously into the head; in the latter, it is unduly carbonaceous, and probably detained in the head by some obstruction to its return. Paleness also has its significations, as of anaemia, debility, nausea, &c.; and there are different kinds of paleness having different meanings, as that of scrofula or phthisis, and that of cancer. Yellowness of face is well known to point to disease of the liver. The colour of the lips is peculiarly expressive, in its different tints of crimson, purple, and paleness. The fea- tures may be full, swollen, turgid ; or they may be shrunk, contracted, fallen; in the former case indicating oedema, or congestion, active or passive; in the latter, exhaustion, prostration, general collapse, &c. The Hippocratic face, so named because described by Hippocrates, is often referred to by writers as marking the near approach of death. It is characterized by a general contraction of the features. The nose is pinched, the temples hollow, the eyes sunken, the ears cold and shrunk, the skin of the forehead tense, the lips parted and relaxed, and the colour of the face pale or livid. Coldness of the ears and tip of the nose occasionally indicates the approach or presence of a chill, when other symptoms are wanting or ambiguous; and, in infantile cases, coolness of the cheeks, nose, and ears, sometimes enables us to decide upon the existence of a degree of prostration requiring support, when we might be embarrassed without that sign. Certain positions or movements of the features are sometimes also highly expressive. Thus, alternate con- traction and expansion of the alae nasi frequently indicate dyspnoea; irregular motions of the eyes, with contracted or expanded pupil, disease of the brain; and a falling of the under jaw, the last agony. 8. Symptoms belonging to the Motor Function.—These arise from a deficiency or entire want of muscular contraction, as in debility, palsy, or local disease of the muscles ; from an excess of contraction, as in cramps, con- vulsions, and subsultus tendinum; or from irregular or perverted contraction, in which the muscles act under the will, but not to the end proposed, as in chorea. Under this head are included all the voluntary motions; the gestures, the manner of walking, running, &c.; the positions, as standing, sitting, and lying; and all the symptoms connected with the voice and speech, as sup- pression of voice, hoarseness, shrillness, dumbness, stammering, &c. But these symptoms, and many others belonging to the different functions not here noticed, will be most advantageously studied in connection with the seve- ral diseases in which they are found. SECTION II. COURSE, DURATION, AND TERMINATION OF DISEASE. By the course of disease is meant the succession of its symptoms, in rela- tion both to order and rapidity. When, from the commencement to the ter- mination, the symptoms show no disposition to abate, or when they regularly increase in violence up to the point at which recovery begins, or the patient sinks, the disease is said to be continued. Neither of these events, however, often happens, unless in diseases of very brief duration. More commonly, the symptoms, after a shorter or longer continuance, abate considerably, with- CHAP. III.] COURSE AND DURATION OF DISEASE. 199 out, however, entirely disappearing, and, having remained for a time in this state of relaxation, resume their original violence, again to abate as before; and this alternation of excitement and relaxation continues to the end. The disease, under these circumstances, is said to be remittent, the period of abate- ment is called the remission, and that of excitement the exacerbation. Fre- quently, all the symptoms yield entirely for a time, so as to leave regular intervals in which the patient is apparently free from disease. The complaint is then said to be intermittent, and the interval is called the intermission; while the stage of excitement is designated as the paroxysm. The period at which the remission occurs may depend on the nature of the morbid condition, and, in that case, is peculiar in each disease; as on the third or fourth day in smallpox, and on the second and third day in yellow fever. It may also depend on causes unconnected with any particular dis- ease, and existing either in the constitution of the frame, or in the influences to which it is subjected from without; and, under the operation of these causes, the remission occurs, in most diseases, at similar intervals, usually once in twenty-four hours. It is a law of our physical as well as moral nature, that excitement, even under the constant influence of stimulating agencies, cannot be long sustained at a particular point of elevation. We see this every day in health. The various agents, such as food, drink, heat, light, &c, which are necessary to sustain the system in its proper condition, may be present in an equal degree throughout a given period; yet the excitement produced by them flags after a time, and sleep, with a general reduction of the vital actions, occurs. So, under some morbid excitant influence the action flags for a time, though the influence may continue. During this state of com- parative rest or diminished excitement, the system acquires additional excita- bility, which renders it again susceptible to the stimulant influence; and the temporary reduction is, therefore, followed by a renewed elevation of the dis- eased process. It has been before observed that this change of remission and exacerbation usually takes place once in twenty-four hours. The cause of this is probably to be found in that habit of the system, acquired by the daily alter- nation of sleeping and waking. The gradually accumulated excitability of the former condition being regularly diminished in the latter, a flux and reflux is established, which, in cases of disease, though it may occasionally vary in the precise point of accession or decline, is still, as a general rule, experienced within the habitual limits. Upon the same principle, to a certain extent, may be explained the dispo- sition observable in intermittent diseases to a daily return of the paroxysm. The cause of the disease gives rise to the first paroxysm at that period of the twenty-four hours, at which, in the advance or recession of the excitability, the system is in the most favourable condition for its action. The same con- dition is experienced about the same time on the following day, and the same result necessarily takes place, if the cause continue to operate. That the paroxysm should often occur every other day, and sometimes every third day, tis in the tertian and quartan agues, must be referred to some unknown mo- dification in the character of the cause, or in the properties of the system, which prevents the equilibrium of health from being disturbed on the first favourable occasion, and enables the vital resistance to triumph over the morbid influence, till, weakened by continued assault, it is compelled at last to give way. Disease sometimes runs its course speedily, and sometimes is of long dura- tion. In the former case, it is said to be acute, in the latter, chronic. These terms, however, are not definite. There are no characteristic signs which serve in every case to distinguish an acute from a chronic complaint; and the terms are not unfrequently employed to express different stages of the 200 GENERAL PATHOLOGY. [PART I. same affection; the disease being called acute in its earlier course, when the symptoms are most severe, and chronic, when its duration has become pro- tracted, and its violence considerably abated. There is another distinction between diseases, which is of considerable practical importance. Some appear to have no definite course, duration, or end; being more or less variable in the succession of their symptoms, lasting a less or greater length of time, and terminating favourably or otherwise, according to circumstances in the constitution of the patient, and in his rela- tion to surrounding objects. Others, on the contrary, whatever may be the constitution, habits, or exposure of the patient, are disposed to pursue a cer- tain course, and in a given time to end in recovery, unless fatal disorganiza- tion arrests their progress, or derangements of structure of a less violent character, resulting from the disturbance into which the system has been thrown, impede their march towards health. A third set of diseases are those which exhibit no tendency to a favourable issue, and which, if left to themselves, and sometimes in defiance of all treatment, go on gradually in- creasing in intensity till they ultimately destroy the patient. Examples of the first class are presented in rheumatic inflammation and neuralgia, of the second in smallpox and other exanthemata, and of the third in cancer. It is obvious that our treatment must be very much influenced by these differences in the tendencies of disease; being directed to the subversion of the morbid action, in cases which admit of a direct cure, and to the prevention, as far as possible, of dangerous consequences in those which run a fixed course; while, in those of an incurable nature, we must be content with endeavours to alle- viate the sufferings and protract the life of the patient. It is particularly important that the practitioner should bear in mind the disposition of many, perhaps we might say of most diseases, to terminate favourably after having run a certain course, provided fatal organic injury can, in the mean time, be prevented. With this conviction ever present to his mind, he will be less disposed to waste his own efforts, and the vigour of the patient, in vain at- tempts to effect an immediate cure; and, even in cases in which the disease may possibly be arrested in its progress, will often prefer such moderate m'easures as will insure ultimate recovery, in the natural course of things, to the chance of more speedy success from violent remedies, with the risk of serious mischief. Crisis.—The name of crisis is usually applied to the turning point of dis- ease ; the point at which it begins to give way, if its end is to be favourable, or to become decidedly worse, if unfavourable. This period is often attended with certain phenomena which mark the favourable or unfavourable change, and are, therefore, denominated critical symptoms. The most common of these are augmented secretions, hemorrhages, cutaneous eruptions, glandular swellings, and abscesses. The secretions are usually from the skin, bowels, and kidneys, constituting critical sweats, critical diarrhoea, and critical diu- resis. At one time, great importance was attached to these discharges. It was supposed that they carried the peculiar peccant matter out of the system, thus proving positively curative; and any interference with them was strongly deprecated. To some extent, this idea has recently been revived ; as, for ex- ample, in the case of gout, in which the paroxysm sometimes seems to pass off with a free secretion of urine, loaded with uric acid or the urates; and the discharges alluded to are still regarded as often useful, by removing irritation or congestion, or, when of an inflammatory character, by acting revulsively on the disease. In most affections, however, there are no symptoms which can strictly be denominated critical; and, when they do occur, they may be con- sidered, in general, as coming under one of the three following heads. They are either, first, regular results of the pre-existing morbid conditions, explicable CHAP. III.] COURSE AND DURATION OF DISEASE. 201 upon ordinary pathological principles, as when the excited vessels of the skin in fever unload themselves by perspiration; or secondly, transfers of disease from one organ to another, under various accidental influences, as when rheumatism ends in diarrhoea; or, thirdly, new diseases supervening upon those already existing, and superseding or increasing them, as the case may be, as when an attack of bleeding piles, occasioned by straining at stool, re- lieves an existing attack of splenitis or hepatitis. Hippocrates believed that disease, in general, was more disposed to change at certain periods than at others; and he designated the 7th, 14th, 20th, ^7th, 34th, and 40th days, as constituting the periods alluded to, which he named critical days. It will be perceived that the intervals between the days mentioned are very nearly a week; and Hippocrates considered the crisis as falling on the last day of each septenary period. He carried the doctrine further, and supposed that there were certain intermediate days, in which, though the tendency to change was not so strong as in those men- tioned, it yet existed in a certain degree; while there were others in which the disposition was still less, and others again in which a crisis never oc- curred. These notions of the father of medicine certainly do not apply, with any great accuracy, to diseases as they now exist; yet there appears to be some vague relation between disease and weekly periods of time; for many complaints show a disposition to end in about seven days, more or less; and it is a subject of constant observation, that miasmatic fevers, when they re- turn after being checked, are apt to do so in one, two, or three weeks, or some other septenary period, most frequently perhaps at the end of the second week. This tendency is, at present, quite inexplicable. Termination.—A particular disease may terminate in convalescence, in some other disease, in the chronic form of the same disease, or in death. Convalescence is sometimes sudden. There is an immediate transition from disease to health This is most apt to happen in nervous affections. But much more frequently the change is gradual. Among the first symptoms of convalescence from acute disease are generally a commencement of the clean- ing of the tongue, and a diminution in the frequency of the pulse. The skin, if before dry, is apt to become moist, the other secretions are gradually re- stored to their normal condition, and all the functions are in the end re-esta- blished. Emaciation, however, is usually more striking in convalescence than in the previous illness. This may possibly be in part merely apparent, and the result of the principle of association, which expects healthy looks in re- turning health; but it is probable that the nutritive process does not at first keep pace with the vigour of absorption, and that the body for a time really loses more than it gains. Convalescence often goes on happily; but often also, it is disturbed by unpleasant symptoms, and interrupted by drawbacks, consequent upon the irregular action ofthe debilitated or perverted functions. Copious night sweats are frequent; the appetite is sometimes feeble, and re- quires stimulation; the bowels are apt to be constipated; the pulse often remains frequent; and the patient is troubled with various nervous symptoms, such as restlessness, wakefulness, and extraordinary dejection of spirits, or fanciful and hypochondriacal notions. These, however, gradually disappear, spontaneously, or under appropriate treatment; all the functions become active; and the oscillation not unfrequently extends even beyond the original standard of health. The appetite becomes voracious, nutrition abnormally active, and the body swells considerably beyond its previous dimensions. The various tvisibilities have been as it were regenerated, everything is for a time enjoyed with the zest of youth, and life has acquired new charms. Some- times the increased fleshiness continues a confirmed habit of the body; but more frequently it subsides to the original level, and the individual becomes 202 GENERAL PATHOLOGY. [PART I. his former self again, with the exception, it may be, of the loss of some pre- vious morbid tendency, or the acquisition of a new one. The hair is very apt to fall after severe illness, and sometimes does not return, especially in advanced life; but generally its place is supplied by a new and equally luxu- riant crop. It is thought that shaving the head has the effect of favouring the latter result. Sometimes convalescence is interrupted by a return of the disease, which is then said to have relapsed, and the new attack is called a relapse. Some diseases seldom if ever relapse. This is especially the case with those which depend on a specific poison, run a certain course, and are usually taken but once, as smallpox, measles, &c. These not unfrequently leave unpleasant sequela? behind them; but it is very rarely that they run over their course again. Others are very prone to relapse, as the miasmatic fevers, rheuma- tism, and the phlegmasia? generally. In relapses, the patient suffers under the disadvantage of the debility and unrepaired mischief of the first attack, and, therefore, not unfrequently sinks; though the real force of the returning, is usually less than that of the original disease. Convalescence is sometimes imperfect, and the health is not completely re-established for months or years, if ever. Sometimes a tendency to a new disease is awakened. Thus, phthisis and scrofula frequently follow attacks of the exanthematous fevers. Sometimes an organ which has suffered in the disease cannot recover itself; sometimes, again, the vigour of the vital functions is permanently impaired, and dropsy, anaemia, or other cachectic condition is established. Not unfrequently, an acute disease becomes chronic. The symptoms sub- side without disappearing. The result here is not a new disease called into action or generated by the old, but is a continuance of the latter, with its essential characters, though much modified in degree, and sometimes in the phenomena. The termination in death may take place either by a general exhaustion of the powers of the system, so that the flame of life lessens and lessens until it goes out; or in consequence of the failure of one or more of the functions, the integrity of which is necessary to life. The latter mode of death is beyond all comparison the most frequent. It is seldom, indeed, that the vital powers give way so gradually and equably throughout the system, that it is impossible to say that any one part or function suffers prominently, and becomes the im- mediate avenue by which life escapes. In almost all cases, whatever may be the nature of the disease, death approaches through one of three vital organs; namely, the lungs, the brain, or the heart. When respiration ceases, the blood can no longer circulate through the lungs. It is arrested in the capillaries of that organ, and death necessarily follows, unless the respiration is restored. The heart ceases to act, and all other organs cease to act, because the neces- sary support of their functions is denied to them by the stoppage of the blood in the lungs. Death, under such circumstances, takes place by asphyxia, or, as it may be more appropriately denominated, apncea. The brain presides, as the centre of the nervous actions, and the great link which binds the func- tions together, over all the vital processes; and none can go on without its continued influence. If the brain become powerless, respiration must cease, the circulation must cease, and life of course along with them. Death may now be said to occur by coma. But both the lungs and the brain may be per- fectly sound, and death may come through the heart; the morbid cause acting directly on that organ. In this case, death is said to take place by syncope. For a longer or shorter period before death, certain symptoms usually ap- pear which mark its inevitable approach. The patient, under these circum- stances, is said to be dying. Sensation and consciousness are extremely im- CHAP. III.] DIAGNOSIS. 203 perfect or quite lost; the features are collapsed and without expression; the under jaw is often fallen; speech and deglutition are difficult or impossible; there is often rattling in the throat, from inability to expectorate; respira- tion is irregular, at first sometimes hurried, but gradually becoming less and less frequent, with intervals gradually lengthening until it ceases; the pulse is usually small and feeble, often irregular, and sometimes quite absent at the wrist long before death; the extremities are cool; the skin often clammy, and the colour of the surface pale or somewhat livid; and not unfrequently a cadaverous odour may be perceived while the patient still lives. Sometimes death approaches by imperceptible degrees, and the patient passes quietly away as if falling into a breathless sleep; sometimes nature rouses herself for a last struggle, and life ends in convulsions. This dying state is called the agony, though very improperly; for in most cases it is without a strug- gle, and very generally without pain or consciousness. Its duration is various, sometimes not so much as an hour, sometimes several hours; and instances occur in which the phenomena continue for days before death. SECTION III. DIAGNOSIS. This term is employed in two senses, with a slight shade of difference. In the one sense, it signifies the act of determining the character of diseases, and, in relation to any particular case, of ascertaining what disease it is with which the patient may be affected; in the other, it distinguishes diseases one from another by comparing them, and, in relation to particular cases, ascertains what the disease is by determining what it is not. It is used here in both senses. A disease is sometimes so well characterized, that it is immediately known as soon as its symptoms are seen. In such a case, it would be quite supererogatory to bring under examination a number of other diseases, in order to show that, though their symptoms may be somewhat analogous to those of the case before us, they are not actually the disease in question. But, in many instances, the signs of very different diseases are so much alike, that without caution they might be readily confounded. In such instances, it is advisable to compare the symptoms carefully with those of all the diseases about which there might be doubt, and, determining which must be excluded, to narrow down the circle at last to the true one. It is always proper to look beyond the symptoms to the disease. We ought never to be content with putting certain morbid phenomena together, and calling them a disease ; but should endeavour to penetrate to their source. Sometimes, it is true, our search will be vain, and we shall be compelled to remain content with the mere symptoms ; but, should we never proceed fur- ther, the science of pathology would soon cease to make progress. Having determined the character of a disease, we should next direct a par- ticular attention to the modifying circumstances; such as the peculiar in- fluence which may have been exerted by the cause, the qualifying effects of various subordinate agencies, the secondary affections which may have sprung up, and all incidental complications. In making out the nature of a disease, when doubtful, it is sometimes neces- sary to call to our aid every kind of information which has any bearing upon the subject. We must carefully examine all the symptoms, must inquire into the cause, and must take into view all controlling influences, as age, sex, tem- perament, constitutional peculiarities whether original or acquired, habits of life, pursuits of pleasure or business, climate, residence, &c. Accidental cir- 204 GENERAL PATHOLOGY. [PART I. cumstances will sometimes aid us considerably, when the patient is unable or unwilling to answer our questions. Thus, the remains of food in or about the mouth, the colour imparted by substances which may have been chewed or swallowed to the tongue, teeth, and lips, the colour of the hands, stains upon the face and clothing, as of white lead, &c, are circumstances which may lead to valuable inferences as to what the patient may have taken, his trade, or the accidents to which he may have been exposed. In cases, however, which are not doubtful, a too curious prying into all these circumstances should be avoided, as often vexatious and sometimes injurious to the patient, and at best a mere waste of time. Now there are certain symptoms belonging to each complaint, by which it may be more certainly distinguished than by others, and which, when found together, determine the nature of the disease. These are called diagnostic symptoms. Those belonging to the several diseases should be fixed in the memory, so that when we go to the examination of any case, we may be pre- pared to recognize one of these characteristic groups, if presented, and thus come to a speedy conclusion. Again, there are diseases that offer some one peculiar symptom, found in them, and under similar circumstances in no others, which fixes at once, when observed, the character of the affection. Symptoms of this kind are named pathognomonic. Thus, an eruption of red spots like flea bites, preceded by a fever of three or four days, which subsides on their appearance, is a pathogno- monic symptom of smallpox. But such symptoms are unfortunately very rare. In the strictest sense of the term, they are even rarer than, at first thought, they might be imagined to be; for there is almost always something more than the bare symptom itself, necessary to give it the characteristic certainty. Thus, in the case above alluded to, the red spots would have no force, unless accompanied with the circumstances mentioned. Certain rules ought to be observed in conducting a diagnostic examination. The physician should guard against a too purely scientific or professional feel- ing. He should not regard his patient as a mere subject for medical analysis; but should consult his feelings, prejudices, and mental peculiarities; and should endeavour, while attaining his own conclusions, to do so with as little that is disagreeable, and as much that is agreeable to the person chiefly in- terested as possible. Attention to this rule is not only useful to the business interests of the physician, by producing kindly impressions, but greatly pro- motes his immediate object, by securing the hearty co-operation of the patient, and the favourable effects of confidence in his medical adviser. In his examinations, the physician should put as few leading questions as possible. The patient is very apt to imagine that he feels what his attendant may suggest as possible or probable, and may, therefore, by his answers, inno- cently occasion or confirm an error. He should, at first at least, be induced to give an account of his own symptoms; the physician only interfering to secure a proper order to his remarks. It occasionally becomes necessary, in persons disposed, from false modesty or a worse cause, to conceal their symptoms, to set on foot a system of cross- examination ; but this should be done in a manner least likely to excite un- kindness ; and when, especially in the cases of young females, information can be obtained from the mother or attendants, it is much better to procure it thus, at second hand, than to extort it by a sort of violence from the subject. In examining young children, great care must be taken to avoid exciting them. Perfectly correct inferences can seldom be drawn from the examina- tion of a crying and struggling infant. Mothers and nurses are often greatly in fault in this respect. To secure temporary obedience, they often alarm the child by threats of what the physician will do, and thus render his medical CHAP. III.] DIAGNOSIS.—EXPLORATORY PROCESSES. 205 attendant an object of terror. There is not the shadow of a doubt, that the most fatal consequences have ensued from this error on the part of weak or wicked care-takers of the young; and every physician should inculcate upon the parents, in whose families he may attend, the importance of teaching their children rather to love than fear him. In pursuing his investigations, the physician should observe some order. He will thus save time, and gain clearer notions than by a helter skelter ex- amination, which, in its devious course, must often return upon itself. In general, when the organ or function affected is obvious, this should first en- gage attention. Afterwards, or originally in cases of any degree of obscurity, it is probably the best course, first to take a survey of the exterior, and then to interrogate the several functions successively, beginning with the digestive, and following with the others in their natural order, as observed in the fore- going general history of symptoms, namely, the absorbent, the respiratory, the circulatory, the nutritive, the secretory, the sensorial, the intellectual and emotional, the motor, and the reproductive. One accustomed to examinations of this kind can run through the whole routine very rapidly; and often a glance at the function is sufficient to show that it is sound or otherwise. In order to complete the subject of diagnosis, it is necessary that some account should be given of the modes of proceeding, and the implements to be employed. The exploratory processes which require distinct notice may be included under the heads of inspection, palpation or the touch, pressure, succussion, percussion, measurement, and auscultation. 1. Inspection.—Yery many symptoms are observed by simple inspection. This is obviously the case with most of those which are quite external. Such are the attitudes and movements of the patient, the general form of his body, and the relation of its parts, the degree of fulness or emaciation general and local, the colour and other appearances of the skin, the condition of the several features, the expression of the face, and all the other physical charac- teristics, so far as they are visible. We can, to a certain extent,-penetrate by our vision into the interior of the body. Thus, we can examine the mouth and fauces directly by the eye. In the inspection of the fauces, the mouth should be opened as widely as possible, and the tongue, without being in the least protruded, should be depressed by the handle of a silver tablespoon, an ivory folder, or wooden spatula, or even the finger, if no more convenient instrument should be at hand. Many persons have the faculty of so opening the mouth as to exhibit the fauces without the aid of an instrument. In others, the object can be accomplished by directing them to open the mouth, and then quickly make a short, and as it were spasmodic inspiration. In cases of infants, who cannot or will not protrude the tongue, the mouth can often be sufficiently examined by allowing them to cry. Instruments, called speculums, have been invented for the inspection of internal parts, which the eye cannot reach. By this means, the state of the uterus can often be very advantageously ascertained; and the rectum, bladder, and throat have to a certain extent been examined in the same way. 2. Touch.—Palpation.—In this process, the flat ofthe hand, or of one or more of the fingers, is laid gently, and without pressure, on the portion of surface to be examined. Care should be taken that the temperature of the hand should be as near the ordinary healthy medium as possible. In this way, we can judge of the temperature of the surface, of certain physical pro- perties of the skin, as its dryness or moisture, its harshness, roughness, soft- ness, smoothness, &c, and of certain internal movements, which are commu- nicated to the superficies of the body. One of these movements is a certain fremitus, thrill, or vibration, produced in certain morbid states by coughing, respiration, es from the brain becoming involved, and this is most likely to happen when the inflammation invades the scalp, though this last event often occurs without serious consequences. A sudden disappearance of the external disease, with the occurrence of svmptoms indi- cating internal irritation or inflammation, is unfavourable. Such a metastasis is most likely to happen in the wandering variety. The phlegmonous form is. in other respects, more dangerous than the superficial The gangrenous variety is very dangerous. The very old, the intemperate, and those already nearly worn out by previous disease, are apt to die. This is peculiarly the case in dropsy, in which a fatal erysipelas often attacks the swollen limbs, especially after punctures; but death, in these instances, is only a little has- tened. The disease is often fatal when it occurs near the close of febrile dis- eases : though recoveries also, under such circumstances, often take place. The prognosis is always more unfavourable in hospital than in private prac- tice. In new-born children, the disease is exceedingly fatal; as it often also is when it occurs epidemically, and whenever it puts on a malignant form. Coma and continued delirium are always unfavourable symptoms. Sometimes erysipelas is productive of good. It has often permanently cured impetigo, psoriasis, and other obstinate cutaneous affections; and tem- porarily removed svphiMtic disease upon the surface of the body. It is as- serted even to have cured elephantiasis. Treatment.—I shall treat first of the general, and afterwards of the local measures. AtUd cases require little interference. Rest, saline laxatives, re- frigerant drinks, and a low diet, constitute the routine of treatment. The physician, however, should always be on the watch, prepared to counteract any threatening change that may occur. In severe cases, an emetic has been recommended at the commencement. This remedy is supposed to be peculiarly useful in the bilious form. It no doubt does good, when the stomach is loaded with bile or other irritating matters, and may also be beneficial, when the liver is torpid, by rousing it into activity. It may even have the effect, attributed to it in some of the other exanthemata, of favourably modifying the future course of the disease. But I have myself found no such advantage from emetics, in ordinary cases, as to compensate for their inconvenience to the patient, and now seldom em- ploy them. A brisk cathartic at the beginning is almost always proper. Its energy should be graduated somewhat to the apparent violence of the case. Often VOL. l 2'j 450 GENERAL DISEASES.—FEVERS. [PART II. a full dose of Epsom salt will be sufficient. When there is considerable fever, recourse may be had to senna and salts, or to calomel either alone or com- bined with other cathartics, as compound extract of colocynth, jalap, or rhu- barb. The compound cathartic pill is an eligible preparation. When calo- mel is used alone, it should be followed by castor oil, or sulphate of magne- sia. The mercurial is especially indicated whenever there is torpidity of the liver, or too much bilious matter in the circulation; consequently in most of the cases called bilious. After the bowels have been thoroughly evacuated, it will generally be sufficient to procure one or two passages daily, which may be done by means of saline cathartics during active febrile excitement, and rhu- barb in low or typhous states of the disease. Magnesia will sometimes be use- ful to counteract acidity, and castor oil in states of intestinal irritation. Should the pulse be strong and full, and the inflammation severe and threat- ening, bleeding may be employed advantageously in the early stages, and in the young and vigorous with considerable freedom. It may sometimes even be repeated; but this is very seldom necessary. Bleeding is not so well borne as in ordinary inflammation; and it often happens that the loss of a small quantity of blood produces a very decided impression on the pulse and general strength. The habits of the patient, or his previous state of health, have often been such as strongly to contraindicate the remedy; and, under these circumstances, it should not be resorted to unless imperiously called for. In the great majority of cases, it is quite unnecessary, and, in not a few, is posi- tively forbidden by the existing debility. It should be recollected that bleed- ing will not cure the erysipelatous inflammation, unless by inducing such a degree of depression as almost to prevent the blood from circulating in the capillaries; and this is always dangerous. The remedy, therefore, should not be employed for this purpose. It is indicated when danger of suppuration or gangrene may exist from the violence of the local disease, or some internal and vital organ may be attacked. It should be employed when stupor, or other evidence of congestion or inflammation of the brain is presented, unless, as unfortunately often happens, the pulse may be too feeble to permit it. In doubtful cases, the patient should sit erect during the bleeding, and the flow be stopped immediately upon the flagging of the pulse, or the slightest inti- mation of the approach of syncope. Cooling diaphoretics, such as the neutral mixture, effervescing draught, solution of acetate or citrate of ammonia, muriate of ammonia, nitrate of po- tassa, and, when the stomach is not irritable, the antimonials may be used during the active state of the fever. I am usually satisfied with the neutral mixture or effervescing draught, preferring the latter when the stomach is irritable, and adding, when this organ is quite retentive, and the fever de- cidedly sthenic, small quantities of tartar emetic. When the general action is feeble, whether at the commencement or becom- ing so in the course of the disease, and especially when nervous symptoms are exhibited, such as restlessness, wakefulness, and slight delirium, the com- bination of opium and ipecacuanha is an admirable remedy, which may be aided by the spirit of nitric ether, the compound spirit of sulphuric ether, camphor-water, and the warm bath, if deemed advisable. The opiate, how- ever, should not be used in the somnolent or comatose cases. If, after sufficient depletion, the local symptoms are threatening, but with- out any complication of gangrene or malignancy, calomel or the blue mass may be added to the opium and ipecacuanha, and so used as to produce the slightest possible mercurial impression. Sometimes, when opium is contra- indicated, the calomel and ipecacuanha may be used without it. For the doses in which these remedies should be employed, the reader is referred to former articles on febrile diseases. CLASS I.] ERYSIPELAS. 451 When the symptoms assume a typhous form, with a failing pulse, and per- haps a gangrenous tendency in the local affection, it becomes necessary to sup- port the system by stimulants and nutritious food. Opium, sulphate of quinia, the mineral acids, carbonate of ammonia, wine-whey, animal broths and jellies, and, in extreme cases, milk-punch, egg and wine, &c, should be used; the stimulation being graduated to the degree of depression or debility. In the cases of drunkards, wine or brandy should be allowed freely, as soon as the system begins to falter, and moderately at the commencement, even though it might be necessary to bleed at the same time. Chlorate of potassa has been usefully employed in the malignant epidemic erysipelas, or black tongue, by Dr. R. L. Scruggs, of Tennessee. (Med, Exam., N. S., v. 227.) When retrocession of the cutaneous inflammation takes place, if internal inflammation be the cause, bleeding should be employed as far as the patient can well bear it; but, if it be connected with debility, which probably happens quite as frequently, it will be necessary to stimulate. In either case, a blister, or an active rubefacient, as mustard, should be applied to the surface pre- viously inflamed, and the whole body, if convenient, immersed in a hot bath. During the exhaustion ofthe suppurative and gangrenous state, it is highly important to support the strength of the patient until the process is over; and quinia, the mineral acids, wine or the malt liquors, opium, and nutritious food, are the most suitable means. In the periodical cases, the chief object of the physician, in the intervals, should be to discover any deviation from health to which the tendency may be owing, and to apply his remedies accordingly. It should, however, be borne in mind that the erysipelatous attack sometimes protects the system against a worse disease, and its prevention might, therefore, be a positive evil. It has appeared to me that the blood is probably in fault in some of these cases, and that, by altering the condition of that fluid, we might safely prevent the return of the disease. With this view, I have employed a diet exclusively of bread and milk for a considerable time, and with apparent benefit. Mr. C. Hamilton Bell, of Edinburgh, has introduced the use of the tincture of chloride of iron in the treatment of erysipelas; giving from fifteen to twenty- five drops, every two hours, night and day, throughout the disease, without reference to the degree of fever, or the delirium. The only other treatment he employs is at first freely to act on the bowels, and afterwards to keep them properly open. His local applications are hair-powder and cotton wadding. He has used this method for more than twenty-five years with invariable suc- cess. (Ed. Monthly Journ. of Med, Sci, June, 1851, p. 498.) Since the publication of Dr. Bell's paper, the remedy has been tested by many prac- titioners, and the reports have generally been in its favour. I have myself used it in all cases which have come under my notice, whether in private or hospital practice, and hitherto with uniformly favourable results; not one patient having died of the disease. But I have not depended on the chaly- beate alone, having used conjointly such other remedies as the symptoms appeared to indicate. The diet should be regulated in erysipelas, as in other febrile diseases. Local Measures.—The head, or whatever other part may be affected, should be kept in as elevated a position as may be compatible with the comfort of the patient. An infinite diversity of local remedies has been proposed. Some doubt their propriety altogether, and prefer leaving the inflammation to na- ture, at best with only slight alleviating means. My own opinion is, that local measures are often of great use, but that they should be employed with some caution. The external affection is not the whole disease. If suddenly repelled by applications, the irritation may retreat with fatal effect to some interior organ. It is best, therefore, not to aim at its subversion, but only to 452 GENERAL DISEASES.—FEVERS. [PART II. regulate it; to check its advance when disposed to proceed too far, to diminish its violence when likely to lead to unpleasant results, and at all times to alle- viate the uneasiness which it causes to the patient. Perhaps, on the whole, the most comforting, alleviating, and least hazard- ous application, is that of some bland mucilage, kept constantly upon the inflamed surface, by means of soft folded linen thoroughly saturated with it. I usually prefer the infusion of slippery elm as being the most agreeable; but the infusion of sassafras pith or flaxseed may also be employed, especial care being taken that the flaxseed is not rancid. Should the inflammation be severe, advantage may accrue from the use of a solution of acetate of lead, in the proportion of a drachm or two to the pint of water. Slight narcotic impregnation of the liquids employed, as by acetate of morphia, infusion of opium, or decoction of poppy heads or lettuce, may not be improper, though not likely to be very useful. Should the inflammation be disposed to spread too far, and especially into inconvenient or dangerous positions, it becomes proper to arrest it. This is peculiarly necessary in facial erysipelas, when disposed to ascend to the scalp. It can generally be accomplished by one of three measures; blisters, nitrate of silver, or tincture of iodine. The last is probably, on the whole, the most convenient, and, when I have employed it, has generally answered well. A border, of an inch and a half or two inches in breadth, should be drawn across the path of the advancing inflammation, one-half on the inflamed, and the other half on the sound skin. The tincture of iodine of the U. S. Pharma- copoeia may be employed, and applied freely over the surface mentioned, so as completely to discolour it; and the operation may be repeated daily, if ne- cessary, until the inflammation begins to decline. The colour imparted by the iodine is soon dissipated, and the cuticle desquamates. Blisters may be employed in the same way, and they generally succeed, though more incon- venient than the iodine. Nitrate of silver is also very efficient; but the dis- coloration of the skin is of longer duration ; and I should not be disposed to apply it upon the face. The most effectual plan is that of Higginbottom, who employs the stick itself, or a strong solution, made with eight scruples of the nitrate and twelve drops of nitric acid in a fluidounce of distilled water. Should the inflammation leap over the border formed in either of these modes, it will usually be with mitigated severity, and it may often be arrested by a repetition of the application upon the surface invaded. Some apply the last-mentioned remedies to the whole surface inflamed; and there may be cases in which the apprehension of gangrene might render this plan advisable; but, after the experience I have had, I fear it under ordinary circumstances. I have known blisters, applied in this way, to be followed by extensive ulceration of the skin. Some allusion to other local measures which have been recommended may not be improper. Leeching has high authority in its favour. I fear, how- ever, the ulceration of the bites, and seldom use them. To obviate this danger, it is advised to apply them to the sound surface in the vicinity of that inflamed. But, in the general predisposition to this form of inflamma- tion, is there not some danger that the bites themselves may become new foci of the disease ? The only circumstance which calls strongly for this remedy is, I think, the existence of some threatening internal inflammation or irrita- tion, especially of the brain. Under the same circumstances, it might be proper to apply a blister to the nape of the neck. ^ A very common and simple application, more frequently used some years since than at present, is rye-meal, or other dry, unirritating, absorbent powder, plentifully sprinkled upon the inflamed surface. The object of the applica- tion is to absorb the acrid fluid, which sometimes exudes from the vesicles. CLASS I.] ERYSIPELAS. 453 It certainly alleviates, in some instances, the burning heat; but it is also liable to the inconvenience of forming hard crusts upon the surface. Whether it has any influence in reducing the inflammation is doubtful. Once, how- ever, I enclosed a severely inflamed leg in a thick layer of this powder, with the apparent effect of immediately curing the inflammation. Possibly the result may have been a mere coincidence; possibly it may have been owing to the exclusion of atmospheric air. Mercurial ointment at one time enjoyed much credit as a local application. Simple ointment or lard was afterwards found about as effectual. Perhaps they both act by excluding the air. Rayer, however, states that, in erysipe- las of the face, he has often caused one side to be rubbed over with lard, and the other with mercurial ointment, and, on several occasions, one of these unguents wras applied to one side, while the other was left untouched; and he never perceived that the disease was influenced by any of these proceed- ings. (Diseases ofthe Skin, Am. Ed., p. 69.) Some apply lard, with the addition of acetate of lead. Solution of chloride of lime, in the proportion of half a drachm to a pint, solution of sulphate of iron and of corrosive sublimate, the liniment of Spa- nish flies (TJ. S. Ph.), raw cotton, and compression by means of a roller, are other means which are asserted to have been used with benefit. Velpeau ascribes extraordinary efficiency to sulphate of iron, a solution of which, in the proportion of half an ounce to a pint of water, applied by compresses frequently wetted, so as to keep the skin moist, cuts short the disease in a day or two. The application of cloths wet with ice-water has also had its advocates, and may be a useful measure in phlegmonoid erysipelas of the extremities. Dr. Trevor, of Illinois, has employed collodion externally with advantage. (N W.,Med. and Surg. Journ., Jan. 1850.) The same substance mixed with one-fifteenth of castor oil has been highly recommended. Dr. C. D. Meigs, of Philadelphia, has found Kentish's ointment a very useful application in erysipelas, especially in that of new-born children. His mode of employing it is to render basilicon ointment soft, but not fluid, by the addition of oil of turpentine, and then to rub it on the part with the fingers. (N Am. Med. and Surg. Journ., vi. 77.) Dr. P. Fahnestock, of Pittsburg, speaks in strong terms of the efficacy of creasote, as. a local application, in.different forms of erysipelas. He has never known the disease refuse to yield to this remedy. In the ordinary form of the complaint, it is generally sufficient to apply the purest creasote once over the whole surface inflamed, and somewhat beyond it, on the sound skin. The phlegmonous variety requires a more frequent repetition of the remedy. Ac- cording to Dr. Fahnestock, the application should immediately whiten the surface. (Am. Journ. of Med. Sci., N. S., xvi. 252.) Deep incisions into the inflamed part have been employed with asserted benefit; and they are indispensable when the inflammation has extended beneath one of the fascia?, and is producing organic mischief there. Another plan is that suggested by Dobson, and recommended by Bright, of making a very great number of minute punctures with the point of a lancet, and wiping off the blood as it flows. AVhcn the erysipelatous surface is covered with small blisters, it is advisa- ble to open them so as to prevent their communication, and the consequent loss of the cuticle before a new one has formed. When a raw surface is pro- duced, in consequence of the separation of the cuticle, and seems indisposed to heal, it may be advantageously dressed with Goulard's cerate. The progress of gangrene may sometimes, possibly, be arrested by a blister applied over the surface. After it has taken place, the parts should be covered with emollient dressings, to which creasote, pyroligneous acid, or 454 GENERAL DISEASES.—FEVERS. [PART II. solution of chlorinated soda or lime may be added, both to correct fetor, and as gentle stimulants. When extended from without into the fauces or larynx, or originating there, a strong solution of nitrate of silver should be applied to the seat of the disease. When suffocation is threatened from closure of the rima glottidis, tracheotomy may become necessary. For the affection seated in the pharynx, and endangering life by inanition, Dr. Todd recommends that, while the nitrate of silver is applied locally, the strength of the patient should be supported by beef-tea and quinia, thrown into the rectum, until the power of deglutition returns, when nutriment and stimulants are to be given by the mouth. Article XIII GLANDERS. Syn.—Equinia (Elliotson).—Morve (French). This is a malignant febrile disease, contracted by man from glandered horses, and characterized by a peculiar inflammation of the nasal passages, and a peculiar pustular eruption upon the skin, occurring either separately or conjointly, and attended in general by suppurating, bloody, or gangrenous tumours. In modern times, attention has been but recently attracted to the disease. Isolated cases were recorded by different writers in Germany, Eng- land, France, and Italy, between the years 1821 and 1830; but the first satisfactory account of it was given by Dr. Elliotson, in the latter of these years, in a paper published in the London Medico- Chirurgical Transactions. Subsequently, various contributions on the subject have been made to the journals; and several valuable treatises have been published, among which that of M. Rayer is probably the most elaborate. The name of equinia was proposed for the disease by Dr. Elliotson, in- tended to express its derivation from the horse ; as that of vaccinia was be- fore given to cowpox. Dr. Shedel, in a dissertation contained in Tweedie's Library, adopts the name; but applies it also to a much milder affection, derived from the grease in horses, designating this by the title of equinia mitis, while he confers that of equinia glandulosa upon the glanders. The former is a trivial eruption of phlyzacious pustules, similar to those of ecthy- ma, which now and then occur on the hands of ostlers, &c, arising from the contact of an acrid discharge, proceeding from the heels of horses affected with the disorder of the feet called grease. The eruption is attended with slight febrile symptoms, runs a course of ten or twelve days, then begins to decline, scabs, and ultimately disappears, leaving small well-defined scars. It occasions little inconvenience to the patient, and is without danger. It does not bear the least resemblance to the malignant affection now under consideration; and the mere circumstance of originating from the horse, would scarcely seem to entitle it to the same designation, however qualified by epithets. The general adoption of one generic name for the two com- plaints might lead to the injurious impression, that they were but different grades of the same affection. The disease which forms the subject of the present article has been called simple glanders, when it affects the nasal passages especially, and farcy glanders, when attended by an eruption of small suppurative and ulcerative tumours, such as are denominated farcy in horses. But, though cases may occur with these distinctive marks, yet in most instances the symptoms are CLASS I.] GLANDERS. 455 commingled; and, as both forms have the same cause, are equally destructive, and, so far as known, require no difference of treatment, there does not seem to be any necessity for separating them. A great difference has been noticed in the duration of the disease in different cases ; and authors are generally agreed in treating of it under the two heads of acute and chronic glanders. Symptoms of Acute Glanders.—When the disease has been imparted by accidental inoculation, in a period of time varying from two or three days to a week, inflammation occurs at the point where the poison was applied, and extends more or less along the absorbents, and into the neighbouring cellular tissue, with the occurrence of febrile symptoms. Sometimes, however, there is little or none of this preliminary affection, and sometimes, after having taken place, it subsides before the characteristic phenomena show themselves. In many instances, the disease commences without any apparent local cause, as if contracted through the atmosphere. The first symptoms are those of an attack of fever, such as general uneasi- ness, languor, weariness, rigors, sometimes nausea and vomiting, headache, &c, followed by a frequent pulse, hot dry skin, thirst, and a furred tongue. Along with these are acute pains in the joints, generally confined to the limbs, but sometimes affecting the trunk, bearing a close resemblance to those of rheumatism, for which they have in some instances been mistaken. These pains are among the most characteristic phenomena of the earliest stage, and occasionally precede for a considerable time the occurrence of other symp- toms. Portions of the skin over the painful joint or joints, or upon the face, become red as in erysipelas ; but soon assume a violet colour, and show the bad tendencies of the disease by vesicles and patches of gangrene. At a variable time from the commencement of the attack, usually, perhaps, in about a week, an eruption of phlyzacious pustules takes place, most abund- ant on the face and limbs, about the size of the vaccine vesicle, having fre- quently a small red areola, sometimes umbilicated, and presenting occasionally a dark-purple hue. They occur in successive crops, and appear, therefore, in different stages of progress at the same period of the disease. Dr. H. Graves, of Dublin, has observed a white zone about the pustules in two cases, and considers this as characteristic of the disease. Along with these pustules are gangrenous bulla?, especially on the face and scalp; prominent ecchymoses filled with a reddish sanies, and having sometimes a gangrenous base; and tumours from one to three inches or more in diameter, which are at first hard and painful, but soon suppurate, and form abscesses in the subcutaneous cellular tissue, and often deep in the substance of the muscles. At a still later period, sometimes not until a few days before the close of the complaint, the nostrils begin to discharge a mucous or purulent fluid, which is at first yellowish, afterwards dark from the admixture of blood, and often extremely offensive. In some instances, it is thin and sanious, but more frequently viscid and tenacious, adhering to the sides of the nostrils, and to the upper lip, forming characteristic crusts, and excoriating the parts which it touches. Sometimes this secretion flows back into the fauces, and, being swallowed, does not appear externally. The nostrils are more or less obstructed by the swelling of the membrane, even before the occurrence of the discharge, and become still more so afterwards, so as much to impede respiration. Gangrenous openings sometimes take place in the cartilaginous septum, so that a probe may pass from one nostril into the other. In cer- tain cases, the discharge makes its appearance early in the disease ; and in most, it is probable that, long before its occurrence, a close examination would exhibit evidences of inflammation in the Schneiderian membrane. The salivary glands are occasionally swollen ; the mouth and fauces are in- flamed in spots or patches; and the larynx, in some instances, so much par- 456 GENERAL DISEASES.—FEVERS. [TART II. ticipates in the disorder as to endanger suffocation by the closure of the glottis. The lungs are not unfrequently involved, and a cough occurs with rusty or adhesive expectoration. The face exhibits in a peculiar manner the ravages of the disease. The nose is red and swollen ; a gangrenous inflammation extends to the lips, eye- lids, and forehead ; one or both eyes are closed by tumefaction ; and eschars form, surrounded by a dark-red or livid edematous border, with awful muti- lation of the features. The general symptoms are in accordance with these local phenomena. The skin is hot; the tongue dry and coated; the respiration hurried or laborious and sometimes stertorous ; the pulse frequent, small, and feeble. There is often extreme thirst. Diarrhoea is an almost constant symptom, with fre- quent, offensive discharges. The body exhales a fetid odour. The mind wanders, and delirium alternates with coma. At length involuntary dis- charges and extreme prostration indicate the immediate approach of death. The duration of the disease varies in general from two to three weeks. Some- times death takes place earlier than the former period, from some incidental cause, such as closure of the glottis, and occasionally it is postponed to the end of the fourth or fifth week. The symptoms enumerated do not all occur in every case, nor always in the order stated. In some instances, the nasal phenomena predominate, in others, the carbunculous or eruptive; and one of these sets of symptoms may occur to the exclusion of the other. But, whatever may be the precise course of the acute complaint, the event is almost invariably the same. The patients nearly all die. In only a few cases, and those either very mild or of doubtful nature, is recovery reported to have taken place.* Symptoms of Chronic Glanders.—The cases which have been recorded as belonging to this variety of the affection are comparatively few, and its his- tory is less satisfactorily made out than that of the acute form. Nevertheless, there seems no good reason to doubt that the complaint does occasionally assume a chronic character. In the mildest cases, the symptoms are some- times confined to the nasal passages and the communicating cavities, from which an offensive discharge issues, sometimes glutinous, sometimes purulent or sanious. This form of the disease may get well under treatment; in which case, unless its origin be very clearly traced, its nature must always remain doubtful. In other instances, after a variable duration of several months, the nasal affection becomes complicated with tumours, acute symptoms super- vene, and the patient speedily perishes. Instead of being at first restricted to the nostrils, the complaint may show itself by pains in the joints, with spots of redness on the limbs, and suppurating tumours, which may continue for months, and at length, becoming complicated with disease of the nostrils, may run on to a fatal termination. There have been no instances of chronic glanders, in which the peculiar pustular eruption has existed. Anatomical Characters.—Besides the external lesions wliich are evident during life, dissection reveals bloody infiltration, gangrene, and suppuration of the cellular tissue; abscesses in the muscles; thickening, softening, and redness of the Schneiderian membrane, which is covered with a grayish mucus, and is studded with numerous minute yellowish elevations, of the size of a small shot, sometimes isolated, sometimes clustered, and filled with pus or a thick lymph; ulceration and gangrene of the same membrane, with de- * See Archives Gen., 4e ser., xiv. 89; xviii. 222; and xxvii. 419. For cases described by Dr. F. W. Mackenzie, see the Lond. Journ. of Med. for Sept., 1851, p. 789, and the Lond. Mad. Times and Gaz. for July, 1852, p. 7. Neither of these cases can, I'think, be considered as undoubted examples of the disease; and still less a third case, in which a cure took place, described in the last-mentioned Journal for March, 1854, p. 303. CLASS I.] DENGUE. 457 nudation and caries of the bone, and sometimes an opening through the sep- tum ; the same eruptive appearances, to a certain extent, in the soft palate and the fauces ; tumefaction of the glottis; and abscesses in the lungs, or more frequently the marks of lobular pneumonia abundantly diffused through those organs. The alimentary canal, the heart, and the large interior glands, are not prominently affected. The blood retains its coagulability, and does not present the dark tar-like appearance sometimes noticed in malignant fevers. Cause.—The cause is well ascertained to be a poison generated in the horse, and other animals of the same genus, as the ass and mule, affected with glan- ders. The disease is imparted either by contact of the poisonous secretion with some abraded point on the surface; by its introduction into the stomach, as when the patient has drank out of the same vessel with the animal; or through the medium of the atmosphere, though this last mode of communica- , tion is somewhat doubtful. Persons have been affected with it who have lodged in the same stable, or been otherwise in close communication with the diseased animal, without being able to trace it to direct contact of the matter with an abraded spot. The case of a woman is recorded who was supposed to have been attacked from working among horse-hair. Others have suffered in consequence of washing the linen of persons diseased, showing that it is communicable from man to man. It appears that few individuals are sus- ceptible of glanders; for the proportion of those who have been attacked after exposure is extremely small. It is said that the persons affected have generally been of intemperate habits, or of constitutions otherwise debilitated. Treatment.—In relation to the acute disease, the methods of treatment hitherto employed having proved almost invariably unavailing, it is scarcely worth while to occupy space by detailing them. The practitioner must be left to the guidance of his own medical principles. Having had no experience in the complaint, I do not feel authorized even to offer suggestions. In a case of supposed glanders recorded by Dr. Mackenzie, which ended favourably, the treatment consisted in an emetic dose of ipecacuanha, followed by five grains of the carbonate of ammonia every two hours, the use of wine or porter, an opiate at night, nourishing food, a small quantity of the blue pill, and a gargle of solution of chloride of lime. Another case reported by Mr. Car- penter, of England, and considered by him to be glanders, recovered under the use of opium and mercury pushed to ptyalism, and subsequently of alco- holic stimulants, nutritious food, and citric acid given as an antiscorbutic. (Lond. Med. Times and Gaz., Aug., 1855, p. 111.) In the chronic affection, Dr. Elliotson found advantage from the injection of a solution of creasote into the nostrils, while the same medicine was given internally. Two cases in which only one nostril and the frontal sinuses were affected, are stated by him to have yielded to this remedy. Another case, which recovered under the care of Mr. Travers, was treated chiefly with emetics. Article XIV DENGUE. Syn.—Breakbone Fever.—Dandy Fever.—Dunga. By the above names has been designated a peculiar febrile disease, char- acterized by the presence conjointly or separately of rheumatic symptoms and cutaneous eruption, and always, so far as has been observed, occurring epidemically. The first notice of it is contained in an account by Dr. Rush of an epidemic which prevailed in Philadelphia, in the summer and autumn 458 GENERAL DISEASES.—FEVERS. [PART II. of 1780, and which he described under the name of " bilious remitting fever," stating, at the same time, that it was commonly called "breakbone fever," in consequence of the violence of its attendant pains. (Medical Inquiries and Observations, 3d ed., ii. 385.) In 1824, the disease prevailed at Calcutta, and was described by Dr. James Mellis, iu the Transactions of the Medical and Physical Society of that city. (Am. Journ. of Med. Sci, iv. 495.) To- wards the close of 1827, an epidemic broke out in the West Indies, whence it proceeded to the continent, reaching New Orleans in the spring, and Charleston and Savannah in the summer and autumn of the following year. It was to this that the name of dengue was first applied, the origin of which is somewhat uncertain, though it is supposed to be a Spanish corruption of the word dandy; the name of dandy fever having been jocosely conferred on the disease by the negroes of St. Thomas, where it first appeared, from the stiff carriage of those affected with it. Various accounts were given of this epi- demic, of which the most satisfactory are probably those of Dr. S. H. Dick- son, who described it as it appeared in Charleston (see BelVs Library for 1839), and Dr. Wm. R. Waring, whose communication in relation to it ap- peared in the North American Medical and Surgical Journal (ix. 374). Ac- cording to Dr. Waring, the disease first appeared in Savannah in the autumn of 1826, and prevailed to a certain degree in the following year; but the Spanish name dengue was not applied to it until the attack of the epidemic in the autumn of 1828. For a long time after this period nothing was heard of it; but in the summer of 1850 it again visited the South, and Charleston suffered from it with special severity. A history of the epidemic, as it pre- vailed the second time in that city, was communicated to the Charleston Medi- cal Journal for November of the same year, by Dr. S. H. Dickson; and it is from the published accounts of that author, and of Dr. Waring, that the fol- lowing summary has been chiefly drawn. I have had no opportunity of seeing the disease. Symptoms, Course, dec.—In many cases, the complaint comes on gradually; but in the greater number its commencement is somewhat abrupt, though there is seldom a regular, well-formed chill. The first symptoms are usually headache with intolerance of light, general uneasiness, restlessness, sometimes more or less chilliness, a sense of great debility, and violent pains in the back, limbs, and joints, attended often with some degree of tumefaction, and with soreness and stiffness of the muscles, very much resembling rheumatism. The small as well as the large joints are affected, and sometimes the pain is first felt in the thumb or fingers. It is occasionally confined to one part, but sel- dom ; and, when it attacks several parts, may seize upon them all at once, or successively. In some cases it affects the stomach and bowels. The skin soon becomes hot and dry, the pulse increased in frequency, the face flushed, and the eyes red and watery. The tongue, however, though red, is usually clean at this stage. Sometimes a rash or papular eruption appears, but not gene- rally at this early period. Not unfrequently the patient exhibits drowsiness, which may continue in greater or less degree throughout the complaint. Children are sometimes attacked with convulsions, and pregnant women are apt to miscarry. Painful swellings of the lymphatic glands in the neck, axilla, and groin, and of the testicles, occur in some cases, and continue after the subsidence of the other symptoms. The initial fever lasts from twelve hours to three or four days, perhaps, on the average, about a day and a half; after which it subsides, leaving the patient much more comfortable, but often very feeble. Then follows an interval of two, three, or four days, during which the patient is without fever, and suffers less from the pains, though he still complains somewhat of rheumatic sensations, and of general weakness. On the fourth or fifth day, there is often a return of the fever and pains, and the CLASS I.] DENGUE. 459 tongue now becomes thickly coated. In some instances, however, there is no febrile heat or frequency of pulse, but severe pain in the head. Nausea and epigastric uneasiness are prominent symptoms, but the patient seldom vomits. On the fifth, sixth, or seventh day, an eruption usually appears, more especially upon the upper portion of the body, and gives relief to the symp- toms of internal irritation. This eruption is extremely variable in character, being sometimes smooth, red, and continuous, as in scarlatina; sometimes in patches, rough, and of a darker hue, as in measles; and occasionally, also, either papular, vesicular, pustular, or furunculous; and often there is a mix- ture of two or more of these forms. Cutaneous affections like urticaria and erysipelas are also occasionally observed; and even carbuncles occur. In some few instances, the eruption assumes the petechial character; the gums are red, spongy, and bleeding; and soreness of the mouth, with ulcers, com- plicates the case. The cutaneous affection is attended usually with heat and itching. Upon disappearing, it is sometimes followed by a furfuraceous or scaly desquamation. The complaint gradually subsides, leaving the patient for the most part with some rheumatic stiffness or soreness for a longer or shorter period, and with feelings of weakness, and occasionally of mental depression. Sometimes the debility is very considerable, and even alarming, with a slow, weak pulse, cold sweats, and a purplish or livid appearance of the eruption. The duration of the affection varies with the length of the remission, but on the average, is about eight days. Sometimes the cases are much milder; and, as in other epidemics, there is every grade, from a scarcely observable disorder to the greatest intensity of which the disease is susceptible. The course of symptoms above detailed bears a considerable resemblance to that of yellow fever; and the two affections have sometimes been confounded. The persevering rheumatic symptoms, and the cutaneous eruptions are, how- ever, sufficiently diagnostic ofthe dengue. It is not improbable that the causes ofthe two affections may sometimes prevail at the same time ; in which case, the yellow fever may take on some of the characters of this peculiar epidemic, and the diagnosis be rendered more difficult. Another striking distinction between the two diseases is the great difference in their results. The yellow fever is very often fatal, the dengue almost never. Cause.—No other cause of this affection is known than epidemic influence. It has been ascribed to contagion; but the proofs of this are insufficient. Conta- gious affections do not so rapidly disappear without leaving traces behind them. Besides, it is stated that, when families are attacked, it is not a single member of the family that is first affected, and afterwards at a certain period several others; but almost all are seized at once, or in rapid succession, so that there are not enough well to attend on the sick. This epidemic differs from almost all others in the numbers affected in proportion to the population. The great majority of the people usually suffer. The epidemic which in this respect most nearly resembles it, is the influenza. It attacks indiscriminately persons of both sexes, of all colours, and of all ages from earliest infancy to extreme old age. The period of incubation is extremely variable, being in some in- stances, as asserted, only twenty-four hours, and in others as long as ten days. Prognosis.—This is almost always favourable. Perhaps no disease with so much severity of symptoms is so seldom fatal. When death occurs, it is almost always in consequence of some incidental complication, or of the great previous weakness of the patient, as in very advanced life. Treatment.—Where all the patients recover, treatment is to be employed simply to palliate and alleviate. An emetic, administered at the very earliest period, is said sometimes to have arrested its progress; but so disagreeable a remedy will probably not be generally resorted to in an affection attended with so little danger. Some gentle aperient may be given early in the attack, 460 GENERAL DISEASES.—FEVERS. [PART II. and subsequently if the bowels should be confined. When the skin is hot and dry, the neutral mixture or other refrigerant diaphoretic maybe adminis- tered. In very violent cases of headache, a small bleeding has been recom- mended as affording relief. But the most important remedies are anodynes, to relieve the exquisite pains. Of these opium is the most efficient. It may, be given in any quantity requisite to produce the desired effect, so that it do not occasion stupefaction. When there is no nausea, it is probably best given in the form of Dover's powder. In light cases, the camphorated tinc- ture of opium is sufficient. The warm bath might be expected to afford relief. It is often advisable to counteract the depressed state of the system by stimulants, as by wine, the malt liquors, or even brandy; and nutritious food should be given at the.same time. Some practitioners treated their patients on the expectant plan; prescribing rest, a recumbent position, cold to the head, hot pediluvia, and a regulated diet. Article XV MILK-SICKNESS. This affection, though frequently described in the medical journals of this country, has not hitherto, I believe, been fully considered in any systematic treatise. This is owing partly to its limited prevalence, so that very few relatively have had the opportunity of seeing it, and partly to the uncer- tainty which has existed as to its origin and character; many physicians, even among those residing at no great distance from the places infested by it, entertaining strong doubts of its claims to be considered as a distinct dis- ease, and some denying its existence altogether. I have myself never seen a case of it; but, having examined carefully the accounts of those who have witnessed and practiced among it, and compared the statements of different physicians, who at different times, and from different sections of the country, have recorded the results of their observation, I have remarked so close a coincidence in their descriptions, and at the same time so peculiar and char- acteristic an association of symptoms in the pictures they present, that I cannot hesitate to recognize the disease as quite distinct and specific; not less so, indeed, than most of those belonging to the class now under con- sideration. My reasons for placing it in this category will soon be obvious. I will here merely state, that I believe it to be a febrile disease, arising from a specific cause, which operates through the blood upon the system at large, and, like the contagious poisons, has the property of reproducing itself in all parts of the body. In preparing the following notice, I have relied mainly on four papers; one by Dr. Win. W. Lea, published in the year 1821, in the Philadelphia Journal of the Medical and Physical Sciences (vol. ii. p. 50.); another, by Dr. Guy W. Wright, in the Western Medical and Physi- cal Journal, for October, 1827, published at Cincinnati; the third by Dr. Geo. B. Graff, in the American Journal of Med. Sciences, for April, 1841 (N. S., i. 351) ; and the fourth, an elaborate and excellent essay, by Dr. W. H. Byford, in the Nashville Journal of Medicine and Surgery, for Decem- ber, 1855 (vol. ix. p. 460). Each of these writers has seen the disease in a distinct locality; Dr. Lea, in Tennessee; Dr. Wright, in Kentucky; Dr. Graff, in Illinois; and Dr. Byford, in Indiana. Many others have contributed valuable papers to the journals; but most if not all that is known of the affection is contained in those mentioned. Any fact derived from other sources will be referred to the proper authority. The disease derived its name of milk-sickness, from the supposition that CLASS I.] MILK-SICKNESS. 461 it is received through the milk of cows affected with it. According to the late Dr. Drake, it was known in North Carolina more than 80 years ago. (West. Journ. of Med. and Phys. Sci, ix. 243.) But it attracted little at- tention until after the beginning ofthe present century; and I am not aware that anything was communicated to the medical journals anterior to the year 1812. From North Carolina it followed emigration westward to Ten- nessee and Kentucky, and has prevailed in various parts of Ohio, Indiana, and Illinois, where it is still occasionally seen in the new settlements. An interesting and most significant fact in relation to its locality is, that it oc- curs only in places where the soil is still in its virgin state, and disappears immediately after cultivation. The subject of its etiology will be treated of more particularly hereafter. At present it is sufficient to say, that the dis- ease in man is generally believed to be produced by the use, as food, of the flesh, or milk, or of the butter or cheese made from the milk, of cows or other animals, which have become poisoned in a peculiar way, in consequence of frequenting certain limited places of pasturage. Symptoms in the Lower Animals.—The disease occurs originally only in the herbiverous animals, as the ox, horse, sheep, and goat; but is imparted to the carniverous which feed on the flesh of the former, as the dog, and the vulture. * In the beginning, the symptoms are not well marked, so that the milk and flesh of really diseased animals may be inadvertently used, under the supposition that the animal is in good health. If, however, in this condition, they are made to run rapidly, or to exert themselves violently in any other manner, they evince signs of the affection in muscular weakness and trem- blings ; and, if greatly over-fatigued, sometimes fall, and die speedily in con- vulsions. If left undisturbed, the animal loses its appetite, walks about as if without object, is inattentive to things around it, has its eyes red and suf- fused, after a while begins to stagger, trembles throughout the whole body, and at length falls, is seized with convulsions, and dies. The trembling is so characteristic a symptom as to have given origin to the name of "trem- bles,^ by which the disease is called as it occurs in the lower animals. Dr. Graff, in his experiments on dogs, found them to show signs of disease in forty-eight hours after eating the poisoned food, and to die in about six days or earlier. Symptoms in Man.—Like most other affections of this class, the disease begins sometimes abruptly, but more frequently with preliminary symptoms of disorder in the nervous and digestive functions. Sensations of weariness or lassitude, general uneasiness, muscular weakness, anorexia, and constipa- tion, are among the most frequent of these symptoms. In some instances, the patient is restless and irritable; in others, heavy, stupid, and indifferent. Dr. Graff says that an offensive odour of the breath may be generally per- ceived, before the other characteristic symptoms become developed. The occurrence of excessive nausea and vomiting, with sensations of burn- ing and weight in the epigastrium, mark the commencement of the fully formed disease. The vomiting is incessant, and extremely difficult to be con- trolled ; the matter discharged being first the substances swallowed, and after- wards a sour and acrid fluid, of a greenish, bluish, or brownish colour, which separates into a clear liquid and coagulated matter on repose. The bowels are obstinately constipated, and, if any spontaneous evacuation takes place, it is scanty, and in small, hard, and dry lumps, which are discharged with difficulty. There is also excessive thirst, and, often, as is asserted, an urgent and irresistible craving for spirituous liquors. The abdomen is contracted * Dr. Graff says that the hog is insusceptible of the disease. He fed a sow for a fort- night on the poisonous tiesh, such as had killed dogs, with no other effect than to fatten the animal. (Am. Journ. of Med. Sci., April 1841, p. 362.) 462 GENERAL DISEASES.—FEVERS. [PART II. and hard; and the pulsation of the aorta may be felt along its whole course, from the epigastrium to the bifurcation of the vessel. The pulse is in general at first little increased in frequency; and the skin is scarcely warmer than in health, but dry, and somewhat dusky. The tongue is furred, and of a whitish, yellowish, or brownish colour. The respi- ration is disordered, with occasional sighing, and a distressing sense of op- pression in the chest. The bilious and urinary secretions are diminished; and the patient is usually low-spirited and apprehensive. Neuralgic pains are sometimes felt in the back and extremities. One of the most characteristic symptoms is an excessively offensive smell of the breath, which renders the apartment almost untenantable by sensitive persons, and may sometimes be perceived on entering the outer door of the dwelling. The odour is peculiar, and quite distinct from that of any other disease. Dr. Byford compares it to a mixed smell of chloroform and mer- curial salivation. If the disease is not arrested, the irritation of stomach increases, and the discharges, if not previously black, now become so, and sometimes have the coffee-grounds character of the black vomit of yellow fever. The breathing becomes more oppressive, with a sense of sinking in the chest, and an ina- bility to supply the want that is felt. The pulse is now small, frequent, and feeble; the countenance shrunk and anxious; and the surface either gene- rally cool, or cool in the extremities, while the trunk is hot. After several days, perhaps a week from the commencement, if the bowels have not been evacuated, they are apt to give way spontaneously; tympanitic distension takes place; and the patient suffers with griping pains, and has frequent watery or mucous discharges tinged with blood. The tongue now becomes dry, red, and fissured, or is covered with a dark fur, while sordes collect about the teeth; soreness of throat, with difficult deglutition, sometimes oc- curs ; and the patient not unfrequently lies on his back, with his legs drawn up, as if to relieve the tension of the abdomen. The urine, as in other low fevers, if secreted at all, is liable to be retained in the bladder. These symp- toms may continue a few hours, or perhaps a few days ; when stupor*comes on, the pulse ceases to be felt at the wrist and death takes place, preceded by profound coma. A favourable course of the disease is marked by a gradual diminution of all the characteristic symptoms, till they quite disappear, and the patient is restored to sound health. But not unfrequently the convalescence is very tedious, and a liability to relapse remains, which may at any time, for months, be called into action by fatigue, or exposure either to excessive heat or to vicissitudes of temperature. The description above given applies to the ordinary form of the disease; but it is subject to considerable diversity. Dr. Byford calls attention to two varieties, which he distinguishes as the inflammatory and congestive ; the lat- ter term belonging to the cases which are frequently designated as malignant, with a depraved state of the blood, and great nervous prostration. The inflammatory variety is characterized by high febrile excitement, with severe headache, heat of skin, a frequent, full, and hard pulse, and severe pain and tenderness on pressure in the stomach and bowels; the symptoms in other respects being those of the ordinary form. The malignant variety is exceedingly violent and fatal, resembling in this respect pernicious miasmatic fever. It is distinguished by extreme anxiety from the beginning, restlessness, jactitation, a sense of suffocation, insatiable thirst, and longing for spirituous drinks, a small, frequent, and very feeble pulse, coldness of the extremities, and great prostration. There are the same offensive odour, irritability of stomach, and obstinate constipation as in the CLASS I.] MILK-SICKNESS. 463 other cass. The urine is often suppressed. When not prevented by efficient measures, early employed, death with coma generally takes place within two or three days, and sometimes in as short a period as twelve hours. Besides the variations described, the disease is also liable to modification through any epidemic influence which may be prevalent. Though in the uiaiignant cases death, as already stated, may occur in twelve hours, the disease generally runs a course, whether to convalescence or to a fatal issue, in a period varying from five to fifteen days. Anatomical Characters.—Little that is satisfactory is known upon this point; as post-mortem examinations are generally precluded by the pre- judices of the people where the disease prevails. Dr. Graff found in dugs. which had been suddenly destroyed by the poison, congestion of the brain, with extravasation of blood upon the surface and in the ventricles, and also congestion of the thoracic and abdominal viscera. In those which had perished more slowly, coagulable lymph or pus was found beneath the dura mater and in the ventricles: the brain was softened; the liver and spleen were conges too. and the latter much enlarged and softened; evidences of peritonitis were sometimes visible: the stoma-.-h was much contracted, and its mucous membrane softened and disorganized. The blood was perfectly bquid through- out the body, and no coagulum was anywhere seen. In a woman who died of the disease, he found inflammation of the meninges, and congestion with softening of the substance of the brain; the stomach and bowels were slightly contracted, and the mucous membrane was reddened in places: there were a few ounces of bloody serum in the peritoneal cavity; the liver was deeply engorged and darker than in health, and the gall-bladder was distended with viscid 1 'i.e. Dr. Wm. Trafton, of E vansville. la., is stated by Dr. Byford to have found inflammation of the mucous membrane of the stomach, rigid contraction of the pyloric orifice, a dry and hard condition of the feculent matter in the bowels, and a total absence of intestinal gases. Cau^e.—On this point there has been and continues to be great difference of opinion. Facts admitted on all hands are, that the cause ofthe disease is confined within certain definite limits, to certain fields for example, certain valleys or recesses in the hills, or certain veins or tracts of country of con- siderable extent -. that it is operative only wlnle the sod remains in a virgin state, and ceases immediately after cultivation; and that herbiverous animals while fed in these grounds, and especially if they are confined upon them during the night, or are driven to them early in the morning, are often attacked with the disease, and perish in great numbers. Most persons, more- over, admit that the disease prevails more especially in the latter part of sum- mer and during autumn, when the miasmatic fevers are most rife; though it may occur at any season. But here the agreement ends. Very different opinions are entertained as to what it is that imparts the disease to the ani- mals, and how man becomes affected. Some have looked for the cause in mineral impregnation of the sod or the springs, or inorganic exhalation- of a poisonous character. But nothing of this kind has been found upon the most careful search; nor is there any known mineral which is capable of producing such pathological results. Others, and perhaps the majority, ascribe the disease in animals to the eating of one ■ r more poisonous plants which grow only in the virgin soil, and are destroyed by cultivation; and some imagine that they have detected this plant in the common Rhus radicals or poison vine. But, when it is con- sidered that this plant grows abundantly, and i- equally liable to be eaten by cattle, in many place- where the disease is unknown, this idea must be aban- doned. There is no known plant which produces effects at all corresponding with the symptoms of milk-sickness; and to me it seems quite impossible, that 464 GENERAL DISEASES.—FEVERS. [PART II. any single vegetable poisonous principle should, by entrance into the stomach, and absorption into the circulation, produce that series of phenomena, which, upon the best authority, are alleged to result from the influence of the real poisonous agent in the case. We must, therefore, I think, seek further for the cause of the disease in animals. But first it is necessary to determine, if possible, how it is imparted to the human subject. The weight of testimony, and, as it appears to me, of probability, is alto- gether in favour of the universal popular opinion, that man derives the dis- ease from the lower animals, by eating their flesh, milk, or some derivative of the milk, as butter or cheese. It is true that some medical men ascribe the affection in the human subject, as well as in the lower animals, to malarious influence; and in favor of this opinion adduce the asserted fact, that persons have sometimes been attacked by remaining exposed, in the infected region, during the night, or early in the morning, while the dew was yet on the ground. They also rely much upon the occurrence of the disease more espe- cially at the malarious period. But the first supposed fact is very doubtful; and the great mass of testimony is strong to the point, that the disease is produced in man solely by partaking of some product ofthe diseased animal. Most of the cases can be directly traced to such an origin; and, as to the few in which no positive proof exists, presumption is decidedly in favour of the idea that they must have partaken of poisoned food unawares. As to the other fact, that the disease occurs more particularly at the period when mias- matic fevers prevail, it amounts to nothing, unless a strong resemblance can be shown between the two affections; and certainly, if any reliance can be placed on testimony, no such close resemblance exists. It may well happen that the cause, whatever it may be, is liable to be affected in a similar manner with the malarious cause, by a change in the seasons, without giving any grounds for the hypothesis of an identity, or even close similarity of character. The bilious and yellow fevers prevail at the same season; but are wholly dis- tinct diseases. Besides, experiments on other animals have proved the fact of the conveyance of the disease through the flesh or milk of the diseased. Thus, dogs have been fed on the poisonous flesh, and have speedily perished with all the characteristic phenomena of the complaint. Vultures have fed on the carcases of dogs which have thus died, and have themselves been fatally poisoned. The young litter of a bitch, which had been poisoned, quickly suffered death after having sucked the mother's milk. All these facts show, not only that the flesh and milk of diseased animals are capable when eaten of imparting the disease to others, but also that, when the cause has once been introduced into the system, it has the property of self-propagation, and of imparting the same poisonous properties to the flesh and secretions of the animal last affected. Thus, each pound of the flesh of a dog, which has been poisoned by a pound of the flesh of a cow, is capable of producing as much effect on another animal as the single pound taken by the dog. Now there is no known mineral or vegetable principle, which, taken into the system, can thus multiply itself; and the miasmatic influence, which produces intermittent and remittent fevers, is equally incapable of such self-propagation. It appears to me that there is but one mode of approaching an explanation of these various phenomena. Providence may have planted in the rotten soil of our new lands certain germs, which find a nidus, and circumstances favourable to their development only there; and, when these circumstances cease upon the cultivation of the lands, the germs necessarily perish. Thus the germ of yellow fever finds its home in the decaying vegetable and animal matters of the tropics; that of the plague in the filth of Egypt; that of the proper typhus fever in the decomposing effluvia and excretions of congregated men. It is possible that the germ of milk-sickness may rise into development CLASS I.] MILK-SICKNESS. 465 with the plants of its native fields, and die with them in the winter; leaving new germs in the soil, to be developed in their turn in the following season, or to perish utterly, should the ground be turned up to the sun and air in the process of cultivation. Now these germs, taken, along with the plants in which they may be undergoing development and reproduction, into the system of the grazing animal, find there a suitable nidus, in which they maybe developed and reproduced, so as to impregnate the whole body, while they often destroy the animal by interfering with its vital functions. Taken with the flesh or milk of the herbivorous animal, into the human system, they may undergo the same changes there, with the like result as to their own multiplication, and the health and life of the individual. Of the nature of these germs we are quite ignorant. They may be microscopic animalcules or mushrooms; or they may be something else, of which we know absolutely nothing but their effects. All that is required is that they should have the property of self-propagation under favouring circumstances. According to Dr. Graff, the period of incu- bation, from the reception of the poison to the appearance of the symptoms, varies from three to ten days. Nature.—My opinion as to the nature of this affection will be inferred from the above remarks in relation to its cause. It seems to me most in accordance with known facts and analogies, to consider it as belonging to the category of what are called zymotic diseases; those, namely, which owe their existence to a cause received into the blood, and having the property of reproducing itself in its new site; the same category as that to which belong also the plague, smallpox, and typhus fever. That milk-sickness is not contagious. like smallpox or typhus, may be owing to the non-volatile nature of the cause; and, if it cannot be imparted by inoculation, as has been asserted, this may be owing to the insufficient quantity of the poison, existing in the matter employed in the process. If these views of the nature of the malady be cor- rect, boiling or roasting the poisonous meat ought to destroy the germ, and thus render it innoxious.* Milk, butter, or cheese would be the most effective vehicle of the poison; and, taking into view the probability that these articles, at least the last two, maybe sent from the infected localities to distant places. and there consumed, we have an explanation of certain violent anomalous affections occasionally occurring in our cities, which those not familiar with milk-sickness are unable to classify, and a warning to provide against possible injury from such a cause. Prognosis.—Very different accounts have been given of the fatality of this disease. It is highly probable that, in certain localities and seasons, like most other diseases of the kind, it is much milder or severer than in others. Some- thing is probably also due to the different modes of treatment. Copious bleeding and the profuse use of mercury have sometimes been resorted to; and it can be readily understood that, if these measures were employed indis- criminately, the natural fatality of the disease might be much increased. Some- times almost all the members of a family attacked with it die. Dr. Graff states that the mortality greatly exceeds one-half of those affected. On the other hand, some writers speak of it as in general a very curable disease. Dr. Wright treated thirty cases, and lost but one. Dr. J. W. Crooks, of Rockport, la., states that for fifteen years, during which he had been prac- tising among the disease, not a patient of his had died of it. (North-Western Med. and Surg. Journ., Nov. 1857, p. 492.) Dr. Byford very judiciously * Confirmatory of this view as to innoxiousness of the flesh of the diseased animal, when properly cooked, is the fact stated by Dr. G. W. Wright, that a butcher had pur- chased not less than 1000 cattle annually from the infected districts, which had been sold from his stalls in Cincinnati in the shape of beef, and yet no case of milk-sickness had resulted. (West. Med. and Phys. Journ., Oct. 1827, p. 378.) VOL. I. 30 466 GENERAL DISEASES.--FEVERS. [PART II. considers the mortality in connection with the several varieties of the disease. In the common form of it, almost all recover whether treated or not, and sometimes under very inappropriate treatment. The variety complicated with severe inflammation is much more dangerous. The malignant form is extremely fatal, unless properly managed; but even this, if treated early and judiciously, often ends in recovery. Diagnosis.—The prominent diagnostic characters of milk-sickness are vio- lent and incessant vomiting, obstinate constipation, the absence for the most part of bile in the matters discharged, a retracted and hardened state of the abdomen, distressing sensations in the stomach and bowels, great mental dis- comfort, an excessively offensive and peculiar odour of the breath, and, with these, the evidences occasionally present of abdominal or encephalic inflam- mation, and, in the worst cases, of a depraved state of the blood, and great nervous prostration. Treatment—The indications of treatment appear to be to correct func- tional disorder, to obviate injury from inflammation or active congestion when it occurs, and to support the system until the poisonous matter has been eliminated. Some add to these an obedience to the apparent call of nature in the craving for ardent spirit, which they give, moreover, under the impression that it has an antidotal effect to animal poisons. In reference to the first indication, all agree that it is important to over- come the characteristic constipation, and relieve the excessive nausea and vom- iting. There is considerable difference of opinion as to the proper methods of effecting these objects. Some have employed calomel very largely, and in repeated doses ; others appear to eschew this medicine altogether. Opium would seem to be indicated for the relief of the vomiting, and is employed by some; but the general opinion seems to be adverse to its use. It is said to fail in relieving the vomiting, while it increases the difficulty of pro- curing biliary secretion, and of evacuating the bowels. Perhaps, after the bowels have been thoroughly evacuated, it might be found useful by enema, if the vomiting should continue. The course of treatment which seems to me fairly deducible from the symptoms, and from the statements of ex- perienced practitioners is the following. First, let the patient drink freely of some bland, warm fluid, so as tho- roughly to wash out the stomach; then apply to the epigastrium a large cataplasm of strong mustard, which should be allowed to remain until the patient can well bear it no longer; and, when this has made itself felt de- cidedly, administer from five to twenty grains of calomel, according to the urgency of the occasion, or the known susceptibility of the patient. It ap- pears to me that calomel is indicated, as one of the cathartics which is best tolerated by an irritable stomach, and, on account of its weight, least likely to be wholly rejected. Besides, it is wanted as a cholagogue. From the quantity mentioned, as much good can be obtained as from much larger doses, while the risk of a disagreeable salivation is much less. The calo- mel should be followed in a short time by other cathartics. In similar con- ditions of the stomach, I have found the infusion of senna, with manna fennel-seed, and sulphate of magnesia, or one of the other neutral purgative salts, given in wineglassful doses every two hours, to be among the most acceptable and efficient cathartic preparations. Dr. Byford suggests a Seid- litz powder, with a double portion of the Rochelle salt contained in it to be given every hour; and this is undoubtedly an excellent cathartic under ' the circumstances. Magnesia seems to be indicated as an antacid and might with propriety be added to the other medicines. The solution of citrate of magnesia might prove useful; being rather agreeable to the taste and usually well retained by the stomach. Castor oil, if not repulsive to CLASS I.] MILK-SICKNESS. 467 the patient, might be tried. Dr. Byford states that Dr. Bacon employed cro- ton oil, enclosed in the centre of a bolus of blue mass, and seldom failed to procure the desired effect. The action of the cathartic should be aided by purgative enemata; and, if these fail, recourse may be had to the injection into the bowels of large quantities of warm water, with sulphate of mag- nesia or castor oil. Dr. Byford has thrown up from half a gallon to a gallon at a time. While these measures are in operation, the patient maybe allowed to hold in his mouth, and occasionally swallow small pieces of ice. If carbonic acid water could be obtained, small draughts of it cooled with ice, and frequently repeated, would probably be very useful. Dr. Trafton, who was very suc- cessful in the treatment of the disease, was in the habit of using yeast for the same purpose. Some allow the patient to drink wine or whiskey and water ad libitum. Dr. de Bruller gives whiskey and sulphate of magnesia to- gether, and considers nothing else necessary. (Nashv. Journ. of Med. and Surg., Dec, 1855, p. 471.) Dr. J. W. Crooks, who for fifteen years has not lost a patient, uses alcoholic drinks, morphia, and blisters to arrest the vomiting, and states that, if compelled to limit his choice to a single remedy, he would select whiskey. He thinks that the alcohol neutralizes the poison, and that, in its turn, the alcohol is neutralized, as "it is almost impossible to produce intoxication." He prefers, for the cathartic effect, sulphate of mag- nesia with calcined magnesia. After the bowels have been well evacuated, care should be taken to keep them so ; and, if the secretion of bile should not have been restored, the blue mass or calomel, in small doses, should be given in connection or alternation with the purgative. Lime-water and milk in tablespoonful doses of each, mixed, and repeated every hour, may be tried if the vomiting continue. In simple cases little other treatment is necessary. Perhaps one of the antacids to correct acidity, and one of the simple bitters to give tone to the debilitated stomach, may be advisable; and, in cases with general debility, and anemic blood, sulphate of quinia and the chalybeates may be used ad- vantageously. Should the debility be considerable, recourse may be had to egg-nog or milk-punch, and carbonate of ammonia. In the inflammatory form, it may be necessary, when the pulse is full and strong, to take blood from the arm, and subsequently from the part affected by cups, which may be followed by blisters. In other respects the treatment is the same as in the ordinary form of the disease. When the head is the seat of the inflammatory symptoms, the hair should be thinned or removed, and cold applications made, in addition to the local depletion. The malignant cases require early and vigorous stimulation, both internal and external. The great point is to bring about reaction. Brandy or whis- key should be given internally with the cathartic medicines employed, and at the same time administered by enema, associated with an equal measure of oil of turpentine, and sufficient water for dilution. Externally, sinapisms should be applied to the extremities and over the abdomen, frictions with heated oil of turpentine, or Cayenne pepper heated with spirit, to the spine and limbs; and heat in the usual mode by bottles of hot water, heated bricks, kc, or by means of the vapour bath. After reaction, the case is to be treated in the ordinary method. During convalescence, care should be taken to keep the bowels open by mild measures, to maintain the biliary secretion, and to guard against the causes of relapse, as over-eating, improper exposure to heat or cold, and all fatiguing exertion. 468 CONSTITUTIONAL DISEASES. [PART II. CLASS II. CONSTITUTIONAL DISEASES. The above title does not exactly designate the diseases belonging to this class. It is used, for the sake of brevity, with a somewhat arbitrary applica- tion. As already stated (page 245), the second class embraces constitutional affections, which may display themselves in local disease of any part of the system, but not in all parts at the same time. This want of universality excludes them from the first class ; and, as they frequently occupy several different organs at once, and may pass from one organ to another during the same attack, they cannot be placed in the category of affections strictly local. The only diseases which I place in this class are rheumatism and gout. There are others that properly belong to it, but, for convenience sake, are considered elsewhere. One of these is scrofulous or tuberculous disease. This is certainly a constitutional affection, and may show itself in any one part, or in many parts of the system, at the same time. But the local affec- tions are of so fixed a character, are in some instances so strongly marked, and are so universally looked upon as constituting distinct diseases, that they are advantageously described rather in reference to their position than their nature. Hence, I have treated of what concerns the disease generally under general pathology, and propose to treat of its local exhibitions, as phthisis, external scrofula, mesenteric disease, &c, among the local affections belong- ing to the third class. The same remarks are applicable to carcinoma or cancer, and to melanosis. Syphilis, in its advanced stages, would also be attached to the present class, were it admitted into this work; but it is so generally considered as a surgical disease, and so fully treated of by surgical writers, that it may be omitted, without inconvenience, in a treatise upon the practice of medicine. Some of the non-febrile eruptive affections hereafter to be considered, are really constitutional; but I have found it most conve- nient not to separate them from the proper local diseases of the skin, to which they have very close relations. With regard to rheumatism and gout, it may be thought that the fever which attends them should rank them in the first class ; but fever is not a necessary accompaniment of these diseases; and, when it occurs, is probably in general secondary, and dependent on the local affection. Article I. RHEUMATISM. Syn.—Rheumatismus. Rheumatism (from faZ/ia, rheum or flux) is a constitutional affection, at- tended with a peculiar irritation or inflammation, to which all parts of' the system are liable. Its general characters might have been described, in the first part of this work, under the heads of irritation and inflammation,' as one of the specific forms of these affections ; while its appearance in particular parts, organs, or tissues might have been reserved for the department of special diseases But it so frequently occupies many parts, at the same time or successively, m the same attack, and presents so strong an individuality in whatever part it may exist, that it is most conveniently considered as one CLASS II.] RHEUMATISM. 469 disease wherever it may appear, and therefore as belonging to this section of the work. It was formerly confounded with gout, under the common desig- nation of arthritis; and, according to Dr. Chapman, the application to it of the name rheumatism first occurs in Ballonius's treatise, "De Rheumatismo, &c," published in Paris in 1642. It is considered by most writers to be peculiar to some one, or to a few of the tissues, as the fibrous, muscular, and serous. I believe that it may affect one or all of them ; and proofs of the fact will, I think, be afforded in the following pages. Rheumatism may be divided, according to its seat, or its grade of excite- ment. Thus, some writers treat of it under the heads of articular and mus- cular rheumatism, the former occupying the joints, the latter the muscles; but the fact is, that, though the disease is often situated exclusively in one or the other of these parts, it often also occupies both, to a greater or less extent, in the same attack. A better division is that founded upon difference in grade; and, for convenience of description, the four following varieties may be recognized :—1. the acute, in which violent local inflammation is at- tended with considerable constitutional disturbance, or fever ; 2. the subacute, in which the inflammation is less violent, and there is little or no fever; 3. the chronic, characterized by long duration, and the lowest grade of in- flammatory action ; and 4. the nervous, in which there is neither inflamma- tion nor fever, the disease consisting exclusively in irritation, and that di- rected especially to the nervous tissue. 1. Acute Rheumatism. Symptoms, Course, dec.—Fever invariably attends this form of the disease. It is said sometimes to precede the inflammation ; but this event is rare. The primary symptoms are generally local. In the great majority of cases, they show themselves in the extremities, and usually first in the lower. The dis- ease may be confined to a single joint, or to a part or the whole of one limb; but much more frequently it affects several limbs, and different portions of the trunk, jointly or successively ; * and occasionally it involves almost the whole exterior of the body. It has been observed, however, that, when this last event occurs, one side of the body is more severely affected than the other. The small joints, as those of the fingers and toes, are less frequently inflamed than the larger, as the ankle, knee, wrist, and elbow. Sometimes the complaint begins with a feeling of uneasiness or stiffness in the part, which soon amounts to soreness or positive pain, especially upon motion. In other instances, the first symptom is acute and violent pain. Heat and swelling soon come on ; and, when the pain has been sharp and lancinating, it is very commonly moderated after tumefaction. Extreme soreness, however, remains, and the slightest movement of the part occasions suffering. The swelling is usually tense and elastic, and the surface often reddened, with a light rose colour gradually shading off into that of the healthy skin ; but, in many instances, the natural colour is unaltered. Commencing generally in one part, the inflammation quickly extends to others, as from the ankle to the knee, or from the ankle or knee of one side to the corresponding joint on the other; then to the wrist or elbow; some- times in its progress attacking neighbouring parts, sometimes distant parts in succession ; and often declining or disappearing in one seat, after fixing upon another. The swelling of the deserted joint does not immediately sub- side with the pain, but usually becomes softer, and, instead of being firm and elastic, will often pit somewhat upon pressure. Not unfrequently, a joint is attacked a second time, and occasionally a third or fourth time, or even more frequently, before the disease ends. In most cases, the inflammation 470 CONSTITUTIONAL DISEASES. [PART II. is confined chiefly to the neighbourhood of the joints ; in some it affects more especially the muscles; in others again, both structures are involved, and indeed all the tissues; the whole limb being swollen, tense, and ex- tremely tender. In the joints, the disease may be confined to the ligaments, or may affect also the synovial membrane. In the former case, the swelling is firm and elastic, in the latter often somewhat soft and fluctuating, in con- sequence of the increase of the synovial secretion. The latter condition is especially observable in the knee, where fluctuation may be perceived on each side of the patella. The swelling is usually greater in the more super- ficial joints, as the ankle, knee, and elbow, than in those more protected by muscles, as the hip and shoulder. In severe cases, the suffering is often intense. The pains, which are scarcely ever entirely absent, are at times almost excruciating, being described as tearing, rending, &c.; and the slight- est movement, or the least jar or pressure, occasions so much suffering that the patient does not dare to change his position, and dreads the approach of any one to his bed. Very soon after the local seizure, rigors and other symptoms of commenc- ing fever are experienced, followed by increased frequency of pulse, heat of skin, furred tongue, anorexia, thirst, and occasionally headache. The fever is almost always of the sthenic character, and generally of a violence propor- tionate to that of the local affection, though not invariably so. The pulse is full, strong, and usually not very frequent, varying from ninety to a hun- dred and ten, and probably, in the greater number of cases, not exceeding a hundred. Respiration is not sensibly disturbed, while the disease confines itself to external parts. The surface, though warm, is less heated than in most other fevers, and is often moist, sometimes indeed bathed in copious sweats, which have a peculiar sour and sickening smell, and have no effect in relieving the inflammation or pain. The tongue is usually moist, and thickly covered with a whitish fur. There is seldom nausea or vomiting. The bowels are generally constipated, and sometimes obstinately so. The secretions are little diminished, with the exception of the urine, which is scanty, high coloured, and disposed to let fall lateritious sediments upon cooling. The brain is usually remarkably exempt from disorder; the patient being seldom delirious, though not unfrequently deprived of sleep by the violence of his pains. I have, however, seen delirium a prominent symp- tom, without any reason to suspect cerebral inflammation. The fever is usually remittent, with exacerbations in the evening, which are often accom- panied'with an increase of the pains. These are consequently worse at night, and relax somewhat with the fever in the morning. The disease may run its course, and very often does so, without penetrat- ing any of the great cavities. But often, also, either by a simple extension, or by a metastasis of the inflammatory action, various internal organs become affected, and the case very seriously complicated. The most frequent of these complications is inflammation of the lining and investing membranes of the heart, constituting endocarditis and pericarditis. The fact that serious organic disease of the heart occasionally originates in rheumatism, and even the peculiar liability of the cardiac membranes to become inflamed have been long known to the profession; but Bouillaud was the first to prove the frequency of the affection, and its existence in many cases in which the ordi- nary symptoms would not have indicated it. According to that author, it occurs in the great majority of cases of acute rheumatism. Dr. Wm. Budd states that, out of forty-three cases of wliich he preserved accurate notes the symptoms of rheumatic inflammation of the heart were unequivocal in twenty- one, of which five were pericarditis. (Tweedie's Syst, of Pract. Med.) I am convinced that this is a much larger proportion than occurs in this country. CLASS II.] RHEUMATISM. 471 Probably our energetic practice in acute rheumatism may be one cause of the difference. According to Dr. Budd, the period at which the cardiac dis- ease comes on varies from the eighth to the twenty-seventh day; and, though it is stated by Dr. Fuller that it occurs at all stages, and sometimes even pre- cedes the inflammation of the joints, yet there can be no doubt of its greater frequency at a somewhat advanced stage ofthe disease. (Treatise on Rheu- matism, Am. ed., 1854, p. 165.) With us, acute rheumatism often term- inates within the limits stated by Dr. Budd, and probably before the time at which the cardiac inflammation would ensue, were the case to run its natural course. Endocarditis is much more frequent than pericarditis; and, when the latter occurs, it is very apt to be accompanied by the former. In the great majority of cases, both affections yield to proper remedies. Pericarditis is more imme- diately dangerous, endocarditis leaves the most unpleasant effects behind it. In the former, the two surfaces of the pericardium often coalesce in case of recovery, without disagreeable consequences. In the latter, disease of the valves sometimes remains, which is followed in time by hypertrophy and dila- tation, and ultimately by death. For further details in relation to these af- fections, their symptoms, physical signs, anatomical characters, and results, the reader is referred to Diseases of the Heart. It may be proper here to state that, whenever, in the course of acute rheumatism, pain and oppression in the precordial region, difficult or hurried breathing with or without cough, palpitation, increased frequency of pulse, and an anxious, disturbed, or pe- culiar expression of countenance, supervene, disease of the heart may be sus- pected ; and an examination should be made, by means of auscultation and percussion, into the condition of that organ and its membranes. The cardiac affection may, indeed, occur without announcing itself by any of these symp- toms, and, in its earlier stages, may entirely escape attention, unless sought for by the means alluded to. But some caution is to be observed not to draw too hasty a conclusion, as to the existence of endocarditis, from the circumstance that cardiac murmurs are heard in auscultation; for they may sometimes arise from the deposition of fibrin from the highly fibrinated blood, independently of inflammation of the endocardium; and it is well known that they are frequent attendants on an anemic state of the blood, which is not uncommon in acute rheumatism, especially in its advanced stage. In general, the occurrence of endocarditis or pericarditis is not attended by any material abatement of the external inflammation, so that they must be looked upon as an extension, and not as a transfer of the disease. .A case, however, of acute rheumatism in a young lady occurred to me, in which a retrocession of the inflammation from one of the lower extremities was fol- lowed by disease of the heart, which proved fatal in a few days. Either there was metastasis here, or the concentration of a powerful excitement in the central organ called off the disease from the limb upon the principle of revulsion. It is said that rheumatism affecting the ligamentous structure of joints, is more apt to extend to the heart than the same affection, seated in the synovial membranes. Children, when affected with inflammatory rheu- matism, are much more liable to this complication than adults; and, in relation to the latter, the liability appears to diminish with the age. Women are said also to be more frequently affected than men. Next to the membranes of the heart, the pleura is probably the most fre- quent seat of internal rheumatic inflammation. Pleuritis, however, seems, in most cases, to be an extension of the cardiac disease, or at least to occur simultaneously with it. There is every reason to believe that the lungs them- selves are occasionally attacked with rheumatic inflammation, causing a va- riety of pneumonia. 472 CONSTITUTIONAL DISEASES. [PART II. Sometimes the brain or its investing membranes are affected. It is pro- bable that the disease is seated more especially in the membranes, though an irritation is undoubtedly propagated to the cerebral substance. Disease of the heart has generally of late been observed in these cases, and the cerebral affection has been considered by some as depending upon the cardiac. The probability is, that the two are mere coincidences, depending upon a common cause. Pain in the head, with increased sensibility to light and sound, de- lirium, and coma, are signs of the extension of rheumatism to the brain. The use of large doses of quinia in acute rheumatism is said to have caused this complication, in some instances. Occasionally the symptoms are so vio- lent, and a fatal termination so speedy, occurring even within a few hours, as to have gained for this form of the affection the name of rheumatic apoplexy. This probably de'pends upon an overwhelming congestion of the brain, under the peculiar irritation of the disease. Insanity is said to have followed ce- rebral irritation of rheumatic origin. (Arch. Gen., Juin, 1856, p. 713.) The peritoneum is sometimes though rarely affected. I do not remember to have witnessed an instance of the kind. Occasionally violent affections of the stomach and bowels supervene in rheumatism, but oftener, I believe, in other forms of it than in the acute. The same may be said in relation to the kidneys. (See Subacute and Nervous Rheumatism.) All these internal attacks of rheumatism may occur, either as accompani- ments of the external disease, or originally; in which latter case the diagnosis is often difficult. One circumstance common to all of them is, that they are less serious in their character, and generally yield more readily to the means employed for their relief, than ordinary inflammation of the same parts. They may always be suspected when they occur either coincidently, or in alternation with external attacks, however slight. A variety of acute rheumatism denominated bilious has sometimes been noticed, especially in miasmatic districts. Its peculiarities may be dependent upon two causes. The transfer or extension of rheumatic irritation to the liver may derange the functions of that organ, giving rise in some instances to bilious vomiting from an excess of secretion, in others to yellowness of the tongue, conjunctiva, and skin, with bilious urine and clay-coloured stools, from a suspension of the secretion, as in jaundice. (See Jaundice.) But more frequently, the rheumatism is coincident with an attack of intermittent or remittent fever, and exhibits, along with its own peculiar phenomena, the bilious symptoms and paroxysmal character of those affections. The disease occasionally assumes an adynamic character, marked by di- minished force and increased frequency of pulse, copious sweats during sleep, a feeling of great debility, and a more than ordinary tendency to metastasis. The symptoms, however, are very seldom of the peculiar kind denominated typhous. The duration of acute rheumatism is uncertain. By proper remedial mea- sures it may frequently be arrested in a week or two ; but sometimes it runs on for six weeks, two months, three months, or even longer. Perhaps from ten days to three weeks is the ordinary duration, under judicious treatment from the beginning. In its course it not unfrequently exhibits alternations of amendment and aggravation; and sometimes, when everything promises fairly, the disease resumes, without obvious cause, all its original violence. In some cases, it appears like a succession of local attacks in different parts, each run- ning a course of a week or ten days, and not unfrequently recurring again and again in the same part. In any one position, a decline of the disease is indicated, first by the diminution or disappearance of the pain, then by a softening of the part, so that, instead of being tense and elastic as at first, it will not unfrequently retain for some time the impression of the finger, and CLASS II.] RHEUMATISM. 473 lastly by a gradual subsidence of the swelling. When the general disease is about to give way, new accessions of inflammation cease, or, if they occur, exhibit a much milder character; the violence of the pain everywhere sub- sides ; the patient loses his excessive sensibility to impressions from without, and the febrile symptoms are moderated or disappear. Some swelling and soreness are apt to remain, for a considerable time, after the violence of the disease is passed; and weakness and stiffness of the joints and muscles are frequently left, after convalescence has been long established. In some cases, the febrile movement does not cease with the obvious inflammation, being kept up probably by some lurking affection of the internal organs, possibly by inflammation of the inner coats of the arteries. On the contrary, more or less local disease is not unfrequently left after the fever has gone, and the acute degenerates into chronic rheumatism. Anatomical Characters.—The blood abounds in fibrin, and almost always exhibits the buffy coat when drawn during life, and allowed to coagulate. Indeed, with the exception of pneumonia, there is no one ofthe phlegmasia? in which these characters exist so strongly as in acute articular rheumatism. In one instance, Andral and Gavarret found in 1000 parts of blood, 10.2 parts of fibrin, the healthy standard being 3. But it is only during the ex- istence of the acute pain and fever that this excess is so striking. The pro- portion after their disappearance, though swelling and soreness may remain, is sometimes below the healthy mean. Dr. Garrod, after the examination of a great number of cases, states that he has found in the blood of acute rheu- matism no more uric acid than exists in that fluid in health, that is, only a trace. (Lond. Med. Gaz., Feb. 1848, and July, 1854.) After death, the synovial membranes have been found red and thickened, and the liquid in their cavities simply increased, without material alteration of character. In some rare instances, however, pus has been observed in the joints, and, still more rarely, false membrane and albuminous flocculi. The fibro-cartilages have also exhibited evidences of inflammation in softening and erosion. Urate of soda does not appear to have been, in any instance, de- tected in the joints. The muscles affected by the disease have presented a dark-red colour, with softening, and the effusion of a bloody serum into their interstitial cellular tissue. Signs of inflammation have also been noticed in the lining membrane of the arteries. Internal inflammation, attendant on the disease, leaves the same effects behind as under other circumstances. Causes.—Almost the only known exciting cause of acute rheumatism is cold. Moisture increases its effect, but, in all probability, only by serving as a more rapid conductor than dry air. The cold operates most powerfully during perspiration from previous exercise or exposure to heat. Sleeping in damp sheets or upon damp ground, the wearing of wet clothes, exposure to cold rains without subsequent change of dress, and sitting in a clamp, cold room, are examples of the kind of exposure which is apt to be followed by the disease. From a knowledge of the cause, it would be inferred that rheu- matism must be most prevalent in damp, changeable climates, and, as relates to the seasons, in the latter part of autumn and in spring. But something more is requisite than cold. There must also be a peculiar state of system predisposing to this form of disease. There must be a rheu- matic diathesis. In what this diathesis consists has not been discovered. There are no signs by which its existence can be detected, with an approach to certainty. Large jointed, muscular, and lank frames are probably more frequently affected than those of opposite characteristics. Men are more sub- ject to the disease than women, but in all probability, because more exposed to vicissitudes of temperature. The predisposition is certainly much affected by age. Children under ten years, and adults over sixty, are seldom attacked; 474 CONSTITUTIONAL DISEASES. [PART II. and the period of life at which the disease is most prevalent is probably be- tween fifteen and thirty-five or forty. Among the most powerful predisposing causes is a previous attack. At least, persons once affected are more liable to the complaint afterwards than they had previously been ; and, when it occurs in the old, it is almost always in those who have been attacked in earlier life. I think it is no less certain that a predisposition to the disease is often in- herited. It is apt to exist in members of the same family, whether inherited or not. Debility appears to favour the predisposition; though full and vig- orous health does not afford protection. The diathesis, when strong, is alone sufficient to generate the disease, without the aid of exciting causes. Diagnosis.—Gout is the only complaint with which acute rheumatism is liable to be confounded; and from this it is in general readily distinguished. The same, however, cannot be said of some other forms of rheumatism. The diagnostic symptoms will be more conveniently given under gout. Prognosis.—Acute rheumatism, though an exceedingly painful disease, is in adults very seldom immediately fatal, and, if properly managed, rarely leaves any fatal effects behind it. If uncomplicated with the internal inflam- mations alluded to in the account of the symptoms, it may almost always be conducted to a favourable issue. Of these complications, the cerebral, though comparatively unfrequent, is probably, in proportion to the number of cases in which it occurs, most fatal. The dangers to be apprehended from endo- carditis and pericarditis have been already alluded to. I cannot, however, avoid expressing my conviction, that these dangers, so far as acute rheuma- tism is concerned, have been greatly exaggerated. I do not remember to have met with more than a single case of fatal affection of the heart in adults, either during or subsequent to an attack of acute rheumatism, which I had the opportunity of seeing in its earlier stages. In children, however, the case is otherwise. In these, though the complaint is comparatively very rare, it is always dangerous, in consequence of its tendency to give rise to a condition of the heart, ending in fatal hypertrophy and dilatation. 2. Subacute Rheumatism. Very many cases of rheumatism occur, so limited in extent, and attended with so little constitutional disturbance, as to have no claim to be ranked with the acute variety; while their brief duration excludes them from the chronic. These are embraced in the division at present under consideration. As in the preceding variety, the disease may in this affect either the muscles or the joints ; but, while in the acute the joints are most frequently affected, in the subacute, the precedence belongs to the muscles. Symptoms, Course, &c.—Two or more joints may be inflamed; but, in probably the greater number of instances, the disease is confined to one at a time; as, with the grade of action often present in these cases, an extension to several of the articulations simultaneously would give rise to decided fever, and thus constitute acute rheumatism. The local symptoms are not materially different from those described under the preceding variety. The pain, how- ever, is usually less severe, amounting often only to slight aching or soreness. There is also less redness and heat, and the swelling is less tense and elastic. There is sometimes increased secretion of the synovial fluid, and that of the bursa?; and fluctuation may be noticed in the joint, especially the knee. In the muscular form, as in the articular, the disease may extend to several muscles^ or be limited to one. It very frequently extends to several in the same neighbourhood, and concerned in the same office. In some instances there is at first a feeling of soreness, which gradually increases until it amounts' to a dull aching pain, which becomes acute when the muscle contracts. In CLASS II.] RHEUMATISM. 475 others, the patient first becomes sensible of the complaint by a very severe sharp lancinating pain, which seizes the muscle upon some occasion when it is suddenly called into action, as upon attempting to rise from the sitting pos- ture, to turn in bed, or to lift a burthen. The pain is sometimes excruciating, so that the patient is unwilling to repeat the motion; and, when the part is necessarily moved, as in respiration, coughing, &c, the suffering is very great. During the intervals of motion, there is generally also a sense of uneasiness or aching, with increased heat, and the part is usually more or less tender when pressed. Sometimes there is tumefaction ; but it is seldom if ever con- siderable, and is often wanting. The pulse is sometimes excited, and the general heat increased; but the constitutional disturbance scarcely amounts to fever. Any of the external muscles may be affected, and the disease often takes a name according to its seat. The internal muscles also are often attacked either primarily or secondarily. But this variety of rheumatism is not confined to the joints and muscles. It is probably capable of attacking any of the tissues. There is reason to believe that it sometimes seizes upon the nervous sheaths, producing pain upon pressure along their course, and extending an irritation to the nerves themselves, which is felt in pain and spasm of the parts to which they are distributed. Many of the severe and complicated nervous disorders both of external and internal parts, connected with tenderness of the spinal column when the spinous processes are pressed, are probably owing to subacute rheumatism in the sheath of the spinal marrow. This variety of rheumatism is peculiarly liable to metastasis, certainly more so than either the acute or the chronic. In the acute, the inflammation is so severe as to give a strong direction of the disordered constitutional tendencies to its own seat; in the chronic, the disease appears often to be almost local, and indisposed to change. In the subacute, the constitutional tendency is strong, while the local affection is so feeble, that it readily yields to causes which give the irritation another direction. The variety is intermediate between the highly inflammatory and the pure nervous forms. To complete a view of subacute rheumatism, it will be necessary to consider it in some of its more frequent seats. In the Scalp.—The subcutaneous muscular and fibrous tissue of the scalp is occasionally attacked with this form of rheumatism. It is known by head- ache, often quite severe, soreness of the scalp on pressure, pain on the move- ment of the occipito-frontalis muscle, and the presence of rheumatism pre- viously, or at the same time, in some other part of the body. These symptoms will in general suffice to distinguish it from nervous or sick headache, for wliich, without care, it may be readily mistaken. In this latter affection, pressure, instead of causing pain, often yields relief. In the Eyes.—Rheumatism sometimes attacks the muscles ofthe eye, and sometimes its fibrous coat. In the former case, the motions of the ball are affected, and every movement which tends to put the diseased muscle on the stretch, or every attempt to contract it, occasions severe pain. When all the muscles are affected, the eye is held firmly in one position, from which it cannot move ; but this is very rare. When the sclerotica is the seat of the disease, the ball is painful to pressure, and a dull redness may sometimes be seen through the conjunctiva; but it is difficult to distinguish the affection from ordinary inflammation, except by taking into consideration the constitu- tional tendencies of the patient, and the state of his system at the time. It is highly probable that the function of the organ is sometimes impaired by rheumatism seated in the nervous centre of vision, or in the course of the nerve connecting the retina with the centre. Dr. D. J. Cain, of Charleston, S. C, relates a case of amaurosis apparently proceeding from this cause, 476 CONSTITUTIONAL DISEASES. [PART II. which yielded immediately to a blister to the back of the neck. (Charleston Med. Journ. and Rev., xi. 614.) In the Face.—The masseter muscle is sometimes affected with rheumatic inflammation, so that the patient cannot open his mouth, and great alarm is sometimes created under the apprehension of tetanus or locked jaw. It is sufficient for the physician to be aware of the occasional existence of such a condition of the muscle, to avoid all danger of so gross an error. In the Neck.—Under the name of stiff-neck, wry-neck, or torticollis, rheu- matism sometimes exists in the muscles of the side of the neck, especially in the sterno-mastoid. It may occupy both sides of the neck equally, in which case the head is held stiffly erect, and steadily looking forward ; but much more frequently one side only is disordered, and the head is drawn towards that side, usually more or less obliquely. While the head is allowed to re- main at rest, the patient is easy, or feels only a dull aching ; but every move- ment is exquisitely painful. In the Parietes ofthe Chest.—Pleurodynia.—This complaint is not unfre- quent. It is a rheumatic affection of the intercostal muscles, and is charac- terized by severe, acute, and generally shifting pain in the side upon taking a full breath or coughing, by soreness of the intercostal spaces upon pressure, and by the general absence of fever. It resembles pleurisy in its most ob- vious symptoms, and, when attended, as sometimes happens, by a slight fever, or by an accidental cough, the diagnosis is so uncertain that it can be made out only by attending to the physical signs. (See Pleurisy.) The risk of confounding the two affections is increased by the fact, that, in consequence of the pain arising from contraction of the intercostals, there is little expan- sion of the affected side of the chest, so that the respiratory murmur is less distinct than in health. As other muscles about the chest are often affected at the same time, the diagnosis is sometimes aided by the occurrence of severe pain upon attempting to twist or bend the trunk. In the Abdominal Parietes.—This is a very rare seat of rheumatism, which nevertheless does sometimes attack the abdominal muscles, producing symp- toms that might be mistaken for those of peritonitis, though distinguishable by the effect of movement, and the want of the constitutional symptoms of that affection. In the Lumbar Muscles.—Lumbago.—This occupies the muscles situated in the small of the back, sometimes extending up the spine, sometimes shoot- ing round towards the abdomen. It may be upon one side exclusively, or upon both. It is often first recognized by the occurrence of a sharp pain, as if from the thrust of a knife, upon attempting to rise from the sitting pos- ture, or to raise a burthen. When very severe, it confines the patient to bed, and in one position, from which he cannot move without exquisite suffering. In milder cases, the patient can often walk, but always stiffly, and generally partially bent forward upon the hips, with the spine perfectly rigid. It is not unfrequently attended with more or less febrile action, and may even be so severe as to come with propriety under the division of acute rheumatism. In such a case, however, it usually forms a part of a more extensive affection. The effects of motion, and the tenderness on pressure, sufficiently distinguish it from the violent pains of malignant fevers. From inflammation of the kid- neys it differs in wanting the peculiar direction of the pain towards the groin, the retraction of the testicles, the irritation of the urinary passages, and the nausea and vomiting which characterize that disease ; as also in the more decided tenderness, and greater pain on certain motions which bring the muscles of the back into play. Disease of the spine occasions also se- vere lumbar pains, which are sometimes increased by motion ; but there is CLASS II.] RHEUMATISM. 477 less pain upon pressure, less acuteness in the symptoms, and more or less dis- order in the functions ofthe lower extremities, which is wanting in lumbago. In the Hip.—Sciatica.—The parts about the hip are often attacked with rheumatism, which is seated sometimes in the muscles, sometimes in the joint or in the ligaments of the pelvis, and occasionally also, there is reason to be- lieve, in the neurilemma of the sciatic nerve, showing itself by tenderness along the course of that nerve, and pain with other disordered sensations in the corre- sponding thigh and leg. The simultaneous occurrence, or previous existence of rheumatism in other parts, is the surest diagnostic sign of this affection, which might otherwise be readily confounded with neuralgic pains, or those having their origin in common inflammation. The steadiness of the pain, which is rather dull than acute, and its increase when the patient becomes warm in bed, are other signs of its rheumatic character. Sciatica, however, is more frequently chronic than either acute or subacute. In the Heart.—The subacute form of rheumatism is peculiarly apt to invade the internal parts of the body. I believe that it is more frequently the origin of serious organic disease of the heart than the acute variety; at least, of the cases of chronic cardiac disease originating in rheumatism which have come under my notice, I am confident that the larger number have succeeded ex- ternal attacks of rheumatism, too moderate or limited to be considered as be- longing to the acute variety, as defined in this work. It is this form, too, which is most likely to seize upon the muscular structure of the heart, pro- ducing, according to its severity, immediate death, or severe pains, palpita- tions, oppression, &c, and not unfrequently terminating in a chronic affection with hypertrophy and dilatation of the organ. Cases of sudden death, leaving no satisfactory post-mortem evidences of their cause, are, I believe, occasionally attributable to the transfer to the heart, or the original occur- rence in the heart, of a rheumatic irritation so severe as wholly to disable the organ, or the part of it affected, from contracting. In the Alimentary Canal.—Instances of subacute rheumatism in the oeso- phagus sometimes occur, attended with a feeling of constriction, and severe pain in swallowing, but they are rare. In the stomach it is not uncommon, producing, according as it attacks the muscular or mucous coat, severe pain, with a sense of constriction, and great tenderness on pressure, or a sense of heat, weight, and oppression, with nausea and vomiting; and sometimes the two sets of symptoms are combined. Another not unfrequent seat of rheumatism, not sufficiently noticed, I think, by authors generally, is the muscular coat of the bowels. The patient complains of a constant aching in some portion of the bowel, especially of the ascending or descending colon, which is increased at times into the most violent pain, whenever the muscular coat is stimulated into contraction by the contents of the bowels, or by purgative medicine. Some- times the muscle is so severely affected, that it ceases to be able to contract, and obstinate constipation ensues. There is generally tenderness on pressure, within a limited portion of the abdomen. The disease may often be recog- nized from occurring upon the retrocession of an external attack, or in in- dividuals known to be subject to rheumatism. It differs from colic in being less decidedly spasmodic, and from ordinary inflammation of the whole thick- ness of the bowel, in the much less violence of the constitutional disturbance. Rheumatism sometimes also attacks the mucous coat ofthe bowels, producing diarrhoea and dysentery. Every practitioner, I presume, is familiar with in- stances, in which subacute external rheumatism has alternated with one of /these affections. There is no reason, whatever, for considering the disease essentially different in its two seats. In the Diaphragm.—Rheumatism sometimes attacks the diaphragm ; and 478 CONSTITUTIONAL DISEASES. [PART II. there is probably no seat in which it is more painful and distressing. A severe pain shoots from the epigastrium to the spine, sometimes through the body, sometimes circularly along the edge of the ribs, which, in violent cases, is increased to agony by every attempt to take a full inspiration. Breathing, which is performed chiefly by the ribs, is often very difficult and oppressed, and sometimes attended with feelings of suffocation. Hiccough, the sardonic laugh, and delirium, are said occasionally to attend the complaint. The swallowing of food produces acute pain at the point where the oesophagus penetrates the diaphragm, and sometimes the food is rejected in consequence of the spasm thus excited. In some instances, only a portion of the muscle is affected, and the pain may be confined to one side. In the Liver and Kidneys.—In both these glands, attacks simulating ordi- nary inflammation occasionally happen, in rheumatic individuals, either originally or by metastasis, which I have no hesitation in classing with the other forms of internal subacute rheumatism. When the liver is affected, there are pain and tenderness in the right hypochondrium, often a jaundiced hue of the skin and conjunctiva, and sometimes bilious vomiting, or mela?na. In the nephritic affection, there is pain in the back, extending to the abdo- men, and shooting towards the groin, and sometimes retraction of the testi- cle, but not, so far as I have observed, the copious deposition of urates which characterizes gout, nor so urgent a disposition to frequent micturition as in ordinary nephritis. The complaint, whether in the liver or kidney, is at- tended, as a general rule, with much less fever than ordinary inflammation of these organs, and very seldom ends unfavourably. In relation to other organs little need be said. Neither the brain nor its membranes are often attacked with this form of rheumatism. There is reason to believe that the pleura sometimes becomes involved by its contiguity with the seat of the disease in pleurodynia; and it is not impossible that the in- flammation may sometimes penetrate from the abdominal muscles to the peri- toneum. The 'uterus is, I believe, frequently the seat of rheumatism; and it has appeared to me that some of the cases of dysmenorrhcea, which have come under my notice, were nothing more than examples of this affection.* Rheumatism also occasionally attacks the ovaries and testicles. It has even been noticed in the skin, either confined to one part, or attacking several parts scccessively, and exhibiting itself under the form of exquisite sensitive- ness, so that the slightest friction produces severe pain, or as a steady aching or feeling of soreness, or a sharp pricking or darting pain of a neuralgic character, occurring at irregular intervals, and excited sometimes by the touch. (Archives Gen., Be ser., xii. 120.) This variety of rheumatism, when seated in the spinal marrow or its mem- branes, or in the neurilemma of the nervous trunks, shows itself occasionally by rigid spasmodic contractions of the muscles ; and the particular muscles affected are, of course, those corresponding with the diseased centre or trunk. The contractions may be confined to the muscles of the arms, or may affect those of the trunk, and even, in all probability, the involuntary muscles. The contractions usually alternate with relaxation, in other words are paroxysmal. Sometimes they are so violent as to imitate tetanus; and it is highly pro- bable that some ofthe milder and more manageable cases of idiopathic tetanus are simply subacute rheumatism of the spinal meninges. This variety of the disease is sometimes attended with considerable fever. The late Prof. Chap- man called attention to this character of rheumatism in his published lectures. The duration of subacute rheumatism is exceedingly uncertain and de- pends greatly upon the treatment. It is often relieved in two or three days, * For some supposed cases of rheumatism of the uterus, see a paper by Dr. J. E. Taylor, of New York, in the Amer. Journ. of Med. Sciences for July, 1845. CLASS II.] RHEUMATISM. 479 and sometimes runs on for weeks or months if neglected, degenerating, in the latter case, into the chronic form. Though much more readily subdued than the acute, it is much more liable to return quickly. Causes.—The causes are the same as those of the acute variety. The complaint is very apt to result from a partial exposure to cold, as from small currents of cold air, or the uncovering, in a cold place, of a part of the body usually protected. It is said that sudden muscular movements, or violent straining, are apt to induce it. They may sometimes do so when a strong predisposition exists ; but more frequently, when supposed to be the cause, they merely serve to make known to the patient the existence of the disease. When the constitutional tendency is very strong, it is probable that anything excitant may serve to bring on the local affection, such as stimulant drinks, or heating articles of food. Some individuals have a peculiar predisposition to this form of rheumatism. Diagnosis.—The suddenness of the attack, the severity of the local com- pared with the general symptoms, the sharpness of the pain upon movement when the muscles are concerned, the frequent mobility of the affection, and the utter absence of any tendency to suppuration, are characters by which subacute rheumatic inflammation may be distinguished from common inflam- mation occupying the same parts. Prognosis.—This is rarely otherwise than favourable. The disease is almost never fatal, unless when it seizes upon some vital organ, as the sto- mach, brain, or heart; and even then may very generally be relieved by appropriate remedies. The greatest danger is probably a sudden seizure of the muscular structure of the heart, so as to arrest its movements. Another danger is the production of chronic enlargement of that organ, through fre- quently repeated irritation. 3. Chronic Rheumatism. This variety of rheumatism may exist in the fibrous, synovial, or muscular tissue; but is most frequent in the joints. It may occur either as an original affection, or as the consequence of an acute or subacute attack. It is some- times limited to a single part, sometimes extends to several; and may be either fixed or movable. Generally speaking, however, it is more apt to fixed firmly in its original seat than either of the other varieties. In relation to the joints, the swelling is generally not great, sometimes scarcely if at all visible, unless the synovial membrane is affected, when there is often tumefaction from the effused fluid. In old cases, however, the liga- ments are often thickened, and there is not unfrequently some effusion into the cellular tissue. Redness is generally quite wanting. There is, in almost all cases, more or less pain, which is obtuse and aching rather than acute, is often increased by the warmth of the bed at night, and is usually worst in damp chilly weather. Rheumatic patients can not unfrequently foretell a storm, from the pains produced by the damp cold winds that precede it. In some instances, however, there is little pain; but only a feeling of stiffness and weakness upon motion. The heat of the part is seldom increased. On the contrary, the patient often complains of chilly sensations, and these are sometimes the most unpleasant local effects of the disease. When the muscles are affected, they often waste away, shrink, and become shortened; and, when an opportunity has been offered of examining them after death, they have sometimes been found to contain a yellowish, translu- cent, gelatinous secretion in the cellular tissue connecting their fibres. There is generally a complete absence of fever in chronic rheumatism; unless in some cases in which disorganization of the joints has taken place, 480 CONSTITUTIONAL DISEASES. [PART II. with purulent secretion, ulceration, kc, in consequence probably of the de- velopment of common or scrofulous inflammation. In obstinate and very old cases, there is often stiffness or immobility of the joints, arising from contraction, thickening, and rigidity of the ligaments, from firm contraction or shortening of the muscles and tendons, and some- times from changes in the cartilaginous and bony structures, which undergo degeneration or absorption under the long-continued irritation. The joints are often distorted by the same causes, especially the joints of the hand, in which the fingers are bent to one side, or abnormally extended or flexed; and it has been observed that the deformity of the one side corresponds singularly with that of the other, in shape and direction. These results, however, belong rather to a peculiar form of the disease called rheumatic gout, than to ordinary chronic rheumatism. (See Rheumatic Gout.) Not unfrequently, in cases of long standing, the muscles affected become almost powerless, or even quite paralyzed. The disease may generally be relieved or cured for a time, but is exceed- ingly apt to return. Sometimes it perseveres steadily, in spite of remedies, rendering the life of the patient miserable, and wearing him out at last by the incessant pains. In some instances, too, suppuration takes place in the joints, the synovial membrane ulcerates, the cartilages are absorbed, abscesses form in the soft parts and discharge externally; and the patient is at last worn out by hectic fever; or the denuded ends of the bone granulate and unite, forming complete anchylosis. But I have before mentioned my impres- sion that, in these cases, common or scrofulous inflammation has been super- induced. It is highly probable that chronic diseases of the internal organs are occasionally of a rheumatic nature ; and it is no unreasonable supposi- tion, that changes in the structure of the heart are, in many instances, the result of chronic rheumatism of that organ. The duration of chronic rheumatism is altogether irregular. It may con- tinue for months, years, or a lifetime. Many persons affected with it have intervals of comparative comfort, recovering their health more or less com- pletely during summer, to relapse again in winter, or varying with the con- dition of the weather, to the changes of which they become exceedingly sensi- tive, so as frequently to anticipate them before they are obvious to others. The causes of this form of rheumatism are the same as of the acute; but the predisposition to it is not strongest in the same individuals. Age has great influence in this respect. The old are peculiarly liable to chronic rheumatism, though seldom attacked by the acute. The complaints with which it may be confounded are common and scrofu- lous inflammation, and sometimes possibly paralysis of certain muscles. From the former it may be distinguished by its occurrence in individuals known to be rheumatic, its frequently shifting character, especially in the earlier stages, the absence of any tendency to suppuration, the sense of coldness which some- times attends it, and its aggravation by wet damp weather, and by the warmth of the bed. A muscle may be deprived of the power of motion by rheu- matism or by palsy, but the march of the disease is so different that, if proper investigation be made, there can be little difficulty in the diagnosis'. 4. Nervous Rheumatism. ^ Rheumatism very often assumes the form of irritation, without the least sign of inflammatory action. It may be directed especially to the nervous system, evincing itself by pain, or other disordered sensation, and by irregu- larities ofthe motive power; or it may affect any other portion of the body, or any one of the organs, producing derangement of function in the part or CLASS II.] RHEUMATISM. 481 organ affected. The question may perhaps be asked, how it can, under these circumstances, be known to be rheumatism ? The answer simply is, that these irritations often alternate with, supersede, or are superseded by inflammatory attacks of rheumatism, without the operation of any discover- able additional cause. A patient will be attacked with a neuralgic pain in the face, dyspeptic sensations in the stomach, or colicky pains in the bowels, which will instantly cease upon the occurrence of an attack of subacute rheumatism in one of the joints or muscles, and return upon the retrocession of the latter affection. It is scarcely possible to resist the conclusion, that the same peculiar state of system, the same predisposition or diathesis, lies at the foundation of both these modes of derangement, which are, in fact, nothing more than signs of the real disease, the essence of which escapes our notice. But the particular disorders of sensation and function, which fall under this head, are so precisely like those of a similar variety of gout, that it would be useless repetition to treat of them particularly in this place; and I shall con- tent myself with referring the reader to the subject of nervous gout. In fact, the only mode of deciding, in relation to any one of these disorders, whether it belongs to rheumatism or to gout, is to notice with which of these diseases, in their inflammatory forms, it is apt to be associated or to alternate; and, if no such association or alternation exist in the case, which is a very rare cir- cumstance, then to ascertain what are the hereditary tendencies of the indi- vidual. Yet, that there is some real difference, though it may altogether escape our powers of observation, is proved by the fact, that, when the irritation is connected with inflammation, the latter almost always assumes the same form in the same individual, whether that form be gout or rheumatism. There is one form of nervous disorder supposed to be not unfrequently of rheumatic origin, wliich does not equally occur in gout, probably in consequence of the age at which it generally makes its attack; I allude to chorea. It is not impossible that nervous gout and rheumatism, like the same diseases when of an inflammatory character, might be distinguished by the different con- dition of the blood as to uric acid. To give a very general idea of these derangements, it is sufficient here to state that rheumatic irritation may assume the form of neuralgic pains in any part of the body; of vertigo, dizziness, headache, tinnitus aurium, perverted vision, &c, when it affects the brain; of hurried or irregular breathing, and even violent dyspnoea, in the respiratory apparatus; of palpitations, oppres- sion, and precordial distress, in the heart; of dyspeptic sensations, nausea or vomiting, spasm, &c, in the stomach; of colicky pains in the bowels; and of painful sensation, and perverted function in the liver, kidneys, and genitals. The exciting causes of this variety of rheumatism are the same as of the others; but there is a different condition of system in the individuals subject to it, which determines this rather than the inflammatory forms. A predom- inance of the nervous temperament, sedentary habits, abstemious modes of living, and, generally, whatever tends to depress the powers of the system at large, may be considered as favouring the production of nervous rheumatism. Hence, it is most frequent in females, students, and professional men, espe- cially those of temperate lives. Though a painful, sometimes alarming, and in many instances a most harassing disease, it is not often really dangerous; and persons liable to it often live to an advanced age, and, occasionally, after passing the prime of life, find the liability to diminish or cease altogether. It is true that it some- times seizes upon the heart, brain, lungs or stomach with a fatal violence; but these cases are rare; and, when death occurs in the course of the dis- ease, it is much more frequently from the supervention of some organic affection, than from the simple uncomplicated irritation.. VOL. i. 31 482 CONSTITUTIONAL DISEASES. [PART II. Nature of Rheumatism. Having taken a view of the different forms of rheumatism, we are now pre- pared to consider its nature. The opinion was at one time prevalent, that this disease was dependent on a peculiar offending matter pervading the system; and even at the present time, not a few pathologists are disposed to ascribe its peculiarities to the abnormal presence of an acid in the circulation, which, according to Dr. Prout, is the lactic, according to others, the uric acid. But there is so utter a want of proof as to the uniform existence of any such offending cause in rheumatism, that, in the present state of our knowledge, the opinion must be looked on as purely speculative.* Another notion is, that the disease is nothing more than ordinary inflam- mation, owing any apparent peculiarities to the tissue in which it is seated. But the truth is, that the disease is not necessarily inflammatory. It is often purely nervous, and no explanation of its nature is admissible, which does not take this fact into consideration. Besides, ordinary inflammation, occu- pying precisely the same parts, presents different phenomena. All that we know of the real nature of the disease is, that it is peculiar, and that it owes this peculiarity, not to the character of the cause, but to some unexplained condition of the system, called the rheumatic predisposition or diathesis. I am inclined to the opinion, that this diathesis is in itself a mor- bid state, in fact, the true disease, and that the irritation and inflammation by which it is recognized, are merely symptoms of its full development. That the rheumatic differs essentially from ordinary inflammation, is shown chiefly by its shifting character, its disposition to alternate with mere irrita- tion or functional disorder, and the almost entire absence of any tendency to suppuration, even in the most violent cases. Treatment of Rheumatism. 1. Of Acute Rheumatism.—When the pulse is full and tense, and the in- flammation severe, bleeding should be employed with a freedom proportion- ate to the vigour of the patient's constitution, and to the resistance of the pulse. It is never proper to bleed for the pain alone. This is often ex- tremely severe, where there is comparatively little activity of inflammation, or vigour of circulation. The pulse, and the obvious amount of local disease, as exhibited by the heat, swelling, tension, and redness, are much surer guides than the degree of pain. The loss of blood is generally borne well; and the operation may often be repeated once and again, if called for by the symptoms. The quantity to be taken at each time must vary with the effects produced upon the circulation. The orifice should be closed as soon as the pulse begins to flag; and syncope, or an approach to it, should never be aimed at. Generally, from twelve to twenty-four ounces may be taken from a robust individual, with a strong pulse. One or two full bleedings are gen- erally sufficient; and, when the pulse begins to become more frequent, with diminished strength, the remedy should no longer be employed. It should be remembered that bleeding alone often fails to cure the disease. * Before the humoral theory of the nature of rheumatism can be admitted as estab- lished, it is necessary to demonstrate not only the presence of the otfending matter in so large a number of instances as to leave no room for reasonable doubt that it is universal in this disease, but also its absence in other febrile and inflammatory affections. Now acid in the breath, perspiration, and urine is so common in complaints having none of the characteristics of rheumatism, that even if it should be shown that an acid is always present in this affection, which has not been done, we should be justified in considering it simply as a result of morbid processes common to rheumatism and other diseases and not as the essential characteristic and essence of the former. (Note to the fourth edition.) CLASS II.] RHEUMATISM. 483 Carried to great excess, it may cause such a collapse of the vessels that they cannot support the inflammatory process; but the disease does not necessa- rily cease, under such circumstances, with the subsidence of the inflammation. The morbid tendency may still exist, and, though it may not be able to raise the vascular actions to inflammation, is still competent to the production of irritation even of a violent character. No longer attracted externally by the local disease, it may fix upon one of the internal and vital organs, with even fatal intensity. Sudden death has resulted from an apparent transfer of rheumatic irritation from the exterior to the heart, after copious depletion. The remedy must, therefore, be used with caution; and, though there are many cases in which it may be employed freely, there are many others in which it is of doubtful propriety, and some in which it is altogether forbid- den. In feeble and anemic individuals, it should not be employed unless in obedience to some urgent necessity. Purging is probably not less efficacious than venesection. Nature occa- sionally points out this remedy by curing an external attack, through the supervention of diarrhoea. The purgation should be active, but not drastic. Senna with sulphate of magnesia, jalap and bitartrate of potassa, and, when there is torpor or congestion of the liver, calomel, alone, or in combination, are generally suitable articles to begin with. The purgation should be re- peated every other day; but, after the first or second occasion, it will usually be sufficient to employ sulphate of magnesia alone, or combined with magne- sia and wine of colchicum, as recommended by Scudamore. This mixture is well adapted to cases originally mild, or in which the excitement has been reduced by depletion.* Should the bowels become irritable, the purgation should be suspended. An objection to purging is the difficulty of changing position; but this may generally be obviated by the use of the bed-pan. The refrigerant diaphoretics are well adapted to the earliest and most in- flammatory stage of the disease. Tartar emetic and nitre form an excellent combination. From one-twelfth to one-sixth of a grain of the former, and from five to ten grains of the latter, may be given dissolved in water, at in- tervals of one, two, or three hours. Citrate of potassa, in the form of neutral mixture or effervescing draught, may be used if the former combination offend the stomach. These remedies may be aided by the occasional use of the warm bath, if not too inconvenient on account ofthe difficulty of moving the patient. The object, in the use of the diaphoretics above mentioned, is nbt so much to induce perspiration, as to sustain a moderate sedative im- pression upon the circulation. The old plan of heaping bedclothes upon the patient, and forcing copious sweat by draughts of hot water or herb teas, has been abandoned as generally useless, if not injurious. Very soon after the commencement of the disease, the bowels having been thoroughly evacuated, and blood, if deemed advisable, taken from the arm, opium and ipecacuanha should be given at bedtime, to allay the violence of the pain, and procure sleep. A grain of each, repeated, if necessary, at the end of two hours, and increased somewhat as the system becomes accustomed to it, will generally be sufficient. The ipecacuanha is advisable to correct the stimulant tendency of the opium. After a few days, when excitement has been considerably subdued by depletion, this combination may be given steadily, at certain intervals, through the day and night, so as to keep the system always under its influence. Ten grains of Dover's powder may be given every four, six, or eight hours, according to the susceptibility of the patient to the opiate influence. Sometimes it will be sufficient to give half * The following formula may be used. R.—Magnesiie Sulphat. 3SS; Magnesias £ss; Vin. Colch. Rad. f^ss; Aquae fluv., vel Aq. Acid. Carbonic, q. s. Fiat haustus. 484 CONSTITUTIONAL DISEASES. [PART II. the quantity. Should it be doubtful whether excitement has been sufficiently reduced for the remedy, as just recommended, the proportion of ipecacuanha may be doubled, unless found to nauseate the patient. When the pulse has lost its tension, and especially if it be rather feeble, advantage will accrue from combining powdered guaiac with the Dover's powder. The guaiac is supposed to exercise an alterative influence over the disease. From ten to twenty grains of it may be given with each dose.* Should these remedies have failed to make the desired impression at the end of one or at furthest two weeks, or should the disease assume in any re- spect a threatening character, it will be advisable to employ calomel with a view to its alterative influence. Advantage will often accrue from its use at an earlier period, with the opium and ipecacuanha, in the dose of two grains at bedtime. This quantity will sometimes of itself exercise a favourable in- fluence, without positive salivation, while it prepares the way for the more ready production of a decided mercurial impression, should this become de- sirable. I have no doubt whatever of the frequently controlling influence of mercury over acute rheumatism at this stage. If employed early, before the requisite reduction of the general excitement, it may fail to remove the dis- ease, while it adds to the other inconveniences that of a sore mouth, and to the existing excitement the additional one produced by the mercury. Should the case be in a somewhat advanced state when it first comes under the no- tice ofthe practitioner, the calomel and opium treatment maybe commenced immediately. There is generally a speedy abatement of the symptoms on the occurrence of soreness of the gums. It is seldom desirable to induce a copious salivation ; and I always suspend the mercurial at the first decided indications of its action upon the mouth. It is at the same stage that colchicum proves most effectual. This may sometimes be tried advantageously before the mercurial, or may be given in aid of it. It is usually best combined with one of the salts of morphia; and this combination may be substituted for the Dover's powder; twenty or thirty drops of the wine of colchicum root, and a fluidrachm and a half of the solution of sulphate of morphia, equivalent to about a grain of opium, being given every four, six, or eight hours. Occasionally an adynamic condition of system comes on in the course of the complaint, attended with very copious sweating during sleep, and some- times considerable nervous disturbance. Under these circumstances, I have been long in the habit of using sulphate of quinia, and have scarcely ever known it to fail, not only in obviating the debility, but also in greatly re- lieving if not curing the disease. A grain may be given every hour. More than this will seldom be required. It must be particularly remarked that one of the conditions is the occurrence of copious sweats during sleep. This occasionally happens without the least alleviation ofthe pains, swelling, &c, and is probably the mere result of debility, with some irritation of the circu- lation. When there is considerable prostration, it may become desirable to administer carbonate of ammonia; and the ammoniated tincture of guaiac may now also be used with hope of benefit, in the dose of a fluidrachm every four hours, or less frequently. Should the heart or the brain become seriously involved, in the course of the disease, depletion by the lancet must be carried as far as it can be borne • leeches or cups must then be used freely; and these must be followed quickly by a large blister. In the cardiac affection, the cups may be applied between the shoulders, and a blister eight inches by ten over the region of the heart • * The following is a convenient formula. R.—Opii pulv., Ipecac, pulv aa gr vi ■ Potassae Nitrat. 5 j; Guaiaci Resinae pulv. ^iss. Misce, et divid. in chart, no. vi ' S One to be taken in syrup or mucilage, every four, six, or eight hours. CLASS II.] RHEUMATISM. 485 in the cerebral, the head should be shaved, leeches or cups applied to the scalp and temples, and afterwards, should the symptoms continue alarming, a blister over the whole head. Along with these means, calomel should be given promptly and freely, so as to induce ptyalism. Efforts should be made, in case of retrocession of the external disease, to invite it back to its original seat by sinapisms or other active rubefacients, or by blisters, and, should the feet have been the part affected, by hot stimulating pediluvia. The same plan of treatment, in greater moderation, would be applicable to any other internal inflammation supervening upon acute rheumatism. In the form of the disease which occurs in miasmatic regions, and which has been already described under the name of bilious rheumatism, calomel should be given as a cathartic in the early stage, and recourse be had to quinia as soon as an intermission, or a decided remission shall have been obtained. The local measures applicable to acute rheumatism have not yet been men- tioned. I believe that, upon the whole, the less that is done in this way the better. Should the disease be confined to one part, advantage might result from leeches ; but to follow it up by this remedy, in its course over the body, would be futile. Should the spinal column be found tender, with rheuma- tism in the lower section of the body, cups should be applied to the tender part. Perhaps the best plan, as a general rule, is to keep the affected part enveloped in soft flannel, lambs'-wool, or carded cotton; but these applica- tions should not be persevered in if uncomfortable to the patient. Some- times, when the pain is excessive, emollient cataplasms with the addition of laudanum or other narcotic will afford relief. The late Dr. M. B. Smith, of Philadelphia, spoke highly to the author of the efficiency of the tobacco cataplasm. Towards the decline of the complaint, when the parts are still somewhat swollen and painful, but the fever has subsided, anodyne and rube- facient lotions are sometimes useful, such as camphor liniment, the campho- rated tincture of soap with laudanum, and the same preparation with the addition of spirit of ammonia. At a still more advanced period, when the disease may seem peculiarly adhesive in one or a few parts, and threaten to become chronic, repeated blistering is the most efficient remedy; and, if the rheumatic pains are severe, acetate of morphia in powder may be sprinkled upon the blistered surface, denuded of the cuticle. Cold water, as an appli- cation to the inflammation of acute rheumatism, has been recommended; and it will no doubt often remove the local affection; but there would always be great hazard of serious internal disease. Flannel bandages, as recommended by Dr. Balfour, may be occasionally used with advantage, when the case threatens to assume the chronic form; but they are wholly inapplicable to the acute condition. They have been known to occasion a retrocession of the inflammation, and the supervention of severe cardiac disease. The hot bath comes in very usefully, in some cases, after the subsidence of fever and acute inflammation, when the surface is pale and inactive, and the local disease adhesive. It may be used daily. The above is the plan which I have usually employed in the treatment of acute rheumatism, and with results, upon the whole, so satisfactory as to have rendered me backward in resorting to experimental measures. It is, nevertheless, proper to allude to other modes of treatment, which have received more or less attention from the profession, and have been sanctioned by authoritative names. M. Bouillaud relies chiefly on large daily bleedings, with the free applica- tions of cups or leeches in the intervals. From robust patients, during the first four or five days, he takes by these methods an average quantity of four or five pounds; in very severe cases, as much as six, seven, or eight pounds; in mild cases only two or three pounds. Under this plan, the medium dura- 486 CONSTITUTIONAL DISEASES. [PART II. tion of rheumatism in his hands is only one or two weeks, instead of six or eight; and, up to the publication of his treatise, there had been no death, even in cases complicated with disease of the heart. Other practitioners have not met with the same success from this plan ; while the records of medicine are not without cases of fatal results, attributed to excessive depletion. Dr. Hope, along with moderate depletion, recommended the early and vigorous use of calomel and opium, alternated with active purgation. The plan, which he adopted from Dr. Chambers, was, after full bleeding in the robust, but without that measure in the weak, to give eight or ten grains of calomel, with a grain and a half of opium, every night, followed in the morn- ing by the infusion of senna with salts, sufficient to procure at least four or five stools. At the same time, a saline draught with fifteen or twenty minims of wine of colchicum, and five grains of Dover's powder, was administered three times a day. The calomel was omitted when the swelling and pain greatly abated, or the gums became in the least tender. According to Dr. Hope, the patients generally recovered under this plan in a week. The use of Peruvian bark in rheumatism is a very old practice. A few years since the plan of giving enormous quantities of sulphate of quinia, in the acute form of the disease, was proposed by M. Briquet, of Paris, and carried into effect with the most surprising results; the disease being almost as promptly cured as intermittent fever by the same remedy. From a drachm to a drachm and a half was given daily, in divided portions. As might have been anticipated, though the external inflammation was suppressed by the powerful influence of the remedy on the brain, yet that organ often be- came violently affected, and sometimes with fatal results. I consider the practice, at this risk, altogether unjustifiable. Sulphate of quinia is often, however, of great benefit in acute rheumatism, moderately administered; and I have already pointed out the circumstances under which it has appeared to me most effective. MM. Gendrin and Solon revived, in 1833, a plan which had been long be- fore proposed and abandoned, of treating the disease with large doses of nitre, dissolved in large quantities of water. The mean quantity of the salt given daily was an ounce, dissolved in three quarts of water; and the average length of treatment was eight days. The practice is likely to fall again into neglect. The risk of injury to the stomach from the large amount, as well of the liquid as of the salt, will probably always be an insuperable objection to the general adoption of this plan. The same quantity of nitre, with a small quantity of water, would endanger poisonous effects. Among the other heroic plans of treatment is that of large doses of opium, as employed by Dr. Corrigan, of Dublin, who gave, on the average, ten or twelve grains of the narcotic daily, and in some instances more than double the amount. Full doses were given at first, and increased until decided relief was obtained, after which the medicine was continued in the same amount, until the disease had declined. The average duration of the treatment was nine days; and no evil effects were experienced. It might, however, be very dangerous, should a tendency exist to cerebral disease. Still another of the heroic plans is the use of tartar emetic, in the quantity of twelve grains or more through the day, according to the contra-stimulant method. The danger from this plan, independently of the possible prostra- tion, would be the excitement of an irritation in the stomach, which mio-ht render it the focus of the rheumatic disease. The same objection lies ao-ainst the repeated use of emetics. Phosphate of ammonia has been strongly recommended in rheumatism by Dr. T. H. Buckler, of Baltimore, under the impression that it tends to elimi- nate uric acid from the system, by forming with it a soluble urate of ammonia; CLASS II.] RHEUMATISM. 487 the phosphoric acid being neutralized by the soda with which the uric acid may be combined in the blood. The salt is recommended in doses varying from ten to twenty grains, and given from three to six times in the twenty-four hours. It may be employed in all the different forms of rheumatism. (Am. J. of Med, Sri., N. S., xi. 108.) Dr. Samuel Edwards, of Bath, England, has published statements strongly confirmatory of those made by Dr. Buckler. (Prov. Med. and Surg. Journ., Nov. 17, 1847.) Alkaline remedies have been employed in the cure of rheumatism, on the ground ofthe essential acidity ofthe system in that complaint. Dr. S. Wright, of Birmingham, England, has for years depended chiefly on these remedies, and found them extraordinarily effectual. He prefers soda to the other alka- lies, giving the bicarbonate internally, and applying the carbonate externally in baths. (Med. Times, June 5, 1847.) Others prefer potassa; and the offi- cinal solution, or liquor potassa? is sometimes employed. Dr. Garrod prefers bicarbonate of potassa, which he gives in the dose of two scruples, every two hours, day and night, until the signs of the disease have disappeared for two or three days ; employing at the same time local depletion from the precor- dial region, should the heart be affected. In a large number of cases thus treated, the average duration of the disease was about two weeks, and of the treatment about a week. (Lond. Med. Times and Gaz., March, 1855, p. 219.) Besides the correction of acidity, another effect expected from the alkalies is to render the fibrin more soluble in the blood, and thus to prevent or correct the fibrinous deposits in the heart, which sometimes so seriously complicate the disease. Another method of bringing the system under alkaline influence is by means of the salts of the alkalies with vegetable acids. It is well known that, during the use of these medicines, the urine in a few days becomes alkaline, show- ing that the vegetable acid has been decomposed, and the alkali carried into the circulation probably as a carbonate. Dr. Golding Bird used the ace- tate of potassa, and considered it superior to all other remedies in the treat- ment of rheumatism. (Lond, Lancet, Feb. 15,1851, p. 177.) In this country, tartrate of soda and potassa was used in a large number of cases in the New York Hospital, with very happy effects; the duration of the disease being considerably shorter than under former treatment, and the frequency of car- diac complications diminished. (See a paper by Dr. J. B. Chapin, N Y. Med. Times, Aug. 1854, p. 386.) The practice was repeated with the same re- sults by Dr. J. T. Metcalfe. Marked relief was also found from lotions of carbonate of potassa and opium to the parts affected. (Ibid., Oct. 1855, p. 1.) I have myself employed the remedy in a large number of cases in the Penn- sylvania Hospital, and frequently with good results; but on the whole less satisfactory than those of the treatment recommended in the earlier part of this article, to which I have repeatedly been compelled to recur, after failure with the Rochelle salt. I have also derived much advantage from the steady use of the alkaline bicarbonates in some obstinate cases, but with the similar want of success in others. It will have been observed, however, that the employment of citrate of potassa constitutes a part of the treatment recom- mended by me in the earlier stages. On the whole I am inclined to view the alkaline remedies as valuable adjuvants; but do not think that they should be relied on to the exclusion of other efficient measures. A directly opposite plan has been proposed by Dr. Owen Rees, of Lon- don, who has found lemon-juice, in the dose of one or two fluidounces from four to six times a day, very efficient in acute rheumatism, rapidly reducing the pulse and relieving the pains, and effecting cures in a shorter average period than the plans ordinarily followed. It is only the sthenic cases to which the remedy is applicable. The method has been followed by other 488 CONSTITUTIONAL DISEASES. [PART II. practitioners with similar results. Dr. Wm. Pepper, of Philadelphia, has reported a number of cases, successfully treated by him with this remedy in the Pennsylvania Hospital. Great relief was generally obtained in about a week, and in some in a shorter time; and most of the patients were discharged cured in less than two weeks. (Trans, of Col. of Phys. of Philadelphia, N. S., i. 124.) Dr. Babington, of London, has found the juice very suc- cessful, and believes that no other remedy is equally efficient. But he em- ploys it in larger doses than above mentioned, giving as much as six ounces three times a day. (Lancet, Nov. 8, 1851, p. 431.) Others have not been equally successful; but it must be recollected that it is only in acute rheu- matism that much is expected from it. In two cases in the Pennsylvania Hospital, both acute, and closely resembling each other, I employed in one the lemon-juice, and in the other the plan of treatment recommended in this work. At the end of about a week the latter was convalescing, and no ap,- parent effect had been produced in the former. I then abandoned the lemon-juice, and adopted the same treatment as in the other case, under which the patient speedily recovered. This is the amount of my experience with the remedy. Dr. Ruschenberger, of the U. S. Navy, has found great advantage from cold water dresssings to the joints, and the use of from three to six grains of opium at night, with an equal quantity of sulphate of quinia. (Am. Journ. of Med. Sci, N. S., xiv. 263.) Dr. John Hastings has employed pyro-acetic spirit both in acute and chronic rheumatism, and in gout, "with a success quite extraordinary." (Lancet, Jan. 16, 1847.) Iodide of potassium, sulphur, and aconite, which have been lauded in acute rheumatism, are better adapted to the other varieties. The leaves of the common European ash, in substance or infusion, have been recently recommended on the continent of Europe. (See Lond. Med. Times and Gaz., v. 650.) MM. Piedaguel and Trousseau cure acute rheumatism generally in seven or eight days by veratria, in the dose of about one-thirteenth of a grain; one dose being given on the first day, two on the second, three on the third, and thus with a like increase up to the sixth or seventh, if the symptoms do not previously abate. When this happens, the number of doses arrived at is con- tinued for two or three days, then diminished daily with the decrease of the disease. (See Am. J. of Med. Sci, N. S., xxvi. 496.) American hellebore was long since employed in this country, with no less efficiency. (See U. S. Dispensatory.) Great success has been claimed for an expectant plan, pursued by M. Gouzee in the military hospital at Antwerp. A comfortable and uniform temperature, pure air, the free use of diluent drinks, prolonged local tepid baths once or twice daily, cataplasms in the intervals, confinement to bed for a few days during convalescence, and the use of simple bitters or quinia at this period, constitute the sum of the treatment. The disease naturally, it is stated, tends to recovery in a week or two, and the patient gets well as speedily as when actively treated, if not more so. (Banking's Abstract, xviii. 234.) Most of the efficient plans of treating acute rheumatism have this thing in common, that they depress the circulation, and lower the quality of the blood • and it is probably more to these effects that they owe their curative power, than to any specific mode of action, or to any mere chemical influence. Thus bleeding, purging, the antimonials, nitre, the alkaline salts with vegetable acids' the carbonated alkalies, citric acid, all have a sedative action on the circula- tion, and more or less impair the blood; and, though of apparently opposite nature, they really act on the same general principles. The same, so far as concerns the circulation, may be said of aconite, veratria, white and American CLASS II.] RHEUMATISM. 489 hellebore, and colchicum; though these may act also as alteratives to the ultimate components of the tissues, or as sedatives to the nervous system. 2. Of Subacute Rheumatism.—In this variety, venesection is seldom requisite ; though, when the patient is robust, and the pulse tolerably strong, a moderate bleeding will occasionally hasten the cure. Purging is highly useful. A full dose of sulphate of magnesia, or of this with infusion of senna, followed, every other day, with the mixture of magnesia, Epsom salt, and wine of colchicum root, already referred to, may be given in ordinary cases. Should the patient be too much weakened to permit a continuance of this course, his bowels may be kept open by sulphur, or a mixture of sulphur with magnesia, or with bitartrate of potassa. After the bowels have been once thoroughly evacuated, opium and ipecacuanha maybe prescribed, either in the form of pill, or that of Dover's powder. This is often very effectual in sub- acute rheumatism, putting an almost immediate end to the complaint. A large dose of the opiate may be given at bedtime, and smaller doses regularly at intervals of four, six, or eight hours. Colchicum also displays very strong powers in this variety of the disease. It may be given alone, in doses of twenty drops of the wine of the root, or a grain of the acetic extract, repeated every four hours, and diminished or increased according to its effects. It is always desirable to procure from it some influence upon the skin, kidneys, or bowels; but to suspend it, or diminish the dose, when the stomach is nau- seated. It may often be advantageously combined with the solution of sul- phate of morphia, so as to keep the patient under a moderate narcotic impres- sion ; or the acetic extract may be combined in pill with the ipecacuanha and opium, in cases in which the stomach is not easily nauseated. Should the patient have a sour breath, or sour exhalations from the body, or should his urine exhibit an excess of uric acid, the alkaline remedies may be added, especially bicarbonate of potassa or of soda. The warm or hot bath is often very useful in this variety of the disease, and may be associated, with great propriety, in somewhat obstinate cases, with the Dover's powder, or colchicum. The hot bath is preferable when the actions of the system are feeble, and the skin pale and bloodless. Aconite, belladonna, stramonium, and conium, severally, or variously com- bined, maybe resorted to in obstinate cases; and sometimes act very promptly and efficiently in the cure. Somewhat similar, probably, in their action, are the decoctions of dulcamara and cimicifuga, which have been recommended. In debilitated cases, the ammoniated tincture of guaiac is an excellent remedy. Mercury would no doubt be as efficient in this as in the other varieties of rheumatism; but it is only in cases verging towards the chronic form, and threatening, if not arrested, to be of lasting inconvenience, that its employ- ment would be justifiable. Local Treatment.— When the inflammation is considerable and fixed, as in lumbago and pleurodynia, cups or leeches are often very useful, and may be freely applied. They are, however, comparatively seldom required; as the disease, in the great majority of cases, yields in a few days without them. When the affection can be traced to the spinai column, the blood should be taken, not from the seat ofthe pain, but the immediate vicinity ofthe tender spot in the spine; and the same remark is applicable to the subsequent use of rubefaction, blistering, or pustulation, should either of these methods of revulsion be deemed advisable. In relation, however, to the appropriateness of local irritant remedies in this variety of rheumatism, though they are often very efficient in unseating the disease, yet I have long entertained some doubt. This is a peculiarly changeable form of rheumatism, and dangerous metastasis to internal parts 490 CONSTITUTIONAL DISEASES. [PART II. sometimes takes place. When a young practitioner, I witnessed fatal results, in an attack of lumbago, from the transfer of the irritation from the back to the interior organs of the chest, consequent upon the application of a blister to the lumbar region. The apprehension of similar results has since deterred me from the frequent use of repellent remedies, in cases of external subacute rheumatism. My practice has generally been to keep the part covered with flannel, carded wool, or cotton, or to leave it protected only by the ordinary clothing, of which a part, in this and all other kinds of rheumatism, should be flannel next the skin. But many practitioners freely use and recommend local irritant applications; such as Cayenne pepper with hot spirit, oil of tur- pentine, solution of ammonia, sinapisms, and blisters. Anodyne applications are also frequently employed, as camphor liniment, camphorated soap lini- ment or tincture with or without laudanum, chloroform, plasters made with extract of belladonna, or of aconite, &c. Ointment of iodide of potassium has been used with asserted benefit. Cyanuret of potassium has been em- ployed, either in solution in the proportion of one part to seventy-five parts of water, or in the form of ointment made with three grains of the cyanuret and an ounce of lard; the remedy being applied three times a day. ( Valleix.) Cold water has been recommended; but this I should consider very hazardous. It is in this form of rheumatism, and in the neuralgic, that acupuncture has been most efficient. In some cases, as in stiff-neck, heat may be advantage- ously employed, by placing a batch of carded tow or cotton over the part, and then applying a hot flat-iron. Internal rheumatism, belonging to this variety, must be treated upon the same principles as ordinary inflammation of the same organs, though it will seldom be necessary to push depletion to an equal extent. General or local bleeding or both, purging, blistering, the ordinary methods of recalling dis- ease to the external parts, and, if these fail, the use of mercury, are the chief remedial measures. The combination of opium, calomel, and ipecacuanha often answers an excellent purpose. Sometimes, after due depletion, the dis- ease gives way to the use of colchicum or aconite, when it has resisted other means; and all the general remedies, found useful in external rheumatism, may be employed in obstinate cases. Individuals who are very liable to this form of rheumatism, will find great advantage in watching its first approaches, and averting it by means of a full dose of one of the salts of morphia with wine of colchicum, at bedtime. Should this combination produce constipation, the addition of half an ounce of one of the neutral salts will obviate the result. Great watchfulness, however, will be necessary to avoid contracting the habit of using the narcotic as a luxury rather than as a medicine. 3. Of Chronic Rheumatism.—An immense variety of remedies has been employed in this complaint, many of which are probably quite useless, and owe their reputation to their introduction at one of those frequent conjunct- ures, when nature is on the point of effecting a temporary cure. Of all the means which I have employed, none has seemed to me so effectual in obsti- nate cases as mercury. It will, I am very certain, cure the disease, at least for a time, in the great majority of instances. I have repeatedly commenced my rounds in the Pennsylvania Hospital, with numbers of old rheumatic cases in the wards, and have been able to clear them out effectually by the use of this remedy. By the late Dr. Otto, of Philadelphia, the attention of the medical public, in this country, was first strongly called to this application of mercury. (See Eclectic Bepertory, ix. 528.) The disease will often give way to a moderate use of the remedy ; but, when of long standing, it may require a perseverance for two or three weeks of decided ptyalism, to effect a cure. The remedy, however, is so inconvenient and disagreeable in its action, that CLASS II.] RHEUMATISM. 491 efforts should always be made to relieve the patient by other means; at least, the mercurial plan should not be hastily and recklessly resorted to in ordinary cases. The following remedies and plans of treatment appear to me to merit attention, the general being first mentioned, and afterwards the local. General bleeding is seldom required, or, indeed, admissible in chronic rheu- matism ; though sometimes, when the complaint approaches to the subacute form, and the patient is robust, a moderate quantity of blood may be taken from the arm with advantage. Purging is often of great use. The character of the cathartic employed should vary with the degree of activity in the local affection, and with the strength of the patient. When the disease is fixed in one of the large joints, and there is no apprehension from debility, a dose of jalap and cream of tartar or of senna and salts, may be given twice a week, for a long time. When something milder is required, Scudamore's mixture, or one of the neutral salts alone may be used, as in the former varieties. Sulphur is also fre- quently useful as a laxative. During the continuance of the purgative plan, the patient, if he suffer much from pain, may take the Dover's powder every night; and, if this be pre- ceded by the hot bath, the curative effect will often be very decided. At the same time, he may employ, during the day, some one, or some com- bination of those numerous medicines which have proved useful in rheuma- tism by a supposed alterative action. As the precise mode in which these remedies do good is not known, they need not be employed with any great discrimination. Those which the experience of the practitioner may suggest as likely to be most effective may be first tried, and others resorted to suc- cessively as the exigencies of the case may require. Attention, however, should always be paid to the existing grade of excitement, and the remedies should be selected accordingly; those of a debilitating character being avoided when the patient is weak, and the stimulating when the condition of the system is decidedly sthenic. Of these alteratives, colchicum is one of the most efficient, and may be given three or four times a day, in doses within the nauseating or purging point. This remedy has appeared to me most beneficial in those cases in which the local affection is migratory, and approaches the neuralgic form. Iodide of potassium is often very useful. I have found it most effectual in cases in which there was reason to suspect a syphilitic origin. In some of these it has operated like a charm, relieving, in the course of a few days, rheumatic pains which have lasted for months. It may be resorted to in all cases of vague pains in different parts of the body, with little or no swelling, particularly when there is reason to suppose that they are seated in the peri- osteum or the bones; and in cases of this kind it often operates admirably well, even when there is no suspicion of syphilitic taint. It may be given in the dose of from five to twenty grains, three or four times a day; but its operation should be carefully watched, and the medicine omitted, or moderated, if it irritate the stomach, or produce any other unpleasant effect. Nitrate of potassa has been used in chronic as well as in acute rheumatism. Of 100 cases treated by Dr. John Carghill with nitre, 61 wTere cured in an average period of about 14 days; while of 43 treated with colchicum, only 14 were cured after a treatment of about 15 days. He gave from two scruples to two drachms in barley-water three times a day. (Lond. Med. Gaz., xiii. 639.) Dr. Fuller, in his treatise on rheumatism (Am. ed., page 29), speaks of mu- riate of ammonia as a remedy "of singular efficacy." Sulphur, besides being useful as a laxative, is an excellent alterative in chronic rheumatism, well adapted to mild cases, and sometimes of itself adequate to the cure. Guaiac has long enjoyed a high reputation in this disease. In the chronic 492 CONSTITUTIONAL DISEASES. [PART II. variety, it is most frequently used in the form of simple or ammoniated tinc- ture ; but its stimulating properties should always be borne in mind. The other alterative diaphoretics are occasionally employed, most frequently in the form of compound decoction or compound syrup of sarsaparilla, which is frequently associated with a mercurial course. Turpentine, or its volatile oil, and copaiba, are occasionally used with advantage, and are especially re- commended in chronic lumbago and sciatica. The late Prof. Chapman used to speak in strong terms of the efficacy of savine, which he introduced into the treatment of this disease. Some have found advantage from capsicum freely used. Arsenic has occasionally proved efficacious, and is thought to be spe- cially useful in cases in which the periosteum is affected. Other remedies wliich merit notice are cimicifuga, the berries and root of Phytolacca decan- dra or common poke, and xanthoxylum or prickly ash, for the modes of using which the reader is referred to the U. S. Dispensatory. Cod-liver oil is very highly praised by the German practitioners. It is particularly applicable to cases in which the rheumatism is complicated with a scrofulous taint. I have seen obstinate cases of what was originally supposed to be rheumatism of the knee or of the ankle, with an anemic state of the circulation, a frequent pulse, and tendency to night-sweats, get well under perfect rest of the joint, and the use of cod-liver oil, after the ordinary anti-rheumatic remedies had been exhausted without effect. The use of the chalybeates may often be ad- vantageously conjoined with that ofthe oil. Purging flax has recently been brought into notice, or rather its old reputation has been revived, by Dr. Butterlane, as a remedy in chronic rheumatism. He gives it in extract or infusion, and in such doses as to purge moderately, and act as a diuretic. (Med, Times, July, 1850.) Various narcotics are much and usefully employed, especially when the disease is very painful, and somewhat neuralgic. The extracts or tinctures of belladonna, stramonium, conium, and aconite, are especially worthy of notice. They are usually given in connection with some one or more of the other remedies mentioned. Different kinds of bathing are among the most efficacious methods of cure. The hot bath taken daily, and persevered in for a considerable time, often does much good; and obstinate local affections sometimes give way to a stream of hot water directed upon them, or the hot douche. A visit to the hot springs in Virginia may be recommended. Sulphur baths have also proved very useful, conjoined with the drinking of sulphurous waters. To obtain the advantages of this remedy, the patient may resort to some one of the sulphur springs among the mountains of Virginia, to the Blue Lick springs of Ken- tucky, or to the springs of Avon and Sharon in New York. Sea bathing is sometimes beneficial; and I have no doubt that the plans of the hydropathists often break up obstinate cases of this complaint, by thoroughly changing the condition of the system. Care should be taken, whenever cold bathing is employed, that reaction should subsequently take place, and be sustained by friction and exercise. Vapour baths are also among the vaunted remedies for chronic rheumatism, and no doubt often prove efficacious. Very obsti- nate cases have yielded to the vapours of sulphur, and those of camphor are asserted to have been successfully employed. These vapours are applied by means of a wooden box, in which the body of the patient is confined, while his head projects. Baths of the vapour of turpentine, at a temperature of from 140° to near 160° F., have been found safe and effectual by M. Che- vandier, of Die, in France. (See Archives Gen., 4e ser., xxviii. 80.) A long journey often acts very usefully as an alterative ; and, perhaps, no means of cure is more effectual than residence in a warm climate during the colder seasons. Vigorous exercise sometimes proves an effectual remedy. CLASS II.] RHEUMATISM. 493 The patient should always wear flannel next his skin, unless in the very hot- test weather, when silk may be substituted. The diet must be adapted to the state of general excitement, and the degree of inflammation. Confinement to milk and vegetable food, or even to vegetable food alone, may sometimes be desirable ; but generally it is sufficient to take care that the articles em- ployed are digestible, and not likely to irritate the stomach. Local Bemedies.—These are scarcely less numerous than the general. Oc- casional leeching or cupping is often very useful; but, when the disease is fixed permanently in one or a few parts, and does not change, repeated blis- tering is incomparably superior to all other remedies. The part should be covered with the blister, and, as quickly as one heals, it should be followed by another. Caustic issues and moxa are sometimes used; but I prefer blis- tering. Great benefit is said to have accrued from the application of iron, heated somewhat above the boiling point, and made to touch the surface of the affected part, at various points, in quick succession.* In mild cases, rube- facient and anodyne liniments may be used with benefit. A great variety of these liniments have been employed both in regular and empirical practice. They generally contain camphor, one or more volatile oils, such as those of origanum, rosemary, turpentine, and horsemint, and some preparation of opium. The vehicle is generally alcohol. Probably none are better than the officinal camphorated soap liniment, or camphorated tincture of soap, to which laudanum may be added. Ammoniacal liniments, with or without laudanum, are often used. The bitumens enter into some nostrums. Poultices contain- ing carbonate of soda, and lotions with a solution of the same salt or of car- bonate of potassa, are said to have proved beneficial. Friction with castor oil has been recommended. The tincture ofiodineh&s been applied advan- tageously to the surface of the inflamed part, and has been particularly recom- mended in disease of the joints. Plasters of aconite, belladonna, dec, may be used when the part is very painful. Other local remedial measures which have been recommended, and occasionally prove useful, are electricity; com- pression by means of a flannel or muslin roller; the same in connection with the local use of sulphur; a thin covering of caoutchouc; the soap, ammoniac, or compound galbanum plaster, in affections of the joints ; dili- gent frictions ; and in some instances exercise, in others rest of the affected parts. 4. Of Nervous Rheumatism.—The treatment of this affection is so exactly like that ofthe analogous variety of gout, that I shall content myself with referring the reader to that disease. * This process is called firing. Dr. Corrigan, of Dublin, has suggested a neat mode of applying it, with very little pain to the patient. A thick iron wire, about two inches long, is at one end inserted into a small wooden handle, and, at the other end, which is slightly curved, attached to a disk of iron, one-quarter of an inch thick, and half an inch in diameter, and with its face quite flat. The disk of iron is to be heated in a spirit-lamp, until the finger, placed on the wire half an inch above it, becomes uncom- fortably hot, and is then to be applied very lightly to the skin, passing as rapidly as possible from point to point, at intervals of half an inch, until the whole surface over the affected part has been touched by it. The whole flat surface of the disk should be made to come in contact with the skin. The spots touched become instantly white, and in a few minutes the whole surface is reddened; but an eschar is never formed, and very seldom a blister, if the operation be well performed. Instant relief is often obtained, and not unfrequently a permanent cure is effected. Dr. McCormack, of Donegal, speaks in the strongest terms of the efficacy of this treatment. (See Braithwaite's Retrospect, N. Y. ed., xiii. 55, and xv. 82.) 494 CONSTITUTIONAL DISEASES. [PART II. Article II GOUT. Syn.—Arthritis. This is a constitutional affection, exhibiting itself in a peculiar irritation or inflammation in various parts of the body, of which probably no one vital por- tion or tissue is at all times exempt. The modern name gout was derived from the Latin gutta (drop), probably through the French goutte, and owed its origin to an old pathological notion, that a peculiar liquid matter, upon which it was supposed that the disease depended, fell drop by drop into the affected joint. To the ancients the disease was known under the general designation of arthritis; and particular names were given to it, according to the part in which it was seated, as podagra when in the foot, and chiragra when in the hand. Various divisions of the disease have been made by authors, and given rise to as many different designations. Thus, gout is called regular or irregular, according as it pursues or deviates from the ordinary course; tonic or atonic, according to the accompanying strength of system, and energy of local action; acute or chronic, according to its duration and violence ; misplaced, when it appears originally in some part not ordinarily attacked by it; and retrocedent, when, having occurred externally, it leaves its position to seize upon some interior organ. It has appeared to me that the disease may be most conveniently considered under the three divisions of acute, chronic, and nervous goid, There are cases which might be denominated subacute; but they are much less frequent relatively than the analogous cases of rheumatism, and I have not deemed it necessary to make a distinct class of them. A variety of disease participating in some degree in the characters of both gout and rheumatism, and therefore often called rheumatic gout, presents, nevertheless, so distinct a phasis as to merit a separate consideration. I shall first describe these varieties sepa- rately, and afterwards treat of them conjointly in relation to their cause, treatment, &c. 1. Acute Gout. Symptoms, Course, &c.—This form ofthe disease occurs generally in per- sons of vigorous constitution, and at an age when the powers of life are greatest. It is characterized by paroxysms of acute inflammation, generally confined at first to one spot, especially one of the smaller joints, and at- tended with fever. The disease appears to have a singular predilection for the metatarsal joint of the big toe. Sometimes it first attacks the ball of the foot, or the ankle, and occasionally one of the finger joints, or the wrist. Of 193 cases compared by Scudamore, 130 began in the joint of the great toe and all but 8, in the smaller joints or the ankle of one or both feet. After the disease has repeatedly recurred, it often deviates from its original course and the paroxysm may commence in any one of the joints, or even in an in- terior organ, though it still shows a preference for the parts originally affected. In the ordinary regular form of the disease, the patient is seized either after a longer or shorter duration of certain preliminary symptoms, or abruptly in a state of apparently sound health, with acute pain in the large joint of the great toe, or in whatever other part is to be the seat of the inflammation. This pain is sometimes intensely severe, and is described by patients as tearing CLASS II.] GOUT. 495 rending, boring, piercing, kc, as if the joint were torn by pincers, or pene- trated by a gimlet or nail, or were under the action of a saw. At first, there is little or no appearance of inflammation ; but the joint soon begins to swell, the skin becomes hot and of a bright-red colour, and the tenderness is so ex- quisite that the least jar is intolerable, the weight even of the bedclothes cannot be borne, and the patient dreads the approach of any one, lest by acci- dent the limb might be touched. A characteristic phenomenon ofthe gouty inflammation is the turgescence of the superficial veins, not only near the part, but for some distance up the limb. The symptoms continue with little abatement for six, eight, twelve, or even twenty-four hours, after which the excessive violence of the pain subsides, though the swelling rather increases than diminishes, becoming somewhat edematous, and appearing to contribute towards the relief of the previous acute suffering. The attack is apt to take place in the middle of the night, the patient being awakened out of sleep an hour or two after midnight by the violence of the pain. In such instances, the affection not unfrequently continues, with little relaxation, until about the same time on the following night, when the patient falls asleep, and wakes in the morning much relieved, and perhaps moderately perspiring. Simultaneously, or nearly so, with the local affection, febrile symptoms ap- pear, commencing usually with chilliness or rigors, which are followed by acceleration of pulse, increased heat of skin especially of the face, loss of appetite, a furred tongue, constipated bowels, and scanty, high-coloured, late- ritious urine. Not unfrequently the discharges from the bowels are pale, or green and offensive, indicating deficient or deranged action of the liver ; and sometimes an unpleasant odour exhales from the surface. The febrile symp- toms remit, along with the local affection. But the paroxysm is not yet ended. Both the inflammation and the fever undergo an exacerbation to- wards evening, which continues more or less through the night, to abate again in the morning; and this daily alternation goes on for a period, varying greatly in different cases, but, in the early attacks of the complaint, generally not exceeding a week or ten days, and not unfrequently falling short of the first mentioned period. The pain and fever generally leave the patient before the swelling; and their disappearance is sometimes attended with looseness of the bowels, or the occurrence of perspiration, or a copious discharge of urine, which deposits a lateritious sediment on cooling. The remaining tumefaction, which is usu- ally edematous, now gradually subsides, and the affection terminates in a de- squamation of the cuticle of the part, often attended with itching. After the first attacks of the disease, the affected joint is restored perfectly to its functions, and the patient generally enjoys, for some time, an unusual exemption from morbid sensations, and considers himself in better health than before. It is not always, however, that gout begins as above described. Some- times, before the occurrence of a severe and regular paroxysm, there are several slight attacks, at distant intervals, of pain and soreness in some part of the foot or hand, which are insufficient to confine the patient, and which he is often disposed to ascribe to a sprain, or other accident. In other in- stances, the attack begins moderately, and gradually increases until it becomes severe and febrile, and then as gradually subsides. The existence, in certain cases, of disordered symptoms preliminary to the onset of the paroxysm, has been already referred to. These are not unfre- quent. Indeed, to a greater or less extent, they are experienced in the great majority of cases. In character, degree, and duration, they are exceedingly diversified, being sometimes so mild as scarcely to attract attention, in other 496 CONSTITUTIONAL DISEASES. [PART II. instances very distressing; occasionally lasting only a few days, and again persevering, with greater or less steadiness, for months or years Most of them will be more particularly described under nervous gout; as they are often the same as those which characterize that variety of the disease. It is sufficient here to say that they are, for the most part, either simply neuralgic, or such as indicate mere disorder of function. Among the most prominent of the latter are dyspeptic sensations, an impaired or craving appetite, acid eructations, flatulence, deficient or deranged biliary secretion, a tendency to constipation or looseness, nephritic disorder, occasional palpitations and dyspnoea, giddiness, buzzing or roaring in the ears, dimness or other disorder of vision, and emotional irregularities, as depression of spirits, hypochon- driacal notions, and unusual irascibility of temper. Dr. Cullen enumerates, among the premonitory symptoms, " the ceasing of a sweating which the feet had been commonly affected with before ; an unusual coldness of the feet and legs; a frequent numbness, alternating with a sense of pricking along the whole ofthe lower extremities ; frequent cramps ofthe muscles of the legs; and an unusual turgescence ofthe veins." Not unfrequently, an experienced gouty patient can foretell an approaching attack by the occurrence of some one or more of these symptoms. They generally disappear upon the attack of the paroxysm, and so harassing are they in some instances to the patient, that the inflammation of the joint is welcomed as a relief. After the sub- sidence of the inflammation, if severe and of the usual duration, the system seems to have been cleared of some offending cause, and the patient enjoys for a time excellent health and spirits. It seldom happens that an individual has only a single paroxysm of acute gout. In some rare instances, the patient has been able, by a complete change of habits, to throw off the gouty tendency, and has escaped a second attack. But generally the disease recurs sooner or later. Sometimes the second paroxysm does not occur for three or four years, or even longer; but usually it makes its appearance in a year; and the returns afterwards continue to be annual, and, with remarkable uniformity, at about the same season, even in the same month. As the disease advances, the length of the paroxysms in- creases, while the intervals shorten. Instead of lasting from five to ten days, as at first, they continue for two or three weeks, or longer; and, instead of returning annually, they make their appearance twice a year, afterwards four times a year, and at last so frequently that, with their longer duration, the patient is hardly ever quite exempt. At this stage, one paroxysm does not completely subside before another appears; so that the patient labours under a remittent disease, except, perhaps, for six or eight weeks, in the middle of summer, when the gouty symptoms leave him. In its first returns, the disease is generally confined, as in the beginning to a single joint, and often to the one originally attacked ; but this tendency to fixation diminishes with the progress of the case, and at length the in- flammation occurs in some other joint, or, after appearing in one, passes into another, and thus sometimes successively attacks the joints of the foot the ankle, the knee, the fingers, wrist, elbow, &c. In some instances, though thus migrating from point to point, it occupies but one position at a time • in others, it affects several joints simultaneously, though even in these one is generally more inflamed than the others. As the local affection thus extends, both in duration and position, it loses much of its violence. The pain is less intense than in the earlier attacks, and there is also less redness. The swelling, it is true, is often greater; but' it is less tense, and more edematous. The grade of the inflammatory action has obviously lowered, corresponding, in this respect, with the diminished energy of the system. The joint, after the paroxysm is over, does not now so com- CLASS II.] GOUT. 497 pletely recover its natural healthy power as at first; but is apt to remain stiff, and sometimes becomes almost incapable of motion. The febrile action is also less vigorous than in the earlier paroxysms; but the patient is more troubled with the internal symptoms before alluded to previously to his attack, and gets less thoroughly rid of them when the local affection subsides. During the continuance of the paroxysm, he is more lia- ble to be affected with visceral disease ; and attacks of gouty inflammation or irritation in the stomach, bowels, kidneys, liver, lungs, heart, and brain, are more apt to occur, whether originally, or in consequence of the retroces- sion of the external affection. In this advanced stage, the gout may be considered as having passed from the acute into the chronic state. Without losing its claim to be ranked as acute gout, the disease not unfre- quently, at all stages of its progress, retrocedes from the extremities to fix upon some interior organ, or attacks one of these organs without having ap- peared externally, constituting what has been called misplaced gout. Either of these events may happen, through the influence of causes calculated to fix an irritation in any one of the viscera, and thus to invite the morbid tenden- cies of the system to concentrate themselves upon it. Retrocession may re- sult from anything which tends to put an end to the external inflammation, without, at the same time, correcting the general diathesis; as, for example, the application of cold to the affected joint. Fatal metastasis has often re- sulted from this cause. It may be stated, in general terms, that the greater the energy of the system, the stronger is the disposition of the disease to fix itself, in a highly inflammatory form, in its legitimate external seat; and that, consequently, whatever tends to debilitate the system, renders the occur- rence of retrocedent or misplaced gout more frequent. It may be proper to refer briefly to the phenomena of the disease in the more important organs. In the stomach, gout may occur in two distinct forms; the inflammatory, namely, and the nervous or functional. In the former, the symptoms are those of acute gastritis. There are burning pain, exquisite tenderness upon pressure, and not unfrequently nausea and vomiting. If not depressed by the state of nausea, the pulse has considerable volume and strength; but, in the other case, it may be slender and feeble, with a cold, pale, damp surface, which may readily be mistaken for evidence of debility. Sometimes the brain sympathizes with the stomach, and stupor attends the gastric inflammation. I have seen a case of this kind, in which the patient appeared perfectly un- conscious, and insensible to ordinary impressions, but exhibited by a violent and convulsive start, evidence of extreme pain, when a very slight pressure was made on the epigastrium. It is important not to confound such cases with cerebral inflammation. The case in question yielded at once to remedies applied to the stomach. In the nervous or functional affection, there is either violent spasm, or op- pression, distress, nausea, and vomiting, according as the muscular or mucous coat is the seat of irritation. But the burning pain is wanting, the tender- ness on pressure is less, and, instead of febrile action, there is often great prostration, with a cold clammy skin, and an alarming feebleness of the pulse. The bowels are sometimes attacked in the form of diarrhoea or of colic. In the heart, which, however, is rarely affected in acute gout, precordial op- pression, dyspnoea, sharp pains, and syncope more or less complete, may be produced. In the lungs, symptoms of intense bronchial congestion sometimes appear, with difficult breathing, great anxiety and distress, a purplish or livid hue of the face and hands, a feeble pulse, and coolness of the surface. I have seen symptoms of this kind promptly relieved by the loss of blood from the arm. But sometimes the pulmonary symptoms are those rather of nervous vol. I. 32 498 CONSTITUTIONAL DISEASES. [PART II. than vascular irritation, and appear in the form merely of dyspnoea or asthma. The diaphragm is sometimes affected, with symptoms similar to those which occur in rheumatism of the same organ. The liver is less frequently in- flamed than functionally deranged. Deficient, depraved, or superabundant secretion of bile is among the most common internal derangements of the system in gout; so common, indeed, that some have supposed the disease to be essentially connected with the hepatic disorder. Hence the clay-coloured, soap-like, or green and offensive stools, and the bilious vomiting and purging, which often attend the gouty paroxysm. The kidneys are probably more frequently affected than any other internal organ. Gravelly symptoms are not uncommon during the paroxysm, conse- quent upon the excess of uric acid or the urates in the urine. But genuine at- tacks of nephritis alternate, in some individuals, with external inflammation; and retrocedent gout occasionally seizes upon these glands. It is not difficult to explain this fact. In gout, there is often an excessive production of uric acid, which, thrown off with the urine, irritates the pelvis of the kidney and its excretory duet, thus rendering these parts the centre of afflux for the gouty tendencies, when anything may unseat the disease of the joints. Sometimes the inflammation fixes on the urethra, producing purulent discharge, scalding pain upon the passage of urine, and other symptoms analogous to those of gonorrhea. Occasionally the gouty irritation displays itself in the skin, producing the phenomena of urticaria, erythema, or other exanthematous eruption. The brain is sometimes attacked by acute gout, with the production of stupor, and occasionally of complete apoplexy or palsy. Sometimes the cerebral affection assumes the form of meningitis, and cases of this kind are said to have ended in insanity. The eye also may suffer. One of the most obstinate instances of ophthalmia that have fallen under my notice, was in a gouty patient. The eye appeared to have become the point in which the force of the disease centred ; and, though it was frequently relieved for a time, a new paroxysm would restore the inflammation; and the affection was thus sustained for more than a year, and did not yield at last, until the gouty tendencies appeared, of their own accord, to take another direction. It is unnecessary further to extend the list of parts which may become the seat of gouty inflammation. The probability is, that no part of the system, possessed of a capacity for the inflammatory process, is entirely exempt. The organs most frequently and prominently affected are probably the stomach and kid- neys. It is often difficult, in misplaced gout, to determine whether the inflam- mation is of the common kind, or of gouty origin. The occurrence of a reg- ular paroxysm, and the consequent relief of the disease in its irregular seat, or the alternation of the two affections, is the best diagnostic sign. But one of these attacks, occurring in a gouty individual, may generally be suspected of the gouty taint, and treated accordingly with good effect. When the gouty diathesis exists in a person of otherwise feeble health, or debilitated system, though it may still show itself in the form of external in- flammation, yet this will be of a lower grade than in more vigorous individ- uals, more disposed to change its position, and more apt consequently to fix upon the internal organs. In these cases, the internal affections often do not rise above the grade of nervous or functional disease, and, therefore, belong to nervous gout; but sometimes they are slightly inflammatory, though less dangerous than similar affections attending the more sthenic cases. Gout is not generally regarded as a very dangerous disease; and many who suffer under it console themselves with the reflection that it serves to guard the system against others more dangerous than itself. There is pro- bably some truth in this impression. In gouty individuals, the causes which CLASS II.] GOUT. 499 ordinarily produce internal inflammation may be directed, by the peculiar tendencies of the constitution, to an external and comparatively safe position. Yet gout itself is not unfrequently fatal. In the earlier stages, the greatest danger is from internal seizure, whether original or by translation; and every now and then we hear of a victim to gout in the stomach, the brain, or the heart. These cases, however, are comparatively few. It is from the slow wearing influence of the disease, every year extending its sway more and more over the constitution, which every year becomes less and less able to resist it, that the greatest danger arises. The internal vital organs, by the frequent stress to which they are exposed, become at length so far weakened or de- ranged that slight causes give rise to the most serious effects. Hence fatal attacks of apoplexy, of pulmonary congestion or inflammation, and of cardiac disease. But one of the most frequent terminations is in dropsy, consequent either upon general debility, or organic visceral disease, as of the heart, liver, lungs, or kidneys. In this condition, however, the affection may be consi- dered as having assumed the chronic form. 2. Chronic Gout. Symptoms, Course, &c.—Chronic gout is generally the result of a long continuance of the acute, though sometimes the disease is of the chronic grade from its commencement. The period at which it takes on this form varies greatly in different persons; those of vigorous constitutions retaining the acute symptoms much longer than the feeble. The boundary between the two states of gout is altogether arbitrary. The one runs into the other by im- perceptible gradations. The disease may be considered chronic, when the local affection is not sufficiently active to produce fever. In this condition of gout, the paroxysms are more frequent than in the acute, but much less severe. There is often little pain unless upon motion of the joint. There is also little increase of heat; and redness is either entirely absent, or of a purplish hue. When there is swelling, it is usually edematous. Not unfrequently, the synovial liquid of the joints, and the fluid of the neigh- bouring bursa?, are so much increased as to produce a considerable appear- ance of tumefaction, and to fluctuate obviously under pressure. This is par- ticularly the case in the knee and the elbow. The paroxysms occur less regularly than in the acute form; sometimes coming at intervals of a month, sometimes of two or three months. They also last much longer; and it not unfrequently happens that they run into each other, a fresh attack coming on before the preceding one has quite sub- sided ; so that the patient is scarcely ever free from disease. In some instances, the disease is fixed in certain joints; in others is more or less migratory, wandering from joint to joint, now attacking one part and now another, and not unfrequently retroceding from the surface to seize upon one of the interior organs. In the latter form, the local affection is apt to be more painful, and to exhibit more redness than in the former; and the case might, perhaps, in many instances, be considered as rather a mixture of the acute variety, in its mildest grade, with more or less of the nervous, than as strictly chronic. In the more fixed form of chronic gout, the joints often become perma- nently altered, so as to bend with difficulty, and sometimes to be nearly or quite useless. This arises partly from a thickening or other structural ehange of the ligaments, partly from the deposition of insoluble earthy matter, like chalk, either in the cavity of the joint, or in the cellular tissue about it. This deposition is more especially apt to occur in the joints of the fingers. The earthy matter is first extravasated in a liquid, or semi-liquid state, and 500 CONSTITUTIONAL DISEASES. [PART II. afterwards becomes dry by the absorption of the fluid parts. The tumours which it forms are called chalk stones. They vary in size from a mustard seed to that of a walnut, and are sometimes very numerous, forming large masses about the knuckles and other joints. They have been found upon chemical analysis to consist chiefly of uric acid or its compounds, especially urate of soda. Sometimes they contain also urate and phosphate of lime. By their pressure they cause an absorption of the soft parts, and their white surface may sometimes be seen through the cuticle, with which they have come into contact in consequence of the destruction of the true skin. Occa- sionally they produce much swelling in the neighbouring parts, with a purple redness which appears to threaten mortification, and the collection of a con- siderable quantity of serous fluid beneath the cuticle. This at last breaks, and the fluid escapes along with portions of the chalk-like matter, but without pus at this stage. Subsequently, however, suppurating ulcers are formed, which continue open for a long time, and prove very rebellious to treatment. The earthy matter, being contained in the cells of the areolar tissue, is not readily discharged, and art can do little to hasten the process. At length, however, the whole of the offending cause is eliminated; and the ulcers heal; or cicatrization takes place, notwithstanding that portions of it may be re- tained in the tissue beneath. Old gouty individuals have sometimes been able to write with their knuckles, in consequence of the exposure of the chalky tumours in the yicinity of the joints. It is an interesting fact, ascertained by Dr. A. B. Garrod, of London, that in cases attended with this deposition about the joints, there is a deficiency of uric acid in the urine, and an excess of it in the blood. Another peculiarity of chronic gout is the formation of small hard nodosi- ties upon the surface or in the substance of the ligaments, cartilages, and tendons. These sometimes increase till they attain a considerable size. In most instances, they are without pain, but not always so. They sometimes consist of the chalky matter surrounded by a dense membranous coating, sometimes apparently of the hypertrophied tissue of the part. Dr. Garrod considers these little nodosities, occurring on the ear, as diagnostic of gout. Though fever is not a regular attendant upon chronic gout, and is often quite absent, a slight degree of it sometimes takes place, when a fresh acces- sion of inflammation occurs, or some internal disorder is superadded. The patient has a pale or sallow complexion, a flaccid state of the flesh, and the general aspect as of one worn by long-continued ailment. He is frequently troubled with dyspeptic symptoms, functional disorder of the liver and kid- neys, irregularity of the bowels, and acute muscular pains, sometimes attended with cramps, in various parts of the body. Unless cut off by some acute dis- ease which the debilitated state of his system is unable to resist, he at length falls into general dropsy, suffers with serous effusion in his chest, and dies most frequently from an interruption of the respiratory process. Anatomical Characters.—Dissection has revealed little that is of peculiar interest either in chronic or acute gout. In the former, the synovial mem- brane of the affected joint, and the interarticular cartilages, exhibit evidences of inflammation; the cartilages covering the articulating ends of the bones are sometimes partially absorbed; and the bones themselves near the joints are injected with blood, softened, and occasionally eroded. The external ligaments, though less affected, are sometimes injected and thickened, and the muscles in the neighbourhood wasted or rigidly contracted. Layers of chalky matter are found, in some instances, either within the synovial mem- brane, or between it and the cartilages; and the same matter, without the joints, is observed in the cells of the areolar tissue, in the muscles, fascia?, ligaments, and periosteum. In cases of death from internal inflammation, CLASS II.] GOUT. 501 the ordinary signs of that affection are exhibited; but pathological anatomy is not rich in records of this kind; partly, perhaps, because death from this cause seldom occurs in the hospitals. 3. Nervous Gout. Symptoms, Course, dec.—This form of gout is sometimes quite distinct from the others ; but is generally more or less mingled with them, constituting cases which have been described by various names, as irregular gout, atonic gout, movable chronic gout, &c. It is apt to affect persons who have inherited a gouty diathesis, but, from original temperament or abstemious habits, are little liable to inflammation. Women, and individuals generally of a nervous temperament, who have descended from gouty ancestors, are very liable to it. Sometimes all the members of a family are prone to'it; or the female members may be affected with this variety of the disease, while the males, from their more active habits, and freer lives, are attacked with the acute form. There is reason to believe that it is much more common than formerly, having, to a considerable degree, superseded the old-fashioned gout, pro- bably in consequence of greater temperance in the modern modes of living. I have no doubt that much of the neuralgia, now so prevalent, is only gout or rheumatism in the nervous form. It may be asked how the disease is known to be of the gouty character. It may be reasonably suspected to be so, when the person affected has had gouty parents or grandparents, and no other cause can be detected. Its fre- quent intermixture or alternation with slight attacks, or abortive efforts at external inflammatory gout, raises the suspicion pretty nearly to certainty. An individual has an attack of regular gout, which relieves him from various functional derangements, to which he has long been subject. Alarmed for the future, he changes his mode of life, avoids all stimulating drinks, uses animal food in great moderation, and finds himself, for the remainder of his life, exempt or nearly so from inflammatory paroxysms, but, in place of them, is frequently harassed by this variety of the disease, in some one or more of its protean forms. Nervous gout shows itself in the form either of simple neuralgic pain, or functional disorder. The pains may be dull and constant, or sharp, lancinat- ing, and intermittent, and may occur in any part of the body. Sometimes they remain long fixed in certain parts; but are more frequently changeable, appearing now in one part and now in another, without any regularity in their course. I have known an individual who was for many years subject to a fixed pain in the region of the liver, without the least sign of hepatic derangement, and in whom the pain suddenly disappeared upon the occur- rence of an attack of insanity, to return again when the insanity ceased. That the affection was of the character supposed, was evinced by occasional external attacks of the disease in a subacute form. It is not uncommon for a fixed pain of this kind to continue for months in one spot, varying, how- ever, very much in intensity, and sometimes scarcely noticed, and then to disappear without any obvious cause, to be followed at a shorter or longer interval, or immediately, by a similar pain elsewhere, or by some functional derangement of one of the internal organs. The right iliac region, the pre- cordial region extending to the left arm, the right side of the chest, and the scalp, are not unfrequent seats of it. Hemicrania is one ofthe forms which the disease sometimes assumes. The severe shooting neuralgic pains are apt to occur more especially in the temples, cheeks, or front part of the upper and lower jaws, though they may also attack the extremities, particularly the smaller joints, the genera- 502 CONSTITUTIONAL DISEASES. [PART II. tive organs, the anus, and any one of the viscera. Not unfrequently, they attack the muscles, which become painful on contraction. Sometimes these pains, as well as various functional disorder, are found to be dependent on the disease seated in one of the nervous centres, or in the neurilemma of one of the larger nerves, from or through which nervous influ- ence is extended to the part affected. Thus, pains in the trunk and extremi- ties may proceed from the disease in some portion of the spinal marrow, or its envelope. But, in most instances, the pains can be traced to no such origin, appearing to be the direct result of the morbid cause. Let us now turn our attention to the several functions. The digestive function is among those most frequently deranged. All the varieties of disordered sensation which usually attend dyspepsia are experienced in this affection. Vague uneasiness in the epigastrium, a feeling of weight or op- pression, irregular appetite, cardialgia, sour or acrid eructations, flatulence, sometimes nausea and vomiting, sometimes severe spasm, are among the pro- minent symptoms. The bowels are generally costive, occasionally loose, with frequent deficiency of bile, or other unhealthy condition of the stools. Colicky pains, and flatulent distension are not uncommon. Sometimes the patient suffers with severe neuralgic pains in the bowels. The respiratory function is occasionally also much deranged. The larynx is now and then the seat of irritation, and the patient is worried with a fre- quent cough, which might well be mistaken for pectoral without care. I have a patient subject to this form of gout, who was at one period afflicted with an incessant cough, which continued for months, and scarcely ceased for a minute except during sleep and meals. Paroxysms of oppression and dys- pnoea, almost like those of spasmodic asthma, indicate the existence of the disease in the lungs. The circulatory system is often greatly disordered, as indicated by pre- cordial oppression, palpitations, darting pains in the region of the heart, intermittent and irregular pulse, and sometimes syncope, or a strong ten- dency towards it. Of the secreting organs, the liver and kidneys are most frequently affected. When the irritation seizes upon the former, together with a dull pain in the side, or an indescribable uneasiness in the whole upper region of the abdomen, there is frequently deficiency of bile, with pale or clay-coloured stools, and a sallow hue of the surface, or excessive secretion with bilious vomiting and purging, or black stools approaching to mela?na; or there may be derange- ment of the secretion with little local uneasiness, though the affection is almost always attended with depression of spirits. Excessive secretion of a pale urine, or a scanty secretion of a red urine loaded with uric acid, and sometimes a dull pain in the small ofthe back, or pains like those of gravel, indicate that the kidneys are affected. The sensorial functions are often greatly disturbed. Vertigo, dizziness, tinnitus aurium, perverted vision, musca? volitantes, and violent headaches are common symptoms. Sometimes even coma and convulsions are expe- rienced. These cephalic attacks are often very sudden. A person will be feeling perfectly well, and as if capable of performing any duty effectively ; when suddenly he will be seized with vertiginous pain in the head, with roar- ing or other distracting noises in his ears, and often some perversion of vision, and immediately all his energy is lost, and he feels himself quite incompetent to the least exertion. Sometimes the eyes become extremely sensitive, so that any attempt to use them, even for a few minutes, occasions intolerable pain. Every variety of mental depression accompanies these affections of the head. The spinal marrow and nerves become not unfrequently the seat of irritation, which displays itself in irregular muscular contractions, cramps or CLASS II.] GOUT. 503 spasms, and occasionally a vague and unaccountable uneasiness, extending through the limbs, with a universal feeling of oppression, heat, anxiety, weari- ness, soreness, &c., which they only can fully appreciate who have felt them. These various disorders usually occur quite irregularly, the irritation being sometimes in one part, sometimes in another; in certain instances fixed for days, weeks, or months in a single organ or function, in others rapidly chang- ing its seat; occasionally leaving the patient entirely, with the most exquisite sense of freedom from suffering, and the best hopes for the future, then re- turning, and often without apparent cause, with all its former violence. Not unfrequently the disease assumes a regularly intermittent form, return- ing at a certain hour every day, and leaving the patient in the interval. As before stated, an attack of subacute inflammation occasionally takes place in an exterior joint or muscle, and affords a temporary relief to the ner- vous irritation ; and there are, perhaps, few patients in whom, at one period or another, the disease does not afford this evidence of its nature. This form of gout does not often directly destroy life. Sometimes a quick and violent seizure of one of the vital organs, as the heart or brain, appears completely to arrest its function, and thus to occasion sudden death; but instances of this kind are rare. More commonly the patient lives many years, perhaps in some instances surmounting the affection, but more fre- quently falling a victim to some incidental disease, or worn out at last by chronic organic derangements, in which the fanctional disorder may finally terminate. 4. Rheumatic Gout. This term is often rather vaguely applied to any condition, in which the symptoms of gout and rheumatism seem to be intermingled, or in which, from any other cause, the physician is unable to determine to which of these affec- tions the case properly belongs. In this place, however, it is restricted to a particular form of disease, noticed by Sydenham, but first distinctly described by Haygarth, in 1805, which, though partaking in some respects ofthe nature of both diseases, is yet different from either in its symptoms and course, as well as in the class of persons usually attacked. Since the time of Haygarth, it has received the attention of several writers, English and French, who have described it under the different names of capsular rheumatism (Macleod), chronic rheumatism of the joints (Todd), and nodose rheumatism (rhu- matisme noueux, Lasegue and others). It is fully described, under the title of rheumatic gout, by Dr. H. M. Fuller, in his treatise on rheumatism and gout; and a copious monograph on the subject by Dr. Robert Adams, of Dublin, is announced in the London medical press, as having just been pub- lished,, which, however, I have not had the opportunity to consult. Dr. James Jackson, of Boston, in his "Letters to a Young Physician" (pp. 169, 170), refers to it as an extremely obstinate if not incurable affection. With the first attack of the disease, there is occasionally so much febrile excitement as to entitle it to be considered as acute, though the fever is much less than that which ordinarily attends acute rheumatism. More frequently the disease begins with the chronic character, attended, perhaps, with some derangement of the digestive, hepatic, or menstrual function, but without in- creased heat of skin, or frequency of pulse; and, when originally of the acute form, it subsides ultimately into the chronic. The local disease usually shows itself first in the finger joints, several of which are ordinarily affected; being swollen, reddish, and somewhat painful, and especially painful at night; though all these signs of inflammation are less in degree than in the acute forms of gout or rheumatism. In some rarer cases, one of the larger joints is primarily affected; and, in the progress of 504 CONSTITUTIONAL DISEASES. [PART II. the case, they generally become involved. After a time, either spontaneously or under treatment, the symptoms abate, and a kind of remission takes place, which, after a shorter or longer time, is followed by another paroxysm ; and thus the disease goes on indefinitely; each successive exacerbation being at- tended with an increase of the local affection, and perhaps its extension to other joints. In the advanced stages, however, this paroxysmal tendency be- comes less decided, and the complaint more regularly continuous. The swelling is somewhat peculiar in its character. Instead of extending into the neighbouring tissues, and gradually subsiding as it recedes from the centre affected, it has a disposition to limit itself immediately to the joint, around which it forms a somewhat circumscribed bulging, which at first is soft and puffy about the small joints, and in the larger, somewhat fluctuating under the finger, from effusion into the synovial cavities and the bursa?. As the disease advances, the swelling becomes firmer, and the joints are perma- nently enlarged. Deformity now takes place; the fingers being forced to one side, or bent backward or forward ; and bony projections or hard protu- berances forming about the joints. These "nodosities" are characteristic of the disease. They are not formed, as similar prominences in chronic gout, by deposition of urate of soda; but are bony, and caused by enlargement of the bone itself, or its projection in consequence of displacement. The joints often give a cracking sound, at this stage, when moved. The nodosities in- crease as the disease proceeds, impeding the motion of the joints, which are now apt to become stiffened, and are sometimes partially dislocated. A remarkable symmetry has been noticed in the distortions, occurring on different sides of the body; the corresponding joints of the right and left side being affected in the same manner, the fingers turned in the same direction, and even the nodosities occupying the same relative position. These deformities and nodosities affect also the larger joints, as the ankle, knee, hip, wrist, elbow, and shoulder; and bony prominences may sometimes be seen at the maxillary joint, and at the junctions of the clavicle with the sternum and acromion. The hip is sometimes the seat of a partial dislocation and stiffness, by which the direction of the thigh is somewhat altered, the limb apparently shortened, and the rotary movement impeded. The disease usually goes on for years, often for many years, and sometimes continues, gradually increasing, from early to advanced life ; ending at last fatally, either from a failure of the vital powers under incessant irritation, or through some supervening affection. It is seldom accompanied with the cardiac complaints so common in the ordinary forms of rheumatism. Anatomical Characters.—When the joints are examined after death, the ligaments, periosteum, and synovial membrane are found thickened ; the car- tilages of the joint often separated from their connections, and in a greater or less degree absorbed; the ends ofthe bones denuded, and sometimes polished by friction to the appearance of ivory; and the bones themselves enlarged, as well by accretion of bony matter to their surface, as by interstitial growth. The knotty protuberances are found to be owing to this enlargement of the bones, or the projection of some portion of them, consequent upon the loss of the proper adjustment of the articulating surfaces, from the unequal growth of their structure. It is this want of proper adaptation, too, according to Dr. Adams, that causes the stiffness and immobility of the joints, rather than bony adhesion, which he has not met with. (Lond. Med. Times and Gaz., Jan., 1858, p. 17.) Urate of soda, mixed more or less with other urates, is sometimes found, in the form of a white earthy powder, forming layers upon the denuded articulating surfaces, or interspersed in the bony tissue. (Fuller, p. 256.) But this is not generally the case; and Dr. Adams states that he has never found it in the affection as it came under his notice in Ireland. (Lond. Med. Times and Gaz., ut supra.) CLASS II.] GOUT. 505 Causes.—These are uncertain. In many instances, the disease may be traced to inheritance, and in others to some disturbance of the menstrual function, or at least to some state of the system connected with that function; and these are the only known causes. Women are more frequently affected than men, and the periods of life when they are usually first attacked are those at which the menses are most liable to disorder; from puberty, namely, up to 25 or 30, or at the age when the function ceases. High living has no influence in producing the disease; as it generally occurs in the humble walks of life; nor can it be ascribed, as is often the case with rheumatism, to exposure to cold. It is not, I think, common among persons born in this country, at least I have seldom seen a native American affected with it. The cases which have fallen under my observation have been almost exclu- sively among Irish immigrants, and especially among the young women who serve as domestics, and, when they become disabled by disease, find their way to the Hospital. Nature.—There has been some difference of opinion upon the point, whether this affection is to be considered as rheumatism or gout. It re- sembles the latter in its somewhat paroxysmal character, in affecting especi- ally the small joints, in its great obstinacy, and in the circumstance that deposits of the urates are sometimes found in the joints; but it differs in the persons attacked, the steady continuance of the disease between the par- oxysms, and in its peculiar anatomical lesions. With rheumatism it has a general agreement in its aspect, but in its causes so far as known, its pre- ferable position in the small joints, its paroxysmal course, its intense persis- tency, its indisposition to affect the heart, and the nature of the lesions in the joints, it presents features which strikingly distinguish it from the ordi- nary forms of that disease. Some consider it a mixture of the two diseases; and hence the name of rheumatic gout. This is certainly not impossible. Analogous diseases are capable of forming hybrids like analogous species. Scarlatina and measles are, I have no doubt, sometimes mingled when there has been exposure to their causes jointly. In the same manner, the co- operation of the causes of gout and rheumatism may be readily conceived to produce a mixed disease. It has not been ascertained that uric acid is uni- formly or even generally found in the blood in abnormal amount; but, from the occasional presence of urate of soda in the joints, there is reason to think that this peculiar feature of gout is not always wanting. If, however, it were present in all, this would not prove that the disease is exclusively gout; for, though purely rheumatic patients want this abnormal amount of uric acid in the blood, the fact by no means proves that rheumatism may not coexist in cases where it prevails. But, though it is not impossible that this affection may be a mongrel compound of the two diseases; yet it appears to me as difficult to show an identity of character between the symp- toms of this affection, and any possible combination of gout and rheumatism, as between it and either of those diseases separately; and it would be no matter of surprise if, in the course of future investigation, some principle in its nature should be discovered, confirmatory of the opinion of those who are disposed to consider it as a distinct disease. A strong argument in favour of this opinion is the fact, that it seldom yields to the remedies which are found effectual in gout and rheumatism. Causes of Gout. The most frequent cause of gout is inheritance. This not only gives a predisposition, but is sufficient of itself, wholly without aid from other causes, and even in opposition to whatever influences can be brought against it, to 506 CONSTITUTIONAL DISEASES. [PART II. give rise to the disease. It does not follow that every child of gouty parents must inherit the diathesis. On the contrary, many escape entirely. But the proportion of those affected is so great as to offer a strong warning, to all who are thus descended, to use every possible preventive measure. Of 522 gouty patients, of whom Sir C. Scudamore collected information, 322, or nearly two-thirds, could trace the disease to a parent, grandparent, uncle, or aunt. But, though so frequently hereditary, there is no doubt that the gouty diathesis may be created. Persons out of classes in society among whom the disease is almost unknown, if removed from the sphere occupied by their forefathers, and introduced into modes of life which dispose to the complaint, are frequently attacked with it. It is generally believed that the most effi- cient causes in generating the gouty diathesis, and in promoting it when inherited, are the use of animal food in undue proportion, especially high- seasoned meats and soups, indulgence in alcoholic drinks, and sedentary hab- its. Vigorous exercise obviates, to a considerable extent, the effects of high living, by consuming the excess of blood in the support of the functions. From the nature of its causes, the disease would naturally be looked for among the wealthy and luxurious, or their descendants; and it certainly is much more common in the higher than the humbler walks of life. It is very rare among an agricultural or hard-working population, in any part of the globe. Yet the same causes will produce the disease among any class of people ; and persons in the lowest grades of society are found to be attacked by it, when they imitate the luxurious habits of their superiors; as the keepers of petty inns, and household servants in the wealthy families of Europe. It has been supposed that intellectual superiority favours the devel- opment of gout; but, if the disease has been common among men celebrated for their mental powers, it has probably been much more from the union of sedentary with convivial habits, than from any influence either of superior talent or its exercise. In relation to the influence of alcoholic drinks, though there is little or no difference of opinion as to the general fact, yet writers are by no means agreed as to the varieties which are most apt to produce the effect. Some have supposed that the light, acescent wines peculiarly predispose to gout. It is probably true that the use of them will often bring on a paroxsym of the disease, in those who have the diathesis, more quickly than the stronger wines, perhaps by irritating the stomach; but it is certainly not true that they are more apt to generate the diathesis; for the agricultural classes of France, who use the lighter wines often as their common drink, are said to be almost wholly exempt from the disease; while the English gentlemen, who drink freely of port and other stronger wines, are said to be more fre- quently than any other people affected with it. The same may be said of cider, which has been accused of inducing gout. It may act sometimes as an exciting cause, but will probably seldom produce the predisposition. Other- wise, gout would have been formerly much more common than it was among the people of New England, and the middle Atlantic States, in which this drink was very commonly employed by the country people. The very free use of malt liquors, particularly of the stronger kinds, has frequently been known to generate the disease, even among the lowest classes ofthe popula- tion. It is probable that strong ale or porter, and the stronger wines, are more conducive to the disease than other alcoholic drinks. The distilled liquors, when freely indulged in, though they sometimes contribute to the production of gout, appear generally to exhaust the excitability of the system below the point requisite for the development of that disease, and conduce rather to internal visceral disorder, with a tendency to the mania of drunk- ards. It is probable that habits of vigorous exercise, in persons who use CLASS II.] GOUT. 507 strong drinks to great excess, so far from warding off gout, as they do in moderate drinkers, have a tendency to generate it, by sustaining a certain degree of energy in the system, which seems requisite for the development of the diathesis.* From what has been said it may be inferred that, so far as alcoholic drinks are concerned as causes of gout, it is not so much the particular variety used, as the mode of using them that has the effect. No matter what kind may be employed, if it be taken in such quantities, and with such associations as to food and exercise, as to support a certain degree of vigour of system in the midst of the repletion and excess, it may give rise to the disease. If it be too feeble to produce this degree of excitement, or so strong and so much abused as speedily to exhaust the excitability and powers of the system, gout will probably not result in either case. It is a remarkable fact, that, according to the best testimony, acute gout has very much diminished of late years. This is said to be true in England. It certainly is so in this part of the United States. The fact can be ascribed only to the greater prevalence of temperance. Even persons who drink sel- dom carry the indulgences of the table to that beastly extreme which was common half a century ago. But, though inflammatory gout has greatly diminished, I believe that the nervous form of it has increased; because tem- perance, or even abstemiousness, cannot eradicate the diathesis when existing, though it may subdue the tendency to inflammation ; and they who would, under the old habits of life, have been attacked with the disease in its old- fashioned form, now have it in the shape of neuralgia and functional disorder. It has been imagined that liability to gout is indicated by the possession of certain sensible characters of body; but the notion has been contradicted by experience ; as the disease exists in persons of every variety of structure and outward appearance. Season is not without its influence. The first paroxysm of gout is apt to occur about the vernal equinox; and, when the affection returns semi-annually, the attacks are usually made in the spring and autumn. Age has certainly much to do with the development of gout. The disease generally makes its first appearance between the twentieth and fiftieth year, and most frequently from the twenty-fifth to the thirty-fifth or fortieth. It is exceedingly rare before the age of puberty; though the late Prof. Chapman knew it to occur in a boy of thirteen; and Dr. Gairdner has seen it more than once in infants at the breast. (Ed. Month, Journ. Med. Sci., Dec. 1854, p. 534.) It also very rarely begins in old age. I have, however, attended a gentleman of near eighty in his first attack. All writers agree in the statement, that the disease is much more frequent in men than women. In relation to the acute and chronic forms of gout, there can be no doubt of the fact. But, in its nervous forms, judging from my own observation, I should say that the contrary is true. The female descend- ants of gouty ancestors are exceedingly prone to nervous gout. Their tem- perate habits prevent the inflammatory explosions of the disease to which the males are so liable ; while their sedentary lives interfere with the attainment of that strength of constitution, which would enable their systems to resist the inherited morbid tendency. It is thought that a damp, variable climate is peculiarly favourable to the * A fact strongly illustrative of this statement is mentioned by Dr. William Budd, in his Essay on Gout, in Tweedie's System of Practical Medicine. A body of workmen is employed on the Thames, in a peculiarly fatiguing duty, requiring frequent exposure to inclement weather, and labour both by night and day. In consideration of this exposure and fatigue, they have a large allowance of liquor; and each man drinks daily two or three gallons of porter, besides, in general, a considerable quantity of spirit. Among these men'gout is remarkably frequent. 508 CONSTITUTIONAL DISEASES. [PART II. generation of the gouty diathesis. The disease is certainly rare among the inhabitants of intertropical regions, and is less common at the extreme north than in the temperate latitudes, where the weather is more variable. Its great prevalence in England has been ascribed partly to the climate; but it probably depends much more on the habits of the people. The exciting causes of the gouty paroxysm are exceedingly numerous. Whatever disturbs materially the condition of health, whether it be of an exciting or debilitating character, is probably capable of bringing on an attack. Exposure to cold, violent exercise, a debauch at table, venereal excesses, paroxysms of anger or other strong emotion, indigestible food, articles of diet which disagree with the idiosyncrasy of the patient, vegetable acids, and local injuries of all kinds, such as falls, bruises, sprains, and even the wearing of a tight boot, may act as exciting causes. I have repeatedly known the nervous form of the disease to fix, in the shape of neuralgia, upon a part which had been bruised or otherwise injured. This is a fact worthy of recollection; as it will often enable the practitioner to explain unusually obstinate pains, attending slight local injuries, and immediately to apply the proper remedy. A severe sprain sometimes leaves behind it a condition of the joint which long afterwards determines this as the seat of an attack of acute gout. Nature of Gout. The humoral pathology taught that the phenomena of gout were owing to a peculiar peccant matter existing in the system, which it was the business of the paroxysm to eliminate. This opinion, abandoned after the times of Cul- len, is again gaining ground, and ranks at present among its advocates men of high name in the profession, of whom not the least conspicuous is Sir Henry Holland. (See Medical Notes and Reflections.) The fact which lends the strongest support to this opinion is the tendency evinced in gout to the ex- cessive production of uric acid. Not only is that acid thrown out in excess in the urine, giving rise to frequent lateritious sediments, but it is also often de- posited in the joints, or their vicinity, in the state of urate of soda or of lime. Dr. Garrod has proved by chemical examination that the blood in gout con- tains urate of soda, the acid of which can readily be separated in a crystalline state. He has also shown that, before the occurrence of the gouty paroxysm, there is, along with this excess of urate of soda in the blood, a deficiency of uric acid and its salts in the urine. The use of an excess of animal food, with insufficient exercise, which disposes to an excessive production of uric acid, predisposes also to gout; and the uric acid lithiasis, or gravel, not un- frequently alternates with that complaint. But these arguments, as well as others drawn from the movable character of the local disease, as if it depended upon an offending matter carried everywhere with the blood, and from the relief experienced after the paroxysm, as if the offending matter had been discharged, appear to me to be inconclusive. Uric acid, I think, certainly cannot be the matter in question. This sub- stance is generated in excess, and thrown out by the kidneys, in diseases in which no sign of gout is exhibited; and, though it may be admitted as a demonstrated fact, that an excess of uric acid exists in the blood in inflam- matory gout, the same has not yet been proved in relation to its nervous forms.* Nor can I exactly perceive how the production and elimination * Thus, Dr. Garrod found much uric acid in the blood in a case of collapse from cho- lera, and in four other non-arthritic cases; and, out of sixty patients affected with various diseases, there were thirteen in whose blood more or less of the acid could be detected. (Medico-chirurg. Trans., xxxvii. 210.) CLASS II.] GOUT. 509 of this matter, if not itself essential to gout, should lend any support to the idea of the existence of some other unknown and concealed matter, which is the real offending cause. It is possible that there may be such a substance ; but its existence, not to mention its nature and properties, has certainly never yet been demonstrated. The excess of uric acid in the blood is probably nothing more than one of the results of some disorder in the nu- tritive or assimilative function, attendant on the gouty diathesis; but of the nature of which we are wholly ignorant. Some pathologists search for the origin of gout in disease of a particu- lar organ. The disciples of Broussais consider it simply an inflammation, which they would denominate gastro-arthritis from its supposed chief seats. The late Prof. Chapman referred its origin to disease of the digestive organs. It has even been supposed to be essentially connected with disease of the liver. The fact, I think, is, that its nature is yet unknown; and, though the uneasi- ness of a state of acknowledged ignorance will probably continue to induce the formation of hypotheses, in which the mind may find temporary rest; yet, until some new light is obtained, they can be nothing more than conjectures, which will probably in the end prove to be without foundation. It appears to me, however, that no explanation of the nature of gout can be correct, which does not take into view the nervous phenomena. The violent pain which often precedes the inflammation, the frequent attacks of pure neural- gia, the rapid and almost instantaneous transfer of disease from one part to another, even the most distant, together with the frequent sensorial disturb- ance, and striking emotional phenomena, evince, I think, beyond doubt, a strong participation of the nervous system in the pathological condition, whatever that may be. All, of a general nature, that we can fairly deduce from the symptoms is, that there is a morbid state of the system, which probably involves all its essential constituents, and which evinces itself now and then by peculiar local phenomena, which may be either purely nervous, purely functional, or inflam- matory. That the inflammation is peculiar is proved by its shifting character, and indisposition to the exudation of fibrin, or production of pus.* Diagnosis. The only disease with which acute or chronic gout is liable to be confounded is rheumatism. There is no difficulty in discriminating well marked cases of these diseases; but it must be confessed that there are cases in which the diag- nosis is difficult, if not impossible; and it is not at all improbable that the two complaints sometimes coexist, fused, as it were, into one. In such sup- posed instances, it is common to denominate the affection rheumatic gout. That the diseases are different is evinced, independently of the symptoms, by the difference in their origin, and in the subjects attacked by them. Thus, gout is much more frequently hereditary, and much less frequently generated by obvious causes, than rheumatism. The former almost never attacks child- ren under puberty, the latter does so not unfrequently, though it must be con- fessed that it is more common in adults. Gout is found most frequently * It has been objected to this view of the nature of gout that it is extremely general and vague. I admit the charge; but I have never met with any view more satisfactory to my own mind; and if, after a careful examination ofthe more precise theories which have been put forth, I cannot be convinced of their correctness, the fault may be as- cribed to my want of penetration, but certainly not to any indisposition to admit the truth. It seems to me that we know no more of the real nature of gout than what is stated in the text, and that, when we are ignorant, it is best to confess the fact; as we are then more likely to be open to the truth when presented. (Note to the fifth edition.) 510 CONSTITUTIONAL DISEASES. [PART II. among the wealthy, the luxurious, and the physically idle, and is seldom heard of among those subjected to labour, privations, exposure, and hard- ships. Exactly the reverse is the case with rheumatism. The circumstance, moreover, already alluded to, that uric acid has been found by Dr. Garrod, in abnormal proportion, in the blood of persons affected with gout, while only a trace of it can be detected in the blood of acute rheumatism, must be re- ceived as an evidence of the difference of the two diseases; and such an excess, when existing, may be considered as a diagnostic sign of gout, if sup- ported by the presence of the ordinary symptoms of the complaint.* The diagnostic symptoms of gout, in relation to rheumatism, are, chiefly, the more frequent preliminary occurrence of disordered digestion and various functional derangement; the disposition of the disease to fix itself upon the small joints; its paroxysmal form, and tendency to recur at certain periods; the more remittent character of the fever ; the greater violence of the pain; the brighter redness of the inflamed part; its greater tumefaction and more decided tendency to oedema; and, finally, the desquamation which follows the subsidence of the swelling. When gout has become chronic, and fixed upon a number of parts, the diagnosis is more difficult The history of the case will, under such circumstances, afford much assistance. It may be said, in general terms, that the swelling is more apt to be edematous in gout, and the local affection to retrocede, or to leave one part and fix on another; while in pure rheumatism there is no deposition of the urates in the joints, or ligamentous tissues. Nervous gout can be distinguished from the same form of rheumatism, with any approach to certainty, only by the character of the external inflammation, which occasionally occurs in both affections, and in each may assume the form characteristic of the particular disease. Of the prognosis of gout sufficient has been said in the description of the several varieties. Treatment. 1. Acute Gout.—The treatment in acute gout naturally divides itself into that which is proper in the paroxysm, and that adapted to the intervals. It was formerly a prevalent opinion, which is still retained by many, that the paroxysm should be allowed to exhaust itself, with little or no interfer- ence from the physician. Being designed to carry off offending matter, or at least morbid tendencies, it was supposed that any measures calculated to shorten it would cause its office to be left unaccomplished, and the system exposed to fresh attacks, possibly in unsafe positions. Retrocession to some internal organ was greatly feared; and, as a vigorous condition of system was considered favourable to an external direction of the disease, all deple- tory measures were especially apprehended. It was, indeed, no uncommon practice of gouty patients to indulge freely in wine, even during the con- tinuance of the inflammation, with the view of sustaining it, and of guarding the stomach against attack. While there was some truth in this reasoning, the practice founded on it was carried much too far; and the consequences were, that the disease was often greatly aggravated, the sufferings of the patient unnecessarily increased, and life probably not unfrequently shortened. * The following is the mode in which Dr. Garrod tests the presence of uric acid in the blood. About a fluidrachm of the clear serum is placed in a deep watch-glass with six minims of strong acetic acid; a very fine fibre of hemp is then introduced • and the glass, being covered with a piece of paper to protect it from the dust, is allowed to remain at rest for about forty-eight hours, when it will probably have become nearly dry. Should uric acid be present in the blood, it will be found to have crystallized on the fibre in the form of rhombs, which may be readily detected with the aid of the microscope. (Note to the third edition.) CLASS II.] GOUT. 511 But we should take care not to suffer the bad consequences ofthe abuse of a sound principle to lead us to abandon it. The paroxysm in gout is certainly not the whole disease. There is undoubtedly a morbid state of system to which the paroxysm is owing, and which it has a tendency to relieve, if allowed to run its course. It is no less true that the removal of the paroxysm has no effect in removing the state of system alluded to If, therefore, by remedies addressed exclusively to the former, we succeed in cutting it short, we may possibly leave the latter still in existence, ready to display itself by some assault, it may be, upon one of the joints as before, or, it may be, upon one of the interior and vital organs. The most prudent procedure, therefore, is to allow the inflammation of the joint to complete its course; contenting ourselves with moderating its violence if excessive, and endeavouring to render the patient as comfortable as possible. But we may do more. We may endeavour to supersede the office of the paroxysm by addressing our remedies to the morbid state of system; and, if we succeed in favourably modifying this, we shall find the local disease to subside without our direct interference. Such, it appears to me, are the correct principles of treatment in the paroxysm of acute gout. But what are the remedies calculated to modify the constitutional affec- tion ? It is experience only which can teach us ; for, ignorant of the nature of the general affection, we have no foundation for a purely rational treat- ment. Bleeding has been proposed. But this remedy has been found to exercise no influence over the proper disease. It may lessen the fever, and cure the inflammation of the joint; but it leaves the source of the evil un- touched, while, if incautiously employed, it impairs the vigour of the consti- tution, and certainly favours the production of various functional disorder. I have known gout, treated by bleeding at each paroxysm, to end prematurely in fatal dropsy. The only proper ground for the employment of this remedy is the existence of danger to life, or risk of serious inconvenience from the violence of the local inflammation, or of the general excitement. When the former is external, and no vital organ appears to be threatened by the latter, it is, as a general rule, best to avoid the lancet. The same objection does not lie against moderate purging, which appears, indeed, to exercise a favourable influence over the proper disease. Two cau- tions should be observed in the use of this remedy; the one, not to carry it to the point of exhaustion ; the other to employ such substances as are not likely to irritate the mucous coat strongly, so as to make this a centre of afflux to the disease, and thus to relieve the inflammation of the joint, by inducing an attack of gout in the stomach or bowels. As the liver is frequently torpid or deranged, and there is often an excess of acid in the prima? via?, mercurials and antacids would seem to be indicated. A moderate dose of calomel, or of the mercurial pill, may be given in connection with rhubarb, and afterwards followed^ by magnesia, with Epsom salt or other saline cathartic. Should the bowels be torpid, infusion of senna may be used in addition. Afterwards, throughout the attack, one or two stools should be procured daily, if neces- sary, by means of liquid or common magnesia, or one of the neutral salts, or by the two combined. Should there be colicky pains, with an irritable con- dition of the bowels, and small, ineffectual discharges, castor oil with lauda- num or morphia should be preferred. But the most effectual remedy iu the gouty paroxysm is colchicum. This was introduced into use under the impression that it was the main ingredient in the famous eau medicinale d'Husson, which formerly enjoyed a great reputation in the treatment of this disease. When first used, it was generally given in large doses, so as often to purge and vomit; and, in this way, was found not unfrequently to shorten very much, or set aside the paroxysm; but 512 CONSTITUTIONAL DISEASES. [PART II. serious consequences were asserted to have occasionally ensued ; and the medicine is now given with greater caution, and without evil results. It cer- tainly exercises an extraordinary influence over the disease. But in what manner it does good has not been determined. Some suppose that it acts merely by a revulsive influence, drawing off the external disease from the joint, by establishing irritation in the alimentary canal. It certainly does frequently produce nausea and more or less catharsis, in the doses in which it is ordinarily given; but the same curative influence does not proceed from an equal or much greater amount of the same effects from other substances. It very generally promotes the secretions of the skin and kidneys; and the idea has been entertained that it cures gout by eliminating some offending matter by one of these emunctories. That it is not by a mere increase of these functions that it acts is proved by the fact, that other and more active diaphoretics and diuretics have not been found equally beneficial; and col- chicum is believed to be useful, even when it exercises no sensible influence over the secretions. It has no decided narcotic property, and, therefore, cannot act as an anodyne. Experiments seem to have shown that the quan- tity of uric acid and urea in the urine is increased under the action of colchi- cum ; and, with those who consider uric acid in the blood as the offending agent through which the phenomena of gout are produced, this fact affords a sufficient explanation of the therapeutic action of the medicine; but it does not explain how the disposition to the overproduction of this offending agent is obviated, which, even upon the humoral hypothesis, is the real pathologi- cal condition. It is by modifying the morbid state which gives rise to the overproduction of uric acid, along with the other phenomena, that colchicum cures gout. We may say that it acts as an alterative; that it changes the morbid character of the ultimate cell-action which may be the real gouty dis- ease ; but this is pure hypothesis; and it is as well to confess that we do not understand its mode of action. The general conviction of its usefulness rests upon experience. The objection has been made to its employment that, ■ though it may relieve the existing paroxysm, it leaves the patient liable to a more speedy return. But this view was theoretical, and has not been confirmed by experience. Different authors recommend different prepara- tions, and seem to attach importance to their particular mode of exhibiting the remedy. Any one of its preparations will, I believe, answer the pur- pose, which is capable of producing the effects of the medicine on the system. I generally prefer the wine of the root, as the most certain, from its mode of preparation; being a saturated vinous infusion. When the medicine is desired in the form of pill, the acetic extract maybe used. After the bowels have been well evacuated, from fifteen to thirty minims of the wine, or from one to three grains of the extract, may be given every four, six, or eight hours, according to the urgency of the case, and the suscepti- bility of the patient's system. This quantity, if the preparation be properly made, will often produce excessive nausea, or much intestinal irritation, and will require to be reduced. In other cases, it will be necessary to augment the dose somewhat, in order to insure its effect. Given in this way, colchi- cum often greatly moderates and abbreviates the paroxysm; and, as it does so rather by acting upon the real disease, than merely on the inflammation, its effects are attended with no injury. In order to eradicate the existing tendency, Dr. Budd insists upon the necessity of continuing the use of the colchicum, in small doses, for some time after all the symptoms of gout have disappeared. This is certainly rational practice, if the medicine has really as it is supposed to have, a direct influence over the gouty state of the sys- tem. Ten or fifteen drops may now be given twice or three times daily. Should the medicine purge too much, this tendency may be controlled by CLASS II.] GOUT. 513 the addition of a little laudanum. When there is little febrile action, and the pain is severe, one of the salts of morphia may be added in full dose to the colchicum, with much comfort to the patient. Colchicum may also, with great propriety, be associated with any purgative which may from time to time be given to the patient; the wine being pre- ferred, if the medicine is given in the form of a draught, the extract, if in pill. The mixture recommended by Scudamore, of colchicum, magnesia, and sul- phate of magnesia, is an excellent purgative in gout. (For a formula, see Note, page 483.) When the liver is torpid, the extract of colchicum may be given at bed- time, with from three to five grains of the blue mass, and followed by the laxative draught above alluded to in the morning. When the urine is very scanty, or heavily loaded with uric acid, so as to irritate the kidneys and urinary passages, half a drachm of the bicarbonate of potassa or of soda may be given three or four times a day in carbonic acid water, and the colchicum may be administered at the same time. Sometimes spirit of nitric ether may be advantageously added to the draught, especially when the patient is restless, or otherwise affected with nervous disorder. Much comfort sometimes accrues from a full dose of Dover's powder at bedtime. It should not, however, be given until the inflammatory and fe- brile symptoms, if considerable, have abated. In relation to the local affection directly, the less that is done, as a gene- ral rule, the better. It was formerly the custom to wrap the part in carded wool or warm flannels, with the view of cherishing the external disease, and preventing retrocession to the stomach or other internal organ; and this was certainly preferable to the repellent plan which some have advised. It pro- bably, however, sometimes occasioned an unnecessary amount of inflamma- tion, and led to ultimate injury of the joint, which might have been avoided. In ordinary cases, the joint may be lightly covered, so as to protect it from cold, and left to the operation of those measures which it may be deemed proper to address to the constitution. Should the inflammation be unusually violent or obstinate, it may not be amiss to apply a few leeches, though this should always be done with caution. Some recommend anodyne and evapo- rating lotions, with the view of moderately reducing the heat, and relieving the pain; and, when these are excessive, such applications may not be im- proper, if kept within due bounds. Scudamore's plan, which he found to afford relief in numerous cases, and to do injury in none, was to apply to the inflamed joint a lukewarm mixture of three parts of camphor-water (aqua camphora?, U. S.) and one of alcohol, by means of linen compresses com- posed of»six or eight folds, or of bread poultices saturated with the liquid. When this was removed, the part was lightly covered with flannel. Some bathe the joint with camphor liniment; others steam it, or employ pediluvia of warm water; and others again apply warm emollient cataplasms, with or without anodyne additions, as the decoction of poppy-heads, hops, camphor, kc I have sometimes used a warm mixture of tincture of camphor with milk, applied by means of compresses, and frequently renewed. The practice of immersing the feet in cold water cannot be too strongly condemned. It often, no doubt, affords immediate or speedy relief, and sometimes with impunity; but there is always great danger that the disease may seize with fatal violence on some internal part. An instance has been reported to me, upon the best authority, in which a gentleman, anxious for speedy relief, and contrary to the advice of his physician, ordered a bucket of cold water to be taken into his chamber at bedtime, with the view of employing it in this way. In the morning he was found dead in his bed. vol. I. 33 514 CONSTITUTIONAL DISEASES. [PART II. Should the joint remain swollen and edematous after convalescence, ad- vantage will often accrue from the application of moderate pressure by means of a flannel or muslin bandage. When acute gout attacks one of the internal organs, either originally or by retrocession from the exterior, the case must be treated, if of an inflam- matory nature, as inflammation of the same part would be treated arising from ordinary causes. Bleeding is here often necessary to save life. The greatest danger now arises from the local disease, and this must be relieved, at whatever cost may be necessary. All other considerations must yield to the present urgency. When the pulse is strong in these cases, there can be no doubt as to the propriety of using the lancet. But sometimes, when the disease attacks the stomach, lungs, or heart, the symptoms are apparently those of great depression; the skin being pale and cool, the pulse small and feeble, and the strength greatly prostrated. This depression may be conse- quent upon the crippled state of the organs upon which the general functions depend, and not upon real debility ; and bleeding may still be indicated as the most efficient means of relief. It should, however, be used with caution. The physician should himself superintend the operation, should keep his fingers on the pulse while the blood is flowing, and close the orifice if he find the circulation becoming feebler. Generally, however, the pulse will rise under the operation, and thus justify the measure. Local bleeding, fomentations or emollient cataplasms, sinapisms, and blis- ters, in the vicinity of the inflamed organ, may also be resorted to. But there is one measure of the utmost importance, which is demanded in all cases; and that is the application of irritants to the part from which the gout may have receded, or which may be its ordinary seat when external, in order to invite the disease back to a safe position. If one of the joints of the foot has been affected, pediluvia of hot water, rendered more stimulating by mustard or Cayenne pepper, should be employed; and the application should be continued as long as the patient can conveniently bear it. To render the impression more permanent, the foot-bath may be followed, if necessary, by sinapisms, or other active rubefacients, or by blisters. The necessity of thus attempting to draw the disease to the extremities, in cases of severe internal gout, can- not be too strongly insisted on. When the retrocedent disease attacks the stomach in the form of irritation merely, producing, as it sometimes does, violent spasm of that organ, it is necessary to procure relief by means of powerful anodynes, or nervous stimu- lants. The most effectual is opium, which may be given in doses twice or three times as large as those for ordinary purposes, and still further increased if necessary. Laudanum, or some other liquid preparation of opium should be employed, as more prompt than the solid drug. Its operation may be aided by aromatic spirit of ammonia, ether, or musk if necessary. If the stomach reject these medicines, they may be administered by enema. A large sinapism should be immediately applied to the epigastrium. In the treatment ofthe gouty paroxysm, reference must be had to the con- stitution and habits of the patient. The remedies which may be employed safely and efficiently in individuals of strong constitutions, and temperate habits, may prove too powerful for the feeble and intemperate. In the latter, purgative tinctures, as the tincture of rhubarb, or the tincture of rhubarb and senna (Warner's gout cordial), maybe substituted for, or added to the cathar- tics ordinarily used. They may in general be appropriately conjoined with magnesia. Colchicum must be employed with more reserve; and greater care should be taken not to cause retrocession by injudicious applications to the external disease. It is often necessary to allow the patient to continue the use of his accustomed beverage, for fear that its sudden abstraction may produce prostration. It should, however, be diminished in quantity. CLASS II.] GOUT. 515 The diet, during the paroxysm, may be regulated somewhat by the inclina- tions of the patient. If so much affected by the fever as to be averse to food, he may be confined to gruels or other farinaceous drinks; if he still retain an appetite, he may take solid vegetable substances, with a limited allowance of the lighter and more easily digested kinds of animal food, as milk, oysters, soft boiled eggs, boiled fowl, &c, when there is reason to fear a failure of strength. The previous habits of the patient must here also be taken into view; immoderate eaters, and those who use chiefly high seasoned animal food, not bearing abstinence so well as the temperate, and often rapidly sinking upon the withdrawing of their accustomed support. During convalescence, care should be taken not to permit too rapid a re- turn to habits of indulgence; the food should continue light, digestible, and unirritating ; and the bowels should be kept regularly open. The treatment in the interval is highly important. If the same course of life which induced the disease, or favoured its attack, be continued, there can be little hope of averting future paroxysms, unless at a cost greater than that of the paroxysms themselves; and the patient must surrender himself to that long course of steadily increasing disease, and ultimate death, which has been already described as the general lot of gouty subjects. The complaint cannot safely be averted by any course of known medicinal agents. Various attempts have been made to cure gout by medicines ; but they have all proved to be failures. The famous Portland powder, employed, in variously modified forms, from the time of Galen to that of Cullen, has fallen entirely into disuse, in consequence of its fatal effects. Consisting chiefly of tonic or stimulating ingredients, and continued for a great length of time, it probably made the stomach a centre of afflux to the gouty irritation, and thus obviated the exter- nal paroxysms; but Cullen states that, in every instance which he knew of its exhibition for the length of time prescribed, the patients were affected with many symptoms of atonic gout, "and all, soon after finishing their course of the medicine, were attacked with apoplexy, asthma, or dropsy, which proved fatal." There is only one safe mode of curing gout; and that is strictly and perseveringly to avoid its causes. If this plan is begun soon after the first development of the disease, and the constitutional tendencies to it are not irresistible, there may be some hope of escaping it in future, and good reason to expect, that, if not eradicated, it may be very favourably modified, and dis- armed in great measure of its violence and danger. Temperance in eating, a rigid abstinence from stimulating drinks, the avoidance of excesses of all kinds, and steady habits of moderate exercise, both on foot and on horseback, so as to keep the digestive organs in a healthy state, are the chief prophylactic measures required. In relation to the diet, it should be light and of easy digestion, not entirely vegetable, but with a smaller proportion of animal food than is usually indulged in, and prepared with little condiment of a stimulant character. (See Dyspepsia.) Care must be taken also to keep the bowels regular, to correct derangement of the hepatic or nephritic function, to obvi- ate any temporary excess of acid in the prima? via? or the circulation, and to avoid all the known exciting causes of the paroxysm. For these purposes, occasional use may be made of mild laxatives, such as rhubarb, magnesia, Saratoga water, &c, of the antacids, as the bicarbonates of potassa and soda, and of blue pill as an alterative. But caution is necessary not to get into the habit of depending upon these or any other medicines. Occasionally, when a paroxysm is threatened, it may be averted by a mild cathartic of mag- nesia, sulphate of magnesia, and wine of colchicum. Among the prophylactic measures, the wearing of flannel next the skin must not be neglected. Even in those who have long suffered with gouty paroxysms, much may be done, by the prophylactic measures above recommended, towards moderat- 516 CONSTITUTIONAL DISEASES. [PART II. ing the force ofthe disease; though a cure is not to be expected. In elderly persons, who have long been in the habit of indulging in wines, it is scarcely desirable to attempt the breaking up of the habit. There may be some dan- ger that, in removing this artificial support, the natural powers may prove so much decayed as to be insufficient for the sustenance of life ; and, in all cases, due attention should be paid to the danger of a sudden change of long esta- blished habits. 2. Chronic Gout.—As there is no precise boundary line between this va- riety of gout and the acute, there is of course no such line in the treatment. It may be said, in general terms, that bleeding from the arm is never neces- sary or proper, in chronic gout, for external inflammation. Moderate purg- ing may be employed in the paroxysm, when the bowels are disposed to con- stipation ; but substances should be selected which are not likely to debili- tate, as rhubarb, aloes, sulphur, or magnesia, which may be given separately, or variously combined,'according to the circumstances ofthe case, and, when there is considerable debility, may be very properly conjoined with aromatics and cordials, as with compound tincture of cardamom, compound spirit of lavender, tincture of rhubarb, or tincture of rhubarb and senna. Colchicum may also be used; but with more caution than in the acute form. Pain and restlessness may be quieted by opiates with or without ipecacuanha, or, if these disagree with the patient, by hyoscyamus, stramonium, or belladonna. In the remissions of the disease, attention should be paid to the general health, and all the functions kept as free from disorder as possible. It may happen that the internal affections, so common in certain cases of chronic gout, may have so much of the inflammatory character as to require local depletion by cups or leeches; and even bleeding may sometimes be imperi- ously demanded to save life, when the disease seizes on one of the vital or- gans ; but this remedy should be employed with much reserve. Revulsion by sinapisms, strong solution of ammonia, oil of turpentine, blisters, &c, as near as may be to the part affected, is here always indicated ; while attempts should also be made to invite the disease to its ordinary external position by hot water and the rubefacients. ' More frequently, the internal disorders are simply functional, and should be treated as recommended for similar conditions in the more purely nervous variety. An anemic state of the system should be corrected by the simple bitters and chalybeates. If the patient sweat profusely, sulphate of quinia may be used. The debility may even be such as occasionally to call for car- bonate of ammonia, and the alcoholic drinks. Arnica and the simple or ammoniated tincture of guaiac may be given, in the hope that, along with their stimulant effects, they may exercise an alterative influence over the disease. Acidity of stomach and other dyspeptic symptoms, constipation or looseness of the bowels, derangement of the hepatic and renal secretions, and, in women, disorder of menstruation, should all receive attention, and be treated as recommended for these conditions when occurring as original affec- tions. Dryness and want of action of the surface should be corrected by frictions, and the use of either the hot or cold bath, according to the reacting powers of the system, the former being preferred when this power is feeble, the latter when it is still considerable. There is little doubt that the famous water-cure may prove useful in some of these cases of chronic gout, when the excitability of the system has not been exhausted. Dr. Seymour recom- mends benzoate of ammonia or of potassa, in cases in which there is a tend- ency to the deposition of urate of soda in and about the smaller joints, and thinks he has found deposits of this kind, already in existence to diminish under its use. (Med. Gaz., May 14, 1847.) Dr. Owen Rees has found lemon- juice very useful in similar cases. He employs it in the quantity of one or CLASS II.] GOUT. 517 two fluidounces four or five times a day, combined with small doses of the tincture of chloride of iron; and, in several instances, has thus succeeded in removing deposits which had resisted all other treatment. (London Lancet, Dec. 14, 1850, p. 561.) Mr. T. Spencer Wells regards iodide of potassium as the most efficient solvent of urate of soda, and gives it habitually in refer- ence to this property in all varieties of gout except the acute. (See Am. J. of Med. Sci, N. S., xxviii. 178.) Dr. Wm. Thorn has found this clepositto disappear, in one very bad case, by giving alternately, each three times a day, twenty minims of solution of potassa, and the same quantity of spirit of nitric ether. (Lancet, Am. ed., iii. 61.) In chronic gout, with con- tractions of the limbs or paralysis, the internal and external use of savine has been advantageously resorted to by practitioners in Germany. The diet should be that recommended for dyspepsia; and the patient should be extremely careful to clothe himself warmly, with woollen garments next to the skin, and to avoid all unnecessary exposure to cold and wet. He should especially avoid such exposure when not exercising. Sleeping in damp sheets, sitting in a cold damp room, or allowing the feet to remain wet when at rest, is hazardous for patients with chronic gout. Moderate exercise, in a pure atmosphere, is highly useful. Excessive mental exertion should be avoided, as all other excesses; and the patient should make it a study to cul- tivate equanimity of mind, and to subdue all tendencies to the indulgence of a fretful, melancholy, or irascible temper. Gouty patients may be assured that they will often greatly prolong their life, as well as render it more com- fortable, by an observance of* the last mentioned rule. Great advantage sometimes accrues, in this variety of gout, from visits to the watering places, and the use of the waters both internally and externally. The hot springs of Virginia are sometimes very beneficial. So also are the sulphur springs of Virginia, Kentucky, and New York. For anemic cases, the chalybeate springs may be recommended, as those of Bedford, Schooley's Mountain, Brandywine, &c. For deranged hepatic secretion and general disorder of digestion, especially with a tendency to constipation, those of Saratoga should be preferred. It is not only the mineral waters that act usefully; but the exercise of the journey, the pure air, and the agreeable re- laxation and social pleasures of these resorts. Sea-bathing sometimes also proves beneficial. A residence during the winter in a warm climate is very desirable for chronic gouty patients. In relation to the local treatment, when the disease is seated in one joint, and apparently fixed there, it may be proper, if permanent injury to the joint is threatened, to employ leeching and subsequent blistering; and it may be advisable to repeat the blister several times. But, when the disease has any disposition to change its seat, these measures are inappropriate. In the lat- ter case, if any other application is made than a light covering of flannel, it should be something very lenient in its action, as emollient or anodyne cata- plasms, mild camphorated lotions, &c. Some have recommended a covering of oiled silk, or thin layers of caoutchouc, so as to confine the perspiration of the part, and thus make a kind of vapour bath about it. Poultices with carbonate of soda are said often to prove beneficial. Little can be done locally for the removal of the gouty concretions. When the part ulcerates, it should be dressed with poultices, and nature may be somewhat aided by mechanical, and possibly by chemical means, in removing the deposition; but not much can be done in this way, in consequence of the enclosure of the urate within the cells of the areolar tissue. Should gan- grenous symptoms present themselves, the yeast poultice, or cataplasms made somewhat stimulating by the addition of creasote, or of some alcoholic liquor, as porter or beer, may be employed. 518 CONSTITUTIONAL DISEASES. [PART II. The nodosities that form upon the tendons and fascia? will often yield to steady external counter-irritation, by means of the galbanum or ammoniac plaster, one of the turpentines, the ointment or tincture of iodine, strong solution of nitrate of silver, or repeated blistering. For the contraction ofthe muscles, and stiffening of the joints, little more can be done than to immerse the part frequently in warm water, to employ the hot douche occasionally, and to induce the patient, by frequent efforts of his own, to endeavour to regain his command over the movements of the limb. 3. Nervous Gout.—This very diversified disease, which shows itself in almost all parts of the body, and in almost every variety of form, requires an equal diversity of treatment; and the ingenuity of the practitioner is often severely tried, to find out modes of relief which shall at the same time accord with his own sense of propriety, and the incessant demands of his patient. Much, however, can be done towards removing present symptoms, and obtaining a longer or shorter respite from suffering ; and sometimes pos- sibly the patient may surmount the disease; but, though life may be pro- longed not unfrequently to old age, it is rare that an individual, constitu- tionally liable to the complaint, does not continue during life to be at times more or less affected by it. I wish the reader to understand that the follow- ing observations apply as well to the rheumatic, as to the gouty affection. One universal rule in these cases is, whenever the faintest disposition is shown by nature to give an external direction to the disease, to encourage her efforts by means calculated to attract irritation to the surface, and espe- cially to the extremities. These have been already sufficiently detailed. Much may be expected from a judicious use of medicines supposed to have an alterative influence over the disease, such as colchicum, guaiacum, aconite, veratria, arnica, sulphur, iodine, arsenic, kc ; care being taken, in their use, not to allow them materially to disturb the stomach or bowels. When the system is anemic, as not unfrequently happens, recourse should be had to the preparations of iron, simple bitters, and a nutritious diet. Whenever the disease is intermittent, no matter what form it may assume, whether that of neuralgic pain, spasm, or functional derangement of some one of the organs, provided there is any approach to regularity in the recur- rence of the paroxysm, sulphate of quinia should be freely employed, and will almost always succeed very speedily. The practitioner may often spare his patient long and exquisite suffering, by being upon the watch for this in- termittence, and prepared at once to take advantage of it. Not unfrequently, when at first quite irregular, the affection assumes the regular periodical form under the use of alterative or tonic treatment, and will then yield to the salt of quinia. Twelve, eighteen, or twenty-four grains, should be given between the paroxysms, or even more, if required to bring on the peculiar cerebral phenomena which characterize the action of the medicine. In the severe neuralgic forms, it often becomes absolutely necessary to have recourse to anodynes. When the attack is of some internal organ, as of the stomach, bowels, heart, &c, opium or some one of its preparations must be given, and often in very large doses, for example, double, triple, or quadruple the ordinary quantity, before relief can be obtained. The opiate may often be usefully combined with colchicum; and I am in the habit in these cases, of prescribing a mixture of solution of sulphate of morphia, and the wine of colchicum root. But, whenever the urgency of the case will admit of recourse to some other narcotic, and especially when the pains are external, one of these should be preferred to opium, from the danger that the patient may be led into the habit of its abuse. The extracts of bella- donna, stramonium, and conium, are often very efficient, especially the first. Chloroform may also be usefully employed in some instances. CLASS II.] GOUT. 519 A very powerful remedy, in the purer neuralgic forms, is subcarbonate of iron in large doses, say a drachm three or four times a day; and tempo- rary cures will often be effected by the combined use of this medicine and extract of belladonna. I think that I have seen more cases of pure gouty and rheumatic neuralgia, without inflammation, get well under this combina- tion, than under any other single plan of treatment, except that of quinia in intermittent cases. In these neuralgic forms, moreover, large doses of sulphate of quinia will often effect cures, even when there is no regular intermission. It will fre- quently be necessary to push the remedy to the extent of twenty-four or thirty grains in the twenty-four hours. This is especially useful when the disease assumes the form of hemicrania; but in these, as well as in other cases, it may be advantageously combined with the oil of valerian. The effect of the remedy is not unfrequently to aggravate the headache, for the first day or two, after which the complaint gradually diminishes, and ceases altogether, in three or four days or a week. Hemicrania seldom fails to yield to this treatment. It is scarcely necessary to follow the disease through the various internal organs; as the functional disorder which it produces in each closely resem- bles that proceeding from other causes, and requires the same treatment. Thus, when it attacks the stomach in the form of dyspepsia, or of gastro- dynia, it must be treated exactly as those affections are usually treated. (See Diseases ofthe Stomach.) The same may be said of the form of colic, which it not unfrequently assumes. Deficient or deranged action of the liver, which is a very common attendant upon this, as well as other forms of gout, requires the occasional use of the mercurial pill, or small doses of calomel; care being taken not to carry the remedy so far as to affect the gums. Nitro-muriatic acid is sometimes also very useful in these cases, but should not be given in connection with the mercurial. Taraxacum and the alkalies are now and then beneficial, and may be alternated with the other remedies. Constipation of the bowels should be obviated by laxatives, as rhubarb, sulphur, magnesia, Cheltenham salt, Saratoga water, &c, or by a regulation of the diet, as by the use of bran bread, tomatoes, &c. Nephritic disorder may be treated with the alkaline bicarbonates, and sometimes, when the urine is excessive, by narcotics and astringents, or by terebinthinate remedies. Palpitations, and precordial oppression, will often yield to the aromatic spirit of ammonia, Hoffmann's anodyne, oil of valerian, assafetida, or musk; and dyspnoea, when purely spasmodic, may be treated in the same way. In relation to all these affections, and others of analogous character, the general rules already given must be borne in mind, of relieving violent pains by opiates or other narcotics, of endeavouring to give an external direction to the disease by hot fomentations, rubefacients, blisters, kc, and of addressing remedies to the constitution with the view of subverting the disease, as col- chicum, quinia, &c. Not unfrequently, also, even when there is no reason to believe that there is any inflammation, leeching in the neighbourhood of the part, or even the loss of blood from the arm, will afford great relief in painful internal affections. When the disease seizes upon the head, these last remedies are especially useful. Gouty or rheumatic headache often yields very happily to a few leeches or cups to the temples, or nape of the neck. But bleeding must always be used with some reserve ; as, though it may afford relief, it does not eradicate the tendency, and, too frequently re- peated, may produce an anemic condition, favourable to the perseverance of the disease. Another important fact to be borne in mind is, that, in many of these cases of disordered function and neuralgic pains, the real cause is an attack of the disease in the ligaments or internal membranes of the spinal 520 CONSTITUTIONAL DISEASES. [PART II. column, producing irritation in the spinal marrow, and consequently derange- ment in all its dependent functions. In such cases, the remedies must be addressed especially to the spine. Besides the local measures already referred to, various others may be used with much temporary benefit, in the more painful forms of the disease. Emol- lient, anodyne, and rubefacient embrocations or cataplasms; frictions with aconite, veratria, and colchicum, in ointment, or strong spirituous solution; plasters of belladonna and stramonium; morphia sprinkled on the skin de- nuded of the cuticle; chloroform in poultices, or applied by means of linen moistened with it, and protected from evaporation by a covering of oiled silk ; have all been employed, and with excellent apparent results; but, in this affection, it is not always possible to determine how much is owing to the pecu- liar virtues ofthe remedy, how much to the mere process employed in its application, and how much to the mind of the patient. I have repeatedly known gentle and continued friction with the hand to dissipate the pain en- tirely for a time ; and nothing is more common than for the same effect to follow any strong mental movement, whether emotional or intellectual. In this variety of gout, it is especially necessary to invigorate the consti- tution ; for which purpose moderate exercise, pure air, a nutritious but easily digested and unstimulating diet, the pleasures of agreeable social intercourse, and the avoidance of all excesses, whether mental or physical, are the chief measures to be relied on. More even than in chronic gout, will advantage accrue from travelling, frequenting the watering places, &c. Any plan of life, which, while it favours health in general, places the system of the patient under entirely new influences, will often prove of the greatest benefit, and sometimes completely renovate the constitution. Hence the advantages of a foreign tour and residence. Hence the wonderful revolution sometimes effected in the health by a change of fortune, which reduces the patient from the luxuries, indolence, and self-indulgences of wealth, to the necessity of daily exertion for a livelihood. Hence, probably, also, in part, the advantage which has frequently accrued, in such cases, from the famous water-cure. 4. Rheumatic Gout.—Limiting this term to the affection specially de- scribed in the foregoing pages under the name, we must confess that our therapeutics are much at fault in the disease. A few observations, however, are required. In the earlier stages, when the symptoms are in any degree acute, a moderate employment of the same antiphlogistic measures as those recommended in acute rheumatism is indicated. General bleeding, however, is very seldom required. Occasional leeching is useful. I have found a steady treatment with the bicarbonate of soda, long persevered in, quite suc- cessful in removing the symptoms in one case, in which the disease had pro- ceeded so far as to render one of the elbow joints almost immovable; and another case, which refused to yield to the ordinary measures, gave way to a decided and sustained mercurial impression; but, as both patients were in the Hospital, I do not know that the complaint did not afterwards return, as it generally does. Dr. Fuller states that all the local treatment usually required under these circumstances is the steady application of an alkaline solution with opium. An alternation of leeching and blistering may be ad- visable when all acute symptoms have subsided, and the local disease remains steadily fixed in one or a certain number of joints. This treatment is safer here than in ordinary rheumatism or gout, as there is less tendency to in- ternal translation, especially to the heart. Of course the joint should be kept at rest. By these measures the disease may be materially moderated and retarded, perhaps sometimes cured; but, as the affection is constitu- tional, and paroxysmal, there is little probability, as in the case of gout that it will not return. CLASS II.] GOUT. 521 The chronic cases are more difficult to manage. One important rule is to correct all functional disorder, and to obviate debility when it appears. In response to this indication, the bowels should be kept regular, torpor of the liver should be corrected, the menstrual function brought, as far as pos- sible, into a healthful condition, the action of the skin and kidneys duly sup- ported, ana?mia corrected by the chalybeates, and general debility counter- acted by quinia, cod-liver oil, the shower-bath, when well borne, and judicious exercise. The alteratives may be tried, as colchicum, iodide of potassium, mercury, arsenic, sulphur, guaiac, &c.; though much must not be expected from them ; and they too often fail altogether. Something may be hoped for from a steady use of the hot bath, alkaline or sulphurous baths, and the hot douche perseveringly applied. By means of leeches, the hot douche, hot baths, and guaiac given internally, Haygarth cured one case of four years duration, in which the nodosities had become developed. At the end of five years all the nodosities had disappeared. (Arch. Gen., Sept. 1856, p. 303-4.) Dr. Charles Lasegue recommends the tincture of iodine, which he has found re- markably successful in one deplorable case, in which the patient had been three years affected with the disease, and for a year had been unable to leave his bed, on account of pain and deformity of almost all his joints; not even those of the cervical vertebra? having escaped. The treatment consisted in the use of tincture of iodine internally, aided after a time by the application of warm dry sand to the joints. In a few weeks the progress of the disease was checked, in a month some of the stiffened joints became movable, and at the end of four months the patient was able to perform the laborious duties of a nurse in the hospital. Other less striking cases, also successful under the same treatment, afterwards came under his notice. The tincture was the only preparation of iodine used. This point is particularly insisted on; as M. Lasegue considers that the iodide of potassium and other preparations act in a different manner, and will not answer as substitutes. The dose given was increased gradually from ten drops, twice daily, to a drachm and a half at a meal; sweetened water, or preferably Spanish wine, being used as the vehicle. No iodic intoxication or appreciable emaciation took place, nor any other evil result. It must be observed, however, that the tincture was taken with food, the starch of which no doubt modified the local irritant effect of the iodine. Bromine has also been used, internally and externally, with asserted success. (Ibid,, p. 307.) It is said that thermal springs, and the hydropathic treatment, have proved useful in this obstinate disease. As to the local treatment, the most promising measures, in the chronic state, are the hot douche, repeated leeching or blistering, the continued use of rubefacients such as the gum-resins in the form of plaster, the mercurial ointment, the frequent application ofthe tincture of iodine, and finally a strong solution of nitrate of silver perseveringly used. It has been a question whether the joint should be kept at rest or exercised. There can be no doubt that rest is all-important during the existence of active inflammation; but when the case is quite chronic, and the joint begins to stiffen, it may be best to exercise it moderately and judiciously, in the hope of at once exciting an absorbent action, and preventing the utter loss of the joint. 522 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. CLASS III. LOCAL DISEASES. This is much the largest of the three classes in which diseases are arranged in the present treatise. It embraces all those which have their seat primarily or essentially in any one organ, tissue, or function. The local affection is often accompanied with constitutional symptoms; but these are secondary, as in the phlegmasia?, in which the fever depends upon the inflammation. It is true that, among the following diseases, are also many which are results of constitutional derangement; but, in these instances, the local affection is so striking and important as chiefly to engage attention, and always to have ranked among diseases, with a distinct title; while the constitutional dis- order, from which it may have sprung, is often concealed and unknown. Such are the local tuberculous affections, many instances of dropsy, and not a few cutaneous eruptions. I have preferred the several functions, as the basis of arrangement in this class, to the regions of the body; because it often happens that a particular disease, though confined to one function, overleaps the region, and may in fact occupy several regions, as dropsy occurring at the same time in the chest, abdomen, and external areolar tissue. In the order of the functions, I begin with that Avhich nature has placed first and lowest in the scale, and follow her course through the remainder. Pursuant to this plan, the diseases connected with the digestive system come first in order ; then those of the absorbent sys- tem ; and afterwards successively those ofthe respiratory, circulatory, secretory, and nervous. Diseases of the reproductive system, so far as they peculiarly belong to it, come generally under the care of the surgeon or obstetrician. In each group of diseases, those which consist in inflammation ofthe parts concerned are first treated of; because they are in general better understood and more easily recognized, and consequently, when known, serve as standards of comparison for the more obscure functional affections. SECTION I. DISEASES OP THE DIGESTIVE SYSTEM. These are most conveniently distributed into minor groups, connected severally with distinct portions of the digestive tube. The first embraces diseases ofthe mouth, the second those of the fauces, pharynx, and oesopha- gus, the third those of the stomach, and the fourth those of the bowels. But, as there are several affections which occupy the stomach and bowels jointly, & fifth group is made, including such diseases, together with those of the peritoneum, which may be considered as an appendage. SUBSECTION I. DISEASES OF THE MOUTH. In this subdivision are included, 1. the different forms of inflammation of the mucous membrane of the mouth ; 2. inflammation of the tongue ; 3. mor- bid states of dentition ; and 4. diseases of the teeth, under the general heads of toothache and falling of the teeth. CLASS III.] INFLAMMATION OF THE MOUTH. 523 Article I. INFLAMMATION OF THE MOUTH, or STOMATITIS. The term stomatitis (from ffr6/j.a, mouth) is applied to inflammation of the mucous membrane of the mouth. The disease appears under various forms. The inflammation may be diffused equably over portions or the whole of the membrane, or may occupy chiefly or exclusively the mucous glandules. When diffused, it may exhibit no peculiar secretory product, or may cover the sur- face with a consistent curd-like, or a pseudo-membranous exudation. It may be attended with eruption, ulceration, or gangrene, and receive from each of these attendants the character of a distinct variety. In fine, it may be pecu- liar from the nature of the cause, as when it accompanies scurvy, or is the result of mercurial action. It will be most convenient to treat of each of these forms separately. 1. Common Diffused Inflammation.—This appears in reddened some- what elevated patches, or occupies large portions of the surface, sometimes extending apparently over the whole mouth. In some cases, it is superficial, with little or no swelling, and may be designated as erythematous; in others, it occupies the whole thickness ofthe membrane, extending sometimes to the submucous tissue, and even to neighbouring structures, as the sublingual and submaxillary glands, and the absorbent glands of the neck, and occasions con- siderable tumefaction in all these parts. In the erythematous form, it is characterized by redness, a sense of heat, and sometimes considerable tender- ness, but is not usually attended with acute pain; when deeper in the tissue, it is often very painful. Portions of the epithelium sometimes become opaque, giving an appearance of whiteness in streaks or patches. Occasionally this coating is elevated in blisters, or even detached like the cuticle from the skin in scalds. Superficial ulcerations not unfrequently occur, which may spread over considerable portions of the membrane. In certain states of the consti- tution, the ulcerative tendency is very strong, and deep and extensive sores occur, which are sometimes attended with gangrene. There is often a copious flow of saliva; though, in some instances, this secretion, as well as that of mucus, is checked, and the mouth is clammy or dry. The sense of taste is usually impaired, and speech and mastication are often difficult and pain- ful. When the tongue is affected, its surface is in general at first covered with a whitish fur, through which the red and swollen follicles may often be seen projecting. The fur sometimes breaks off, leaving the surface red, smooth, and glossy, with here and there prominent follicles, and very sensitive to the contact of even mild substances; or the surface may be dry, hard, and gashed with painful fissures. When the gums are involved, they swell, and rise up between the teeth, around which they not unfrequently ulcerate. In some rare instances, this ulceration is very obstinate, and does not cease until it has extended into the socket, and destroyed altogether the connections of the teeth, which become loosened and fall out, after which the gum will heal. There is a mild variety of stomatitis, which may be denominated catarrhal, attended with a copious secretion of mucus and saliva, with a furred tongue, and deficient taste, but with little redness, swelling, or pain. This is some- times mistaken for disease ofthe stomach, especially when it becomes chronic; but may be distinguished by the undiminished powers of digestion, and the absence of direct gastric symptoms. Upon careful observation, it will be found that the discharged liquid proceeds from the mouth, and does not rise from the stomach either by eructation or vomiting. A mistake of this affec- 524 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. tion for gastrorrhoea would be very inconvenient in practice. Ordinary sto- matitis is seldom so violent as to induce symptomatic fever. Causes.—The form of inflammation of the mouth, above described, is more frequently a complication of other diseases than an original affection. When of the latter character, it is generally caused by the direct action of irritant bodies, as by scalding drinks, acrid or corrosive substances taken into the mouth, or unhealthy secretions from decayed teeth. The sharp edges or spicula of a broken tooth sometimes give rise to much inflammation, and even deep and obstinate ulcers, especially of the tongue. The tartar which collects about the neck of the teeth often keeps up a state of chronic inflammation of the gum, which sometimes ends in destructive ulceration. Stomatitis may also result from the reaction which follows the long-continued contact of very cold substances, such as ice, with the interior of the mouth. It sometimes pro- ceeds from the propagation of inflammation from the fauces, and is a frequent consequence of gastric irritation, produced by sour and acrid matter in the stomach. Drunkards seem peculiarly predisposed to it. Of the constitutional causes none are so frequent as the state of fever, which always affects the mouth, and not unfrequently occasions inflammation. Treatment.—In the acute stage, little treatment is required. In some very severe cases, in which the neighbouring parts are involved, leeches be- neath the jaw or over the parotid may be advisable. But, in general, cooling and demulcent liquids locally, magnesia or one of the saline cathartics inter- nally, with a soft and spare diet, from which meat is excluded, constitute all that is requisite. Where the inflammation results from some corrosive sub- stance taken into the mouth, almond oil, spread over the surface, will be found a useful application. In the latter stages, and in chronic cases, astringent washes, such as weak solutions of acetate of lead, sulphate of zinc, and alum may be advantageously applied; and, if ulcers exist wliich are indisposed to heal, their surface may be touched with a strong solution of sulphate of zinc, sulphate of copper, or nitrate of silver, care being taken that the application does not extend beyond the limits of the ulcer. In the chronic catarrhal va- riety of stomatitis, Dr. Pfeifer recommends a mouth-wash consisting of a grain or two of corrosive sublimate dissolved in a pint of water. In cases accompanied with gangrene, washes of chloride of soda, chloride of lime, or aqueous solution of creasote may be used. In an inveterate case of cracked tongue, Dr. Brinton found great advantage from a solution of two scruples of borax in a mixture, composed of an ounce of glycerin and four ounces of water; iodide of potassium and bark being given internally. (Lond, Lancet, Am. ed., ii. 91.) Should the inflammation depend upon the condition of the teeth, whether upon sharp edges or points wounding the adjacent parts, or acrid secretions, or the deposition of tartar about the neck of the tooth, care should be taken to correct the evil. 2. Diffused Inflammation with Curdy Exudation.__Thrush.__In- fantile Sore-mouth.—Muguet, of the French writers.—As this affection, though it may occur at all ages, is far more common in early infancy than at any other period, it is here described as it appears in the infant. A super- ficial or erythematic inflammation is first observed, which, in two or three days, or even in a shorter time, presents small whitish points at the angles of the mouth, or on the inside of the lower lip. These increase in number, and coalesce, forming patches, consisting of a whitish curd-like matter • and the affection gradually extends to the tongue, the roof ofthe mouth, and the inside of the cheeks, and not unfrequently reaches the fauces and even pha- rynx. The exudation is sometimes thick, and covers the whole surface but is more commonly in irregularly scattered patches and points. It occasionally assumes a yellowish or brownish colour, and the latter is considered as an CLASS III.] INFLAMMATION OF THE MOUTH. 525 unfavourable sign. After a time it falls off; but its place is supplied by a new exudation; and this change may occur several times. The mouth of the infant is hot, and the nipple of the nurse not unfrequently excoriated. When the throat is affected, the voice is apt to be hoarse. The complaint is sometimes preceded, and is often attended by diarrhoea, with flatus and colicky pains; and the stools are frequently green and slimy. The child also vomits green matter, smelling strongly sour; and the breath often has an acid odour. Redness about the anus is not uncommon, dependent probably on the acrid discharges. It is asserted that masses of the caseous matter are sometimes found in the stools, showing that the affection has extended to the bowels. The child is often somnolent, especially in the worst cases. The affection is sometimes entirely local, but, in the greater number of cases, is attended with some acceleration of the pulse and febrile heat. As it usu- ally occurs, it is without danger, but, when the stomach and bowels become involved, in children of bad habit of body, it often proves fatal. Generally, however, in fatal cases, the affection of the mouth is a mere complication of some independent disease, which is the cause of death. The complaint is of no certain duration, sometimes, when merely local, terminating favourably in a few days, sometimes becoming chronic, and lasting for several weeks. It often returns after apparent cure, and this may happen repeatedly during a period of several months. It appears from dissection that the disease sometimes extends into the oeso- phagus, as far as the cardiac orifice, presenting the same appearance as in the mouth. Patches of the exudation have even been observed in the stomach and small intestines ; and a case is on record in which it was found lining the lower end of the ileum, and the whole of the large intestines as far as the anus. (Bevue Bled., Juin, 1830.) But this is comparatively rare ; and the gastric and intestinal irritation, which so often attends the disease, does not seem to be the result of its extension, in an unaltered form, to the alimentary canal. In the matter thrown out upon the inflamed surface, Dr. Gruby, of Vienna, and Dr. Berg, of Stockholm, discovered, by means of the microscope, acrypto- gamic growth, belonging to the lower order of fungi, to which the disease has been ascribed. It is true that, under the microscope, the curdy matter of thrush is seen to consist mainly of thickened epithelial cells, mingled with numerous minute cryptogamic sporules or seeds, from the midst of clusters of which long thread-like, jointed, and branching plants arise, intertwining among one another ; but the question is not determined whether the vegeta- tion is the origin of the complaint, or whether this consists of an inflamma- tory product, which simply affords a nidus for the growth and propagation of the fungus. The name of Oidium albicans has been given to this plant. They who believe it to be the cause of the disease, suppose that its sporules, floating in the respired air, attach themselves to the mucous surface, and under favourable circumstances become developed, and propagate. These circum- stances may consist in some previous morbid state, changing the buccal secretion from its normal alkaline character to that of acidity, which pro- bably favours the growth of this as of other microscopic fungi. With this view of the cause, the complaint must be regarded as contagious; and it is stated that portions of the matter transferred from a diseased child to a healthy one, have given rise to the affection. Though most common among very young infants, the disease is not con- fined to any age, and not unfrequently attacks adults. But, in the latter case, it is almost always a consequence of other diseases, especially of long- continued affections in which the alimentary canal is primarily or secondarily involved. It is not uncommon in the last stage of phthisis; and, whenever 526 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. it occurs in the chronic complaints of adults, it must be considered as an un- favourable sign, often indicating the breaking up of the constitution. Causes.—The causes of this variety of stomatitis are not always evident. It is very apt to occur in situations, such as foundling hospitals, where the air is impure and the diet unwholesome. Children prematurely born, or brought up by the hand, or nursed by unhealthy women, are more liable to be affected than others. In fact, whatever tends to impair the health and vigour of the infant, to induce acidity of stomach or other gastric or intestinal disorder, dis- poses to its occurrence. Yet it often comes on, under apparently the most favourable circumstances, and in healthy, well-fed children. It seems occa- sionally to assume something like an epidemic character, being more than usually prevalent in certain families, or certain neighbourhoods, without any obvious cause. I have already stated the views of those who believe it to be dependent on a peculiar microscopic fungus ; and it is possible that these views may be correct; but they require further confirmation from observation and experiment before they can be admitted as established. Treatment.—In cases which are purely local, little or no constitutional treatment is required. Costiveness*>should be obviated by an occasional dose of castor oil, or of magnesia; and fever by small doses of the neutral mixture, or, if attended with acidity, by one of the alkaline carbonates. Should diar- rhoea occur, with green stools, magnesia may be given alone or combined with rhubarb; or, if the child be too weak for purgatives, prepared chalk or oyster- shell may be substituted ; or the two may be alternated. Whichever of these antacids is used, it maybe advantageously administered in some aromatic water, as that of spearmint, peppermint, or fennel, and combined with small portions of laudanum.* Emollient enemata, and poultices over the abdomen, maybe employed to relieve the intestinal irritation. Dr. Dewees recommended a flui- drachm of fresh butter, melted and washed by means of hot water, to be given three times daily, when the discharges are small and bloody. Vomiting may be treated with lime-water and milk, emollient poultices, fomentations, or rubefacients to the epigastrium, or if these fail, by anodyne enemata. It may sometimes be advisable, though very rarely, to apply a few leeches to the epigastrium or anus. In cases of great debility, infusion of bark, or sulphate of quinia in solution, with a little laudanum or paregoric elixir, may be resorted to. The best diet is the milk of the mother if healthy, or of a healthy nurse, who should avoid acescent food. In cases, however, attended with much gas- tric or intestinal irritation, it may be proper to substitute, wholly or in part, drinks of farinaceous or demulcent substances, such as barley, arrow-root, and gum arabic, prepared with little or no sugar. In debilitated cases, rich broths, without fatty matter, should be given. Care should always be taken to keep the apartment well ventilated, and that the infant breathes a pure air. In relation to local applications, some writers recommend only demulcent liquids in the early stages, such as infusion of flax-seed or marsh-mallow, solu- tion of gum arabic, or almond emulsion; while others approve of the use of borax, either dissolved in honey, or in the form of powder mixed with suo-ar. One part of borax to eight or ten of loaf sugar are the proportions usually adopted; but Dr. Dewees directed equal parts. A small pinch of the mixture should be placed on the tongue, and the infant allowed to spread it over the mouth. When the irritation is severe, Bateman recommends an emollient * B-—Magnesiae gss; Rhei pulv. gr. xv. Misce et divid. inchart. no. vj. S. One for a dose._ &.—Magnesiae.Qij; Acacias pulv., Sacch. alb. aa, gj ; Aq. Menth. P., Aq. fluv. aa f§j. Misce. S. A teaspoonful, every two or three hours till it operates. R.—Cretae ppt., vel Testae ppt. £j; Tinct. Opii Uliv; Acaciae pulv., Sacch. alb. aa zj • Aq. Cinnam. fgss; Aq. fluv. fjiss. Misce. S. A teaspoonful every three or four hours in diarrhoea. ' CLASS III.] INFLAMMATION OF THE MOUTH. 527 combination suggested by Van Swieten, consisting of cream, yolk of eggs, and syrup of poppies. In the advanced stages, when the disease is somewhat obstinate, a solution of sulphate of zinc, in the proportion of two grains or more to a fluidounce of water, with a little honey, will often be found useful. In the same stage, rose water acidulated with muriatic or sulphuric acid, and solutions of alum, chlorinated soda, and nitrate of silver, are also occasionally used.* These applications should be made carefully, from four to eight times a day, with a camel's-hair pencil, or a pencil of lint, and the greatest caution should be observed not to irritate the inflamed parts by rubbing them. No attempts should ever be made to remove the white exudation forcibly. Dr. W. Jenner finds the application of a solution of sulphite of soda, in the proportion of a drachm to an ounce of water, to effect a speedy cure. He ascribes its beneficial effect to the destructive influence of the sulphurous acid, liberated by the acids of the secretions of the mouth, upon the parasitic fungus on which he supposes the disease to depend. (Lond. Med. Times and Gaz., vii. 181.) In adults, the same local applications may be made, and the mouth may be frequently washed with cold water, or solution of acetate of lead. 3. Follicular Inflammation.—The mucous glandules may be affected with inflammation independently of the neighbouring parts, or in connection with them. In the latter case, they are distinguished as small red eminences, projecting beyond the general reddened surface of the membrane, and are particularly observable upon the tongue and soft palate. When independ- ently inflamed, they are, according to M. Billard, the source of those small round or oval ulcers, which are so common in the mouth, and have long been known by the name of aphth.se. That these muciparous glands are occasion- ally the seat of aphthous ulcerations there can be no doubt; but a much more common source of them is the affection which will be noticed in the next sec- tion.^ As described by M. Billard, the inflamed glandules may be sometimes felt by the finger before they can be clearly distinguished by the eye. When first distinctly visible they are in the form of minute, hard, round, whitish eminences, surrounded by a circle of redness. If the inflammation should not subside, the little tumours soften in the centre and ulcerate, and the surface of the ulcers is covered with a whitish adhering matter. These ulcers are usually distinct; but, when numerous glandules in the same vicinity are inflamed, they become confluent, and form a continuous whitish ulcerated surface of considerable extent. This affection, according to M. Billard, is apt to appear during dentition; but it sometimes also attacks adults, and is asserted to oc- cur in early infancy, when it is usually confounded with the thrush. In its confluent form, it is said frequently to attend the last stages of exanthema- tous fevers, and of various chronic complaints, such as phthisis, cancer, and chronic inflammation of tkte abdominal viscera. The treatment is not differ- ent from that ofthe following variety of stomatitis. 4. Eruptive or Vesicular Inflammation.—Aphthae.—The term aphthae was employed by the ancients to signify various iaflammatory affections of the mucous membrane of the mouth. Willan proposed to restrict it to a peculiar vesicular eruption upon the membrane, but committed the error of confounding with this affection the thrush of early infancy, which, in general, as already described, is attended neither with eruption nor ulceration. The two complaints are quite distinct, and should not be similarly designated. * R.—Acid. Sulphuric. Dilut., vel Acid. Muriat. f^j ; Syrup, vel Mellis fgj ; Aq. Rosae fsij. Misce. R.—Alumin. gr. x ; Mellis f^ss; Aq. Roste fgiss. Misce. R.—Liq. Sodas Chiorinat. f^iss ; Aquas Rosae fgiss. Misce. R.—Argenti Nitrat. gr. j ; Aq. Destillat. f^j. Misce. Some recommend a much stronger solution of nitrate of silver, containing from five to eight grains ofthe salt to a fluidounce of distilled water; but such a solu- tion should not be applied oftener than once or twice a day. 528 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. The term thrush, in this work is applied to the infantile sore-mouth already treated of; while aphthae, in compliance with very general usage, is extended to all those small ulcers, with whitish surfaces, which so frequently appear in the mouth, whatever may be their origin. Their most frequent source is probably the vesicular eruption, which constitutes the subject of this section. The vesicle is small, oval or roundish, white or pearl-coloured, and consists of a transparent serous fluid under the elevated epithelium. In a few days, the epithelium breaks, the serum escapes, and a small ulcer forms, more or less painful, with a whitish bottom, and usually a red circle of inflammation around it. The vesicles are sometimes distinct and scattered, sometimes numerous and confluent. The distinct variety, though painful, is a light af- fection, continuing in general only a few days or a week, and is usually con- fined to the mouth. It produces little or no constitutional disorder, though it may be associated with fever and gastric irritation as an effect. It attacks equally children and adults; but it is said not to be very common in early infancy. In adults it is frequently occasioned by the irritation of decayed teeth. The confluent variety is much more severe and obstinate. This fre- quently extends into the fauces and pharynx, and is even said to reach the intestinal canal. When it occupies the fauces, it renders deglutition painful. It is sometimes attended with gastric uneasiness, vomiting, intestinal pains, and diarrhoea. Fever occasionally precedes it, and lessens without en- tirely ceasing upon the appearance of the eruption. The fever sometimes assumes the typhoid character. The complaint is not common. It occurs most frequently in adults, and is said to attack preferably women in child- bed. It may continue for several weeks, and sometimes proves fatal. Treatment.—In ordinary cases, no general treatment is necessary. Mag- nesia may be given to correct acidity, and the diet regulated by the state of the stomach. In the severer cases, fever should be obviated by refrigerant cathartics and diaphoretics, and by a liquid farinaceous or demulcent diet. When the disease attacks the fauces or pharynx, occasions painful swallow- ing, and is attended with much fever and a strong pulse, general bleeding may become necessary, and subsequently the application of leeches to the throat. Diarrhoea must be counteracted by the means calculated to relieve in- testinal irritation, among which may be mentioned as especially useful, emol- lient applications to the abdomen, and the warm bath. When the fever assumes the typhoid form, a supporting treatment may be required. In the early stage, the local treatment should consist of demulcent appli- cations, as flaxseed tea, mucilage of gum arabic, or almond emulsion, with or without a little laudanum, or some preparation of morphia. But, after the inflammation has somewhat subsided, and ulcers are left indisposed to heal, astringent washes may be resorted to. Solutions»of acetate of lead, sulphate of zinc, and alum; water acidulated with sulphuric or muriatic acid, and sweetened with the honey of roses; and various vegetable astringents and tonic infusions have been recommended. The author usually employs a strong solution of sulphate of zinc, in the proportion of 15 or 20 grains to the fluidounce of water, which he applies by means of a camel's-hair pencil exclusively to the ulcers, with the almost uniform effect of disposing them to heal; and, even in the eruptive stage, this application will often be found to effect an almost immediate cure. Equally effectual are probably the nitrate of silver and sulphate of copper, applied to the ulcers, either in strong solu- tion or in the solid form. 5. Ulcerative Inflammation.— Ulcerative Stomatitis.— Ulcero-mem- branous Stomatitis.—Cancrum Oris.— Canker.—Any inflammation of the mouth may be attended with ulceration; but the complaint here referred to is essentially ulcerative, appearing in this form at the commencement, and CLASS III.] INFLAMMATION OF THE MOUTH. 529 presenting characters which entitle it to rank as a distinct affection. Dr. Symonds considers cancrum oris as a synonyme of gangrene of the mouth; but such is not the ordinary application of the term. It is true that the ul- cers, usually called canker, may, in constitutions predisposed to gangrene, terminate in that affection, but in the great majority of cases they have no such tendency, and are comparatively innocent. The complaint usually makes its appearance in the gums or inside of the cheeks or lips; though it may occur in any part ofthe mouth, or in the fau- ces. When first noticed it is in the form of an ulcer, often of considerable size, with a yellowish-white or grayish surface, and an inflamed border. The neighbouring parts are also inflamed and swollen, and, when the ulcer is in the cheek or lips, the tumefaction is observed externally, the cheek of the side affected being red, shining, and prominent. The swelling in the mouth is sometimes so considerable as to render an examination of the sore difficult. There is a very copious flow of saliva; and the breath is very offensive, though the fetor is distinct from that of gangrene. The ulcer is generally painful, and is usually attended with fever and constipation. It may continue for weeks or even months without very serious consequences; though, when upon the gums, it sometimes lays bare the alveolar processes. I have never known it to penetrate through the cheek, nor to end fatally; though what might be the ultimate consequences of continued neglect I am unable to say. I have always found it to yield to treatment. Patches of pseudo-membranous inflammation, (pseudo-membranous sto- matitis) now and then occur in the mouth, bearing much resemblance to the ulcerative affection above described, and probably constituting, in many in- stances, its first stage. The patches covered with the plastic effusion are whitish at first, then grayish, and sometimes at last livid or blackish. In consequence of the inflammation around them, they appear set in the mem- brane, and hence bear a close resemblance to ulcers. They end either by a gradual absorption or separation of the pseudo-membranous matter, or by a destruction of a portion of the mucous tissue, when an ulcer results. The causes of cancrum oris are obscure. It generally occurs in children from two to six years old; has been ascribed to a debilitated habit of body, arising from deficient or improper food, bad air, want of cleanliness, &c.; and is said to prevail most among the poor. I have seen it, however, in children otherwise apparently healthy, well fed, and well provided for in all respects. Treatment.—From two to six grains of calomel may be given at the com- mencement, either associated with some other cathartic, such as rhubarb or jalap, in order to insure its operation upon the bowels, or followed, should it not operate in six or eight hours, by a dose of castor oil. The bowels may afterwards be kept open by the occasional administration of castor oil, mag- nesia or its carbonate, or the sulphate of magnesia; small doses of the neu- tral mixture, or of antimonial wine should be given when the fever is con- siderable ; and, if the breath should be sour, a few grains of the bicarbonate of soda in carbonic acid water, repeated three or four times a day, will be found useful. In protracted cases, attended with debility, it may be advisa- ble to have recourse to the mineral acids, and to infusion of bark or sulphate of quinia. Iodide of potassium often operates very favourably. Chlorate of potassa, recommended originally by Dr. T. H. Babington, of Coleraine, Ireland, as having been employed by him with extraordinary success (Dub- lin Quart. Journ. of Med. Sci., xv. 236), has been subsequently found equally effectual by other practitioners. It may be given in sweetened water, in doses, increased if necessary, from five to twenty grains three times a day. In the febrile state, the diet should consist exclusively of farinaceous vol. i. 34 530 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. liquids. In the absence of fever, milk may be allowed ; and, in cases of de- bility, animal broth, jelly, kc Sour and acescent food should be avoided. In the local treatment, various applications have been recommended. Among these are mouth-washes of tincture of myrrh with Peruvian bark, dilute mineral acids with honey, and solution of alum, and weak solution of chloride of soda. I have found nothing so useful as a solution of sulphate of zinc, in the proportion of fifteen or twenty grains to the fluidounce of water, applied twice or three times a day to the ulcer, by means of a camel's-hair pencil, and continued until the yellowish-white exudation is removed, and the surface assumes a reddish hue. With this application I have in no instance failed to effect a cure. It is highly probable that strong solutions of sulphate of copper or nitrate of silver, which have been recommended, would prove equally effectual. Nitrate of copper and the diluted nitric acid of the phar- macopoeia have also been found useful. The pseudo-membranous patches above described may be treated in the same manner. 6. Sore-Mouth of Nursing-Women.—There is a form of ulcerative in- flammation of the mouth, peculiar to women while suckling, or in the ad- vanced stage of pregnancy. It was described by Dr. E. Hale, in a commu- nication to the Massachusetts Medical Society, published in 1830, and sub- sequently by Dr. F. F. Backus in the American Journal of the Medical Sci- ences for January, 1841. It comes on with a loss of taste, and a sensation described as similar to that produced by scalding liquids, and is sometimes very sudden in its attack. According to Dr. Hale, one or more minute, hard, painful tumours occur, at the beginning of the complaint, on the side of the tongue, which after a time ulcerate, producing very painful sores, with hard elevated borders, and a circle of inflammation around them. According to Dr. Backus, the ulcers often do not make their appearance until a con- siderable time after the commencement of the inflammation. They gradually increase in size, while others appear upon the tongue and inside of the cheeks, and the inflammation sometimes extends over the whole mouth. The surface is red and extremely tender and painful, so that no drinks or food can be borne but those of the blandest character. The tongue is not coated, but is red and smooth, and there is a copious flow of saliva. The disease is at first local, being unattended with fever or loss of appetite; but, if not arrested, it is apt to extend to the fauces, oesophagus, through the eustachian tube into the cavity of the tympanum, and into the nasal passages; the stomach and bowels become irritated; diarrhoea often takes place ; and the patient falls into a state of great debility and emaciation, which sometimes terminates in death. Dr. W. H. Byford treats of three varieties of the disease ; 1. a dif- fused superficial inflammation of the buccal mucous membrane; 2. a vesicular eruption which may be superadded to the first variety; and 3. an ulcerative affection similar to that above described. (Am. Journ. of Med. Sci, N. S., xxv. 393.) Dr. David Hutchinson, of Morgan Co., Indiana, in an interesting essay on the subject, states that, in addition to the affection of the mouth and neighbouring parts, the colon is sometimes ulcerated, inflammation extends into the bronchial tubes, the vaginal surface may become implicated, and, in short, that there is no one of the mucous membranes which is not liable to be affected. The cause is some influence exerted on the system by nursing, or by the advanced state of pregnancy; as persons are not affected under other circumstances, and the disease almost always gives way upon the wean- ing of the child. What is the nature, however, of this influence is not cer- tainly known ; but, as believed by Dr. Hutchinson, it is probably an altered and impaired condition of the blood, dependent partly on the pregnant state, and partly on exhausting discharges and imperfect nutrition, and frequently favoured by some epidemic constitution of the atmosphere in certain localities CLASS III.] INFLAMMATION OF THE MOUTH. 531 disposing to disease of the mucous membranes. (Ibid. Oct. 1857, p. 369.) The complaint is apt to recur in subsequent nursings; and Dr. Hale thinks that, when pregnant women are attacked, it is in consequence of a predispo- sition acquired from having had the disease while nursing on a previous oc- casion. It appears to be especially prevalent in particular localities. The most efficient remedies are said to be tonics, antacids, and laxatives. Dr. Hale gave sulphate of quinia or infusion of Peruvian bark, serpentaria, ale or porter, and Seidlitz powders or rhubarb; Dr. Backus, a combination of carbonate of iron, rhubarb, aloes, and ipecacuanha, in the form of pills. Dr. Byford recommends cod-liver oil. Dr. H. D. Holt states that the dis- ease has invariably yielded under his observation, in less than forty-eight hours, to iodide of potassium, given in the dose of five grains three times a day. (New. York Journ. of Med., x. 372.) Chlorate of potassa is extolled by Dr. L. Faulkener, and is probably an efficacious remedy. (Va. Med. Journ., Dec. 1857.) The diet should be of milk and farinaceous substances. As local applications, mild astringent infusions, or a solution of nitrate of silver, solution of chloride of soda, and creasote-water have been recom- mended. Should these remedies fail, the child should be removed from the breast; and a cure then speedily takes place. Upon the whole, the most efficient remedies appear to be those calculated to alter or enrich the blood; as iodide of potassium, chlorate of potassa, quinia, the preparations of iron, and cod-liver oil. Not a few essays have recently appeared presenting peculiar views of the disease, or somewhat peculiar modes of practice. Dr. R. Wilcox has met with uniform success from the decoction of smart-weed, (Polygonum punctatum of Elliot), made by boiling an ounce of the dried leaves and tops in a pint of water for twenty minutes, and applied to the affected part every hour through the day. (Am. Journ. of Med. Sci, N. S., xvi. 248.) Dr. J. Y. Ware, of Massachusetts, has found the compound mixture of iron (U. S. Ph.), given internally in doses of a tablespoonful three times a-day, and a so- lution of nitrate of silver containing two grains to the fluidounce, used as a gargle, to be infallible. (Poid,, xviii. 290.) Dr. M. L. Knapp, formerly pro- fessor of Materia Medica in the University of Iowa, considers this disease as essentially scorbutic; and has treated cases on this principle successfully which have come under his notice. (See New York Journ of Med., N. S., vii. 206.) Dr. W. H. McKee, of N. Carolina, employs preferably a combina- tion of iodide of potassium and tartrate of iron and potassa, with magnesia when required as a laxative, and morphia at night to relieve pain, or procure sleep. (Trans, of Med. Soc. of N. C, A. D., 1857, p. 24.) 7. Gangrenous Inflammation.—Gangraena Oris.—Sloughing Phage- daena of the Mouth.—Necrosis Infantilis.—Gangrene may originate in the mouth, as elsewhere, from inflammation, in consequence either of the violence of the affection or of constitutional predisposition ; but the complaint which it is intended to designate by the above title is one of peculiar character, occur- ring under peculiar circumstances, and presenting peculiar phenomena. In- deed, it is an unsettled point, whether it has in general any dependence upon inflammation. By many the gangrene is considered as an original affection, and the inflammation which sometimes attends it rather as an effect than a cause. The probability is that it depends upon a peculiar morbid condition of system, which is sometimes capable of immediately producing it, but more frequently acts as a predisposition merely; inflammation or ulceration of whatever kind serving as the exciting cause, which calls this predisposition into action. In this way, the ulcer, described in a previous section as canker of the mouth, may sometimes be the first stage of the true gangraena oris. Gangrene of the mouth occurs usually in children between the periods of the first and second dentition, though accounts are not wanting of its occa- 532 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. sional occurrence also in adults. It is not often seen by the practitioner in its earliest stages. When it first attracts notice, it commonly exhibits a whitish or ash-coloured eschar, situated upon the gums, most frequently be- tween the lower incisors, though it may occur in any part of the mouth or fauces, and is often seated on the inside of one of the cheeks. This ulcer is sometimes, though not generally, preceded by a slight degree of inflamma- tory redness and swelling. When on the inside of the check, it is usually accompanied with considerable swelling, so that the cheek appears externally quite prominent; and this is sometimes the first mark of the disease which attracts notice. The exterior surface of the cheek is for the most part po- lished, and whiter than in health. In this stage the child suffers little or no pain; nor are any striking constitutional phenomena presented. There is often an air of languor and weakness about the little patient; but the func- tions are apparently regular, and the usual avocations or amusements are not interrupted. There are seldom any signs of fever. As the complaint ad- vances, the slough spreads, the saliva flows copiously, and the breath becomes excessively fetid. The disease penetrates to the bony structure, necrosis of the alveolar processes takes place, and the teeth are loosened and fall out, with portions of their bony sockets. An acrid fluid is poured out by the sloughing and ulcerating surface, which inflames and excoriates the inner surface of the mouth, and, by thus over-exciting the enfeebled structure, gives rise to new centres of mortification. Upon the swollen cheek exter- nally, a pale ash-coloured spot sometimes makes its appearance, which becomes livid or black, and spreads rapidly, till much of the cheek is destroyed ; and portions of the upper jaw, and even the palatal and ethmoidal bones, are said to have been, in some instances, involved in the mortification ; but death usually takes place before the disease has had time to effect so much local mischief. In the progress of the gangrene, a febrile action sets in, probably occasioned, in part, by inflammation ofthe mouth and throat, resulting from the sloughs and the acrid discharges, and, in part, by the putrid matter swallowed by the patient. The pulse is frequent and feeble, and the child very restless and morbidly wakeful. There is often, in the advanced stages, an almost total inability to take food, which tends to increase the debility. An exhausting diarrhoea, moreover, supervenes towards the close of the dis- order. Death is preceded by cold extremities, and the other customary evi- dences of extreme exhaustion. The disease seldom occurs after the period of the second dentition. It is most apt to attack children of debilitated constitutions, resulting from habit- ual exposure to a vitiated air, and the use of unwholesome or insufficient food. Hence, it is most prevalent in miasmatic districts, and in public establishments where children are crowded together. It is a frequent sequela of other diseases, especially of intermittent and remittent fever, and the exanthemata. Mercury has sometimes been accused of producing it, though generally upon insufficient grounds. It is possible that the mercurial sore- mouth may sometimes have degenerated into this complaint, in persons pre- disposed to it. The opinion is highly probable, which ascribes the constitu- tional predisposition to the disease to a depraved condition of the blood. It is not unfrequently complicated with pneumonia, which greatly increases the danger. Of twenty-one fatal cases, Rilliet and Barthez found this complica- tion in nineteen. (Traite des Maladies des Enfants, ii. 152.) Treatment.—The disease, when taken in hand in an early stage, is almost always curable; but, after considerable sloughing, especially of the cheek, is generally fatal. The remedies addressed to the constitution are those calculated to support the strength of the patient. Sulphate of quinia, or infusion of Peruvian bark, the mineral acids, and a nutritious diet, are CLASS III.] INFLAMMATION OF THE MOUTH. 533 usually advisable. Chlorate of potassa, in the dose of from five to twenty grains for a child from six to eight years old, repeated three or four times a day, may be employed with hope of advantage. Chalybeates will sometimes prove useful, especially in cases originating in miasmatic diseases. In cases of great debility, wine-whey, with carbonate of ammonia or camphor, and animal broths should be resorted to. Constipation should be obviated by rhubarb, with or without magnesia; and opiates should be given throughout the complaint to relieve restlessness and pain. But local measures also are very important. As soon as a white or ash- coloured surface appears, some escharotic substance should be freely applied to it. Dr. B. H. Coates, of Philadelphia, who had seen much of the disease, found a strong solution of sulphate of copper, in the proportion of half a drachm of the sulphate to a fluidounce of water, applied two or three times daily, so as to touch every portion of the diseased surface, by far the most effectual remedy. (N Am. Med. and Surg. Journ., vol. ii. p. 20.) Solid nitrate of silver, or a strong solution of the salt if sloughs are already formed, the mineral acids, and undiluted tincture of chloride of iron, have also been recommended as topical applications, and will in most cases be found effectual. The same may be said of a solution of sulphate of zinc, in the proportion of half a drachm to the fluidounce. Tincture of myrrh, decoction of Peruvian bark, and solution of alum have been employed ; but are of little use, unless in promoting the healing process after the separation of the slough. The mouth should be washed with a solution of chloride of soda or of creasote, to correct the fetor. The removal of the loosened teeth will sometimes be found useful, as their presence serves as a source of irritation, and sometimes inter- feres with the application of remedies to the whole surface diseased. When a gangrenous spot appears on the cheek, M. Billard advises, as the most effectual remedy, to make a crucial incision in the affected part, and to fill it with the butter of antimony, or to apply the actual cautery. The charcoal, carrot, or fermenting poultice, may be applied when the gangrene advances, the parts being frequently washed with an aqueous solution of creasote. 8. Mercurial Inflammation of the Mouth.—Mercurial Stomatitis.— There are various morbid states of the mouth depending upon peculiar general diseases, such as the scorbutic and syphilitic ulcers, and the variolous erup- tion ; but these are more properly treated of under the heads of the diseases severally, of which they constitute a part. The effects of mercury upon the mouth may with greater propriety be considered in this place, as an account of its general effects upon the system does not come within the plan of the present work. Among the first indications of the action of mercury are often a metallic taste in the mouth, like that of brass or copper, and some increase of the saliva. At the same time, a close examination will detect a slight redness and swell- ing of the gums, particularly about the necks of the lower incisors, while somewhat below their edge, a broad white line may often be observed, de- pending on opacity of the epithelium. The patient soon begins to feel some uneasiness, complaining of soreness when the gums are pressed, and of pain when the teeth are forcibly closed together. There is also a sense of stiffness about the jaws when the mouth is opened, and the teeth feel as if projecting above their usual level. The flow of saliva increases, the inflammation extends, the gums and palate become obviously swollen, and the tongue covers itself with a yellowish-white or brownish fur, and is often so much enlarged as to exhibit the impressions of the teeth when projected from the mouth. The throat frequently becomes sore, and the cheeks, and salivary and absorbent glands, swollen and painful. There is often severe toothache or pain in the jaws. A whitish exudation along the edges of the gums is very common. 534 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. The breath, which, from the beginning, and sometimes even before the appear- ance of any one ofthe symptoms mentioned, has a peculiar disagreeable odour, now becomes extremely offensive, and in bad cases almost intolerable. Ulcer- ation often occurs, especially about the necks of the teeth, which are conse- quently loosened, and in the cheeks, lips, and fauces. The ulcers often have their origin in a vesicular eruption, such as that already described. (Seepage 527.) The whole mouth with its appendages is sometimes so much swollen that it can scarcely be opened; and the tongue so much enlarged as to project beyond the lips. The patient is now nearly or quite unable to articulate, or to masticate his food, and sometimes can scarcely swallow. A case was related by Dr. Physick, in his lectures, in which an obstinate dislocation of the jaw resulted from the enormous tumefaction of the tongue. Hemorrhage is not an unfrequent attendant upon these bad cases, and is sometimes so profuse as to be alarming. Sloughing also takes place, and portions of the jaw bone are occasionally laid bare. There is always, in the severe cases, more or legs fever, which is partly symptomatic of the local affection, partly the direct effect ofthe mercury. Death, from the exhausting influence ofthe irritation, want of nourishment, and hemorrhage, has occurred in numerous instances; but the patient generally recovers from the worst forms of the affection, though sometimes with a deformed mouth. The tongue and cheek have occasionally adhered at points where their ulcerated surfaces were in contact, and a surgical operation has been necessary to remove the evil. Some individuals are exceedingly susceptible to sore mouth from mercury; the smallest quantity of the mineral being sufficient to produce severe effects. Others again are scarcely affected, in this way, by any quantity of the medi- cine which can be administered. The preoccupation of the system by a very violent disease presents, in many instances, a complete obstacle to its action upon the mouth. Thus, in yellow fever it is sometimes utterly impossible to induce the mercurial salivation. Treatment.—Mild cases of this affection require no treatment. In severe cases, it is usually advisable to keep the bowels loose by saline cathartics, to confine the patient to a liquid farinaceous or milk diet, and to allay nervous irritation and pain by opium. In some rare instances, when the inflammation is intense and the pulse strong, it maybe proper to draw blood from the arm. Care should be taken that the patient be clothed in flannel, and breathe a pure air. The compound decoction of sarsaparilla, to the amount of a quart daily, has been recommended as a diluent. The internal use of chlorate of potassa has very strong testimony in its favour; and, though in one or two cases in which I tried it I could discover no decided effect, yet, if testimony can be relied on, there is no remedy more effectual. In the local treatment, it is usually sufficient to wash the mouth and throat with warm demulcent liquids, or mild astringent decoctions or infusions. Of the former, barley-water, flaxseed tea, and infusion of sassafras pith or benne leaves; of the latter, common green tea, decoction of galls or black alder, and infusion of red roses, or of the berries or inner bark of the upland sumach, may be employed. The astringent preparations should be weak, and may be advantageously associated with laudanum. Perhaps no wash for the mouth is preferable to a solution of acetate of lead, in the proportion of two or three grains to the fluidounce. A solution of alum may also be employed ; and, when ulcers exist, a strong solution of sulphate of zinc or nitrate of silver may be applied by a camel's-hair pencil to the ulcerated surface. Half a drachm of nitrate of silver may, for this purpose, be dissolved in a fluidounce of dis- tilled water. To correct the fetor, washes made with chloride of soda or of lime, or with creasote, will be found most effectual. Tar smeared over the surface of the mouth has been recommended. Dr. Wilcox, of Elmira, New CLASS III.] INFLAMMATION OF THE TONGUE. 535 York, has obtained extraordinary success from the use of a decoction of the smart-weed, employed in the same manner as recommended in the sore-mouth of nursing-women. (See page 531.) When the inflammation and swelling are great, leeches may be applied under the lower jaw, or over the parotids. I have found blisters to the sides of the face and neck very useful in reliev- ing pain. Article II INFLAMMATION OF THE TONGUE, or GLOSSITIS. The term glossitis (from yXwo-aa, tongue) is here applied to inflammation of the substance of the tongue; inflammation of the mucous membrane of that organ having been included in stomatitis. This is often very sudden in its attack, and rapid in its progress. Some portion ofthe tongue, most commonly the anterior part, becomes red, painful, and swollen; and, in the course of a few hours, the inflammation extends throughout the organ, which enlarges so much as to fill the whole mouth, to force open the jaws, and sometimes to project considerably beyond the teeth and lips. The floor of the mouth is ob- viously much depressed, the soft palate elevated, and the epiglottis, in some instances, so much pressed down as to endanger suffocation. Deglutition is very difficult, if not impossible ; and the patient is wholly unable to articulate. The tongue is usually red or dark-coloured, and dry upon the surface ; though sometimes it is moist, and covered with a thick whitish or yellowish fur. Not unfrequently the neighbouring parts participate in the inflammation. The system sympathizes, and a quick strong pulse, and hot skin usually exist in the earlier stages ; but, as the complaint advances, and respiration becomes embarrassed, the pulse loses strength, and cold sweats occur. The inflam- mation may terminate in resolution; but, if not interrupted by remedial treat- ment, it is apt to run into suppuration or gangrene, unless, indeed, the patient previously die of suffocation, or of apoplexy from the impeded return of blood from the head. Sometimes permanent induration is left upon the subsidence of the inflammation. Less destruction is produced by gangrene than might be imagined from the large sloughs thrown off by the tongue ; for, when the organ shrinks to its original size, the loss is often found inconsiderable. Causes.—Glossitis may result from the usual causes of inflammation. Per- haps the most frequent cause is direct injury, resulting from irritating or cor- rosive substances, scalding drinks, wounds or bruises, or the bites or stings of venomous insects. Sometimes the affection is produced by a direct propaga- tion of inflammation from the tonsils, and it occasionally arises in the course of exanthematous fevers. In some instances, the chief force of the mercurial action appears to fall upon the tongue, and to produce immense tumefaction. Treatment.—The rapid and dangerous character of this disease requires prompt and efficient treatment. As much blood should be immediately taken from the arm as the strength will permit, and the bleeding should be repeated once and again, if necessary to arrest the progress of the inflammation. If deglutition is possible, the patient should be purged freely with sulphate of magnesia, or with this salt combined with infusion of senna, or with some other active cathartic. Should it be impossible to administer medicines by the mouth, the bowels should be kept open by enemata. The diet should consist exclusively of farinaceous drinks. When the patient is unable to swallow liquids, thirst may be alleviated by bathing, copious diluent enemata, and the cautious application of lemon-juice to the surface of the tongue. The remedy on which, however, after general bleeding, the chief reliance must be placed, are leeches applied beneath the lower jaw, and to the upper 536 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. anterior part of the throat. To be efficient, it is necessary that the bleeding should be very copious. As many as one hundred American leeches may be applied at once, if the strength of the patient permit. They should have been preceded by venesection. Some recommend their application directly to the tongue ; but, in general, leeches act better when applied in the vicinity of an inflamed organ than immediately to it; as the irritation from their bites is sometimes very injuriously superadded to the existing disease. The opening ofthe ranular veins has also been recommended; but it is not always easy to reach them in the swollen state of the tongue ; and there is danger of wounding the ranular arteries in the operation. The cases seen by the author have yielded to the free use of leeches externally, beneath the floor of the mouth, after suitable general depletion. After the leeching, emollient poul- tices may be employed; or recourse may be had to blisters. But, should leeches not be attainable, or should they have been employed without success, and the danger of suffocation appear imminent, free incisions should be made into the substance of the tongue, one on each side of the median line, extend- ing from the base to the tip. Care, however, should be taken, not to make them so deep as to endanger the wounding of the ranular arteries. Blood flows freely from the incisions, and the size of the tongue is rapidly dimi- nished. Another advantage is the escape of the pus, if suppuration should have taken place. If, notwithstanding all these measures, suffocation is threatened, it will be necessary to open the larynx ; and cases may exist so immediately dangerous, that this operation should be at once resorted to, without awaiting the slower effect of other means of relief. If an abscess form in the tongue, it should be opened by a bistoury, and mild emulsions or mucilaginous liquids, with the addition of honey of roses or simple oxymel, may be afterwards applied. Should the healing process be slow, it may be advantageously stimulated by tincture of myrrh and decoc- tion of bark, or other analogous washes. In cases of gangrene, the mouth should be washed with chloride of lime or of soda, aqueous solution of crea- sote, or decoction of bark acidulated with the mineral acids. Article III MORBID DENTITION. It has long been observed that, during the process of dentition, children are more liable to disease than at other times, and that this is the most fatal period of life. It is probable, however, that the influence of the process has been much exaggerated. It occupies a large portion of that stage of growth, when the susceptibilities of the system are most acute by nature, and least blunted by habit, and when morbific causes in general must have the greatest influence. It is at this time of life also that exposure usually begins, and the child becomes liable to those diseases, such as measles, hooping-cough, &c, which occur but once. It is, moreover, during dentition that the change of diet usually takes place from the milk of the mother to other and unaccus- tomed kinds of food, and that the maternal milk itself becomes deteriorated by the institution of new or suspended physiological processes. Independ- ently of teething, therefore, it would be inferred that this period of life must be unusually fatal; and it is an error to ascribe the result exclusively to that process. Still, there can be no doubt that it exercises an important influence, and that its derangements are among the most fruitful sources of danger to infant life. The pressure of the growing teeth upon the surrounding parts CLASS III.] MORBID DENTITION. 537 almost necessarily occasions some uneasiness, and frequently produces so much irritation and inflammation as not only to cause great local suffering to the child, but also to call various functions into sympathetic disorder, and even to set on foot serious organic diseases. This is easily understood, when it is considered that, in infancy, not only are the susceptibilities most acute, but the sympathies also peculiarly active, from the necessity in which -the system is placed, in the rapid development of all its parts, to guard against irregular results by the rapid diffusion of impressions from each part to every other. The investing membrane of the tooth, and the gum over it, against which the body presses in its progress, and which is absorbed in consequence of this pressure, are the parts which chiefly suffer; though it is highly probable that the roots also occasion distress, during their development, by incommoding the dental nerves. The irritation thus occasioned is probably often pro- ductive of tingling, itching, or other vague uneasiness, different from pain, and even more difficult to be borne; for the child instinctively seeks relief by biting upon hard substances, or otherwise pressing them against his gums; the slight pain thus occasioned being more tolerable than the sensation which it displaces. This irritation may sometimes even occasion serious constitu- tional disturbance, especially of a nervous character; for such disturbance has been apparently relieved by lancing the gums, even when no obvious inflammation existed. The feeling of relief from pressure may be expe- rienced, even when the gum is considerably swollen, hot, and painful; but, when the surface becomes of a deep-red, or assumes that vesicular appear- ance which sometimes precedes the eruption of the tooth, it is usually ex- ceedingly tender to the touch. During difficult dentition, the saliva flows more freely; the child becomes fretful, peevish, restless, and wakeful at night, frequently putting his fingers into the mouth, and sometimes screaming vio- lently, and almost incessantly. In some instances, the inflammation extends to neighbouring parts, affecting the absorbent and salivary glands, and the mouth becomes hot and dry. The sympathetic effects of teething are generally in proportion to the local affection, which is greatest when many teeth are advancing at the same time. They bear also some relation to the constitution and age. Delicate children usually suffer more than the robust, because the process is more protracted ; and the danger is greater in premature than in late dentition, because the susceptibilities of the system are greater. From the peculiar mobility of the nervous system of infants, this is very apt to suffer, especially the brain. Hence restlessness, wakefulness, occasional spasmodic movements, and even convulsions. The respiratory organs sometimes participate in the nervous derangement; and there is reason to believe that spasm of the glottis, and very obstinate coughs, may originate in this source. But the irritation is most frequently directed to the alimentary canal. Looseness of the bowels is a very common attendant on teething, and, when not severe, may be con- sidered as a salutary effort to relieve or prevent more dangerous affections, especially of the brain. Sometimes, however, it assumes itself a dangerous character, being attended with vomiting and great prostration, or becoming protracted, and wearing out the strength of the patient. .The skin is also a frequent seat of the sympathetic irritation, and various eruptive affections are apt to appear during dentition. Among these, a pustular and ulcerative or scabby disorder behind the ears is not uncommon. The circulation generally participates more or less in the irritation; and fever not unfrequently occurs. Besides all these direct results of diseased dentition, it is apt to aggravate almost all co-existing diseases. Dr. James Jackson, of Boston, in calling attention to the second dentition, states that the period of suffering is usually from the tenth to the thirteenth 538 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. year, and that the morbid effects are emaciation and nervous disorder, marked by low spirits, a change of temper, whimsical notions, more or less debility, pain in the head or eyes, and sometimes chorea. (Letters, &c, p. 146.) Treatment.—The child should in general be exposed to cool fresh air, and the bowels, if at all disposed to costiveness, should be kept open by a laxa- tive diet, or by mild cathartics, such as manna, magnesia, or castor oil. If there should be much fever with costiveness, a dose of calomel will often be found useful. In this case, cool drinks, and some of the refrigerant diapho- retics may also be given, particularly the neutral mixture, and the spirit of nitric ether, which often has a happy effect in controlling irregular nervous action. The stomach should never be loaded with food, and the diet should be light and of easy digestion, and proportioned to the degree of existing excitement. Attendant or consequent diseases must be treated as when they occur under other circumstances; reference, however, being always had to the fact, that diarrhoea and cutaneous eruptions often afford a safe outlet to the irritation, and should not be too hastily removed, lest this might fall dan- gerously upon the brain. The disorder behind the ears is apt to be unsightly and troublesome ; and mothers are often anxious for its cure; but it should rather be encouraged than removed; and the late Dr. Joseph Parrish, of Philadelphia, used to insist upon the importance, not only of not interfering with this salutary process of nature, but even of imitating it, in cases of much obstinacy or danger, by keeping blisters open in the same situation. The local treatment of diseased dentition is highly important. When a mere irritation exists, without much inflammation or disturbance of the health, it may be sufficient to allow the child to chew upon some hard sub- stance, as a smooth piece of wood or ivory; but, when the gums are swollen, and any derangement in the functions occurs, incisions should be made with- out hesitation down to the teeth, so as to divide both the gum and the in- vesting membrane. These may be made by a gum-lancet, or a sharp pen- knife, and should always be free. Over the front teeth, the incision should be single, but over the double teeth of a crucial form. Lancing the gums often affords great and immediate relief. It is useful, in some measure, by the bleeding which ensues, and is therefore not always without benefit, even when superficial; but its chief advantage is the liberation of the tooth, and the removal of the tension of the gum and membrane. The objection which has been urged against it, that the incision often heals before the tooth appears, and thus leaves a scar more difficult to penetrate than the original gum, is altogether without foundation. So far from affording an increased resistance to the progress of the tooth, the scar partakes of that diminished vitality of all new formed parts, which causes them to yield to the absorbent process more readily than the original structure. It is asserted that lancing the gums is sometimes useful, even when no swelling appears, by relieving the tension and irritation of the parts immediately around the tooth. Some caution, however, is requisite; as too early a division of the capsule which secretes the enamel may interfere with the proper formation of that struc- ture ; and Guersent states, as the result of observation, that teeth, thus pre- maturely exposed,.make their way through the gums more slowly than the others. (Diet, de Med., x. 139.) Should the inflammation be obstinate or extensive, and not yield to the division of the gums, a few leeches may be ap- plied upon the outside of the jaws, and a pair of blisters behind the ears; and the blisters may be repeated, or kept open by stimulating dressings. For children suffering from the second dentition, Dr. Jackson recommends a suspension of severe study, agreeable exercise, removal from town to country, and an avoidance of the debilitating measures too often employed under the impression that the child has worms, or is threatened with disease of the brain. CLASS III.] TOOTHACHE. 539 Article IV TOOTHACHE, or ODONTALGIA. Toothache scarcely deserves the name of a disease, being merely a symp- tom of various morbid states of the affected part; but, as it is in general the most prominent circumstance in connection with the affection which it accom- panies, and that to which the attention of the practitioner is chiefly called ; and as it affords the means of presenting in one view several disorders of the teeth, or their appendages, which scarcely deserve a distinct heading in a work like the present, it is employed as a title to this article. Toothache offers every possible variety in degree, character, and duration. The pain runs through all the grades which intervene between a slight sensa- tion of uneasiness and insupportable agony. It maybe dull, aching, heavy, sharp, pungent, throbbing, grinding, or lancinating. It may be continued or paroxysmal, remittent or intermittent, and regular or irregular in its recur- rence. It may come in flashes, and as suddenly disappear ; or may continue a long time with little variation. Its varieties will be best considered under the different pathological conditions which it attends. 1. Nervous or Neuralgic Toothache.—A purely neuralgic condition of the teeth is not uncommon. The affection may be seated in the nerve of a single tooth ; but it much more commonly occupies the nervous trunk from which several teeth are supplied; and not unfrequently affects rather the jaw than the teeth themselves. The pain is in general of the acute character, sometimes mild in the beginning, gradually increasing in intensity, and as gradually declining; but usually very irregular, at one time moderate, at an- other severe, and occasionally darting with excruciating violence through the dental arches. Not unfrequently it assumes a regularly intermittent form. Instead of pain, strictly speaking, the sensation is sometimes of that kind which is indicated when we say that the teeth are on edge, and is apt to be excited by certain harsh sounds, such as that produced in the filing of saw teeth, by mental inquietude, and by the contact of acids or other irritant sub- stances. Neuralgic toothache sometimes persists, with intervals of exemption, for a great length of time, and becomes the torment of the patient's existence. The diagnosis is occasionally difficult. When, however, it occurs in sound teeth, is paroxysmal in its character, is attended with little or no swelling of the external parts, occupies a considerable portion of the jaw, and especially when it alternates or is associated with pain of the same character in other parts of the face, there can be little doubt as to its real nature. This variety of toothache may depend on a morbid state of the nerve or nerves which are the immediate seat of it, but more frequently originates in a condition of the nervous system, such as disposes to neuralgic pains gene- rally. This will be considered under the head of neuralgia. With an exist- ing predisposition, it is sometimes invited by caries, but very frequently oc- curs in teeth which are perfectly sound. Almost anything which disturbs the system may serve as an exciting cause; but the most frequent causes are probably vicissitudes of weather, and the application of very cold or very hot substances to the teeth, especially in alternation. The disease appears to be sometimes sympathetic with morbid states of the stomach or other distant organs; and not unfrequently occurs in gouty or rheumatic individuals. Treatme>d.—In plethoric cases with a strong tense pulse, general bleeding may be employed; but this is seldom necessary or advisable, and in cases of 540 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. debility might aggravate the affection. In the latter cases, after due evacua- tion of the bowels, tonic medicines, especially subcarbonate of iron, in doses of one or two drachms three or four times a day, and sulphate of qui- nia freely administered, are often useful, and sometimes will effect a cure. The narcotics are also beneficial. The extracts of belladonna, stramonium, hyoscyamus, conium, and aconite, may be employed singly or in combination. Opium or some of its preparations are occasionally necessary to relieve the violence of the pain. When the neuralgic affection can be traced to sympathy with disease elsewhere, this should be corrected. Thus, antacids should be given in acidity of stomach, laxatives in constipation of the bowels, the blue mass or calomel in deranged or deficient hepatic secretion, aloes or other emmenagogue in amenorrhcea; and not unfrequently the co-existence of two or more of these affections calls for the simultaneous use of the appropriate remedies. If a rheumatic or gouty diathesis be suspected, wine of colchicum, hot pediluvia, and other means adapted to these disorders may be tried. Peru- vian bark or sulphate of quinia will be found an almost certain remedy in re- gular intermittent cases, and often useful in others. Mercury is sometimes effectual, when the disease has resisted all other treatment. In fact, what- ever alters materially the distribution of nervous influence, and changes the condition of the system, offers a chance of benefit. Hence the employment of general frictions, and of cold and hot baths, sometimes proves advantageous. In very obstinate cases, a total change of scene and habits is often highly beneficial. An excursion to some watering-place, a protracted journey, and especially a sea voyage, with long-continued foreign travel, will often effect permanent cures when the catalogue of medicines has been exhausted in vain. The diet should be accommodated to the condition of the system, and of the digestive organs. The local treatment consists of leeching in plethoric cases, anodyne embro- cations or poultices, sinapisms and other rubefacient applications, frictions with veratria or strong tincture of aconite, blisters with a salt of morphia sprinkled on the denuded surface, moxa in the course of the nerves or on the side of the neck, cold water or ice to the cheek, steaming the face with the va- pour of hot water, either pure or combined with volatile narcotics, tobacco fumigations, irritant and anodyne masticatories, errhines, electricity or galvan- ism, and all the other topical means employed in the treatment of neuralgia. (See Neuralgia.) Chloroform, locally applied, will probably be found the most efficient anodyne. When a single tooth is affected, relief is sometimes af- forded by its extraction; but this measure often fails, and always when seve- ral teeth are involved. Carious teeth should generally be removed in these cases, if the affection has proceeded far. 2. Inflammatory Toothache.—This may exist with or without caries, but is in the great majority of instances dependent upon that affection. Be- fore proceeding, therefore, to an account of its phenomena, it will be proper to say a few words on the subject of carious teeth. Caries is an affection of the interior or bony structure of the teeth, the enamel being without vitality, and therefore not subject to morbid action. Some have denied to this disease a claim to the title of caries; because nerves and blood-vessels have not been traced in the substance of the teeth, and no process of absorption or granulation, by which the diseased part can be sepa- rated, and its place supplied by new structure, takes place. Thos. Bell, how- ever, maintains that nerves and blood-vessels do exist, the former, because the tooth has a certain degree of sensation, the latter, because a red injection may occasionally be observed in its substance, and a yellowish colour is some- times imparted to it in jaundice. (Bell's notes to Hunter on the Teeth.) There can scarcely be a doubt, that the bony portion of the tooth is organized, and CLASS III.] TOOTHACHE. 541 is therefore subject to morbid action ; and, though this may not present ex- actly the phenomena observed in caries of bones of a higher degree of orga- nization, it approaches somewhat towards it in character. Caries sometimes begins on the internal surface of the tooth, and extends outward, exhibiting usually, as the nrst evidence of its existence, a dark appearance beneath the enamel. (Good's Study of Med.) But, much more frequently, it proceeds from without inward, commencing in the bone imme- diately beneath the enamel, and exhibiting a yellowish or brownish spot in this situation. The tissue is softened, and a small cavity formed, which, after a time, communicates externally by the crumbling of the unsupported enamel over it. The substance of the tooth now decays more rapidly; and the caries, exlnbiting a yellowish, brownish, or blackish colour, gradually approaches the central cavity of the tooth, which is at length opened. The caries is said to advance most rapidly in those cases in which the surface is yellowish. At first there is little or no suffering; but, when the disease has reached the cavity of the tooth, the pulp becomes sensible to heat, cold, and the action of irritant substances, and pain is experienced. At length inflammation takes place, which speedily advances to suppuration, and the pulp is gradu- ally destroyed by ulceration or gangrene. The body of the tooth, deprived of the nourishment which it received from the pulp, decays entirely, leaving only the outer coating of enamel, which then breaks off by degrees, until nothing but the roots are left. These usually, though not always, cease to give pain. In some cases, especially when the surface is black or very dark, the caries advances very slowly, or is altogether arrested. In such cases, the surface is commonly also harder and less friable than in the yellowish caries. This decay of the teeth is not necessarily attended with pain. Occasionally the affection runs through its whole course, with little or no suffering to the individual; and sometimes, after having been painful, it ceases at certain pe- riods of life to be so, though the process of decay may continue. In some instances of caries without toothache, the irritation appears to be felt sympa- thetically in other parts; and painful affections of the head, ears, and eyes, have ceased upon the extraction of a decayed tooth, which had never ached. I have seen violent and obstinate headache yield to the extraction of a tooth which had not been painful; and Dr. I. Hays, of Philadelphia, has described several cases of excessive photophobia which depended on the same cause, and yielded to the same remedy. In these cases, though the tooth may not ache, it will be found painful when pressed upon, or struck smartly. (Trans. of Col. ofPhys. of Philadelphia, ii. 411.) The most frequent cause of caries is probably some condition of the bone acquired during its formation, in consequence of peculiarity of constitution, or the state of health existing at the'time. Thus, persons affected with scro- fula or scurvy, during dentition, are apt to be affected with decay of the teeth in after life. There is reason also to believe that the predisposition is some- times hereditary. Women and young children are more subject to the disease than men. The direct or exciting causes are either such as destroy the in- tegrity of the enamel, and thereby expose the bone to the influence of irritant substances, or such as operate directly upon its vital susceptibilities. Among the former are acids and other corrosive substances taken into the mouth, sour eructations from the stomach, depraved salivary or mucous secretions, the sordes which collect about uncleaned teeth, the contact or near vicinity of a carious surface in another tooth, the attrition of opposing surfaces of the teeth, and all kinds of mechanical violence. Of the latter, the principal are heat and cold suddenly applied, and especially in quick alternation. Hence it is, perhaps, in part, that caries of the teeth is more common in civilized life, where hot drinks are habitually used, than among savages. The very free 542 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. use of sugar, as an article of diet, is thought by many to be a frequent cause of the disease. Some have ascribed its effects to direct action on the teeth; but it is more probable that it operates, if at all, by impairing digestion. Whatever deranges the digestive function may occasion caries indirectly, by giving rise to acrid and corrosive eructations, and by altering the secretions which are poured into the mouth. Nevertheless, sugar is certainly strongly irritant to the dental nerves; as is evinced by the severe toothache so often occasioned by its contact with a carious surface. When the caries is slight, and especially when it occupies the sides of the teeth, it may often be arrested by removing the diseased portion with the file; and the same end may be attained by filling the cavity with some metallic substance, such as lead, tin foil, or gold leaf, so as to exclude the air and all irritant bodies. Plugging may be resorted to in all cases when the tooth has not begun to ache, or when it has ached but moderately and for a short time. Having premised these remarks respecting caries of the teeth, we are prepared to enter upon the consideration of inflammatory toothache. It is proper previously to state that, in carious teeth, and in those deprived of their enamel without being absolutely carious, pain may be produced by the contact of irritant bodies without the existence of inflammation. But the action thus excited, when not purely neuralgic, is an irritation which is the first step towards inflammation, and will inevitably lead to it if continued. The inflammation which occasions toothache may be seated in the pulp of the tooth, in the cord which enters its lower extremity, or in the periosteum investing its roots, and reflected over the interior of the alveolar cavity. Sometimes this inflammation terminates in resolution, without producing any swelling of the gum; and, in such cases, especially when the tooth itself is sound, the diagnosis is not easy between the inflammatory and neuralgic toothache. But the former is usually confined to one tooth, while the latter generally extends to several. Besides, the pain in the inflammatory variety is less sharp, less irregular, and less disposed to the paroxysmal form. Most commonly, however, after the pain has continued a short time, some external swelling appears. At first the pain is usually moderate, and it may con- tinue thus throughout; but generally it increases, and at length becomes intense, in consequence probably of the pressure to which the swollen and inflamed parts are subjected by the unyielding bone around them. The tooth is at the same time very tender; and any force applied to it greatly increases the pain. The inflammation is propagated by contiguous sympathy to the gum and other parts of the face, which become much swollen; and the swelling sometimes extends to the salivary and absorbent glands, and even to the tonsils. The violence of the pain often abates somewhat upon the occurrence of this external inflammation, which appears to act as a re- vulsive. The tumefaction not unfrequently subsides without the occurrence of suppuration, and the toothache ceases for a time. Very frequently, how- ever, an abscess forms either in the gum, upon the upper or lower jaw, in the roof of the mouth, or, more rarely, in the substance of the cheek. There is often much constitutional disturbance, with fever, headache, and inability to sleep. The pain, during the suppurative stage, is usually pulsative or throbbing. The abscess at length opens and relief is obtained. The dura- tion of an attack of this kind is usually six or seven days, though sometimes much longer. When the abscess is seated in the palate, it is generally of slower progress, and sometimes continues for weeks or months without open- ing ; but in the latter case the pain is not acute. The patient, though re- lieved for a time, is liable to constant returns of the affection' in cases of carious teeth, until these are wholly destroyed in the course of the disease or are artificially removed. CLASS III.] TOOTHACHE. 543 Suppuration also takes place in the pulp or dental cord. If an opening exist into the central cavity of the tooth, the pus may be discharged by this route; but, if there be no such outlet, the matter accumulating occasions inflammation and absorption of the socket, and thus makes itself a way out, either between the tooth and the gum, or directly through the latter, forming an abscess in its substance. When this opens, the pain is relieved; but the opening is apt to become fistulous, and a continual purulent discharge to be maintained until the tooth is wholly removed. There is some distinction between the symptoms of the inflammation seated in the different parts above referred to. When it is in the pulp alone, the tooth is painful upon percussion, but suffers less when pressed against the opposite tooth, as in the closing of the jaws. The pain is often exceedingly severe, and is increased by hot and cold liquids taken into the mouth. Some- times, in these cases, a fungous growth projects through the carious cavity. This, if inconvenient, may be removed by excision or by caustic. _ When the inflammation occupies the cord, the pain is seated deep in the jaws, and is much increased by closing the teeth firmly. It may be dull or acute; but is less excruciating than that of the pulp, and is not equally affected by hot and cold liquids. When the tooth is extracted in these cases, pus is often dis- covered about the extremity of the root, and is sometimes collected in a small pouch. If the upper molar teeth are affected, the inflammation sometimes extends to the antrum, producing very serious results. When the periosteum of the root is the seat of inflammation, the pain is deep in the jaws, and the tooth feels elevated above its usual level, and is often somewhat loose. Closing the teeth is here also very painful. Rheumatic inflammation is apt to attack this part. The most frequent cause of these inflammatory affections is the exposure of the pulp, consequent upon caries, or other destruction of the tooth. They may result also from vicissitudes of temperature, retrocession of cutaneous eruptions the suppression of accustomed discharges, the translation of rheu- matic or gouty inflammation from other parts, the pressure of osseous con- cretions in the cavity of the tooth, and from direct violence. _ Treatment.— Little general treatment is requisite. Saline cathartics, and abstinence from animal food may be recommended when the inflammation affects the neighbouring parts; and an opiate at night is generally advisable when the pain is severe. The loss of blood may become necessary if there should be strong determination to the brain. Much may be done locally to afford relief, and hasten the cure. The means are sedative, anodyne, and revulsive applications, and depletory measures, either within the mouth or externally. Among these remedies are brandy, or tincture of camphor, held in the mouth; the chewing or smoking of tobacco ; various masticatories, such as ginger, calamus, pelhtory, &c.; poultices to the face either simply emollient, or rendered anodyne by the admixture of lauda- num hops, &c.; anodyne lotions, as tincture of camphor with laudanum ; rube- facient applications, as capsicum, ginger, and mustard m the form of cataplasm; blisters to the side or back of the neck, or behind the ears; steaming the face and head with the vapours of hot water; scarification of the gums; and, finally, leeches outside of the face or to the gums when the inflammation is considerable, and it is deemed highly desirable to bring about resolution. In most cases, the milder of these means are sufficient; as the disease is gene- rally soon relieved by suppuration, and the discharge of the pus After the ab- scess has formed, it should be opened if it do not speedily discharge itself; and if it occupy the substance of the cheek, care should be taken to make an early opening inwardly, lest it might break externally and leave an un- sightly scar. 544 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. When caries exists, in addition to the means just mentioned, applications may be made to the cavity of the tooth itself. These are usually such as relieve pain by their anodyne, or obtund sensibility by their excessively irri- tant action. They consist chiefly of laudanum or opium, in reference to the former effect; and of certain volatile oils, as those of cinnamon, cloves, and cajeput, in reference to the latter; all of which should be introduced on cot- ton. The most efficient of these applications, in the experience of the au- thor, is creasote. Put undiluted into the carious cavity, this substance not only relieves, but also for a time often effectually cures toothache. It pro- bably acts both by obtunding the sensibility of the pulp, and by coagulating any albuminous matter which may be present, and thus forming a barrier against the external air. A solution of copal in chloroform has been strongly recommended. The chloroform relieves the pain, and the copal, by its adhe- siveness, retains the cotton in the cavity, and protects it from the air. (Journ. de Pharm. et de Chim., xiv. 125.) Collodion has been applied to the in- terior of the cavity, with the view of protecting the part from the air and from irritating substances, with great asserted advantage. Strong astrin- gents, such as galls and catechu, are sometimes used; but they answer better as preventives than cures, and are not unfrequently employed to prepare the carious tooth for plugging. If opium is used, care should be taken that the quantity be not so great as to do serious injury if swallowed. Attempts are sometimes made to effect a permanent cure of toothache by destroying the nerve by means of a heated wire, or removing it by means of suitable instru- ments ; but, though sometimes successful, they often fail in unskilful hands, and are not generally advisable When there is reason to believe that the pulp is inflamed, in consequence of caries or from other cause, the practice, sug- gested by Dr. Hullihen, of Wheeling, has been adopted by several American dentists, with great asserted benefit, of drilling a hole into the cavity of the pulp; thus allowing any pus which may have been produced to escape, and aiding the recuperative efforts of the pulp by removing pressure. (See a pa- per by Dr. John Trevor, in the New York Med. Gaz., iv. 104.) When a tooth frequently becomes painful, and is too far gone to be saved, especially if the general health suffer, it should be extracted. In cases of dental fistula?, it is generally advisable to remove the tooth, or such part of it as re- mains. The first teeth in children may be freely extracted, when carious and painful, as they are followed by others. But, in deciding as to the propriety of extraction, it should always be borne in mind that, when the permanent teeth are removed, the alveolar processes of the jaws are absorbed, and the cheeks or lips fall in, producing an appearance of old age Besides, a cari- ous tooth is often useful in mastication, in the intervals of pain. Another consideration is, that the occurrence of caries of the teeth sometimes appears to act as a derivative from the lungs, and to afford relief in pulmonary com- plaints. In such cases the teeth should be allowed to remain. As a means of preserving the teeth, they should be thoroughly cleansed, and not only in the morning, but after each meal. Dr. Bowditch, of Boston, has found that, in healthy states of the mouth, animal and vegetable parasites rapidly form between the teeth, and at their roots, probably from the presence of impurities; and it is not improbable that they may contribute to produce disease in these parts. (Am. Journ. of Med. Sci, N. S. xix. 364.) 3. Rheumatic and Gouty Toothache.—This is either neuralgic or in- flammatory, and might have come, accordingly, under one or the other of the two preceding heads. But there is something peculiar in its character, which often serves to distinguish it from toothache of a different origin, and demands a somewhat peculiar treatment. It may, in general, be recognized by its oc- currence in individuals of a rheumatic or gouty predisposition, by the simul- CLASS III.] FALLING OF THE TEETH. 545 taneous or immediately antecedent existence of these diseases in other parts of the body, by its extension for the most part through several teeth or even the whole jaw, and by the fact, that it is seldom or never attended with suppura- tion. The pain is, in the inflammatory variety, rather dull than acute. It is apt to be induced by vicissitudes in the weather. It may occur either in carious or sound teeth. In most cases, it-is probably seated in the perios- teum about the root, in the lining of the alveolar cavity, or on the external surface of the jaw, rather than in the pulp, or the dental cord. In addition to the local measures enumerated, the constitutional treatment applicable to other forms of rheumatism or gout may be employed; and efforts may be made by stimulating pediluvia to invite the disease to the lower extremities. 4. Toothache from Exostosis.—As a consequence of inflammation, or from some other cause, the periosteum about the root of the teeth sometimes becomes ossified, and a bony deposition takes place so closely connected with the root, as to have been taken for exostosis. It is possible that a proper exostosis of the fang may also occur; but the affection, as ordinarily observed, has its seat originally in the periosteum. The tumour has been known to acquire considerable size and to occasion great inconvenience. The pain is at first slight, but becomes severe in the advanced stage, in consequence of pressure upon the sensitive parts. There are no means of distinguishing this, with certainty, from other forms of toothache; but it may be suspected when the pain is constant, and not materially increased by closing the teeth or by striking them, and when no external inflammation is observable. It is said to occur most frequently in persons of a rheumatic or gouty habit. In the advanced stage there is no other remedy than extraction. According to Dr. Good, it may be cured in the early stage by leeches and mercurial ointment; though it must be confessed that the obscurity of the diagnosis throws some doubt over the accuracy of this statement. It is due to M. J. E. Oudet, to state that many of the facts detailed in this article are derived from his elaborate essay on the teeth, contained in the Dictionnaire de Medecine. Article V FALLING OF THE TEETH. The absorption of the socket, and consequent loss of the teeth, which are apt to occur in advanced life, are to be regarded rather as a physiological than a morbid process. But, in consequence of certain diseases affecting the alveoli and gums, the teeth occasionally fall out prematurely, although not themselves apparently diseased. This happens in scurvy, in canker and gan- grene of the mouth, and occasionally as a consequence of mercurial inflam- mation of the gums. In carious teeth, after the loss of the body by the advance of the disease, the roots are sometimes cast off through the ulcera- tion and absorption of the alveoli, occasioned by their irritative influence. These affections, however, have already been, or will hereafter be noticed. The object, in this section, is to call attention to two morbid conditions, which lead to the same result, and are not elsewhere described in this work. In one of these affections, the gums swell and assume a deep-red colour, and the inflammation appears to be propagated into the alveoli, producing a thickening of the periosteum, and a consequent elevation of the tooth above its ordinary level. This condition is relieved after a short time, but again recurs; and, by its frequent returns, the tooth is lifted out of the socket, while vol. i. 35 546 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. the gum retreats from the neck, leaving portions of the roots exposed. The bony alveoli, thus in a certain degree unoccupied, appear to undergo absorp- tion ; and the tooth, deprived of its support, and separated by the ulceratfon of the gum from its soft connections, at length falls. The gum then heals, and the patient, who has usually suffered considerably during the progress of the affection, is restored to comfort. The disease commonly attacks a few teeth at once, commencing sometimes with the incisors, sometimes with the molars, and, though it occasionally produces only a partial loss of the teeth, in other cases does not cease until it has destroyed the whole. It seldom occurs before the thirtieth year. It appears, in some instances, to result from long-continued mental trouble, and is said especially to affect women during pregnancy, and about the period of the cessation of the menses. Its causes, however, are not well known. The remedies indicated are those calculated to relieve inflammation of the gums ; but they generally fail. The other affection has been named by Jourdain, conjoint suppuration of the gums and sockets. It usually comes on insidiously, showing itself at first only by a slight oozing of purulent matter from behind the edges of the gums, when they are pressed. Sometimes, however, the gums are swollen and soft, disposed to bleed, and somewhat painful before suppuration; and, in a few instances, a real phlegmonous abscess in the gum is the commencement of the disease. The periosteum of the fang and of the socket after a time takes on the suppurative process, and matter escapes freely between the gums and teeth. The portion anterior to the tooth is generally first affected, but the whole socket is ultimately involved. The gums, at first of their natural colour, now become deep-red, and the teeth loose and painful. The bony socket is absorbed, first anteriorly and then behind ; and the gums come into contact with the roots. This excites additional inflammation, and the ulcera- tive process at length separates the gum from the teeth, which then fall out, if not previously removed by the dentist or surgeon. After the loss of the teeth, the gums heal without difficulty. This complaint, as a general rule, attacks the incisors first. It occurs usually between the ages of thirty-five and fifty, more frequently in women than in men, and especially about the period of the cessation of the menses. Oudet thinks he has observed that those females who have not suckled their children are more subject to it than others. Among the causes of it enumerated by that author are residence in low and damp places, the action of mercury, the presence of tartar about the teeth, depressing emotions, suppression of hemorrhoidal discharges, retroces- sion of cutaneous eruptions, and certain disorders affecting the system, such as scrofula and syphilis. It appears also to be sometimes hereditary. M. Oudet considers the purulent discharge in this affection as in some instances salutary, by preventing or suspending serious diseases. I once attended a female with tuberculous consumption, who was several years labouring under such an affection of the gums, and in whom the symptoms of phthisis were not developed until this affection ceased, in consequence of the loss of all her teeth. The circumstance that the loss of the teeth is uniformly followed by the healing of the gums has led to the idea, that the complaint may be occa- sioned by the presence of teeth previously deprived of their vitality; but there is no sufficient proof of this fact, at least there is strong reason to be- lieve that the disease has its origin, sometimes at least, in constitutional causes. The prospect of a cure is slight. In the early stages, it is possible that the application of nitrate of silver, or other caustic substance, to the whole diseased surface of the gum, might prove serviceable. M. Bourdet advises the actual cautery, applied by means of a flat and delicate instrument inserted between the gum and tooth, to the depth of the destruction of the socket. If this application, repeated once or twice, should fail, he advises CLASS III.] INFLAMMATION OF THE FAUCES. 547 the removal by the scissors of all that portion of gum which has been deprived of the bone which it covered. The most effectual mode of affording relief is to extract the teeth as they become loose. During the local treatment attention should be paid to the general health ; and, where any tendency to pulmonary disease may be suspected, it may be advisable to attempt its pre- vention by the establishment of an issue. Might not cod-liver oil and iodide of potassium prove useful in these cases, if employed in the earliest stage ? SUBSECTION II. DISEASES OF THE FAUCES, PHARYNX, AND CESOrHAGUS. Article I INFLAMMATION OF THE FAUCES, or ANGINA. Under the name of fauces, are included the velum pendulum, the half arches, the uvula, the tonsils, and the upper part of the pharynx; in other words, all those parts, behind the mouth, which become visible when the jaws are widely opened, and the tongue depressed. These parts maybe attacked, like the mouth, by thrush and aphthae, which, however, present nothing pe- culiar in this situation, and have been already fully considered. Nor shall I treat here of those forms of inflammation of the fauces which occur as attend- ants upon other diseases, such as scarlatina, smallpox, and syphilis. The va- rieties of inflammation now to be considered may be embraced under the heads of 1. the common, 2. the pseudo-membranous, 3. the ulcerative, and 4. the gangrenous or malignant, all affecting the mucous membrane. Inflamma- tion of the tonsils will be separately treated. 1. Common Inflammation of the Fauces.—Sore-throat.—Simple Angi- na.—Angina Simplex.—The first evidence of the complaint is usually some pain in swallowing. The fauces, if examined, are found to be of a bright- red colour, and occasionally somewhat swollen, and, in the advanced stages, often exhibit small whitish patches, especially on the surface of the tonsils, consisting probably of coagulable lymph, effused by the inflamed follicles. The redness may occupy one or both sides of the throat, the velum, or the pharynx, or may be diffused over the whole. The patient has a feeling of heat and dryness in the throat, with constant soreness, which becomes acute pain when he attempts to swallow. The pain is in general greatest in the morning, in consequence partly of the position of the head favouring the ac- cess of the blood, partly of the dryness resulting from the mouth being kept open during sleep. Drinks occasionally regurgitate through the nostrils. The voice is sometimes nasal, but more frequently hoarse, in consequence of the extension of irritation to the glottis. A viscid mucus is after a time se- creted, which leads to frequent efforts to clear the fauces, and, when dis- charged, is sometimes mingled with blood. In some cases, the secretion of mucus is abundant, and these are usually attended with less redness and pain. They are considered by some as constituting a distinct variety of the com- plaint, and called catarrhal inflammation. They are apt to occur in persons of feeble constitution, with impoverished blood. The uvula is sometimes much swollen and elongated, in consequence of effusion into its tissue. In this case, there is added to the other symptoms a frequent disposition to swallow, and to clear the glottis by coughing, or by expelling the air through the nostrils, and sometimes vomiting is produced. 548 LOCAL DISEASES.---DIGESTIVE SYSTEM. [PART II. The disease often runs its course without producing fever; but frequently also the constitution sympathizes, and the febrile movement, with chilliness, heat, frequent pulse, headache, and loss of appetite, occurs. The fever is usually of the sthenic character; but sometimes is typhoid, and, in certain cases, is attended with an exceedingly frequent pulse like that of scarlatina. In these cases, the colour of the inflamed membrane is usually deeper than ordinary; and the flushed appearance of the face and neck marks a still closer analogy with scarlet fever. Dr. R. B. Todd, of London, describes a variety of angina, which he con- siders erysipelatous. (See page 443.) The inflammation, in ordinary cases, runs on for several days, and then gradually declines, terminating almost always in resolution. In some rare cases, suppuration takes place in the substance of the uvula or soft palate, and gangrene may occur in persons of debilitated and unhealthy constitu- tion. The tonsils sometimes inflame, and the external parts participate in the disease; the jaws becoming stiff and painful, and the absorbent glands swelling. The most unpleasant ordinary result, however, is the travelling of the inflammation downward into the larynx, and even into the lungs; and, in some persons, severe bronchitis is very apt to follow an attack of simple angina, if not early arrested. Not unfrequently the eustachian tube partici- pates in the inflammation, and partial deafness results from its closure. This may be ascertained by causing the patient to close firmly the mouth and nos- trils, and then endeavour to expire forcibly, or, as suggested by Mr. Toynbee, simply to perform the act of deglutition. If the tube is open, the air will readily enter the tympanum, otherwise not at all, or with difficulty. Another method, suggested by Prof. Richter, is to auscult over the ear with the car- tilaginous portion pressed down so as to cover the external meatus. If the tube is open, the sound of the breath and voice is heard, otherwise not. (See Am. Journ. of Med. Sci, N. S., xxv. 223.) Chronic Angina.—Inflammation of the fauces often becomes chronic, in which case there is a constant feeling of heat and uneasiness with some red- ness of the parts, which, with alternations of remission and exacerbation, may continue for many months. In such cases, the membrane sometimes appears irregularly thickened, or exhibits here and there small eminences produced by the enlarged mucous glandules, particularly observable on the soft palate and the pharynx. These granulations are often covered with a matter resembling the white of eggs, or a muco-purulent secretion. They are sometimes so numerous in the pharynx as to give its surface a mammillated appearance, and occasionally are associated in long prominences, or ridges, like pillars lying upon the membrane. The name of granular or follicular angina has been adopted by some writers for this variety. Ulcers also sometimes form, either superficial, affecting only the surface of the membrane, and then disposed to spread irregularly so as to occupy large portions of the fauces, or deeper seated, penetrating through the membrane, and even into the structure beneath it, and in rare instances, producing considerable loss of substance. In such cases, however, the result is in general attributable either to a debilitated state of system, or to some vice of constitution, such as a scrofulous or scorbutic tendency, or a syphilitic contamination. The affec- tion is often attended with an habitual hawking, in order to clear the fauces or to get rid of the uneasy sensation as of something present in the throat, which may be delusive. A dry laryngeal cough is not uncommon, arising from the extension of the irritation to the glottis. In some persons, the dis- ease ceases entirely for a time, and again recurs from the slightest cause, proving exceedingly inconvenient by its disposition to extend into the throat or chest. Sometimes it extends into the eustachian tube, as in the acute form causing hardness of hearing. CLASS III.] INFLAMMATION OF THE FAUCES. 549 One ofthe consequences of repeated or long-continued inflammation of the fauces is a chronic enlargement of the uvula, which proves very inconvenient by the irritation it produces about the root of the tongue and the glottis. Long-continued and serious coughs have arisen from this cause, or been sus- tained by it. The irritation may even extend to the cerebral centres; and M. West, of Belgium, has recorded a case of long-continued and harassing nightmare, which was completely relieved by the amputation of a much elon- gated uvula. (See Am. Journ. of Med. Sci, N. S. xxi. 222.) Causes.—The most frequent cause of this complaint is exposure to cold and moisture; and it is, therefore, most apt to occur in the cool damp weather of the spring and autumn. In some persons, the slightest partial application of cold to any part of the body, when they are warm or perspiring, is sufficient to produce it. There is reason to believe that it may arise from the reaction which follows the direct effect of very cold air upon the fauces. Irritating or corrosive substances swallowed, and acrid eructations from the stomach, also occasion it. The inflammation appears sometimes to be of the nature of rheumatism or gout, as it alternates with these affections elsewhere. It is often sustained, especially in its chronic forms, by disorder of the stomach, irri- tation being propagated by sympathy from that organ, or kept up by acrid eructations. Hence, in these forms, it is very common among professional men of sedentary habits. The tuberculous or scrofulous diathesis sometimes probably contributes to give obstinacy to the disease. The acute disease occurs at all periods of life, but is most frequent with the young. Treatment.—If taken at the commencement, this complaint may usually be cut short by a dose or two of sulphate of magnesia, or other saline cathar- tic, abstinence from animal food, and the use of a gargle made by dissolving alum in water in the proportion of 15 or 20 grains to the fluidounce, and em- ployed twice daily. For persons in whom the disease is apt to end in laryn- gitis or bronchitis, it is highly important to obtain this result. At a more advanced period, or in severe cases, this treatment will not al- ways succeed, and alum appears sometimes to aggravate the inflammation. In such cases, it may be advisable, if fever and headache exist with a strong pulse, to take blood from the arm. An active saline cathartic every clay or every other day, with the use of refrigerating diaphoretics, as the neutral mixture and tartar emetic, may also be usefully employed. Emetics have been recommended; but, though occasionally beneficial, they are unnecessa- rily violent, and are not often used. The diet should be strictly vegetable; and liquids or soft substances, as mush, are preferable to solid food. Should the general powers of the system be very feeble, and the attendant fever of a typhoid character, which, however, is a very rare event, the depletory treat- ment should be very moderately employed, or altogether avoided; and it might even become necessary to resort to stimulation. When the disease is associated with acidity of the stomach, small doses of magnesia frequently repeated will be found useful; and I have known a purgative dose of calo- mel effectual in cases complicated with hepatic derangement. Externally, rubefacients, such as the liniment of ammonia, the tincture of Cayenne pepper, oil of turpentine, or sinapisms may be employed; the neck being guarded against the cold by a piece of flannel around it. Leeches, however, applied beneath the ears or under the jaw, will be found the most effectual external remedy; but, when there is much fever, they should be preceded by venesection. In obstinate cases, blisters on the sides or back of the neck may be resorted to; but they are seldom necessary. The most appropriate applications to the inflamed parts are mucilaginous, or very mild astringent gargles. Infusion of flaxseed, slippery elm, or sassa- fras pith, and decoction of marsh-mallow are, perhaps, the best. Sage tea, 550 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. infusion of galls, decoction of oak bark or pomegranate rind, and solution of acetate of lead in the proportion of two grains to the fluidounce, or of alum with five grains to the fluidounce, may also be employed, and may prove use- ful by facilitating the discharge ofthe viscid mucus, and even diminishing the inflammation. If, however, they increase the discomfort of the patient, they should be omitted. Very frequent gargling should be avoided as productive of too much movement in the inflamed parts. A strong solution of nitrate of silver, and powdered alum applied directly to the part by blowing through a tube, will often effect speedy cures; but they are seldom necessary. It is advisable that the patient should speak little, should resist the dispo- sition to frequent hawking and swallowing, and should keep the head as much as he conveniently can in an erect position. For the mode of treating the erysipelatous cases described by Dr. Todd, the reader is referred to the article on erysipelas, page 454. In the chronic disease, astringent and caustic applications to the inflamed membrane are among the most effectual remedies. Should weak solutions of acetate of lead, sulphate of zinc, alum, and nitrate of silver, employed as gar- gles, fail, very strong solutions ofthe same salts maybe applied by means of a camel's-hair pencil, or of a stick having a piece of sponge attached to it, or a narrow strip of old linen wrapped several times round one end of the stick, with its edge projecting. Of these salts the most effectual is the nitrate of silver, which may be used even in the solid state in very obstinate cases; great care being taken that none of the caustic breaks off, and escapes into the stomach, or lodges in the throat. The mineral acids, more or less diluted, have been recommended for the same purpose. Dr. A. P. Merrill, of Memphis, employs with great advantage a liquid consisting of a drachm of iodide of potassium, half a drachm of iodine, half an ounce of syrup, and an ounce of water, which he applies by means of a large camel's-hair pencil. (N. 0. Med. and Surg. Journ., ix. 151.) Glycerin, used in the same way, is sometimes bene- ficial by lubricating the membrane, and protecting it against irritating influ- ences. This direct method of local application must be used in all cases when the pharynx is affected. At the same time, external irritation may be kept up by blisters, or pustulation with croton oil or tartar emetic. But all local measures sometimes fail, unless assisted by remedies addressed to the system Disorder of the stomach should be corrected by antacids, tonics, a properly regulated diet, or other appropriate means. A small dose of magnesia daily is often very useful. Constipation or diarrhoea should be obviated, hepatic derangement corrected by alterative doses of mercurial pill or calomel, and, in general, all such measures adopted as may be necessary to restore and sustain health. Sulphurous baths are supposed sometimes to prove advan- tageous by modifying the constitutional diathesis which gives obstinacy to the affection. When there is reason to suspect a gouty taint, wine of colchi- cum may be employed with the other remedies. A long journey or voyage, and residence for a short time in a foreign climate, are often found effectual. The chronic form of the disease is not unfrequently a source of great trouble, especially when associated with a similar affection of the larynx; and the physician is urgently pressed to afford relief. When other means fail, mercury may be employed with reasonable hope of benefit. In scrofulous cases, re- course may be had to cod-liver oil, or the preparations of iodine. In the relaxed and edematous condition of the uvula which follows acute inflammation, or attends the chronic form of it, the astringent gargles above mentioned may be used, or stimulant substances, as powdered pepper, gino-er, or tincture of capsicum, applied directly to the part. A piece of catechu kept constantly in the mouth, and allowed slowly to dissolve, is also highly useful. When the uvula is hypertrophied, and resists measures for reducing its size, it should be amputated, if productive of any unpleasant effects. CLASS III.] INFLAMMATION OF THE FAUCES. 551 2. Pseudo-membranous Inflammation of the Fauces.—Membranous Angina.—Angina membranacea.—Diphtheritis.—This is characterized by the exudation of fibrinous matter, in the form of pellicle, upon the surface of the membrane, underneath the epithelium. Its precise nature was first satis- factorily shown by Bretonneau, from whom it received the name diphtheritis, derived from the Greek dupOepa, skin or hide. Symptoms.—The disease commences with some redness of the fauces and uneasiness, such as occur in ordinary sore-throat, but usually in a less degree. This condition lasts but a very short time, before the exudation commeuces ; and, when first seen by the physician, the surface almost always exhibits small, irregularly circumscribed, whitish, yellowish-wdiite, or ash-coloured patches, sometimes seated in a portion only of the fauces, sometimes scattered here and there over almost their whole extent. These patches bear no incon- siderable resemblance to superficial sloughs, or to the surface of ulcers, for both of which they have not unfrequently been mistaken; but it has been shown, by the most careful microscopic observations, that they consist of a concrete exudation similar to false membrane, and that the surface of the membrane beneath them has not necessarily undergone any loss of substance, unless of the epithelium. Sometimes, however, ulceration is found to have taken place beneath them. In some instances the patches are translucent. Their consistence is various, occasionally pultaceous, but more frequently somewhat dense and even tough. The membrane around them is inflamed and reddened, and the tonsils are usually more or less swollen, as are fre- quently also the cervical and submaxillary glands, and sometimes even the parotids. Examined by the microscope, they have been found to consist mainly of interlacing fibrils, with molecular granules, epithelial cells in dif- ferent stages, and often pus or blood corpuscles. In mild cases, such as often occur sporadically, the patches are few, more regularly circumscribed than in the severer forms, and not disposed to spread; while there is little tumefaction either of the tonsils or the external parts, and little or no fever. They are apt, however, to be attended with much pain in swallowing. In the severer cases, the patches spread with greater or less rapidity, sometimes in the course of a few hours coalescing and covering the whole fauces, but more frequently advancing rather slowly, and leaving portions of the membrane uncovered. There is commonly more of the exuda- tion on one side than on the other; and on that where it is more abundant, the swelling of the tonsils and external parts is greatest. The deglutition now becomes more difficult, and liquids often return by the nostrils in attempts to swallow. The patches, soon after they are completely formed, begin to be removed, sometimes separating in strips, sometimes softening and mixing with the fluids ofthe mouth, and in a few cases disappearing by absorption. They are often renewed, occasionally several times, each time becoming whiter and thinner, till at length they leave the surface covered with a puriform mucus. The process of separation usually lasts eight or ten days. (Guersent.) During its progress, it is attended with the discharge of some blood, and copious vitiated secretions, which occasion much hawking and spitting, and have a very offensive odour. There is often also a flow of extremely fetid sanies from the nostrils, indicating the extension of the disease to the nasal passages. The odour of the discharges in these cases has tended to confirm the erroneous idea, that the disease is essentially gangrenous. In the course of the complaint, the disposition to exudation often travels downwards, and the larynx, trachea, and even bronchia, become lined with false membrane, which obstructs respiration, and often leads to fatal results. This extension of the disease constitutes, indeed, its chief danger. It may come on at any period from the first appearance of the patches to the seventh or eighth day 532 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART IT. (Guersent), and is indicated by those changes in the voice and respiration which characterize pseudo-membranous croup. A distinguishing character of this diphtheritic affection, showing that it is connected with the state of the system at large, or of the blood, is that it is disposed to appear on most other surfaces which may be excoriated or suppurating. (Arch. Gen., 4e ser., xxii. 281.) The mucous membranes to which the air has access, and the skin, are peculiarly liable to be affected; but the mucous lining of the stomach and bowels is remarkably exempt. (Ibid, Mars, 1857, p. 327.) When the local affection is considerable, the system is brought into sym- pathy, and fever is developed. The stomach is sometimes irritable, and the bowels, though at first generally disposed to constipation, are apt, towards the close of the disease, to be affected with a fetid diarrhoea. Both of these results are ascribable to the acrimony of the liquid secreted in the fauces, more or less of which is swallowed. In good constitutions, the fever is usually sthenic ; but sometimes, especially when the disease prevails epidemically, it has a typhoid or malignant character ; and this condition of the system reacts on the local affection. In the former case, the inflamed membrane is bright- red, the patches white and of a firm consistence, and the pulse full and strong. In the latter, the membrane, when visible, is purplish or livid, and the exu- dation yellowish or ash-coloured, or darkened by the bloody liquid effused, and often of a soft pultaceous consistence. The discharges from the mouth and nostrils are excessively acrid and offensive, and often mixed with dark blood, which oozes from the fauces, and even from the gums and lips. Occa- sionally obstinate hemorrhage from the nostrils takes place. The pulse is rapid and feeble; the delirium of the early stages is succeeded by coma; and the whole system is in a state of great prostration. Between the two condi- tions here presented there are various grades, in which their characteristic symptoms are more or less mingled or modified. In the malignant cases, the system is probably under some poisonous influence superadded to that of the local affection. Such cases are happily rare. The diphtheritic exudation differs decidedly from that of thrush, and in some points also from that which accompanies scarlet fever. In the thrush, the white coating appears first in separate points which afterwards coalesce; is formed upon the surface of the epidermis, or at least not beneath it; may be readily removed without affecting the integrity of the mucous membrane, or causing the least hemorrhage, and, when examined under the microscope, is found to contain abundantly a peculiar fungous plant. The diphtheritic exu- dation forms in patches, beneath the epidermis; adheres strongly to the mem- brane, so that it can rarely be detached without causing the extravasation of some blood; and under the microscope exhibits the ordinary constituents of false membrane ; namely, interlacing fibrils, molecules or granules, and exu- dation or pus corpuscles. The exudation in scarlatina occurs generally first in points like the thrush, is much less cohesive than the diphtheritic, less adherent to the mucous membrane, much less disposed to spread into the larynx, and also less disposed to make its appearance upon surfaces else- where that maybe excoriated. (Empis, Arch. Gen., ie ser., xxii. 284.) The duration of the disease, when severe, is usually two or three weeks or more. Except in its malignant form, or when it occurs in constitutions pre- viously much enfeebled, or assumes the character of pseudo-membranous croup, the prognosis is favourable. Causes.—The causes of ordinary angina will give rise to the pseudo-mem- branous variety in those predisposed to it. What constitutes this predisposi- tion, however, is not known, although it is probably ascribable to a peculiar state of the blood. The disease is said to be most prevalent in moist seasons and countries, in temperate latitudes. It prevails sometimes epidemically CLASS. III.] INFLAMMATION OF THE FAUCES. 553 though confined within comparatively narrow limits. It occasionally attacks a single household, as a boarding-school, for example, without extending to others in the same vicinity; and, when prevalent in any particular place, it is apt to select certain families, of which several individuals suffer, while most of the neighbouring families escape entirely. This result has been ascribed to contagion ; but, as several persons in a family are often seized about the same time, it may with greater propriety be referred to similarity of constitution and of exposure. Nevertheless, there can be little doubt that the disease is occasionally contagious, especially in its epidemic and malig- nant form. From its resemblance to the malignant sore-throat of Fothergill, Huxham, and others, with which it is by some writers maintained to be iden- tical, and from the simultaneous occurrence of both these affections with epidemic scarlatina, and the close analogy of their local symptoms with the throat affection of that disease, the inference is not without plausibility, that they may all be produced by the same cause, in those cases in which they have an epidemic or contagious character. The disease occurs at all times of life, but is most common in infancy and early childhood, and is very rare in old age. Diagnosis.—Besides thrush and the sore-throat of scarlatina, the only com- plaints with which this can be confounded are common angina, ulcerated and gangrenous or malignant sore-throat, and pseudo-membranous croup. From the first of these it is readily distinguishable by the exudation in the fauces. It is usually without the excavated surface of the ulcerated variety, and the proper gangrenous sloughs of the malignant; though both of these conditions may sometimes be presented after the false membrane has been thrown off; and there is occasionally a mixture of these affections in the same case. It is only in those instances in which the exudation extends into the larynx, that this complaint can be confounded with proper pseudo-membranous croup. The latter affection, however, differs by commencing in the larynx, and in seldom or never being associated with those typhoid or malignant symptoms which are occasionally present in the former. Treatment.—In the mildest cases, little general treatment is required. The patient may take a dose of sulphate of magnesia, or some other saline cathartic, and should strictly avoid animal food. In somewhat severer cases, with moderate fever, the cathartic may be repeated, and antimonials and the neutral mixture administered at short intervals. When the pulse is full and strong, blood should be taken freely from the arm, especially in adults; but venesection does not exercise the same controlling influence over this, as over the common inflammation ; at least, it does not obviate the tendency to the plastic effusion; and, in some instances, in consequence of the feebleness of system, is not well borne. It is generally quite inapplicable to those cases which occur epidemically, or in which a dark hue or fetid odour of the ex- udation, indicates a depraved state of the blood. When the symptoms are threatening, either from the general condition of system, or the disposition in the local disease to enter the respiratory passages, calomel should be re- sorted to. Under these circumstances, no general means of cure is so ef- fectual as the establishment of the mercurial influence. If the patches should have reached the glottis, or be extended towards it, a full purgative dose of calomel should be given, and the medicine afterwards continued in doses of from half a grain to two grains, every hour or two, until the mouth is affected, or the disease relieved. Even young children, under these circumstances, bear calomel well in the quantity mentioned. Should it irritate the stomach and bowels very much, the dose may be diminished, or the mercurial pill, and frictions with mercurial ointment substituted. Emetics have been recom- mended; but they scarcely modify the peculiar character of the affection; 554 LOCAL DISEASES.--DIGESTIVE SYSTEM. [PART II. and are only sometimes useful, in the advanced stages, by promoting the ex- pulsion of the false membrane from the larynx. Bromine and bromide of potassium have been recently strongly recommended as having a specific curative influence over pseudo-membranous affections. (Bost. Med. and Surg. Journ,, lv. 236.) A similar influence is claimed for chlorate of potassa very freely given. (Ibid., Ivi. 489.) Should the symptoms be malignant, with great depression, Peruvian bark or quinia, wine-whey, carbonate of ammo- nia, and animal broths may be required. The exterior local treatment is not very important. Leeches may be used, as an adjuvant to the lancet, or as a substitute for it in doubtful cases ; and recourse may be had to rubefacients and blisters, as mentioned under the head of common inflammation of the fauces. By far the most important remedies are those addressed immediately to the part affected. By these the peculiar character of the inflammation, upon which its danger chiefly depends, may be changed; and, if the disease has not already reached the larynx, its progress may be arrested. In the slighter forms, a solution of sulphate of zinc containing fifteen or twenty grains of the salt in a fluidounce, applied daily or twice a day to the pseudo-membranous patches, will be found sufficient. When a stronger impression is required, caustic substances must be employed. Of these the best is nitrate of silver, which may be applied either in the solid state, or dissolved in six or eight parts of water. Muriatic acid is highly recommended by some writers, and in the worst cases is used undiluted. In those of slower progress, it may be diluted more or less according to the impression desired. Alum is another very efficient application. It is used in saturated solution, or in the form of a very fine powder, which is applied directly to the part by blowing it through a tube adapted to the purpose. These substances should be allowed to come in contact, as little as possible, with any other part ofthe surface than those covered with the exudation. The liquids may be applied by means of a large camel's-hair pencil, or of a piece of sponge or soft linen attached to the end of a stick. In the intervals between the caustic applications, muci- laginous gargles, sweetened or not with honey of roses, may be beneficially used. A gargle, made of a fluidrachm of chlorinated soda and four fluid- ounces of water, is recommended in cases attended with fetid discharge. Howard's calomel, applied to the diseased surface by means of a tube, was advised by Bretonneau; but its chief advantages are probably derived from the portion of it which may be swallowed. For the local treatment of those cases in which the disease has entered the larynx, the reader is referred to pseudo-membranous croup and chronic laryngitis. When it enters the nasal passages, the solution of nitrate of silver may be injected up the nostrils. 3. Ulcerative Inflammation of the Fauces.—Ulcerated Sore-throat. —Ulcers in the fauces are an occasional result of common angina, especially in its chronic state, and are attendants upon various constitutional affections both acute and chronic, as scarlatina, smallpox, syphilis, and the mercurial action. But they sometimes also occur as an original disease, at least they are present when the case first comes under medical notice. It is highly probable that many of the cases, commonly considered as ulcerative, may be really examples of pseudo-membranous inflammation; but this is certainly not the case with others, as, after the removal of the whitish surface which they at first present, an actual loss of substance is observed. Attention is first called to the throat by the occurrence of a sharp pain in swallowing ; and, when the fauces are examined, one or more roundish or oval whitish spots exhibit themselves, surrounded by a red and inflamed margin. The pain which they occasion upon any movement of the fauces is sharper than that of ordinary angina, though there is less heat or uneasiness in the "• CLASS III.] INFLAMMATION OF THE FAUCES. 555 interval. The sensation is like that produced by something sharp sticking in the part. The spots sometimes remain very nearly of their original dimen- sions, sometimes spread considerably. The whitish matter after a while dis- appears, leaving a red, excavated, somewhat irregular surface, which in healthy constitutions speedily rises to the proper level and cicatrizes. In some instances, there is a complete absence of febrile action ; in others, fever occurs, and in this case the pulse is apt to be very frequent, as in scarlatina, to the milder forms of which the affection bears a considerable resemblance^ except in the absence of the eruption. The general treatment is essentially the same as in ordinary angina, though depletion is much less efficient, and bleeding seldom called for. Should the ulcers become chronic, iodide of potassium maybe employed internally. By far the most efficient remedies are local; and the best of these are solutions of sulphate of zinc, sulphate of copper, and nitrate of silver, applied exclu- sively to the whitish surface, and continued daily, or twice a day, until the colour is changed to red. The solutions should contain from ten to twenty grains of the salt in a fluidounce. In cases unattended with constitutional disturbance, a cure may be expected in a few days. 4. Gangrenous Inflammation of the Fauces.—Angina maligna.— Cynanche maligna.—Malignant Sore-throat.—It is very doubtful whether any distinct disease exists which merits this title. There is no doubt that gangrene occasionally attends inflammation ofthe fauces of all varieties. In common angina, pseudo-membranous angina, and even ordinary inflammation of the tonsils, portions of the mucous membrane, and of the structure beneath it, sometimes lose their life ; and true gangrenous sloughs are formed. This result almost always depends either on some pre-existing state ofthe blood, or of the system in general, predisposing to mortification, or upon some gene- ral disease independent of the throat affection, coexisting with it, as in the typhoid forms of fever. In malignant cases of pseudo-membranous angina, the surface beneath the exudation is sometimes covered with a slough, the result of mortification. Thrush and aphtha? occurring in the fauces occasionally become gangrenous ; and the infantile affection called gangrene ofthe mouth may have its seat in the same part. Indeed, whenever intense inflammation of the fauces occurs in persons whose health has been depraved by insufficient or unwholesome nourishment, or who are affected by some malignant or typhoid disease, or dark-red or livid eruption, or in whom mortification exists in some other part of the body, we may apprehend gangrene, especially in children. The malignant sore-throat described by Fothergill and Huxham, and by Dr. Cullen under the name of cynanche maligna, is now generally admitted to be a modification of scarlatina; the local and constitutional symp- toms being the same as those which attend the worst forms of that complaint, except that, in a comparatively few instances, the scarlet eruption is absent, In relation, therefore, to the causes and treatment of this affection, it will be sufficient to refer to the article on scarlet fever. Article II. INFLAMMATION OF THE TONSILS, or TONSILLITIS. gvn,—Cynanche tonsillaris.—Angina tonsillaris.—Amygdalitis.—Quinsy. By these terms is here meant inflammation of the substance of the tonsils, that of the mucous membrane covering them being included under some one of w 556 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. the forms of angina already treated of. Sometimes only one tonsil is affected, but more frequently both. Symptoms.—The local affection is first indicated by difficulty in swallow- ing, a sense of heat in the fauces, and a constant uneasiness, which gradually increases until it amounts to severe pain. This often shoots through the ear, and the patient sometimes refers it chiefly to that part. The difficulty of swallowing increases, each attempt being attended with an expressive con- traction of the features, and an almost convulsive action of the muscles con- cerned ; liquids are apt to pass into the nostrils ; and, in severe cases, when both tonsils are involved, deglutition becomes almost or quite impossible. At the same time, there is a constant disposition to swallow, in order to free the fauces from a tenacious colourless mucus, which is also discharged by frequent hawking and spitting. The voice is much changed, assuming a nasal character, and, when the disease is at the height, is sometimes quite suppressed. The hearing is also frequently impaired, in consequence proba- bly of obstruction of the eustachian tubes. The respiration is not much affected, unless in very bad cases, with great swelling of the tonsils, when a sense of suffocation is sometimes experienced. Upon being examined, the fauces exhibit at first redness, with some projection of one or both tonsils, which gradually increase in size, and, if both are affected, at length almost or quite touch each other. Their surface frequently exhibits a white concrete matter, in spots or diffused, the result of morbid secretion, apparently from the mucous follicles. The uvula is usually much swollen and elongated, and the soft palate inflamed. There is also almost always external inflammation, with swelling of the cervical glands and the cellular tissue, and so much stiff- ness of the jaws, that, when the disease is at its height, the mouth can some- times scarcely be opened. The tongue is heavily furred. The fever is of the sthenic character, and is often very considerable, with headache, and a full, strong pulse. The rigors with which the fever com- mences sometimes precede any obvious inflammation of the tonsils for some hours, or even a day ; but much more commonly, the general and local affec- tions begin at the same time, or the latter precedes the former. The patient generally experiences great restlessness, with inability to sleep. In some cases, there is little or no fever, and the patient does not lose his appetite throughout the attack. When the inflammation is slight, or is actively treated, it often ends in resolution ; but, under ordinary circumstances, suppuration is the more usual result. The establishment of this process is known by the occurrence of slight rigors, and by the greater softness of the tumour to the touch, which may not unfrequently discover fluctuation. Sometimes an elevated pale spot is seen, indicating a disposition of the abscess to open at that point. At this stage of the disease, the sufferings of the patient are often very great; and the relief obtained by the discharge of the abscess is exquisite. This is hastened by the efforts which the patient makes in coughing, swallowing, or clearing his throat. It often occurs in the night, and the patient falling asleep, wakes in the morning entirely relieved, without being conscious of the time when the change took place. The pus is usually swallowed, though occasionally portions of it are discharged by the mouth. After the opening of the abscess, recovery is rapid. The disease is usually about a week in arriving at its height, though sometimes not more than five or six days, and sometimes as much as ten days or two weeks. In some very rare cases, the abscess has opened externally; and still more rarely the pus has dissected its way down into the lungs, and produced fatal inflammation. After the relief of the acute symptoms, the tonsils are not unfrequently left swollen and indurated; and this is especially apt to be the case in persons CLASS III.] INFLAMMATION OF THE TONSILS. 557 of a scrofulous habit, and in those frequently attacked. Sometimes the tume- faction becomes at length so great as to be seriously inconvenient, producing difficulty of deglutition, and an alteration of the voice. The tonsils, more- over, may come into this hypertrophied condition in consequence of a chronic irritation or inflammation, without any preceding acute symptoms. Inflammation of the tonsils almost invariably terminates favourably unless complicated with some vice of constitution, which would render inflammation, wherever seated, hazardous. Suffocation is mentioned among its dangers; but this must be very rare, unless the larynx becomes involved. I have never witnessed a fatal case. One, however, is recorded in the Am. Journ. of Med. Sci. (N. S., xxiv. 96), which was caused by the pressing downward of the epiglottis, so as completely to close the orifice of the larynx. Causes.—By far the most frequent cause of this disease is exposure to changes of temperature, especially to partial cold, when the body is warm and perspiring. Hence, the complaint is most prevalent in seasons when the weather is changeable, as in the latter part of autumn and beginning of win- ter, and in spring. It seems sometimes to be influenced by the epidemic constitution of the atmosphere, and is apt to prevail along with scarlet fever and measles. It not unfrequently occurs in scarlatina and smallpox, though materially modified by the character of the affection. It is less disposed to suppuration, when a mere attendant upon these complaints, than in its ordi- nary state. Certain individuals are very subject to it, and in these the slight- est exposure is often sufficient to bring on an attack. It is not common in infancy, or in advanced life; and those who have been subject to it in youth and adult age, generally cease to be so when they become old. Treatment.—At the period of the complaint at which the physician is called, it is generally difficult to prevent suppuration, unless by an energy of depletory treatment which may lead to more unpleasant consequences than the disease; and the most copious admissible depletion often fails. It is, therefore, scarcely advisable to aim at effecting resolution, unless in the early stage. The moderate depletion, which will at first often check the complaint, will, at a more advanced period, be found useful by moderating the violence of the inflammation, and consequently diminishing suppuration. This is, therefore, in general, the appropriate treatment. When the pulse is full and strong, the system plethoric, and the head painful, blood should be taken from the arm, and, in severe cases, the bleeding may be repeated. But, if the patient was previously feeble, or has been subject to frequent returns of the complaint, venesection as a general rule is better avoided. A brisk purge of calomel and jalap, or of senna tea with sulphate of magnesia, may be given at first, and the bowels afterwards kept freely open with some one of the saline cathartics. Generally speaking, however, no other cathartic is requi- site than Epsom salt. In the intervals, the circulation should be kept down by small doses of tartar emetic, and by refrigerant drinks. Emetics have been recommended ; but they have little influence over the progress of the complaint when formed. In the very commencement, they may arrest it, and, in advanced suppuration, may give relief by breaking the abscess; but for the latter purpose other means are preferable. Opium, or the powder of ipecacuanha and opium, should be given at night, in cases of restlessness and want of sleep. The diet should be low, consisting of soft or fluid substances, as mush with molasses, and mucilaginous or farinaceous liquids. When the appetite remains, vegetable broth is usually acceptable to the patient. Dr. Brinton treats this disease very successfully by purging with large doses of guaiac, of which he gives from a scruple to a drachm every four hours, often combined with other cathartics, as aloes and jalap, and with opium. This treatment is said, if commenced early, generally to prevent suppuration. (Lond. Lancet, Am. ed., July, 1857, p. 90.) 558 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. Not much can be expected from external local treatment. Leeches, how- ever, may be employed, though less useful than in simple angina. Various rubefacient applications and blisters may also be used, as recommended in that complaint. Perhaps the best external application is an emollient poul- tice of bread and milk, flaxseed meal, Indian mush, or mashed potatoes, so large as to embrace the whole throat in front and on the sides. Gargles are useful only by alleviating the discomfort of the patient, and enabling him to discharge the viscid mucus which lines the fauces. Muci- laginous, acidulous, or slightly astringent liquids, may be employed for this purpose; such as infusion of flaxseed, sassafras pith, or slippery elm bark, vinegar and water, infusion of red roses or of sage sweetened with honey of roses, and a very weak solution of alum. Simple warm water used as a gargle often gives some relief. Scarification of the tonsils has been recommended, as also has bleeding from the ranine vein. There are two remedies which, applied in the early stage of the disease, will often arrest it; namely, pow- dered alum and nitrate of silver. Alum may be brought into contact with the surface of the tonsils, either by the index finger moistened and then touched to the powder, or by blowing it into the fauces through a quill or other tube into which it may have been introduced. Nitrate of silver is applied in sub- stance, by touching the surface with a stick of it, or in strong solution by means of a camel's-hair pencil. When suppuration has commenced, gargling with warm water, or milk and water, or a decoction of figs in milk, and the inhalation of warm vapour, have been thought to advance it. When fluc- tuation can be detected by the finger, the abscess should be opened. In chronic enlargement of the tonsils, occasional scarification, with the intermediate application of strong astringent solutions, especially that of alum, may be resorted to with some hope of advantage. Repeated leeching, blisters, and frictions with mercurial or iodine ointment have been used, but with no very satisfactory results. Dr. Symonds has found most benefit from the daily application of nitrate of silver, in substance or solution. Tincture of iodine, applied occasionally to the tumour, is said to have effected cures. All these measures, however, are apt to fail; and it is frequently necessary to remove the enlarged tonsils by excision. Article III INFLAMMATION OF THE PHARYNX, or PHARYNGITIS. Inflammation of that portion of the pharynx which can be seen when the tongue is depressed, belongs to inflammation of the fauces, and has been treated of under that head. When it occurs alone, it is characterized by pain, and the absence of alteration of the voice. Inflammation of the invisi- ble portion is much less common. Its diagnostic symptoms are pain in swal- lowing opposite to the top of the larynx, and tenderness on pressure from without immediately behind the larynx, without redness in the fauces or change of voice. It is seldom attended with fever, and is not often dangerous. It terminates usually in resolution; but the inflammation sometimes extends to the cellular structure posterior to the pharynx, when suppuration may take place, and an abscess result, extremely dangerous in its consequences. There is nothing peculiar in the causes of pharyngitis. Like inflammation of the fauces, it may be of the ordinary character, or pseudo-membranous, and like it may assume a chronic form. It is to be treated, moreover, in the same way, except that little good is to be expected from gargles. For observations on erysipelatous inflammation of the pharynx, preventing deglutition by paralyzing the muscles, see pages 443 and 454. CLASS III.] INFLAMMATION OF THE PHARYNX. 559 Abscess ofthe Pharynx.—Collections of pus form in the cellular structure around the pharynx, in various positions, and from various causes. But the affection here referred to is seated in the cellular tissue posterior to the pha- rynx, between it and the cervical vertebra?. It is not a frequent, but is nevertheless an important complaint. When behind the upper part of the pharynx, it may be known by a projection in the back of the fauces, visible to the eye when the jaws can be sufficiently opened, and sensible to the finger, which at the same time detects fluctuation. When lower down, it is not so easily recognized. Deep-seated pain in the region of the pharynx, tenderness upon pressure from without, stiffness of the neck, great difficulty of deglutition followed by absolute inability to swallow, suppression of the voice, and the most distressing dyspnoea, attended with laborious efforts to inspire, are symptoms which should lead the physician to suspect its exist- ence, and, if it be invisible, to attempt by the careful introduction of a sto- mach tube to ascertain whether the passage is closed. The danger arises partly from inanition, but chiefly from pressure upon the larynx, producing suffocation. Several fatal cases are on record; and it is probable that others have occurred, which have been mistaken for laryngeal disease. The chief diagnostic symptoms are the seat of pain, and the inability to swallow. There is usually considerable fever, and sometimes cephalic symptoms, which tend to direct attention away from the real danger. The abscess is more danger- ous in the lower than the upper part of the pharynx. This affection may attend the advanced stage of certain fevers, or may re- sult simply from inflammation of the pharynx. It may also be produced by disease of the cervical vertebra?. As hitherto observed, it has been most com- mon in children under four years; but it may occur at any age. The treatment consists simply in opening the abscess ; and the chief cau- tions requisite are to avoid making too deep an incision, and to strike as nearly as maybe the middle line, so as to avoid any considerable artery. Dr. Abercrombie relates three cases of children, who were apparently rescued from suffocation in this way. Should the abscess be out of sight, and beyond the reach of the finger, the cutting instrument should be sheathed in a tube, until in contact with the tumour.* Article IV INFLAMMATION OF THE (ESOPHAGUS, or OESOPHAGITIS. This is a very rare affection, unless originating from the direct application of irritating substances, or from mechanical violence. Symptoms, &c.—A sense of heat and pain, increased by swallowing, and frequently referred to the lower extremity of the pharynx, or to the cardiac orifice of the stomach, no matter what part of the tube may be affected, is the earliest symptom. Sometimes the pain is felt between the shoulders, or is referred to the larynx. Tenderness upon strong pressure from without is experienced, if the disease is seated in the upper part of the oesophagus. Deglutition is usually more or less difficult, and sometimes impossible. The complaint is said to be frequently attended with hiccough, and sometimes with the eructation of a glairy mucus, and with vomiting. There is usually little or no fever. The inflammation generally terminates by resolution, though suppuration sometimes takes place, and an abscess may form between the * For an elaborate account of this affection, the reader is referred to an article by Dr. Charles M. Allin, in the New York Journal of Medicine (N. S., vii. 307.) 560 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. mucous membrane and the muscular coat. Ulcers occasionally result. The inflammation may also be of the pseudo-membranous character, in which case it is usually propagated from- the fauces or larynx, though it does occasion- ally originate in the oesophagus, and has been known to occupy its whole extent. The vomiting of flakes, or a tube of false membrane, would lead to the suspicion of its character. In some cases of oesophagitis, the mucous glandules are exclusively affected ; but this cannot be ascertained during life. The disease occasionally becomes chronic, in which case we have the ordi- nary symptoms of the acute in a moderated form, and especially a copious discharge of mucus by the mouth. Causes.—The usual causes are acrid, corrosive, or very hot substances swallowed, and mechanical violence from sharp, rough, or hard bodies intro- duced into the oesophagus, or from undue efforts by the surgeon in the use of the stomach tube, the bougie, or the probang. The disease may also be propagated downward from the fauces, or upward from the stomach. It has been ascribed, in some instances, to the retrocession of cutaneous eruptions, and of rheumatism. There is little doubt that the muscular coat sometimes becomes the seat of the latter affection. Treatment—Venesection when the pulse is strong and excited, saline ca- thartics, stimulating pediluvia, a liquid farinaceous diet, repeated leeching or cupping, emollient poultices, and, in the advanced stages, blisters upon the neck or between the shoulders, constitute the chief remedies. In chronic cases, revulsion should be sustained by a perpetual blister, by pustulation with croton oil or tartar emetic, or by a seton. Should the case not yield to other measures, mercury should be resorted to ; and this should be employed early, if there is reason to believe that the inflammation is pseudo-membranous. When inability to swallow exists, attempts may be made to support the pa- tient by nourishing liquids injected into the bowels. Article V STRICTURE OF THE ESOPHAGUS. 1. Organic Stricture.—The consideration of this subject belongs pro- perly to the surgeon; as it is by surgical means that relief is to be afforded. A few remarks, therefore, will be sufficient. The complaint is indicated by difficulty of deglutition, at first moderate, but gradually increasing so that the patient can at length swallow nothing but liquids, or ceases to swallow even these, and dies of inanition. Sometimes, however, the stricture continues many years without perceptible increase. It may arise from thickening of the coats consequent upon inflammation, from contraction produced by the healing of an ulcer, from excrescences growing out of the mucous membrane, from cancer, from cartilaginous or osseous degeneration of the tube, or from the pressure of exterior tumours. Among its effects is a dilatation of the oesophagus above the place of stricture, sometimes to a very great extent. When there is much pain, leeching, blistering, and narcotics may be employed. When it originates in inflammation, some advantage may be hoped from a careful course of mercury, or the internal and local use of iodine. Caustic to the stnctured part has been employed by some English surgeons ; but the only means upon which much reliance can be placed is the use of the bougie. 2. Spasm of the Oesophagus.—This is a morbid muscular contraction of the tube producing more or less difficulty of swallowing. m Symptoms.—The spasm generally comes on suddenly, often, for the first time, during a meal. Upon an attempt to swallow, the food is arrested, and CLASS III.] STRICTURE OF THE CESOPHAGUS. 561 is either rejected immediately and with force, or is retained for a time, and then rises by regurgitation. The former event is apt to occur when the stricture is near the upper extremity, the latter when it is near the lower. Occasionally, after the food has been a short time in contact with the stric- ture, this yields and allows it to pass into the stomach. In some instances, solids can be swallowed better than liquids, and the reverse is sometimes the case ; but in general any sort of food is sufficient to excite the spasm when the morbid susceptibility exists. Severe pain often attends the spasmodic action, and the irritation occasionally extends to the larynx or lungs, pro- ducing much embarrassment of respiration, with a feeling of impending suf- focation. Even where no effort at deglutition is made, there is frequently present a sense of constriction, and in some cases a feeling as of a ball as- cending in the throat, or moving from one part to the other. This is the globus hystericus of older writers. Hiccough and vomiting sometimes ac- company the affection. Its duration is exceedingly various. An attack may consist of a single paroxysm, lasting only a few hours, or the spasmodic action may continue with exacerbations and remissions, and occasional complete in- termissions, for months or years. Like most other nervous affections, it some- times assumes the regular intermittent form. From organic stricture, the only complaint with which it can be con- founded, it may in general be readily distinguished by the suddenness of the attack, by the occasional absence of all the symptoms, so that the patient can swallow easily, and by the other evidences of nervous disorder with which it is frequently attended. A large bougie can also be passed with facility in periods of relaxation, and, even when arrested by the spasm, if held for some time against the stricture, will often be allowed to enter. Causes.—Irritation of the mucous coat, from whatever cause, may produce the spasm when a predisposition to it exists. It is sometimes excited by in- flammation of the oesophagus. Among the causes may be mentioned acrid substances swallowed, cold drinks during perspiration, partial exposure to cold air, violent and depressing emotions, the operation of the imagination, and the influence of disease existing elsewhere, as of dentition, organic affec- tions of the larynx, stomach, and uterus, and inflammation of the upper part of the spinal marrow. The predisposition usually consists in an excitable state of the nervous system, such as exists in hysteria, hypochondriasis, and generally in a debilitated and anemic condition of the body. Treatment.—The indications of cure are first to relieve the local affection, and secondly to correct the predisposition. The first is answered by remedies suited to relax the spasm directly, and to diminish the nervous excitability of the part, so as to prevent the disposition to its recurrence. If inflamma- tion exist, it should be removed by the means already indicated. If the affection be purely nervous, recourse may be had to narcotic cataplasms, as of tobacco, henbane, or hemlock, to acetate or sulphate of morphia upon a blistered surface, to rubefacients, epispastics, pustulating substances, or a seton applied to the back of the neck, and to the internal use of antispasmo- dics and narcotics, such as assafetida, valerian, Hoffmann's anodyne, cam- phor, opium, henbane, and hemlock. Much good is said to have resulted from very cold drinks, and even ice swallowed by the patient. To meet the second indication, remedies must be employed calculated to remove the disease of other organs with which the spasm may be associated, and to correct any existing morbid state of system. These remedies are de- tailed elsewhere. It is sufficient here to mention that it is usually desirable to invigorate the general health by chalybeates or other tonics, exercise, fresh air, a nutritious diet, the avoidance of coffee, tea, and tobacco as habitual luxuries, and attention to the bowels and the various secretions. Strychnia vol. I. 36 562 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. has been employed successfully in one severe case by M. Mathieu. A com- plete cure was effected in six weeks. (Journ. de Pharm., 3e ser., xxii. 390.) In the regular intermittent form of the complaint, sulphate of quinia will prove effectual. Foreign Bodies in the QJsojihagus.—This subject properly belongs to sur- gery ; but there is one point which merits notice in this place. When the obstructing substance is an article of food, and difficulty exists in removing it by mechanical means, recourse can be had to the solvent properties of the gastric juice. A case in which this measure was successfully employed is recorded by Dr. P. W. Ellsworth, of Hartford, Conn., in the Boston Medical and Surgical Journal for April 17th, 1856 (p. 212). In this case, in conse- quence of a permanent stricture in the oesophagus, a small portion of animal food which had been swallowed completely obstructed the passage, and could not be removed. A teaspoonful of the strained liquor from the stomach of a pig, killed fasting, was given every hour ; and in twelve hours the obstructing substance was dissolved, and the patient relieved. Dilatation of the Pharynx and Oesophagus.—Besides the dilatation con- sequent upon stricture, other forms of the affection occasionally take place, interfering much with the comfort of the patient, and sometimes ending fatally. The dilatation may be in the form of a pouch, made either by the distention of all the coats of the tube at one spot, or by a hernial protrusion of the mucous membrane between the fibres of the muscular coat, or it may be a general distention of the tube in some portion of its length. The symp- toms are gradually increasing difficulty in deglutition, the regurgitation of food at a longer or shorter interval after swallowing, and occasionally a tumour which can be felt by the fingers, and which may be lessened by press- ure. The treatment of these affections belongs to the surgeon ; but in gene- ral little can be done. For a collection of cases of this kind, see the Edin- burgh Monthly Journal of Medicine for March, 1855 (p. 223). SUBSECTION III. DISEASES OF THE STOMACH. Article I. INFLAMMATION OF THE STOMACH, or GASTRITIS. The inflammation in this disease is usually seated in the mucous mem- brane, and the submucous cellular tissue; though it sometimes extends to the other coats, and may even involve the whole stomach. The peritoneal coat is seldom exclusively affected, unless in cases of general peritonitis, to which disease, therefore, inflammation of that coat properly belongs. Gas- tritis exists under the two forms of acute and chronic. Some make an in- termediate grade, which they call subacute; and cases frequently occur of slight, temporary phlogosis of the organ, scarcely severe or extensive enough to produce fever, and soon passing off with the removal of the irritating cause, which might be conveniently distinguished by this title; but these cases are little noticed, and of little consequence, except that, by their fre- quent repetition, they give rise to chronic inflammation, of which, therefore, they may be considered as the initial stage. Whatever concerns them sepa- CLASS III.] INFLAMMATION OF THE STOMACH. 563 rately will be best treated of under irritation of the stomach, which they scarcely exceed in severity, and with which they are generally confounded. Acute Gastritis.—This is not common as an independent affection, though frequently associated with other diseases, of which it may be either an effect, or a mere attendant, having its origin in the same cause. Few organs resist so firmly the ordinary direct causes of inflammation as the sto- mach, and few are so readily affected through the sympathies. The object of this provision is evident. An organ so important in its functions, and so much exposed to irritant influences from without, would be constantly suffer- ing, and causing the system to suffer, if readily excited into inflammation by such influences; while, if undisturbed by inflammation, or morbid excitement in other organs, it would continue to furnish, through the function of diges- tion, materials to the blood calculated to sustain the disease. Symptoms.—In severe cases of acute gastritis, there is usually a burning pain in the epigastrium, with incessant nausea and vomiting, commencing with the attack, and continuing, with greater or less intensity, till near the close. The pain is increased by pressure from without, and by a deep inspi- ration, and is sometimes excruciating in the act of vomiting. The substances thrown up from the stomach are at first the food or chyme, and afterwards bile or mucus, and whatever may be swallowed, and are sometimes more or less deeply tinged with blood. There is occasionally considerable difficulty of deglutition, in consequence of spasm of the oesophagus or cardiac orifice. The thirst is intense, and the patient is constantly calling for cold water, although, if taken freely, it produces uneasiness and oppression by the dis- tension of the stomach, and is often immediately rejected. The tongue is at first usually covered in the middle and posterior part with a whitish fur, while its tip and edges are red, and red papilla? are visible through the coat- ing; but sometimes it is red, smooth, dryish, and without fur, from the com- mencement. The bowels are almost always constipated, unless they partici- pate in the inflammation, in which case they are looser than in health. The patient lies on his back, is apt to be low-spirited, is restless and wakeful, and has a feeling of great debility, with an expression of face indicating anxiety and distress. The pulse is frequent and sometimes full, but usually small and corded, the respiration often short and hurried, the skin hot and dry, and the urine high coloured. A hard, dry cough, occasionally paroxysmal, is also mentioned among the symptoms. Should the disease now take a favourable turn, the pain, and vomiting abate; the tongue becomes paler and moister, the pulse slower, fuller, and less corded, the skin cooler and softer; and sometimes a general moisture of the surface, or relaxation of the bowels, evinces that the crisis is passed. But, should it advance unfavourably, the tongue, if before coated, becomes • smooth, red, and dry, and towards the close is occasionally covered, as well as the inside of the cheek, with a thrush-like exudation; the skin becomes cool and pale, and the pulse more frequent, feeble, and thread-like; the body emaciates rapidly; debility and restlessness increase; delirium frequently occurs; hiccough harasses the patient; active vomiting is succeeded by mere regurgitation; instead of mucus or bile, a black matter like coffee-grounds is sometimes ejected; the tenderness on pressure diminishes, and pain some- times ceases entirely; the countenance sinks, and assumes a haggard aspect; and death occurs, preceded by cold extremities, a scarcely perceptible pulse, and other evidences of extreme exhaustion. The complete suspension of pain, without amelioration in other respects, is an unfavourable sign. In some rare instances, in the latter stage, the pain suddenly increases and be- comes more diffused, and extreme tenderness upon pressure is felt over the whole abdomen, which swells and assumes a tympanitic condition. In such 564 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. cases, the stomach has been perforated, and peritoneal inflammation has been produced by the fluids which have escaped through the opening. Inevitable death speedily follows this event. When the stomach has been disorganized from the commencement by the violence of the cause, as when one of the concentrated mineral acids has been swallowed, great prostration comes on almost immediately, with a cold, clammy skin, and a very feeble pulse; and death soon takes place. In milder forms of the disease, the symptoms above enumerated as charac- terizing the earlier stages, are experienced in a less degree. Sometimes, in- stead of severe pain, there is merely a feeling of oppression, weight, or con- striction ; instead of obstinate and incessant vomiting, merely a slight nausea, or a disposition to vomit ingesta. The pulse, too, in such cases, is usually more full and developed. Epigastric tenderness is seldom absent. Occasion- ally, even in severe gastritis, there is a want of all the characteristic symp- toms ; so that the first evidence of the nature of the complaint is afforded by dissection. This is sometimes attributable to the fact, that secondary or sympathetic affections, such as severe headache or delirium, pains in the back or limbs, or irritation of some portion of the pulmonary apparatus, become so prominent as to act revulsively in relation to the gastric sensibilities, and thus to mask the real disease. When gastritis attends other diseases, it is peculiarly liable to be thus concealed, as in the delirium of drunkards which immediately follows an occasional debauch, and in which it is highly important that it should be recognized. (Stokes.) The duration of acute gastritis is very variable. In violent cases, as from irritant poison, death, in some instances, takes place in less than twenty-four hours; while in others, the disease con- tinues from two to six weeks, and then, if not fatal, ends in a slow convales- cence, or subsides into chronic gastritis of indefinite duration. Milder cases often yield speedily to appropriate treatment; but, if not taken in time, may run on for weeks, and at last assume the chronic form. Anatomical Characters.—The stomach is more or less contracted, some- times so as not to exceed the transverse colon in size. The mucous membrane is often much wrinkled, and sometimes covered with a viscid or puruloid mucus, upon the removal of which it exhibits the usual marks of inflamma- tion. The colour is bright-red, brownish, livid-red, or blackish-brown, and is more or less diffused over the stomach; sometimes extending over the whole mucous surface, sometimes confined to a portion of it, most commonly the fundus, and usually deepest in this part. The redness may be uniform, in patches or stripes of greater or less extent; or it may be in points, or stellate, or arborescent with innumerable capillary ramifications, or branching with larger trunks. Sometimes it is found of one form in one part of the stomach, and of a different form in another. The darker shades of colour, the brown and black, for example, are, according to Andral, very seldom found in acute gastritis, and only in cases of great intensity and brief duration, such as result from the corrosive poisons. Ecchymosis is not unfrequent, usually in patches, sometimes in isolated spots in the submucous tissue, producing small promi- nences on the surface. Solid reddened eminences are also frequently seen, which were formerly ascribed to increased development of mucous follicles, but are now thought to be produced simply by inflammatory exudation in the tissue. The discoloured portion of the membrane is generally thick- ened, and more or less softened, so that it is more easily torn than in health. Sometimes it is reduced to the state of a soft pulp. These various alterations may be confined strictly to the mucous membrane, or may penetrate one or more of the remaining coats; and Andral relates a case, in which the whole of the coats of the left half of the stomach were in a friable, almost pulpy condition. Eschars are occasionally seen with purulent secretion, oedema, CLASS III.] INFLAMMATION OF THE STOMACH. 565 emphysema, and other accompaniments of disorganization, and the conse- quent vital process of separation, in various states of advancement. Ulcers are rare, as a result of acute gastritis, except in cases of poisoning. It is highly important, in a toxicological point of view, that the post-mortem evidences of gastric inflammation should not be mistaken. It was at one time generally supposed that redness was a sufficient indication; and it was taken for granted that any stomach which presented this appearance had been inflamed. Yellowly, however, by experiments made in 1813, satisfac- torily proved that stomachs, previously in a healthy state, often appear much reddened after death ; and observations, made since that period by Andral and others, go to show that no modification of colour alone can be admitted as certain proof of inflammation. All the varieties of shade, and all the diversities of arrangement above stated, may result from causes wholly independent of that condition. Not to mention irritation, or mere healthy excitement, which often occasions intense redness of the mucous membrane, the same effect is produced by congestion of the portal circle, or any other cause obstructing the return of blood from the stomach, and by agencies operating at the time of dissolution, and after death, particularly gravitation, which causes the blood to settle in the most dependent parts of the stomach. The fact, moreover, should be borne in mind, that the gastric mucous mem- brane, in very young subjects, is of a rosy hue in health. Even softening of the membrane cannot always be relied on; as it may be entirely cadaveric, resulting from the action of the gastric juice, or from incipient putrefaction; and, in very low states of the system, the vital properties may be so much enfeebled in parts which have become the seat of a passive sanguineous con- gestion, that the chemical forces may predominate, even during life, and pro- duce a material change of consistence. It should also be remembered that the healthy consistence of the membrane is different in different parts, being firmer near the pylorus than in the remainder of the stomach. Notwithstand- ing these difficulties, however, there is usually, in cases of real inflammation, abundant evidence of its having existed, in the state of the stomach after death. The facts just mentioned should only serve as a caution not to mis- take, for proofs of inflammation, appearances which may have had a wholly different origin. Causes.— Acute gastritis is rarely produced by those vicissitudes of tem- perature which are so often the cause of other inflammations. It most fre- quently results from caustic or irritant substances taken into the stomach. The corrosive mineral, and acrid vegetable poisons often prove fatal in this way. Milder stimulants, such as alcoholic drinks, the stronger condiments, and even an excess of food, sometimes produce acute inflammation of the stomach, but rarely unless in cases where a strong predisposition exists. Large draughts of very cold water after fatiguing and exhausting exertion, when the body is heated and perspiring, are among the causes. Very severe cases sometimes result from the translation of acute gout or rheumatism. Andral relates a striking case of this kind, in which a predisposition to dis- ease of the stomach appeared to be occasioned by distress of mind. But the state of convalescence from certain acute diseases, especially cholera, and the previous existence of chronic inflammation of the stomach, constitute the strongest predisposition. It is in these conditions that excess in eating and drinking most frequently brings on an attack of acute gastritis. But this disease occurs much more frequently as an attendant upon other diseases, than as an original or independent affection. It is peculiarly apt to occur in the course of idiopathic fevers, particularly in the bilious remittent and yellow fevers, and not unfrequently also attends the exanthemata and phlegmasia?. It is sometimes lighted up in the advanced stages of phthisis. 566 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. In some instances, it is very difficult, nay impossible to decide, whether the gastritis is the original, or a secondary affection. The decision, however, is of the less consequence; as, in either case, a prominent indication would be to combat the disease of the stomach; as this is at least one of the chief sources of danger. General Treatment.—Should the gastritis have been caused by a corrosive or acrid poison, and the stomach not yet been fully evacuated, the first object in the treatment should be to remove the offending matter, either by means of copious draughts of warm water, or other bland liquid, or, if these should be insufficient, by means of a gentle emetic of ipecacuanha accompanied with free dilution. At the same time, substances should be administered calcu- lated to act as antidotes by neutralizing the poison; and, after the stomach has been thoroughly cleansed, castor oil or sulphate of magnesia should be given along with the antidote, in order to evacuate any portion of the poison which may have passed into the bowels. The inflammation is then to be treated as if it had arisen from other causes, attention being always paid to whatever peculiar condition of the system may have arisen from peculiar pro- perties in the poison, and to the fact, that, if great organic injury has been inflicted, the system is too much prostrated to admit of copious depletion. In the early stage of gastritis, if the patient has not been previously de- bilitated, and the system is not under the influence of some powerfully de- pressing agent, as in typhus fever, and the case of certain poisons, blood should be taken freely from the arm; and, if the pulse and general strength do not fail under the loss, the bleeding may be repeated once and again, until a decided impression is made on the disease. The pulse and muscular strength of the patient are not to be taken as exclusive guides in acute gas- tritis. They both feel the depressing influence of the attending nausea, and will often rise under depletion, in consequence of the diminished force of the disease in which the nausea originates. Besides, a certain energy of stomach seems necessary to support the actions of the circulatory system, and, when the functions of that organ are wholly suppressed by excessive inflammation, the heart, though irritated, contracts with comparatively little force. Dimin- ish the inflammation, and the heart resumes its power. Venesection is safe, so long as the pulse, as it not unfrequently does, rises and becomes more de- veloped under the lancet. As constipation is an almost uniform attendant on uncomplicated gastritis, cathartics would appear to be indicated; but medicines of any kind taken internally are apt to be rejected, or to aggravate the inflammation; and most authors recommend either their very sparing employment, or a total abstinence from them. Nevertheless, from five to fifteen grains of calomel may often be usefully given, in the earlier stage, after the due loss of blood. This cathartic is but slightly if at all irritant to the inflamed membrane, and is sometimes retained with the effect of calming the stomach, when other sub- stances, even small quantities of cold water, are rejected. Besides, it ope- rates favourably by unloading the portal veins through the secretion of bile, and thereby diminishing congestion in the stomach. The bowels should afterwards be kept open by the frequent use of enemata. In some cases, when medicines are tolerated, a little castor oil or carbonate of magnesia, or other mild cathartic, may be administered with advantage; but, if found to disturb the stomach, they should not be persevered in. The effervescing draught will often operate favourably by promoting perspiration and reducing fever; but this also will sometimes prove irritant, and must be relinquished. Opium, or one of the salts of morphia, may be given when the first violence of the inflammation has subsided. A full dose may be administered at bed- time, and repeated in an hour or two if it should not procure rest. Calomel CLASS III.] INFLAMMATION OF THE STOMACH. 567 may often be usefully combined with the opium, and, if the disease does not appear disposed to yield to depletion, may be repeated at Such intervals as to bring the system carefully under the mercurial influence. Half a grain or a grain of opium with one or two grains of calomel, in the form of pill, re- peated every four, six, or eight hours, will generally be sufficient for the purpose. When the vomiting is obstinate, and easily excited, so that even these medicines cannot be retained, advantage will accrue from enemata of laudanum with a solution of starch or flaxseed tea. Throughout the com- plaint, stimulating pediluvia, or other measures for exciting action in the lower extremities, should be employed when these are pale and cold. In the last and most prostrate stage, when the symptoms indicate threatened or ex- isting gangrene, the most efficient remedy is oil of turpentine with laudanum or a salt of morphia, given frequently in small doses. I have seen one ap- parently desperate case recover, under the use of this combination. The patient should not be allowed to drink largely; but he will derive relief from occasionally swallowing a mouthful of very cold water, or from keeping ice in his mouth, and swallowing it as it dissolves. Few measures will be found more grateful than this, while it proves positively useful in the relief of the inflammation. Dr. Stokes recommends that small pieces of the ice should be swallowed undissolved, after they have remained in the mouth a short time, so as to round off the angles. Iced lemonade, or carbonic acid water may sometimes be favourably substituted for pure water. In the early stages, no other nutriment should be allowed than a solution of gum arabic, weak barley-water, or some other mucilaginous or farinaceous drink; and even these may be dispensed with at first; but, in the more advanced stages, when the debility is great, and an absolute necessity exists for the support afforded by nourishment, fresh milk mixed with lime-water will be found both grateful and useful. These should be given in small quantities frequently repeated, as from half a fluidounce to a fluidounce of each every hour. In a still more advanced stage, chicken broth, plain cream, or ice cream may be carefully administered. In convalescence, the utmost caution should be ob- served to guard the patient against imprudence in eating, as nothing would be more likely to occasion a relapse. Local Treatment.—No one remedy in the treatment of acute gastritis is more important than leeches to the epigastrium. These should be resorted to after bleeding, and immediately in cases where bleeding is deemed unne- cessary or inadmissible, and should be repeated occasionally until the symp- toms give way. The most decided relief is often experienced from this remedy, in some instances even while the leeches are drawing. Some writers recommend them to the exclusion, or nearly so, of general bleeding; but I am convinced that this is a great mistake. The principle upon which leeching operates with so much advantage is not obvious. Some refer it to revulsion, and the direction of the current of blood from the stomach to the surface. But in this way the leeches should prove equally useful applied to the sides or back, as these parts are nearer even than the epigastrium to the source whence the stomach receives its supply of blood. May not the result be ascribed to some undefined sympathy between the epigastrium and the gastric mucous membrane? In the intervals between the leeching, warm fomentations, or light emollient cataplasms should be applied over the region of the stomach, unless found very oppressive by their weight. Care, how- ever, must be taken that they do not produce too copious a flow of blood from the leech bites. Cold applications, and even ice, have been recommended as preferable to warm fomentations; but I can say nothing of this remedy from experience. In the advanced stages, decided benefit will sometimes accrue from blistering, and advantage may be taken of the raw surface thus obtained, 568 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. to hasten a mercurial impression by applying dressings of mercurial ointment, or to relieve nausea and vomiting by the endermic use of acetate or sul- phate of morphia. It is scarcely necessary to state that the above plan of treatment may be applied, in various degrees, and with various modifications, according to the nature of the case, as well to the inflammation of stomach which attends other diseases, as to idiopathic gastritis. Chronic Gastritis.—There is no distinct line of division between this and the former variety of gastritis. The extremes could not be confounded; but of the numerous intermediate grades, it would often be difficult to decide which might belong to the one, and which to the other variety. If the prac- titioner, however, observe the same gradation in the treatment, which he finds in the character of the disease, no harm can result. Symptoms.—When not the result of the acute form, chronic gastritis in general approaches so gradually that it seldom attracts the serious attention of the patient, or comes before the notice of the physician, until it has ex- isted a considerable time. The first symptoms are usually some uneasiness in the region of the stomach after eating, more or less derangement of the appetite, and a feeling of general discomfort during digestion, with occasional headache, and vague pains or soreness in the limbs as if from fatigue. Some- times nausea and vomiting occur at the commencement. The symptoms gra- dually increase in intensity and diversity; and the disease puts on a great variety of aspects, dependent on the degree, extent, stage, cause, and charac- ter of the inflammation, the tissue or part affected, the constitution and habits of the patient, and the almost infinite diversity of sympathetic derangements. In almost all cases, perhaps in all, there is more or less epigastric uneasiness. This generally amounts to pain, which, however, is exceedingly variable, being sometimes acute, lancinating, or spasmodic, sometimes slight, dull, and little more than soreness. Frequently there is a sense of heat or burning, which sometimes extends up the oesophagus, or over the chest, particularly on the left side, and is hence called heartburn. Instead of pain, there is often a feeling of fulness and distension, or of weight, or constriction, or of gnawing at the epigastrium, which is for the most part also, though not inva- riably, sore when pressed. The uneasiness is sometimes general over the epigastric region, or even extends under the ribs on both sides, and under the sternum; but, in other cases, it is shifting, or confined to one spot; and this occasionally answers to the particular part of the stomach affected. Fre- quently also pain is felt in other places, as in various parts of the chest, in the shoulder and arm, and in the back immediately behind the epigastrium. The sensation is seldom constant; but has exacerbations and remissions, or entirely intermits, and is generally worse immediately after eating, or during digestion. It sometimes commences at a certain period after a meal. The appetite is variable in different cases, and sometimes in the same case. Occasionally it is little affected; and, in such cases, there is reason to think that the inflammation is confined to a comparatively small portion of the sto- mach. Very generally, however, it is deranged, for the most part diminished, sometimes nearly or quite lost, and occasionally craving. In the last case, though the patient may begin to take food eagerly, yet the disposition is apt to pass away after a small portion has been swallowed, and is even followed by a feeling of disgust. Instead of a genuine appetite, there is often a sen- sation of hollowness or sinking at the stomach, and of faintness, which leads to the desire for food, and is sometimes relieved by it. The same want of the system is, in some instances, expressed by a headache or dry cough, which ceases after a meal. The patient sometimes dreads food from the remem- brance of the uneasiness it has occasioned. The taste is often vitiated, and CLASS III.] CnRONIC INFLAMMATION OF THE STOMACH. 569 substances leave an impression of sourness in the mouth after being swallowed. There is usually thirst, with a desire for cold drinks, which, if moderately taken, afford relief; while hot and stimulating drinks increase the uneasi- ness. Sometimes, however, the thirst is not greater than in health. Large quantities of gas are sometimes evolved in the stomach, which occa- sion frequent belching. The gas is in some instances inodorous, in others fetid and irritating. Eructations of sour and acrid liquids are not uncom- mon. Vomiting is also a frequent attendant. It occurs seldom at the com- mencement of the attack, but is apt to become more frequent, and at length, in some cases, attains such a degree that not a meal, and scarcely a mouthful of food can be swallowed without being discharged. It is wonderful how long patients sometimes live, and even retain their flesh, who vomit appa- rently all their food. Portions, however, must remain and be digested. The matters vomited are food, bile, mucus, sour and acrid liquors which' seem to excoriate the throat in their passage, and, in some instances, blood mixed or unmixed, fresh or altered by the action of the gastric juice. Some- times, especially in the latter stages, and when ulceration exists, a dark matter resembling coffee-grounds is discharged from the stomach, and is also found in the alvine evacuations. This is blood somewhat modified either in its passage through the epithelium, or by the chemical action of the gastric liquids. The discharge of these various substances often affords so much re- lief to the patient, that he acquires the injurious habit of throwing them up voluntarily. In some cases, large quantities of a glairy fluid like the unco- agulated white of eggs, or of the ordinary mucus of the stomach, or of a taste- less colourless liquid like saliva, are discharged, usually rather by a species of eructation than by vomiting. Constipation almost invariably exists, unless in cases in which the inflam- mation extends to the bowels. The tongue is, in some rare cases, little if at all affected ; but generally it is either coated more or less with a whitish or yellowish fur, with the reddened papilla? projecting, or is red and smooth, or has the papilla? enlarged and red- dened without other change. It is seldom so dry as in acute gastritis, but is often clammy or dryish, especially in the morning, or after sleep. In the advanced stages, it is occasionally covered with aphtha?, or a thrush-like exu- dation. This is supposed to indicate ulceration of the stomach, and is usually an unfavourable, though by no means necessarily a fatal sign. The pulse is sometimes scarcely more frequent than in health, and may even be less so. Occasionally it is irregular and intermittent. Usually, however, it is somewhat increased in frequency and tension. In some instances, there is a slight febrile paroxysm after eating; and, in the advanced stages, the pulse often becomes very frequent, and even hectic fever may set in. Except in this latter state, the skin is almost invariably dry, and sometimes harsh, with a disposition to eruptive affections of various kinds, especially urticaria. The soles of the feet, and palms of the hands, are in some persons distress- ingly hot; while in others there is a disposition to coldness of the extremities. The secretions are almost always more or less deranged. The saliva is not unfrequently sour, the bile scanty, superabundant, or deranged, and the urine variously disordered. The nutritive process is differently affected in different cases. Sometimes the patient appears not to lose flesh for a considerable time after the com- mencement of the disease, and, in a few instances, retains his fulness till near the close. But usually there is great emaciation. The sympathetic disorders of the nervous system are almost infinitely numerous and diversified. Among the more common may be enumerated headache, giddiness, perverted vision, musca? volitantes, buzzing or roaring in 570 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. the ears, dyspnoea, a dry hard cough, palpitations, violent pulsations in the epigastrium, a general feeling of uneasiness, vague pains in the extremities, and great mental anxiety or dejection, with perverted feelings, and notions amounting sometimes to hypochondriasis. The duration of the disease is usually considerable, not unfrequently for years. It seldom marches steadily forward, but is liable to frequent changes; the patient sometimes approaching to recovery and then relapsing, and going through this alternation several times before recovery or death. Under favour- able circumstances of position, constitution, and treatment, the disease very generally terminates favourably, unless complicated ; and the patient some- times recovers from the most alarming symptoms. Even large ulcers heal. But death is not an unfrequent result. It is usually preceded by great ema- ciation and debility, sometimes by hectic fever; and the patient often sinks under a complication of visceral affection, originating in sympathy with the stomach, but constituting ultimately the chief source of danger. The fatal result is sometimes immediately produced by an attack of peritonitis, conse- quent upon the escape of the contents of the stomach, through an ulcerated opening, into the cavity of the abdomen. The ulcer having destroyed nearly the whole thickness of the coats, the remaining slender portion is ruptured by some mechanical violence, as by over-distension of the stomach, the act of vomiting, or by voluntary straining. The penetration, however, of the coats of the stomach is not necessarily fatal. The diseased surface may contract adhesions with that of an adjacent viscus, the body of which thus forms a floor for the ulcer. The liver, spleen, or pancreas may serve this useful purpose. Sometimes the stomach and colon become united, and communicate so that the contents of the former escape through the latter. These results, how- ever, are more common in cancer of the stomach than in ordinary ulceration. It has been mentioned that numerous varieties of chronic gastritis exist. Sometimes the symptoms are comparatively mild from the commencement, and continue so through its whole course. In other cases, though mild in the beginning, and for a variable length of time afterwards, they gradually increase until the case assumes a serious aspect. In others again, they exhibit an alarm- ing intensity almost from the outset. In a few instances, the complaint runs on in its mildest form for a long time, and then suddenly breaks out into fatal violence. Under such circumstances, there is reason to suppose that the in- flammation may have been confined to a small portion of the stomach, but, ending in ulceration, exhibits at length evidences of great organic mischief. This condition may be suspected when vomiting of blood, or of matter like coffee-grounds, supervenes upon the ordinary symptoms of chronic gastritis. The inference, however, is by no means positive ; as both these results may occur without any solution of continuity in the mucous membrane. Perfora- tion of the stomach is another of those cases in which the course of the disease is very insidious. Every now and then a case occurs, in which the patient, previously in tolerable health, or complaining occasionally of some stomachic uneasiness, is suddenly seized with severe pain, and dies with all the pheno- mena of peritonitis. Dissection reveals an ulcerated opening in the stomach. It is desirable, in reference to treatment, to be able to diagnosticate those cases of deep solitary ulcers, which are most apt to end in perforation. Such a con- dition may be suspected when a patient, with little constitutional disturbance, complains of almost constant pain in a particular point of the stomach, in- creased by pressure and after eating, with sour eructations, occasional vom- iting, and the discharge of blood, either pure, or variously altered. An- other variety of the disease is so peculiar as to merit a separate paragraph. Under the name of gastrorrhcea, modern writers describe an affection, char- acterized by the copious discharge from the stomach of a glairy fluid, usually CLASS III.] CHRONIC INFLAMMATION OF THE STOMACH. 571 insipid and inodorous, bearing a close resemblance in appearance to the unco- agulated white of eggs, or to mucus in its ordinary form. The vomiting occurs most commonly in the morning, as if the fluid had collected in the stomach during sleep; but it may take place at any time; and a singular circumstance is, that the matter is often thrown off after eating, without a simultaneous discharge of the food. The vomiting is usually very easy, sometimes in fact little more than a species of regurgitation. The disease may be considered as a sort of catarrh of the stomach. It is sometimes attended with the ordinary phenomena of chronic gastritis ; but, in other cases, neither exhibits during life, nor leaves after death, evidences of inflammation. Still, like the similar affection of the nostrils and the bladder, it probably originates, even in the latter cases, in an inflammatory condition, or at least irritation of the mucous membrane, which has yielded to the discharge, while the membrane contin- ues, from habit, its disordered action. It is often a mild disease ; but, in some instances, runs a long course, and at last ends fatally, especially in old persons. Anatomical Characters.—The portions of the mucous membrane which have been inflamed usually exhibit a brown, grayish-slate, or blackish colour, arranged in the different modes mentioned under acute gastritis. The colour is sometimes, though rarely, red. In some instances innumerable minute black points are seen, so close together as to give the whole surface of the membrane a black or dark-gray appearance. Occasionally dull-white patches of greater or less extent, are observed, considerably lighter than the healthy membrane. The mucous coat is very often thickened, sometimes to a con- siderable extent, sometimes only in small spots. Numerous granules in some instances appear to be dispersed through the membrane, and occasionally the prominences are so large as to give to the surface a mammillated appearance. This may be owing to increased development or distension of clusters of the minute gastric glands, to inflammatory exudation in the tissue, or to both causes jointly. In some instances, the membrane is found thinner than in health. It is almost always altered in consistence, being frequently indu- rated, but still more frequently softened. Ulceration is also not unusual, though less common than in inflammation of the ileum and colon. The mu- cous membrane exhibits either slight superficial erosions, or small isolated ulcers, or a larger and deeper ulcer, which sometimes penetrates into the other coats of the stomach, or even through them. In the latter case, the stomach is not unfrequently found adhering to the neighbouring viscera, the substance of which forms the bottom of the ulcer. These solitary ulcers are round or oval, an inch more or less in diameter, with abrupt edges often thickened and indurated in old cases, and appear as though excavated out of the membrane. The ulcer is usually situated in the lesser curvature. Though generally solitary, there are in some rare instances, two or more. These ulcers are seldom or never found in persons under sixteen. The points in which chronic gastritis differs from the acute, in relation to post-mortem appearances, are, chiefly, that in the former the colour is usually dark as above stated, induration frequent, and ulceration not uncommon; while in the lat- ter, the colour is usually red, induration scarcely ever present, and ulceration rare. * * SIMPLE ULCER OF THE STOMACH.—This affection, though referred to in the text, has from recent investigations attracted so much interest, and is in itself so im- portant as to merit a fuller consideration. In using the above title, which originated with Cruvoilhier, I do not wish to be considered as implying that the affection has in it anything peculiar or specific. It is in fact simply one of the phases of inflammation; according to the views taken of that process in this work. It was first distinctly de- scribed, in the year 1830, by Cruveilhier, in his great work on pathological anatomy; having been previously confounded with cancer of the stomach. In 1839. Rockitansky cave an account of it under the name of perforating ulcer ofthe stomach. A new and valua- 572 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. It is important not to confound real pathological appearances with those which are merely cadaveric. It has been proved by Dr. Carswell that the colour of the blood, remaining in the vessels of the stomach, is often darkened ble essay in relation to it was published by Cruveilhier in the Archives Generates for February and April, 1856. Dr. Wm Brinton, of London, has also done much by his statistical researches, and careful observation and collection of facts, to give precision to our knowledge of the subject. His contributions are contained in the British and Foreign Medico-Chirurgical Review for January and July, 1856, and in the London Lan- cet (Am. ed. Jan. 1857, p. 12). Others have written upon the subject; but the following details have been drawn chiefly from the authorities above referred to. Anatomical Characters.—The ulcer is in most instances solitary; but there are not unfrequently two or more; and sometimes the ulcers run together. They may be seated in any portion of the stomach, but are most frequent in the posterior wall, the small cur- vature, and near the pylorus; these several parts having precedence in the order men- tioned. They are generally circular or oval, from two or three lines to several inches in diameter, with thickened and indurated borders, abrupt or sloping edges, and a grayish surface. At bottom they often approach almost to a point. The mucous mem- brane around them is usually somewhat reddened and inflamed. Commencing in the mucous membrane, they gradually extend in circumference and depth, penetrating in the latter direction through the areolar and muscular tissues, and not unfrequently reach- ing the peritoneum. This in many instances either sloughs, or is ruptured, and the coats of the stomach are thus completely perforated. But provision is often made against effusion and its fatal consequences, by adhesion between the stomach and some conti- guous structure, as the liver, pancreas, colon, duodenum, diaphragm, or abdominal walls, which thus become the basis of the ulcer, and may themselves be penetrated to a considerable depth. In the instances ofthe colon and duodenum, their coats may be perforated, and a communication formed between their cavities and that of the stomach. Cruveilhier states that a similar perforation of the diaphragm has taken place, and the contents of the stomach been discharged through the bronchia. When the stomach and colon are thus connected, the affection is called gastro-colic fistula. It may be supposed to exist, when, after the ordinary symptoms of an ulcer in the stomach, fecal matters are occasionally vomited, and undigested food passed by stool. Sometimes, however, no adhesions are formed, and the contents of the stomach are effused into the ab- dominal cavity, with the result of peritonitis, and inevitable death. According to Dr. Brinton, adhesion occurs in about 40 per cent, of the cases, and perforation in about 13 per cent. The latter result is relatively most frequent in the young, in whom there is a general tendency of ulceration to penetrate deeply. Hemorrhage is another serious effect of the ulcers. This takes place either from the capillaries of the ulcerated surface, from the larger blood vessels eroded in the process of ulceration, or from the vessels of the penetrated viscera: The most dangerous is that from the large arteries, as the splenic and coronary. The tendency of the ulcers is to heal, and they will generally do so unless prevented by mechanical or irritant causes. In the healing process, much contraction takes place, and the surrounding membrane thus contributes to fill the cavity ; the remainder being occupied by a firm fibrous tissue, which forms the proper cicatrix, and has frequently been mistaken for scirrhus. Around this the mucous membrane forms a somewhat ele- vated border, and exhibits radiating lines or furrows. The cicatrix is apt to become the seat of a new ulceration; and, according to Cruveilhier, perforation and copious hem- orrhage are more apt to occur from the secondary than from the primary ulcers. Symptoms.—Besides the ordinary symptoms of chronic gastritis, which are sufficiently detailed in the text, there are a few which may be considered as specially diagnostic of this affection. One of these is a circumscribed pain, usually felt at the ensiform carti- lage, and variously described as burning, pinching, gnawing, cutting, &c. It comes on after eating, either immediately, or at periods varying from five minutes to an hour, and usually continues until the stomach is emptied. There is sometimes also an equally circumscribed pain in the back, opposite to that in the epigastrium. In both cases, it is increased by pressure. Occasionally the pain shoots through from the epigastrium to the spine, or radiates from the central spot to different parts of the chest. Another characteristic symptom is frequent vomiting, almost everything that is taken being rejected; and the stomach often throwing up its own acrid secretions, quite inde- pendent ofthe ingesta. After eating there is almost always not only pain, but an al- most intolerable sense of weight and oppression; which induces the patient to favour vomiting, or even to provoke it by putting his fingers into his throat, in order to get rid of the offending cause. Very soon after the formation ofthe ulcer, the vomited matter begins to be occasion- CLASS III.] CHRONIC INFLAMMATION OF THE STOMACH. 573 by the gastric juice so as to resemble that of chronic inflammation. In this case, however, the blood has not usually been extravasated, and as it were incorporated with the membrane, as in gastritis. John Hunter long ago ally mixed with blood, which is sometimes bright and red, but more frequently some- what changed by retention in the stomach, and the action of acids on it, and not unfre- quently black like coffee-grounds. For the most part the hemorrhage is slight, but it is Bometiuies copious, so much so as greatly to prostrate the patient, and even cause death. This copious hemorrhage is apt to come on after the eating of indigestible food or a full meal; but it may occur without any obvious exciting cause. In some rare cases, death has been suddenly produced by hemorrhage into the stomach without vomiting. At the same time with the occurrence of hemorrhagic vomiting, there are also black stools, consisting of blood which has been changed in its passage through the bowels. Hem- orrhage is one of the most dangerous attendants on the gastric ulcer; exhausting the sys- tem gradually by frequent repetition, when not immediately fatal through syncope. Perforation is indicated by the occurrence of peritonitis. It is most apt to come on after a full meal. Constipation is a frequent symptom, consequent on the small amount of food which passes into the bowels. Sometimes, however, the hemorrhage appears to excite diar- rhoea, which is then accompanied with black stools. A striking general symptom is emaciation with anaemia; and, if the patient escape immediate death from hemorrhage or perforation, there is still danger of fatal exhaus- tion from defective nutrition. The affection with which ulcer of the stomach is most likely to be confounded is can- cer, wliich resembles it closely in some of its characteristic phenomena. The diagnosis will be given under cancer of the stomach. Causes.—So far as the inflammation is concerned, the causes are the same as those stated in the text; but there is something additional which gives to the affection the ulcerative tendency. I am under the impression that this results from a debilitated Btate of system produced by the mode of living, and especially the character of the diet, among the classes in Europe most liable to the affection. The statistics given by Dr. Brinton, which are upon a very large scale, are based upon hospital cases, in which this cause was peculiarly liable to be felt. According to the statistics referred to, in 2-5 per cent, of all post-mortem observations, there were open ulcers of the stomach, and in 5 per cent., evidences of present or past affections of the same kind. This is certainly much beyond anything to be met with in the United States. During more than twenty years in which 1 have been physician of the Pennsylvania Hospital, I have not met with one fatal case of simple ulcer of the stomach; and my colleague, Dr.i Pepper, assures me that his experience corresponds with my own. Nor have I seen, in the same Insti- tution, more than four cases, in which the symptoms authorized the inference that they might proceed from simple ulcer of the stomach, and of these, two at least were in foreigners. In private practice, moreover, instances of the kind are extremely rare. The difference can be ascribed only to the mode of living; and, when it is considered that every person in this country, even the poorest, uses a diet consisting largely of meat and other forms of animal food, we may, I think, justly infer that this is the chief cause of the scarcity of the affection among us. Cruveilhier states that the simple ulcer is more frequent than cancer. I am very sure that cancer here is much more frequent than the simple ulcer. The affection is twice as frequent proportionably in women as in men ; and this is probably ascribable to the same cause. All persons are liable to it after puberty ; but it is most prevalent among those of middle age, and the very old. Prognosis.—This is generally favourable when the patient can be placed under proper influences. There is nothing malignant in the character of the ulcers. Two sources of danger, however, exist, which the utmost care cannot always avert; hemorrhage, namely, and perforation. Either of these incidents may happen, in the progress of the ulcer, from accidental causes; and, even when cicatrization has taken placef there is liability to return of the ulceration, and as before stated, even greater liability, in such a case, than originally, to the two dangers referred to. Another source of incon- venience, and of ultimate danger, in cases in which the ulcer is seated at the pylorus, is the contraction attendant on cicatrization. This may cause stricture of the pylorus, with consequent distension of the stomach, and various digestive disorders, which only great caution in the regulation ofthe diet can obviate. Treatment.—Two important points, in the treatment of simple ulcer of the stomach, are to keep the or^an as much at rest as possible, and to prevent the contact of irritating substances with the diseased surface. These objects are best accomplished by the regu- lation of the diet. The directions given in the text upon this point, in reference to chronic gastritis, are equally applicable here. To these, therefore, the reader is refer- 574 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. ascertained that softening and even destruction of the coats of the stomach might take place after death, from the action of the gastric juice. This was afterwards disputed; but the fact is now established beyond reasonable doubt. Cadaveric softening is usually found in the fundus, or in that part towards which the liquids in the stomach gravitate from the position of the body. Dr. Budd states, in his work on diseases of the stomach (Am. ed., p. 16), that it is more apt to be found in hot weather than cold, as heat increases the solvent property of the juice. The presence of acid in the juice is necessary for the effect; and it is counteracted by strong alcohol. It may be confined to the mucous membrane, or may extend to the whole of the coats; which may even be perforated, so as to allow the gastric juice to exercise its solvent power on neighbouring organs, as the diaphragm and spleen. The oesophagus even red, with the caution that, in these ulcerative cases, it is necessary to support the strength by sufficient animal food, in order to favour the healing process. It is especi- ally important that no hard solid substance should be swallowed ; and everything, therefore, should be given in the liquid form, or thoroughly comminuted. Upon the whole, whatever is found to produce least pain or sense of weight or oppression should be preferred. In very bad cases, where everything is vomited, the plan recommended in the text of total abstinence from food by the stomach, and the use of enemata of rich soup with a little laudanum to support the strength, should be tried. The bowels should be kept open if necessary by enemata, or by such gentle laxatives as the stomach may best tolerate, as magnesia, solution of citrate of magnesia, castor oil, &c.; but in relation to the use of cathartics, it is better to err on the side of absti- nence than on that of interference ; for experience has shown that the bowels may often be left undisturbed for many days without inconvenience; and there is always risk from introducing offending substances into the stomach. To aid in allaying the vomiting, as well as to relieve pain, opiates are often useful. When borne by the stomach they may be given in this way ; the extract of opium, or one of the salts of morphia being preferred; but generally their effects can be more con- veniently obtained by introducing them into the rectum, or applying them to a blistered surface of the epigastrium. With the similar object of allaying the vomiting, small pieces of ice may be occasionally swallowed, if comforting to the stomach; and recourse may be had to cold carbonic acid water, the effervescing draught, or lime-water, mixed with the milk employed as food. In resuming nourishment by the mouth, in cases of entire abstinence, when the stomach begins to call for food, nothing on the whole is so suitable to com- mence with as a mixture of equal parts of lime-water and milk, given in the quantity of a fluidounce or less every hour. Repeated blistering to the epigastrium is also very bene- ficial ; and, if circumstances forbid this, dry cupping or rubefacients may be substitu- ted. When the pain is in the back, the same remedies may be applied over the spine. Excess of acid in the stomach, which is often extremely irritant, should be corrected by means of bi-carbonate of soda or potassa, lime-water, or prepared chalk, or, when a laxative effect is required, a little magnesia. When dangerous hemorrhage takes place, it should be arrested by opiates, acetate of lead, or kino; and, in alarming cases, the last-mentioned remedy should be given very freely. It is possible that ice to the epigastrium might sometimes prove useful. There is also an indication, when the ulcers are obstinate, to apply to their surface alteratives, such as experience has shown to be useful in similar affections in the mouth and fauces. The most efficient of these I believe to be nitrate of silver. If given in the form of pill, it is not immediately decomposed on reaching the stomach; but, being gradually dissolved, acts as the nitrate immediately on the diseased surface. In all the cases of suspected simple ulcer of the stomach which I have treated, I have employed it, as%tated in the text, and with favourable results. I have also repeatedly observed that its omission has been followed by a retardation of the amendment, which has again begun to advance on its resumption. Though I have not used subnitrate of bismuth in these cases, it has been highly recommended, and I can conceive that it may be useful by adhesion to the ulcerated surface, and thus protecting it against the irritating liquids of the stomach. To obviate the ulcerative tendency, attention should also be paid to the general health; and there is no reason why measures addressed to this object should not prove as useful here as in cases of chronic ulcers elsewhere. Hence an indication for the use of chalybeates, iodide of potassium, and sometimes a little sulphate of quinia; care being always taken to employ these remedies in a manner least likely to irritate the stomach. (Note to the fifth edition.) CLASS III.] CHRONIC INFLAMMATION OF THE STOMACH. 575 may be affected through the intrusion into it of the juice by pressure or po- sition. The excavations are usually in patches of various extent, with thin, soft, irregular, and sometimes fringed edges, unlike the swollen, often abrupt, and hardened borders of ulcers. Sometimes the softening is found in bands or stripes, when the stomach is wrinkled so as to bring the summit of the folds only into contact with the gastric juice. The softened parts have none of the odour of gangrene, and in fact putrefy less readily than other parts, in consequence of the antiseptic property of the juice. When the softened or excavated spots are stained of a brown or chocolate colour by the action of the juice upon the blood, the liability to form a wrong opinion is increased. One means of diagnosis is afforded by the fact, that the cadaveric softening is most apt to occur in the cases of individuals who were in good health, and had eaten a short time before death. Care must also be taken not to con- found the softening of putrefaction with that of inflammation. It is, more- over, certain, that softening may result from other morbid processes besides the inflammatory. Causes.—Chronic gastritis occasionally follows the acute; but, in the great majority of cases, it is an independent affection, resulting for the most part from long persisting, or frequently repeated irritation. The abuse of alco- holic liquors, habitual excess in eating, the employment of indigestible food as ordinary diet, and the excessive use of medicines, are among the most fre- quent causes. Congestion of the portal circulation, and the sympathetic irritation arising from disease in other organs, especially in the liver and spleen may also give rise to the complaint. It is a frequent attendant upon phthisis, especially in the latter stages; and the tuberculous diathesis com- municates to it an extraordinary obstinacy when it arises from other causes. But no disease probably is so productive of chronic gastritis as dyspepsia; and the two affections are so frequently associated, that by some authors they are considered identical. This subject will be discussed under dyspepsia. It is sufficient here to say that the chronic inflammation, which so often ac- companies or follows that complaint, may be ascribed in great measure to the constant irritation of the undigested, or badly digested, or chemically altered food, and of the acrid secretions, which take the place of the healthy stomachic fluids, in consequence of the impaired energy of the organ. Diagnosis.—The only complaints with which chronic gastritis is liable to be confounded, are cancerous and other organic affections of the stomach, gas- tralgia and analogous nervous affections, and dyspepsia. For the diagnostic characters, the reader is referred to the several diseases mentioned. Treatment.—The first and most important indication, in the treatment of chronic gastritis, is the removal of the cause. As the disease in most in- stances either arises from irritating ingesta, or is sustained by them, and in all instances is aggravated by this cause, it is indispensably necessary to sub- ject the patient to strict dietetic regulations. This, indeed, is often all that is necessary to effect a cure. But the same diet is not applicable to all con- ditions of the disease. It is necessary, in regulating it, to have reference to the stage and degree of the inflammation, and the state of the system. It must be borne in mind that the organ inflamed is that through which the system is nourished, and that, although it might be desirable in reference to the organ alone to restrict the diet most rigidly, yet the general debility may be such as to present still stronger claims to observance. Besides, the sto- mach itself may be injured by extreme abstinence, where the system is calling for support. Such are the sympathies of this viscus with the remainder of the body, that the suffering arising from deficient nutriment in every part is reflected upon it with especial force, and it may thus be irritated in the midst of starvation. In this state of sympathetic suffering, its secretions 576 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. are deranged, and themselves become an additional source of irritation. Hence, there is sometimes danger from that extreme abstinence upon which some authors have insisted; and patients have rapidly improved under a nu- tritious diet, after a long and fruitless abstemiousness. No precise rule can be laid down for all circumstances, except that in every case the food allowed should be of the kind most easily digested, as indigestible food, whether highly nutritious or otherwise, acts as a powerful irritant to the stomach. When the inflammation borders on the acute, and a slight febrile action ex- ists, with loss of appetite, farinaceous or mucilaginous liquids, such as solu- tions of tapioca, sago, arrow-root, and gum arabic, and decoction of barley, should be exclusively used. If the disease be quite chronic, and without fever on the one hand, or debility on the other, a more nutritious diet may be employed, consisting of stale bread, crackers, boiled rice, mush, and gruels; care being always taken that the solid substances should be thoroughly mas- ticated. In cases of general debility, the diet may be improved by the addi- tion^ milk or fresh cream. In some instances, great advantage will accrue from restricting the patient to milk exclusively. This is especially useful in the cases attended with obstinate vomiting. The milk may, under such cir- cumstances, be usefully mixed with one-third, or one-half, or an equal bulk of lime-water. I have found few means so effectual in relieving this exceed- ingly unpleasant form of chronic gastritis, as the exclusive use of such a diet. Patients who for weeks and months have scarcely been able to retain a meal, and who have been reduced to the lowest state of emaciation, have expe- rienced an almost immediate change for the better under this treatment. As the symptoms improve, bread or crackers may be used with the milk and lime-water, and the latter ingredient may be gradually omitted. When the debility is considerable, a more nutritious animal diet sometimes becomes necessary. Oysters raw or roasted, soft-boiled eggs, animal jellies, the white flesh of poultry and wild fowl, mutton, venison, &c, may be used; the caution being always observed to select only those meats which are easily digested. Boiled meats will also in general be preferable to those cooked in other modes. Of course, the diet will be varied in the same case according to the indica- tions ; and it will generally be proper, after persevering for a considerable time with a rigid antiphlogistic regimen, to allow a gradual improvement, as the patient is found to bear it. Attention should always be paid to the calls ofthe stomach; and, when the patient perseveringly demands certain articles of food, even though they may seem improper, the physician will often do well to allow their use, cautiously at first, and afterwards freely, should they be found, as they often will be, to agree well with the stomach. Alcoholic drinks should in all cases be scrupulously avoided, except when the habitual and intemperate use of them may render a cautious withdrawal of them advisable. Coffee and tea should also be avoided; at least, only black tea should be allowed, and that weak. The patient may drink in- fusion of cocoa, or sweetened milk and water at breakfast and tea. On the whole, however, cold water is the best beverage. Whatever drink may be allowed, it should be taken in moderate quantities at a time, so as not to distend the stomach. By the means above mentioned, without the aid of medicines, cures may often be effected; but it is necessary to persevere long, and to guard the patient against any premature relaxation of the dietetic plan. A single de- bauch, or indulgence for a short time in forbidden food, may undo the work of months. _ When there is reason to suspect the existence ofthe deep, soli- tary ulcer, it is of the utmost importance to adhere rigidly and for a long time to these rules of diet; and the food especially adapted to these cases is milk, with farinaceous substances finely comminuted, or in the liquid state. CLASS III.] CHRONIC INFLAMMATION OF THE STOMACH. 577 In some obstinate cases, attended with incessant vomiting, a system of entire abstinence from food by the stomach, the strength being supported by nutri- tious enemata of soups, with or without an opiate addition, has sometimes proved successful. I have known at least one case rescued from immediately impending death by this plan, conjoined with the use of nitrate of silver in- ternally ; and in another case, very severe but less immediately threatening, the plan succeeded, after entire failure with all others. The return to food must be very cautiously regulated. Other remedies, however, will often prove useful as adjuvants. Should the local symptoms be severe and the pulse strong, blood may sometimes be taken from the arm with advantage ; but general bleeding is very rarely re- quired. Perhaps the most effectual measure, next to a proper regulation of the diet, is local bleeding from the epigastrium by leeches or cups. Leeches are generally preferred ; asthe pressure of the cups may prove hurtful to the stomach. It is usually better to take a small quantity of blood, and to repeat the operation occasionally, than to exhaust the patient by large numbers of leeches at once. Revulsion by means of small blisters on the epigastrium, frequently repeated, or of croton oil or tartar emetic applied so as to pustu- late, is often highly useful. Should the tartar emetic, however, sicken the stomach, as it sometimes appears to do when externally applied, it should be omitted. Costiveness must be obviated by means of laxatives, or cathartic enemata, or both combined. The free use of medicines of any kind by the stomach is injurious ; but enemata are of themselves scarcely sufficient to meet the indication to evacuate the upper as well as the lower bowels. The gentlest laxatives should be selected and sparingly used. Magnesia is one of the best, as it answers the purpose of an antacid, which is often wanted. Rhubarb, castor oil, and the Seidlitz powder may also be employed. The same end may often be advantageously accomplished by a laxative diet of bran bread, or rye mush, or of stewed fruits when these are found not to irri- tate the stomach. Attention should be paid to the skin. Frictions with the flesh-brush, the warm or hot bath, according to the degree of excitement, and flannel next the skin are all useful. Opium and ipecacuanha at bedtime sometimes answer a good purpose, by producing perspiration, as well as by enabling the patient to sleep. When there is great local suffering with gene- ral restlessness, small doses of the acetate or sulphate of morphia may be given occasionally with advantage ; but care is always requisite to avoid establishing an injurious habit, which the patient may have difficulty in breaking. Hydrocyanic acid has been recommended under the same circum- stances. The feet should be kept warm, if necessary, by rubefacient applica- tions. Congestion of the portal circle, visceral disease, whether functional or organic, and, in the female, disorder of the menstrual function, should be relieved by appropriate remedies; regard being always had to the probability of injuring the stomach by irritating medicines. When the measures above detailed do not answer, recourse may be had to the alterative remedies. Subnitrate of bismuth, the sulphates of iron, zinc, and copper, and the nitrate and oxide of silver, have all been usefully em- ployed. The nitrate of silver has within a few years attracted considerable attention, and has been given in larger doses than were formerly thought ad- visable. From one-quarter of a grain to a grain is often administered two or three times a day without disadvantage. Cures, in apparently desperate cases, are sometimes obtained by nitrate of silver thus employed. I have re- peatedly seen patients rescued by this remedy, for whom all other hope had been abandoned. It has appeared to me to be peculiarly advantageous in those cases, frequently attended with vomiting, in which the tongue is smooth and glossy, as if deprived of the papillary structure. I cannot too strongly vol. i. 37 578 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. express my conviction of its great usefulness in chronic gastritis of this cha- racter. It is generally advisable to combine the metallic salts with small doses of opium, or one of the salts of morphia. In the use of nitrate of silver, I always combine about one-sixth of a grain of opium with each dose, and give them in the form of pill, beginning with one-quarter or one-third of a grain of the nitrate, gradually increased, if necessary, to a grain, three or four times a day; but never exceeding the last-mentioned quantity. Minute doses of mercurial pill, with or without ipecacuanha, according as the stomach will or will not tolerate the latter medicine, are also highly useful. A grain of the blue mass, with a sixth of a grain of ipecacuanha, may be repeated every two or three hours through the day, until the gums are very slightly touched. Tonics in the advanced stages are sometimes useful, probably by giving to the tissue, relaxed by the previous inflammation, sufficient energy to take on a healthy action, and resume its ordinary functions. The chalybeates and simple bitters should be preferred. Oil of turpentine and copaiba have also been recommended. In gastrorrhaea, which is often rather a condition consequent upon pre- vious inflammation than itself inflammatory, the treatment by the mineral alteratives above mentioned, and by tonics, is peculiarly applicable. Should symptoms of inflammation exist, they should be combatted in the ordinary manner. Should they be absent, the treatment may be commenced by an emetic of ipecacuanha followed by a calomel purge; and the bowels should afterwards be kept open by preparations of rhubarb or aloes, or a combina- tion of the two. The vegetable bitters, chalybeates, and mineral acids may be used; but most confidence is generally placed in the subnitrate of bis- muth and nitrate of silver, the latter remedy being given in the dose of half a grain or a grain twice a day. Opium or some one of its preparations may be combined with the mineral salts to relieve pain and check secretion. Chalk and the vegetable astringents have also been recommended. Copaiba and the turpentines, or their volatile oil, may be given with a view to their alterative action on the mucous membrane. These also may be usefully combined with opiates. The diet should in general be nutritious and diges- tible, consisting chiefly of farinaceous substances and animal food. During the course of the treatment, in every form of chronic gastritis, efforts should be constantly made to prevent the mind from reacting injuri- ously on the stomach, and at the same time to remove excitement from this organ by diffusing it equably over the whole system. Hence the importance of regular though not violent exercise, of relaxation from the cares and anxie- ties of business, and of agreeable mental occupation. A complete change of scene often proves serviceable. Excursions to different parts of the country, visits to the springs and to the sea-shore, sea voyages, and a residence or travelling abroad, often prove effectual, when much movement is not con- traindicated, in bringing about a cure, or confirming convalescence. Article II CANCER OF THE STOMACH. Carcinoma attacks the stomach in all its different forms, whether of scir- rhus, medullary cancer, or colloid cancer. The notion, at one time enter- tained by certain pathologists, that these tumours are simply the result of inflammation, has been entirely exploded. There is little doubt that mere effects of chronic inflammation, neglected or abused, have sometimes been CLASS III.] CANCER OF THE STOMACH. 579 mistaken for cancer; and there are also instances in which it would be diffi- cult or impossible to determine, upon a mere inspection of the diseased parts, especially in scirrhous cases, to which of these complaints they should be referred. But the microscope has removed the difficulty, so far as post- mortem examination is concerned, and has satisfactorily shown, in many of the cases otherwise doubtful, that the disease is true scirrhus, by the detec- tion of the proper cancer-cells. Symptoms and Diagnosis.—The symptoms of cancer in the stomach are so nearly those of chronic inflammation, that it is often impossible to distin- guish the two complaints during life. It is unnecessary, therefore, to notice any other characters of the disease than those to which some value has been attached in reference to diagnosis. The pain, which is almost always experienced, in a greater or less degree, and is sometimes excruciating, varies very much in its character. Lancina- ting pains have been thought to be diagnostic of cancer in the stomach, as of the same complaint elsewhere; but the fact has been well ascertained, that such pains occur occasionally in chronic gastritis, and are by no means pres- ent in all cases of cancer. Vomiting is a very common, and very distressing symptom ; but is some- times wanting; and, in many instances, is unfrequent at the commencement. At first, the patient discharges his food or a glairy mucus; afterwards, to- gether with these, sour, bitter, or acrid fluids; and, in the end, not unfre- quently, blood, or a black matter which has been compared to soot and water, or to coffee-grounds. This black vomit, which has been looked on as char- acteristic, is, in fact, common to cancer and chronic ulcerative gastritis. But, though not a certain sign, the character of the vomiting assists in forming a precise diagnosis, and sometimes points to the seat of the disease. Thus, when the food is rejected after it has been swallowed, and before it has en- tered the stomach, or when, after entering the stomach, it is retained, but quickly occasions excessive nausea and the discharge of a glairy mucus, there is reason to suppose that the cardiac orifice may be affected. If the stomach reject almost everything which it receives, after having retained it for some time, the probability is that the pylorus is occupied by the cancerous tumour, and resists the passage of the chyme. When, after frequent vomiting, the patient ceases to be troubled in this way, but is seized with a severe and ex- hausting diarrhoea, it may be inferred that the mucous membrane at the py- lorus has been destroyed by ulceration, and thus opened a wider passage. Generally speaking, when the mucous coat has become disorganized, there is less vomiting, as the sensibilities through which this action is excited reside chiefly in that membrane. The bowels are usually obstinately constipated, though diarrhoea sometimes occurs towards the close. The cachectic countenance of cancerous patients is one of the most charac- teristic symptoms. The complexion has a peculiar yellowish-white, waxen appearance, which is not often met with in other complaints. But the most certain diagnostic symptom is a tumour in the epigastrium. This is discovered at various periods in the progress of the complaint, and of course is obvious in proportion to the emaciation. It is most readily per- ceivable when in the pylorus, or great curvature of the stomach. Sometimes, however, the absorbent glands in the vicinity of the stomach are much swol- len, and other tumours in the same neighbourhood may be mistaken for scirrhus. But, when the tumour is associated with the other symptoms above mentioned, there can be little doubt of its carcinomatous character. From simple gastric ulcer, which cancer of the stomach most closely re- sembles, it may generally be distinguished by the difference in the character of the pain, which is more spasmodic and intermittent, and less localized than 580 LOCAL DISEASES.—DIGESTIVE SYSTE.M. [PART II. in simple ulcer; by the greater tenderness on pressure in the latter; by the early occurrence of black or hemorrhagic vomiting in simple ulcer, while in cancer it does not usually take place until the advanced stage; and by the differ- ence in the march of the disease, which in cancer is irresistibly onward to a fatal result, with little modification from remedies, but in simple ulcer may generally be interrupted or suspended, though it may be again resumed. The progress of cancer of the stomach, and its duration, are very variable. Sometimes the complaint runs its course in a few months, sometimes con- tinues for many years. Occasionally it appears to be latent for a long time, and then to start at once into vigorous action; and instances are not wanting, in which the symptoms have so much remitted as to give hope of cure, but have again returned with increased severity. Death usually occurs from the exhaustion of combined irritation and deficient nutrition, and is preceded in general by great emaciation, and a long and wearisome period of diversified suffering. It is sometimes hastened by ulcerative openings into the cavity of the abdomen, producing peritoneal inflammation. The tortures of hunger are added to the other sufferings, when the disease affects the cardia. Anatomical Characters.—The stomach is sometimes much contracted, with thickened coats, and sometimes greatly enlarged. The latter is apt to be the case when the pylorus is diseased. The interior surface is usually covered with a brown mucus. The cancerous disease may occupy the whole stomach, or any part of it; but is most frequent at the two orifices, and especially at the pyloric. It is sometimes limited by these orifices, and sometimes extends beyond them into the oesophagus or duodenum. The appearances vary with the period at which the patient dies, and with the character of the cancerous affection. In scirrhus, if ulceration has not taken place, the inner coats of the stomach are found in general more or less confounded together, into a whitish, indurated, semi-cartilaginous mass, from two or three lines to several inches in thickness. The peritoneal coat is much less liable to be affected than the others, and often remains free from disease. The muscular, mucous, and intervening cellular coats may often be recognized in a state of greater or less alteration. Sometimes the disease is confined chiefly to the submu- cous cellular tissue, and sometimes to the mucous membrane itself. Instead of this thickening ofthe coats, the disease occasionally consists of a roundish mass or masses, projecting from the submucous tissue, or the mu- cous membrane, into the stomach. Instead of being indurated and white, the tumour is sometimes of a soft or brain-like consistence, constituting medul- lary cancer, and sometimes red, as if injected with blood, resembling fungus haematodes. In another form of the disease, the parietes of the stomach are thickened, and, instead of their usual structure, present numerous cells sepa- rated by fibrous partitions, and filled with a gelatinous deposit. This is colloid cancer. In a more advanced state of the disease, ulcers are found with hard, elevated, and reverted edges, and a surface irregular with fungoid excrescences, and often exhibiting the open orifices of blood-vessels of considerable magnitude. They are found in different stages of their progress, showing a disposition to extend both in breadth and depth, and not unfrequently perforating the coats ofthe stomach. In this case, the peritoneal coat has often contracted adhesions with the liver, spleen, pancreas, or other neighbouring organ, the substance of which is thus penetrated by the disease, and forms the basis of the cancerous ulcer. Sometimes the adhesion is formed with the colon or diaphragm, and the contents of the stomach thus escape into the bowels or lungs. A^-ain the ulcer is seen opening directly into the cavity of the abdomen, which ex- hibits the marks of severe peritoneal inflammation. Cases are on record in which the carcinomatous affection has extended anteriorly to the abdominal parietes, or posteriorly to the spine, before the fatal issue. CLASS III.] IRRITATION OF THE STOMACH. 581 Causes.—Cancer in the stomach arises probably from the same causes as those which produce cancer elsewhere. What these causes are is uncertain. We must be content with ascribing the result to a peculiar predisposition or diathesis ; but of the origin of this we know nothing. It is highly probable that whatever irritates or inflames the stomach may call the predisposition into action. It is certain that the disease is at least aggravated by such in- fluences. The abuse of alcoholic liquors, excesses in eating, and the employ- ment of tonic and stimulant medicines, which are often administered in the early stage of cancer of the stomach, under the impression that it is dyspepsia, hasten the progress of the complaint, and perhaps call it prematurely into existence. The depressing emotions are thought to favour its production; and Napoleon, on the Island of St. Helena, may be cited as an example. The disease is exceedingly rare before puberty, and seldom occurs until after the twenty-fifth year. It is most common in middle life; but is not unfrequent in the old. Males are said to be more subject to it than females. Treatment.—This must be entirely palliative. All that can be expected is to protract life, and alleviate suffering. For this purpose, nothing is so important as to regulate the diet properly. As a general rule, no stronger drink should be allowed than water, and spices and other condiments should be avoided. The food should be mild, easily digestible, and nutritious, so as not to stimulate the stomach either by its quality or quantity. It may con- sist of the farinaceous substances, milk, cream, boiled meats, broths, oysters, &c. Nothing, on the whole, is so suitable as milk. Large quantities either of food or drink should not be taken at once. The bowels should be kept open by enemata, or by the mildest laxatives. Attention should be paid to the skin as in chronic gastritis. Acidity may be corrected by bicarbonate of soda or of potassa, or by lime-water with milk as food. A few leeches occa- sionally to the epigastrium, and revulsion towards the same place by means of rubefacients or epispastics, will sometimes prove useful by diminishing inflam- mation. To relieve the pain or distress, to quiet irritation, and promote sleep, it is necessary to resort to anodynes; and the preparations of opium are the most effectual. The salts of morphia, or the black drop, are probably the best for the purpose. The extracts of hemlock and henbane, and lactucarium may be used as adjuvants of opium, or as substitutes. Sometimes it is best to ad- minister opium or laudanum by enema, or to sprinkle acetate of morphia, in powder, upon a raw blistered surface in the epigastrium. Fibroplastic tumours and fibroid degeneration, as well as all other morbid growths and degenerations, may be seated in the stomach as elsewhere; but they are for the most part, in the present state of our knowledge, mere ana- tomical curiosities, as we are neither able to diagnosticate them, during life, with an approach to certainty, nor to use any other plan of treatment than that wliich the symptoms might suggest. Article III IRRITATION OF THE STOMACH. By this term is meant any morbid excitement of the stomach, not amount- ing to inflammation. Instances of disorder of this kind are exceedingly com- mon, although not usually associated by writers under this name, and often too much neglected in practical treatises. Though seldom in itself danger- ous, irritation of stomach is in many of its forms very distressing to the patient, and, if not arrested, often terminates in gastritis, either chronic or acute. It presents itself in a variety of forms, dependent on the tissue or 582 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. function affected, the nature of the cause, and the previous condition of the stomach or the system. It may affect the organic functions especially, the nervous exclusively, or both at the same time. Though often merely the antecedent of inflammation of the stomach, or frequently a secondary or attendant affection of other diseases, it yet has in numerous instances an in- dependent existence, and therefore requires an independent consideration. I shall treat of its different forms first in relation to the causes, and secondly in relation to the phenomena. This will necessarily lead to some repetition, but is necessary to a satisfactory view of the subject. 1. In Belation to its Causes. Irritation from Congestion of the Portal Veins.—From a sluggish state of the portal capillaries of the liver, or from other causes, the blood frequently accumulates in the veins which supply the vena portarum, and consequently in the capillaries of the stomach, wdiich is excited into morbid action by the unusual amount of stimulus. The affection is attended with a sense of fulness, weight, or uneasiness in the epigastrium, sometimes amounting to pain. The appetite is somewhat impaired, the tongue often slightly furred near the root, the stools scanty, or light-coloured from defi- ciency of bile, the complexion sometimes sallow, and the mind irritable or depressed, and disposed to view everything in a gloomy light. The condi- tion is one of those to which the name of bilious complaint is often vaguely applied. It is a frequent antecedent to bilious fevers, cholera morbus, jaun- dice, and vomiting of blood; and there is reason to believe that some of these diseases might often be prevented by its timely treatment. It occurs most commonly at the commencement, or during the prevalence of hot weather, but is found at all seasons. A full dose of the compound cathartic pill, or other active purgative combination containing calomel or the mercurial pill, with a farinaceous diet for a day or two, will frequently remove the complaint. Should the hepatic secretion not be sufficiently restored in this way, a mer- curial pill, or a grain of calomel may be given at night, and followed by a mild laxative in the morning; and this plan should be continued every day, or every other day, until the passages indicate that the liver is acting freely. Very frequently this alterative treatment will be sufficient, without the ante- cedent use of a brisk cathartic. Irritation from the Gastric Contents.—The cases are very nu- merous, in which the excitement of stomach produced by irritating substances contained in it, though so slight or brief as not to be entitled to the name of inflammation, is yet sufficiently beyond the line of health to call for the notice of the physician. The symptoms, in such cases, are exceedingly diversified. The patient generally experiences more or less epigastric uneasiness, which is of a variable character, sometimes not exceeding a morbid feeling of heat, or a slight gnawing sensation, sometimes amounting to burning pain, or cardi- algia, and occasionally gastralgic or spasmodic. Some of the most violent cases of spasm of the stomach that I have witnessed, have arisen from the presence of indigestible food. This uneasiness is frequently associated with nausea, and occasional but ineffectual efforts to vomit, or with eructations of fetid, sour, acrid, or bitter fluid, according to the nature of the cause. The pulse is generally slow, sometimes more feeble than in health, the skin often cool, and the tongue either unaltered, or slightly furred towards the root, or covered with a clammy mucus. Among the sympathetic affections are often supra-orbital headache, pains in the loins and extremities, general malaise, chilliness, urticaria or other cutaneous eruption, and sometimes stupor or coma. In children and delicate females, the nervous disorder amounts some- CLASS III.] IRRITATION OF THE STOMACH. 583 timesto convulsions. When the sympathetic affection is considerable, the gastric symptoms are usually masked, and wrong inferences may be drawn. Under these circumstances, the existence of nausea, or tenderness on pres- sure in the epigastrium, will often indicate the real seat of disease. After a variable period, either full vomiting takes place, or the contents ofthe stom- ach pass downward through the pylorus; and, in both cases, prompt relief is obtained. Occasionally, however, when the irritation has been severe and pro- tracted, the consequent depression is so great as to incapacitate the stomach, for one or two days or more, for the proper performance of its functions. Should the cause continue to act, inflammation becomes established. Excess in drinking or eating; indigestible food; substances which from idiosyncrasy disagree with the patient; acrid medicines and poisons; the pro- ' ducts of acid fermentation, or other chemical change in the food after it has been swallowed; excess of acid in the gastric liquors, and other acrid secre- tions of the stomach; bile which has ascended from the duodenum ; worms in the stomach; such are the most frequent agents in the production of this variety of gastric irritation. There is some little difference in the operation of these causes. Thus, indigestible food is most apt to produce spasm of the stomach, acid or other acrid matters to occasion cardialgia, and excess of bile probably to provoke vomiting. The results may take place in a stomach otherwise healthy, if the cause be sufficiently intense ; but, when the irritation proceeds from substances used as food, it is most easily induced by eating heartily when the stomach is temporarily debilitated, as after violent exercise, by which nervous energy has been diverted from the viscera to the muscles. The character of the offending agent may often be known by the taste or colour of the matter discharged by eructation. Worms are often indicated by a sense of choking, and frequent ineffectual efforts to vomit, as if there were some foreign body in the oesophagus. Treatment.—This is very simple. In mild cases, abstinence or the use of a very restricted diet for a day or two will be sufficient. In severer cases, the most effectual remedy is an emetic. When the patient is disposed to vomit, large draughts of warm water, or of warm chamomile tea, will often be suffi- cient to evacuate the stomach. I have seen the most violent stomachic spasm, which had resisted powerful anodynes and nervous stimulants, give way im- mediately after vomiting produced by a copious draught of warm molasses and water. When an emetic is necessary, ipecacuanha should be preferred, and its administration accompanied with free dilution. Large draughts of warm water sometimes prove useful without emesis, probably in part by diluting the acrid contents of the stomach, in part by promoting the peristaltic motion downward by means of the distension they occasion. After the evacuation of the stomach, an aperient may often be advantageously given; such as mag- nesia, one of the saline cathartics, especially the Seidlitz powder, castor oil, infusion of rhubarb, &c. If the cause of irritation be an acid matter, the antacids may be resorted to originally. Magnesia is the most efficient; but the carbonates and bicarbonates of soda and of potassa, and, in cases of en- feebled stomach, some one of the preparations of ammonia, particularly the aromatic spirit, may be used. Powdered charcoal has been recommended, and is probably sometimes useful by absorbing the irritating matters. The remedies applicable in the case of worms will be mentioned, when the effects of these parasites are treated of. Should spasm continue after the removal of the cause, it must be treated, as hereafter indicated, by anodynes, nervous stimulants, and revulsives to the epigastrium. Irritation from Gout and Rheumatism.—These diseases affect- ing the stomach sometimes produce inflammation, but more frequently irrita- tion merely, which may be seated in the mucous membrane, or in the muscular 584 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. coat. In the former case, it is attended with a vague uneasiness in the epi- gastrium, and all the other symptoms which characterize dyspepsia, so that it would be difficult to distinguish the affections except by reference to the mode of onset and of relief, which in gout and rheumatism are often sudden, being consequent the one upon a retrocession of the disease from some other part to the stomach, the other upon its transfer again to the original seat, or elsewhere. Even when the gouty or rheumatic seizure occurs primarily in the stomach, it may generally be recognized by its disposition to alternate with pains in other parts. When the affection is seated in the muscular coat, it generally pro- duces spasms, which in some cases are exceedingly violent. The remedies especially applicable to the gouty or rheumatic disease have been treated of elsewhere. It is sufficient here to say that, when the gastric symptoms are urgent, revulsion towards the extremities should be effected by sinapisms or hot and stimulating pediluvia, and the local symptoms relieved by anodynes, given either by the mouth or by the rectum, according as the stomach is re- tentive or otherwise. When the affection is purely spasmodic, nervous stimu- lants may be conjoined with the anodyne. Emollient and anodyne applications to the epigastrium may also be used ; but by far the most efficient external remedy is a sinapism of pure mustard immediately over the stomach, kept on for half an hour or an hour, or as long as the patient can well support it. Irritation from Spinal Disorder, &c—Gastric irritation arising from functional or organic disorder in the spinal marrow, semilunar ganglia, or other sources of nervous supply to the stomach, is a very common affection, especially in females, and is often very injuriously confounded with dyspepsia. It is attended, in different cases, by almost every variety of symptom by which the stomach is capable of expressing its suffering. All kinds of pain men- tioned under chronic gastritis are occasionally experienced, from the vague distressing uneasiness of epigastrium so common in dyspepsia, up to violent spasm. The uneasiness referred to is sometimes more intolerable than acute pain, and is occasionally attended with great restlessness, mental dejection, and even with convulsions. In some cases the most prominent symptom is vomiting, which is incessant and excessive, so that the patient can retain scarcely anything upon the stomach. The tongue is generally clean, or but slightly furred, and the appetite very variable, being in some cases wholly wanting, and in others unimpaired. Occasionally slight febrile symptoms appear. The duration is altogether uncertain, sometimes for a few hours only, sometimes for days, weeks, and even months or years. It is obvious that those cases must be the most obstinate, which depend on organic disease of the spine. Such cases are easily recognized. So also are those in which the spine is painful on being pressed, in the region opposite to the stomach. The most obscure cases are those in which the ganglia or nervous plexuses are the source of the mischief. The cause of these must always be more or less conjectural. It is important, in doubtful gastric affections, to make pres- sure on the spinous processes of the vertebra?; as very often a seat will thus be discovered for the effectual application of remedies. Treatment.—This must be directed especially to the spine. It will be vain, as a general rule, to address remedies to the stomach. Temporary relief may be obtained from anodynes, especially, according to M. Barbier, from the pre- parations of codeia, when the solar plexus is the source of irritation; but the symptoms return wdth undiminished force upon the suspension of the medi- cine. The most effectual remedy is leeching or cupping upon the spine, at the point where tenderness is discovered upon pressure. Almost instant re- lief is sometimes obtained in this way. It is often, however, necessary to repeat the local bleeding, and, in some cases, several times before a cure is accomplished. When the complaint does not yield to this remedy, blisters CLASS III.] IRRITATION OF THE STOMACH.—CARDIALGIA. 585 may be applied over the spine at the spot affected ; and, in cases of a chronic character, pustulation by croton oil or tartar emetic, sustained for a consi- derable time, will be found very useful. In very obstinate cases, setons, issues, or moxa may become advisable. The diet should consist chiefly of farinaceous substances, as stale bread, crackers, boiled rice, gruels, Chronic Enteritis.—This may follow the acute disease, or may be the direct result of the same causes, operating with less force, or upon a less sus- ceptibility. Diarrhoea is even more characteristic of chronic than of acute enteritis. Most cases of very obstinate diarrhoea are, in fact, nothing more than chronic inflammation of the bowels. The frequency, quantity, and quality of the stools vary exceedingly. Sometimes the number does not exceed two or three in twenty-four hours, sometimes the patient enjoys no rest from their recurrence ; and this diversity is often found at different periods of the same case. The amount discharged is in some instances trifling, in others exceed- ingly abundant. In character, the evacuations are not unlike those of acute * R— Cretae Ppt , vel Testae Ppt. ^ij ; Pil. Hydrarg. gr. viij ; Tinct. Opii gtt. xxx ; Acacme pulv., Sacch., aa sriss; Aquaj Cinnam. f£j; Aq. fluvial, fgiij. Misce. S. A tablespoonful for an adult every two, three, or four hours; to be diminished for children. f R.—Acid Nitromuriatic. gtt. xl; Tinct. opii gtt. xl; Aquae fluv. fgviij. Misce. S. A fluidounce to be taken six times a day, diluted with water, in a glass vessel. CLASS III.] INFLAMMATION OF THE SMALL INTESTINES. 621 enteritis. Occasionally portions of false membrane are discharged, and, in some rare instances, tubes of considerable length, obviously the result of a plastic inflammation, throwing out coagulable lymph upon the surface of the mucous membrane. Such cases are apt to be somewhat tedious, but may nevertheless do well in the end.* In the advanced stages of the complaint, the evacuations are sometimes mingled with pus, which is an unfavourable sign. There is generally more or less pain; and strong pressure, or any sudden jar, as in coughing or jumping, occasions uneasiness. Sometimes the pain is severe, and, though relieved after each evacuation, returns so fre- quently as to keep the patient in almost constant distress. In many cases, it * Peculiar Eruptive or Pseudo-membranous Inflammation ofthe Bowels. Prof. Simpson, of Edinburgh, so long since as 1846, called attention, in the Edinburgh Monthly Journal, to a peculiar morbid condition of the bowels, prevalent in that city, which he considered to be essentially an eruptive affection of the alimentary mucous membrane. (Boston Med. and Surg. Journ., May 3, 1855.) He spoke of this to me, when upon a visit to Edin- burgh in 1848, and told me that he was using the arsenical solution as a remedy, which had been suggested to him by the supposed analogy between this intestinal affection and the cutaneous eruptions. In the Ed. Medical Gazette for December, 1849 (p. 257), Dr. W. Cumming, of the same city, described a variety of pseudo-membranous inflammation of the bowels, which, from its characters, I presume to be the same affection as that referred to by Dr. Simpson, and which has been noticed in preceding editions of this work. In the Boston Medical and Surgical Journal (May 3, 1855, p. 257), is a commu- nication containing in greater detail the views of Prof. Simpson in reference to the pa- thology and treatment of the disorder. From these sources the following account has been prepared. A frequent attendant of the disease, if not a pathognomonic symptom of it, is the appearance in the passages of coagulated mucus or fibrin, sometimes in the form of shreds, pellicles, or stringy tape-like or worm-like pieces, and sometimes in soft shape- less masses, or diffluent and gelatinous. This phenomenon is not considered as an essential attendant on eruptive complaints of the bowels; but, when seen, may be re- ceived as an evidence of the existence of this particular affection. Other characteristic symptoms, according to Dr. Cumming, are a feeling of emptiness or faintness in the epigastrium, a more or less fixed pain in the left hypochondriac or iliac region or both, an appetite and digestion not materially impaired, and pain in the route of the colon an hour or two after eating. The bowels may be either loose or constipated. There is great nervous disorder, producing sleeplessness, unpleasant dreams, mental depres- sion, hallucinations, &c. This condition of the nervous system is also referred to by Dr. Simpson, who mentions, moreover, among the symptoms, general debility and ema- ciation, without any very appreciable cause; impaired memory; sensations of prick- ing or numbness in the extremities; a dry and inactive state of the skin, with occasion- ally an eruption coexistent or vicarious with intestinal irritation; and often sensations of heat, soreness, distension, and uneasiness rather than pain in some part of the bowels. Ln general, direct evidence of the tendency to mucous eruptions is afforded by small ulcers, or eruptive affections on the visible mucous surfaces, as the mouth, fauces, and nostrils, which appear and disappear, sometimes almost periodically, and are occasion- ally attended with a slight febrile movement. The appetite is little affected, unless the ** stomach participates in the disease. Prof. Simpson treats the affection on the same principles as cutaneous eruptions, giving alkaline medicines, &c. in the periods of aggravation, but depending for cura- tive effect mainly on pitch or tar, and the preparations of cerium and of arsenic. The remedy which, after the failure of all ordinary measures, has been found suc- cessful in these cases by Dr. Cumming, is electro-galvanism, which he believes compe- tent of itself to the cure of almost every case, and, aided by the internal use of tar, which was suggested by Dr. Simpson, will cure the disease both certainly and promptly. Dr. Cumming used the instrument of Kemp, of Edinburgh, which supplies a continuous stream of any required intensity without a "jerk or shock." He connects pieces of sponge to the extremities of the two conducting wires, applies one to the spine in the lumbar region, and carries the other from point to point on the abdomen over the tract of the colon. One of the peculiarities of its action is to develope pain, or extreme tenderness, in the affected parts of the bowel. It has the effect of keeping the bowels duly open. The remedy should be applied for fifteen minutes daily, and used perse- veringly. The tar is to be given in pill or capsule three times a day. (Note to the fifth edition.) 622 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. comes on at a certain period after eating, indicating the time at which the ingesta reach the spot affected. The abdomen is sometimes very flat, some- times much distended, and even tympanitic. The appetite is often craving, and seldom wholly wanting, unless when the stomach participates in the dis- ease. Occasionally, the system scarcely evinces any other signs of sensibility to the local affection than a diminution of strength, and a more or less rapid emaciation. Generally, however, the pulse is somewhat increased in fre- quency, the tongue slightly furred, and the skin dry and harsh. In bad and protracted cases, the tongue is sometimes red, smooth, and dry, or aphthous, and the pulse very frequent. The spirits are usually depressed, sometimes greatly so, the patient being gloomy, morose, or irritable, dwelling on nothing but his own suffering, and seeing no hope before him. The mental disturb- ance amounts, in some instances, to insanity, which may be very obstinate. The stomach not unfrequently participates in the inflammation, and then all the symptoms of chronic gastritis are superadded. The duration ofthe dis- ease is exceedingly variable. It may be cured within a week or two from the commencement of treatment, or may run on for years. When of long dura- tion, it generally undergoes numerous vicissitudes ; the patient being at one time much relieved or nearly well, and then again relapsing, upon some new exposure, or even without obvious cause. Towards the close of fatal cases, hectic fever usually takes place, and the patient becomes much emaciated. Besides the usual marks of inflammation in the mucous membrane, the surface, upon dissection, often appears strewed over with enlarged or ulcer- ated follicles. Ulcers are even more common in this than in the acute form of the disease. The mesenteric glands are sometimes found enlarged, and even suppurating. The causes are the same as those of acute enteritis. A tuberculous dia- thesis strongly predisposes to the complaint; and, in very obstinate cases, which cannot be traced to cancerous disease of the bowels, or other obvious cause, there is great reason to apprehend that tubercles may have been developed in the mucous membrane. Chronic enteritis is a very common attendant upon the advanced stages of phthisis. Treatment.—One of the most important parts of the treatment is the re- gulation of the diet. As the appetite is often unimpaired, and sometimes craving, the patient is constantly tempted to transgress, both in the quantity and quality of his food ; and this is one of the chief causes of the occasional obstinacy of the complaint. The dietetic rules applicable here are so nearly the same with those already given under chronic gastritis, that it is unneces- sary to repeat them. The particular kind of food which, on the whole, is most suitable, is milk ; and patients will frequently get well without medicine, if confined to that article exclusively. But, as it would thus be very irksome, it may be taken with stale bread or water-crackers, or boiled and thickened with wheat or rice flour, arrow-root, Carrageen moss, &c. A decoction of Iceland moss with milk is sometimes useful, as well by its tonic as its nutri- tive properties. When the debility is considerable, it is necessary to have recourse to animal broths, &c. (See Chronic Gastritis.) General bleeding is seldom admissible in chronic enteritis; but occasional leeching may be resorted to with great advantage. Laxatives are required only when the bowels are slow, as sometimes though rarely happens, or when an accession of irritation arises from acrid accumulations. Opiates are almost always indicated. They prove useful by relieving pain, moderating secre- tion, and quieting that excessive action of the bowels which is itself injurious to the complaint. Opium may be used in the manner recommended for acute enteritis, or in small doses combined with the various remedies wliich may be given to meet other indications. I have found the camphorated tincture CLASS III.] INFLAMMATION OF THE SMALL INTESTINES. 623 of opium an excellent preparation in this complaint. A fluidrachm of it given three or four times a day, is, in many cases, the only medicine which will be required, in connection with a properly regulated diet. Acid in the bowels may be corrected by cretaceous preparations, as in the acute form. The astringents, as kino, catechu, rhatany, logwood, alum, acetate of lead, &c, sometimes answer a good purpose, when the inflammation is very moderate, and its consequences, rather than the affection itself, are to be combatted. (See Diarrhoea.) They should be combined with an opiate, and often form a good addition to cretaceous mixtures. But not unfrequently they either fail to arrest the discharge, or, by arresting it, aggravate the inflammation, produc- ing an increase of pain, abdominal distension, fever, &c. When such results occur, the astringents should be immediately omitted; and, on the whole, they should be used with much caution. There is, however, a set of mineral substances, which, independently of their astringent properties, exercise an alterative influence over inflamed and ulcerated surfaces, which renders them highly useful in some cases. Of these sulphate of copper is one of the best. In the dose of one-sixth or one-quarter of a grain, combined with from a sixth to a twelfth of a grain of opium, and given every three or four hours, I have seen it do great apparent good in obstinate cases of chronic enteritis. To be effectual, it must be continued for a considerable time. The nitrate and oxide of silver with opium have also been highly recommended, and sul- phate of zinc may be similarly employed. Oil of turpentine and copaiba sometimes prove useful through their alterative influence over the mucous membranes. I have found the oil especially useful in those cases in which the tongue is destitute of fur, smooth, and perfectly dry. They should be given in emulsion, and, like the other remedies, combined with an opiate. Tar-water is also sometimes useful; and creasote is thought to exercise a similar influence. In some feeble cases, the simple bitters, sulphate of quinia, and the chalybeates are serviceable by imparting a degree of tone to the ulcer- ated and relaxed mucous surface, which is necessary to the curative process. In conjunction with the above measures, the warm or hot bath is highly important; the former being preferred when the temperature of the skin is above, the latter when it is at or below the healthy standard. In the latter case, the warm salt-bath is an admirable remedy. It should be given daily, and may sometimes be advantageously repeated twice a day. Frictions to the surface are also useful. When the symptoms are somewhat acute, a large blister may be usefully applied over the whole abdomen; and a small blister near the affected part, frequently repeated, or kept open by stimulant dress- ings, will often be found beneficial in ordinary cases. Pustulation with tartar emetic or croton oil may be tried, when the complaint is obstinate. The pa- tient should always wear flannel next the skin; and a broad flannel roller passed frequently round the abdomen is sometimes of service. Should other means fail, recourse should be had to a mercurial impression, which should not be carried beyond a very slight effect upon the gums, and should be sustained for a considerable time. Obstinate cases often yield speedily to this remedy. In cases attended with the discharge of false mem- brane in considerable quantity, an alterative course of mercury should be im- mediately instituted. Iodide of potassium might be found useful in the same cases, and oil of turpentine and creasote have been specially commended. Moderate passive exercise, mental recreation, relaxation from business, sea- bathing, a journey into the country, a sea voyage, and a residence abroad may be resorted to, as recommended in chronic gastritis, when the condition of the disease, or the circumstances of the patient, do not forbid them. 624 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. 3. DYSENTERY. Syn.—Inflammation of the Large Intestines.—Colitis.—Colo-rectitis.—Bloody Flux. Dysentery is inflammation of the mucous membrane of the colon and rec- tum, characterized by small mucous or bloody evacuations, griping pains in the abdomen, straining at stool, and tenesmus. Inflammation in the colon, without these phenomena, would rank under enteritis. Dysentery may be acute or chronic. 1. Acute Dysentery.—The disease may occur with or without pre- monitory symptoms. In the former case, it is preceded by general uneasiness, lassitude, impaired appetite, dull or transient pains in the abdomen, costive- ness or diarrhoea, and other evidences of moderate intestinal irritation. Some- times the local symptoms make their appearance before those of a general character; and, in very mild cases, of moderate extent, the disease may run its course without fever. Sometimes the local and febrile phenomena com- mence simultaneously, the patient being attacked with a chill almost at the moment that he begins to complain of pain and tenesmus. Again, the fever often precedes, and occasionally for a considerable period, any evidence of disorder in the bowels. In such cases, however, the dysentery is usually a mere attendant upon some other disease. We are presented, in different cases of dysentery, with a regular gradation in severity, from a very slight affection, occupying but a small extent of the rectum and colon, unattended with fever, and passing off in two or three days, up to one of the most violent and dangerous forms of disease to which the human frame is liable. This diversity is dependent partly on differences in the activity of the cause, and the susceptibility of the patient; but it is im- portant to recollect, that it may also depend upon the degree in which the disease is simple or complicated. Generally speaking, mere mucous inflam- mation of the large intestines is a mild affection ; but it is very frequently associated, at the outset, with disease in some other organ or organs, or with some morbid state of the system at large, which, in various degrees, compli- cates the symptoms, and increases the danger. I shall first describe simple dysentery, and then allude to its more frequent combinations. In the beginning of a case of simple dysentery, there are usually griping pains in the abdomen, technically called tormina, irregular in their position and periods of recurrence, and attended with discharges from the bowels, by which they are partially relieved. After a very short time, a sense of weight, burning, or other uneasiness is experienced in the rectum, with a painful and frequently returning inclination to go to stool, without the ability to evacuate anything more than a little bloody mucus. This feeling of tenesmus increases, and at length becomes the most striking feature of the case ; the abdominal pains appearing to concentrate themselves in some measure about the rectum. The calls to stool are very frequent, in some cases almost incessant; are attended with much straining, so much so as sometimes to produce prolapsus ani, especially in children; and are followed by only partial relief. The dis- charges often occasion a burning or cutting pain in the anus, which leads the patient to dread their return, and to resist the disposition as long as possible. The passages are seldom less than a dozen in twenty-four hours, are often double or triple that number, and sometimes, in very bad cases, have been known to amount to one hundred and even two hundred. After the first few evacuations, which are often more or less fecal, the stools are very small, and consist of transparent or whitish mucus, or of mucus mixed with blood, and sometimes of almost pure blood. With these, as the complaint advances, a CLASS III.] DYSENTERY. 625 little vitiated bile, and shreds or patches of false membrane, or small masses of coagulated matter, are occasionally intermingled ; and, in some instances, small hardened lumps of feces called scybala are discharged, though these are less common than might be inferred from many published accounts of dysen- tery. Feculent evacuations are almost always followed by considerable relief. At first the discharges have little smell; but after a time they acquire a disagreeable odour, almost peculiar to dysentery, and quite distinct from the feculent. The bladder and urethra sometimes sympathize with the rectum, and along with the tenesmus there is frequent and difficult micturition. In females, the vagina may participate in the same irritation. There is generally more or less tenderness in the abdomen ; and the extent of the inflammation upwards, along the colon, can sometimes be traced by ascertaining in what parts pain is produced on pressure. When the tenderness is observed across the epigastrium, and along the right side, there is reason to believe that the inflammation has reached the transverse and ascending colon, and that the whole of the large intestines is involved. There is always fever, except in cases of very small extent. The pulse is accelerated, and usually somewhat full and forcible, the skin warm and dry, the urine scanty, the tongue moist and covered with a whitish fur. The secretion of bile is generally diminished. Occasionally, in cases of some severity, the vital forces sink temporarily under the violence of the impres- sion made on the nervous system. The patient experiences an indescribably painful feeling of hollowness or sinking in the abdomen, attended with a cold damp skin, a feeble and almost threadlike pulse, and sometimes nausea and vomiting. This condition, however, soon passes over, as the acrid secretions descend. In the simple form ofthe disease above described, vomiting is not frequent; and the symptoms of cerebral affection are still less so. In the vast majority of cases, the disease takes a favourable turn between the sixth and tenth days, and the patient recovers. Sometimes, however, from the extent and severity of the inflammation, symptoms of depression appear at the outset, and the system never fairly reacts. Here the same condition appears to exist continuously, which has been above described as occurring occasionally in milder cases. The nervous system yields to the violence of the first shock, and is unable to react under the continued violence of the dis- ease. The patient has, throughout, a very small, feeble, and frequent pulse, a pale, cool, and clammy skin, anxious and sunken features, and a somewhat livid or purplish appearance under the eyes, about the lips, and at the roots of the nails ; while, at the same time, there is extraordinary violence in the local symptoms, with much tormina and tenesmus, incessant discharges, tense and tumid abdomen, and great tenderness on pressure. Such cases prove fatal in a few days. They are happily very rare, and I have seen them only during epidemics. Danger much more commonly accrues from a continuance of the disease, in ordinary cases, beyond a week or ten days. Should the symptoms not give way by that time, they are all apt to become aggravated. The tormina and tenesmus increase; the abdomen becomes swollen and more tender; the dis- charges, more frequent; the pulse, weaker and more rapid; the tongue as- sumes a dryish and brownish appearance, or throws off its fur and becomes red, smooth, and sometimes gashed ; the patient is weak, exhausted, and very restless ; the stools are more copious and offensive, and, instead of consisting chiefly or exclusively of mucus or blood, are mixed with puruloid matter, sanies, or vitiated secretions from the upper bowels, and are sometimes nothing more than a kind of bloody serum (lotura carnium). Even after the worst of these symptoms, however, the patient may recover, though the convales- cence is usually tedious, and the case not unfrequently runs on into the chronic VOL. i. 40 626 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. form. Should the event prove unfavourable, a set of symptoms usually super- vene, wliich will be mentioned under the head of prognosis. Bilious Dysentery.—In almost all cases of dysentery, the bilious secretion is somewhat diminished; but, in the simple form of the disease, this may be considered as nothing more than a result of the colitis, in like manner as the dry skin and scanty urine. But occasionally disorder of the liver and stom- ach attends the disease from the beginning, being the result of causes either identical or coexistent with those which produce the intestinal affection. The complaint, under these circumstances, is sometimes called bilious dysentery. It is characterized by a feeling of oppression in the epigastric region ; more frequent vomiting ; occasional yellowness, in various degrees, of the tongue, conjunctiva, skin, and urine; a higher degree of fever; a greater tendency to delirium ; and either an entire absence, morbid increase, or depraved condi- tion of the biliary secretion. It is this complication which adds so much to the violence and danger of dysentery, occurring in tropical climates. Adynamic Dysentery.—Another form of the disease is that which occurs in individuals previously exposed to the action of various depressing causes, as in ships, prisons, besieged towns, camps, and marching armies, in which ex- posure to wet and cold, unwholesome or insufficient food, fatigue, and wretch- edness of every kind, combine with a contaminated atmosphere to prostrate the vital powers, and vitiate the blood. The same influence is sometimes exerted by certain epidemic constitutions of the air. Under these circum- stances, along with the symptoms of ordinary dysentery in an aggravated degree, are those of malignant, typhoid, or scorbutic disease; such as nausea and vomiting; great thirst; a frequent, feeble, irregular pulse; a foul, brown or black, dry tongue, with sordes about the teeth ; a dusky skin, sometimes hot, sometimes cold, and occasionally marked with petechia?, dark livid spots, gangrenous vesications, &c.; reddish, brown, or black stools, more copious than in the simple disease, and excessively fetid, or large hemorrhagic dis- charges, consisting often of altered uncoagulable blood; great prostration of strength even from the beginning ; and, finally, various evidences of nervous disorder, as anxiety, depression of spirits, headache, low delirium, subsultus tendinum, and stupor. All these symptoms are not found in every case, but are variously mingled, and in various degrees; sufficient generally existing to indicate pretty clearly the character of the affection. In the worst cases, the patient appears to be struck with death from the very beginning, and the disease proves fatal in a few days. In all cases, the danger arising from the mere colitis is very much increased by the complication. When the causes producing this form of dysentery unite with those which produce the bilious variety, we have occasionally a combination of symptoms unsurpassed in ma- lignancy by those of any other disease. Intermittent and Bemittent Dysentery.—Dysentery is not unfrequently associated with other diseases. It is very common in miasmatic countries, and during the prevalence of epidemic intermittent and remittent fevers, sometimes apparently occurring as a distinct disease more or less modified by the prevailing atmospheric influence, sometimes in connection with the proper miasmatic fever. In the latter case, the colitis may come on as a mere acces- sory of the fever, after it has continued a greater or less length of time, or it may first occur, and the miasmatic fever afterwards set in. When a decided fever, preceded by chill, has existed for one, two, or three days before the dysentery begins, there can be little doubt as to the nature of the case. Greater difficulty is presented when the two occur simultaneously, or when the fever is the last to make its appearance. Generally speaking, however, such cases may be distinguished from uncomplicated dysentery, by their par- oxysmal tendency. The fever is aggravated at a certain time every day or CLASS III.] DYSENTERY. 627 every other day, and in the interval either relaxes or entirely intermits ; the dysenteric symptoms undergoing, to a certain extent, the same change. There is, moreover, during the paroxysm, more flushing of the face, pain in the head, tendency to delirium, general arterial excitement, and nervous disorder, than usually attend an attack of pure colitis; and the appearance of perspi- ration at the subsidence of each paroxysm is an almost certain diagnostic symptom. I have known dysentery to be intermittent, occurring paroxys- mally and violently every other day, with very little disease of any kind in the intervening day. A correct diagnosis in these cases is important, because essential to the proper course of treatment. Typhous Dysentery.—Dysentery is also sometimes associated with proper typhus fever. I have already treated of that form of the disease, in which symptoms resembling those of typhus attend it, in consequence of a previous or coexisting adynamic state of system. In that case, however, the fever is the result of the colitis, and the peculiar phenomena flow from the diminished energy of the solids, or the vitiated state of the liquids. But I now allude to the coincidence of dysentery with a distinct febrile disease, the result probably of a peculiar poison, which exists altogether independently of the bowel affection associated with it. Such cases occur during the prevalence of typhous epidemics. It is not so important, in a therapeutical point of view, to make an accurate diagnosis here as in the former variety; because the practice must be regulated by the obvious condition of the system. But these cases are interesting in reference to the question of the propagation of dysentery by contagion. Authors speak also of rheumatic dysentery; but this is not distinguishable from the disease arising from ordinary causes, except sometimes in the mode of its attack, when the irritation is suddenly translated from some other seat to the large intestines. Besides the complications which have been mentioned, colitis may coexist with gastritis, enteritis, enteric fever, and various other diseases, local or general; in which case, the symptoms will of course be modi- fied by combination with those of the associated affection. Epidemic dysentery is frequently spoken of as if it were a peculiar form of the disease. But this is not the case. Every variety of the affection above referred to may occur epidemically, according to the peculiar influences which may be conjoined with the special cause of the colitis. Thus, the disease may be quite uncomplicated; it may be associated with results of miasmatic in- fluence, as frequently happens in our own country; or it may exhibit the con- joined action of the typhous poison, as in the epidemics of Ireland. There is, however, in general one important characteristic of epidemics of dysentery; namely, that they are apt to be attended with evidences of malignancy, and that, on the whole, the disease is much more violent than when it occurs spo- radically, or as the result of ordinary causes. Prognosis.—When dysentery is about to terminate favourably, the pains gradually become less frequent and severe, and tenesmus diminishes, the stools become more copious and less frequent, and assume a fecal or bilious character, and at length nothing but a slight diarrhoea remains, which soon ceases. On the contrary, a sudden cessation of the tormina and tenesmus, the occurrence of tympanites, coldness of the extremities, or a cool clammy state of the skin in general, a livid or purplish hue about the nails, a very feeble, frequent, and irregular pulse, hiccough, involuntary stools, delirium, subsultus tendinum, and stupor, are symptoms of the most unfavourable kind, and together por- tend a speedy and fatal termination. Death may result in dysentery from a failure of the powers of life under the intensity of the irritation, from general debility, from gangrene, or from the continued wearing and exhausting effect of the combined inflammation and discharge. The longer the disease con- 628 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. tinues without amendment, the greater is the danger; and a persistence beyond the fourteenth day may itself be looked upon as a ground for great solicitude. The danger is also proportionate to the extent of the colon involved, and, if tenderness be discoverable upon pressure along its whole tract, indicating a similar extent of the inflammation, the prognostication is unfavourable. Ordi- nary sporadic cases of dysentery, in temperate climates, are seldom fatal. It is when prevailing epidemically, or among great masses, as in armies and garri- sons, or in the miasmatic districts of tropical countries, that it is most malig- nant; and, under these circumstances, it sometimes commits terrible ravages. Anatomical Characters.—The mucous membrane of the rectum and lower portion of the colon always evinces signs of inflammation, in cases of death from dysentery. The inflammation is sometimes diffuse, affecting the whole membrane equally, in other cases is seated especially in the solitary glands, or in the mucous follicles, as evinced by the greater prominence of these structures. The membrane is much reddened and thickened, and not unfre- quently ulcerated. Ulcers, in fact, exist in this disease much more frequently than in any other acute inflammation of the alimentary canal, unless in the enteric affection of typhoid fever and smallpox. They are either small and roundish, or large and irregular from the confluence of the smaller, have usu- ally an abrupt edge, and are often covered with a concrete exudation having the appearance of a slough. In some cases, almost the whole of the mem- brane is covered with a coating of coagulated lymph, upon the removal of which it appears red and swollen, but without loss of continuity. Occasion- ally real gangrenous sloughs are found; and cases are mentioned in which very large portions of the mucous membrane have been removed, probably by a combination of mortification and ulceration. In many cases, the redness, thickening, and ulceration extend beyond the mucous membrane, and some- times involve the whole of the parietes of the bowel, unless, it may be, the peritoneal coat. Perforation of the latter coat is exceedingly rare in dysen- tery. In protracted cases, the mesenteric glands are enlarged and softened, though seldom or never in a state of suppuration. In some instances, evi- dences of inflammation have been found extending throughout the colon, into the small intestines, and, it is said, even to the stomach. The liver is fre- quently diseased, especially in the dysentery of tropical latitudes. Out of twenty-five fatal cases examined by Dr. Parkes in India, seven were affected with hepatic abscess; and about the same proportion has been found by others. In the adynamic or malignant variety, gangrene is much more frequently observed than in ordinary dysentery, and the mucous membrane, when not mortified, exhibits a dark-purple or livid appearance. Causes.—A predisposition to dysentery is produced by the continued in- fluence of heat, augmenting the excitability of the alimentary mucous mem- brane, disordering the hepatic function, and relaxing the surface of the body so as to render it more susceptible to the influence of cold. Under these cir- cumstances, causes will often produce an attack of the disease, which, under others, are wholly inoperative. One of the most common of the exciting causes is cold, especially when combined with moisture. Hence the frequency of dysentery among persons exposed to the cold dampness of night, after having been much heated during the day. The perspiration is checked, and excitement thus directed inward; while the hepatic secretion is at the same time arrested, and congestion of the portal circle, and consequently of the mucous membrane of the bowels results. Substances directly irritant in their action on the bowels are often exciting causes. Among these may be mentioned unripe and acrid fruits, ripe fruits in large quantities, vegetables of difficult solution in the stomach, and unwholesome and indigestible food of all kinds; acid and imperfectly fermented alcoholic drinks, such as cider, CLASS III.] DYSENTERY. 629 weak wines, malt liquors, etc; putrid water; drastic purges; worms; and feculent accumulations in the large intestines. Formerly much importance was attached to collections of hardened feces as the cause of dysentery, and undoubtedly they occasionally produce or aggravate the complaint; but they are much less influential than was supposed. Exhalations from putrid animal substances, and vegetable miasmata are also among the causes Dysentery is not unfrequently epidemic, prevailing in some instances over considerable extents of country, but more commonly confined within small, and sometimes very accurately defined limits. In the latter mode, it often occurs in different parts of the United States. It is especially apt to prevail in miasmatic districts, preceding or accompanying intermittent and remittent fevers ; but sometimes it cannot be traced to any local cause whatever. It is a frequent accompaniment also of typhus epidemics. The question has been much agitated whether dysentery is a contagious disease. The profession is now almost universally agreed that it is not so in its ordinary form. The circumstances under wliich individuals are succes- sively affected in epidemics have led to the opinion, with some, that most dis- eases assuming this character are propagated by contagion. When no obvi- ous cause appears, and one person after another is affected in the same neigh- bourhood, or in the same family, it has always been a favourite conclusion wdth many that the complaint is communicated from individual to individual. But a closer examination has, in most cases, detected the error of this con- clusion. There is little doubt that it is a mistake in relation to epidemic dysentery. In certain confined situations, where many dysenteric patients are crowded together, without due attention to cleanliness and ventilation, the disease appears to be communicated to others who may be exposed; but the result is probably owing to the influence rather of putrid exhalations, which are acknowledged to be capable of producing dysentery, than of any really contagious effluvium. Nevertheless, it must be admitted that the evi- dence is in favour of the occasional propagation of this complaint by conta- gion. The result may, perhaps, be best explained by the supposition, that, iu cases of this kind, the dysentery is associated with the proper typhus fever, now generally admitted to be contagious, and that it is this disease which is actually communicated; the inflammation of the bowels being dependent upon some peculiar atmospheric or other incidental influence, as we occasion- ally see the same fever prevailing in certain districts, very generally attended with pneumonia. Dysentery attacks indiscriminately persons of both sexes and all ages, and if one class of individuals is affected more frequently than another, it is pro- bably owing to their greater exposure to the causes of the disease. It is much more prevalent in summer and autumn than in winter, and in hot than in temperate climates. Miasmatic countries are more subject to it than others; and strangers are more apt to be attacked in these countries than natives. In all ages, armies and garrisons have been peculiarly liable to suf- fer from it; and the records of campaigns and military marches are full of accounts of its devastating ravages. Treatment.—A great variety of remedies have been employed in dysentery, and very different plans have been found successful under different circum- stances. To be rational, the treatment must vary with the degree of violence in the disease, the existing state of system, and the diversities arising from associated affections. In ordinary uncomplicated colitis, the indications are simply those presented by inflammations in general; though some are more than usually prominent; as the relief of pain and distress, and the removal of causes of irritation, whether applied directly to the affected part, or con- sisting in a congested state of the portal circulation. The modifications of 630 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. treatment required by the state of system, and by the coexistence of other diseases, will be presented after an account ofthe remedies for simple dysen- tery. These are so numerous, as recommended by different practical writers, that it will be most convenient to consider the value of each remedy and its modes of employment, before describing the general course of treatment; as this would otherwise be constantly interrupted by the necessary remarks upon individual measures. Bleeding is not necessary in all cases of dysentery, and, iu the adynamic form of the disease, maybe injurious. It should, however, always be resorted to when there is much pain and tenderness of the abdomen, with febrile action, and a vigorous pulse. As the disease generally occurs in temperate latitudes, and when not epidemic, one moderate bleeding will usually be sufficient; but, if the pulse remain firm, and the local symptoms unabated, it may be repeated again and again." In violent inflammatory cases, threatening immediate'danger if not relieved, and especially in persons of vigorous constitution or plethoric habit of body, it may be necessary to bleed largely at once. In such cases, the remedy should be promptly resorted to, and the blood allowed to flow, until a decided impression is made on the pulse. If postponed, it may be- come useless or worse than useless; as the powers of life are rapidly exhaust- ed under the violence of the disease. It is seldom advisable to bleed in the ad- vanced stages of dysentery, whatever may have been its previous character. Emetics have been highly recommended by numerous authors, and are un- doubtedly often serviceable at the commencement of the disease. Given at its very outset, they will sometimes effect an immediate cure. They were formerly, however, much more used than at present. The physician is gene- rally called too late for their most efficient application; they are to most patients a very disagreeable remedy; and sometimes, when the stomach par- ticipates in the inflammation, or great abdominal tenderness exists, they may do positive harm. They are clearly indicated when the stomach is loaded with acrid accumulations of any kind, as shown by epigastric oppression, nausea, eructation of bile or other irritating matter, and frequent but inef- fectual efforts to vomit, without the pain and tenderness of gastric inflam- mation. If employed with any other view, it should only be at the very commencement. Some have used the antimonial preparations; Chisholm re- commended sulphate of zinc; but ipecacuanha is now generally preferred, and, from its mildness as well as efficiency, deserves the preference. Cathartics are among the most efficient remedies. One of the most promi- nent indications in dysentery is to free the bowels from irritating secretions and accumulations; a second is to diminish congestion in the portal circulation; and both are best answered by this class of medicines. But it is necessary to use discrimination both in the selection of the articles, and in the circumstances of their application. Drastic purges produce more harm by irritating the inflamed membrane, than they can do good by their evacuating effect. Laxa- tives, therefore, or the milder purgatives should always be preferred. Nor is it in all cases advisable to persevere with them until feculent discharges, and especially consistent feculent discharges, are obtained. Occasionally the dysentery has been preceded by a diarrhoea, which has cleansed the bowels; and in such cases solid feces are not to be looked for in the stools. When the disease has commenced abruptly, without antecedent diarrhoea, it is generally proper to obtain at first a pretty brisk cathartic effect, and then to be satisfied with sustaining a gentle peristaltic movement, so as to keep the bowels free from irritating accumulations. It is better to run the risk of allowing some scybala to remain in the colon than to persevere with active purgation, when the great probability is, that there is nothing in the bowels which can require it. But another important object, in the use of purgatives, is to unload the CLASS III.] DYSENTERY. 631 portal veins. The capillary circulation in the liver is often sluggish, and in many instances the secretion of bile appears to be suspended. Blood, there- fore, accumulates in the veins proceeding from the abdominal viscera, and must distend injuriously the capillaries of the bowels. By stimulating the hepatic circulation and secretion we remove this evil. Hence one great advantage of calomel. This is indeedf one of the most useful cathartics in dysentery, having the advantage of mildness in its action on the mucous mem- brane, while it excites the liver. But, as it is not quick in its operation, and in moderate doses is sometimes uncertain, it should be assisted by other medicines. In ordinary cases, from five to fifteen grains of calomel should be given at the commencement, and followed in from four to six hours by the adjuvant. In severe bilious cases, it may be given in a larger dose at first, and subsequently repeated in the same quantity once or oftener; but, as we generally meet with the disease, if the medicine be repeated, it should be in small doses of from one to three grains, so as to sustain a moderate secretion of bile, which should be carried off by other cathartics. Of these, castor oil is on the whole probably the best. Should it offend the stomach in its ordi- nary form, it may be administered in emulsion with gum arabic, sugar, and some aromatic water. In the advanced stages of dysentery, this oleaginous mixture may often be advantageously combined with a little laudanum, and given in small divided doses at short intervals. Thus administered, it often produces a soothing effect on the bowels, while it operates as a laxative. Some prefer the neutral salts, as sulphate of magnesia, sulphate of soda, tartrate of potassa and soda, &c These are especially applicable when there is much fever, with a hot dry skin. In such cases, they are sometimes associated with tartar emetic in solution, and given in divided doses, so as at once to relax the skin and operate on the bowels. Hufeland recommends a mixture of manna, tamarinds, Glauber's salt, and tartar emetic. When the stomach is irritable, the Seidlitz powder may be used. Bitartrate of potassa has been highly recommended as possessing peculiar powers. Dr. Cheyne found it, in doses of half an ounce, repeated at intervals of four or six hours, to cure cases of dysentery which, in his opinion, would have sunk under any ordinary treat- ment. Some practitioners employ the compound powder of jalap. It is desirable that, by means of the cathartics mentioned, one or two evacuations, if not spontaneously produced, should be obtained daily or every other day, of such a character as to evince that they have come from the upper bowels. In the advanced stages of the disease, cathartics must be employed more sparingly than at the commencement; though even here, so long as the affec- tion remains strictly dysenteric, they are often useful. When the strength fails, or the symptoms assume a chronic form, rhubarb or one of its prepara- tions may be substituted for the other cathartics. Under the same circum- stances, melted butter, prepared by introducing solid butter into hot water, agitating, and then skimming the oil from the surface, has been given advan- tageously in the dose of a tablespoonful every two hours, until it produced some effect upon the bowels. Great benefit will often accrue from combining an opiate with the cathartic. So far from uniformly counteracting the opera- tion of the latter, it will not unfrequently promote it by resolving spasmodic constriction of the bowels, while it is also useful by relieving pain. Diaphoretics are useful by giving an external direction to the circulating fluids, and by depleting from the blood-vessels; but, in consequence of the exposure of the surface from frequent rising, they are sometimes hazardous when the temperature of the apartment is much below that in which the patient is kept in bed. When the skin is hot and dry, small doses of tartar emetic, or of the neutral mixture, may be given, separately or combined, at intervals of an hour or two. The effervescing draught is preferable when 632 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. there is nausea or vomiting. Dr. Henry Tiedemann has met with much success from the use of nitrate of potassa as the chief internal remedy. (On Dysentery and its Treatment, p. 26.) Dr. Eberle speaks favourably of a combination of fifteen or twenty grains of asclepias tuberosa with half a grain of ipecacuanha, and a quarter of a grain of opium, every two or three hours. After the general excitement has been subdued by depletion, or has sub- sided in the course of the disease, and early in cases of feeble general action, the powder of opium and ipecacuanha is preferable to the refrigerant dia- phoretics. Great advantage sometimes accrues from the warm bath, which is liable, however, to the same objection as diaphoretics internally adminis- tered. It is peculiarly useful in cases of children, because in these it can be managed with less exposure of the person to cold. The vapour bath may be substituted in the advanced stages. In all cases, the caution cannot be too carefully observed, not to allow the patient to be exposed to cold when the skin is moist. At the same time, he should never be kept oppressively hot by the bedclothes in order to promote perspiration. Opium is an invaluable remedy in dysentery. Recommended by Syden- ham, and afterwards neglected upon theoretical grounds, it came again into repute, and is now almost universally employed. Besides relieving the suf- ferings of the patient, and procuring sleep, which is necessarily much inter- rupted in this disease, it does good by diminishing the morbid sensibility of the bowels to the irritating matters they contain, by relieving spasmodic con- striction and thereby facilitating the action of cathartics, and, when combined with ipecacuanha or tartar emetic, by directing action to the surface of the body. When there is much fever, it is best to postpone its administration until the force of the circulation has been reduced by the lancet; but in general the use of it may commence very early. It may be given along with cathartics, or combined with ipecacuanha, which somewhat diminishes its stimulant properties, and causes it to act as a diaphoretic. In the early stages, it is best administered in full doses, and generally at bedtime, so as to procure rest and sleep at night. In the advanced stages, it may often be usefully given in smaller doses, at stated intervals, so as to sustain a constant impression. Some rely mainly on large doses of opium after due depletion. Mercury.— Not only is calomel useful in the commencement as a purgative, but afterwards also, in smaller doses, so as to stimulate the hepatic secretory function, and sustain a flow of bile into the bowels. For this purpose it is conveniently combined with the opium and ipecacuanha given at night. Two grains of opium, from two to four of ipecacuanha, and from two to four of calomel, may be made into four pills, two of which may be given at once, and one every hour or two afterwards till rest is procured. The ipecacuanha'may be omitted if it should sicken the stomach, and the blue mass substituted for the calomel, if the latter should inconveniently irritate the bowels. If the disease should not begin to yield in six or seven days, the mercurial may be more freely administered, so as to affect the mouth. In severe hepatic or bilious cases, and in those of a typhoid character, unconnected with a scor- butic state of the blood, it may be carried to salivation at an earlier period. When this indication is to be fulfilled, the mercurial, instead of being admin- istered only at night, should be given in small doses at intervals of two, four, or six hours, still in combination with opium and ipecacuanha. The quantity of each ingredient must vary with the peculiar susceptibilities of the patient, and the urgency of the symptoms. No remedial influence is more effectual in dysentery than that of mercury. The chief cautions to be observed are to stop short of profuse salivation, and to avoid the remedy altogether in those malignant cases in which the blood is dark, and either feebly or not at all coagulable. CLASS III.] DYSENTERY. 633 Numerous alterative remedies have enjoyed more or less credit in the treat- ment of dysentery. Ipecacuanha has been thought to exercise a peculiarly favourable influence, and some practitioners have confided the cure chiefly to that remedy. I have spoken of its use as an emetic and diaphoretic. It has been highly recommended in doses of from half a drachm to two drachms, with from thirty to sixty drops of laudanum; and it has been asserted that, if the patient be kept quiet on his back, it will in this quantity effect cures without producing nausea or vomiting. Mr. Twining, of Calcutta, found it very useful in doses of five or six grains, given night and morning, with compound powder of jalap in the interval. He administered it in pill with extract of gentian, and rarely observed it to occasion sickness of stomach. Acetate of lead has been employed in all stages of the disease. The atten- tion of the profession in this country was especially called to it by the late Dr. Harlan, of Philadelphia, who employed it successfully in acute cases; and several writers have since attested its efficacy. It is not, however, gene- rally employed in the earlier stages. After sufficient depletion, and a thorough evacuation of the bowels, should the symptoms not yield, this salt may be given with some hope of advantage ; but it is best adapted to chronic cases, and to those of an acute character which are attended with considerable hem- orrhage. No remedy is perhaps so effectual in the hemorrhage of typhoid or malignant cases. It may be given in doses of from one to three grains every two hours, and should generally be combined with opium. Sulphate of copper and sulphate of zinc have also been recommended. These are applicable to the advanced stages, and to chronic cases, when ulceration has taken place. They should be given in the ordinary doses, combined with opium, at intervals of two, three, or four hours. Acids have sometimes been found beneficial. Much notice has been attracted by Hope's mixture, consisting of a fluidrachm of nitrous acid, forty drops of laudanum, and eight fluidounces of camphor-water, of wliich one- fourth was given every three or four hours. The proportion of acid is too great, if of the officinal strength or near it; though perhaps not so, as the acid is usually found in the shops. Nitric acid is equally effectual; as the common impure preparation called nitrous acid is converted into the former by dilution. I have found this preparation useful in the advanced stages, and in chronic cases, but should not be disposed to employ it when the in- flammation is acute, and attended with fever. Nitromuriatic acid with laudanum may be employed under similar circumstances. The vegetable acids have also been recommended ; and cures have been referred to the free use of lemon-juice, vinegar, and pyroligneous acid. Dr. Young, of Chester, Penn- sylvania, has employed buttermilk with success, as the exclusive remedy in numerous instances. (Am. Journ. of Med. Sci, N. S., iii. 260.) Cheyne's treatment by cream of tartar has already been referred to. There appears occasionally to be in dysentery a predominance of alkali in the secretions, indicating the use of this set of remedies. Among the alterative remedies may also be mentioned copaiba and oil of turpentine. Given in emulsion with laudanum, in small and frequently re- peated doses, these are certainly useful in some cases of advanced or chronic dysentery, and are probably more especially applied to such as are attended with ulceration. In typhoid cases, a combination of oil of turpentine with castor oil in emulsion is sometimes an excellent remedy. Creasote has been found useful in the low dysentery of camps. Peruvian bark has been recommended; but it is applicable only to parox- ysmal cases, or those requiring tonic and stimulating treatment. Nux vomica has been much employed by the German physicians. It should never be used in the acute febrile stage of the sthenic form of the 634 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. disease. In epidemic dysentery, it is asserted to have proved very effective. (Cornell, N Y. Journ. of Med., N. S., iii. 122.) Hufeland states that it is very useful in obstinate cases. The powder, extract, or active principle strych- nia, may be given in the ordinary dose three or four times a day. Dr. J. W. Sterling employed powdered guaiac with great success in acute dysentery. He gave about two scruples in a wineglassful of sweetened muci- lage three times a day. (N. Y. Journ. of Med., N. S., i. 370.) Dr. Frick, of Baltimore, found a mixture of naphtha and charcoal very useful in certain cases of the disease, in its epidemic form. (Am. J. of Med. Sci, N. S., xxii. 310.) Aconite has recently been recommended in the dysentery of hot climates. (Marbot, Archives Generates, 4e ser., xxi. 214.) The use of yeast has been suggested in the sloughing stage of the adynamic or malignant forms of the disease. Sulphur, cerated glass of antimony, chloride of lime, nitrate of soda in the quantity of from half au ounce to an ounce in twenty-four hours, and wax both animal and vegetable, and in various modes of combination, have been recommended. Dysentery has also been treated by affusion of cold water; and Tissot asserts that he cured many cases by means of warm water alone, given in the quantity of a cupful every quarter of an hour. In relation to many of the above remedies, it is difficult to say whether the cure took place merely with them, or through them, or in spite of them. Local Bemedies.—As auxiliary to general bleeding, and in the place of it, when not required or forbidden, cups or leeches are of great importance. They should be used when there is much pain and tenderness; and should be ap- plied along the course of the colon, where the tenderness is greatest. Leeches about the anus are peculiarly useful; and are especially adapted to cases of severe tenesmus. The operation may often be advantageously repeated. Fomentations and emollient cataplasms to the abdomen are useful, and are rendered still more so by anodyne additions, such as camphor, laudanum, and decoction of poppy capsules. Warm hop poultices often afford relief. Dr. O'Beirne, of Dublin, recommends fomentations with infusion of tobacco. Blane gave much relief by fomentations of chamomile with a little laudanum to the anus. The warm hip-bath is useful on similar principles. Bubefacient and anodyne embrocations, consisting of solution of ammonia, oil of turpentine, oil of monarda, &c, with laudanum, camphor, or chloroform, variously combined and diluted, may be employed, though less beneficial than the applications just mentioned. A broad flannel roller passed repeatedly around the body, so as completely to cover the abdomen, has been strongly recommended; but this is applicable rather to chronic than to acute dysen- tery. Blisters over the abdomen come in appropriately when these measures have failed; but they should never be applied until after sufficient depletion both local and general. Great relief may sometimes be obtained by sprink- ling morphia on the blistered surface. Large emollient enemata have been strongly recommended. They act as adjuvants to the cathartics, and are supposed to soothe irritation, and operate as poultices to the bowels. They undoubtedly afford occasional relief by diluting the acrid fluids, and, when composed of demulcent materials, in some measure protect the inflamed surface. But they sometimes also cause pain by distension; and the irritation about the lower rectum is increased by the mechanical disturbance. When found to yield comfort to the patient, they may be repeated daily or more frequently. In the early stages, warm water, solution of starch, and infusion of flaxseed, marsh-mallow, or bran, and, in the advanced stages with debility, veal-water, and mutton-water, are the proper materials. Glycerin is said to have been used beneficially, in the proportion CLASS III.] DYSENTERY. 635 of an ounce to five ounces of flaxseed tea or other mucilage. Melted butter has also been used with asserted advantage. Opiate enemata, or supposito- ries, are sometimes very useful in allaying the local distress. Dr. O'Beirne recommends injections of infusion of tobacco; but this remedy must be used with great caution. The vapour of chloroform has been thrown up the bowels with great relief to the tenesmus. Thirty drops of the liquid, intro- duced into a common syringe and allowed to vaporize, may be thrown up at once. Dr. Wilmot has obtained good results from creasote, a fluidrachm of which is to be given by enema with twelve fluidounces of starch. (Bost. Med: and Surg. Journ., liii. 236, from N W. Med. and Surg. Journ.) Ac- cording to Dr. Kent, very cold water thrown upon the bowels every half hour, speedily alleviates all the distressing symptoms. (Phil. Journ. of Med. and Phys. Sci, x. 411); but it is necessary to take care that the system be not too far depressed by the remedy. Injections of acetate of lead or sulphate of zinc are most valuable adju- vants to the general treatment, after febrile action has been moderated, and especially when the disease is confined chiefly to the rectum and lower colon. I have seen the happiest effects from these remedies; the disease being often almost immediately arrested by them after a long continuance. Acetate of lead is preferable when the affection retains its acute character; sulphate of zinc, when it verges towards the chronic state. Of either of them six or eight grains may be given in three or four fluidounces of water, with twenty or thirty drops of laudanum, and repeated once, twice, or three times daily. Nitrate of silver is said to have been employed in the same way very advantageously. From two to ten grains to a fluidounce of water have been used; and from three to six fluidounces thrown up at one time. Iodine has also been em- ployed by injection, with great asserted advantage, even in recent cases. It is recommended by Dr. Eimer, of Germany, who administers, from twice to four times a day, an enema consisting of from five to ten grains of iodine, the same quantity of iodide of potassium, and two or three ounces of water, with ten or fifteen drops of laudanum, when the rectum is too irritable to retain the solution otherwise. (B. and F. Med.-Chir. Bev., April, 1852.) Summary of the Course of Treatment.—In very mild cases without fever, it is often sufficient to give a single dose of castor oil, with or without twenty drops of laudanum. If the case be of a somewhat higher grade, a dose of calomel may be given at the commencement, and followed in a few hours by castor oil or sulphate of magnesia. If there should be evidences of a loaded stomach, and the physician be called early, he may add an emetic dose of ipecacuanha to the calomel. Should the symptoms increase, and fever with a strong pulse be superadded to the abdominal pains, the patient ought to be bled moderately from the arm; and, if this condition exist from the begin- ning, the bleeding should precede the other remedies. In violent inflamma- tory cases, it may be necessary to bleed very copiously. After the bowels have been thoroughly evacuated, and the patient bled if necessary, he may be allowed to rest for a short time upon cooling drinks and some one of the refrigerant diaphoretics, if the skin be hot and dry. Should the strength of the pulse and the local symptoms continue unabated, it may be proper to bleed again moderately, though this repetition of the remedy is seldom re- quired, as the disease ordinarily occurs. If the degree of general excitement be not sufficient to call for the lancet, and considerable pain and tenderness exist, cups or leeches should then be employed, and warm fomentations or emollient cataplasms applied over the abdomen. The combination of opium, ipecacuanha, and calomel or blue mass, before alluded to, may be given at bedtime, and afterwards repeated daily at the same hour, being followed in the morning by a laxative. While this plan is in operation, the fomentations 636 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. or cataplasms should be continued, the leeches or cups repeated if called for by pain and tenderness, mild refrigerants administered internally, the warm or vapour bath applied if circumstances should be favourable, and one or more of the various local measures before enumerated for the relief of tenesmus, resorted to. Should the disease not seem disposed to yield to this treatment by the sixth or seventh day, the mercurial plan, for which the foundation has been already laid, should be carried to a slight salivation ; and, at the same time, if the local symptoms are violent, a large blister should be applied over the abdomen. The mercurial impression is in general most conveniently brought about by small doses of opium, ipecacuanha, and calomel or mercu- rial pill, repeated every two, four, or six hours, so that from two to three grains of opium, four to six grains of ipecacuanha, and four to six grains of calomel, or three times the weight of mercurial pill, may be given in twenty- four hours. If the system resist salivation, and the symptoms be urgent, the blistered surface of the abdomen may be dressed with mercurial ointment, and frictions with the ointment applied to the inside of the thighs. The dis- ease seldom fails to yield to this treatment, unless considerable ulceration of the bowel exists. But the prejudices of the patient, the peculiarities of his constitution, or some other circumstance may forbid the employment of mer- cury. In this case, or in the event of a failure of the mercurial plan, some of the various alterative measures already enumerated (see page 633) may be resorted to, the choice being directed by the peculiar circumstances of the case. I would, however, invite an especial attention to the injections of acetate of lead and sulphate of zinc. (See page 635.) The course of treatment above indicated applies to dysentery as it ordi- narily appears. The bilious variety requires a more energetic employment of mercurial remedies. In the severer cases of this kind, calomel may be given in doses of fifteen or twenty grains daily, or of five grains three or four times a day, until some impression is made on the disease or upon the mouth. Upon the occurrence of salivation, the symptoms are almost always amelio- rated. Opium may often be advantageously combined with the calomel; nor should the other measures, above detailed, especially general and local bleed- ing, emollient applications, and the means for relieving tenesmus, be neglected. In dysentery associated with intermittent or remittent fever, the same course of treatment should be pursued as in the common form, so far as regards the bowel affection ; but it is highly important also to bear in mind the indica- tions presented by the general disease. The most striking of these is for the use of measures calculated to prevent the return of the paroxysm, and no remedy is so effectual for this purpose as Peruvian bark, or sulphate of quinia. It may be questioned whether this remedy should be employed be- fore the cure of the dysentery; as the tonic properties of the bark might aggravate the inflammation. But the fact is, that the dysentery is a mere attendant upon the fever in this case, and is sustained by it; and whatever may cure the latter will be very likely to cure the former also. Whenever, therefore, an intermission is obtained, or a regular remission, with only so much general action in the interval as may be supposed to be sustained by the local disease, the sulphate of quinia may be safely given, after a thorough preliminary evacuation of the bowels, and the loss of blood, if that be deemed necessary. The quantity taken and the mode of administration should be regulated as in intermittent fever. Severe and obstinate dysenteries are sometimes rapidly cured in this way; the colitis ceasing almost immediately when the prop which supports it is removed. The prompt and free use of quinia is especially necessary, when, as sometimes happens in epidemics, the fever has a typhoid or malignant tendency. It is probably owing to the association of miasmatic fevers with the disease of the bowels, that some CLASS III.] DYSENTERY. 637 practitioners have met with extraordinary success in certain epidemic dysen- teries by the use of bark, which is quite useless if not injurious in the ordi- nary form of the complaint. In the adynamic or typhoid form of dysentery, which, it will be remem- bered, is apt to occur when the disease prevails epidemically, general bleed- ing and active purgation are not admissible; at least in such cases as exhibit this character at their commencement. An emetic of ipecacuanha is some- times serviceable at the very beginning, and a moderate cathartic dose of calomel may be given if the patient is seen early. If it be afterwards deemed advisable, as often happens, to keep the bowels clear of irritating or depress- ing matter, this should be effected by medicines calculated rather to support than to weaken, such as infusion or tincture of rhubarb, or castor oil with oil of turpentine in small doses. In cases where the depression is not great, leeches may sometimes be useful. But the remedial measure on which reliance should be chiefly placed, is the mercurial impression, which should be effected by combinations of opium and calomel or blue mass, or of these with ipecacu- anha, given in small and frequently repeated doses. This plan should be put in operation immediately after the patient is first seen, unless it may be con- sidered proper to precede it by an evacuation of the prima? via?. The only cases to which it would be inapplicable are those of excessive debility, or great malignancy, or of a scorbutic character. It is often necessary, in ady- namic dysentery, to support the strength of the patient by stimulants, and nutritive drinks, such as carbonate of ammonia, wine-whey, wine and water, brandy and water, opium, infusion or decoction of bark or sulphate of quinia, oil of turpentine, egg and wine, animal jellies, chicken broth, &c, to which some writers add valerian, arnica, and the more stimulating aromatics. These remedies should be used with caution, and proportioned carefully to the de- gree of prostration. The mineral acids are also occasionally useful. In hemor- rhage from the bowels, acetate of lead combined with opium and kino, is perhaps the most effectual remedy. Rubefacient embrocations over the abdomen are peculiarly useful in this form of dysentery; and a blister may be resorted to much earlier than in the disease as it ordinarily occurs. Diet.__In very light cases, without fever, solid farinaceous substances, such as boiled rice, stale bread, crackers, &c, may be allowed ; but in febrile cases, at least in the early stage, the diet should consist exclusively of mucilaginous or farinaceous drinks, which may be rendered more palatable by sugar and lemon-juice, if the patient desire it. Suitable preparations are solutions of gum arabic and arrow-root, thin gruels, infusions of flaxseed, slippery elm, and sassafras pith, and decoctions of barley, rice, sago, tapioca, and Irish moss. After the general excitement has somewhat subsided, rennet-whey may be given ; and, in cases of great debility, animal jellies and broths. Sir G. Baker recommends mutton suet mixed with warm milk. In convalescence, the patient should, as a general rule, be confined to milk, butter, and farina- ceous substances, until recovery is confirmed. Relapses are very apt to follow improper indulgence. Great care should be taken to keep the person of the patient and the bedclothes clean, to remove all excrementitious matters, to ventilate the apartment, and preserve the air sweet and pure, and, as far as possible, to remove the patient from the influence of causes which may have contributed to produce the disease. 2. Chronic Dysentery.—Chronic dysentery is often associated with chronic enteritis ; and it is not always easy to determine how far the two por- tions of the bowels are severally involved in the inflammation. Nor is the decision a matter of much importance, as the treatment of the two affections is essentially the same, at least in those cases in which the symptoms are commingled. Chronic dysentery, when not thus combined, is readily known by the frequency and comparatively small quantity of the evacuations, their 638 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. character, and the tenesmus with which they are attended. The greater num- ber of the stools consist chiefly of mucus, sometimes mixed with a pusdike matter or blood. Occasionally, however, feculent or bilious matter is mixed with the proper dysenteric discharge. When the disease occupies the rectum and lower portion of the colon, the feculent discharge is often consistent, and, instead of being uniformly mixed with the mucus, is either irregularly per- vaded by it in layers or streaks, or enveloped in a thick coating of it, derived from the surface of the bowel with which the feces lay in contact. There is usually more or less tormina, and tenderness on pressure; though the latter is by no means present in all cases. The pulse, skin, tongue, appetite, &c, are affected as in chronic enteritis; but the symptoms of general derangement are, upon the whole, less. When the disease is confined to the lower extremity of the bowels, the constitution often sympathizes but little. In such cases, the complaint sometimes continues for months or years, without making very serious inroads on the general health. But, for the most part, in chronic dysentery, if a favourable change is not effected by treatment, the patient gradu- ally emaciates, the countenance becomes pale, sallow, and shrunken, the appe- tite fails, the general strength gives way, and ultimately the disease closes with hectic fever, anasarca, or some other form of dropsy. The association of chronic dysentery with a tuberculous constitution gives great obstinacy to the disease; and, in some cases, the inflammation of the mucous membrane of the colon is owing to tubercles diffused in the membrane, which finally soften and ulcerate. Occasionally the inflammation extends from the bowels to the venous trunks, especially the internal iliacs, and thence descending into the lower extremi- ties, gives rise to the phenomena, in a greater or less degree, of phlegmasia dolens. (Mayne, Dublin Quart. Journ. of Med. Sci., x. 375.) Anatomical Characters.—Besides the usual signs of chronic inflammation in the mucous membranes, ulceration is very generally found in cases of death from chronic dysentery. An interesting fact is, that some of the ulcers are not unfrequently observed in a state of cicatrization, and others completely cicatrized, rendering it certain that patients may recover in this disease, even after extensive ulceration of the mucous coat. Abscesses of the liver are not unfrequent in chronic dysenteric cases; but whether they are to be considered in the light of cause or of effect, it is not easy to deter- mine. Sometimes they may be of the metastatic character, dependent on pu- rulent infection of the blood by the sanies of the intestinal ulcers. Chronic dysentery is seldom an original disease, but, when it occurs, is almost always the consequence of an acute attack. Slight cases of it, affect- ing only the rectum and lower extremity of the colon, may sometimes per- haps arise from an extension of inflammation from hemorrhoidal tumours. Treatment.—The regulation ofthe diet is among the most important points in the treatment of this disease ; and the same rules are applicable here as in the cases of chronic inflammation of the stomach and small intestines. Gene- ral bleeding is scarcely ever admissible; but leeches may sometimes be applied when the pain and tenderness are considerable. When the disease is connected with chronic inflammation of the small intestines, cathartics are seldom re- quired ; as the bowels are sufficiently opened spontaneously. Indeed, in this case, the treatment is altogether so closely analogous to that directed for chronic enteritis, that it is sufficient to refer the reader to the account of that disease. In pure dysentery, especially when seated in the lower colon and rectum, it is often advisable to employ mild laxatives, in order to prevent morbid accumulation in the bowels above the part affected. This indication is presented when no fecal matter is passed in the course of the day. Small doses of castor oil, confection of senna, rhubarb, manna, or some other very mild laxative should be employed. When the pain is considerable, and the discharges frequent, opium and ipecacuanha should be given at bedtime, and CLASS III.] DYSENTERY. 639 with these calomel or the mercurial pill should be associated when hepatic action is deficient. Indeed, great powers over the complaint have been ascribed to the alterative action of the mercurial pill, independently of any disorder of the liver. The late Prof. J. K. Mitchell stated, as the result of his observa- tion, that most cases of chronic dysentery might be cured by the exclusive use of pure mucilage as a diet, and of the blue pill given once everyday or every other day, in doses of from three to five grains. (Am. Journ. of Med. Sci., ii. 323.) Pushed to moderate salivation, it will undoubtedly often effect cures; and this measure should always be resorted to if others fail. The various alterative medicines before mentioned as sometimes useful in the advanced stages of acute dysentery, are still more applicable to the chronic form of the disease. Such are sulphate of copper, sulphate of zinc, nitrate of silver, nitric acid, nitromuriatic acid, Hope's mixture, a mixture of alum and sulphate of zinc as recommended by Moseley, copaiba, and the turpentines or their vola- tile oil. Moderate doses of these medicines should be given three or four times a day, and may often be usefully combined with from the eighth to the quarter of a grain of opium. Copaiba and turpentine are best administered in emulsion. I have seen the happiest effects from oil of turpentine, given in the dose of ten drops every two hours, in chronic dysentery, especially when attended with a perfectly dry and smooth tongue. Cases have repeat- edly recovered under this remedy, which had long resisted others. One case of recovery I remember, in which the disease was considered quite desperate when the oil was first administered. I cannot too strongly press this remedy on the attention of the reader under the circumstances referred to. In two or three days, or sooner, the tongue begins to become moist, and to be covered with a delicate white fur, and there is a corresponding improvement in the intestinal symptoms. The oil should be given in emulsion, and asso- ciated with a little laudanum. Mr. R. W. Ellis, of Bristol, England, has found much benefit in chronic dysentery from the compound tincture of ben- zoin, given in the dose of twenty minims three times a day. (Lancet, Aug. 23, 1856, p. 221.) The root of arnica is used by the Germans in the dose of a scruple every two or three hours. The vegetable astringents, formerly so much employed in chronic dysentery, though sometimes beneficial when the complaint borders on the character of diarrhoea, are generally, in the unmixed cases, worse than useless. Dr. Blackburn recommends strongly the wild-strawberry leaves, which he employs in strong spirituous decoction, made by boiling a pound of the fresh leaves in two pints of brandy to a pint, and given in the dose of a tablespoonful every three hours. (Bost. Med. and Surg. Journ., xxxvii. 342; from South. Med, and Surg. Journ.) The warm or hot salt-bath, given every day, is one of the most beneficial adjuvants to internal remedies. Swathing the body with flannel, as recom- mended by Dewar, may also be resorted to. " Four or five folds of fine flannel, or a large piece of thick fleecy hosiery, ought to be laid over the ab- domen, and, over this, a flannel bandage should be bound, rather tight, and in a uniform manner, from the groin nearly to the arm-pits and back again." (Dewar on Diarrhoea and Dysentery, p. 111.) When the disease is confined chiefly or exclusively to the lowest portion of the bowels, I have found no remedy comparable in efficiency to injections of sulphate of zinc, given in solution along with a little laudanum, and repeated twice a day. (See page 635.) It is worthy of consideration, whether the rem- edy might not be advantageously employed by injection through a tube, when the higher portions of the colon are affected. There can be little doubt that it operates by a direct influence on the surface which it touches, exactly as in ulcerations of the mouth. In relation to clothing, exercise, &c, the same observations apply here as in chronic enteritis. 640 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. Article II CANCER OF THE BOWELS. This is a rare disease. All portions ofthe intestinal canal are not equally liable to it. The parts most frequently affected are the duodenum, ca?cum, rectum, and sigmoid flexure of the colon. There are in general no means by which the disease can be certainly distinguished in its earlier stages. It is often for a long time latent, or attended only with occasional pain or uneasi- ness, which is usually referred to some other cause. No decided symptoms appear until the tumefaction has become so considerable as materially to inter- fere with the passage of the contents of the bowels, or until ulceration has taken place so as to occasion great pain in their passage, or until the disease has begun to involve other structures. Obstinate vomiting and constipation are symptoms which usually mark its encroachment upon the cavity of the bowel. Along with these are paroxysms of severe lancinating or spasmodic pain, extending from a particular spot over the abdomen. The pain usually comes on at a certain time after eating, longer or shorter, according to the distance of the disease from the stomach. When the complaint is seated in the ca?cum or below, there is usually great and distressing abdominal disten- sion from feculent accumulation and flatus, and the patient is much troubled with eructation of air. Stercoraceous vomiting sometimes occurs, when the obstruction is very great. In some cases, however, a sufficient passage re- mains open from the beginning, and the patient suffers comparatively little from vomiting, constipation, and abdominal distension. In others, the passage is enlarged by ulceration, or a new one is created, and temporary relief is obtained from these alarming symptoms. Sometimes diarrhoea occurs, with bloody, glairy, gelatinous, sanious, or otherwise disordered evacuations; and, in the latter stages, the passages are often very offensive. The extension of the disease to neighbouring organs, as the liver, pancreas, kidneys, kc, gives rise to various complications of the symptoms. The patient emaciates rapidly; the countenance assumes the peculiar cancerous pallor; the pulse becomes frequent; edematous effusion takes place; and the patient dies, worn out with pain, loss of blood, and general irritation. In some cases, death occurs more suddenly, as the result either of complete obstruction of the bowel, or of peri- toneal inflammation consequent upon ulcerative perforation. The diagnosis between cancer and other organic affections is not always easy. It is, how- ever, very much assisted* when, as often happens, a tumour can be felt through the abdominal parietes, corresponding with the seat of suffering. The phenomena presented by cancer in different parts of the bowels are not exactly the same. When it affects the duodenum, there must obviously be less of the distressing distension of the bowels, while the patient is in a still greater degree troubled with vomiting, which, as well as the greatest severity of pain, comes on generally from two to four hours after eating, when the chyme passes out of the stomach. AVhen the caecum is the seat of the disease, the obstruction is often very great, in consequence of the valve becoming affected; although a case has been recorded by Dr. T. E. Beesley, in which the passage was even larger than is usual in health, notwithstanding a great thickening ofthe parietes. (Phil. Journ. Med. and Phys. Sci, vi. 350.) In cancer of the rectum, there is less disposition to vomit than when the upper part of the canal is affected, and less general disturbance of health until the complaint has made great advances. The tenesmus and great but often CLASS III.] IRRITATION OF THE BOWELS. 641 ineffectual straining, the discharge of feces in a flattened tape-like form, or in slender cylinders not thicker than a quill, or in other distorted shapes, and the acute lancinating pains in the region of the sacrum, extending down the limbs even to the feet, will be sufficient to indicate the necessity of an exami- nation of the rectum, in which the finger will encounter a stricture, more or less completely surrounded by an almost cartilaginous hardness. When to these symptoms are added an ichorous fetid discharge, and an extension of irritation to the vagina in females, and to the bladder in males, there can be little doubt as to the nature of the disease. In all these cases, dissection shows the same morbid structure as in cancer of the stomach. Sometimes the whole parietes of the bowel are thickened, and the passage contracted to the size of a crow's quill; sometimes irregular indurated tumours, or others of a medullary character are found projecting into the cavity of the intestine. Ulceration of various extent is discovered, not unfrequently penetrating into neighbouring parts, which have become agglutinated with the bowel in a mass of cancerous disease. Contiguous con- volutions of the intestines have been found thus agglutinated; and a passage, made by ulceration through their coats, is one of the means by which that sudden relief from the most imminent danger, which occasionally marks the progress of a case of intestinal cancer, is produced. Treatment.—Only palliative measures can be employed. If there be some doubt whether the case may not be simply chronic inflammation of the bowels, the treatment for this affection should be employed, and the more especially as, though it cannot cure, it may somewhat alleviate the complaint if really cancerous. The chief indications in cancer of the bowels are to facilitate the passage of the intestinal contents, and to allay pain. The former is answered by the use of a laxative diet, and of laxative medicines, the latter by opium, conium, or hyoscyamus; care being taken to counteract the constipating effect of the first of these narcotics. Opiates may be used by the mouth, or rectum, or by the endermic method. When the disease is in the rectum or lower colon, relief may be obtained by the use of demulcent enemata, which pene- trate the stricture, and, by diluting the feculent accumulation above, facilitate its passage. These may sometimes be advantageously thrown up by means of a gum elastic tube previously passed through the stricture. A bougie may be occasionally employed to obtain present relief from distressing flatulence, kc, but not with the view of effecting permanent dilatation. The diet should be light, digestible, and nutritious, without being stimulant; and substances should be preferred which yield but a small proportion of excrementitious residuum. Farinaceous substances, animal broths, milk, cream, and the most digestible of the laxative fruits, whether fresh or dried, may be allowed. Milk is peculiarly suitable. Article III. IRRITATION OF THE BOWELS. This, as in the case of the stomach, may be vascular, affecting especially the mucous membrane, or nervous, affecting the muscular coat, or both at once. Diarrhoea, the different forms of colic, flatulence, spasm of the rectum, and hemorrhoids may come under this head, though all occasionally asso- ciated with a debilitated condition of the bowels. vol. I. 41 642 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. I. DIARRHCEA. Those cases are denominated diarrhoea in which the alvine evacuations are more liquid, frequent, and copious than in health, without being hemorrhagic or dysenteric in their character. The affection is rather a consequence of certain pathological conditions than itself a disease. These conditions are various, and sometimes even opposite; as is rendered obvious by a consideration of the different agencies which may produce increased evacuation from the bowels. A simple increase of the peristaltic action may have this effect, without the co-operation of any other cause. It may also result from an elevated excitability of the bowels, causing them to receive a stronger impression from their usual contents than in health, or from an increase in the quantity or stimulating quality of the ingesta act- ing upon the ordinary excitability, or from a condition of the digestive organs, allowing bland materials introduced into the stomach to undergo changes which may render them irritant. Again, irritation or inflammation of the intestinal mucous membrane may produce secretions, which, from their quantity or quality, shall prove purgative; and, in one portion of the ali- mentary canal, matters may be generated which shall operate in this way upon another portion further down. The biliary and pancreatic secretions, moreover, may be so altered as to excite the bowels to increased action, though the latter may be in perfect health. Finally, debility of the mucous mem- brane may allow the elimination of fluids, which, by mere distension of the bowel, shall cause the muscular coat to contract more rapidly. These are very different conditions, yet all attended with diarrhoea. The only common circumstance is increased peristaltic action. With this diversity in the sources of diarrhoea, there is an equal diversity in the attendant symptoms; and there is scarcely any phenomenon common to all the varieties except those mentioned in the definition. The evacuations may be very few, not exceeding two or three daily, or so frequent that the patient scarcely satisfies one call before he experiences another. Their quan- tity, which is sometimes but little greater than in health, has been known to amount to forty pounds in a day. (Dalmas, Diet, de Med,, 2e ed., x. 271.) There is generally more or less pain before the evacuations, which are almost always followed by relief; but in some cases no pain whatever is experienced throughout. Along with the discharge is occasionally a very disagreeable sinking sensation in the abdomen, with a general feeling of exhaustion or faintness, a cool skin, and a feeble irregular pulse. This condition, however, is almost always temporary. Diarrhoea is sometimes attended with fever, which is generally an indication of inflammation, or very high and extensive irritation of the mucous coat. But in the great majority of cases there is no fever. The skin is usually dry, and the urine scanty. Every possible diversity exists in the degree, duration, and danger of the complaint. It may be quite trivial, getting well in a day or two without aid, or may run on for months or years, resisting every variety of treatment, In some rare cases, death occurs suddenly from great exhaustion, even while the patient is on the stool. But, more commonly, a fatal termination is preceded by a slow emaciation and gradual failure of strength. Very protracted and fatal cases are gene- rally connected with tuberculous or cancerous lesions of the bowels, organic disease of the liver, or a depraved state of the blood. In simple diarrhoea, whether acute or chronic, without organic lesion, the prognosis is almost always favourable, provided proper treatment can be applied. ^ In reference to the pathological condition of the bowels, three varieties of diarrhoea maybe recognized: 1. that in which the increased peristaltic move- CLASS III.] DIARRHOEA. 643 ment results from causes acting directly on the muscular fibre, with a per- fectly healthy state of the mucous membrane; 2. that in which it is brought about through irritation or inflammation of the membrane; and 3. that in which it proceeds from debility of the membrane. 1. Diarrhoea from Increased Peristaltic Action alone.__Of this kind is probably the looseness of bowels induced by terror or other sudden and strong emotion, which appears at the same time to relax the sphincter and excite the peristaltic action. The same result is sometimes seen in hysterical or other nervous affections; and to this head, moreover, we may refer the crapulous diarrhoea of great eaters, in which the exciting cause of the increased peri- staltic movement is probably distension of the bowels, which is felt as a direct stimulus by the muscular coat. Dr. James Jackson, of Boston, calls atten- tion to a diarrhoea of this kind, not unfrequently occurring in young infants from excessive sucking. (Letters, kc, p. 131.) In these cases, the stools are always fecal, and usually semiliquid, and of a healthy colour. The affec- tion is very slight, and yields without difficulty. 2. Diarrhoea from Inflammation or Irritation ofthe Mucous Membrane.— This is beyond all comparison the most frequent of the three varieties referred to. Inflammation of the membrane has been already sufficiently considered under the head of enteritis. The remarks which follow, therefore, have refer- ence to irritation of the bowels; although it is often very difficult to decide between the two conditions, as they run into each other by insensible shades. Diarrhoea of irritation may exist independently of any concurrent disorder in other parts of the system, or may originate and be sustained by such disorder. Upon this difference of origin two sub-varieties may be founded. In both there is often a morbid predisposition in the alimentary mucous membrane, rendering it susceptible to impressions which it would not feel under ordinary circumstances. This predisposition consists in an increased excitability, which is little else than the first step towards positive irritation. Such a condition is induced by continued exposure to heat, and is often left behind by idiopa- thic fevers and other acute diseases. Hence in part it is, that diarrhoeas are most prevalent in summer, and are so apt to occur during convalescence. The same predisposition may also arise from any of the ordinary causes of irrita- tion, acting in a degree insufficient to bring on* obvious disease. Thus, under the continued influence of fatigue and improper diet, exposure to cold will occasion an attack of diarrhoea, which neither the former nor the latter cause alone might have been sufficient to produce. Here a slight and latent irri- tation is provoked by a new cause into open violence. a. From irritation of bowels independent of disease elsewhere.—This may be produced by causes acting either directly upon the mucous membrane, or intermediately through the system. Of the causes acting directly, the most prominent are insufficiently masticated or indigestible food; acidulous and saccharine fruits, such as cherries, plums, melons, &c, particularly when un- ripe or used in excess ; spoiled meats, and mouldy or corrupted provisions of all kinds, such as are often used in armies and on shipboard; newly and im- perfectly fermented or spoiled liquors, as new cider, table beer, sour ale or porter, spruce and ginger beer, &c.; certain natural waters, especially lime- stone water in persons unused to it; sour milk, or the milk of unhealthy nurses ;* cold water in excess ; acid or other irritating matters resulting from * Dr. Vogel has found, upon microscopic examination, in the milk of nurses which has proved unwholesome to children, even when quite fresh, infusoria such as are ob- served in incrustations upon the teeth; little rod-shaped bodies, dark in the middle, without head or tail, but with numerous feet, and often swimming actively in the liquid. Children fed on this milk are attacked with diarrhoea, which ceases on substituting good cows' milk. (See Am. J. of Med. Sci, N. S., xxvii., 204.) 644 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. spontaneous changes in the food, after introduction into the stomach ; worms and collections of feculent matter in the bowels; and the abuse of irritating, stimulant or purgative medicines. Particular kinds of food always induce diarrhoea in certain individuals, in consequence of idiosyncrasy. Ofthe ex- citing causes acting through the system cold is by far the most common. This, however, alone, is seldom sufficient to produce diarrhoea. It is after previous exposure to heat, and especially when the body is perspiring, that it acts so energetically. The diarrhoea induced in this way is denominated by some writers catarrhal, probably because attended with increased serous or mucous secretion ; by others rheumatic, from the similarity of its cause with that producing rheumatism, though any other irritation or inflammation re- sulting from cold might with just as much propriety receive the same desig- nation. Nevertheless, a rheumatic or gouty predisposition is sometimes called into activity in the form of diarrhoea; and this complaint not unfrequently results from the translation of rheumatism or gout from some other part of the body to the bowels. Sometimes very sudden and alarming discharges from the bowels are brought on in this way. In like manner, the retrocession of cutaneous eruptions, and the cessation of some habitual discharge either natural or artificial, occasionally produce diarrhoea. Fetid exhalations, and the continued influence of anxiety or other mental disturbance, are also capa- ble of calling into action this form of intestinal irritation. Long-continued, exhausting, and fatal attacks of diarrhoea sometimes arise from breathing an atmosphere loaded with putrid animal effluvia, which probably operate through the blood. It is probable that vegetable miasmata have a similar effect. Diarrhoea is very apt to accompany epidemic cholera and dysentery, sometimes acting as a forerunner to them, and often, during the continuance of the epidemic, preceding individual attacks of those diseases, so that the practitioner frequently has it in his power, by a proper management of the diarrhoea, to prevent a much more serious affection. In these cases, how- ever, the diarrhoea is frequently associated with hepatic derangement, and might fall under the following variety. In diarrhoea of irritation, proceeding from the above mentioned causes, the stools are more or less fecal, often of the healthy colour, though some- times green from the action of acid upon the healthy bile, and occasionally somewhat bloody, when the irritation is very severe, or a hemorrhagic ten- dency exists. In some instances, they are copious and watery, constituting the serous diarrhoea of authors; in others, chiefly composed of mucus, in which case the disease is sometimes denominated mucous diarrhoea. Not unfrequently portions of the food undigested are found in the stools, and this may even constitute the chief feature of the affection. Such cases are always connected with a feeble digestion. They were formerly designated by the name of lientery. In the diarrhoea of infants nothing is more common than to find undigested coagula of milk in the passages. b. From irritation of bowels dependent on disease elsewhere.—Diarrhoea of irritation so often proceeds from disease of the liver, that it merits a dis- tinct consideration in its relations to that organ. As proceeding from all other extraneous sources, it may be considered in one general view. Dependent on hepatic derangement.—Of this variety of diarrhoea there are three distinct forms, characterized respectively by an increased, perverted, and diminished secretion of bile. 1. The first form, or that connected with an increased secretion of bile, is commonly called bilious diarrhoea. The stools are liquid, of a bright-yellow colour, sometimes green from the action of acid in the bowels, generally rather frequent, and attended with consider- ble tormina, and a burning or otherwise painful sensation in the rectum during the discharge. Some excitement of the circulation is not unfrequent. CLASS III.] DIARRH03A. 645 The bile is, in these cases, the direct cause of the intestinal irritation, by coming in greater quantity than usual into contact with the mucous mem- brane. An aggravation of the affection, attended with vomiting, constitutes cholera morbus. 2. The second form differs from the first only in the cir- cumstance that the bile is secreted not only in abnormal amount, but of an unhealthy or perverted character. The stools are brown, or black, or other- wise deranged in colour, and not unfrequently of a tarry consistence. In bad cases, they are sometimes very profuse, and exquisite pain attends the passage of the bile through the bowels. It is important to distinguish the passages, in these cases, from those black discharges which depend on intestinal hemorrhage, as the treatment required is different. In the bilious cases, however black the stools may appear in mass, they always exhibit a yellowish tinge, if viewed in very thin layers. This perverted secre- tion, though perhaps in most cases dependent on mere functional derange- ment of the liver, is often also connected with serious organic disease of that organ. 3. The third form is wholly different in character from the two pre- ceding. In this, the biliary secretion is much diminished or entirely suspended. The evacuations are consequently light-coloured, and often of a dirty white, being more or less colourless as they are more or less deprived of bile. They are usually opaque, and sometimes almost milky in appearance. Hence, they have been supposed to consist of chyle ; but they are in many instances too copious to allow of the truth of this supposition. When very abundant, they resemble somewhat the rice-water evacuations of cholera. In most instances, the diarrhoea appears to depend upon the suspension of the hepatic secretion, and very soon ceases upon its restoration. Congestion probably takes place in the intestinal mucous membrane, in consequence of a torpid capillary cir- culation in the liver, and relieves itself by secretion from the distended ves- sels. Occasionally it is possible that the case may be reversed, and a profuse secretion from the bowels, consequent upon intense irritation, may diminish that supply of blood to the liver which is necessary for the formation of bile. The former, however, is a much more frequent occurrence. It is highly prob- able that the two pathological conditions occasionally coexist. This form of diarrhoea, though attended with less acute pain than the two preceding, is often very distressing from a feeling of indescribable uneasiness in the abdo- men with depression of spirits, is obstinate unless properly treated, and some- times produces fatal exhaustion. As it ordinarily occurs, it may almost always be speedily arrested by suitable remedies, and hence the importance of an early inspection of the evacuations. It is obvious that the various forms of diarrhoea above described may be more or less mingled one with another, and that from such an admixture an almost infinite variety of appearance may be given to the passages. Occurring sympathetically in various diseases.—Diarrhoea is a very common attendant upon teething, in wliich, when not severe, it sometimes forms a useful outlet for irritation^ and should not be too hastily arrested. In such cases attention should be directed especially to the gums. (See Morbid Dentition.) It frequently supervenes in the course of febrile affections, espe- cially the exanthemata. Thus, it is common in scarlatina and smallpox. It has already been spoken of as attendant upon the thrush or sore-mouth of children. But in these cases, as well as in typhoid fever and phthisis, the diarrhoea depends rather upon inflammation of the bowels than mere irrita- tion. In the course of dropsy, and at the close of febrile complaints, attacks of diarrhoea sometimes come on, which appear to be an effort of nature to relieve the morbid condition of system. Thus, a paroxysm of fever some- times goes off with increased secretion from the bowels instead of perspira- tion. In such cases, the diarrhoea has been called critical, and should not be too hastily interfered with. 646 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. 3. Diarrhoea of Debility.—Diarrhoea may depend upon debility of the mucous membrane of the bowels, with or without antecedent inflammation. The most numerous cases of this kind are undoubtedly those which, originat- ing in inflammation, continue after all inflammatory action has subsided. The capillary vessels and secreting orifices, enlarged during the inflammation, are left by the subsidence of the excitement too feeble to contract vigorously, and the more fluid parts of the blood escape, with more or less modification, according to the greater or less amount of remaining energy in the vessels. Of this character may even be considered the diarrhoea attended with chronic ulcers of the bowels, which are too feeble or indolent to take on the healing process. But occasionally we meet with this disease, without any previous intestinal inflammation or irritation which can be recognized. The eliminat- ing tissue appears too feeble to resist the force with which the blood is moved; and the serous and even fibrinous parts of the blood escape, attended some- times with more or less of the red colouring matter. An increased degree of the same affection constitutes passive hemorrhage. It is not unfrequently associated with a wratery or depraved condition of the blood, which becomes incapable of sustaining a due energy in the extreme vessels. An example of this kind is afforded in the colliquative diarrhoea of phthisis, which, though generally associated with ulceration of the mucous membrane, sometimes oc- curs without any evidence of organic disease in this structure, alternating with the colliquative sweats which depend upon the same cause. The diar- rhoea of scurvy may be placed in the same category, when not the result of a low form of enteritis. Diarrhoea of debility is generally without pain or ten- derness of the bowels, and without febrile excitement. Nevertheless, in the mucous membrane ofthe bowels as in other parts, debility and inflammation may coexist, in which case the symptoms would be modified. Treatment.—This must vary with the character of the disease. In relation to the treatment of diarrhoea, the propriety of inspecting the evacuations cannot be too strongly urged. When the complaint depends simply upon increased peristaltic movement, it usually subsides with the cessation of the cause. Should it require treatment, from five to ten drops of laudanum, or a fluidrachm of camphorated tincture of opium may be given, and repeated if necessary. In the crapulous form, the loaded bowels may be relieved by castor oil or other mild cathartic, and the diet afterwards reduced in quantity, and made to consist of materials which yield a comparatively small propor- tion of excrement, as meats, milk, and farinaceous substances. The treatment for inflammatory diarrhoea has already been detailed. (See Enteritis.) In diarrhoea of irritation, respect must be had to the cause. If slight, without discoloration of the passages, without febrile excitement, and with little or no griping, the case will in general require scarcely anything more than a regulation of the diet. If the presence of irritant substances in the bowels is suspected, a dose of castor oil should be given with or without laudanum, according as the pain is considerable or otherwise. When the stools are green, or of a sour smell, or other evidence of acid in the prima? via? is presented, magnesia or a mixture of this with rhubarb, should be substi- tuted for the oil. Purging, however, has been abused in this complaint. It should not be carried further than is necessary to evacuate irritant substances. In some rare cases, collections of feculent or foreign matters in the bowels, somewhat difficult to dislodge, maintain a vexatious diarrhoea, which can be removed only by a removal of the cause. In such cases, the cathartics already mentioned may be repeated, or others more active resorted to. When worms are the offending cause, calomel is the most efficient cathartic, and should be given in connection with vermifuge medicines. These cases, however, are rare; and, in general, a single dose of the cathartic is sufficient. In cases CLASS III.] DIARRHOEA. 647 not requiring laxatives, and in others, after the proper use of these medicines, opiates are the most efficient remedies. If the irritation is moderate, and wholly unattended with arterial excitement, from five to ten drops of lauda- num, with or without a little camphor-water, or a fluidrachm of camphorated tincture of opium, repeated two or three times a day, will generally arrest the disease. If the symptoms of irritation are high, and the case borders on inflammation, it may be proper to bleed moderately. In such cases, and even in those of a milder character, the opium may often be advantageously com- bined with ipecacuanha. This combination is peculiarly suitable at bed- time. When acid continues to be generated, prepared chalk or prepared oystershell should be added to the anodyne, or, if these do not suit the stom- ach, and especially if there should be a slight febrile action, carbonate or bi- carbonate of soda or of potassa should be substituted. If by these means the discharge be not arrested, and the patient complain of little or no pain, one of the vegetable astringents may be added, such as logwood, kino, catechu, rhat- any, geranium, or pure tannic acid. The more bitter astringents should be avoided at this stage. These various remedies may often be conveniently com- bined in mixtures, of which the precise form must differ with the circumstances of the case. A suitable vehicle for them is diluted cinnamon-water, and in- soluble substances should be suspended by means of gum arabic and sugar.* It is best, as a general rule, to give the mixtures in small doses often re- peated. If the astringents increase the pain, they should be omitted. In bilious diarrhoea with bright-yellow or green passages, a gentle cathartic may first be administered with or without laudanum, and then small doses of calomel and opium, about the sixth of a grain of the former to the twelfth of a grain of the latter, for example, every hour or two. The sixth of a grain of ipecacuanha may be added to each dose, if there is no nausea. Not more than two grains of the mercurial should, in general, be given in this mode during the day. Should there be fever and much pain, a little blood should be taken from the arm, and the refrigerant diaphoretics administered, the pa- tient being confined to his bed. In cases attended with black or very bilious evacuations, the alterative mercurial plan should in general be commenced immediately, and continued until the colouris changed. When the discharges are not copious, and the pain not severe, the calomel may be given without opium. Advantage is sometimes derived, in these cases, from alternating the mercurial with the syrup or infusion of rhubarb. In the form of diarrhoea attended with white passages, it is often highly important to stimulate the liver as speedily as possible. When the stools are small, and the patient not materially weakened, from five to ten grains of calomel may be given at once. In children two or three years old, one or two grains may be given every two hours until it produces some effect on the bowels, care being taken not to exceed four or six grains. The happiest effects sometimes immediately result. But, if the passages are somewhat copious, or the patient feeble, the calomel should be conjoined with opium, or the powder of ipecacuanha and opium, and followed by some preparation of rhubarb, or a little castor oil, if the bowels should be confined. The alter- * The chalk mixture of the Pharmacopoeia is a convenient formula for the adminis- tration of chalk, and the same will answer for oystershell. The dose is a tablespoonful repeated several times a day. Opiates being generally indicated at the same time, from five to ton drops of laudanum, or from fgss to f£j of camphorated tincture of opium, may be added for every fluidounce of the mixture. If the vegetable astringents are employed, from ton to twenty grains of kino, catechu, extract of logwood, or extract of rhatnny, or from two to four grains of tannic acid, should be added to the same quantity. Logwood, rhatany, and geranium may also be conveniently used in decoction or infusion; and these preparations may be used as the vehicle of the chalk, and of the laudanum or paregoric. 648 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. ative plan may afterwards be followed, by giving smaller doses of the mer- curial with opium or Dover's powder. When the evacuations are alarmingly copious and exhausting, I have found great advantage from small and fre- quent doses of calomel, opium, and acetate of lead.* In infants, affected with this or any other form of bilious diarrhoea, which in them is very gene- rally attended with acidity, I can from experience recommend the formula below, f If the alterative mercurial plan fail in these cases, or circumstances prohibit its employment, nitromuriatic acid, with or without laudanum may be substituted, and will sometimes operate most happily on the hepatic func- tion. Should the diarrhoea continue after the secretion of the liver has been corrected, it should be treated as a case of simple irritation. Sulphuric acid, which has long been occasionally used in diarrhoea, has recently attracted much attention in England as a remedy in this disease, and, according to the statements in the journals, has proved successful in a most extraordinary degree. From twenty to thirty minims of the officinal diluted acid (acidum sulphuricum dilutum) are given every hour, two, or three hours, in about two fluidounces of water or other vehicle; and, in very urgent cases, the dose is still more frequently repeated. It seems to be es- pecially applicable to diarrhoea of irritation. J Creasote has also been very highly commended. Mr. Kesteven, who em- ployed it upon the recommendation of Air. Spinks, speaks of it as signally beneficial in every case, generally checking the disease at the first dose, and veiy seldom requiring to be repeated more than once. He gives from one to five minims, mixed with aromatic spirit of ammonia, in about a wineglassful of water. (Lond. Med. Gaz., N. S., xii. 235.) Dr. J. R. Cormack states that, if two or three drops can be taken twice, at the interval of an hour or two, it scarcely ever fails (Association Med. Journ., Nov. 11, 1853); and Dr. Woodson, of Tennessee, found it more successful than any other remedy which he had ever used. (Am. Journ. of Med. Sci, N. S., xxiv. 237.) In diarrhoea of debility, in which may be included most cases of chronic diarrhoea not attended with pain or fever, after correcting the biliary secretion if deranged, we may resort to astringents and tonics, of which a vast variety have been recommended. Among the vegetable astringents may be enume- rated, besides those already mentioned, galls, oak bark, blackberry and dew- berry root, black alder, alum root, pomegranate, &c.; among the tonics, co- lumbo, gentian, quassia, simaruba, angustura, cascarilla, &c. These may be tried, separate or variously combined, in decoction or infusion, flavoured with cinnamon or orange-peel, and with some hope of advantage. Nux vomica has been recommended as having peculiar efficacy. But, on the whole, more good may be expected from the mineral substances belonging to the same classes, especially alum, acetate of lead, sulphate of copper, sulphate of zinc, nitrate of silver, and the various chalybeates. With all these remedies it is usually proper to combine opium. When there is reason to suspect ulcera- tion of the bowels, sulphate of copper in the dose of one-quarter of a grain, with the sixth of a grain or more of opium, given four times a day, I have found a most effectual remedy. Of the chalybeates, the solution of nitrate of iron (U. S. Ph.) has of late years acquired considerable reputation; but, in my own experience, it has not proved superior to the other preparations of # * R-—Hydrarg. Chlorid. Mit. gr. ij ; Opii gr. j; Plumbi Acetat. gr. vj. Misce, et fiant pil. no. xii. S. One to be taken every half hour. t R-—Testte Praeparat. ^ss; Tinct. Opii gtt. vj; Pil. Hydrarg. gr. iij; Acacia pulv., Sacch.. aa ^ss: Aquae Cinnam. fgss; Aq. fluvial, f^j. Misce. S. A teaspoonful to be given at intervals of two, four, or six hours, or less frequently. % See a communication by Dr. II. W. Fuller, in the Lond. Med. Times and Gaz. (Jan. 1852, p 31), and various other communications in the same journal, and the London Lancet, in the years 1851 and 1852. CLASS III.] DIARRHCEA.—COLIC. 649 the same metal. Ergot was used successfully by Dr. Stout, of Bethlehem, Pennsylvania, in the dose of six grains three times a day, in a case which had long obstinately resisted tonic and astringent treatment. (Phil, Journ. of Med. and Phys. Sci, vi. 118.) M. Rayer employs subnitrate of bismuth, with great advantage, in the diarrhoea of phthisis, that of typhus fever, and in the cases of children. (See Am. Journ. of Med, Sci, N. S"!, xiv. 219.) M. Mon- neret uses the same remedy, with great asserted success, in the atonic diar- rhoea of children, in the quantity of two drachms gradually increased to twelve drachms daily. (Ibid., xviii. 462.) He considers the remedy innocent in these large doses; but, never having employed them, I cannot speak of them from my own experience. When stimulation is requisite, good port wine should be preferred. For the treatment especially applicable to the diarrhoea of chronic enteritis, the reader is referred to that disease. There are various accessory measures which may be resorted to, in any of the forms of diarrhoea. Of these, the warm bath, in acute cases, when the skin is warm and dry, the hot bath, and especially the warm salt-bath, in chronic cases when it is cool and pale, are perhaps the most efficient. They may be used with great advantage in the cases of children. A bath of de- coction of oak bark has been recommended in similar cases. Benefit may also be expected from a flannel roller about the body. Frictions to the surface are decidedly useful, when the cutaneous circulation is languid; and rubefa- cients or blisters to the abdomen may be tried in obstinate cases. Anodyne enemata are sometimes highly serviceable in allaying the intestinal irritation. Warm clothing, with flannel next the skin, is important. This precaution is too often neglected in children, whose feet, legs, and arms, are apt to be exposed unprotected to the changes of temperature, which they are less able to bear than adults. Regular exercise should not be neglected in chronic cases, when the patient is in a situation to take it. Diet.—Attention to diet is indispensable. In many cases, indeed, no other remedial measure is necessary, especially when the disease has originated from improper food. In infantile diarrhoea, it is important to ascertain whether the milk of the nurse is healthy, and, if there is reason to suspect that it is otherwise, to substitute another nurse, or to remove the child from the breast altogether. Care, too, must be taken that the child do not over- feed itself. The farinaceous substances, such as stale or toasted bread, water- crackers, and boiled rice, constitute a suitable diet in the early stages of diar- rhea of irritation. Milk is admissible in mild cases. ' Farinaceous drinks may be employed when the irritation is considerable, and especially when the stomach participates in it. Fresh vegetables and fruits should, as a general rule, be avoided. Whatever is eaten should be thoroughly masticated. For infants, fresh milk, diluted with water, and thickened with arrow-root or pul- verized water-crackers, is a good diet; but, when there is fever or evidence of acute inflammation, the food should consist exclusively of mucilaginous or farinaceous liquids. In the more advanced stages, milk, broths, and boiled meats, with fresh butter and cream, may be allowed; and, in diarrhoea of de- bility, this kind of food should be given from the beginning. In many chronic cases, an exclusive milk diet will often alone effect cures. The dietetic rules applicable to dyspepsia should be observed during convalescence. II. COLIC. Colic (from v.ujXov, colon, or xo>Ma, the belly) is characterized by pain in the bowels, usually more or less paroxysmal in its character, associated with con- stipation, and occurring independently of inflammation either of the mucous or peritoneal coat. Pathological conditions essentially different are included 650 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. in the above definition; but there is a convenience in considering them to- gether; as their most prominent symptoms are the same, and their treatment similar. I shall first give the symptoms of colic in general, and then treat of the varieties of the disease, so far as they are peculiar. Symptoms.—The pain of colic occurs usually in frequently returning pa- roxysms, with irregular remissions or intermissions; but, in some instances, is continued and almost uniform for considerable periods. During the exacer- bation, it is often exceedingly severe, so as to cause even persons of fortitude to groan or cry out. It occurs most commonly about the umbilicus, though not unfrequently in other parts, and sometimes over the whole abdomen. It is described as twisting, rending, pinching, &c, and is often attended with a feeling of spasmodic constriction. The patient is for the most part extremely restless, frequently changing his position, turning from one side to the other, sitting up in bed, or rising and walking about the room with his body bent, and his hands frequently pressed against the abdomen. The muscles of the abdomen are sometimes spasmodically contracted, either in knots, or so as to produce a general rigidity of the anterior parietes. The violence of the pain occasionally depresses temporarily all the vital actions, producing paleness of the skin, cold sweats, a shrunken countenance, and a feeble pulse. When very sudden in its attack, it may produce faintness, and even temporary insensi- bility, and in infants frequently occasions general convulsions. It is often relieved by pressure on the abdomen, but not uniformly so. When the vio- lent pain has ceased, a feeling of soreness is generally left behind. The pain, in true colic, is always accompanied with constipation, either as cause or effect; and, when this is overcome by medicines, not unfrequently ceases. In certain cases, howrever, it continues without abatement, notwith- standing the operation of cathartics. Along with the pain and constipation there is often vomiting, but this is by no means constantly present. The stomach occasionally participates with the bowels in the spasmodic pain. The pulse is generally either healthy, or some- what depressed. Occasionally, however, the disease is originally associated with inflammation, or this condition ensues in the course of it, or there is high irritation in some neighbouring organ. Under these circumstances, a febrile condition may be developed. Colic, in the great majority of cases, yields readily to suitable treatment. In some instances, however, the constipation persists, and the disease assumes the most alarming character, in spite of all that can be done. The vomiting is now frequent, everything taken into the stomach is rejected, the action of the bowels themselves is inverted, and even feculent matter is discharged from the mouth. Along with these symptoms are a swollen, tense, and tympanitic abdomen, hiccough, great anxiety, cold sweats, a feeble pulse, and a general expression of the last degree of prostration. This condition is denominated ileus or the iliac passion, and is frequently, though upon insufficient grounds, treated of as a distinct disease. It is the closing stage of the severest forms of colic, and is often connected with some irremovable mechanical obstruction. It may occur, in fact, in any case in which, no matter from what cause, whether spasm, or partial paralysis of the bowel, or obstruction, the alvine contents cannot find their way downward. Even ileus, however, is not always certainly fatal. Patients have, in numerous instances, recovered under apparently des- perate circumstances; and hope and consequent efforts should never be aban- doned, unless when some insuperable obstacle, such as scirrhous occlusion of the bowel is known to exist. Colic has no fixed duration, sometimes terminating in a few hours, and sometimes running on for two or three weeks. Diagnosis.—The complaint with which colic is most likely to be confounded CLASS III.] COLIC. 651 is strangulated hernia. In fact, the only difference between this and some forms of colic depending on mechanical obstruction is, that the former pre- sents certain external characters by which it can be recognized, and may be relieved by the timely application of surgical means. But this distinction is of the highest importance, and the possible existence of strangulated hernia should be borne in mind, in every case of severe or obstinate colic, and a close examination instituted. Many lives have been lost from want of attention to this caution. From mucous enteritis colic may be distinguished by the con- stipation which attends it; from both this and peritonitis, by the more parox- ysmal character of the pain, by the relief frequently derived from pressure, by the absence of fever, and by the restless movements of the patient. Simple Spasmodic Colic.—The essential character of this variety is spasm of the bowel, unattended with any other necessary pathological con- dition. Constipation is here the result, and not the cause of the spasm. Attacks are most commonly brought on by indigestible food, especially flatu- lent vegetables, and are peculiarly apt to occur in dyspeptic persons. Under these circumstances, the disease is sometimes called dyspeptic colic. The pre- sence of the undigested matters in the bowels occasions frequently a copious extrication of flatus, which increases the spasm by the stimulus of distension. Gases evolved from other causes sometimes produce attacks, without any irri- tant substance in the bowels. In either case, the disease is often called flatu- lent colic. The patient is affected with borborygmi, distension of the abdomen, and eructations of flatus, which are sometimes exceedingly copious, and usually afford more or less relief. When the attack is induced by indigestible food, or other irritant taken into the stomach, this organ is apt to participate in the spasm, and occasionally the symptoms are ofthe most violent character. The presence of irritant secretions in the bowels, or the retention of portions of hardened feces insufficient to obstruct the passage, may sometimes act as an exciting cause ; but the irritation from these sources is more apt to fall upon the mucous coat than upon the muscular, and to produce diarrhoea or dysen- tery, than colic. This variety of colic is also frequently induced by cold, especially by cold feet, and sometimes results from rheumatic or gouty irrita- tion acting upon the nervous tissue of the bowel, from suppressed discharges, repelled cutaneous eruptions, mental disturbance, and an hysterical state of the nervous system. In the last case, it has been called hysterical colic. To the same variety belongs also the intestinal spasm induced by worms, denom- inated by some verminose colic. Simple spasmodic colic is very rarely fatal. Sometimes, however, it is so; and then large portions of the bowel are usually found, upon dissection, in a contracted state, while the portion above the stricture is distended, and marked more or less with appearances of inflammation, though not enough to account for the fatal issue. Death probably results from the spasmodic closure of the bowel, operating as an obstacle to the passage of the intestinal contents. It is probable that the great distension ofthe bowel, above the contracted por- tion, may in some measure paralyze the muscular coat, and thus act as an additional cause of constipation. Bilious Colic.—The peculiarity, in this form of colic, is the coincidence of derangement of the biliary organs with the intestinal spasm; the former being probably the source of that irritation which evinces itself in the latter. An attack of bilious colic is frequently preceded by loss of appetite, nausea, a feeling of lassitude or weariness, and other symptoms of disordered hepatic action. The paroxysms of pain are often attended with much irritation of stomach, and vomiting of yellow or green bile, the discharge of which affords temporary relief. There is at the same time usually some sallow- ncss of the skin, or a yellow tinge of the conjunctiva; the urine is deep- 652 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. coloured and yellowish ; and there is a yellowish-white fur on the tongue. Not unfrequently some tenderness will be found upon pressure in the epigas- trium or right hypochondrium ; and the pulse, though usually calm at first, is sometimes febrile from the beginning, and often becomes so, if the disease continues. There is also occasionally incomplete paralysis of some portion of the upper or lower extremities, with convulsive movements in different parts of the body. When stools are obtained, they are sometimes bilious, and some- times light coloured, indicating a want or deficiency of bile. The immediate cause of the spasm is probably an irritation of the muscular coat of the bowels, induced either by sympathy with irritation of the liver, or by a con- gested state of the portal veins, or by both. The vomiting of bile does not necessarily indicate an increase of hepatic secretion ; for the bilious matter may proceed from the gall-bladder, discharging its contents in consequence of the pressure upon it in the act of vomiting. Either an increase or dimi- nution of bile may be a consequence of irritation of the liver, and an attendant upon portal congestion, and either may therefore occur in bilious colic. The original causes are probably the same as those which give rise to cholera morbus and bilious diarrhoea. Perhaps the most common is exposure to cold, after previous lengthened exposure to heat. Hence the disease occurs most frequently in hot weather, especially when the nights are cool; and is pecu- liarly prevalent in those regions where this alternation of temperature between the day and night is a usual event. It is probable, also, that miasmata are capable of producing colic by their influence upon the biliary organs. Colic from Obstruction.—In this variety, the spasm of the bowel is the result of its accumulated contents, consequent upon a stoppage more or less complete of the passage. The constipation is here the cause, instead of being, as in the preceding cases, the effect of the spasm. The obstruction may depend upon accumulated and compacted feces, upon insoluble sub- stances taken largely or repeatedly by the mouth and arrested in the bowels, upon invagination ofthe intestine, tumours, &c. Of these various causes, as well as of the diagnosis of obstruction in general, and of its varieties, I shall treat at large under the head of obstruction ofthe bowels; as it is this which constitutes the real disease, of which the colic is merely a symptom. It is sufficient here to say that, unless the impediment to the passage of the ali- mentary matters be removed, the complaint will generally end in death, pre- ceded by the symptoms of ileus. Inflammatory Rheumatic Colic—inflammation of the mu- cous or the peritoneal coat of the bowels, though almost always attended with spasmodic pain, is characterized by symptoms which strikingly distinguish it from colic. This, however, is not the case with inflammation of the muscular coat exclusively. It is true that this coat is seldom or never inflamed without more or less participation of one of the others, unless in cases of rheumatism or gout attacking the bowels. Hence, this variety of colic may emphatically be styled rheumatic or gouty j and, as these two affections are sometimes also exhibited in the bowels in a simply neuralgic or spasmodic form, it may be dis- tinguished by adding the epithet inflammatory. Rheumatism of the muscular tissue of the bowels is not very uncommon. It may be either original or trans- lated. It may frequently be recognized by coming on immediately after the retrocession of rheumatism from some external part. A portion more or less extensive of the muscular coat becomes tender and painful, and either refuses altogether to contract under the stimulus of the alimentary or feculent matter, like an external muscle similarly affected, or is thrown into the most exquisitely painful, and at the same time inefficient efforts at contraction. The pain, in these cases, is more steady and uniform than in spasmodic colic ; and, when parox- ysms occur, they appear to depend upon the effort of the bowel to carry for- CLASS III.] COLIC. 653 ward its contents by the ordinary peristaltic movement. Hence, purgatives produce occasionally severe pain during their operation. The constipation is a consequence of the insufficiency of the peristaltic action, and does not depend necessarily upon spasm ; although a portion of the bowel, not affected to the point of inflammation, may sometimes be thrown into spasmodic con- traction. There is often tenderness upon pressure, and sometimes fever. The pain is in general more circumscribed than in spasmodic colic, and pur- gatives do not afford the same relief. Within my observation, the ascend- ing and descending colon have been the portions of bowel most commonly affected. Though exceedingly painful, and sometimes apparently threaten- ing, this form of colic is very seldom fatal. Neuralgic Colic.—Neuralgia ofthe Bowels.—Nervous Colic.—The bowels, like most other parts of the body, are subject to attacks of severe pain, without inflammation, or necessary vascular excitement. Such attacks, when complicated with spasm, belong to simple spasmodic colic. When not thus complicated they cannot be better designated than by the title at the head of this section. The pain, though somewhat paroxysmal, is usually more steady during a certain length of time than in spasmodic colic. There is not the same frequent alternation of severe pain and comparative ease. The pain is sometimes extremely distressing, without being very acute, and is attended with great depression of spirits. As in the preceding variety, paroxysms are sometimes induced by the passage of alimentary matters and purgative medicines; and constipation is owing to the indisposition of the muscular coat to contract, in consequence of the pain which contraction induces ; but there is less difficulty in procuring evacuations from the bowels than in most other forms of colic. The pain, during exacerbation, is not increased by pressure, although the bowel is afterwards left tender. The pulse is either at the standard of health, or beneath it. Sometimes the disease is distinctly intermittent, occurring at the same time every day or every other day, and, after having continued for some hours, leaving the patient quite easy in the interval. The causes of neuralgia of the bowels are not less obscure than those of the same affection elsewhere. Sometimes it depends on disorder in the spine, or in the ganglia of the sympathetic nerve, and sometimes appears to have its origin in general debility, or in a rheumatic or gouty diathesis. A form of colic closely resembling colica pictonum has been described under the name of nervous colic; but I believe that, in such cases, a very close scrutiny will generally detect the operation of some preparation of lead. Lead Colic, Painters' Colic, or Colica Pictonum, is so peculiar both in its origin and character as to merit the rank of a distinct disease; and will there- fore be treated of under a separate head. Besides the varieties of colic above referred to, several others have been enumerated by authors. Spasm of the bowel sometimes occurs from sympa- thy with irritation or inflammation in various neighbouring parts, as during the passage of biliary and urinary calculi, in painful menstruation, and in hemorrhoids. Hence the designations of hepatic, nephritic, uterine or men- strual, and hemorrhoidal colic. In all these cases, so far as the intestinal spasm is concerned, the complaint would come under the variety of simple spasmodic colic above described. The designation of metallic colic is used, by some medical writers, for painful bowel affections among persons who work in different kinds of metal. It is only the lead or painters' colic, however, which deserves this name. The intestinal affection which sometimes attacks workers in copper, and other irritant metals, is properly enteritis. The dis- ease which has occasionally appeared endemically or epidemically in certain localities, and has been named from these localities Madrid colic, Devonshire colic, Poitou colic, &c, and by some French writers vegetable colic, appears 654 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. from the descriptions of authors to have been, in some instances, identical with lead colic, and in others with bilious colic. It not unfrequently happens that different causes of colic operate at the same time, and thus produce mixed cases, in which the peculiar symptoms of two or more of the several varieties may be observed. Treatment,—The general indications in the treatment of colic are to relieve pain, and evacuate the bowels. Different modes of effecting these objects are required, under different circumstances, and in different forms of the disease; and the indications themselves are more or less modified in certain cases. I shall first consider the plan applicable to simple spasmodic colic, and afterwards the modifications demanded in the other varieties severally. In simple spasmodic colic, when the pains are moderate, and dependent upon flatulence or mere exposure to cold, without the presence of irritating solid or fluid matter in the prima? via?, relief may often be quickly obtained by the exhibition of moderate stimulants, especially of those which are rather local than general in their action, such as the aromatic oils, infusions, and tinctures. A cupful of hot infusion of ginger, cloves, or calamus ; from fifteen to thirty drops of the essence of peppermint or spearmint, dropped on sugar, or diffused in sweetened water; or from one to four fluidrachms of the com- pound spirit of lavender, or compound tincture of cardamom, sufficiently diluted with hot water, may be employed. One or two teaspoonfuls of the camphorated tincture of opium will usually be found still more efficient. When the complaint has originated in exposure to cold, the feet may be soaked in hot water, or held before a hot fire; and this simple remedy will often give relief without other means. In severe cases of the same kind, or in such as have resisted the above treatment, a full dose of opium or some one of its preparations should be given, and repeated at intervals of one, two, three, or four hours, according to the urgency of the symptoms, until the pain is moderated, or decided narcotic effects are experienced. The above-mentioned aromatics, or even more power- ful stimulants, may be advantageously associated with the opiate, especially when.the system sinks under the severity of the pain. Under these circum- stances, laudanum may be given with tincture of camphor, oil of turpentine, oil of juniper, aromatic spirit of ammonia, ether, or even musk when the stomach is the seat of the spasm. In cases complicated with hysteria, infusion of valerian, mixture or tincture of assafetida, or the anodyne liquor of Hoffmann, may be substituted for the stimulants mentioned. When danger is apprehended from the violence of the spasm, the inhalation of ether or chloroform may be resorted to; and, in less severe cases, the latter remedy may be given by the mouth, with a view to its ana?sthetic effects. The anodyne and stimulating remedies should be accompanied, or soon followed, by some quick cathartic, especially castor oil, wliich is beyond all others adapted to these cases. A fluidounce of the oil with twenty-five or thirty drops of laudanum, given in peppermint-water, will very often effect- ually meet all the indications. At the same time, external means should not be neglected. Strong friction over the abdomen sometimes proves serviceable by the expulsion of flatus. Warm fomentations, anodyne and emollient cataplasms, and, in urgent cases, hot oil of turpentine applied by means of a folded flannel moistened with it, or a large sinapism over the abdomen, may also be employed. When the pain arises from irritating matter in the stomach, which maybe inferred to be the case if the attack commence soon after eating, or if the patient be affected with nausea or retching in the intervals of the spasm, full vomiting should be promptly induced, either by copious draughts of warm water or warm chamomile tea, or by a dose of ipecacuanha. The most violent CLASS III.] COLIC. 655 cases sometimes yield immediately to this simple remedy, after powerful anodynes and stimulants have been employed without effect. The attention of the young practitioner cannot be too strongly directed to this fact. If there be reason to suppose that undigested food, acrid secretions, fecu- lent accumulations, or any other irritating substance in the bowels, are the cause of the spasm, the indication for alvine evacuations is still stronger than in other cases, and this should be kept prominently in view. Should castor oil not act speedily, or be rejected from the stomach, recourse may be had to sulphate of magnesia ; to infusion of senna with Epsom salt, manna, and fen- nelseed, cardamom, or ginger; or, in very obstinate cases, to croton oil, of which from half a drop to two drops may be given, and repeated at short in- tervals untU it operates, or produces some obvious inconvenience. When the stomach is very irritable, calomel is often preferable to other cathartics, being retained when almost everything else is rejected. Five grains may be given every two, three, or four hours until it operates, or the whole quantity amounts to twenty grains. The occurrence of salivation will, under such circumstances, in persons of ordinary constitution, be of no disadvantage The most obsti- nate cases sometimes yield immediately after the mouth has become sore. If the irritating matter in the stomach or bowels be acid, magnesia should either be substituted for the other cathartics, or given in conjunction with them ; and it has been observed that mild laxatives of this character sometimes operate, when more powerful purgatives serve merely to increase the spas- modic constriction, and to provoke vomiting. A good laxative mixture for the purpose consists of magnesia and manna, mixed with strong fennelseed tea. To hasten the action of the cathartics, or to supply their place when they are rejected from the stomach, or from other cause fail to operate, purgative enemata are of the utmost importance. Indeed, in some very bad cases, they constitute our chief reliance. The milder should be first employed, and after- wards, if necessary, the more powerful, their strength being increased at each successive repetition. After failure with the common injection, consisting of olive oil or lard, common salt, and molasses, of each a tablespoonful, mixed with a pint of warm water, the operator may resort successively to castor oil, infusion of senna, jalap, extract of colocynth, &c, each in three or four times the quantity usually given by the mouth, and diluted with water so as to mea- sure a pint or more. Tartar emetic may be added to the ingredients of the enema, or may be injected alone, iu the dose of three grains dissolved in water. Oil of turpentine, in the quantity of from half a fluidounce to two fluidounces, mixed with half a pint or a pint of water by the intervention of the yolk of eggs, forms au excellent enema in severe cases. When the spasm is dependent on flatulence, or connected with hysterical disorder, the greatest advantage may be expected from a drachm of assafetida rubbed up with water. In cases of ileus, where danger is imminent, the tobacco enema should be employed. In this country, we usually infuse a drachm of the narcotic in a pint of hot water, and give half the quantity, repeating the operation with the other half at the end of half an hour or an hour, if the first should fail. Dr. Abercrombie recommends fifteen or twenty grains in- fused in six fluidounces of water, to be repeated if necessary, every hour, until slight faintness or giddiness is felt. The smoke of tobacco has also been forced into the rectum, with asserted advantage. Sometimes very cold water, injected into the bowels, produces relaxation of the spasm when other measures have failed ; and very large quantities of pure warm water, thrown up, by means of a self-injecting apparatus, until the patient can no longer support the distension without suffering, have been found very efficient in alarming cases. There may be some hope that intussusceptio, obstruction from twisting of the bowel, or even concealed strangulation may be relieved 656 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. by this latter measure. The introduction of a long gum elastic rectum tube, so as to pass the sigmoid flexure high up into the colon, will afford the means of applying the injected matter more efficiently. Other means may be employed as auxiliary to the above course of treat- ment. Occasionally a stream of cold water, poured from a pitcher at a con- siderable height upon the naked abdomen of the patient, placed on his back upon the floor, has been followed almost immediately by an alvine evacuation, and consequent relief. Bleeding is very useful by relaxing the spasm, and obviating the danger of inflammation. In obstinate cases, when not contra- indicated by the state of the pulse, or the general condition of the patient, it should never be neglected. The warm bath too is often very efficient, and in cases of children is not inconvenient. Irritability of stomach, if not checked by some of the various means employed for the relief of the pain and spasm, may sometimes be happily allayed by an anodyne enema, so as to admit of medicines being administered by the mouth. Sometimes a state of debility comes on, which requires the support of wine-whey, or other form of alcoholic stimulus. The hope of a favourable issue should never be surrendered, but these various means perseveringly repeated, and variously alternated to the end. Patients have often been rescued under the most unpromising circum- stances, and sometimes from apparently inevitable death. After the bowels have been freely evacuated, care should be taken to keep them open by mild means; and, if much tenderness of the abdomen or any part of it, with or without fever, should lead to the apprehension of danger from inflammation, this should be combatted by bleeding, cupping, or leech- ing, fomentations, blisters, &c, as the case may seem to require. The diet ofthe patient should for some time be cautiously regulated; light and easily digested food being employed, and everything likely to occasion flatulence, or excess of acid, avoided. In bilious colic, as the pulse is usually more active, and evidence of existing congestion or even inflammation of the liver not uncommon, bleeding should, as a general rule, be resorted to more freely, and at an earlier period, than in the preceding variety; and cupping over the region of the liver and duodenum will often be advantageous. In the commencement, an emetic of ipecacu- anha or tartarized antimony may sometimes be usefully exhibited; and at any time, if the stomach should be irritable, and small quantities of bilious matter occasionally vomited, this organ should be well washed out, by means of warm water, or infusion of chamomile. But, in the great majority of cases of bilious colic, the most appropriate treatment, at the commencement, is to exhibit a combination of opium and calomel, in repeated doses, until the pain is relieved or rendered tolerable, and then to carry off the mercurial by means of quicker purgatives, such as castor oil, sulphate of magnesia, infusion of senna with salts, &c. I usually direct four grains of opium, with from eight to twelve grains of calomel, to be made into four pills, two of which are to be taken immediately, and each of the others at intervals of an hour, if required. The operation of the cathartics should be assisted by enemata; and recourse should be had to the various measures already enumerated, as calculated to facilitate the opening of the bowels. The remarks before made in relation to external remedies, such as warm fomentations, sinapisms, blisters, the warm bath, &c, are equally applicable here; and the necessity is still greater for guarding against, or correcting inflammation, by general and local depletion. Calomel is much more strongly iudicated than in the simple spasmodic colic; and, if the quantity at first exhibited, as above directed, should fail to effect a cure, the medicine may be administered with tolerable freedom throughout the complaint. Indeed, in obstinate cases, it is almost always desirable to push the mercurial to a moderate salivation, for which purpose a grain or CLASS III.] COLIC. 657 two may be given at regular intervals, varying according to the urgency of the symptoms. The same cautions are requisite here as already given, in relation to the maintenance of a free state of the bowels, and the proper regulation of the diet, during convalescence. Especial care should be taken to avoid exposure to changes of temperature, until convalescence is firmly established. Should the fecal discharges remain clay-coloured, an alterative course of mercury, or nitromuriatic acid may be employed, and the various means resorted to, calculated to restore the function of the liver to its healthy state. (See Jaundice.) Inflammatory rheumatic colic usually presents stronger indications for general and local bleeding than either of the other forms of the disease. In almost all cases, where the constitution of the patient is tolerably robust, the lancet may be employed with freedom. Cups or leeches may also be liberally applied along the course of the affected bowel, which is generally marked by more or less tenderness on pressure. It is desirable to evacuate the bowels at first freely; but this should be accomplished if possible by the milder cathartics, as castor oil or Epsom salt, aided if necessary by enemata, rather than by those of a drastic character, as the portion of the bowel affected becomes exceed- ingly painful, under the stimulus of active purgation. After the bowels have been well opened, and the pulse sufficiently reduced by the loss of blood, ob- jects which in general may be very soon effected, the patient should be put under the influence of opium, which may be advantageously combined with ipecacuanha and calomel. One or two grains of opium, with an equal quantity of ipecacuanha, and from two to four grains of calomel, may be given at bed- time, and the combination may be repeated, with smaller doses of the mercu- rial, at intervals of four, six, or eight hours, so as to keep the patient in tolerable ease, and to sustain a steady perspiration; the plan of treatment being occa- sionally intermitted, in the day, for the administration of a mild cathartic. Should the mouth exhibit the slightest evidence of mercurial influence, the calomel should be suspended. Upon the commencement of such an influence, the symptoms of the disease very generally give way. Should the stomach be irritable, as sometimes happens, the calomel and opium may be given without the ipecacuanha; or the whole may be suspended until the irritability has yielded to anodyne enemata, and suitable external applications. (See Vomiting, page 591.) When it is desirable, upon any account, to avoid the possibility of salivation, the calomel must be omitted, and either the opium and ipecacu- anha employed alone, or their place supplied by a mixture of an opiate with a preparation of colchicum. I have been in the habit of using the officinal solution of sulphate of morphia, in the dose of one or two fluidrachms, with from twenty to forty drops of the wine of colchicum root, repeated every four, six, or eight hours. It has appeared to me that this combination is especially applicable to cases in which the irritation is of a somewhat fugitive and unset- tled character, and liable to ready translation to other, and perhaps still more delicate organs. The remarks already made, in relation to local external reme- dies, and the use of the warm or hot bath, in simple spasmodic colic, are equally applicable to this variety. Revulsion to the extremities is also indicated; and hot and stimulating pediluvia, with sinapisms to the feet and ankles, may be employed. Occasionally cases occur in which the general actions are so feeble as not to admit of depletion. If, along with this debility, there should be a disposition to sweat during sleep, sulphate of quinia will be likely not only to support the strength of the patient, but also to cure the disease. In neuralgia of the bowels, the same indications exist as in the other forms of colic, for relieving pain, and procuring alvine evacuations. The former indication requires the use of opiates, the latter of mild cathartics, which are usually sufficient for the end. But the same relief is not obtained after the VOL. i. 42 658 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. cathartic action, as in ordinary colic. Other remedies must be employed for the cure of the affection. Of these the preparations of colchicum, given as largely and as frequently as can be well borne by the stomach, are perhaps the most effectual. Good may also be expected from the narcotic extracts, as those of belladonna, stramonium, conium, and hyoscyamus, which may be given alone or in combination, and pushed so far as to produce their peculiar impression upon the brain. It is possible that the chalybeates, and other mineral tonics, may also prove serviceable; and I have seen one obstinate case which, after resisting various other remedies, yielded to large doses of sub-carbonate of iron. Alum has been found effectual in certain cases of ner- vous colic, closely simulating, if not identical with colica pictonum. Should the affection assume the regular intermittent form, it will be almost certainly cured by the free use of sulphate of quinia; and this medicine may be given with some hope of advantage, in the remittent and even continued cases. The same external remedies may be applied as in ordinary colic, with the addition of frictions with strong tincture of aconite, or ointment of veratria. Should tenderness upon pressure be observed in any portion of the spinal column, cups or leeches, with subsequent rubefaction, vesication, or pustulation of the part affected, will be required. Bleeding seldom does good, but on the con- trary often much injury in this affection. The diet should be digestible and nutritious without being stimulant. III. LEAD COLIC. Syn.—Painters' Colic.—Colica Pictonum. This disease has been called saturnine colic and metallic colic, from its cause, painters' colic from a class of persons very subject to it, and Devon- shire colic and colica Pictonum, the former from the county of Devonshire, in England, the latter from the province of Poitou, in France, in both of which districts of country it has prevailed. It usually commences with symptoms not unlike those of dyspepsia, as diminution or loss of appetite, epigastric uneasiness, slight and fugitive ab- dominal pains, a disposition to costiveness, with general languor and depres- sion of spirits. These symptoms continue for several days, gradually aug- menting, untd the patient is at length generally compelled by the severity of his pains to abandon his customary avocations, and betake himself to his bed. In some instances, however, the attack is sudden, and without premonition. The pain is felt more especially about the umbilicus, or in the spinal re- gion, but usually extends also in a greater or less degree over the abdomen, and sometimes shoots up into the chest and downwards into the pelvis. It is excessively severe, being described as tearing, rending, boring, &c, and is attended, moreover, with a feeling of indescribable wretchedness, which is forcibly expressed upon the countenance. Though paroxysmal, it is seldom entirely absent, unless momentarily after vomiting, which sometimes appears to afford relief. In the remission, however, there is rather a feeling of con- striction and vague uneasiness than of acute pain. The patient finds it im- possible to remain long in one position ; sometimes rising, and walking about the chamber, and again resuming his bed; now turning upon one side, then on the other, getting upon his knees, or lying upon his face, and assuming the most grotesque postures, often with his body bent almost double, and his hands pressing together upon his abdomen. The suffering is so exquisite as to extort groans from individuals of the greatest fortitude, and I have known a strong man to cry like a child. To an experienced eye, the expression of CLASS III.] LEAD COLIC. 659 extreme wretchedness upon the countenance, in connection with the whimsical movements of the patient, is sometimes alone sufficient to mark the complaint. The paroxysms are often worse during the night, and the patient is unable to sleep. Moderate pressure upon the abdomen does not in general aggravate the pain, but, on the contrary, often yields partial relief. Some uneasiness, however, is occasionally felt, in particular spots, when they are strongly pressed. The belly is in most cases somewhat retracted, especially at the umbilicus, and the abdominal muscles are hard, and often gathered into knots. The testicles are apt to be drawn up during the paroxysm ; and a severe irritation is sometimes extended to the urinary passages and rectum, producing strangury and tenesmus.* Obstinate constipation, sometimes resisting the most active cathartics, and often attended with a desire to go to stool, and a feeling as if an evacuation would afford ease, is one of the most characteristic features of the disease. When evacuations are obtained, the feculent matter first discharged is usually in small, hard, dark-coloured, knotty lumps, sometimes covered with mucus. It is said that the sphincter ani is in some instances so violently constricted as to resist the introduction of a pipe. Nausea and vomiting are very frequent, and the matter discharged is gene- rally bilious. Indeed, irritability of stomach is one of the most distressing circumstances of the disease, and sometimes interferes greatly with the effi- cacy of the medicines administered. Occasionally it is among the first signs of the action of the poison. The tongue is flabby, pale, and often tremulous when protruded; the breath sometimes fetid ; the urine scanty; the pulse usually slow and hard, but occa- sionally frequent; the face of a pale, dingy, or sallow aspect; the hand trem- ulous, with great weakness at the joint of the wrist; the lower extremities affected with painful cramps; and the muscles of the chest sometimes spas- modically contracted, with pains like those of angina pectoris, and palpita- tion of the heart. A symptom, first noticed by Dr. Burton, is a peculiar appearance of the gums, which present, especially at their margin, a pale, bluish-gray colour, characteristic of the action of lead upon the system. The complaint is sometimes attended with evidences of inflammation in the abdominal viscera; such as tenderness upon pressure, a hot dry skin, frequent pulse, and a general febrile condition. Delirium, convulsions, and paralysis are also among its occasional complications. The palsy may affect only the muscles, or it may extend also to the sensorial functions, involving the senses of touch, sight, and hearing; but this affection more frequently follows the colic than accompanies it. * It has been maintained by several pathologists, from the time of Astruc down, and especially by Giacomini, of Padua, that the abdominal pains of lead colic are not seated in the bowels, but in the walls of the abdomen. This opinion has recently been strongly re-asserted by M. Briquet, of Paris, who supports it by the following considerations. 1. Gentle pressure with the fingers on the abdomen, so applied as not to affect the bow- els, always produces pain in one or several points; and these points correspond with those to which the patient refers his colicky pains. 2. Active or passive motion of the -muscular fibres concerned exasperates the pain; and the apprehension of this suffering; restrains the movements of the patient, exactly as in rheumatism of the muscles. 3. Rest calms, and may entirely relieve the pains. 4. The abdominal pains are sometimes attended with excessive, sometimes with diminished sensibility of the skin over the affected muscles. 5. The constipation has no appreciable influence upon the pains. 6. If by therapeutic measures a sudden cessation is effected of the tenderness of the mus- cles on pressure, instantly all painful sensation ceases also. (Archives Gen., Fev., 1858,. p. 132.) It appears to me, however, that these arguments are quite insufficient to prove the absence of intestinal pains, in the face of the positive convictions of the patient, and the obvious symptoms. M. Briquet refers the source of the pains to the morbid- influence of the poison on the spinal marrow. (Note to the fifth edition.) 660 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. The symptoms usually continue unabated for several days, and then gradu- ally subside; and this result will take place, in the great majority of cases, though little or no treatment be employed. The severity of the complaint, however, may be diminished, its duration abridged, and its very unpleasant sequela? in great measure prevented by appropriate remedies; and there can be no doubt that cures may be effected in cases which would prove fatal, if left without aid. Under proper treatment, the proportion of deaths is very small. Of 3569 cases treated by different physicians in Paris, 95 died, or about 2-7 per cent.; and, according to Andral, of more than 500 persons treated during eight years in the hospital la Charite by M. Lerminier, only 5 died, or less than 1 per cent. (Diet, de Med., viii. 388.) The disease usually yields to appropriate remedies in less than a week; and, when it proves fatal, does so as a general rule in consequence of some unfortunate complication, arising from the peculiar susceptibility of the patient, or the intense action of the cause. The cases attended with epileptic convulsions almost all end unfavourably. Sometimes headache, delirium, and coma supervene, and the patient dies apoplectic. In other cases, a general failure of the nervous power takes place, the violent pains cease, dyspnoea occurs, the skin becomes cold and pale, the pulse feeble, the countenance shrunk, sight and hearing impaired, and a fatal asphyxia closes the scene. In some rare instances, death appears to result directly from the morbid state of the abdomen, and the symptoms preceding the fatal issue indicate mortification of the bowels, or intense inflammation. Patients before a perfect cure are liable to relapse, and, after one attack, are much more susceptible to the disease than before, so that a slight ex- posure to the cause frequently induces a return. By repeated exposure, or by the long-continued but slight action of the cause, a state of chronic dis- ease at length ensues, which is often difficult to manage, and sometimes bids defiance to medicines, either terminating fatally in a few weeks or months, or producing a train of complicated evils, which run through long years of suffering. Among the characters of this morbid condition are palsy of the extremities, especially of the forearms, and occasionally also of the voluntary muscles of other parts ; defective nutrition and consequent general emaciation; enfeebled capillary circulation, with a pale, sallow, or dingy skin; oedema of the extremities gradually extending upwards; abdominal dropsy, and effusion in the pleura or pericardium; and general failure of the sensorial functions, indicated by defective touch, impaired hearing and vision, epilepsy, mania, and mental imbecility. The diagnosis of lead colic is not difficult. It can scarcely be confounded with any other disease than one of the varieties of colic already described, from all of which it differs in the peculiar aspect, grotesque motions, and excessive restlessness of the patient, the incomplete remission of the pain, the retracted abdomen with its hard and knotty parietes, the spasmodic pains in the extremities, the occasional paralytic complications, and the dark stain of the gums, which is seldom if ever wanting. On examination after death, constriction of portions of the bowels, particu- larly of the colon, has been observed, so great in some places as scarcely to admit the passage of a crow's quill. It is asserted that, in some instances, the stomach and intestines have been found in a state of preternatural con- traction throughout their whole extent. Marks of inflammation, and even disorganization, of portions of the alimentary mucous membrane have also been noticed. In the United States army report of 1827, a case is given in which the arch of the colon was mortified "all round" to the extent of " five fingers' breadth," and six lines below was a stricture of the intestine. (Forry, Am. Journ. of Med. Sci., N. S., iii. 321.) But these appear to have been CLASS III.] LEAD COLIC. 661 accidental complications, and not essential results of the disease; for of eight cases reported by Andral in his Clinique Medicate (3e ed., ii. 110), only one presented constriction ofthe intestines; and, though slight marks of inflammation were observed in several, the intestinal canal was entirely sound in others, and in none were lesions discovered sufficient to explain the symp- toms. In a case reported by Louis, the alimentary canal exhibited no mark of disease whatever. (Becherch. Anat. Patholog., &c, p. 483.) Several others have obtained similar results from their post-mortem examinations. (Diet, de Med., viii. 389.) In cases of death from epilepsy supervening upon colica pictonum, hypertrophy of the brain has been found in some instances, soften- ing of the brain or spinal marrow in others, while in others again no discover- able lesion existed in any of the nervous centres. (Ibid,, p. 385.) The in- ference to be drawn from these facts is, that the morbid cause acts directly upon the nervous system, and that any organic derangement, which may be detected after death, is merely an incidental occurrence, not constituting an essential part of the disease. Cause.—Lead, admitted into the system, is probably the sole cause of colica pictonum. Hence, painters, glaziers, plumbers, potters, lead-miners, and manufacturers of white-lead and red-lead, are frequent subjects of the disease. Any preparation of the metal capable of finding an entrance into the circula- tion may produce the effect; but the vapours of melted lead, and the carbon- ate of its protoxide are the most frequent agents, probably because the great- est number of persons are exposed to their action. No matter by what avenue the poison enters the system, the effect is the same. Proof is not wanting that lead colic has resulted from the external use of the solution of subace- tate of lead, especially when applied to the skin with an imperfect state of the cuticle. Innumerable observations have shown that various preparations of the metal produce the effect when taken into the stomach. Acetate of lead given as a medicine; water which has long stood in leaden reservoirs; cider and wines wliich have either been introduced into leaden vats, or been im- pregnated with the metal by means of litharge employed to sweeten them; carbonic acid water drawn from the fountain through leaden pipes, in which it had been permitted to stand; acidulous food kept in vessels glazed with lead; these, and various other forms in which the poison enters the stomach with medicine, food, or drink, have been abundant sources of the disease. The prevalence of colica pictonum among painters and manufacturers of white-lead, is ascribed by some to the uncleanly habits of the workmen, in consequence of which the carbonate, adhering to their hands and clothing, finds access to the stomach along with their food; and it is asserted that the disease has been rendered less prevalent among these individuals, by increased attention to cleanliness in their persons and dress. But even the most guarded care in this respect is not sufficient to ward off the disease; as the poison enters the system by the lungs even more readily than by the skin or stom- ach. Hence the peculiar liability of those who work in the melted metal. It is stated that, in white-lead factories, where the practice of grinding the paint under water has been adopted, and the escape of the dry carbonate into the air thus prevented, the disease has become much less frequent. Painters are said to be most liable to be affected when shut up in close apartments, or in those heated in order more rapidly to dry the paint; and, according to Gendrin, they who use only fixed oil as the vehicle of the white-lead almost always escape, while others who employ the oil of turpentine for the same purpose very frequently suffer. The complaint has been ascribed to other causes'. Thus, it has been some- times considered epidemic, from its great prevalence in certain districts; but a local cause has generally been discovered, as in Devonshire and Poitou, in 662 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. the use of cider or wine kept in leaden vessels, or purposely impregnated with litharge. Besides, it is highly probable that the bilious colic, which some- times resembles it closely, has been mistaken for it. Another cause has been found by some in the use of acidulous drinks and food, and crude articles of diet; but the strong probability is, that when the disease apparently result- ing from such causes has really been the one under consideration, and not simple spasmodic colic, it has arisen from some unsuspected impregnation of the article used with a salt of lead. When a disease having the characters of colica pictonum occurs, attention should always be directed to the dis- covery of some possible source of this poison. In a garrison of U. S. sol- diers, at Fort Delaware, numerous violent cases of the disease occurred, which were found to be owing to the use of water collected in cisterns from a large painted roof. (Am. Journ. Med. Sci., N. S., iii. 319.) The constitutional susceptibility to the poisonous action of lead is exceedingly different in dif- ferent individuals; some escaping under precisely the same circumstances as those under which others suffer ; and one being attacked only once or twice in his life, while another is subject to the disease upon every fresh exposure. Women are much less frequently affected than men, probably owing to the circumstance, that they are much less exposed to the cause. The greater prevalence of the disease at certain seasons, which has been observed by some, is ascribable to the greater activity, during these seasons, of those occupa- tions which give occasion for its attack. Inferior animals in the vicinity of white-lead factories, are said to suffer in a similar manner with man. It is probable that lead operates as a poison by an immediate influence upon the nervous matter, wherever it may meet with it, diminishing and ulti- mately destroying the motor power, as well as the property of receiving and conveying impressions, and that it does not produce its local effects, at least primarily, through an influence upon the nervous centres. On the contrary, the cerebral derangement is often the last in the succession of its effects. Its action upon the external muscles appears to be identical with that which it exerts upon the muscular coat of the bowels, which may be considered, in the lead colic, as in a state of partial paralysis. The violent neuralgic pains afford one out of numerous examples of disordered sensation, attendant upon a depressed condition of the nervous power. The disorganization occasion- ally observed in fatal cases, may, without violence, be referred to some inci- dental cause, or be considered as a mere result of the pre-existing nervous disorder. Some of the phenomena, such as the dryness of the alimentary mucous membrane, and the general deficiency of secretion, are ascribable to a stimulant influence upon the organic contractility, in other words an astrin- gency, which is associated with the sedative power of its preparations, and is perhaps the most prominent of their therapeutic properties. Treatment.—This is one of the complaints which, in the great majority of cases, get well spontaneously, and in which various modes of practice have acquired some repute, from the mere circumstance that they have been em- ployed without proving an obstacle to the favourable course of nature. Nevertheless, there are remedies which are capable of producing a positive impression upon the complaint, of relieving it sooner and more effectually than nature would do unaided, and of counteracting its tendency to leave paralysis, and other serious derangements of health behind it. The plan of treatment now generally pursued, consists of a combination of opiates and purgatives, and a resort to the alterative influence of mer- cury, alum, or iodide of potassium. Mercury appears to exercise a specific controlling influence over the poison of lead ; but, as its operation if pushed too far is very inconvenient, and, as in so severe a disease it cannot always be used with that caution which would secure only a slight impression on the CLASS III.] LEAD COLIC. 663 mouth, it is best in ordinary cases to attempt the cure without a salivation, and to resort to this measure only under urgent and threatening circum- stances, and in very obstinate cases. Two grains of opium may be given at once, with from five to fifteen grains of calomel, to be followed in a few hours by sulphate of magnesia, castor oil, infusion of senna, croton oil, or some other active cathartic which the stom- ach may be best able to support; and cathartics should be repeated daily until the bowels are evacuated. The auxiliary employment of injections, as described under colic (page 655), may also be resorted to ; and some advan- tage may be expected from fomentations, anodyne and emollient cataplasms, and rubefacients to the abdomen, and from the warm bath, though these reme- dies are less efficacious than in ordinary colic. The opiate should in general be repeated every night, in such quantities as may be necessary to alleviate the sufferings of the patient, and procure some sleep ; being combined or not combined with calomel, according as the object may be to produce or not to produce the mercurial action. An anodyne enema containing a fluidrachm of laudanum may be substituted for opium by the mouth, when the stomach is very irritable; or sulphate or acetate of morphia, in the quantity of a grain, may be sprinkled upon a small blistered surface in the epigastrium, under the same circumstances. This latter mode of relieving pain, and quiet- ing irritability of stomach, may also be advantageously employed during the day, while efforts are made to evacuate the bowels by cathartics. The in- ternal use of opium is not incompatible with these medicines, but sometimes favours their action by relaxing the spasm which resists it; and the two reme- dies may therefore be employed conjointly throughout the complaint. When the symptoms are unusually urgent, or the case unusually obstinate, calomel and opium may be given together, in the quantity of two grains of the former and half a grain of the latter every two hours, or in equivalent doses at longer intervals, and steadily persevered in, until the gums become somewhat sore. Upon the occurrence of this event, the symptoms are in general greatly relieved, and cathartics which may have before failed will readily operate. At present, however, the use of alum or iodide of potassium, in the man- ner hereafter to be indicated, has almost superseded that of calomel; and I should be disposed to try the former remedies in all cases, previously to the use of the latter, except in the most urgent, in which the mercurial might be employed conjointly with the others. If the pulse should be accelerated, febrile symptoms developed, and the belly painful on pressure, indicating the probable existence of inflammation, blood should be taken freely from the arm, and cups or leeches, followed by an emollient poultice or a blister, should be applied to the abdomen. It is said that, when points of tenderness have been discovered under strong pres- sure, leeches applied directly to these points have afforded much relief. Should delirium or convulsions occur, it may be advisable, if the pulse permit, to employ bleeding, sinapisms or blisters to the extremities, and cups or leeches with cold to the head, while we are going on with the use of purgatives. But, in the ordinary cases of colica pictonum, the loss of blood is not required. When paralytic symptoms remain after the cure of the colic, if the patient has not been already salivated, he may now be put under a moderate mercu- rial impression, as one of the most effectual remedies for this disorder. The daily use of the warm bath, with blisters to the part affected or to the spine, will be found useful auxiliaries. Nux vomica, and nitrate of silver in the dose of half a grain three times a day, united with a little opium and gradually increased, have also been recommended; and alum, or iodide of potassium, if not previously used, may now be tried as a substitute for the 664 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. mercury, or in conjunction with it. Care should be taken to keep the bowels regularly open, and sulphur if necessary may be employed for this purpose. Before dismissing the subject of the treatment of colica pictonum, it will be proper to give a brief account of particular plans or remedies which have attracted attention. The great success of the treatment known in France as that of the Hopital de la Charite, claims for it a special notice. According to this plan, the patient is put upon a certain course of treatment, each day of the disease having its appropriate combination of medicines, without re- ference to the peculiarities of the case. The plan essentially is to vomit in the early stage, to purge daily afterwards, and to administer at night an opiate by the mouth, and wine by enema. With the exception of the emetic, the treatment is founded upon the same principles with that already detailed, viz., the concurrent use of anodynes and purgatives. The whole routine, how- ever, of the medication is so complicated and empirical, that there are few who would be disposed to adopt it, with the present more enlightened views of the affection. Some have treated the disease with purgatives chiefly or exclusively, and croton oil has been especially recommended; others, with opiates; but, though the patients have generally recovered, the cure is neither so speedy nor satis- factory as when the two are combined. By the school of Broussais the complaint was considered as gastro-enteritis, and treated with bleeding, repeated leeching, warm fomentations, baths, emol- lient injections, and diluent drinks. Great success was claimed for this mode of management; but general opinion has not decided in its favour. Alum has been very highly praised as a remedy for colica pictonum, and is asserted to have procured relief where all the usual remedies have failed. It has long been employed by various German and French practitioners. M. Montanceix asserts that, given in the quantity of three or four drachms in the twenty-four hours, it uniformly cures the disease in the course of six or seven days (Arch, Gen. de Med,, xviii. 370); and M. Gendrin has seen it employed in fifty-eight well marked cases without a single failure. (Trans. Med., vii. 62.) I have employed it in several obstinate cases with the effect of producing a prompt cure. Dr. Eberle obtained the happiest effects from a combination of alum and opium, given in the dose of twenty grains of the former and one grain of the latter every three hours, after calomel with opium pushed to salivation, and active purgation had been employed in vain. M. Brachet, of Lyons, author of a prize essay on lead colic, and experienced in the treatment of the disease, though he employs purgatives and opiates, con- siders alum as the most valuable remedy. The quantity administered should generally not exceed two or three drachms in twenty-four hours; as beyond this amount it would be very liable to irritate the stomach. Ascribing the influence of alum, in the cure of colica pictonum, to its chem- ical action in converting the poisonous compound of lead which may have entered the system into the insoluble and probably inert sulphate of that metal, M. Gendrin was induced to try the effects of sulphuric acid alone, and found this remedy not less efficient. He states that he has employed the acid in more than three hundred cases, and uniformly with success. From a drachm to a drachm and a half of sulphuric acid, mixed with three or four pints of water, was given daily. (Diet, de Med., viii. 395.) Whatever may be thought of the results, the explanation is, I think, more than doubtful. If alum and sulphuric acid are capable of curing painters' colic, it is by some other mode of action than by following the salt of lead in its course through the system, and changing it wherever overtaken into the sulphate. Iodide of potassium has been introduced to the notice of the profession by M. Melsens as a remedy in lead poisoning; and others have since employed CLASS III.] LEAD COLIC. 665 it with very encouraging success. Its use was suggested on the ground of its probable chemical agency in eliminating the poison from the system. As iodide of potassium has the property of dissolving the salts of lead, it was supposed that it might render soluble in the blood any compound of lead de- posited in the tissues, and thus enable it to be discharged by some one of the emunctories. Recent observations have tended to confirm this view of its action; as, in several cases of saturnine poisoning, in which no lead could be detected in the urine before the employment of the iodide, it was found in that secretion after the system had been placed for a short time under the use of the medicine.* It may be given in the dose of from five to twenty grains three times a day, and should be long persevered with in obstinate cases. M Malherbe employs belladonna in the treatment of this disease, and generally relieves his patients on or before the third day. (See Braithwaite's Betrospect, Am. ed., xxiv. 116.) Dr. Swett, of New York, states that strych- nia, in the dose of one-sixteenth of a grain three times a day, usually gives relief in forty-eight hours. (N York Med. Times, ii. 352.) Dr. Graves re- commends tobacco fomentations to the abdomen, continued until the peculiar effects of the narcotic are experienced, and then followed by cathartics. (Dub- lin Hospital Reports, vol. iv.) Dr. Aran employs chloroform, both internally and externally, with great advantage in relieving pain and relaxing spasm. (See Am. J. of Med. Sci, N. S., xxi. 484.) Dr. Odier, of Geneva, com- bines valerian and cold baths with purgatives. (Diet, de Med., viii. 396.) Dr. Wilson, physician to the Middlesex (London) Hospital, has employed with success enemata and the hot bath simultaneously, the former being adminis- tered while the patient is in the latter. (Med. Exam., iv. 488, from the London Lancet.) Vinegar diluted with water, and taken as a drink, is said to have effected a speedy cure after the failure of other means. (Phil. Journ. of Med. and Phys. Sci, xii. 172.) MM. Chevallier and Rayer gave hydro- sulphuric acid in several cases with supposed advantage. (Bullet, des Sci. Med., Dec. 1827.) M. Briquet has recently obtained great success from passing electro-magnetic currents (the faradisation of M. Duchenne) through the skin of the abdomen, immediately over the muscles which he supposes to be the seat of the colicky pains, f Baths of sulphuret of potassium have been used * See upon this subject a paper by Dr. F. A. Parkes, of London, in the British and Foreign Medico-Chirurg. Rev. for April, 1853, (Am. ed., p, 410); and another by Dr. H. S. Swift, of New York, in the New York Med. Times (iii. 145), where several interesting cases are detailed in which iodide of potassium was employed with complete success. f M. Briquet's plan of proceeding requires a more precise detail. His views of the seat of the pain may be seen by referring to the note in page 659. He employs the ap- paratus of M. Duchenne, or that of MM. Morin and Legendre. (See the work of the author on Pharmacology and Therapeutics, i. 507.) A continuous galvanic current does not produce the desired effect; and it is necessary to have recourse to one of those mag- neto-galvanic arrangements by which the painful operation of interrupted and induced currents is obtained. The object is to pass the current through the skin over the painful muscle, and not through the muscle itself. A wire from one pole, with a small piece of moistened sponge at the end of it, is placed as near as possible to the seat of pain; while a metallic brush, connected with the other pole, is carried over the whole portion of skin covering the painful parts. The brush should be interruptedly and at first partially ap- plied, so as to accustom the patient to the sensation excited; then the touches should be made in quicker succession, and with the brush held perpendicularly, at the same time bringing the whole force of the machine to bear. The operator must return from time to time to the points already touched, till the skin becomes red, and the pain ceases; which happens in a period varying from one to four minutes at most. The pain excited is intense, exceeding even that of the disease. Immediately upon the cessation of the operation, the abdominal pains cease, whatever may have been their severity or extent. The tenderness on pressure is removed, as are also the sympathetic pains in other parts of the body. In the great majority of cases the pains do not return. In a few they reappear after a period of from less than one day to eight days, and another operation is required. In very few is a third or fourth necessary. After the cessation of the 666 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. by M. Gendrin. The lead is said to be thus eliminated from the system, and to appear on the surface in the form of sulphuret. This should be removed by means of a flesh-brush with soap and water, after each immersion. The diet, throughout the treatment, should be light and easily digested, consisting of farinaceous substances with weak animal broths, when these are not contraindicated by the existence of inflammation. Care should be taken, even after recovery, to avoid flatulent, acescent, and indigestible food, until the stomach and bowels have entirely recovered their powers. Exposure to a cold damp atmosphere should also be avoided, and flannel should be worn next the skin. When an individual has shown himself, by successive attacks, to be peculiarly susceptible to the poisonous influence of lead, nothing remains for him but to abandon the business which has exposed him to this influence. Prophylactic measures are of some importance in guarding against the poison of lead. Frequent washing of the hands and of the whole person, and a change of clothes upon leaving off work ; care not to apply the hands, when soiled with white-lead, to the mouth; sleeping at a distance from the works; free ventilation of the apartments; and the grinding of the white-lead under water, are all measures calculated to diminish the chances of an attack. M. Gendrin recommends the internal and external use of sulphuric acid, largely diluted with water; and it is possible that this may have some effect so far as regards the poison introduced into the stomach, or applied to the skin; but it is difficult to perceive how it could prevent the action of lead inhaled into the lungs. Besides, the continued use of so active a substance might itself lead to serious derangements of health. Not much more, probably, can with justice be said of the prophylactic virtues of fats and fixed oils, as articles of diet; though the use of two ounces of olive oil, every morning, is said to have proved efficacious in warding off the disease. Article IV CONSTIPATION. By this term is indicated a condition of the bowels in which the stools are less frequent or less in quantity than in health. Cases in which the intes- tines are entirely closed against the passage of feces, in consequence of some mechanical impediment, are treated of under the head of obstruction. Symptoms—In deciding as to the existence of constipation in any particu- lar case, it is necessary to take into consideration the interval at which the alvine evacuations habitually occur, in the healthy state of the individual Most persons have one passage in each period of twenty-four hours; but some have two or more daily, others only one every third or fourth day ; and in- stances are occasionally met with, in which the interval is extended to one or even two weeks, without apparent disadvantage. It is probable, however, that, in these latter cases, a close examination would discover derangements, suffi- cient to prove that the long suspension of the evacuations was anything but a healthy state of the function. In general, constipation may be said to exist when the passages occur less frequently than once a day. But a person may be very seriously constipated, notwithstanding that his evacuations are quite regular in the period of their recurrence, if they are insufficient in quantity. pains, the other symptoms gradually disappear, and the patient is restored to health, usually in about a week. The subsequent treatment consists in the use of sulphur-baths, lemonade containing a little sulphuric acid, a solution of alum in gum-water, and a little of the watery extract of opium; but it is doubtful whether these are necessary; as some patients have got well in the same time without them. M. Briquet thinks that the remedy acts revulsively. (Archives Gin., Mars, 1858, p. 296.)—Note to the fifth edition. CLASS III.] CONSTIPATION. 667 It not unfrequently happens that a portion ofthe feculent matter which ought to be discharged at each stool is retained, and an accumulation thus insensibly takes place, which at length becomes manifest by the great inconvenience it occasions. The feces in constipation are usually harder and dryer than in health, and not unfrequently come away in knotty lumps, with much straining, and pain- ful distension of the anus. These lumps are occasionally covered with a white or bloody mucus, and are of different colour, sometimes natural, sometimes blackish, and sometimes light or clay-coloured, indicating a deficiency or total absence of bile. When not pointed out by the diminished number or apparent condition of the stools, the affection may be suspected to exist, if the patient complain of a sense of weight or oppression in the abdomen or at the funda- ment, a frequent but ineffectual disposition to go to stool, flatulence, colicky pains, distension of the abdomen, and nausea with or without vomiting. At- tention to these points is the more important, as in some cases of great fecal accumulation, whether in the rectum or higher up in the colon, the irritation of the bowel gives rise to occasional mucous discharges, tinged with fecal mat- ter, and having a very offensive fecal odour; or small quantities of the liquid contents of the bowels are forced around the mass, or through an opening existing in it, and discharged per anum, so as to simulate diarrhoea. Some- times the discharges are bloody or dysenteric in character. Such a condition is peculiarly apt to occur in old people, and has not unfrequently been treated as diarrhoea to the great detriment of the patient. There is in some instances difficulty in passing urine. If a case be attended by more or less of the above symptoms, constipation should be suspected, and a close examination insti- tuted. If the feculent mass be lodged in the rectum, it will at once be de- tected by introducing the finger through the anus; if in the colon, it will often be obvious in the form of a hard tumour or tumours in the left iliac fossa, or in the course of the descending, transverse, or ascending colon; and when the solid mass cannot be felt through the abdominal parietes, it may often be detected by the flat sound which it will yield on percussion. There is reason to believe that such masses have not unfrequently been mistaken for organized tumours. The impossibility of introducing an injecting pipe far into the rec- tum, or the great resistance made to the entrance of liquids through the in- strument, often leads to the detection of these accumulations. The quantity of feculent matter which has sometimes accumulated in constipation is enor- mous. A case is recorded in the Archives Generates (iv. 410), in which thirteen and a half pounds were found in the intestines. The length of time also, during which patients sometimes sustain a complete want of alvine de- jections, is astonishing. From one to two weeks is no uncommon period, in the experience of most practitioners; and cases are on record in which the patient has survived months of suffering from this cause. But, in most of these cases, the dejection per anum has been replaced by a vomiting of feces, so as to prevent a fatal distension. Generally speaking, should the constipa- tion not yield to appropriate treatment, symptoms of an alarming character come on in the course of a few days, and the case ends fatally, after a longer or shorter period of much and various suffering, with occasional remissions and exacerbations, as temporary relief is obtained from vomiting, the use of remedial measures, or other causes. (See Obstruction of the Bowels.) Causes.—Constipation is either occasional, arising from some temporary cause, or protracted and habitual. In both cases, its pathological condition must consist in either 1. a mechanical impediment to the passage of the alvine contents along the bowels, 2. a diminished contractility of the muscular coat, or a diminished susceptibility of the intestines to the influence of the usual alvine stimuli, 3. a deficient supply of these stimuli, or 4. a combination of 668 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. two or more of the conditions mentioned. The causes must be such as are capable of inducing these conditions. Among those which occasion mechanical impediment are solid masses formed out of the ingesta, or by precipitation from the intestinal liquids; spasmodic or permanent stricture of the bowels; the encroachment of organ- ized tumours upon their caliber; and strangulation of the intestines, as in hernia, intussusceptio, and twisting of some portion of the tube. These will be more particularly considered under obstruction ofthe bowels. The causes which impair the contractility or susceptibility of the bowels, or both, are of more importance in relation to our present subject. These operate more especially upon the colon, though their influence is also felt throughout the intestinal tube. Torpor ofthe colon is one ofthe most com- mon conditions in habitual constipation. Unable to contract sufficiently on the feculent matter, or unduly insensible to its presence, the bowel becomes distended by the accumulation which takes place, and, under the distension, suffers a still further diminution of its power and sensibility. The causes of this condition are numerous. They are, for the most part, the same as those which produce the analogous condition ofthe stomach existing in dyspepsia; as sedentary habits, excessive mental occupation, sensual indulgences of all kinds, morbid diversion of the blood and nervous energy to other organs, the use of narcotics and especially of opium, diseased conditions of the brain and spinal marrow, and, in fine, whatever debilitates the system generally, and con- sequently involves the bowels. (See Dyspepsia.) Old age is attended with a diminished susceptibility of the alimentary canal, and is therefore very subject to constipation. Habit also has a strong influence, and is one of the most frequent causes of the complaint. By means of our control over the sphincter ani, we are endowed, to a considerable extent, with a power of regulating the alvine discharges, and of resisting the solicitations of nature at inconvenient seasons. This power is too apt to be frequently exercised, especially by fe- males. The bowel, thus habituated to the presence of feculent matter, feels less and less its wholesome stimulation, and at length ceases to be excited into action. Habitual constipation is a necessary result. The preparations of lead have a directly paralyzing effect upon the bowels; and obstinate cos- tiveness is therefore an almost uniform attendant on colica pictonum. Ofthe causes which impair the stimulant properties ofthe intestinal liquids, the most common is perhaps a diminished or suspended secretion of bile, or anything which impedes its access to the bowels; the bile being one of the most energetic alvine stimulants provided by nature. Hence the frequent deficiency of the bilious colour in the evacuations. The same may possibly be true to a certain extent of the pancreatic liquor, and is certainly so of the intestinal mucous and serous secretions. Hence the influence of excessive discharges from other organs, as from the skin and kidneys, in producing costiveness. Hence, too, the action of astringents, which diminish or arrest the intestinal secretion. Dr. Dick ascribes the costiveness of the young, in some instances, to a too rapid absorption of the intestinal liquids. (Braith- waite's Retrospect, xvii. 152.) Many of the causes above enumerated operate doubly, impairing the con- tractility and sensibility of the bowel, while they diminish the amount of healthy stimulus by checking secretion. Such especially are those which act through the medium of the brain and spinal marrow. Excessive exercise often produces this effect by directing the energies of the system to other parts. A disposition to constipation is a very common attendant upon a long and fatiguing journey. Effects.—Constipation gives rise, especially when habitual, to a great diver- sity of local and constitutional derangements. Besides its effects upon the bowels, consisting in irritation, inflammation, distension, ulceration, gangrene, CLASS III.] CONSTIPATION. 669 &c, it deranges the neighbouring organs by the pressure ofthe accumulated feces; impedes from the same cause the abdominal circulation, and thus occa- sions various congestions; extends a sympathetic irritation to the viscera of the abdomen and pelvis, as well as to the brain, heart, and other distant parts; and finally gives rise to contamination of the blood, both by checking the secretion of excrementitious matter, and by causing a reabsorption of that already eliminated from the blood-vessels, and of various products of chemical change in the retained contents of the bowels. It is often attended, even in its occasional attacks, with dulness, depression of spirits, drowsiness, irritability of temper, vertigo, headache, flushing of the face, pains in the loins and limbs, palpitation, dyspnoea, furred tongue, gastric derangement, and various disorder in the biliary, urinary, and generative organs. When habitual, it produces the same effects in an aggravated degree, and others even more unpleasant. Bleeding from the rectum, hemorrhoidal tumours, fissures and prolapsus of the anus, fistula in ano, strangury, catarrh of the bladder, dysmenorrhoea, amenorrhoea, menorrhagia, leucorrhcea, colic, diarrhoea, dysentery, hepatic congestion and inflammation, dyspepsia, sick- headache, foul breath, epistaxis, apoplexy, epilepsy, paralysis, hysteria, melan- choly, hypochondriasis, and insanity, are among the disorders which have been traced to constipation as their source. It is not always easy to say, how much of the disease which is found asso- ciated with constipation is properly its effect. Derangements of the same kind as those which it induces arise often also from other causes, and may bring on this condition of the bowels if not previously existing. But, even in this case, it often aggravates the original disorder; and thus, whether viewed as cause or effect, is still a source of mischief. Not unfrequently, the complaints which originate in constipation take on an independent existence, and continue though the cause may cease. From all these considerations, it follows that the disorder in question, whether original or induced, requires a close attention, and should be immediately made an object of treatment whenever it occurs. Treatment.—Occasional attacks of constipation must be met by cathartics, proportionate in their activity to the difficulties of the case; the milder being first employed, under ordinary circumstances, and the more energetic resorted to after these have failed. Castor oil is, from its combination of mildness with quickness and efficiency, one of those best adapted to ordinary cases. Sulphate of magnesia and the other saline cathartics may also be used, and are especially applicable to solid fecal accumulations, in consequence of the copious serous secretion they induce, which penetrates and breaks down the impacted mass. Senna tea combined with the salt adds to its efficiency, by the energetic influence which this cathartic exercises upon the muscular coat; and fluid extract of senna alone is often very serviceable. Croton oil should be employed, when those mentioned have proved insufficient. It is preferable to most other drastic cathartics by its quicker action and greater energy, while less disposed to produce inflammation of the bowel. Cases, however, may occur in which, from great insensibility of the intestines, the irritant properties of jalap-resin, scammony, colocynth, gamboge, or even elaterium, given separately or in combination, may render them preferable. Calomel should always be employed, in full doses, when the constipation is dependent on torpidity or congestion of the liver. It not unfrequently happens that, after the gums have been touched by the use of mercurials, other cathartics will act with facility which had failed before. Dr. Daniel, of Savannah, re- commended charcoal very highly as superior to all other remedies in obstinate constipation. He gave from one to three tablespoonfuls every half hour or hour, and found it successful in numerous instances. (Philad. Journ of the Med. and Phys. Sci, v. 119.) The remedy, however, has not succeeded so 670 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. well in other hands, and is liable to accumulate in the bowels, so as itself to become a source of obstruction. Should the purgative not operate in due time, it should be aided by ene- mata, which sometimes become indispensable, in consequence of an irrita- bility of stomach which precludes the use of most cathartics by the mouth. The reader is referred to the article on colic (page 655) for an account of the substances which may be used in this form. Perhaps, upon the whole, the most safe and at the same time efficient, in cases of great obstinacy, is simple warm water thrown up the bowel, in very large quantities, by means of a self-injecting apparatus, and repeated so as gradually to soften and wash away the feculent matter. Any desirable quantity of water may thus be introduced into the bowels, if care be taken, by twisting a towel round the pipe and pressing it against the fundament, to aid the contractile power of the sphincter. Advantage may occasionally result from introducing the water directly into the colon, through a long gum-elastic tube, passed high up into that bowel. When the feces are impacted in the rectum, the assist- ance ofthe finger, a scoop, spoon-handle, or some similar instrument, intro- duced per anum, becomes necessary to break up and discharge the solid mass. Other measures may be employed in aid of those mentioned, as friction over the abdomen, warm vapour to the fundament, and the application of cold externally, either by ice to the palms of the hands and soles of the feet, or by a stream of cold water allowed to fall upon the abdomen. Spasmodic stricture of the bowels has sometimes given way under this latter measure, after resisting purgatives and enemata. The application of cloths wet with ice-water to the abdomen, and the free use of ice-water internally, persevered in for days if necessary, is an old remedy, which is said to have proved very effectual in ileus. (See Boston Med. and Surg. Journ., xxxvii. p. 229.) The late Dr. Hosack, of New York, was in the habit of employing emetics of tar- tarized antimony and ipecacuanha in obstinate constipation, and ascribed their beneficial influence partly to the increased action of the liver, and partly to the relaxation of spasm which they cccasioned. (Philad. Journ. of Med. and Phys. Sci, iv. 337.) The use of metallic mercury, in large quan- tities, is asserted to have sometimes overcome constipation under almost desperate circumstances. (See Obstruction ofthe Bowels.) It is highly important that the practitioner should bear in mind the occa- sional dependence of obstinate constipation upon local inflammation of the intestine, affecting either the muscular or peritoneal coat, and entirely re- straining the peristaltic motions of the part. In such cases, persistence in the use of violent cathartics can do only harm. Bleeding, general and local, calomel and opium internally, occasional enemata, with emollient applications and blisters, are the chief remedies; and they will often succeed most happily after failure with active purgatives. In habitual constipation, a somewhat different course must be pursued. Attention must here be especially paid to the removal of the cause. Efforts should be made by the patient to establish the habit of regular evacuations by daily attendance at the privy, though it is important that he should avoid severe straining, which often gives rise to hemorrhoids, or prolapsus ani. Moderate exercise, regular habits of life, relaxation from intense mental occu- pation, change of air and scene, all have a favourable effect by contributing to the restoration of tone to the bowels. Frictions over the whole surface of the body, and the occasional use of the cold or shower-bath contribute to the same end; and, whenever the excess of any function may be found to divert the due supply of vital energy from the colon, this excess should if possible be corrected. The use of all narcotic substances, including green tea and coffee, should be abandoned, when there is reason to believe that the com- plaint depends on torpor of the intestines. CLASS III.] CONSTIPATION. 671 The regulation of the diet is highly important, and this alone will frequently be sufficient to restore the proper action of the bowels. The food should in general be easily digestible, and such as is not calculated to yield a large amount of feculent residue. (See Dyspepsia.) An exception to this rule may sometimes be made in favour of substances having laxative properties; but discrimination is necessary. Laxative articles of diet are apt to be of difficult solubility in the stomach, and are not all adapted to a dyspeptic state of that organ. Such as are of this character should therefore be avoided, or used cautiously, in constipation associated with dyspepsia. Bran bread, however, or some other preparation of wheat flour containing bran, may often be em- ployed with great advantage in this case. Dr. John C. Warren, of Boston, recommends highly a preparation made by grinding wheat coarsely in a coffee- mill, adding a little salt, and then boiling for three or four hours, adding water from time to time, so as to bring it to the consistence of hominy. (Am. Journ. of Med. Sci., N. S., xvii. 296.) When the stomach is not dyspeptic, fresh and dried fruits are highly useful. Indeed, it is not uncommon for persons, disposed to costiveness, to be entirely free from this condition at those times of the year when fruits are in season. The different edible berries, peaches, pears, apples, melons, &c, may be taken as freely as the stomach will admit without inconvenience; and tomatoes, used as a vegetable at dinner, have been found highly beneficial, even by dyspeptic persons. In the winter, the imported fresh fruits, such as grapes and oranges, and the dried fruits, such as dried peaches, prunes, figs, &c, maybe substituted. Other laxative articles of diet, applicable to cases in which the digestion is vigorous, are brown sugar, molasses from the plantations, honey, olive oil, rye and Indian meal in the form of mush or bread, oatmeal gruel, rennet-whey, and butter- milk. Broths are sometimes preferable, under similar circumstances, to solid food. Burne recommends the use of bacon at breakfast. An exclusive diet of milk has sometimes appeared to produce very obstinate constipation; and this fact should be attended to in the treatment of children. When constipation is found to be connected with deficient secretion of bile, an alterative mercurial course, or the use of nitromuriatic acid should be re- sorted to. A calomel purge maybe given at first, and afterwards half a grain or a grain of the same mercurial, or three grains of the blue mass every night or every other night, followed by a drachm or two of sulphate of magnesia, or other mild laxative in the morning. Laxative medicines are often indispensable. In the choice of these, refer- ence must be had to the peculiar condition of the stomach and bowels. When the former is weak, and the latter inirritable, as in dyspepsia, atonic gout, &c, the warm tonic laxatives should be selected, and may often be advantageously combined with bitter extracts, chalybeates, or other tonics. Aloes and rhu- barb, separate or combined, are most employed, and are often mixed with extract of gentian or quassia, and pill of carbonate of iron. But aloes should not be used in cases attended with hemorrhoids or irritated uterus. White mustard seed, in the dose of a tablespoonful daily or twice a day, are often advantageous under similar circumstances. Infusion of senna, with columbo and ginger or other aromatic, is also well adapted to constipation complicated with feeble digestion. The torpid bowels of old people require the more stimulating cathartics. Besides aloes and rhubarb, the drastic purgatives may be used in small doses and combined together, as in the compound extract of colocynth, or the compound cathartic pill of the U. S. Pharmacopoeia; and with the cathartics, Cayenne or black pepper, assafetida, myrrh, ammoniac, &c, may be advantageously associated. Not only in these cases, but in all others where the bowels are very torpid, even in the cases of infants, I have been in the habit of combining minute quantities of croton oil with other laxa- tives, especially with aloes and rhubarb, with the happiest effect. The quarter 672 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. or sixth of a drop, for adults, will be found to add considerably to the activity of the dose, and generally without irritating the stomach. When the stomach is not very feeble, the saline laxatives may often be used with propriety. They have this advantage, that they are less apt than some others to leave the bowels in a costive state; and are peculiarly ap- plicable to cases attended with deficient intestinal secretion. A very small quantity of one of these salts, a drachm or two of Epsom or Rochelle salt, for example, taken on an empty stomach, early in the morning, will often act sufficiently. The Seidlitz powder suits some stomachs admirably well. The natural combinations of salts existing in mineral waters are often more effectual than the salts separately. The different waters of the Saratoga springs are deservedly in high repute. The Cheltenham salt made in imita- tion of the Cheltenham water in England, and containing a chalybeate as- sociated with the saline ingredients, has answered admirably in my experi- ence. But the alkaline salts have the disadvantage in general, that, when long continued, they debilitate the stomach and impair digestion. When the digestion is good, the confection of senna or lenitive electuary is an excellent laxative. Given at bedtime, in the dose of a drachm, it usually causes a soft feculent evacuation in the morning, without irritation, or other inconvenience. It is peculiarly suited to constipation with piles. Powdered senna, mixed in very small proportion with stewed dried peaches or prunes, operates in a similar manner. A drink made from cream of tartar, in imita- tion of lemonade, may be used in similar cases, and is often grateful in sum- mer. Flake manna, carried in the pocket, and eaten occasionally, is also adapted to costiveness with unimpaired digestion. Some persons are able to take castor oil without disgust, and find it useful in habitual costiveness ; but in general the stomach cannot be reconciled to its very frequent use. With others, olive oil answers the same purpose, though it requires to be given in larger doses. Sulphur is adapted to cases as well of feeble as of vigorous digestion, and, as it produces unirritating passages, may be usefully employed in piles. In consequence of its alterative properties, it is an excellent laxative in the cos- tiveness of rheumatic and gouty individuals. It is often associated with mag- nesia in dyspeptic cases, and with cream of tartar in inflammatory piles. Its disadvantages are that it is apt to occasion griping, and in time imparts odour to the breath and secretions. Magnesia and its carbonate are peculiarly useful in cases attended with excess of acid in the stomach. It should not, however, be used largely and habitually, unless in association with other laxatives to insure its action ; as it has sometimes accumulated in the bowels, and formed masses interfering with their due movement. Some have employed enemata or suppositories as substitutes for cathartics by the mouth, administering them daily, or every other day, for a long time together. The mildest substances should be selected; as flaxseed tea or other mucilaginous liquid for injection, and hard soap or solidified molasses for in- troduction in the solid form. But both are liable to the objection, that they concentrate in one part of the bowels the irritation which the laxative medi- cine spreads, in a comparatively diluted state, over their whole track; while they do not so effectually evacuate the upper portions of the canal. But laxatives either by the mouth or rectum should be employed only as adjuvants to a properly regulated regimen, and should be suspended the moment that they are no longer necessary. Care should also be taken to administer them in doses no larger than is essential to the end desired. They should always be given on an empty stomach, as they thus operate more speedily and with less uneasiness. Half an hour or an hour before CLASS III.] OBSTRUCTION OF THE BOWELS. 673 breakfast, an hour or two before dinner, and at bedtime, without previous supper, are the proper periods. Given at bedtime, they will often not act until morning, and the patient will experience little or no inconvenience dur- ing the night; while he thus escapes the annoyance of their operation through the day. This, therefore, upon the whole, is the most appropriate time. In cases dependent on deficiency of contractile power in the muscular coat, nux vomica or its active principle, strychnia, has been employed with great success; and, as it is not always possible to distinguish these cases, the re- medy may be tried in any case of habitual constipation, where this cause may be supposed on probable grounds to exist. In similar cases of sup- posed atony of the bowels, sulphate of quinia or the simple bitters may be used in common with laxatives, and sulphate of zinc has also been re- commended. Various other measures have been employed in habitual costiveness. The introduction of a bougie high up into the rectum is favourably spoken of by Burne, who recommends it especially in cases attended with great rigidity of the sphincter ani. The smoking of tobacco has in some persons been found to obviate constipation, though in others it occasions it, when used in excess, by impairing the sensibility of the digestive tube. Friction to the abdomen with rubefacients, coarse flannel, or the flesh-brush; tepid or cold affusion upon the loins ; and leeches or cups to the spine, when the constipation may be supposed to have its origin in disorder of the medulla spinalis, have been recommended. Galvanism or electro-magnetism has also been found useful, a current being directed through the bowels, by applying the end of a wire from one pole to the sacrum, and from the other to various points along the course of the colon upon the front of the abdomen. Article V OBSTRUCTION OF THE BOWELS. This term, as here employed, implies the existence of some mechanical im- pediment to the passage of the contents of the bowels. The obstruction some- times comes on slowly, with the ordinary symptoms of constipation, the patient experiencing gradually increasing difficulty in obtaining evacuations until they cease. In many instances, however, the attack is sudden, and altogether unexpected. It often happens that, for a few days after the cessation of dis- charges, no great inconvenience is felt; but sooner or later, and sometimes immediately, the patient begins to complain of uneasiness in the abdomen, attended frequently with a desire to go to stool, and bearing down efforts, which are either quite ineffectual, or produce only slight, bloody, mucous, or feculent passages, without affording relief. Cathartics are taken without effect, and enemata, after evacuating occasionally small quantities of fecal matter, come away as administered. The discharges which thus occur spontaneously, or are obtained artificially, consist only of matters contained in the bowels below the point of obstruction; and care should be taken that they do not lead to false inferences as to the nature of the affection. Distension of the abdomen now comes on, with flatulent eructation, severe spasmodic pain, great restlessness and anxiety, and at length nausea and vomiting, so that sub- stances taken into the stomach are instantly rejected, and medicines cannot be retained. Symptoms of inflammation, as tenderness upon pressure, a quick pulse, and furred tongue, are often mingled with those of obstruction. Should relief not be obtained, troublesome hiccough occurs; the vomiting not un- VOL. I. 43 674 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. frequently assumes a stercoraceous or bloody character; dysury, with deep- red urine, is added to the other symptoms; the belly becomes enormously distended and tympanitic, the respiration oppressed, the face bathed in sweat, the skin pale and clammy, the extremities cold, the pulse exceedingly feeble, and the countenance haggard; and the patient sinks, completely worn out and exhausted, death being frequently preceded by delirium. This, however, is not the uniform result. The vomiting of feces sometimes affords tem- porary relief; the worst symptoms disappear, to occur again when the bowels become again loaded; or the obstruction may be partially removed by an effort of nature, and again return ; and a course of suffering and exhaustion, alternating with partial relief and reaction, may continue for months, or even years, ending at last in death, or in a complete removal of the obstruction, and recovery. It is singular how, in some cases, the system accommodates itself to defecation by the stomach, so as to dispense for a long time with the ordinary alvine evacuations. Dr. Crampton relates, in the Dublin Hospital Reports (vol. iv.), the case of a young woman, living at the time, who for seven years had laboured under stercoraceous vomiting, with obstinate con- stipation, having had stools at distant intervals, only two or three during the year preceding the report, and none at all during the last eight months. Another case of a young female was reported by Dr. Franklin Bache, in the N. American Med. and Surg. Journal (vol. vi. p. 262), which continued for a period of ten months, during which there was several times an absence of stools for more than twenty days, and once for eighty-seven days, and yet the patient ultimately recovered. In both these cases, the stercoraceous matter vomited had occasionally a strong urinous smell, and there was, during longer or shorter periods, suppression or retention of urine. These latter phenomena are not uncommon attendants upon obstinate constipation. The names of Ileus and Volvulus have been given to cases of stercoraceous vomiting, with pain in the bowels, and constipation. There is nothing, how- ever, in this association of symptoms, which entitles it to be considered as a distinct disease. This kind of vomiting may occur in violent colic, from a spasmodic closure of the bowel, or in cases of gastro-colic fistula; and it is asserted to have arisen from a morbid inversion of the peristaltic movement, without any obstruction; water introduced into the rectum having been thrown out from the mouth. The ileo-ca?cal valve offers an impediment to the up- ward passage of the contents of the colon; but, if it be admitted that the pressure of the fluids above and below the valve is about equal, the valve may be flaccid, and an intermixture of the fluid matters on each side of it may take place. (Roper, Lond. Med. Gaz., Oct. 1849, p. 623.) In cases presenting the above symptoms, a close examination of the abdo- men should be made, in order to ascertain whether the cause of the pheno- mena may not be strangulated hernia. There is reason to think that death has frequently occurred from a neglect of this precaution. Dissection after death exhibits the intestine very much distended, in some instances enormously so, above the place of obstruction. Marks of inflamma- tion are frequently observed, and sometimes those of gangrene. According to Burne, when the obstruction depends upon a purely mechanical cause, and not upon feculent accumulation arising from functional derangement of the bowel, the feces are always found soft; a provision of nature which tends to prolong life, by enabling the bowels to relieve themselves until the passage becomes absolutely closed. Causes.—One of the most frequent causes of obstruction is an accumula- tion of impacted feces. This, though the result of a pre-existing functional derangement of the bowels, becomes itself, when so considerable as to close the passage, and to resist the peristaltic movement, the chief source of mis- CLASS III.] OBSTRUCTION OF THE BOWELS. 675 chief; and the obstruction, therefore, may be strictly said to be mechanical. This is the form of the complaint which is least dangerous, and most easily relieved by proper measures. A case is mentioned by O'Beirne, in which the patient had been without an evacution from the* bowels for nearly six months, in consequence of a mass of solid excrement in the sigmoid flexure, and yet was relieved by a stimulant injection thrown high up into the rectum. (New Views of the Process of Defecation.) Such accumulation may be sus- pected to exist, when the symptoms of obstruction have been long preceded by those of habitual constipation, without any evidence, from the appearance of the stools, of the existence of stricture. The means of detecting it have been already detailed. (See page 667.) Another not uncommon cause of obstruction is the formation of solid con- cretions in the bowels. These have their seat most commonly, for obvious reasons, in the rectum, sigmoid flexure, or ca?cum ; though they may exist in other parts of the colon, and even in the small intestines. They originate in various sources. Insoluble substances taken largely and frequently as medi- cines sometimes concrete in the bowels, held together by a cement of animal matter or calcareous salt, and frequently mixed with indigestible portions of substances used as food. Cases are on record of serious obstruction proceed- ing from the daily and continued use of chalk, sulphur, magnesia, and sub- carbonate of iron. The stones of various fruits, especially of cherries and plums, swallowed along with the pulpy matter, under the impression that they assist digestion, frequently form concretions in the bowels, which have, in some instances, given rise to fatal obstruction. Sometimes solid masses are formed out of the secretions poured into the intestines, especially from the bile; and these concretions are occasionally found to have as a nucleus some insoluble substance accidentally swallowed, or perhaps a gall-stone which has entered the bowels through the common duct. They are not gene- rally numerous, seldom exceeding two or three; but in some instances many have been found, and of various sizes, from a few lines to two inches or more in diameter. When there are several, they can sometimes be felt rubbing against each other. A fatal case of obstruction has been recorded, owing to a large gall-stone which had escaped from the gall-bladder, through an ul- cerated opening into the duodenum, and had thence passed into the ileum. (E. Palmer, Bost. Med. and Surg. Journ,, June 4, 1857, p. 357.) When obstruction has arisen from any of the concretions above referred to, a prob- able inference as to the cause may be drawn from the previous habits or condition of the patient, which should always be inquired into. Their nature may occasionally be detected by examination per anum; and, when beyond the reach of the finger, they may often be felt through the parietes of the abdomen, especially in the right and left iliac fossa?; and will always occasion undue flatness on percussion. When tenesmus attends obstruction, an ex- amination of the rectum should never be omitted. Permanent stricture of the bowels is a third source of obstruction. This appears sometimes to originate in a spasmodic stricture becoming permanent by inflammatory adhesion; but, in most instances, it depends on a thicken- ing of the parietes of the bowel, and a consequent diminution of its caliber. Cancer is probably one of the most frequent causes of this thickening. It may depend also upon a simple inflammatory hypertrophy of the submucous cel- lular tissue, or on the cicatrices following large ulcers; and Dr. Symonds has pointed out another cause in a fatty deposition beneath the peritoneal coat. The stricture is most frequent in the rectum, but it is also found in various parts of the upper bowels. When in the former situation, it may be detected by the finger or a bougie; and its existence may be suspected when the ob- struction has come on by degrees, and the feces have been discharged for a 676 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. long time previously in gradually diminishing cords or ribbons. In many instances, however, it cannot be ascertained until after death. Tumours, cancerous or non-cancerous, projecting into the cavity of the bowel, are another cause. Organized bands across the bowel sometimes produce obstruction. These probably originate in an inflammatory adhesion of the surfaces of the mucous membrane, in consequence of the effusion of coagulable lymph, and a subse- quent separation of these surfaces, before the lymph has become quite con- solidated, so that it is drawn out in apparently interlacing cords. These bands are said to be most common in the rectum, though a fatal case is given by Burne, in which the seat of the obstruction was in the ca?cum. (Burne on Habitual Constipation.) They are very rare. Adhesions of the peritoneal coat of the intestines, arising from inflamma- tion, sometimes produce bands, which, in certain positions of the bowels, act as a cause of external stricture, and produce fatal obstruction. Under this head may perhaps be included the strangulating operation of the appendicula vermiformis encircling the bowel, and bound in its abnormal position by in- flammatory adhesion; and also of those accidental processes denominated di- verticula, which have been known to bridle the intestine in a similar manner. Intussusceptio, or invagination of the bowel, is a frequent and fatal cause of obstruction. This consists of the introduction of one portion of the intes- tine, by inversion, into the portion immediately above or immediately below it, thus producing, in many instances, a complete closure of the cavity. The upper portion is generally received into the lower, but not invariably so; the inversion sometimes taking place from below upward. The extent of the invagination varies from a few lines to a foot or more. Sometimes it is enor- mous. I attended, with Dr. Ashmead of this city, an infant with fatal intus- susceptio, in which, during life, a hard tumour could be felt extending from the pubes along the left side to the middle of the arch of the colon; and, after death, it was found that the right half of the arch, the whole of the ascending colon, the ca?cum, and a large portion of the ileum, had entered the lower half of the large intestine, and that most of the duodenum with a portion of the jejunum had been drawn, for a short distance, into the same opening. Intussusceptio occurs not unfrequently in more than one part of the bowels in the same case, and probably arises from a spasmodic constric- tion of the entering portion of the intestine. There is reason to believe that it frequently takes place during colic, and other spasmodic intestinal affec- tions, without producing serious effects, being relieved by the spontaneous movement of the bowels. Almost any portion of the bowels may become the seat of the affection; but it is said to occur most frequently either at the union of the small with the large intestines, the former being in this case received into the latter, or at the arch of the colon. It is not uncommon in the small intestines, and I have seen it involving the sigmoid flexure and upper part of the rectum. Inflammation not unfrequently takes place, and, by causing tumefaction and adhesions, greatly aggravates the danger. Even in this case, however, the affection, though generally fatal, is not necessarily so. The invaginated portion of bowel mortifies and sloughs, while adhesion is established between the peritoneal surfaces of the upper and lower portion at their place of junction; and, if the constitution of the patient is sufficiently vigorous or pliant to support the shock of the obstruction, inflammation, and gangrene, and the long subsequent exhausting processes of sloughing and reparation, an effectual recovery eventually takes place. The diagnosis of intussusceptio is at first always uncertain. It may be suspected when the symptoms of obstruction come on suddenly, without previous disorder, or as the consequence of an attack of colic, or the administration of a dose of CLASS III.] OBSTRUCTION OF THE BOWELS. 677 active purgative medicine, and when at the same time a tumour, not previ- ously existing, can be felt in any part of the colon. In those cases which continue long, portions of the bowel that have sloughed away are sometimes found in the stools, after the restoration of the alvine evacuations. Twisting of the bowel is still another cause of obstruction. A fold or loop of the intestines sometimes turns round upon itself, and, as in the case of Mr. Legare, reported by Dr. Bigelow (Boston Med. and Surg. Journ., July 5th, 1843), may even make two complete revolutions, thus entirely pre- venting the passage of the feces. This rotation sometimes occurs in conse- quence of external violence ; but more frequently without any known cause. It is most apt to take place in the convolutions of the small intestines, or at the sigmoid flexure of the colon. In its severer forms it is irremediable; but it is probable that slight turns of the kind are susceptible of being un- twisted by movements of the bowels, either spontaneous or excited by medi- cines. There are no means of ascertaining its existence during life ; but it may be conjectured to have occurred, when the obstruction is sudden, and unattended with any discoverable tumour. Still another cause of obstruction is strangulation by the passage of the bowel through some abnormal opening, as, for example, through a rent in the diaphragm, mesentery, mesocolon, or omentum. Organic tumours, formed exterior to the bowel, may sometimes so diminish its caliber as to produce obstruction ; but this result is rare ; the impediment being seldom so great as altogether to prevent the passage of feces. Treatment.—The first object in any particular case of obstruction is, if possible, to ascertain the cause ; so that the treatment may be modified ac- cordingly. But, when this is obscure, or altogether uncertain, as often hap- pens, that plan should be adopted which is most likely to be useful in curable forms of the complaint. As a general rule, the following course of treatment is recommended. If the pulse and constitution admit, and especially if symptoms of inflam- mation exist, blood should be taken freely from the arm, and leeches applied to the abdomen or the anus. Spasm of the bowel, which, if not the cause of the difficulty, may greatly aggravate it, may thus be relaxed, while the dan- gers from inflammation are obviated. Purgatives should be immediately resorted to, as recommended for occasional constipation (see page 669); and these should be aided by suitable enemata. For the composition of the ene- mata, the reader is referred to the article upon simple spasmodic colic. (See page 655.) But, in relation to the use of purgatives, some caution is requi- site. When the vomiting is very obstinate, and especially when it has become stercoraceous, there is strong evidence that the peristaltic movement of the bowels is exerted to its utmost limits; and the only effect of powerful and drastic cathartics would probably be to increase the existing irritation or inflammation, and still further to aggravate the vomiting. The reparatory processes which nature might be disposed to institute may thus possibly be interfered with, and a curable case rendered incurable. At the beginning of the treatment, active purges may be employed; but, when found unsuccess- ful, they should not be urged under the circumstances mentioned. Effer- vescing aperient medicines, or the saline cathartics, given in small doses in carbonic acid water, should be preferred, as more acceptable to the stomach, and calculated to direct downward the already excited peristaltic action. Calomel may also be given in moderate and repeated doses ; as it is often well retained by the stomach, and, if it do not purge, may produce a general mercurial impression, which has often proved highly salutary under very un- promising circumstances. According to Burne, the addition of a drop of 678 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. creasote to the purgative dose, when the stomach is very irritable, will often enable it to be retained, when it would otherwise be rejected. During the above treatment, opiates should be freely used to allay pain and relax spasm; and warm fomentations and the warm bath will be found useful auxiliaries. Indeed, where there is reason to think that further at- tempts at purgation can be of no avail, but may even prove injurious, opium is the remedy which is to be mainly relied on, so far as the stomach is con- cerned. The repeated injection of large quantities of warm water into the bowels by means of a forcing pump, as recommended in obstinate cases of constipation (see page 670), is one of the most efficient remedies. If the ob- struction consists in fecal masses or other concretions, it may thus be loosened, broken down, and gradually brought away; if in intussusceptio or twisting of the bowel, there may be some hope, in the one case, of pushing up the inva- ginated intestine by the force of the stream, provided adhesions have not been formed, and in the other of untwisting the rotation by an impulse oppo- site to that which produced it. To insure its full effect, however, the fluid should be introduced by means of a tube passed as high as possible into the bowel. Even the ordinary purgative and stimulant injections prove much more efficient when introduced in this way. Dr. O'Beirne succeeded in causing, by a single stimulating injection thrown through a tube passed nine or ten inches up the rectum, the breaking up and discharge of a great fecal mass, which had been lodged for six months in the sigmoid flexure, and during that period had resisted purgatives, and numerous enemata exhibited in the ordinary manner. There is often great difficulty in passing a tube through the sigmoid flexure ; some obstacle to its passsge being offered about eight or ten inches above the anus, so that the tube often curves upon itself, and forms a coil in the rectum. This difficulty is ascribed by O'Beirne to a contraction which he supposes always to exist in the upper part of the rectum, in the ordinary state of the bowel, and to relax only when the accumulation of feculent matter in the colon is such as to require evacuation; the rectum being, in his opinion, merely an instrument for the expulsion of the feces, and not a reservoir for their reception. To overcome this constriction, he recommends that the instrument be pressed steadily against it with considerable force, though not sufficient to endanger the penetration of the coats of the rectum; an accident which has happened from the incautious use of bougies. (New Views of Defecation, &c.) Others ascribe the difficulty to the projection of the sacrum, or the oblique direction of the bowel, and recommend the employment of a bent director, or the in- jection of some water through the tube when it reaches the curved part, so as to distend the intestine, and keep the tube in the middle of the stream. The injection of large quantities of air into the bowels may be tried. Mr. D. AI'Leod has recorded a case in the Ed. Med. Journ. (Dec. 1857, p. 519), in which stercoraceous vomiting and other symptoms of obstruction attended a painful circumscribed tumour about the size of a man's fist, to the right of and below the umbilicus, and which, after the vain use of leech- ing, purgatives, enemata, &c, gave way promptly to the pressure of air thrown into the bowels. This was effected by means of an air-pump, such as is used by the gas-fitters, while the escape of the air was prevented by a cone of lint wrapped around the injection-pipe at its base. Similar success, in a case of supposed intussusceptio, was obtained through the expansive force of air, by Dr. K. G. Tate, of West Point, Georgia: but in this case the air was extricated within the bowels, instead of being thrown into them. Haying injected about a gallon of warm water, he next introduced forty grains of tartaric acid dissolved in four ounces of water, and immediately af- terwards the same quantity of a solution of bicarbonate of soda made in the CLASS III.] OBSTRUCTION OF THE BOWELS. 679 same proportions; pressure being maintained with a compress upon the fun- dament, in order to prevent the expulsion of the gas evolved. The patient complained of great distension, and, on the removal of the compress, had a free discharge of fecal matter, with the water and air. (St. Louis Med, and Surg. Journ., Nov. 1857, p. 553, from the Geo. South. Med. Journ.) Tobacco enemata have sometimes been found effectual in very threatening cases, but must be used very cautiously. (See page 655.) Dr. Alexander succeeded, in an obstinate case, by introducing a long tube into the rectum, throwing up through this, by means of a syringe fitted to it, more than a pint of warm water, and then withdrawing the piston of the syringe, so as to bring atmospheric pressure to bear upon the bowel. (Lond. Med. and Phys. Journ., Dec. 1827.) Metallic mercury has by its great weight forced obstructions which have resisted other means. It is recommended in the quantity of a pound or more, given in doses of four ounces at intervals of a few hours; but it should be employed only as a last resort. Cold water thrown upon the lower extremities and abdomen, has occasionally proved effectual. Dr. R. H. Townsend, of Philadelphia, overcame an obstruction which threatened speedy death, by first throwing a quart of ice-cold water into the rectum, then suspending the patient by his feet to the ceiling of the chamber, and kneading the abdomen with considerable force. The signs of obstruction ceased, and in fifteen minutes the patient evacuated the injected water with feculent matter. (Am. Journ, of Med. Sci, N. S., xviii. 547.) Efforts for the relief of the patient should never be abandoned so long as life continues. If one measure fail, another should be tried, and nothing which affords any reasonable prospect of advantage should be neglected; for success has often rewarded the efforts of the practitioner, in these cases, when there scarcely seemed ground for hope. When the strength of the patient be- gins to fail, it should be supported by stimulants and nutritious food. Wine- whey, carbonate of ammonia, egg beat up with wine, milk-punch, animal broths, &c, may be employed. Lime-water and milk, in small and frequently repeated doses, will sometimes lie upon the stomach, when other nutriment is rejected. Opiates should be administered throughout the case, if required to give ease or produce sleep. In low states of the system, it maybe proper to employ the purgative tinctures, as those of rhubarb, aloes, senna and jalap, &c, preferably to other forms of cathartic medicine. In those cases which run on for months, it will be necessary to watch their progress carefully, in order to meet any offered indication, and favour the recuperative efforts of nature. A few remarks may be made in reference to particular cases of obstruction. Should the complaint depend upon feces or concretions lodged in the rectum, the aid of the finger or of instruments should be resorted to. (See page 670.) The latter, if cautiously used, may be even applied to similar obstructions at the lower extremity of the sigmoid flexure. If there be reason to suppose that magnesia has concreted in the bowels, acidulous liquids should be given with the purgative. When the obstruction depends on stricture of the rec- tum, resort should be had to the bougie, unless in cases of scirrhus or cancer, in which this instrument can do no good, and may prove injurious by tearing the easily lacerated structure. In permanent impediments of this kind, the best plan is to administer frequently small doses of the saline cathartics, so as to keep the passages in a liquid state, and thus prevent irritation. The use of laxative mineral waters has been found very beneficial, under such cir- cumstances, in alleviating the pains and protracting the life of the patient. If there is strong reason to believe in the existence of intussusceptio, twisting of the bowel, or other form of internal strangulation, there may possibly, under peculiar circumstances, and in cases otherwise desperate, be some pro- priety in opening the abdomen, and removing the mechanical impediment; at 680 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. least the question of an operation may be entertained. A successful case of the kind is referred to in Dr. Eberle's Practice of Medicine (2d ed., vol. ii. p. 341), quoted from Hufeland's Journal for February, 1826; and another is recorded in the Edinburgh Monthly Betrospect of the Medical Sciences (May, 1849, p. 121). Many cases of obstruction from disease of the sigmoid flexure and rectum are on record, in which the descending colon was success- fully opened by an incision through the loins or in the groin. Of these cases, some terminated unfavourably immediately after the operation, and others in the course of a few weeks; but, in a considerable proportion, the patients survived a long time, with only the inconvenience of an artificial anus. In most of these favourable cases, however, death ultimately occurred, either from a closure ofthe artificial opening, or from the progress ofthe disease in which the obstruction originated. In almost all, the life of the patient was prolonged more or less by the operation.* Article VI. WORMS IN THE ALIMENTARY CANAL. Five different species of worms inhabit the alimentary canal. I shall first briefly describe these parasites, then give some observations upon the symp- toms, causes, and management of intestinal worms in general, and lastly treat of what is peculiar, in these respects, to each species. 1. Ascaris lumbricoides.—Bound worm.—This worm has frequently been called lumbricus, or in the plural lumbrici, from a supposed identity with the common earth-worm, from which, however, it is wholly distinct. It has a cylindrical body, tapering towards the extremities, generally from six to twelve inches long by two or three lines in thickness, smooth, of a whitish, yellowish, or pale-reddish colour, and somewhat transparent when first voided. The head is at the slenderest extremity, and is distinguished by three tubercles surrounding the mouth. The alimentary canal is distinct from the general parietes, and runs from the mouth near one end of the worm, to the anus near the other. The surface exhibits numerous circular fibres, and four lon- gitudinal equidistant lines, the former indicating the course of the muscles, the latter of the nerves and blood-vessels. The two sexes are in different in- dividuals. The male is smaller and much less abundant than the female, and has its tail shortly curved, while that of the female is straighter and thicker. The latter is also distinguished by a constriction, which is the seat of the vulva, at about one-third of the distance from the head to the tail. The ex- ternal genitals of the male are at the caudal extremity. 2. Ascaris vermicularis.—Oxyuris vermicularis. Bremser.— Thread- worm.—Seat-worm.—Maw-worm.—This worm is most commonly designated by the plural term ascarides. It is the smallest of the intestinal worms, the male not exceeding two lines, and the female being about five lines in length. It is very slender, and of a white colour, and bears considerable resemblance to a small piece of thread, whence one of its names was derived. The head, as in the former species, is furnished with three tubercles, which are but faintly marked, and the body gradually diminishes towards the tail, which, in the female, is slender and pointed; in the male, somewhat thicker, obtuse, and " spirally inflected." The interior structure resembles that of A. lumbricoides. 3. Tricocephalus dispar.—Long thread-worm.—This worm is an inch or * See a statement by C. H. Hawkins, Esq., in the Lond. Med. Times and Gaz., March, 1852, p. 302. CLASS III.] WORMS IN THE ALIMENTARY CANAL. 681 two in length, and consists of two distinct portions, of which the anterior, constituting about two-thirds of the whole length of the animal, is scarcely thicker than a horse-hair, and suddenly swells out into the much thicker but shorter posterior portion. Hence the names tricocephalus (from &pi£, hair, and xeyaXr], head), and dispar, unequal. Like the two preceding worms, this also has a distinct alimentary canal, and the different sexes in different indi- viduals. The digestive tube, commencing in a small orbicular mouth, at the anterior extremity, runs longitudinally through the animal to the anus at the opposite extremity, being straight in the capillary portion, and sacculated in the larger. The male, which is generally found convoluted, is smaller than the female. The former has at the posterior extremity a projecting sheathed spiculum, the latter a foramen which serves both for anus and vulva. 4. Taenia solium.—Common tape-worm.—Long tape-worm.—The ta?nia varies much in length, being, as generally found, from five to ten feet long, but sometimes reaching sixty, and, according to some writers, upwards of one hundred feet. It is flat, and where largest, three or four lines broad, but tapers gradually towards the anterior extremity, which is slender and_ thread- like. The body consists of numerous segments, which are most distinct at a distance from the head, and, in the lower part of the worm, are longer than they are broad, resembling when separated the seeds of a gourd, whence the animal has sometimes been called Taenia cucurbitina, or gourd-worm. _ The head is small and flatfish, having a projecting papilla in the centre, furnished with a double circle of hooks, which, however, are sometimes wanting, and surrounded by four equidistant circular somewhat raised disks, depressed in the centre, which have been supposed to be mouths, but in fact appear to be suckers, by which the animal is enabled to attach itself to the surface of the bowel. From these run two parallel canals, one on each side, near the mar- gin of the segments, from one end of the animal to the other, being con- nected by numerous transverse vessels. These canals are not distinct from the body, but merely passages excavated, as it were, in the parenchymatous tissue of the animal, and therefore differ materially in character from the digestive tube of the three species before described. Each joint has a mar- ginal foramen in the centre of a prominent papilla; and the foramina occur alternately on the opposite sides ofthe animal. These lateral pores are con- nected by a duct with an ovarium, occupying the centre of each segment; and the ova, as they escape, are supposed to be fertilized by a fluid derived from a vesicle, the duct of which opens at the same point as that from the ovary; so that in this worm the organs of the two sexes are contained in the same individual. m, , , 5 Bothriocephalus latus—Taenia lata.—Broad tape-worm.—The body of this worm is also long and flat, but is broader than that of the tenia, being from four to ten lines in breadth. It is distinguished also by the shape of the segments, which are broader than they are long; by the form of the head, which is small, elongated, without the hooks and the four circular disks or suckers of tamia, and divided into two lobes by a longitudinal fossa on each side (whence Bothriocephalus from fiodpiov, a fossa or ditch, and xeycdr], head); and by having for mouth a single minute pore in the centre between the fossa? or else two pores, one at the extremity of each lobe. The foramina supposed to be the outlets for the escape of the ova, are situated not on the opposite margins ofthe segments alternately as in the ta?nia, but m a single row, each segment having one pore in its centre. The longitudinal tube is arranged as in the preceding species, being a mere excavation in the parenchymatous substance of the animal, without a distinct coating. The bothriocephalus is said to be somewhat less opaque than the tenia, and, when kept m alcohol, has a somewhat opaline appearance. 682 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. The above descriptions are condensed, with some modifications, from those by Dr. Farre, in Tweedie's System of Practical Medicine. Other animals besides those described are sometimes found in the human intestines, but none peculiar to this situation. The eggs, larva?, or young of various insects, worms, lizards, and serpents, have been taken in with the food or drink, or have crept into the mouth or anus during sleep, and, having undergone a greater or less degree of development in the alimentary canal, have produced derangements of health, sometimes long continued, and of the most serious character. Numerous cases of this kind are recorded in medical journals, or other periodicals; and, much allowance being made for exaggeration, enough remains to justify the above statement. Among the animals particu- larly enumerated are Gordius aquaticus, or horse-hair worm, different species of Hirudo or leech, different species of Musca or fly, Phalaena pinguinalis, Triton palustris, and Lacerta aquatica. (Good, Study of Medicine.) But none of these produce symptoms by which they could be respectively charac- terized. Their effects are essentially the same as those of the proper parasites of the bowels, and for the most part they are amenable to the same treatment. General Observations. Symptoms.—In consequence of their movements, the interruption they offer to the progress of the contents of the bowels, and probably other modes of irritation, worms very generally occasion uneasiness or pain in the abdo- men, sometimes spasmodic, sometimes described as gnawing or biting, and not unfrequently of a vague indescribable character, and yet very distressing. Sympathetic with this is a sensation of itching at the anus and at the nos- trils, producing a disposition to scratch the fundament, and to pick the nose, which is highly characteristic of the verminous affection. The bowels are often disordered, being sometimes constipated and sometimes relaxed, with occasional tenesmus, and mucous or bloody discharges as in dysentery. The mucus is sometimes in shreds or flakes, which are not unfrequently mistaken for fragments of the partially digested worms. It is not uncommon for por- tions of undigested food to pass with the feces. The appetite is exceedingly variable, in some cases natural, in others deficient, craving, or depraved, one condition not unfrequently alternating with another. The belly is often swollen, hard, and tympanitic, the breath heavy or fetid, and the tongue furred, with a disagreeable taste, and a copious flow of saliva. Swellings of the upper lip, bleeding from the nostrils, and a disposition to grind the teeth during sleep, are other characteristic symptoms. But the effects often extend beyond the alimentary canal, and various de- rangements of health are experienced in consequence either of the direct irri- tation of the worms, or ofthe disordered digestion which they occasion. Among the most common of these are nervous affections; such as fretfulness, irrita- bility of temper, wakefulness or somnolence, disturbed sleep, sudden starting out of sleep as if from fright, vertigo, headache, spasmodic movements of the eyelids, dilated pupils, perverted vision, temporary blindness, tinnitus aurium, and partial deafness. General convulsions are not unfrequent in children, and symptoms strongly resembling those of hydrocephalus have been ascribed to worms, and have ceased on their expulsion. Cases of chorea, melancholy, hypochondriasis, and even insanity have been referred with apparent reason to the same cause. In addition to these affections, may be mentioned obsti- nate cough, spasm ofthe glottis, dyspnoea, palpitations, hysteria, menorrhagia, and a general cachectic state of system, marked by a languid circulation, a pale or sallow skin, sunken eyes, a livid circle about the eyelids, and general emaciation, or oedema. A febrile condition occasionally accompanies worms, CLASS III.] WORMS IN THE ALIMENTARY CANAL. 683 with daily exacerbations and remissions, a tumid abdomen, offensive breath, and frequently symptoms of cerebral oppression. The name of worm fever by which it has been called indicates the prevalent opinion as to its origin. There can be little doubt that worms are capable of producing it; but any other cause which induces protracted intestinal irritation, with disordered digestion, may have the same effect; and there is no such necessary connec- tion between the fever and the worms as might be inferred from its name. As to many of the above-described conditions, it is often impossible to say whether they bear to the worms the relation of cause or effect, and sometimes whether the connection may not be a mere coincidence. That worms are sometimes the cause, may be inferred from the frequently observed fact, that all the phenomena vanish when they are removed. Again, it is well known that disordered digestion and general debility favour the production of worms; and the same causes which give rise to the development of these parasites are quite sufficient to produce various derangements by their direct action, wholly independent of the worms; so that the two may coexist without any neces- sary connection as cause and effect. Persons in apparently perfect health are occasionally affected with worms, which give no signs of their existence until they are observed in the ordinary passages, or are expelled during some acute attack of disease, either by the medicines employed, or the influence of the disease itself; and it is no uncommon event to find worms in the bowels of individuals after death, who have evinced no signs of them during life. Hence some have inferred that they are generally if not always harmless, and per- sons have even gone so far as to maintain that they perform a useful office, being intended as scavengers to clear off the noxious matters contained in the bowels. But these opinions are opposed to general experience; and, though it may not be proper to disturb the system of a perfectly healthy individual, supposed to be affected with worms, by active measures for their expulsion; yet, when associated with derangement of health, whether as cause or effect, they should always engage attention, and be removed if possible; as their removal, under such circumstances, is often followed by the best results. A new means of diagnosis is now offered in the microscope. It appears that even when no worms are discharged from the bowels, their ova often are so; and, in any suspected case, a person acquainted with the character of these ova, may decide by their presence or absence in the discharges when sub- mitted to microscopic examination, whether the patient is affected with worms or not; and not only this, but may also determine the species of the parasite. An interesting paper by Dr. W. H. Rausom, upon this subject, with illustrative figures, is contained in the London Medical Times and Ga- zette for June, 1856 (p. 598). Appearances after death.—Worms are rarely fatal; but opportunities are often afforded, in cases of death from other causes, to observe the patho- logical changes they produce in the stomach and bowels. These are very slight, consisting chiefly of an excess of mucus, with occasionally an increased vascularity of the mucous membrane. It has been supposed that worms are capable of piercing the intestine, and escaping through its parietes ; as they have sometimes been found engaged in small openings in the coats of the ali- mentary canal, and even loose in the abdominal cavity. But there is every reason to believe that the openings were the result of previous ulceration, or of changes after death, as in an instance in which great numbers were ob- served to have escaped through holes in the stomach, which may have been produced by a post-mortem action of the gastric juice. Worms have also been discharged with pus from external abscesses connected with the bowels; but it is most probable that the inflammation which gave rise to the ulcera- tive and suppurative processes had some other origin than the irritation of 684 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. the worms. The tricocephalus, however, appears to have the power of insert- ing its capillary head into the substance of the mucous membrane; and a case is on record, in which the ca?cum was found perforated as if with a number of pin holes, and the lining membrane much eroded by worms of this genus. (Brooks, quoted by Farre, in Tweedie's System of Pract. Med.) Causes.—The origin of intestinal worms has been a subject of much con- troversy. The difficulty of otherwise accounting for their presence in the alimentary canal has led some to the notion of spontaneous or equivocal generation; but, before a mode of production so contrary to the general course of nature can be admitted, it must be clearly shown that their origin from a parent animal is quite impossible. This subject has been already sufficiently discussed in the first part of this work, to which the reader is referred. (See page 137.) The conclusion there come to is, that these parasites obey the general laws of animal nature, as well in the mode of their generation, as in that of their development and growth. It is probable that the ova, received into the alimentary canal, are capable of development in a healthy state of this structure, as worms are sometimes found in individuals who are apparently quite free from disease; but, never- theless, it is certain that their growth is favoured by certain morbid conditions of the stomach and bowels, and particularly by a feeble or disordered state of digestion. Hence, persons of sedentary habits, of scrofulous tendency, and of general depraved health, are apt to be affected with them. It is supposed that an excess of food over the powers of digestion is favourable to their growth. Excessive indulgence of the appetite has, therefore, the same effect as defective digestion. The use of certain articles of food also predisposes to worms, such as crude vegetables, unripe fruits, and indigestible substances in general. Bad bread, spoiled cheese and meats, the flesh of diseased animals, and the use of bad water as drink, are fruitful sources of verminous affections. It is said that they seem sometimes to occur epidemically; but the probability is, that, under these circumstances, a close examination might trace their origin to some impropriety of diet affecting great numbers of individuals; and the same remark is perhaps applicable to the well-ascertained fact, that some regions of country are much more subject to worms than others. Neverthe- less, it is not impossible that certain conditions of the atmosphere may favour the production of worms; and it has been observed that they are most abund- ant in moist countries, and during a long prevalence of warm damp weather. Children, after weaning, and up to about the age of puberty, are more fre- quently affected with worms than either very young infants or adults, proba- bly owing to the nature of their diet, which is often ill adapted to their yet immature powers of digestion. Recent developments in relation to the propagation of the long tape-worm, or Ta?nia solium, throw a flood of light on this formerly dark subject. It is well known that this worm, though it produces ova abundantly, does not multiply in the alimentary canal. Experiments have now shown, beyond reasonable doubt, that these ova, escaping in vast numbers from the body with the feculent discharges, either separate, or still engaged in the evacu- ated joints of the worm, are consumed by other animals, especially the hog, in the intestines of which they break a firm investment which encloses them, and set free an embryo, so constructed as to be able to perforate the coats of the bowel, and make its way to its destined home in the muscles, areolar tissue, or other part of the animal. There is reason to think that the embryo is sometimes, if not generally, conveyed to its destination by first entering a blood-vessel, and being carried along with the blood into the interior of the organ which it is to inhabit. Here it is converted into a species Cysticercus, the C. cellulosa, which continues to dwell, perhaps harmlessly, in its birth- CLASS III.] WORMS IN THE ALIMENTARY CANAL. 685 place until the death of the animal. (See page 141.) It retains, however, its vitality, prepared for a further development, when it can find a place suitable for the purpose. As the flesh of hogs is generally submitted to a cooking process, before it is eaten by civilized men, the Cysticercus usually perishes, and no harm results. But sometimes a portion of the raw flesh of the animal is taken inadvertently into the mouth, as for example from the hands or knife of the butcher, the cook, &c, and being then swallowed, carries with it the animalcule into the alimentary canal, where it is de- veloped into the tape-worm. The experimental proof of this course of pro- pagation and development was first given by Kiichenmeister; and his state- ments have since been confirmed by Yon Siebold and others. It appears that each species of Ta?nia has its own Cysticercus; and that, in general, each species of the parasite can undergo complete development only in a particular species of the higher animals. If we admit the correctness of this history of the tape-worm, we can have no hesitation in admitting that all the other in- testinal worms may have their origin in ova introduced into the body from without. Treatment.—Two indications are presented, first, to expel the worms from the bowels, and, secondly, to prevent their reproduction. The first indicationm&j be fulfilled by active purgatives, which expel them by increasing the peristaltic movement, or by anthelmintic medicines, which favour their expulsion through the ordinary contraction of the bowels, by rendering them less able or less disposed to resist this contraction. But a more effectual plan is to combine these two modes, thus at the same time bringing a greater force to bear upon the worms, and diminishing their powers of resistance. The purgatives and anthelmintics may be given con- jointly ; or the latter maybe administered night and morning for a few days, and then followed by the former Anthelmintics are medicines which prove disagreeable to the worms, and thereby dispose them to leave the bowels, or so debilitate them as to disable them from maintaining their position, or destroy their life, and thus expose them to the expulsive powers of the intestines, or the digestive powers of the stomach. They may produce these effects by acting on the susceptibilities of the worm, as medicines and poisons act on the human system, or by mechan- ically bruising or wounding it. Among those which operate in the former method may be mentioned pink-root, azedarach, the bark of Andira inermis, male fern, the bark of pomegranate root, koosso, walnut-rind, common salt, camphor, various bitters, and numerous substances characterized by contain- ing a strongly odorous or highly stimulating volatile oil, as turpentine, copaiba, savine, chenopodium, or American wormseed, semen santonicae, or European wormseed, tansy, rue, wormwood, garlic, and assafetida. Several of the vola- tile oils themselves are still more efficacious, especially the oil of turpentine and that of chenopodium. Electricity passed through the bowels, in suc- cessive and somewhat violent shocks, has been supposed to injure or kill the worms, and favour their expulsion by cathartics. The mechanical anthelmin- tics are chiefly cowhage, which wounds and sometimes destroys the worms by the sharp bristles of its pods, and the powder of tin, or of zinc, which bruises or scratches them by its angular particles. Metallic mercury, which has been recommended in worms, undoubtedly operates by its great weight. The fixed oils are thought to act as anthelmintics by covering the surface of the worm, and thus closing its respiratory pores against the entrance of air. In the choice of purgatives, attention should be paid to their anthelmintic properties. Thus, calomel is a powerful vermifuge, much more so than can be satisfactorily explained by a reference to its mere cathartic power. The probability is, that it proves disagreeable or injurious to the worm by the 686 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. acrid property of the bile which it causes to be secreted. Aloes is also thought to possess vermifuge properties, independently of its purgative action, owing to its intense bitterness ; this property being considered by some as extremely offensive to worms. The same may be said of colocynth. If there is truth in the supposition before alluded to, of the suffocating action of fixed oils on the worm, which, however, is by no means certain, at least in reference to the operation of these oils when taken into the stomach, castor oil and olive oil ought to be efficacious anthelmintics. The oil of turpentine in very large doses, and the bark of pomegranate root, unite purgative and anthelmintic powers. Considered independently of anthelmintic properties, those cathar- tics are the most powerfully vermifuge which act with greatest energy on the muscular coat of the bowels. Senna, jalap, scammony, aloes, black hellebore, cevadilla, colocynth, gamboge, croton oil, and elaterium have been used, variously combined, and in various modes of preparation; but, except in very obstinate cases, it is better to trust to the proper anthelmintics, with the less violent of these cathartics, than to endanger inflammation of the bowels, or exhaustion of the patient, by a resort to the most energetic. To meet the second indication, that, namely, of preventing the reproduction of the worms when once destroyed or evacuated, it is necessary to attend to the food and drink of the patient, and, if the digestion is feeble, to promote that function by tonic medicines, exercise, and other suitable measures. Ex- cess in eating, indigestible substances, unwholesome food of all kinds, and unwholesome drinks should be avoided. Of the tonics, the different prepara- tions of iron are probably the most efficacious; though they may be advan- tageously combined with the simple bitters, as gentian, quassia, and columbo. The bitters in which the tonic principle is associated with an anthelmintic volatile oil, as wormwood, tansy, and rue, were formerly much used, and are probably not without a peculiar efficacy. When there is excess of acid in the stomach or bowels, lime-water, or one of the alkaline carbonates may be use- fully associated with the bitters. The rules applicable to the treatment of dyspepsia may be considered as in force in the present case. Yery often, however, after the expulsion of the worms, all unpleasant symptoms cease, and no further treatment is necessary. It is an obvious inference, from the history of the tape-worm, before given, that great care should be taken to allow the flesh of no animal to enter the stomach, either accidentally or as food, which has not previously been subjected, in the curing or cooking pro- cess, to some agency which must necessarily extinguish the life of any parasitic germs that may possibly be contained in it. 1. Round-worm.—Ascaris lumbricoides.—The round worm generally inhabits the small intestines; but not unfrequently makes its way upward into the stomach, or downward into the rectum; and sometimes escapes from the alimentary canal by the mouth, or by the anus. It occasionally enters other passages which communicate with that canal; having been found in the posterior nares, the trachea, the pancreatic and biliary ducts, and the gall-bladder. It is sometimes solitary ; but more generally in considerable numbers; and two hundred have been known to pass from one patient in a week. The worm is supposed to feed upon the intestinal mucus, which is usually copious where these parasites exist. It occurs most frequently in children, occasionally in adults, and seldom in old persons. Of all the differ- ent worms that infest the bowels, this is usually considered as by far the most common, and certainly is so with the exception of the tricocephalus. The symptoms are those already enumerated as resulting from intestinal worms in general. The most characteristic signs are perhaps a tumid abdo- men, irregularity of the bowels, depraved appetite, picking of the nose, and grinding of the teeth in sleep. When these worms exist in the stomach, CLASS III.] WORMS IN THE ALIMENTARY CANAL. 687 they occasion peculiar deranged sensations in the epigastrium, with nausea, and frequent retching, and motions on the part of the patient as if he were choking from something in the throat, produced probably by attempts of the worm to enter the oesophagus, or by its actual presence in that tube. When these motions occur in an infant, the round worm may be suspected to exist in the stomach. But the only certain proof that a patient is, or has been labouring under this worm, is the sight of it after it has passed from the bowels, or been discharged from the stomach. It sometimes comes away spontaneously from the anus, and is not unfrequently evacuated with the feces, thus affording the requisite evidence of its existence. The general course of treatment for worms already described is applicable to this species. A good remedy at the commencement, and one which will alone, in a great majority of cases, produce an evacuation of the worms, is an infusion of senna and pink-root, with sulphate of magnesia to correct the griping property of the cathartic, manna to cover the taste, and fennelseed or other aromatic to correct the flavour, and to render the whole more ac- ceptable to the stomach. This infusion may be given in a small dose once or twice a day, so as to produce two or three evacuations in the twenty-four hours, and may be continued daily, or every other day, for one or two weeks, or even a longer period, if necessary, and if it do not too much debilitate the patient.* A little savine may sometimes be advantageously added to the infusion, in obstinate cases. Another good preparation is the officinal fluid extract of spigelia and senna, of which a teaspoonful may be given to a child two or three years old, and repeated as above. If evidences of deranged biliary secretion are presented, or the bowels are too irritable for the use of the above infusion, or if the infusion has failed, or any difficulty exists in the way of its exhibition, calomel may often be advan- tageously resorted to. This is, indeed, one of the most efficacious anthel- mintics, and has the great advantage, in the cases of children, of easy admin- istration. It is best given in connection with powdered spigelia, and followed at a proper interval by castor oil. To a child four grains of calomel and sixteen of spigelia may be given at bedtime, followed by a dose of castor oil in the morning; and the remedy may be repeated once and again, if required, at intervals of three or four days. In adults, the calomel and pink-root may be associated with some quicker cathartic, as jalap, scammony, or compound extract of colocynth. Another plan is to administer, morning and evening, for several successive days, a dose of some anthelmintic, and afterwards a purgative dose of calomel or other cathartic, to expel the debilitated or dead worms. For this purpose, in the case of a child, half a fluidounce or a fluidounce of the officinal infu- sion of pink-root, or from ten to twenty grains of the powder ; from twenty to forty grains of powdered wormseed (chenopodium), or from five to ten drops of the volatile oil; from five to twenty drops of the oil of turpentine; or a drachm of an electuary made by incorporating the bristles of cowhage with syrup or molasses, may be employed. Oil of turpentine is peculiarly efficacious in stomachic worms, as pointed out by the late Dr. Joseph Klapp, of Philadelphia. In our Southern States, where the pride of China (Melia Azedarach) grows, the bark of the root of that tree (Azedarach, U. S.) is much employed. Four ounces of the fresh bark are boiled with two pints of water down to one, and a tablespoonful is given to a child for a dose. The cedar-apple, an excrescence upon the branches of _ Juuiperus Yirginiana, or common red-cedar, has been highly recommended, in the dose of from ten * JJ.—Sennse, Spigelise, aa |ss; Magnesiae Sulphat. ^ij; Mannse !§j; Foeniculi ^ij ; Aquae fervent. Oj. To be macerated for two hours in a covered vessel. Dose, for a child two years old, about fjss; for an adult f^iij or f£iv. 688 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. to twenty grains of the powder, repeated as above mentioned, and will often prove effectual. The above anthelmintics may be employed successively, one of them sometimes succeeding when another has failed. In nervous cases, advantage may result from combining assafetida, garlic, or valerian with the more decided anthelmintics. When the digestion is feeble, the vegetable bitters, or chalybeate preparations should be employed in a similar connection, and, in cases of the existence of an excess of acid in the stomach or bowels, antacids should also be added. These different remedies may be combined in the liquid form, in that of powder, electuary, or pill, to suit the views of the practitioner, or the convenience of the patient. Care must be taken, after the expulsion of the worms, to provide against their reproduction, as directed in page 686. 2. Thread-worm.—Ascarides.—Maw-worm.—Ascaris vermicularis.— The peculiar seat of ascarides is the rectum; but they sometimes also inhabit the colon, and are said to have been occasionally seen in the stomach, and to have derived from this circumstance their name of maw-worm ; though Dr. Good ascribes the origin of this name rather to the disagreeable sensations they produce in the stomach, from sympathy with the rectum, than to their actual presence in the former viscus. In the female they sometimes enter the vagina, giving rise to severe irritation and intense itching, and even to symptoms of nymphomania. They are usually in great numbers, and mul- tiply very rapidly. Persons of all ages are liable to them; but they are most frequent in children. Their characteristic symptom is an itching sensation at the anus, which is often distressing and almost insupportable, especially in the evening, and after the patient has become warm in bed. Tenesmus, mucous or bloody discharges, and small tumours about the anus are also among their effects. These local symptoms are in some cases all that are exhibited; but the general derangements, before described as produced by worms, may proceed also from this species. Disorder of the nervous system is especially apt to occur, from the intense local irritation occasioned by the movements of the worms ; and this disorder amounts sometimes in children to general con- vulsions. But this irritation of the anus may proceed from other causes, and the only certain evidence of the existence of ascarides in the rectum is afforded by their occasional appearance upon the bedclothes, or in the stools. They not unfrequently make their way out of the rectum during the night, and may be seen upon the sheets in the morning; and are sometimes discharged in considerable numbers, either mixed with the feces, or enveloped in mucus, or clustered together in the form of a ball. It is extremely diffi- cult completely to dislodge them from the bowels; for, however great the numbers evacuated, or the temporary relief obtained, a few generally remain, and, by the rapidity of their propagation, reproduce all the original symp- toms. Though productive of great inconvenience, and even suffering, they may exist for many years without serious injury to the health, and have been known to continue through almost the whole of a long life, without reason to suppose that they had in any degree shortened it. (Heberden, Trans, of the Col. of Phys., Lond., i. 54.) Treatment.—Medicines taken by the mouth are usually less efficacious in this than the other species of worms. The most successful plan is to address the remedies immediately to the rectum, and, having weakened or destroyed the worms by anthelmintic enemata, then to procure their expulsion by cathar- tics taken in the ordinary way, or thrown into the bowels. The substances most advantageously employed in enemata, are oil of turpentine, aloes, com- mon salt, decoction of rue or wormwood, infusion of tobacco, sulphuretted waters, the alkaline sulphurets, tincture of chloride of iron, chloride of soda, CLASS III.] WORMS IN THE ALIMENTARY CANAL. 689 and vinegar. Great advantage is said to have resulted from an infusion of quassia made in the proportion of two drachms to four fluidounces of water. (Gaz.desHopitaux, Sept. 1846.) Trousseau and Pidoux recommend, as peculiarly efficacious, solutions of biniodide and bichloride of mercury, con- taining three quarters of a grain of the salt in a quart of water; the solution of the biniodide being facilitated by the addition of a very little iodide of potassium. The whole quantity is thrown up at once in the case of an adult, only one-fourth or one-fifth, in that of a child. Some one of these, or some combination of them, should be injected daily, with a sufficient quantity of water, and after several days should be followed by a dose of calomel or aloes, or other brisk cathartic. A dose of sulphur, taken every morning before breakfast, has been found very useful. Advantage has also been derived from the introduction into the rectum of a bougie smeared with mercurial oint- ment, or of a candle or piece of fat pork tied to a string, which, after having been allowed to remain for some time, is withdrawn with the worms adhering to it. In adults, much relief may sometimes be obtained by the greased finger employed in like manner. Injections of olive oil or other mild fixed oil, and the external application of creasote incorporated with some unctuous matter, have been recommended. The oil is supposed to destroy the worm by preventing the entrance of air into its respiratory pores. The frequent lo- cal use of cold water also allays the itching. It is advised to avoid expos- ure to heat, or the use of stimulating articles of food. When the worms have found their way into the vagina, injections of cold water with vinegar are recommended by Bremser. The general health should be attended to as in the other kinds of worms. It is asserted that the change of system which takes place at puberty is unfavourable to the existence of these worms, which often cease to appear after that period. 3. Long Thread-worm.—Tricocephalus dispar.—This worm is found most frequently in the ca?cum or other part of the colon, but sometimes also in the small intestines, either loose, or with its anterior capillary portion in- serted toto the mucous membrane. It is often observed, in great numbers, in the bodies of individuals who have died suddenly, by accident or from some acute disease, and who have exhibited no evidence of its existence during life. The tricocephalus was first noticed as a distinct worm in Ger- many, in the year 1760, and has since generally been considered as very rare. The fact, however, appears to be, that it is very common, perhaps the most so of all the intestinal parasites; but has escaped notice in consequence of its minuteness, or been confounded with the ascaris vermicularis. It is stated in the London Medico-Chirurgical Transactions (vol. xxii. p. 285), that, in the London Hospital, during one winter, this worm was found in almost all the bodies carefully examined, whether of persons destroyed by injuries, or of those who had died of disease. It does not appear that there are any peculiar symptoms which indicate its existence, or that any special course of treatment is to be pursued. Should the ordinary signs of worms be present, the remedies adapted to the round-worm may be employed. 4. Common Tape-worm.— Taenia solium.—Broad Tape-worm.—Both- riocephalus latus.— Taenia lata.—Between these two worms there seems to be no such difference in their habits, residence, symptoms, or treatment, as to, require a distinct practical consideration. The following observations may, therefore, be considered as applicable to both kinds. The bothriocephalus, or broad tape-worm, is said to be found only among the inhabitants of Swit- zerland, Poland, and Russia, or in individuals who have been in those re- gions ; the tenia, or common tape-worm, is met with everywhere. They inhabit chiefly the small intestines; and are often solitary, but some- times also in numbers, though less numerous than the other intestinal worms. VOL. I. 41 690 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. They occur during childhood, but more frequently after puberty, and are very rare in old age. Females are more subject to them than males. They are much more common in some countries than in others, and are comparatively rare in the United States, at least within the limits of my observation. Per- haps this result may be ascribed to the abundance of wholesome food within reach of everybody in this country. Tape-worms often exist in large and tangled bunches, so as to interfere mechanically with the proper performance of the intestinal functions. As the tenia and bothriocephalus cannot propa- gate in the human intestines through their eggs, which require to be trans- planted to another animal in order to become reproductive, it follows that, if the worm can be wholly expelled, there is no danger of an increase from its eggs deposited in the bowels. Symptoms.—In some instances, the tape-worm has long existed in the bowels without producing any very prominent symptoms; but it generally occasions great discomfort, and sometimes materially deranges the health. There is not often perhaps very acute pain; but the sensations experienced are scarcely less distressing than pain, and are often attended with great de- pression of spirits or irritability of temper. These sensations are referred to the movements of the worm. Professor Wawruch, of Vienna, who during a period of twenty years had witnessed 206 cases of tape-worm, gives the fol- lowing summary of the symptoms:—Dull pain in the forehead; giddiness; buzzing in the ears; dulness of the eyes, which are surrounded by a dark circle ; edematous eyelids; dilated pupils ; frequent and spasmodic movements of the eyes; alternate paleness and flushing of the face; paleness of the lips; peculiar movements of the nose and mouth; emaciation; alternate loss and excess of appetite; cravings for particular articles of food; offensive breath; furred tongue; spitting and vomiting of thin mucus in the mornings; itch- ing at the nose, anus, and vulva; grinding of the teeth, especially during sleep; constriction of the throat; swelling of the belly; gurgling, shooting pains, and a sense of pinching about the umbilicus; a feeling in the morning as of a foreign body moving in the bowels; amelioration of all the symptoms under the use of farinaceous food, hot bread, and coffee; finally, depression of spirits, and a train of nervous derangements in protracted cases. (Archives Generates, 4e ser., i. 208, from Oesterrich. Med. Jahrbuch, 1841, No. 2.) Sometimes the nervous disturbance amounts to convulsive movements, of an epileptiform or hysterical character, and, when these occur in a man, with signs of abdominal disorder, the possible existence of the worm should be suspected, and the evacuations examined. The most certain sign is the dis- charge of joints of the worm, which are passed alone or with the stools. These joints usually exhibit signs of life when they first appear; and even after they have perished, the ova contained in them are supposed to retain their life, and to be capable of development under favouring circumstances. Treatment.—In the treatment ofthe tape-worm, it is important to inquire into the habits and pursuits of the patient; and to ascertain whether he may not purposely, as an article of food, or accidentally, in the prosecution of his business, admit portions of the uncooked flesh of animals into his stom- ach. It might readily happen, for example, to the butcher or sausage maker to carry his knife or hand, with adhering portions of the fat or flesh, in- advertently to his mouth, and thereby introduce the embryo worm into his system. It is possible that the difficulty in wholly and permanently getting rid of these worms, may sometimes at least be owing to the constant entrance of their germs into the alimentary canal. As the first step, therefore, of the treatment, the patient should be strictly cautioned to avoid every source of this kind, and always to eat his meat, in whatever shape, well-cooked. Tape-worms have the power of retaining their place very tenaciously in CLASS III.] WORMS IN THE ALIMENTARY CANAL. 691 the bowels, possibly in consequence of holding on to the mucous coat by means of suction. They often continue for years to harass the patient, who passes from time to time separated joints, or even large portions of the worm, without getting entirely rid of it. The duration ofthe affection, according to the observation of Wawruch, varies from a few months to thirty-five years. It is considered important that the head of the worm should be expelled; as, until this happens, there is no certainty that the evil has ceased. Many dif- ferent plans of treatment have been employed with asserted success; most of them including active purgation, and the use of substances calculated to injure or destroy the parasite. Whatever method of cure is followed, much pain is often experienced just before the expulsion of the worm, which is as- cribed to its violent movements under the influence of. the medicine. It is deemed best to prepare the patient by a somewhat restricted diet upon the day preceding the use of the medicine, which should be given in the morning upon an empty stomach. By some it is even advised to precede the anthel- mintic, for four or five days, by a spare diet, consisting chiefly of liquids, and by the use of saline or other laxatives, so as to leave the worm with as little protection as possible from the alvine contents, against the influence of the purgatives or anthelmintics, which may be given for its expulsion. The fol- lowing remedies are those wliich have attracted most notice. Amongst the medicine at present most relied on is the oil of turpentine. This is given in large doses, and very often with the speediest and happiest effects. The quantity administered at once varies from half a fluidounce to two fluidounces, and much exceeds the dose of the medicine for ordinary pur- poses. But, in this large dose, the oil is thought to be less apt to produce constitutional disturbance or irritation of the kidneys; because, acting as a cathartic, it is less apt to be absorbed. The only inconveniences usually ex- perienced are heat of stomach, some general febrile excitement, and a sense of fulness in the head; but sometimes it causes headache, vertigo, a kind of intoxication or delirium, drowsiness, &c.; and these effects will occasionally continue for several days. They are most apt to follow when the medicine fails to act as a cathartic. The oil usually operates quickly upon the bowels, and brings the worm or portions of it away dead along with it. The caution, however, should always be observed, if it do not purge in the course of two or three hours, to administer a full dose of castor oil, and to aid the action of the medicine, if necessary, by enemata. It has been recommended, in order to insure the cathartic action, to give the two oils conjointly, half a fluid- ounce of oil of turpentine being mixed with a fluidounce of castor oil, and the dose repeated in a few hours if it should fail to operate. Olive oil has been substituted for castor oil, in double the dose; but it is not to be relied on. Croton oil has sometimes been given after the oil of turpentiue; but, though powerful, it adds unnecessarily to the intestinal irritation. In order to ob- viate such irritation, it is recommended that the patient drink freely of broths or mucilaginous liquids during the use of the oil. This may be administered in milk, coffee, or some one of the aromatic waters. From the statement of Dr. Knox, who had the opportunity of treating numerous cases of tape-worm among the British troops at the Cape of Good Hope, it appears that the large doses of oil of turpentine above mentioned are not essential. He found that a drachm or two of the oil, given with a little water, morning and evening, for three days successively, was generally sufficient to destroy the worm, even in the most obstinate cases, and to cause its discharge from the bowels without the aid of purgatives; though the administration of a little castor oil, each day about noon, was deemed ad- visable. (See N. American Med. and Surg. Journ., ii. 116.) The success said to have attended upon the use of small and repeated doses of Venice 692 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. turpentine, which depends for its virtues upon the volatile oil, is confirmatory of the statement of Dr. Knox. (Hufeland's Journal, June, 1826.) A preparation known by the name of Chabert's empyreumatic oil, which obtained great reputation on the continent of Europe in the cure of tenia, owes its efficacy, in all probability, chiefly to the oil of turpentine which it contains. It is prepared by mixing together three parts of oil of turpentine and one of the empyreumatic oil of hartshorn, allowing the mixture to stand for four days, and then distilling off three-quarters of it by means of a sand- bath. The liquid should be kept in small and well-stopped bottles; as it is injured by exposure. Bremser found it a most efficacious remedy in tape- worm, having effected cures with it in more than five hundred cases. His treatment consisted in first evacuating the bowels by means of a purgative electuary, afterwards administering two teaspoonfuls of the oil in a little water, morning and evening, for several days, until about three ounces had been used, then interposing a purgative, and finally resuming the oil as at first until the cure was completed. From four to six ounces altogether are required for this purpose. Under the action of this remedy, the worm is thought by Bremser to be destroyed, and to undergo partial digestion, so that it does not come away whole from the bowels, and sometimes is not dis- coverable in the evacuations, though the cessation of the symptoms proves the efficacy of the medicine. The oil is very nauseous, and aromatic addi- tions should be made to cover its flavour. Much published testimony exists in favour of the bark of pomegranate root. The fact that a living tapeworm, introduced into a decoction of the bark, immediately evinces great suffering by its writhings and contortions, and dies in the course of five minutes, while it is capable of living several hours in pure water, is a proof that the bark is poisonous to the animal. The remedy may be administered in powder or decoction; but the latter form is usually preferred. Two ounces of the bruised bark are macerated in a quart of water for twenty-four hours, and the mixture then boiled down to a pint. A wineglassful is to be given every half hour, hour, or two hours, until the whole is taken, or a powerful action is produced. The remedy often occasions nausea and vomiting, and generally purges, and the worm comes away with the stools. It is recommended to diet the patient strictly, and give a dose of castor oil on the preceding day, and, if the decoction should not purge, to follow it with castor oil or an enema. Should the worm not be discharged at the first trial, it is recommended to repeat the remedy dady for three or four days, or until the desired effect is obtained. The root of the male fern is also a remedy which has enjoyed great repu- tation in the treatment of tape-worm. The reports in its favour are too numerous to admit of a reasonable doubt of its efficacy; but the dried root as found in our shops is probably in general nearly or quite inert, in conse- quence of long keeping; and the remedy, therefore, has obtained little credit in this country as a vermifuge. It is given in powder, or in the form of ethereal extract, sometimes called oil of fern. The dose of the former is from one to three drachms, of the latter from twenty to thirty grains, to be given in the form of electuary, and repeated morning and evening for a day or two. It is customary to follow the root by some brisk cathartic. ^ An Abyssinian product called koosso has recently attracted much atten- tion as a remedy for tape-worm; and, from the numerous reports in its favour, there can be no doubt of its great efficacy. It consists of the flowers of a tree, and is administered in the form of powder, of which half an ounce is mixed with half a pint of warm water, and given in two or three draughts at short intervals, in the morning, on an empty stomach. Should the medicine not operate in three or four hours, it should be followed by a brisk cathartic. CLASS III.] WORMS IN THE ALIMENTARY CANAL. 693 For further particulars in relation to it, the reader is referred to the U. S. Dispensatory. Dr. Kiichenmeister has performed some interesting experiments to ascertain the relative poisonous power over the two kinds of tape-worm, out of the body, of the different anthelmintics above mentioned, with the following result. A decoction of the koosso in milk destroyed the worm in half an hour; oil of turpentine mixed with the white of eggs in an hour and a half; root of the pomegranate in three hours and a half; and the ethereal extract ofthe male fern in four hours. (Arch. Gen., ie ser., xxix. 205.) Tin and Zinc, granulated or in filings, have been occasionally employed with success. In order that the worms may be exposed unprotected to their mechanical action, they should be preceded by a cathartic. The dose is some- what indefinite. Dr. Alston, beginning with an ounce in the morning on an empty stomach, administered half an ounce on each of the two succeeding days, and closed with an active purgative. Many cases have recently been reported in the journals in which pumpkin seeds have been used successfully. The dose is about two ounces, which should be taken in the morning, fasting, and followed in an hour or two by a dose of castor oil. They may be administered beaten into a paste, or in the form of emulsion. Another anthelmintic, called kameela, has recently been brought into no- tice, having been used in Hindostan with extraordinary success among the soldiers, who are there very frequently affected with the worm. It consists of the powder and hairs, brushed from the outer surface of the fruit of Bott- lera tinctoria, growing in the E. Indies. For the mode of preparing and exhibiting it, the reader is referred to the U. S. Dispensatory (11th ed., Various other remedies have been recommended. Schmucker employed powdered cevadilla in the dose of half a drachm daily, or half the quantity twice a day, interposing an occasional purge. Mare's milk is asserted to have been used with great advantage in Germany. Hufeland associated a decoction of garlic in milk with castor oil and tin filings. Wawruch used salicin in doses of from two to six grains every two hours, with advantage in some cases. Dr. S. Jackson, late of Northumberland, showed the author a portion of tape-worm ( Taenia solium) thirty feet long, which had been dis- charged by a female patient of his, upon taking a dose of castor oil, after having been, for two months, upon the use of half a fluidounce of olive oil, night and morning, to obviate constipation. Mr. AVhittel has found oxide of silver in the dose of a grain, repeated occasionally, effectual in two cases. Sometimes a portion of an unbroken worm passes out through the anus, while the remainder continues within the bowels. Caution is here requisite not to break the worm in attempting to extract it. Brera recommends that it should be tied with a piece of silk. When thus treated, though the worm may draw itself within the bowel, it begins to descend again not long after- wards Dr Cagnola proposed to touch the extruded portion with hydro- cyanic acid in the expectation that this poison would destroy the worm; and the experiment was successfully tried by Dr. Garleke. Caution, how- ever would be requisite not to incur the risk of injuring the patient Dr. Frank of St. Petersburg, succeeded in withdrawing the tenia whole, by passing the part without the bowel through a canula, and introducing this into the rectum, so as to overcome the resistance of the sphincter am. 694 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. Article VII STRICTURE OF THE RECTUM. The existence of stricture of the rectum may be suspected when there is difficulty in the evacuation of the bowels, with straining, and the discharge of the feces in portions of diminished size and altered shape, either flattened like ribbons, or in worm-like cylinders, straight or spirally twisted, or in small dis- tinct lumps. If an examination be now made, and resistance offered to the passage of the finger or a large bougie up the rectum, the suspicion will be confirmed. The stricture may depend on thickening or other organic de- rangement of the coats of the bowels, or upon spasmodic muscular contrac- tion. These two conditions require a separate consideration. 1. Organic Stricture.—In this form, which is the most frequent, the diffi- culty of expelling the feces comes on almost imperceptibly, and increases gradually, until it becomes a source of great inconvenience. When the affec- tion is considerably advanced, there is usually obstinate constipation, with severe and painful efforts to procure evacuations, and often nothing for some time but bloody or mucous passages; though occasionally, from the irritation produced by purgatives, or by the accumulated fecal matter, a looseness sets in which yields temporary relief. All the morbid effects enumerated under the head of constipation are experienced in this affection. The stricture may remain for an indefinite time in this condition, or it may go on increasing until the passage is nearly or quite closed, and positive obstruction ensues. (See Obstruction of the Bowels.) Death is now inevitable unless from the interference of art, or unless nature, as sometimes happens, creates a new opening for the escape of the feces by means of ulceration. The organic derangement which constitutes the stricture may be of a car- cinomatous character, or it may be entirely destitute of malignancy ; and it is important that the two states should be properly distinguished; as the means which may be found useful in the one, are generally useless if not injurious in the other. In the carcinomatous or cancerous stricture, there is severe lancinating pain, which usually extends down the thighs; and the part affected, if in the scirrhous state, is usually unequal to the touch, and of an almost cartilagin- ous hardness. In the advanced stages, after ulceration has commenced, there is an ichorous discharge of an offensive and peculiar odour, characteristic of cancer wherever met with, and occasional exhausting hemorrhages. To the finger the diseased structure now offers ulcerated surfaces, with hard inverted or everted edges, and prominent friable granulations. The patient has also in general a peculiar cachectic aspect, with a pale waxen or leaden skin, cedema of the extremities, and a very painful and wan expression of countenance, con- sequent upon his protracted sufferings. When the complaint is beyond the reach of the finger, it may, for the most part, be recognized by the odour of the sanious stools, the lancinating and persevering pains, and the cachectic appearance just alluded to. The disease sometimes affects a small portion of the bowel, occupying either one side or the whole circumference, or more rarely projecting in the form of a tumour into the cavity. In other instances, it extends over a large portion or the whole of the rectum, which is unequally thickened and hardened, with a small winding passage through it, and offering to the finger nothing but hard tubercles, or bleeding friable ulcers. Cancer of the rectum is not uniformly attended with obstinate constipation; and the degree of this affection varies with the extent and position of the induration, CLASS III.] STRICTURE OF THE RECTUM. 695 being greater when the whole circumference of the bowel is affected, than when the disease occupies only one side of it. In the ulcerative stage, in- stead of constipation there is often an exhausting diarrhoea. In the carcino- matous stricture art can afford little relief. Bougies and caustics have some- times been employed to open or enlarge the passage ; but they are justifiable only when the danger of death from obstruction is imminent. The same may be said of the attempts to break or tear away portions of the diseased mass, which have been resorted to for similar purposes. The only chance of cure is afforded by the extirpation of the diseased structure, which is very rarely possible, without great clanger. Scirrhus occupying only the anal extremity has sometimes been successfully removed by the knife, and tumours supposed to be scirrhous have been separated by a ligature. The ordinary, non-malignant, organic stricture is distinguished by the absence of the symptoms above described as characteristic of the cancerous. It usually depends upon a thickening of the submucous cellular tissue, conse- quent probably upon inflammation. This may occupy a considerable extent of the bowel, and its whole circumference, or may be confined to a small part of it, and to one side. Sometimes it consists of a sort of crescentic cord, pro- jecting from the side of the rectum, sometimes of a partition extending in a greater or less degree across it, and again of a transverse network of filaments. It may be seated in any part of the bowel, but is most commonly found about two or three inches above the anus. Instances have occurred in which the feces, accumulated above the stricture, have by their pressure produced ulcer- ation, and thus made their way outward by a new passage. Such a passage has been made around the stricture into the portion of the bowel beneath it, into the bladder, and into the vagina; the feces escaping in the first case per anum, in the second with the urine, and in the third from the vulva. In such instances, the relief obtained is usually but temporary; the patient being at length worn out by the continued irritation and discharge. Anything may operate as a cause of this stricture, which is capable of pro- ducing chronic inflammation in the coats of the bowel. It is occasionally, perhaps, ascribable to venereal infection. Polypus of the rectum may produce the symptoms of stricture; but the affection is so purely surgical that I shall not treat of it here. Stricture is in general amenable to treatment. The passages should be kept soft and unirritating by a proper attention to diet, and by the use of laxatives, especially those of a saline character. But the chief means of cure consists in the use of the bougie, which should be introduced daily, and gradually in- creased in size as the passage becomes enlarged. In some instances, the bis- toury may be advantageously resorted to, especially when the stricture con- sists of a thin partition, and the symptoms of obstruction are threatening. In the circular stricture, which is usually seated about one-quarter or one-third of an inch above the anus, M. Robert prefers the use of the Vienna caustic (potassa with lime), which may be applied by means of a speculum. (See Am. Journ. of Med. Sci., N. S., xix. 512.) In cases where there is no alternative between death and the formation of an artificial anus, it is recommended by Amussat to make an opening into the colon, on the left side posteriorly, where it is not covered by the peritoneum; and the operation has been per- formed with success. (Diet, de Med., xxvii. 303.) 2. Spasmodic Stricture of the Bectum.—In this form of stricture there is the same difficulty in evacuating the bowels, and the same lessened dimen- sions, and altered shape of the fecal cylinder; but these symptoms are not constant; and the feces will occasionally be found of the natural size. One of the characteristic signs is a feeling of constriction before or at the time of going to stool, and an occasional severe spasmodic pain, especially upon the 696 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. application of an irritant. The introduction of a bougie will be resisted at one time, while at another, the instrument may pass with little or no difficulty. The stricture sometimes exists at the anal extremity of the rectum, depending on a spasmodic contraction of the internal or external sphincter, or both. It is then characterized by great difficulty in introducing the finger or an instru- ment through the anus, while, above the internal sphincter, the bowel may be quite relaxed. There is the same difficulty in passing the feces as in the other cases; and, after the evacuation, the patient experiences considerable pain for some time. From the great straining, the affection is apt to be attended with hemorrhoidal tumours. Spasmodic stricture is more apt to attack the young than the old, and is not commonly attended with that ca- chectic aspect, or general failure of health, which frequently marks the per- manent organic affection. This form of stricture may result from a peculiar irritability of the rectum; from disorder in the spinal marrow, or neighbouring pelvic viscera, which may radiate irritation to this bowel; or from a morbid excitability of the nervous system in general, such as occurs in hysterical or hypochondriacal individuals. The exciting cause may be anything capable of directly irritating the rectum, as hardened feces, vitiated bile, or acid in the bowels; or, in cases dependent upon the state of the general health, anything calculated to produce disorder in the nervous functions. The indications in the treatment are, 1. to remove or prevent sources of direct irritation to the rectum; 2. to produce a relaxation of the spasm; 3. to diminish the morbid irritability of the bowel; 4. to remove any existing spi- nal disorder, and 5. to correct the morbid condition of the nervous system when this is in fault. To meet the first indication, the feces should be kept in a soft state by the use of a mild laxative diet, aided, if necessary, by the most unirritating laxative medicines, such as sulphur and the saline aperients; the biliary secretion, if deranged, should be corrected, and acid in the bowels neutralized; and all acrid or drastic cathartics, and especially aloes, should be carefully avoided. To produce relaxation of the spasm, recourse may be had to enemata of opium, belladonna, camphor, assafetida, and cold water, and to the use of the warm bath or semicupium. The bougie, frequently in- troduced, will sometimes be found useful by diminishing the irritability of the rectum; but, if this condition be connected with inflammation, leeches to the anus will be a more appropriate remedy. Spinal disorder should be encoun- tered by leeches, and rubefacient, vesicatory, or pustulating applications. Finally, the morbid state of the nervous system is to be corrected by tonics, exercise, a regulated diet, proper mental occupation, and the occasional use of the nervous stimulants, as valerian and assafetida. In women, attention should be paid to the condition of the uterus, as disorder of this organ may operate injuriously upon the affection, not only by deranging the condition of the nervous system generally, but by transmitting a sympathetic irritation directly to the rectum; and the same remark is applicable to diseases of the genital organs in men, and of the urinary apparatus in both sexes. Article VIII HEMORRHOIDS, or PILES. This term has been applied both to hemorrhages from the rectum, and to certain tumours which form in and about the anus. In the former case, whether the hemorrhage is or is not accompanied with tumours, the affection CLASS III.] HEMORRHOIDS. 697 is called bleeding piles; in the latter, when unconnected with any discharge, blind piles. The tumours are also distinguished into internal piles, which are within the sphincter ani, and external piles, which are without the sphinc- ter. I shall pay little attention to these distinctions in the following remarks. Simple bleeding from the rectum, independent of tumours, though it may proceed from the same pathological condition as that which gives rise to the tumours, falls properly among the hemorrhages, and will be considered with them. I shall here speak of the hemorrhage only as an attendant or result of the tumours. Two distinct ingredients often enter into the composition of the hemor- rhoidal disease; 1. a peculiar constitutional disturbance which determines irritation and congestion of the rectum, and 2. tumours at the extremity of the bowel. The two may exist separately—the former occasionally running its course without resulting in tumours, the latter often originating in purely local causes; but they are very generally more or less associated. I distin- guish the one by the name of the hemorrhoidal effort, the other by that of hemorrhoidal tumours, or simply hemorrhoids. The hemorrhoidal effort is frequently marked by certain symptoms of constitutional disorder, preceding or attending those of irritation or conges- tion of the rectum. Of the former are general uneasiness, mental dejection, or irritability, languor, uncomfortable sensations in the head, pain in the loins, dyspeptic feelings, constipation, and colicky pains; of the latter, a feeling of weight or tension in the region of the sacrum, heat about the anus, sometimes pains in these parts extending to the neighbouring pelvic viscera and to the lower extremities, a sensation of fulness in the lower portion of the rectum, and a disposition to go to stool, with little or no evacuation. This condition continues for three or four days, and then subsides spontane- ously or under treatment, to return under various excitements, and some- times periodically, without any known cause, at intervals of weeks, months, or years. It is sometimes relieved by hemorrhage, sometimes passes off without either this or the production of hemorrhoidal swellings, but most frequently either accompanies or produces tumours, and, if these have ex- isted previously, provokes them into irritation or inflammation. Hemorrhoidal tumours are not entirely identical in character. The follow- ing varieties may be distinguished. 1. The simplest form is that of varicose hemorrhoidal veins, consisting in a mere distension of the coats of the vessel, as in varicose veins of the leg. The same vessels are affected in the external and the internal piles, the veins above and below the sphincter being contin- uous, and not suffering dilatation in general at the sphincter, because com- pressed by that muscle. In their simplest state these tumours are full of liquid blood, and may be readily evacuated by pressure, to be filled again im- mediately upon the removal of the pressure. After death they frequently disappear entirely, but may be rendered evident by injecting the inferior mesenteric vein. 2. The varicose tumours, in consequence of inflammation, or from rupture and resulting effusion of blood, undergo various changes. By inflammation their coats are thickened, coagulable lymph is effused into the neighbouring tissue, with which adhesions are contracted, the communi- cation between the varix and the venous trunk is closed, and the blood within coagulates. By rupture, the blood escapes, and, being diffused in the cellular tissue, or forming a distinct cavity for itself either in the substance of the tissue, or between it and the mucous membrane, coagulates, and excites in- flammation and consequent effusion of lymph in the contiguous parts. In either of these cases, a solid, vascular, hard, or more or less spongy tumour results, which, upon being opened, often discloses a clot of blood in its centre, thus showing its mode of production. 3. Instead of being varicose, the tu- 698 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. mours sometimes consist of a sort of erectile tissue, which may be supposed to be formed by the opening of communications between contiguous venous and arterial radicals, and between both and the cellular tissue, which assumes a denser and firmer character, exhibiting numerous interlacing fibres. 4. Fleshy tumours may originate from the altered varices described above, by the organization of the coagulated blood in their centre, or its absorption and the deposition of organizable lymph ; or they may be produced, as Burne suggests, by a circumscribed thickening of the submucous cellular tis- sue, which, thus projecting somewhat into the cavity of the rectum, is carried down during defecation, and, being arrested by the contraction ofthe sphinc- ter, becomes inflamed and enlarged, so as not to admit of return. 5. Tu- mours formed in any of the above modes may, by the influence of adhesive inflammation and subsequent absorption, be converted into dry, hard, indo- lent, wart-like projections in or near the anus; and, even though originating under the mucous membrane, may be covered with skin, in consequence of a not unfrequent transformation of that membrane, when prolapsed and ex- posed long to the air. Another sequela of the proper hemorrhoids consists in folds of the mucous membrane or skin in or near the anus, resulting from the absorption of the contents of previous tumours. Symptoms and Course of Hemorrhoids.—The patient experiences a feel- ing of heat, fulness, and dull pain about the sacrum and anus, radiating more or less to surrounding parts. This continues for a few days, disappears, and again returns; and the event may occur several times without attracting much attention. At length the patient becomes conscious of a swelling, or asensation as if a foreign body were in the anus or above it, and, applying his finger after an evacuation, discovers a small tumour of the size of a pea or larger, which either remains perceptible or retires, according as it origi- nated without or within the sphincter. In other instances, the tumour appears to be formed suddenly in consequence of severe straining at stool. It is covered by the mucous membrane of the rectum, or, if external, partly by this and partly by the neighbouring skin, which is generally movable over it. The little tumour gradually increases; others form around it, occasionally clustering like a bunch of grapes; and a mass at length results, often as large as a pigeon's egg, and sometimes much larger. The progress, how- ever, of the tumour is not uniform. During the periods of hemorrhoidal congestion, it increases most rapidly, acquiring an augmented volume at each successive period, though diminishing and sometimes almost disappearing in the intervals. In its ordinary uninflamed state, the tumour has little sensi- bility, but, when inflamed or strangulated by the sphincter, it becomes the seat of burning, stinging, and otherwise very painful sensations, is often ex- quisitely tender to the touch, and renders defecation difficult, and sometimes exceedingly distressing. Shooting pains extend from it to the back, down the thighs, and to the viscera of the pelvis; irritation is sometimes radiated to the prostate gland, bladder, and uterus; and difficult micturition is not unfrequently produced. Sometimes the patient can neither stand, walk, nor sit with comfort, and finds the horizontal position the only one tolerable.' The phenomena of piles are somewhat different, according as they are ex- ternal or internal. In the external piles, a tumour is observed on the verge of the anus, of greater or less extent, sometimes on one side only of the aperture, sometimes completely surrounding it, and in the latter case usually presenting an unequal outline, as if consisting of several tumours separated by shallow furrows. The consistence and colour of the tumour vary accord- ing to its character. If varicose, it is of a violet colour, soft, and more or less removable by pressure; if fleshy, it is red, solid, firm, and elastic. It has usually a broad base; and the fleshy tumour is often elongated from before CLASS III.] HEMORRHOIDS. 699 backward, in consequence of being pressed on each side by the buttocks. When inflamed, these piles are peculiarly inconvenient by interfering with exercise in almost every way, and even with sitting. The internal piles are attended with a sense of distension which provokes a constant disposition to go to stool, and are peculiarly painful during the act of defecation. At first, though they are apt to descend at each evacuation, they usually return spontaneously when the straining ceases; but, after having acquired a cer- tain magnitude, they can be restored to their position within the sphincter, after protrusion, only by the aid of the finger of the patient. When without the sphincter, they are rendered very painful by its contraction, but become comparatively easy when returned. After a time they descend when the patient walks or stands, especially if the rectum is full, and great inconve- nience is experienced from the irritation and excoriation to which they are subjected. When thus extruded, they are sometimes strangulated by the sphincter, and become in consequence so much inflamed and swollen, that the patient cannot himself restore them, and even the surgeon finds con- siderable difficulty. Occasionally, in this condition, they burst, and by the discharge of blood are so much diminished and relieved, as to admit of easy reduction. In other cases, they swell enormously, become gangrenous, and, after having occasioned vast suffering and inconvenience to the patient, slough off, and terminate finally in a radical cure. There are the same dif- ferences in colour and consistence in the internal as in the external piles. The fleshy tumours are sometimes narrow at the base, and bear no incon- siderable resemblance to polypi of the rectum. Both internal and external piles occasionally suppurate, forming abscesses or ulcers, which are often very troublesome, ending sometimes in the estab- lishment of fistula?, though in other cases they eventuate more favourably, and even lead to a permanent cure. More or less hemorrhage often attends defecation, the blood proceeding either from the abraded mucous coat, or from a rupture of the tumour, or from an oozing over its whole surface in an inflamed state. In general the bleeding is very slight, not more than sufficient to tinge the feces. But it is sometimes copious, and in a few comparatively rare cases, very much so, producing by its frequent returns, and the quantity discharged at each time, an alarming and dangerous anemic condition of the patient. Some individuals are liable to periodical attacks of this hemorrhage, corresponding probably with the periodical returns of the hemorrhoidal congestion; and it is not always easy to decide, whether the bleeding is or is not connected with the tumours. The blood sometimes collects in large quantities in the rectum before being discharged. It is in some instances venous, in others arterial; being of the former character probably when proceeding from a ruptured tumour, and of the latter when from other sources. During the discharge of the feces, fissures are sometimes produced in the mucous coat around the anus, which afterwards bleed at each evacuation, and become occasionally so tender as to render the act of defecation almost insupportable. In consequence of chronic inflammation of the hemorrhoidal tumours, and of the neighbouring mucous membrane, a discharge of whitish mucus some- times occurs, which was formerly distinguished by the name of white piles, or anal leucorrhoea. Among the local consequences of piles is sometimes a thickening of the lower part of the rectum, resulting from repeated inflammation, which forms a sort of stricture, and very much interferes with the discharge of the feces. The general health often suffers much from long-continued and aggravated piles. Preventing exercise, and rendering necessary an almost constant use 700 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. of medicines which interfere more or less with digestion, they lead to the pro- duction of dyspepsia with its train of evils, and, besides, call various organs into a direct sympathy, which cannot but impair their functions. Paleness, emaciation, and mental irritability or dejection, or at least a very uncertain condition of the feelings, are among their frequent concomitants; and dropsy sometimes results from the anemic state of the blood. Diagnosis.—The complaints with which piles are most likely to be con- founded, are polypus of the rectum, and prolapsus ani. It is, however, only the solid and firm hemorrhoidal tumours that resemble polypus. They may be distinguished by the firmer consistence of polypus, and by its gradual and steady development, without the periodical congestions, and alternate in- crease and diminution which characterize piles. The latter, moreover, gene- rally have a broad base, while the polypus is joined to the mucous membrane by a sort of peduncle; but this is not a certain criterion; as the two condi- tions are sometimes reversed. Piles are usually distinguishable from pro- lapsus by their colour, their distension and compressibility, and their greater or less irregularity, even when forming a ring about the anus. Syphilitic tumours may sometimes be confounded with fleshy piles; but they differ in the circumstances of their origin, and in their uninterrupted progress. There is no doubt, I think, that what are called internal piles, are in many instances, perhaps in most, merely prolapsus of a fold of the mucous membrane of the rectum, which, being forced down by frequent straining, and irritated by this cause, and by the contracting sphincter, becomes inflamed and thick- ened, and at last presents the hypertrophied vascular tissue, so frequently protruded during defecation. It is highly probable, moreover, that the two affections are often mixed; the varicose or proper hemorrhoidal tumours existing conjointly with the thickened and protruded membrane. Causes.—These are such as either produce congestion in the rectum, or act with an immediate mechanical violence upon its lower extremity. The former may be constitutional or local. Among the constitutional, the most common is probably a plethoric state ofthe blood-vessels, induced by a rich, nutritious, and stimulating diet, or simple excess in eating, conjoined with sedentary habits. Gouty and rheumatic irritation sometimes shows itself in a congested state of the hemorrhoidal vessels. The suppression of habitual discharges, such as that of the menses, sometimes leads to the same result. Hereditary predisposition has also been considered as one of the remote causes of piles, and there can be little doubt that a peculiarity of constitution favourable to this disease occasionally descends from the parent to the off- spring. Of the local causes, those are most efficient which by any means tend to check the return of blood from the hemorrhoidal veins. Torpidity and congestion of the liver often occasion piles, by impeding the return of the blood of the portal circulation through the capillaries of that organ; and hepatic induration or enlargement may have the same effect, either in the same way, or by narrowing the ascending vena cava. Pregnancy, and a long continuance in the erect position, the former by mechanical pressure upon the returning veins, the latter by the effect of gravitation, often cause a dis- tension of the hemorrhoidal vessels that results in piles. To the above list may be added all causes of irritation of the rectum, whether direct or indi- rect, such as acrid purgatives and especially aloes, irritating injections, the frequent use of suppositories, acrid alvine evacuations, ascarides, violent jolt- ing on horseback, dysentery, inflammation of the prostate or of any of the pelvic viscera, and venereal excesses. The causes which act by mechanical violence are long and severe straining at stool, and the difficult passage of hard fecal matter through the anus. But piles probably have their origin more frequently in constipation of the bowels than in any other source. This CLASS III.] HEMORRHOIDS. 701 operates in various ways in producing them, but chiefly by the pressure of the accumulated and hardened feces upon the returning veins, and by the straining, violent compression, irritation, and even laceration they occasion during their evacuation. Piles are very rare before the age of puberty, and are most common be- tween the thirtieth and fiftieth year. Males are more subject to them than females, if we except pregnant women, in whom they are very frequent. Treatment.—In relation to the treatment of piles, it is proper first to con- sider what effect their cure may have upon the general health, and how far we may venture upon their removal with safety. They have been considered as an outlet through which various morbid tendencies are allowed to expend themselves, and the premature closure of which might bring these tendencies into injurious action elsewhere. There can be little doubt that this opinion is in some degree true. The hemorrhoidal effort depends on a general dis- ordered condition, which, if not directed to the rectum, would find some other point upon which to expend its force. This is the case whether the piles are, or are not attended with a discharge of blood. But, when bleeding from the hemorrhoidal tumours has been frequent, long continued, and con- siderable, there is the additional consideration, that the system has in some measure accommodated itself to these discharges, and, in order to supply the loss, has acquired the habit of elaborating blood more rapidly, so that the danger of plethora from their arrest would be superadded to that of the mor- bid tendency in which the piles originated. The complaints which are most to be feared from the cure of piles are apoplexy and pulmonary hemorrhage; and, when a predisposition to these affections is known to exist, it should always be allowed to have some weight in the decision of the practical ques- tion. But, as piles themselves, when severe, sometimes materially interfere with the general health, it is necessary to weigh carefully the opposing con- siderations, and to strike the balance between them. Should the danger of the very serious complaints, above alluded to, seem to outweigh the inconve- nience of the hemorrhoidal affection, and its direct injurious influence on the health, it will be better to confine our efforts to the alleviation of the symp- toms than to attempt a radical cure; and, in cases in which the latter course is pursued, the propriety is obvious of counteracting the morbid tendencies by a proper regulation of the diet, and the use of suitable depletory or revul- sive means, as bleeding, saline purgatives, and blisters or issues. In all instances, however, where the hemorrhoids are purely a local affection, they cannot be treated too promptly, and the number of cases is comparatively few, in which, though connected with some constitutional derangement, they . may not be removed with safety, if care be taken to obviate the possible evil by suitable precautionary measures. So far as the treatment is directed to the removal of the causes, it may be carried into effect without the least hesitation. In the medical treatment of piles, the first object is to remove the causes. Attention should, therefore, be paid to the condition of the system; and any existing plethora or general excitement, which may act as a predisposing cause, should be corrected by saline cathartics, and an antiphlogistic regi- men. One or two doses of sulphate of magnesia, and a diet exclusively of vegetable food, will often be sufficient to relieve that hemorrhoidal effort of system, and consequent congestion of the rectum, which lead to a paroxysm of piles. In some cases, it may be proper also to take blood from the arm, but this necessity very rarely occurs. As constipation is the most productive cause of piles, so is its removal the most important indication; and the complaint may often be effectually cured by keeping the bowels regularly open, and the feculent discharges in a soft unirritating condition. This is best done by a proper regulation of the diet, 702 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. and by the use of mild laxatives. (See Constipation.) Among the best of these are confection of senna, and sulphur, which may be given separately or together, and may be usefully combined with bitartrate of potassa when the tumours are inflamed. The laxative may be given at bedtime so as to ope- rate gently in the morning, or, as suggested by Burne, a short time before dinner so as to operate before bedtime, and thus allow the parts irritated by the evacuation to become quieted during the night. As a general rule, how- ever, I prefer the former course; as the weight and pressure of the feces upon the rectum through the day, which is the result of the evening evacua- tion, are often more inconvenient than the mere irritation produced by the act of defecation, provided the feces be kept in a perfectly soft, almost semi- liquid state by the laxatives employed. It will sometimes be preferable to administer a quick saline cathartic, in small doses, about an hour before breakfast. The laxative mineral waters, and the Cheltenham salt, may thus be advantageously given, and will generally operate very mildly a short time after breakfast. In connection with the use of laxatives, attention should be paid to the correction of those habits of the patient which tend to produce and maintain the disease. High-seasoned food, alcoholic drinks, and strong coffee should be avoided; moderate exercise should be taken both on foot and on horseback; the patient should not sit habitually on soft cushions, nor sleep too warmly in feather beds; the use of acrid purgatives, especially those containing aloes, of warm emollient or stimulating enemata, and of the warm hip-bath, should be discouraged ; and care should be taken to correct torpor or congestion of the liver, if this be one of the complications. Acrid secretions should be removed by castor oil, and acid in the bowels by magnesia. Irritations in the bowels or neighbouring pelvic viscera should be corrected if possible, and practices carefully shunned which tend to produce such irritations. While removing the causes of piles, we may also advantageously direct our remedies immediately to the seat of disease. One of the most efficacious means of cure is the injection daily, after the bowels have been evacuated, of half a pint or more of cold water into the rectum ; and, by a perseverance in this plan for several months, with laxatives if required, cures have been effected even in very unpromising cases. Care should be taken not to irri- tate the rectum by an unskilful introduction of the pipe. Sponging the anus with cold water every morning and evening will also be found useful. Should the tumours be inflamed, rest in a horizontal posture, with lotions of cold water, or lead-water; and, when the pain is very severe, liniments, • ointments, or cataplasms containing opium, hyoscyamus, belladonna, or stra- monium, or decoctions of poppy heads or hops, should be employed. These anodyne applications are not only useful by allaying pain, but contribute to a cure by obviating the tenesmus and straining, which tend so strongly to sus- tain and aggravate the complaint. But caution is necessary, in their appli- cation, not to allow them too powerfully to affect the system. When the tumours are highly inflamed, and severe pains shoot to the neighbouring parts, leeches, or cups to the sacrum are useful. The application of the leeches directly to the tumour is not advisable ; as the inflammation from the bite may be more injurious than the depletion is beneficial. In the proper varicose tumours, punctures with the lancet so as to evacuate the blood they contain, have been recommended; but the use of needles is preferable, as they answer the purpose of relieving the distended varices, without the risk of inflammation. When the inflammation is not acute, benefit may sometimes be obtained from astringent applications. Ointment of galls with opium may be used when the tumours are external; decoction of galls or oak bark, or infusion of catechu or kino, when they are internal. If the internal piles CLASS III.] HEMORRHOIDS. 703 have protruded, and do not return of themselves, and cannot be returned by the patient, the practitioner must endeavour to reduce them by placing the patient on his hands and knees, anointing the parts well with unctuous matter, then making gentle and uniform pressure so as to force out the blood, and, lastly, introducing by his hands the diminished tumour within the sphincter. Should he not succeed by these means, he may apply cold water to the part in order to produce contraction, or let out the blood by means of needles or a lancet, and then restore the piles. In cases where strangulation and gangrene have taken place, poultices with laudanum should be applied locally, and the patient kept under the influence of opiates, with wine, quinia, and a nutritious diet, if necessary to support his strength. When the hemorrhage is so copious as to require treatment, if it be acute, the patient should lie on his back, cold water should be injected into the rec- tum, and applied externally, and nitre with antimonials, or acetate of lead given by the mouth. If these measures fail, a solution of alum or a strong vegetable astringent infusion, or the two combined, may be used in the form of enema. In more chronic cases, the same astringents may be employed, and recourse may at the same time be had to the internal use of oil of tur- pentine, in the dose of from fifteen to thirty drops three or four times a day, or of copaiba in the same dose, or of ergot to the amount of two scruples or a drachm daily in divided doses. The oil of turpentine has been especially praised in obstinate cases of hemorrhoidal flux. Aloes has been highly re- commended, and may prove useful, in some cases of passive hemorrhage, by . stimulating the rectum. Copious mucous, or muco-purulent discharges may be treated, if acute, simply as inflammation, if chronic, by injections of acetate of lead, sulphate of zinc, or astringent infusions or decoctions. Numerous remedies, besides those already mentioned, have obtained more or less credit in the treatment of habitual piles. Linseed oil, given in the dose of two fluidounces every morning and evening, is said to have rapidly effect- ed cures. (See Am. Journ. of Pharm., xxiii. 87.) The confection of black pepper of the British Pharmacopoeias, made in imitation of Ward's paste, wliich formerly had a very great reputation as a remedy in piles, is highly recommended by Brodie and others. It is given in the dose of a drachm twice or three times a day, and should be continued for two, three, or four months. It probably acts by stimulating the mucous membrane of the rec- tum, as it passes out with the feces, and should not be given during acute inflammation of the parts. Sir Everard Home found it very efficacious, when introduced directly into the rectum. Its employment should be accom- panied with the use of laxatives. Powdered cubebs taken internally, in the dose of a scruple or half a drachm three times a day, has proved useful, probably in the same way. Copaiba, in the quantity of from twenty to forty drops, once or twice a day, was recommended by Dr. Cullen. It pro- bably acts both by its laxative and stimulant properties. Another remedy, which appears to operate in the same manner, is black pitch. Dr. Wardle- worth found it highly efficacious in numerous cases, in the quantity of six grains given in two pills every night. (Lond. Lancet, Aug. 27, 1842.) Even aloes, the abuse of which is thought to be a common cause of hemorrhoids, will prove useful, by its irritant and laxative action, in some cases of piles dependent upon relaxation of the hemorrhoidal vessels. A tincture of aloes and anise, given in such quantities as to produce several soft stools daily, was found highly efficacious by Drs. Pindell and Crockett, of Lexington, Kentucky. (N Am. Med. and Surg. Journ., iii. 193.) Burne recommends an ointment made with a drachm of black hellebore and an ounce of lard, 704 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. applied morning and evening to the parts affected. The pain is much in- creased at first, but in the course of half an hour is greatly diminished or disappears. (Diet, de Med., xv. 211.) Dr. Symonds has known great benefit to result from the assiduous use of citrine ointment properly diluted. ( Twee- die's Syst. of Pract. Med.) Dr. Good states that the tumours, when not very sore, will often yield to a layer of gypsum, or fuller's earth, rubbed into a soft paste. Bougies are extolled by different authors; and radical cures are asserted to have been frequently obtained by their means. They are par- ticularly useful in cases attended with rigid contraction of the sphincter ani. They should be very smooth, and of different sizes, so as to be accommodated to the different circumstances of the case. In some instances, where there is a great tendency to prolapsus of internal piles, advantage may be obtained from the support of a spring pad, connected behind with an elastic belt, or from a compress and bandage. When other means fail, and the health of the patient suffers, or the incon- venience of the tumours is very great, recourse may be had to their extirpa- tion, either by the knife or ligature, or by both united. The evacuation of the tumours by incision, or by the removal of a portion of their summit by the bistoury or a pair of bent scissors, and their destruction by different caustics or the actual cautery, are modes of cure which have had their advocates. But this branch of the subject belongs properly to the surgeon. Nitric acid, applied with a view to its caustic effect, has recently been highly recom- mended. (See Lond. Med. Times and Gaz. April, 1853, p. 343, and Aug. 1854, p. 184.) Should the cure of piles be found to have occasioned any serious injury to the health, endeavours should be made to restore the hemorrhoidal disease by aloetic purgatives, irritating injections, and the use of the warm hip-bath. Article IX. FISSURES OF THE ANUS. Ulcers in and near the anus occur from various causes, as from the abra- sion or tearing of the parts during difficult defecation in hemorrhoids, stric- ture, obstinate constipation, &c, from violence proceeding from some external cause, from venereal infection, and from inflammation; and these ulcers are sometimes very inconvenient from their discharge, and the pain they occasion at the time of going to stool; but they generally yield without much difficulty to suitable remedies, and are a subject rather for surgical than medical treat- ment. But there is a particular form of ulceration, to which the name of fissure of the anus has been applied, which requires a brief notice. The ulcer, in these cases, is situated between the folds of the skin or mu- cous membrane at the anus, and probably owes its exceeding severity and obstinacy to the circumstance that it is embraced by the sphincter muscles, and is therefore liable to constant injury from their movements. It runs in the direction of the rectum, is narrow and elongated, being a line or two in breadth, and from four to ten lines in length, and is generally of a lively-red colour, without much swelling and induration, not unlike the crevices which sometimes occur in the lower lip of those much exposed to the cold in winter. It may occupy any part of the circumference of the anus, and is somewhat differently placed in relation to its length, being sometimes so low as scarcely to reach the mucous membrane at its upper extremity, and sometimes so high as not to reach the skin at its lower. A slight oozing of liquid takes place CLASS III.] FISSURES OF THE ANUS. 705 from its surface, and the feces, when discharged, are occasionally streaked with blood; but neither of these phenomena is constant. At the commencement, the symptoms are not usually very severe. A sense of itching, tingling, heat, and sometimes pain, is experienced during and after a stool, which gradually increases, and at length becomes very distressing; but months or even years may pass before the complaint reaches its greatest height. In some instances, however, the painful symptoms occur at the beginning. When the disease is completely formed, there is felt, whenever the patient goes to stool, a violent burning or rending pain, which sometimes amounts to insupportable agony, giving rise even to syncope or convulsions. This con- tinues for some time after defecation; but at length subsides, leaving only soreness, or occasional lancinating pains, which are quite tolerable. So great is the suffering of the patient during the passage of the feces, that he dreads the recurrence of the act, and is apt to postpone it as long as possible, though he thereby increases the difficulty when the time for an evacuation arrives. The pain is most severe when the feces are hard; but it is by no means entirely avoided by keeping them in a liquid state. In some cases, the suffer- ing at length continues in the intervals of defecation, so that the patient is compelled to keep his bed ; acute pains shooting from the anus to other parts of the pelvis, and the tenderness of the parts being so great that the least effort which causes pressure on the bowels, as the act of coughing or even spitting, produces great uneasiness. The introduction of the finger or an instrument into the anus occasions exquisite pain; and there is almost always great difficulty in introducing the finger, in consequence of a spas- modic contraction of the sphincters, which is considered by some an essen- tial part of the complaint. Fissure of the anus is apt to be mistaken by the patient and his attendant for piles, prolapsus, stricture, disease of the bladder or prostate, or for cancer; but a careful examination of the parts will reveal its nature. The ulcer gene- rally becomes visible between the folds of skin at the anus by separating them; but if not, the patient should be induced to protrude the anus, as in the act of defecation, so as to bring it within view. If too high up to be seen, the finger introduced into the anus will detect it by the exquisite pain produced by pressure upon a particular part, and by a peculiar sensation communicated to the finger by that part, though any considerable induration or thickening is seldom or never present. The disease has no tendency to spontaneous cure, and in general goes on indefinitely unless arrested by proper treatment. It has been asserted, how- ever, that, when above or below the sphincters, the ulcers heal rapidly upon suitable applications, like other sores; and that peculiar obstinacy is expe- rienced only when they are embraced by those muscles. This statement, though not perhaps sufficiently supported by facts, is highly probable; and the mode of cure found most effectual tends to confirm the view, that the con- traction of the sphincters constitutes the chief source of difficulty. Unless arrested, the disease at length affects the general health, dyspepsia and ema- ciation occur, and the patient is worn out by complicated derangements. Causes.—The idea has been entertained that this affection is of a peculiar character, and owes its origin to some peculiar and unknown cause. The probability, however, is, that it may arise from any cause capable of irritating or mechanically injuring the part affected ; and that it is peculiar only from its situation within the limits of the sphincter muscles, which render the ulcers irritable and indisposed to heal, in consequence of incessant disturbance. Treatment.—The measures ordinarily found useful in ulcerative affections generally produce, in fissures of the anus, no other advantage than some alle- viation of the symptoms. Gentle saline purgatives, with a mild laxative diet, vol. i. 45 706 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. prove beneficial partly by keeping the feces in a liquid state, and thus pre- venting mechanical injury in their passage, and partly by obviating any irritant effect from over-excitement. Anodyne and emollient enemata also sometimes afford relief. Boyer employed a mixture consisting of equal parts of lard, juice of houseleek, juice of black nightshade, and almond oil, injected in the quantity of a few tablespoonfuls two or three times a day into the rec- tum. (Diet, de Med.) But this can act only as a soothing application. Dupuytren found great advantage from the extracts of belladonna and stra- monium. He employed an ointment made by rubbing together a drachm of extract of belladonna, a drachm of acetate of lead, and six drachms of lard, a portion being applied several times a day, spread upon a tent, which was small at first, and gradually increased to the size of the index finger. (Am. Cyc. of Pract. Med. and Surg., ii. 121.) M. Bretonneau, of Tours, used with great success injections of extract and tincture of rhatany. His plan was to administer every day an injection of cold water, and, after this had come away, another composed of a drachm and a half of extract of rhatany, half a drachm of the tincture, and five fluidounces of water. Improvement was generally experienced at the end of a week or sooner, and a cure often accomplished in two or three weeks. (Med. Exam., iii. 552.) Dr. W. P. Johnston, of Philadelphia, employed the same remedy with success. (Ibid., iv. 293.) It is probable that kino, catechu, or other astringent extracts, would answer the same purpose. M. Deday recommends tannic acid, mixed with fifteen parts of lard, to be applied by the finger to the fissures, or, when they are situated high up, a solution of the same substance to be in- jected. (Ann. de Therap., 1847, p. 170.) Beclard applied nitrate of silver to the ulcers with almost uniform success; but others have been less fortunate. (Diet, de Med., iii. 300.) Dilatation by means of tents is strongly recom- mended by Velpeau. For this purpose, plugs of lint may be used, covered with some mild ointment, and gradually increased in size till the resistance of the sphincter is overcome. Advantage would probably accrue from com- bining dilatation with the application of lunar caustic to the ulcers. Boyer, by whom the disease was first clearly described and designated, was in the habit of treating it by dividing the sphincters. This practice was eminently successful, but has sometimes failed; and two instances are on record in which it proved fatal. (Diet, de Med., iii. 303.) The operation, therefore, should be resorted to only after other measures have failed. Mr. Richard Quain, Surgeon of the University Hospital, London, considers the division of the sphincter unnecessary, having found the affection to yield to a longitu- dinal incision of the mucous membrane through the ulcer. The tension of the membrane is thus removed, and the ulcer heals. Mr. Quain, though the operation was original with him, ascribes the priority to Air. Copeland. (Lond. Med. Tunes and Gaz., July, 1852, p. 83.) M. Chapelle, believing the affection to be neuralgic, applies to the part, by means of a brush introduced into the anus, a mixture of two parts of chloroform and one of alcohol. The liquid is pressed out of the brush by the contraction of the sphincter, and, though it produces a sharp pain at first, this soon ceases, and relief is ob- tained. (Ibid., Feb., 1857, p. 197.) Article X. PROLAPSUS ANI. Prolapsus ani is a descent of a portion of the rectum or its lining mem- brane below the sphincters, forming a tumour at the anus. In some instances, the upper portion of the rectum descends through the lower, exactly as in CLASS III.] PROLAPSUS ANI. 707 intussusceptio, and protrudes externally. The same thing has happened to the colon; and even the ca?cum has been known to be thus everted, and to be forced through the anus. The extent of this kind of prolapsus is sometimes very great; and a case is on record in which the length of the protruded portion of bowel was two feet. But such incidents as those above men- tioned are rare. The affection commonly called prolapsus ani consists of a protrusion of the lower portion of the mucous membrane only of the rectum, the outer coats being too firmly connected with the neighbouring parts to admit of eversion, under any ordinary circumstances. Symptoms.—Occasionally a considerable protrusion takes place at once, under some peculiarly strong force applied to the part; but in general there is only a small tumour, in the form of a regular ring about the anus, appear- ing when the patient strains at stool, and either retroceding spontaneously, or disappearing under slight pressure when the straining ceases. If the affection be not arrested in this stage, the prolapsus recurs at each stool, and gradually increases, forming at last a considerable tumour, an inch or more in length, which is sometimes difficult of reduction, and always very inconvenient to the patient. Sometimes the protruded membrane takes on inflammation, either from the constriction of the sphincters or some other cause, and be- comes so swollen and painful as to render reduction impossible, until after the inflammation has been subdued. Instances have occurred in which the protruded part has been strangulated by spasmodic stricture of the sphincters, and symptoms resembling those of hernia, with mortification of the mem- brane, have followed. This result, however, is more to be apprehended in cases of eversion of the whole thickness of the bowel, than where the mucous membrane only protrudes. The prolapsus sometimes continues long unre- duced without serious results ; as the parts affected have a wonderful facility of accommodating themselves to their new position, and the mucous mem- brane takes on the characters of the skin. Causes.—Whatever irritates the rectum, and occasions severe straining at stool, may give rise to prolapsus ani. Hence, the affection is common in dysentery. Aloetic medicines, frequent irritating enemata, ascarides, costive- ness, piles, other tumours or thickening of the rectum, and complaints of the prostate, bladder, and urethra act in the same manner. Strong contraction of the abdominal muscles without tenesmus, as in the crying of infants, and in protracted parturition, may also produce prolapsus. But these causes are much more efficient, when a relaxation or atonic condition of the sphincters coexists. When these muscles are much relaxed, the prolapsus sometimes takes place under the ordinary degree of force to which the rectum is exposed in defecation. It is said to have occurred as the result of sudden fright, pro- ducing relaxation of the sphincters. In most cases, however, the straining and relaxation of the sphincters co-operate. The affection is very common in children, and more so in old age than in middle life. Treatment.—The objects in the treatment are first to return the prolapsed bowel, if it remain without the anus, and then to adopt such measures as may prevent subsequent protrusion. The former object is in general easily accom- plished ; nothing more being necessary than to press regularly and gently with the oiled palm of the hand upon the tumour, or to push up the mem- brane with the oiled index finger inserted into the anus. If constriction of the sphincter oppose the reduction, it should be relaxed by means of the warm hip-bath, warm poultices or injections containing laudanum, and bleeding if necessary. Sometimes the sudden application of cold produces the same effect. If the protruded parts be inflamed and swollen, they should be treated with depletion, an antiphlogistic diet, cold applications, and a proper posture. In the prevention of prolapsus three indications are offered; one, to obviate 708 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. • irritation of the rectum, the second, to correct relaxation of the sphincter, and the third, to produce contraction of the membrane liable to protrusion, and adhesion between it and the parts with which it is in contact. The first indication is met by keeping the bowels regularly open, and the feces soft, by means of a mild laxative diet and laxative medicines, by avoiding all causes of direct irritation to the rectum, and removing those which can be ascertained to exist, and by the use of anodyne enemata. Dr. Physick was in the habit of prescribing for children with this affection a diet of rye-mush and molasses, and the performance of the act of defecation in the erect po- sition, so as to prevent much straining. To answer the second indication, that is, to correct relaxation of the sphincter muscles, when it exists, cold water should be applied either by a sponge, or by directing a continued stream against the anus; astringent injections should be thrown into the rectum, or astringent ointments introduced by means of a pledget of lint within the sphincters; and, when the case is wholly unattended with irritation of the rectum, substances calculated to stimulate the sphincters may be given by the mouth, as copaiba, cubebs, or oil of turpentine. To consolidate and fix -the membrane, which is the third indication, infusions or decoctions of the vegetable astringents, as kino, catechu, rhatany, galls, and oak bark, or solutions ofthe mineral astringents, especially alum, should be injected, with a little laudanum, after each protrusion. Mr. Vincent recommends strongly the injection of a solution of sulphate of iron. (See Am. Journ. of Med. Sci., N. S., xv. 546.) In children, almost all cases will yield to this simple treat- ment, with attention to the state of the bowels as above directed. Other remedies, however, have been resorted to, among wdiich is the application of strychnia to a blistered surface, in the cleft of the nates. In old cases, in which the fibres connecting the protruded membrane with the other coats are much elongated, it becomes necessary to establish new adhesions with the neighbouring structure; and this may often be accomplished by clipping off longitudinally, with a pair of scissors, small portions of the membrane, or by applying caustic carefully over small longitudinal strips of its surface. Great advantage is also said to have accrued from passing a ligature through the membrane, and allowing it to remain so as to excite inflammation and adhe- sion; and the plan has even been adopted by some surgeons of amputating the dependent flap. Another plan is to employ caustic. For this purpose nitric acid is preferred by Dr. Henry Smith, of London, and nitrate of silver freely applied to the protruded bowel, by Mr. Lloyd, of the same place. M. Guersant recommends the actual cautery; a small conical iron being applied at four points, at the junction of the mucous membrane and skin, and pene- trating to the sphincter. (Lond. Med. Times and Gaz., Aug. 1856, p. 149.) These latter methods, however, should be resorted to only in extreme cases, after the milder have failed. Dr. S. M. Baer, of Baltimore, has invented a chair, which, by supporting the parts about the anus during evacuation, is said to prevent the prolapsus, and thus ultimately to effect a cure. (Am. Journ. of Med, Sci., N. S., xxv. 552.) When a permanent cure cannot be obtained, and the intestine is disposed to protrude even in the intervals of the evacuations, the patient may be made more comfortable by substances in the form of pessaries introduced into the rectum, or, which is perhaps preferable, by constant pressure upon the anus made by means of a spring-pad, or a suitable bandage and compress. For more particular information on these various points requiring manual inter- ference, the reader is referred to treatises upon surgery. CLASS III.] CHOLERA MORBUS. 709 SUBSECTION V. DISEASES OF THE STOMACH AND BOWELS CONJOINTLY. There are certain diseases so equally shared by the stomach and bowels, that it is impossible to attach them specially to either section ofthe aliment- ary canal. Such are the different forms of cholera. It may be said that in dyspepsia the stomach and bowels are both diseased, and that mucous inflam- mation often attacks both parts conjointly, constituting gastro-enteritis. This is true; but these affections may be restricted to one portion of the canal, and generally have their primary seat in one portion; the other parts being second- arily involved. They may, therefore, be considered as especially belonging to a particular section. But this is not the case with cholera. It would not be cholera, unless both stomach and bowels were involved. It was, therefore, necessary to form this subsection; and, as it has been formed, it was most convenient to consider flatulence in connection with it; as the pathological conditions in which this affection originates, are very apt to involve both divi- sions of the canal. I place peritonitis in the same category; as, when general, it necessarily involves both the stomach and bowels, and could not be with so much propriety associated with any other set of diseases. Article I. CHOLERA MORBUS. The name of cholera is given to any complaint in which the prominent characters are simultaneous and repeated vomiting and purging, with painful spasm of the stomach and bowels, and occasional cramps of the external mus- cles. Three varieties have been observed, so different in the circumstances of their occurrence, as well as in their symptoms, progress, and results, as to merit distinct consideration. These are cholera morbus, epidemic cholera, and cholera infantum. The present article is devoted specially to the first of these affections. It is the variety so common as an endemic disease in various parts of the United States during the summer season, and no doubt the same as that noticed by the ancient authors, and described by Sydenham as occurring epidemically in England towards the close of summer and begin- ning of autumn. By recent European writers, it is distinguished from the epidemic variety by the name of common or sporadic cholera. Symptoms.—Cholera morbus is generally characterized by the vomiting and purging of bilious matter. It often comes on suddenly, especially when the immediate result of some irritant influence on the stomach and bowels; but, not unfrequently, it is preceded for some hours or even days by a feeling of weight or other uneasiness in the epigastrium, colicky pains, more or less headache, and sometimes by furred tongue, chilliness, and a slight febrile ex- citement. The vomiting and purging are usually preceded by a good deal of nausea, and attended by spasmodic pain in the stomach, which is sometimes excruciating, but is relieved after each discharge. In the intervals between the paroxysms of vomiting, the patient, though comparatively easy, often ex- periences distressing nausea, or a burning sensation in the epigastrium, and complains of general languor and exhaustion. The discharges generally con- sist at first merely of the ordinary contents of the stomach and lower bowels ; 710 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. the matter vomited being either food recently taken, or colourless and often sour or acrid liquid, and the dejections fecal. But these are, in the vast ma- jority of cases, soon followed by bilious matter of a green or yellow colour, and very often extremely bitter, and more or less acrid. The pulse is usually feeble, the countenance pale and shrunk, the skin cool and damp, the urine scanty or suppressed; and, in severe cases, the patient is not unfrequently affected with very painful cramps of the muscles of the abdomen and extrem- ities, especially of the legs. These irregular muscular movements amount sometimes to general convulsions. In favourable cases, the more violent symptoms subside after a few hours, or readily give way to treatment, leaving only temporary debility. But occasionally the complaint, either from original violence or neglect, assumes an alarming character. The vomiting and purg- ing are almost incessant; everything taken into the stomach is promptly re- jected, the discharges being often brown or blackish, acid, or even bloody; the sufferings from nausea, anxiety, heartburn, and spasmodic pains, both internal and external, are intense; the patient complains of extreme thirst, and is clamorous for cold drinks; the pulse is small, frequent, irregular, and extremely feeble, the respiration short and frequent, the extremities cold, the eyes sunken and surrounded with a dark areola, the skin bathed in cold sweat; hiccough and abdominal distension come on, with a cessation of the vomiting; and the patient, if not rescued by remedial measures, sinks into a state of complete exhaustion, retaining his mental faculties not unfrequently to the last. Death may occur within twenty-four hours, though more fre- quently the complaint runs on for two or three days, before terminating fatally. In some instances, moderate febrile symptoms attend the disorder, as if an attempt had been made to establish bilious fever, which had been prevented from entire success by the occurrence of the cholera; and, in ordinary cases, a sudden suppression of the discharges by opium sometimes gives rise to a similar state of system. Instead of being bilious, the evacuations are, in some very rare instances, colourless or whitish, somewhat as in epidemic cholera. In such cases, the attendant symptoms are of an aggravated character, though by no means necessarily fatal. Cholera morbus generally subsides under remedies without unpleasant con- sequences, leaving only a moderate debility, from which the patient speedily rises by the aid of a suitable regimen. Sometimes, however, the debility is considerable and protracted, and requires medical interference. Occasionally the patient is left with a troublesome diarrhoea, or with other evidences of a continued irritation of the stomach and bowels. In intemperate persons, the checking of the cholera is apt to induce delirium tremens. In persons of good constitution, the disease is very rarely fatal. It is ! most apt to prove so in the very old, the feeble, and the intemperate. Causes.—Hot weather, long continued, strongly predisposes the system to cholera morbus, and may of itself occasion the disease without any other cause. The same may probably be said of marsh miasmata; for cholera morbus very often precedes the breaking out of miasmatic fevers, as if result- ing from the operation of the same cause in a less degree. Most commonly, however, the immediate attack is brought on by some exciting cause, capable, either directly or through the nervous centres, of irritating the stomach and bowels. Among such causes may be mentioned, exposure to cold when the body is heated and perspiring; the use of certain indigestible and irritating articles of food or drink, as cabbage, cucumbers, melons, various unripe fruits, fat pork, lobsters, crabs, sour and incompletely fermented liquors, putrid wa- ter, &c.; excesses at the table, independently of the character of the food; the use of ice, or very cold drinks in excess; strong mental emotions, as fear or anger; and various movements which produce sickness of stomach through CLASS III.] CHOLERA MORBUS. 711 their action on the brain, as riding backward, turning rapidly in a circle, and sailing upon a rough sea. The disease prevails especially in hot countries, and during the hot season in temperate latitudes. Sometimes it is so preva- lent as to put on the appearance of an epidemic, though probably dependent on the heat of the weather, or the local miasmata, in the same manner as our endemic remittent fever. In this country, it is most common in the months of July and August. It chiefly attacks adults. Nature.—This must be inferred from the symptoms and causes; as dissec- tion reveals nothing which can lead to any accurate conclusion. Sometimes redness or other evidence of inflammation is discovered in the stomach, or some portion of the bowels; but often no such phenomena are presented, and neither the alimentary mucous membrane, nor any other structure exhibits appearances which could explain the symptoms. The probability is, that the disease consists essentially in congestion of the portal system, produced by the continued action of a high temperature, by miasmata, or both, and in- ducing an irritation both in the liver and lining membrane of the stomach and bowels, which exhibits itself in an increased and altered secretion. Should the congestion from these causes be alone inadequate to the result, a super- added irritation, from the various exciting causes above enumerated, may be required for the production of the phenomena of the disease. The painful gastric and intestinal symptoms may result either from the general state of sanguineous congestion in the whole canal, or from the irritating quality of the morbid bile and intestinal secretions, or from both. That the liquids re- ferred to are the source of much of the pain and spasm, is evident from the temporary relief which follows their discharge. The prostration is owing partly to the profuse evacuations, partly to the depressing influence of the nausea. The extreme thirst, instead of being an evidence of inflammation of the stomach, is the mere expression, in the throat and neighbouring parts, of the wants ofthe blood-vessels, deprived of a large portion of their more fluid contents. The spasms of the extremities are probably one of the consequences of the gastric and intestinal irritations, acting through the nervous centres. Diagnosis.—Vomiting and purging with more or less bile in the evacua- tions, are not unfrequent attendants upon other diseases, as bilious fever, gastro-enteritis, and inflammation of the liver. From the first of these, how- ever, cholera morbus may be distinguished by the absence of a hot skin, a strong pulse, and headache, and by its much shorter course; from the two latter by the same absence of decided febrile symptoms, and the less degree of tenderness. There may be greater difficulty in distinguishing it from the effects of certain mineral poisons. I have seen the operation of calomel in some instances so exactly like cholera morbus, that the most experienced eye could scarcely have detected the difference. But, in poisoning by corrosive substances, the vomiting generally precedes the purging by a considerable interval, the discharges are seldom so highly bilious, and the poison may often be detected in the evacuations. The circumstances attending the origin of the complaint, and the season of the year, may also be taken into considera- tion in forming the diagnosis. Bilious diarrhoea is sometimes attended with moderate vomiting; but this affection may be considered as only an inferior grade of cholera. The vomiting and purging produced by indigestible food, in a system not predisposed to cholera morbus, are scarcely entitled to rank with that disease. Treatment.—The following mode of treatment will very generally be found promptly effectual, in ordinary cases of cholera morbus. It is founded on the indications, 1. of removing the irritating causes by clearing out the stomach, 2. of checking the irritation directly by the moderate action of opium, and indirectly by powerful revulsion to the surface, and 3. of changing the morbid 712 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. action of the liver by the alterative influence of calomel. Mild diluent drinks are to be administered freely; a sinapism of pure mustard mixed with water, to be applied over the epigastrium; and a pill containing the sixth of a grain of calomel and from the sixth to the twelfth of a grain of opium, to be given every half hour, or every hour, according to the urgency of the symptoms. The drinks should consist of chicken tea made by boiling, for a very short time, a portion of chicken, deprived of skin, in a large quantity of water, so as merely to impart a slight taste to the liquid; of mucilaginous or farina- ceous fluids, such as solution of gum arabic, mucilage of sassafras pith or flaxseed, toast-water, barley-water, &c.; of mild herbaceous infusions, as balm or mint tea; or, finally, of lukewarm water. They should be given freely at first, so as to facilitate the evacuation ofthe acrid bile, and then sus- pended, or administered moderately merely to relieve the thirst of the patient. For this purpose, also, as well as to quiet irritation of stomach, carbonic acid water, in small draughts of about two fluidounces, frequently repeated, an- swers admirably well. The mustard cataplasm should be left on for half or three-quarters of an hour, or until it reddens the skin intensely, and becomes no longer tolerable. In severe cases, or in the advanced stages, when the prostration is great, it is often necessary to administer opium more freely than above directed. From half a grain to a grain of opium in pill, or, what is generally preferable, from twelve to twenty-five drops of laudanum, or an equivalent quantity of the solution of sulphate of morphia, may be given, and repeated at longer or shorter intervals until the violence of the symptoms abates. But the least quantity of opium that will answer the purpose is the best; as, though it is necessary to allay the pain, and check the discharge, yet a complete and sudden suspension of the secretion is not desirable. There is danger, if the congestion be not allowed to relieve itself, that fever or in- flammation may ensue. Hence one of the advantages of uniting calomel with the opium. Large doses of the mercurial are not required ; as experience has shown that, in the minute doses before mentioned, frequently repeated, it acts effectually on the liver, while it is less liable to irritate the stomach and bowels. If the disease should resist the above measures, recourse may be had to a blister over the epigastrium, and powdered acetate of morphia may be sprinkled on the blistered surface deprived of its cuticle. Injections of laudanum, with thin starch or mucilage, may also be given. In cases of great prostration, rubefacients may be applied externally, and blisters to the insides of the arms or legs; and tincture of camphor, aromatic spirit of ammonia, wine-whey, and even ether, may be given internally, in conjunction with the opiate. Should diarrhoea continue after the vomiting has ceased, it should be treated as directed under the head of that disease. Should fever follow a suspension of the discharges, the bowels should be kept open by small doses of some mild cathartic, as the Seidlitz powder, or a solution of carbonate of magnesia in carbonic acid water, commonly called liquid magnesia ; and the effervescing draught and cooling drinks should be administered at short in- tervals. Symptoms of gastric inflammation may be counteracted by leeches to the epigastrium, followed by warm fomentations or emollient cataplasms. Intestinal irritation may be treated by emollient enemata, and mild laxatives as castor oil with a little laudanum. Various other modes of treating cholera morbus have been recommended. Some practitioners, considering it essentially gastritis or gastro-enteritis have relied chiefly upon bleeding, leeching, and demulcents. But this is hazardous practice. Ipecacuanha, in emetic doses, has had its advocates. Nitric acid has been lauded as a specific. Hope's mixture, consisting of a drachm of nitrous acid, forty drops of laudanum, and eight fluidounces of CLASS III.] EPIDEMIC CHOLERA. 713 camphor-water, and taken in doses of two fluidounces every three or four hours, has in its favour the recommendation of Dr. C. D. Meigs, of Phila- delphia, as well as that of its original proposer. (N. Am. Med. and Surg. Journ., ii. 419.) Dr. D. J. Cain has found great advantage from the use of creasote. (Charleston Med. Journ. and Bev., vii. 145.) Dr. N. Wil- liams, of Phcenix, N. Y., unites morphia with the creasote, and very rapidly cures his patients, giving from one-eighth to one-half of a grain of the former, and from one to three drops of the latter. (Boston Med. and Sura. Journ., Ii. 75.) y During convalescence, the greatest caution should be observed in relation to the diet, which should consist of mild and easily digested aliment, such as farinaceous substances, milk, cream, broths without fat, and the lighter forms of solid animal food. Article II EPIDEMIC CHOLERA. Syn.—Spasmodic Cholera.—India Cholera.—Asiatic Cholera.—Malignant Cholera.— Cholera Asphyxia. This disease appears to have been long known in India; but it first began to attract the attention of the medical profession generally in the year 1817, when it broke out as an epidemic with great violence in Bengal, and from that province, as a centre, commenced the fearful march, which did not cease until it had encircled the globe. In its progress westward, it ascended the Ganges, pervaded Central India, and, crossing the mountainous range of the Ghauts, established itself, in the year 1818, upon the western coast of the peninsula. During the same year, it made its way southward to Madras; in 1819, crossed the sea to Ceylon; and, before the close of the latter year, appeared in the Mauritius and the Isle of Bourbon. At the same time, it was slowly advancing towards the east and southeast; invaded the Burman dominions ; attacked Siam, the peninsula of Malacca, and the island of Su- matra; and, in 1820, had reached Canton and the Philippine Islands. It was subsequently heard of as extending its ravages into the northern parts of China, and into Tartary. After arriving at the western coast of the pen- insula of Hindostan, it paused for a while before leaving its native soil; and it was not till the year 1821, that it appeared on the shores of the Persian Gulf. From this position it ascended the Tigris and Euphrates; in 1822, passed over the desert into Syria; and, in 1823, having made its way north- ward through Persia, reached the shores of the Caspian Sea, and seized upon the Russian city of Astracan. It had now traversed the whole length of Asia, and was pressing upon the confines of Africa and Europe. Here it again paused; and several years elapsed before it crossed the boundaries, and commenced a new career of invasion in these hitherto undisturbed re- gions. In 1828, it appeared at Ohrenburgh, on the borders of European Russia; but it did not fairly enter Europe until 1830, when it advanced as far as Moscow. In 1831, it took a westward course, attacked St. Petersburg, Warsaw, Dantzic, Berlin, and Hamburg, and showed itself in Sunderland, on the northeastern coast of England. In 1832, it reached Paris and Lon- don ; and in the same year, overleaping the barrier of the Atlantic, appeared in Quebec on the 8th of June, and at Montreal on the 10th; and thence pursued a rapid course, along the St. Lawrence and the Lakes, to the valley of the Mississippi River. A detachment from the main line of invasion, as 714 LOCAL DISEASES—DIGESTIVE SYSTEM. [PART II. it crossed the Atlantic, appears to have struck the shores of the United States at New York, where the disease broke out on the 24th of June. Thence it spread northwardly up the Hudson, and southwardly to the Dela- ware and Chesapeake Bay, reaching Albany on the 3d or 4th, and Philadel- phia on the 5th of July, and Baltimore in the course of the same month. About the beginning of November, it appeared in an island off Charleston; in February, 1833, at Havana, in Cuba, where it committed great ravages; and, before the end of that year, in Mexico. At the same time that the epi- demic, leaving the northwestern borders of Asia, was spreading consterna- tion throughout the north of Europe, it took also a southward course from Syria, penetrated the deserts of Arabia, and invaded Egypt, appearing in Mecca in May, and in Alexandria in August, 1831. It was very late in attaining the extreme north, and the extreme south of Europe. Thus, Swe- den was not visited until one or two years, nor Sicily until four years after the epidemic had reached New Orleans. In this country, there were partial returns of the disease subsequently to its original appearance, and it pre- vailed to a considerable extent in the year 1834; but, both in North Ame- rica, and the greater part of Europe, it disappeared entirely in somewhat more than two years from its first visitation. In India, however, the disease continued as an endemic, and, at the date of the first publication of this work, in the early part of 1847, we had re- ceived accounts of its having commenced a new march of desolation in the East. Before the close of that year it again entered Europe, and afterwards advanced regularly westward, pursuing a course singularly corresponding with that of its first invasion, both as to the succession of regions visited, and the period of its approach and departure. Setting out from India as before, it passed destructively through the cities of Persia, skirted the shores of the Caspian, and reached Astracan in July, 1847, and Moscow before the close of the year. Here its progress was suspended during the winter; but in the spring of 1848 it again advanced westward, in June arrived at St. Petersburg, in August at Berlin, in September at Hamburg, and crossing thence to Great Britain, attacked Edinburgh in October, and London soon afterwards. On the ninth of November, a ship with emigrants sailed from Havre for New York. At the time of her departure there was no cholera either in that port or at Paris, and the crew and passengers were all healthy. The vessel had been sixteen days at sea when the disease appeared on board, and she arrived with it at the quarantine ground at Staten Island, on the first of December. The passengers were landed, and very soon afterwards the disease broke out in the neighbourhood. It did not, however, extend beyond the quarantine enclosure, and ceased entirely about the beginning of the new year. Three deaths occurred from it in the city of New York. Another ship, which had left Havre on the second or third of November, without cholera on board, was attacked with the disease twenty-six days after leaving port, and brought it with her to New Orleans, where she arrived on the eleventh of December. Cases of cholera soon afterwards occurred in that city, and rapidly multiplied, the weather being at the time very hot, and of course favourable to the spread of the disease. From New Orleans it ex- tended to Texas, and up the Mississippi, reaching the city of Memphis so early as the twenty-second of December, and sweeping over the valley of that great stream with unheard of rapidity. It did not, however, surmount the Alleghanies; and, with the exception of the slight demonstration made in the harbour of New York, the Atlantic States remained free from the disease during the winter. The epidemic cause, however, was in the mean time pur- suing its regular course across the Atlantic; and, as on the previous occasion, reached our shores in the season following that of its appearance in western CLASS III.] EPIDEMIC CHOLERA. 715 Europe, though somewhat earlier than in the year 1832. It broke out in New York about the beginning, and in Philadelphia about the close of May, 1849; and while, commencing at the Atlantic coast, it visited many parts of our country on this side of the mountains, it seemed to take a fresh start from New Orleans, and again spread along the tributaries of the Mississippi with fearful violence. In its further progress, it invaded the West Indies and Mexico, and, crossing the whole breadth of the continent, reached the shores of the Pacific, producing as it went great havoc among the emigrants on their way, like itself, to California. It attacked the cities of St. Francisco and Sacramento in October, 1850. In the summer of 1850, and in every year since that time, it has occurred to a greater or less extent in various parts of the valley of the Mississippi, in which there is reason to fear that it has become naturalized; but the section of our country, east of the Allegha- nies, with some slight exceptions, remained exempt, from the period of its visitation in 1849, until the summer of 1854, when it again made its appear- ance in the epidemic form, having pursued the same course as on former occasions, from the Eastern parts of Europe, through the north of that con- tinent, to Great Britain, and thence across the Atlantic to the United States. Since that year we have again enjoyed a period of exemption; but at the present time (April, 1858), we are looking forward with some apprehension to another invasion with the approach of summer; as the disease, during the past year, has been pursuing in Europe a similar course to that which, on every former occasion, has preceded its arrival in this continent. From the above brief account of the progress of cholera, it will be seen that its march is extremely irregular, in relation both to time and direction. Sometimes it advances with great rapidity, sometimes slowly, and sometimes pauses for a longer or shorter period, giving hopes to the yet unvisited coun- tries, that they may escape its ravages. In general, its progress is arrested during the winter, to be resumed in the spring; though this is not invariably the case; for at Moscow it prevailed through most of the winter of 1830-31; and the cold weather did not prevent its spreading along the Mississippi in the winter of 1848-49. Though preferably following the course of streams, affecting low and damp places, and attacking the filthy and crowded portions of populous cities, it is yet absolutely confined to no particular character of locality, but shows itself occasionally upon lofty mountains, in the midst of sandy deserts, and among the scattered inhabitants of thinly peopled agricul- tural districts. No barriers are sufficient to obstruct its progress. It crosses mountains, deserts, and oceans. Opposing winds do not check it. All classes of persons, male and female, young and old, the robust and the feeble, are exposed to its assault; and even those whom it has once visited are not always subsequently exempt; yet, as a general rule, it selects its victims preferably from among those already pressed down by the various miseries of life, and leaves the rich and prosperous to their sunshine and their fears. It is exceedingly capricious in the choice of its localities, not unfrequently leaving towns and districts in its line of march untouched, and deviating apparently from its course to seize upon others, in no important respect dif- ferently circumstanced. The period of its duration, in any one spot, is gene- rally from one to two or three months; though this is much influenced by the season, being shorter for the most part when winter is near. When it prevails in the same place more than once, it usually affects fewer persons, and is of a milder character in the second attack than in the first. Course, Symptoms, etc.—The first approach of the epidemic influence, in places about to become the seat of cholera, is usually felt in the more or less general prevalence of moderate disorders of the stomach and bowels, which precede for a short time the appearance of the disease, and continue in vari- 716 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. ous degrees to affect a large portion of the population, after it has become established. Sometimes there is only a slight derangement of digestion, or a simple diarrhoea, or mild dysentery; but very frequently, the premonitory affection takes on a more decided character, and, without amounting abso- lutely to cholera, approaches it more or less nearly. From this circumstance it has received the name of cholerine, adopted from the French writers. Cholerine, in fact, often constitutes the first stage of cholera, and in other cases is undoubtedly produced by the same cause, operating either more mildly, or upon less susceptible subjects. It is marked by a furred tongue, irregular appetite, thirst, impaired digestion, uneasiness in the stomach and bowels with a feeling of weight or distension, colicky pains, hiccough, diar- rhoea sometimes disappearing and again recurring, nausea, sometimes vomit- ing, a feeling of general weakness and languor, a disposition to perspire, occasional neuralgic pains, and cramps in the extremities. In some instances, it is attended with febrile symptoms. The alvine discharges are sometimes bilious, sometimes of a dirty-white colour and turbid, very much resembling oatmeal gruel. Occasionally the force of the cause seems to expend itself upon the nervous system, and the patient is affected with severe neuralgic pains, and distressing spasms, amounting sometimes to convulsions, with little or no evacuation from the stomach or bowels. The affection often sub- sides spontaneously, or yields readily to proper treatment; but it is very apt, upon exposure to any exciting cause, and even, if neglected, without such cause, to be aggravated into cholera. When the epidemic influence has attained an intensity adequate to the pro- duction of the full-formed disease, a few cases are first observed, usually among the lowest orders of the community. These are soon followed by others ; and the numbers gradually increase until the pestilence reaches its acme; when it speedily subsides, and ultimately disappears, leaving behind it, for a short time, that same tendency to bowel complaints which had heralded its approach. The attack often occurs after some imprudence in diet or exposure ; but often also without any obvious exciting cause; and, according to some writers, most frequently in the night. It occasionally comes on with loss of appetite, pain in the back and abdomen, vertigo, noise in the ears, disordered vision, feebleness of the pulse, paleness of the face, copious sweats, a feeling of gene- ral weakness, and sometimes rigors. In the midst of these or similar symp- toms, in most cases after a longer or shorter duration of diarrhoea or cholerine, but sometimes without any premonition whatever, the patient is seized with vomiting and purging, which are frequently repeated, and attended with severe pain in the abdomen, neuralgic pains in different parts of the body, and cramps ofthe voluntary muscles, especially those of the lower extremities. The first evacuations, in cases not originating in diarrhoea or cholerine, consist of the ordinary contents of the stomach and bowels; but the dejections which follow are of a whitish colour, thin, and watery, resembling rennet-whey, thin gruel, or rice-water, and, when allowed to stand, separate into a colourless fluid, and a white, flocculent, insoluble matter, which subsides. In mild cases, or after the subsidence of the severe symptoms, they are sometimes tinged with bile, and a little blood is occasionally discharged. In some instances, they are brown or of a deep-chocolate colour. The matter vomited is generally similar to the stools, but is sometimes white and glairy, as if consisting of mucus, and has an acid reaction. The evacuations are usually forcibly ejected, but with- out apparent straining, or much voluntary effort, and are often very copious. The cramps usually begin in the extremities, affecting especially the calves of the legs, but subsequently extend to the muscles of the trunk and abdomen. They are excruciatingly painful, and almost incessant, the muscles gathering into hard board-like knots, one contracting as another relaxes, and often dis- CLASS III.] EPIDEMIC CHOLERA. 717 torting the fingers and toes in various directions, according to the particular muscle or muscles affected. At the same time the pulse sinks rapidly; the extremities become cold; the features shrink; the patient is restless, and complains of intense thirst; the whole surface is bathed with sweat; the urine is scanty; and the skin begins to assume a bluish, leaden, or violet colour, which extends more or less over the body, but is peculiarly striking in the face, hands, and feet. If the complaint is not arrested, the evacuations become still more copious and watery; the thirst insatiable, with a burning heat at the epigastrium; the pulse frequent, feeble, and sometimes scarcely perceptible; the breath cool; the tongue cool and pale, though still moist; the skin unusually cold, shrunken, and inelastic, so that when pinched into folds it does not resume its former state; the hands and feet shrivelled and wrinkled, as if long soaked in water, and of a dark-purplish, or livid colour, especially at the nails, which are sometimes almost black; the eyes, deeply sunk in their sockets, and sur- rounded with a livid circle ; the conjunctiva dry, and of a dirty whiteness ; the nose and lips blue; the secretion of urine and tears suppressed; the re- spiration short, hurried, and oppressed; and every symptom indicative of extreme prostration. The patient is often exceedingly restless, and calls in- cessantly for cold water or ice, and for fresh air. With all these changes, the external sensibility often remains acute, so that mustard plasters and other irritants produce severe pain; and, though the skin is cold to the touch, com- plaint is frequently made of distressing heat over the whole surface. The intel- lect is generally sound, but more or less obtuse; and, in all his moral relations, the patient evinces an extraordinary apathy, being insensible alike to his own danger and prospects, and to the feelings of those connected with him. The case is now on the borders of complete collapse. But a step further, and the pulse becomes quite imperceptible; a feeble oscillatory movement only ofthe heart is discoverable upon auscultation; the blood stagnates in the capil- laries ; a wound of the surface yields no blood, and little or none follows the opening of a vein; the features and whole body are so shrunken that the pa- tient can scarcely be recognized by his friends ; the bluish or purplish colour often pervades the whole surface ; the voice is feeble, or quite extinct; the breath almost as cold as the external air; the respiration either hurried and feeble, or-very slow and scarcely perceptible ; the countenance calm or quite inexpressive; and the whole aspect of the patient that of utter helplessness. The reduction of temperature is such that the thermometer, with its bulb placed under the tongue, sinks often to 90°, and sometimes as low as 80°, or even 77° F. The body has the appearance of death except the eyes, which sometimes retain an expression of intelligence, and seem as if they were look- ing out of a corpse. But even these are often half closed, glazed, and inani- mate. In some instances, considerable muscular strength remains, and the patient suddenly rises up from bed with an expiring effort, and falls lifeless. There is a total suspension of the urinary secretion. The evacuations some- times continue till the close, and are at last involuntary. Sometimes, how- ever, they cease entirely for a considerable time before death. The same difference is observable in relation to the cramps, which, in some cases, do not end even with life, the muscles remaining stiff and contracted in the dead body. Intelligence is sometimes retained till within a few moments of the close. In other cases, a period of stupor precedes death. The fatal issue sometimes occurs in four or five hours from the commencement of the attack, though more frequently life is protracted for one, two, or three days. The mean duration of fatal cases, according to the report of the Registrar-gene- ral of England for the year 1848-9, was about 49 or 50 hours, and for 1854, according to the report of the general board of health, was 2-39 days. 718 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. The complaint is susceptible of a favourable change, either spontaneously or under treatment, at any stage, even in that of collapse. If it is arrested early, the patient sometimes enters into a speedy convalescence, without any subsequent embarrassing symptoms, though not unfrequently diarrhoea and other evidences of gastro-intestinal irritation continue for a longer or shorter period. But, if collapse has begun before the turn of the disorder, the pa- tient has still great dangers to encounter, and the progress of recovery, when it takes place, is often very tedious, and liable to frequent interruptions. One of the most favourable symptoms, in any stage of cholera, is the appearance of bile in the evacuations. In the case of collapse, after the system has begun to react, a gradual restoration of the suspended functions is observed; the pulse returns, the skin becomes warm, the pallor or blueness of face yields to a red flush, the secretion of urine and bile recommences, the vomiting diminishes ; but the oscillation extends frequently into a febrile excitement; severe headache is experienced; the abdominal pains, thirst, loathing of food, and diarrhoea continue; and convalescence, even in favourable cases, does not set fairly in until after several days of doubt and discomfort. Sometimes a relapse follows the temporary excitement, and the patient sinks with all his foriher symptoms. Much more frequently, the febrile state continues, generally assuming a low form, with most of the characters of idio- pathic nervous or typhoid fever, and unequivocal evidences of gastric or in- testinal inflammation, and ending either in death, or in a very slow recovery. In some cases, the fever assumes the remittent type, and ultimately becomes intermittent. Eruptive affections, resembling those of scarlatina, rubeola, erythema, &c, occasionally diversify the stage of reaction. They are some- times accompanied with wheals, like those of urticaria, but without the itch- ing. Pneumonia, bronchitis, and pleurisy also not unfrequently occur, but so masked by the low state of the system, and the gastro-intestinal irritation, as often to escape the notice of the practitioner, unless upon his guard. But the most dangerous affection, in this stage of cholera, is perhaps that of the brain, characterized by headache, drowsiness, low delirium, stupor, coma, subsultus tendinum, and sometimes convulsions or paralysis. In its severe forms, it is almost always fatal. The convalescence from these secondary dis- orders is often protracted for months, and sometimes even for a year or more. The course of the symptoms in cholera is not always uniform, nor exactly as above described. Sometimes the spasms are comparatively trifling or alto- gether absent; sometimes they constitute the chief feature of the case, to the exclusion of the ordinary evacuations. In occasional instances, the complaint is ushered in by universal and violent convulsions. Cases have been fre- quently observed, in which fatal collapse supervened without vomiting; and others are on record, in which there was neither vomiting nor diarrhoea, though, in such instances, the bowels, upon examination after death, were found loaded with the same whitish liquid of which the discharges consisted. In some rare instances, vomiting occurs with little or no diarrhoea. Though in general there is an interval of some hours, and sometimes of a day or more between the attack and the occurrence of collapse, so as to allow time for the intervention of efficacious treatment, yet instances are not unfrequent, iu which the patient passes almost immediately into that state, and dies appa- rently under the first blow. The bluish aspect of the surface, so characteristic of cholera, is not present in all cases, not even in all those which end fatally. Instead of the sinking pulse, so common even in the onset of the disease, the circulation is sometimes little affected for a considerable time ; and, in some cases, febrile symptoms, with a strong and excited pulse, appear in the first stage. The intellect, usually correct, though obtuse, is in some cases clouded almost from the commencement; and instances have occurred in which deter- CLASS III.] EPIDEMIC CHOLERA. 719 mination of blood to the head, and drowsiness, stupor, and numbness of the extremities were the prominent symptoms. From an examination of the symptoms above detailed, it will be perceived that a fully developed case of cholera, running through a regular course, often exhibits four distinct stages, the observance of which is important in a prac- tical point of view. The first is the forming stage, consisting of a simple diarrhoea, or of more or less of those derangements described under the head of cholerine. The second is that in which the symptoms of cholera are de- cided, but the system has not yet sunk into complete prostration, and the circulation is distinctly observable, both in the larger vessels and capillaries. The third is the stage of collapse, already sufficiently described. The fourth is that of reaction, in which the characteristic symptoms of cholera have given way to local inflammations or irritations, and to general fever. All these stages do not by any means occur in all cases. The disease is often arrested in the first or second, or proves fatal in the third, without ever reaching the fourth ; and sometimes the second or even third stage comes on, without the known existence of those ordinarily preceding it. The Evacuations.—It has been stated that the peculiar choleric evacua- tions, whether from the stomach or bowels, consist of a colourless liquid, holding in suspension a white flocculent matter, which subsides on standing. This insoluble matter, formerly supposed to be coagulated albumen or fibrin, was found by Dr. Boehm, of Berlin, to consist mainly of epithelial cells, in their various stages of development, separated or adhering together; and his statements have been confirmed by subsequent microscopic observers. The clear liquid is water, holding a very small proportion of saline and organic substances in solution. Of the salts, chloride of sodium is by far the most abundant. There is also in the dejections, according to Dr. Guterbock, a little carbonate of soda, with salts of lime and magnesia, but none of potassa. A little albumen may usually be detected by the agency of heat and nitric acid; but the quantity is insignificant. According to Mialhe, there is a con- siderable proportion of a principle which he calls albuminose, analogous to albumen, but differing from it in being uncoagulable by heat or the acids, while it is precipitated by alcohol, corrosive sublimate, tannic acid, &c. (See Am. Journ. of Med. Sci, N. S., xviii. 257.) The stools of cholera are said always to have an alkaline reaction. The evacuations from the stomach differ from them mainly in being slightly acid, and in containing a smaller propor- tion of solid matters. Guterbock states that the former contain somewhat over 98 per cent, of water, the latter 99 per cent. (Ibid., xxi. 198.) The urine appears, from the observations of Dr. J. W. Begbie, to be of diminished density, and to contain in general albumen and bilious colouring matter, with the ordinary salts, but little or no urea. When examined with the microscope, it uniformly exhibits the presence of epithelium, of different forms, and in different stages of growth, from all parts of the urinary pas- sages, and even from the tubuli uriniferi of the kidneys. It presents these characters when it begins to reappear, after its almost total suppression in the prostrate state. If the case goes on favourably, its normal condition re- turns in aday or two. (Ed. Month. Journ. of Med. Sci, Nov. 1849, p. 1207.)* * Dr. W. Lauder Lindsay, of Perth, gives, as the result of microscopic examination, the following ingredients of the cholera evacuations. 1. The vomited liquid contained, besides debris of the food, mucus in fibrillated bands; epithelium of the different kinds, in large amount; granular corpuscles (young epithelial cells?); chloride of sodium and triple phosphates, microscopic fungi, as sarcina, mycelium, and the sporules of va- rious kinds of mould; and animalcules, including vibriones and acari; the two last in- gredients being incidental. 2. The stools contained, besides the debris of food, mucus ; epithelium and granular corpuscles; oily and fatty matters ; chloride of sodium and the phosphates; microscopic animalcules and fungi, and some other bodies, present inci- 720 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. The air expired in the state of collapse contains much less carbonic acid than in health. This in some degree explains the great coldness so charac- teristic of the collapse of cholera. Tlie Blood.—The character of the blood varies with the stage of the dis- ease. At an early period, nothing abnormal has been observed; in the stage of reaction, it.often contains an excess of fibrin, consequent on the develop- ment of inflammation. It is during the collapse, or in the state approaching it, that its composition has been most carefully investigated. In relation to this composition very discrepant statements have been made. The results here given are those obtained by the most accurate observers, among whom may be particularly mentioned, M. Becquerel, and Drs. R. D. Thompson, Gairdner, Garrod, and Wm. Robertson. According to the last-mentioned reporter, the blood was found in the early stage to be defective in red cor- puscles, and somewhat lighter than in health, though the proportion of albu- men was somewhat above the healthy medium. This fact would tend to show that anemic persons are most liable to be attacked. (Ed. Month. Journ. of Med. Sci., Sept. 1853, p. 247.) The blood in the collapse of cholera, whether from the veins or arteries, is darker, more viscid, denser, and less coagulable than in health. It does, however, usually coagulate upon stand- ing, and separates into serum and crassamentum; but the latter has little firmness, and the former is in smaller proportion, considerably heavier, and much more deeply coloured than in normal blood. As might be inferred from the character of the alvine evacuations already referred to, the quantity of water in the blood is much diminished, while that of the solids is propor- tionably increased. The red corpuscles are increased in larger proportion than the other constituents. From 140 parts in 1000, its highest normal proportion, it rises, according to Dr. Garrod, to 166 or 171. The proportion of fibrin cannot be accurately ascertained in consequence of its altered cha- racter, and imperfect coagulability. The albumen is augmented in relation to the water of the serum, as might be inferred from the fact, that the watery evacuations contain but very little of this principle. The salts, contrary to what was formerly believed, are also increased relatively to the whole bulk of the blood; but the soluble are less so than the insoluble, as must neces- sarily happen from the amount excreted with the gastric and intestinal dis- charges. Urea was found in the blood by Dr. O'Shaughnessy; but, from the experiments of Dr. Garrod, it appears to be in much smaller proportion in the collapse than early in the stage of reaction. At the time that the secretion of urine is suspended, and the urea of course ceases to be thrown off, it ceases also to be produced, in consequence of the failure of the organic processes which generate it in health; but, when reaction takes place, ^pro- duction recommences before the kidneys are able fully to resume their func- tion, and it now consequently accumulates in the blood. Hence, possibly, in some degree, the coma often presented at this period of the disease, and the general tendency to inflammations. Becquerel found a very greatly in- dentally, or in minute quantity. It appears from this, that the character of the ejecta from the stomach and bowels is essentially the same. 3. In the urine were hyaline mucus; epithelium of various kinds, and granular corpuscles; fibrinous casts of the tubuli uriniferi; various crystalline bodies, as uric acid, urates, phosphates, oxalate of lime, and chloride of sodium sparingly; and pigmentary matters, blue and gre'en; besides accidental ingredients. In all three of these evacuations were compound granular bodies, the "exudation corpuscles" of other writers, which are usually considered as the product of inflammation. The blue pigmentary matter of the urine had been pre- viously noticed by Mr. Osborne, of London, and was seen only in a few cases. It ap- peared in one case after the urine had been concentrated by evaporation, and in an- other upon the addition of nitric acid to the urine previously heated. (Ed*Med Journ Feb. and March, 1856.) . v CLASS III.] EPIDEMIC CHOLERA. 721 creased proportion ofthe extractive and fatty matters. (Arch. Gen., ieser., Dec, xxi. 199.) The blood, which in the healthy state has an alkaline reac- tion, is said to be sometimes acid in cholera. An indisposition has been noticed in the black blood of cholera to become reddened on exposure to the air. This has been ascribed to a deficiency of the saline constituents of the blood, which, according to Dr. Stevens, are necessary to its conversion from venous to arterial; but some doubt is thrown upon this explanation, as also upon the correctness of the therapeutical deduc- tion that saline substances should be used in the treatment of the disease, by the ascertained fact, that the proportion of salts in the blood is increased instead of being diminished. Anatomical Characters.—After respiration and the action of the heart have ceased, spasmodic movements of the muscles are still sometimes observable; and it is a remarkable fact, asserted by many observers, that, when death occurs suddenly in the cold stage, the temperature of the body not unfre- quently rises after all signs of life have ceased, and- the warmth continues until cadaveric rigidity begins. The appearances upon dissection vary, ac- cording as death has taken place in the stage of collapse, or in that of reaction. When it is very speedy, it is said that sometimes no morbid changes whatever are observable. The following phenomena are ordinarily presented after death in the collapse. The whole arterial system is emptied of blood, with the exception of a few clots in the aorta and left side of the heart. The venous system, on the con- trary, is distended, especially the large veins and right side of the heart, which is gorged with a black, viscid, imperfectly coagulated blood. Almost all parts of the body, the brain and spinal marrow, the substance of the heart, the abdominal viscera, the limbs, even the spongy substance of the bones, exhibit signs of venous injection; and large ecchymosis are frequently found in all the parenchymatous glands. The vessels of the lungs, however, gene- rally contain little blood; and the spleen is sometimes remarkably small and dry. When the abdomen is opened, the peritoneum is observed to be dry, as in fact are the serous membranes generally; and the small intestines have a rose or violet colour, owing to the venous injection of the inner coat. Some- times, however, the serous surface of the bowel is covered with a very delicate layer of viscid matter, rendering it somewhat adhesive ; and the same condi- tion is occasionally noticed in the pleura, and more rarely in the pericardium. The mucous membrane, throughout nearly its whole extent, is usually more or less reddened, and the parietes of the bowels are somewhat thickened, in consequence of this venous injection. Patches of ecchymosis are also fre- quent in their coats. Enlargement of the intestinal follicles, and elevation of the elliptical patches are very commonly met with; but in some cases the mucous membrane is throughout of the natural colour, and there is no abnormal development of the mucous glands. In many cases, an eruption of minute semi-transparent vesicles has been noticed, disappearing upon punc- ture, very closely arranged, and extending from the duodenum to the ileo-ca?cal valve, and even into the colon. These have been considered as morbidly devel- oped follicles; but, according to Dr. Horner, they are altogether distinct from that structure, and are formed by a mere elevation by a serous fluid of the epithelium of the mucous membrane. (Am. Journ. of Med Sci, xvi. 289.) The intestinal mucous membrane is frequently coated, to a greater or less extent, with a layer of a whitish or grayish matter, apparently identical with the flocculent substance deposited by the evacuations when allowed to stand. A similar coating is sometimes found in the stomach. The whole alimentary canal is distended with the same whitish liquid of which the evacuations consist, often mixed with a dark-reddish or chocolate-coloured liquid, which vol. I. 46 722 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. probably owes its colour to effused blood. A glairy mucus sometimes exists in the stomach, more or less adherent to the mucous coat. The texture of the membrane is seldom materially altered in this stage. The brain, spinal marrow, and nervous ganglia are little changed. The lungs are healthy in appearance, except that they are sometimes edematous, and contain a frothy liquid in the bronchial tubes; and the parenchyma of the liver and kidneys exhibits no other irregularity than an occasional venous engorgement. The gall-bladder is usually filled with a viscid, not unhealthy bile. The bladder is often very much contracted, and contains little or no urine. The mucous membrane of the pelvis of the kidneys, ureters, and bladder often exhibits a consistent coating, similar to that found in the bowels. Microscopic investigations have thrown much light on the pathology of cholera. It has been already stated that the white flocculent deposit in the evacuations from the stomach and bowels, has been ascertained to consist mainly of the disintegrated epithelium of the alimentary mucous membrane. The same observer to whom we were originally indebted for this fact, Dr. Boehm, of Berlin, ascertained that the whitish layer which is often found covering the surface of the membrane, and to which reference has been made above, is of the same character. It is, indeed, nothing more than the epi- thelium, detached to a greater or less extent from the basement membrane, and adhering loosely to the bowel. This observation was confirmed by a com- mittee ofthe College of Physicians of Philadelphia, appointed to investigate the condition of the mucous membrane of those dying of cholera. They found the epithelium of the membrane, in all cases, either entirely detached, or ad- hering loosely as a pulpy layer, mixed with mucus or an albuminoid substance. The white matter contained in the prominent mucous glands, is probably the same epithelial tissue detached from the surface of the follicles. The villi are also denuded of epithelium.* But this derangement of the mucous epithe- lium is not confined to the lining membrane of the bowels. By an examina- tion of the character of the cells in the discharges, it has been found to affect, more or less, the whole of the alimentary canal, from the fauces to the rectum. (Burnett, Am. Journ. of Med. Sci, N. S., xviii. 283.) In the account of the urine and of the urinary mucous membrane in cholera, it was stated that the former contained epithelium from all parts of the urinary passages, and that the latter, whether of the kidneys, ureters, or bladder, exhibited the same consistent coating which is found in the bowels. This has, in like manner, been ascertained to consist of detached epithelium; and even the tubuli uri- niferi are found gorged with imperfectly developed epithelial cells. Professor Walther, of Kieff, in Russia, has extended these investigations to the bron- chial mucous membrane, and discovered in the frothy fluid after death in the air passages, large quantities both of the flat epithelial cells of the pulmo- nary air vesicles, and of the cylindrical cells of the bronchial tubes; proving that the epithelial lining of these tubes, as well as that of the air vesicles, is very much disturbed. (Arch. Gen., 4e ser., xxiv. 167.)f After death in the stage of reaction, the phenomena are entirely different * See the Report of the Committee in the Summary of the Transactions of the College of Physicians of Philadelphia, vol. iii. p. 35. The committee consisted of Drs. Samuel Jackson, John Neill, Henry H. Smith, and Wm. Pepper. Dr. Neill made the requisite anatomical injections and preparations. f It has been said, in opposition to the above views, that this desquamation takes place as a post-mortem result of maceration of the membrane in the intestinal liquids; but this conjecture is incompatible with the observations made on the cholera discharges which occur during life; and, besides, did the desquamation arise from this cause, it would be frequently met with in an equal degree in other diseases, which is not the case. (Note to the fifth edition.) CLASS III.] EPIDEMIC CHOLERA. 723 from those of the collapse, but vary with the length of time which has elapsed from the commencement of that stage. The bladder has now resumed its dimensions, the viscid condition of the peritoneum, if previously existing, has disappeared, the venous injection has partially or wholly given way, the blood has lost some of its blackness and viscidity, though still not restored to its healthy state, and the rice-water contents of the bowels have given place to bilious and bloody fluids. Instead of the dark shade of venous congestion, there is now the vivid redness of unequivocal inflammation in the alimentary mucous membrane, which is also sometimes softened or otherwise changed; and the mucous follicles exhibit marks of incipient ulceration. Lesions in the various nervous centres and their investing membranes, such as might be expected from the symptoms during life, and not unfrequently evidences of inflammation of the lungs, are observed. Causes.—The essential and specific cause of this form of cholera is un- doubtedly a peculiar epidemic influence. Various circumstances increase the susceptibility of the system to this influence; and many others hasten the attack, or call into operation a tendency originating in the specific cause, which without them might remain quiescent, and ultimately pass away. The former may be considered as predisposing, the latter, as exciting causes; but neither the one set nor the other, nor both combined, are alone adequate to the production of the disease; while the epidemic influence is capable of producing it altogether unaided. The nature of the specific cause is unknown. In the minds of the specu- lative it has been vaguely associated with astral influence, the approach of comets, the conjunctions of the planets, various meteoric phenomena, the presence of ozone in the air, and peculiar electrical states of the atmosphere; but no facts exist to prove anything more than a mere accidental connection between these circumstances and the appearance of cholera, and nothing cer- tainly to authorize the suspicion, that they stand towards each other in the relation of cause and effect. That terrestrial exhalations of the nature of miasmata cannot be the epidemic agent is inferrible from the fact, that the disease appears in ships at sea, in sandy deserts, and in the depths of a Russian winter. Chemical analysis, and the closest examination by the senses, have been able to detect no new ingredient in the cholera air, nor any deviation in the proportion of its ingredients from the ordinary standard. Some have been disposed to refer the results to invisible animalcules; and the apparently whimsical march of cholera—its rapid advances, long pauses, and sudden resumption of movement; its distant excursions from the regular line of march, its frequently capricious choice of localities, and the occasional deviation which it exhibits from every general rule of government—would seem to have some analogy with the uncertainty of will, which often charac- terizes animal migrations. In opposition to this hypothesis, the fact has been advanced, that the cause of cholera, whatever it may be, withstood the seve- rity of the winter at Moscow; but this has less force when we consider the uniform heat maintained by the Russians in their vast houses, so that the supposed animalcules might be conceived not only to live, but even to pro- pagate within the walls of a large city. The spread of the cause of cholera in opposition to winds, may also be thought to imply some inherent power of movement in the cause, such as belongs to animals. Another interesting fact, in its bearing on this point, is the influence of elevation on the operation of the cholera cause; the mortality from this disease being inversely as the height of the region affected.* The cause, if animalcular, would be apt pre- * In the Registrar-general's Report on cholera in England, for the year 1818-9, it is stated that the mortality, in the 19 highest districts, was 0-33 per cent, of the popu- 724 LOCAL DISEASES---DIGESTIVE SYSTEM. [PART II. ferably to occupy the lower elevations for two reasons; first, that less effort is requisite to maintain the position, and, secondly, that the organic ingredients of the atmosphere which may be supposed necessary to support insect life are here most abundant. Still, it must be confessed that the opinion is entirely without proof; as these animalcules have never been detected. Equally with- out proof, though not without some plausibility, is the doctrine put forth and supported by Dr. Cowdell, that the disease has its origin in invisible atmo- spheric fungi. The reader need scarcely be told, that much interest was some time since excited by the asserted discovery of the choleric fungus in the air and the water of the vicinities where the disease prevailed, and in the evacu- ations of cholera patients ; nor that this supposed discovery has been since entirely exploded by more accurate investigations. This epidemic influence is more analogous, in its movements, to that which produces the epidemic catarrh or influenza than to any other known cause of disease; but it differs also from that in its somewhat less rapid and much less sweeping march; the cause of cholera seizing only upon certain localities in its course, and leaving many others untouched, while that of influenza scarcely passes a spot, how- ever secluded, without giving some evidences of its visitation. The hypothesis that cholera is propagated by contagion has not been with- out numerous advocates. In favour of this the facts have been adduced ; 1. that it travels along the lines of commercial intercourse, as in the course of large streams, in the track of caravans, and from port to port across seas or oceans ; 2. that its rate of advance never exceeds the possible rapidity of human progression; 3. that its occurrence often succeeds the arrival of an infected ship, caravan, or corps of marching soldiers ;'and 4. that its attack is not general in the beginning, but, whether in a city or a particular family, one or a few are seized at first, and then others successively, as if the cause had passed from individual to individual. But it will be perceived that these are not proofs of contagion, but only evidences, so far as they go, of the pos- sibility, or at best of the probability of its existence ; and it is not difficult to explain them without recourse to such an hypothesis. Thus, if the disease prefers the course of streams, this may well be in consequence of the known affinity of its cause for low, damp, and marshy situations ; if it is observed especially along the routes of inland trade, this may be owing to the circum- stance, that the largest and most conspicuous towns, which it is apt to select, are upon these routes, while remote spots which it also visits are less open to observation ; if it passes from an infected port to other transmarine ports between which there is commercial intercourse, the fact could scarcely be otherwise if it travel at all, so intimately are all parts of the world associated in the meshes of a universal traffic ; if its arrival is often preceded by that of a ship or of travellers from an infected place, this may well be the result of accident, and very often no such connection can be traced, while inter- course of the kind is constantly carried on, without the conveyance of the disease ; and, finally, if it sometimes attacks one person after another, instead of all simultaneously, this is nothing more than often occurs in the operation of morbid causes confessedly non-contagious, and is not always true of cholera which occasionally prostrates multitudes at one blow. The case made out by the contagionists, therefore, fails of adequate proof. There are circum- stances, moreover, in the course of cholera, which cannot be explained upon their hypothesis. If propagated by contagion, why should the disease at one lation, while in the 19 lowest it was 1 per cent., or three times greater; and notwith- standing various disturbing influences, this inverse ratio was observed with remarkable exactness, even with differences of elevation not exceeding 20 feet. (See Brit and For Med.-Chir. Rev., July, 1852.) CLASS III.] EPIDEMIC CHOLERA. 725 time march with an awful rapidity, and at another halt for years upon the confines of countries, open to a constant intercourse with the infected terri- tory ? Why should it suddenly seize upon a certain district, rage fiercely for ope or two months, and then leave it altogether ? Why should it attack large cities, and often let the surrounding and closely associated rural villages go free ? How, in fine, does it happen that a distinct line is sometimes drawn between the infected and uninfected neighbourhoods; that a low damp spot is desolated, while a neighbouring height is in safety; that even the upper and lower stories ofthe same house should be in opposite conditions in this respect; while in all these cases there is no suspension of intercourse ? The strictest quarantine regulations have often signally failed. The disease has laughed at walls, guards, and legal penalties.* It may be said that, like scarlet fever, it may be the result of an epidemic cause, and yet capable of propagating itself by contagion after it has been produced. But attempts of the most varied kind have been made to impart it by inoculation, and by introducing its differ- ent products in every way into the system, altogether without success. The sucking infant has failed to receive the disease from its mother. Physicians and other attendants upon the sick are not attacked in larger proportion than the rest ofthe population ofthe same class, similarly exposed in other respects. In hospitals situated in uninfected neighbourhoods, the attendants escape altogether. Individuals affected with the cholera do not become centres of a new infection, when removed to healthy situations. Some few instances have been adduced in opposition to this statement; but their force is entirely lost in the overwhelming numbers of those which might be advanced in support of it; and the very incidents so much relied on are, in fact, either misinter- preted, or offer only such coincidences as happen in all epidemics, and have led to the belief, at one time or another, in the contagiousness of every epi- demic disease, even of influenza. When the disease invades cities, it very generally attacks individuals in quick succession, at distant points, and with- out any previous communication, Thus it acted in Londonf in 1848, in Philadelphia J in 1849, and in Memphis§ in December, 1848. These facts are, I think, sufficient to prove that it is in no degree contagious. Perhaps it may be thought, on first view, that the occurrence of cholera at New York and New Orleans, in December, 1848, affords proof of its propa- gation by contagion. I think that exactly the reverse is the case. The reader is requested to revert to the short history of those two invasions of the disease already given. A ship sails from Havre for New York; the people of the for- mer town, and her own crew and passengers being quite free from the disease. * In the summer of 1853,* I was in Stockholm; and at that time there was not a case of cholera in that city, or, so far as was known, in all Sweden. It had, however, reached the opposite coast of Finland in its westward march from Russia. The most rigid quarantine regulations were inflexibly enforced to prevent communication with the places where cholera prevailed, sufficient to exclude any contagious disease, even smallpox. I had occasion to leave Sweden, and was absent for a month in Russia, and other parts where cholera more or less prevailed. On my return, though the steamship in which I was a passenger had no case of cholera on board, and had never had any, yet, as she came from a Prussian port supposed to be infected, she was placed in quarantine in the bay more than twenty miles from Stockholm, and none of the passen- gers were allowed to go beyond the limits of a small uninhabited island, which consti- tuted the quarantine ground. Here I remained till the ship returned to Prussia. Yet at that very time the cholera had broken out in Stockholm, and soon raged with great violence. It had passed over the gulf directly from Finland, wholly regardless of the legal obstacles. (Note to the fourth edition.) f Parkes. Lond. Med. Gaz., July, 1S49. p. 157.) % Condie, Am. Journ. of Med. Sci., N. S., xix. 457. \ Shanks, Ibid., xviii., 13. * This was printed, by mistake, 1850, in the fourth edition. 726 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. When sixteen days at sea, she is attacked with cholera. Assuredly, the dis- ease could not have arisen, in this instance, from contagion. Even the six- teen days, without claiming a longer exemption from any possible exposure, are too long a period of incubation to admit of this idea. She arrives at the quarantine ground and lands her passengers. A few persons are attacked with cholera in the vicinity. But, according to the report of the attending physi- cian, it was not the individuals most exposed to the sick who were especially attacked.* Nor did the disease spread in Staten Island beyond the boundaries of the quarantine, though more than one hundred of the passengers scaled the walls, and were distributed in the villages around. Three cases only occurred in the city of New York, one of which was in a crowded and filthy house con- taining two hundred inmates, among whom the disease did not spread, f In a short time, the disease disappeared both from Staten Island and the city. These facts appear to me to be incompatible with the idea of contagion. Cer- tainly, there is no other contagious disease which would have pursued the same course. It may be said that the contagion is inoperative in cold weather. If so, it is the only known and admitted contagion that is so. Again, it may be said that the contagion is effective only in certain favourable conditions of the atmosphere. The same reply may be made, that the fact is true of no other. At the utmost, all that the advocates for contagion can claim from the above incidents is, that the disease has an extremely feeble power of propaga- tion, which can operate only under circumstances peculiarly propitious to it. But what of the vessel which sailed from the same French port to New Or- leans ? In this, the passengers were not attacked until they had been at sea twenty-six days. It is utterly impossible that they should have brought the disease with them from Europe. On their arrival at New Orleans, the cholera broke out in a very few days, and with a fearful rapidity spread not only through that city, but through the valley of the Mississippi. Never did contagion pro- pagate itself so rapidly as this. If this was the cause of the spread of cholera on that occasion, it must be infinitely the most contagious disease that was ever before known, immeasurably more so than smallpox, itself perhaps the most contagious of all diseases. How can this idea be reconciled with the incidents at New York ? To believe that cholera was propagated by contagion in these two instances, is to believe that it is at once the most and the least contagious of all known maladies. How then, it may be asked, can the occurrences on these two occasions be explained ? Simply, thus. The cause of cholera, whether organic or inorganic, is self-propagating. In favourable states of the air, it has the property of producing its like, and that with the rapidity of animalcular reproduction. The two vessels, departing from a healthy port in Europe, entered at a certain period of their passage the cholera atmosphere, which, in the regular progress of the epidemic, was making its way westward over the Atlantic. With this atmosphere, impregnated with the germs of the cholera cause, the whole capacity of the two vessels was thoroughly imbued. They outsailed the advancing column of aerial poison, and carried the germs of it with them to the places of their destination. At Staten Island, these germs propagated in the air; but the reproduction soon ceased, either through the influence of cold, or from the want of a due medium for the process. At New Orleans, on the contrary, finding favouring influences in the hot weather, and probably in the state of the atmosphere, the cause multiplied with vast rapidity, and, being carried by the steamboats up the river, diffused itself in the towns which stud the banks of that river and its tributaries. It did not cross the Alleghanies, because there were no boats to convey its aerial germs * See a communication by Dr. Sterling, in the New York Journ. of Med., N S iii 25 f New York Journ. of Med., N. S., ii. 97. CLASS III.] EPIDEMIC CHOLERA. 727 over the hills. Individuals, in numerous instances, brought the disease with them to the villages on this side of the mountains, and died with it; but they did not propagate it, because it is notcapable of being propagated by contagion. It is not impossible that individuals, fresh from a highly charged cholera atmo- sphere, may carry the germs with them, in their clothing, for a short distance, and thus be the means, in some rare instances, of spreading the disease; but this is not contagion. The effect would ensue as well from a healthy as from a diseased person. It will be remembered that, in the spring of 1849, the epi- demic attacked the Atlantic sea-board, and thence spread into the interior. This was in the regular course of its progress. The column of morbific in- fluence through which the ships had passed, and which they had outsailed, had now reached our continent. I have dwelt longer on this subject, because of its importance. A belief in the contagiousness of cholera has done vast mischief by bringing our fears into conflict with our duties to the sick; and it is, beyond all calculation, important to the interests of humanity, that this dread of contagion, if really unfounded, should be believed to be so. The predisposing causes are very numerous. Whatever is calculated to diminish the vital energies, or to reduce the vital actions below the standard of health, may be ranked among these causes. Not only are debilitated in- dividuals in greater danger when labouring under the disease ; they are also much more liable to its attack. Previous disease, old age, intemperance, vicious indulgences of all kinds calculated to impair the health, deficient ali- mentation, an exclusive vegetable diet, confined air, especially in low and damp places, the effluvia of crowded residences, continued grief, fear, anxiety, and other depressing emotions ; all these predispose to cholera. Nor are the exciting causes less numerous. Indeed, the two sets of causes often act interchangeably, those which in some cases excite the disease, pro- ducing a predisposition to it in others, and vice versa. Whatever makes a sudden and powerful impression on the system, and whatever irritates the stomach, may convert a tendency to cholera into its reality. One of the most common exciting causes is a sudden exposure to cold when the body is warm and perspiring. Hence, in part, the injurious effects of the night air and of damp places. Sudden and strong emotions often bring on an attack. Indi- gestible food, such as unripe fruit and crude vegetables; excessive eating even of wholesome food ; unwholesome drinks, including impure water, cider, poor wines, and imperfectly fermented liquors of all kinds ; very cold drinks and ices taken too freely, especially when the body is heated; purgative medicines, particularly those of a drastic character; these, and many other causes, operating in a similar manner, are capable of exciting the disease in persons previously exposed to the specific influence. From a combination of these causes it is, that the ravages of cholera have been experienced especially by the poorest and most wretched of the popula- tion, in every country; by the intemperate, the debauched, the ill-fed and ill-clothed, the badly lodged, the over-worked, the tenants of prisons and almshouses, the inhabitants of crowded and filthy suburbs, or of miasmatic districts, soldiers fatigued by long marches, sailors shut up in the holds of ships and garrisons crowded in damp and badly provided camps or fortresses. In India, the natives, who live chiefly on vegetable food, suffered much more than the'Europeans. In Havana, the proportion of deaths to the population was, among the coloured people in general, more than twice as great, and among the free African negroes, who are probably the worst provided, about four times as great as among the whites. In cities, it has almost always been the lowest, dampest, most crowded, and most filthy sections that have suffered first and most. In general, the well provided classes of society have suffered little in any country, though there have almost everywhere been 728 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. occasional exceptions to this rule. The ravages in different countries or sec- tions of the globe have borne, in general, an inverse proportion to their well-being. Thus, Asia has suffered more than Europe, and Europe more than North America. The time requisite for the production of cholera, after exposure to the epi- demic cause, is indefinite, but often very short. Instances are on record, in which persons, arriving in perfect health in an infected neighbourhood, have been attacked within two or three days, and even within a single day from the time of their arrival. Nature.—The most opposite opinions have been entertained as to the na- ture of the disease. While some have maintained that it is essentially irritation or inflammation of the alimentary mucous membrane, and that all the phenomena have their root in this primary affection ; others have asso- ciated with this pathological condition, as the direct result of the same cause, a deranged state of the nervous functions, and especially those of the gan- glionic system; and others again have rejected altogether the notion of gastro- enteritis, ascribing the phenomena to the combination of a sedative action of the specific cause upon the functions of organic life, with an irritant action upon those of animal life. (Hodge, Am. J. of Med. Sci, xii. 386.) That an irritation of the stomach and bowels exists in cholera can scarcely be doubted. How else can we explain the great abdominal uneasiness, the frequent burning pain in the epigastrium, the antecedent diarrhoea, nausea, and vomiting, and the unequivocal evidences of positive inflammation which are presented after reaction, both by the symptoms and upon dissection ? How else, moreover, explain the action of the various exciting causes, most of them of a directly irritant character ? Is it not by producing or augment- ing irritation, that indigestible food, and active cathartics so often induce an attack of the disease ? But that the affection is a pure gastro-enteritis, ap- pears to be contradicted by all the results of previous observation. We had long been familiar with every shade and variety of inflammation of the ali- mentary mucous membrane; but when had we ever before met with the phenomena of malignant cholera ? Every candid practitioner will, I think, admit that, though he may have seen instances of disease bearing some analogy with this, it struck him, on the whole, when he first saw it, as some- thing new to his experience. Examination of the bodies of those who die in the cold stage reveals no uniform and unequivocal evidences of inflammation. The injection of the mucous membrane is venous or capillary. The same injection is found, though in a less degree, in the skin, the bronchial tubes, and the parenchyma of various organs. The apparent deposit upon the sur- face of the membrane is not fibrin, but mainly the epithelium, separated by the gushing forth of the watery liquid from the blood-vessels. The vesic- ular appearance noticed by Dr. Horner is ascribable to the same cause. The enlargement of the intestinal follicles may depend in part on conges- tion, in part on the separation of epithelium. Besides, in some cases of speedy death, no signs whatever of organic change are observed, to which the symptoms could be ascribed. Inflammation takes place after reaction, and sometimes proves fatal; but the proofs are wanted of its existence, in any considerable degree, during the first stage, or that of collapse ; and the pro- babilities are wholly against it. If there is so violent an inflammation as to produce death in a few hours, how does it happen that the simple measures employed often so readily arrest it, upon the borders of collapse ? Do we see inflammation of such intense severity give way so easily under other cir- cumstances ? If these considerations are of much weight, the inference is, that in cholera there is an irritation, sometimes possibly a moderate or par- CLASS III.] EPIDEMIC CHOLERA. 729 tial inflammation of the gastro-intestinal mucous membrane; but not that intense degree of inflammation which would be implied by the notion that it was_ the essential basis of the disease. But, admitting the existence of irritation, we shall not find this sufficient to account for the phenomena. Even supposing it to be directed especially to the secretory function, still, it is contrary to all our experience of this affection, that it should produce and sustain a secretion so immense in amount, continuing too, even when the pulse has almost ceased to beat, without the co-operation of some other morbid influence. Besides, the excess of secretion is not confined to the alimentary canal. The perspiration is in some instances scarcely less profuse ; yet no one could suppose the existence of cutaneous inflammation. A whitish coating, similar to that of the alimentary mucous membrane, is often found also in the urinary passages; but these are not supposed to be irritated or inflamed. There is some cause, therefore, disposing to this ex- cessive elimination of watery liquid, and especially to this exfoliation of the mucous epithelium, other than a mere excess of excitement. What this cause is, or how it operates, is not so easily determined. The probability is, that a poison is taken into the system, capable of producing a profound im- pression on all its parts; and that, among its effects, is either such a relaxa- tion of the exhaling pores as to admit the ready passage of the more fluid parts of the blood, and sometimes of the red corpuscles themselves, or such a modification of the circulating fluid as to cause it to pass through the struc- tures which ordinarily retain it, or else a combination of these two condi- tions. The effect of extirpating the coeliac plexus in producing intense hy- peremia of the intestinal mucous membrane, as demonstrated by Dr. S. Samuel (Banking's Abstract, Am. ed., xxvi. 288), is very significant in this relation. If the poison has the property of directly paralyzing the sympa- thetic ganglia, an easy explanation is given, upon the basis of these experi- ments, ofthe congestion ofthe alimentary mucous membrane, and the profuse elimination of watery liquid from its vessels. It is also highly probable that other phenomena in the disease are due to the same unknown cause. It is true that the immense loss of fluid from the alimentary canal and skin will account for most of the symptoms of the collapse. The blood is thus ren- dered black, thick, and viscid, and circulates with difficulty through the ves- sels. It loses its capacity of absorbing oxygen, and, no longer changing from venous to arterial, ceases to support the temperature of the body, or to stimulate the heart to contraction. Hence the failing circulation, the stag- nation in the capillaries, the blue skin, the feeble and hurried respiration, and the universal coldness. The more elaborate secretions, as those of the bile, urine, and tears, cease because the serous part of the blood finds an easier outlet through the exhaling surfaces. The whole body shrinks from the exhaustion of its fluids; and the same cause gives rise to the intense thirst, which is only the want of the whole system expressing itself through the fauces. But the nervous phenomena do not admit of the same solution. It is quite doubtful whether they depend upon the condition of the alimen- tary canal, as they are often worst when that structure is least obviously af- fected. Nor is it certain that the symptoms of collapse are always dependent on the alvine discharges. It is not improbable that the exfoliated condition of the epithelium in the pulmonary air vesicles may contribute to it, by pre- venting the due circulation and change of blood in the lungs, and thus pro- ducing a true asphyxia. Cases have frequently been noticed, in which fatal collapse occurred with little or no evacuation from the stomach and bowels ; and though, in these cases, the same peculiar fluid was found in the bowels after death, yet the quantity was scarcely sufficient to account for the symp- 730 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. toms. We are driven, therefore, to the supposition, that the poisonous cause is capable of producing all the characteristic phenomena of cholera by its direct action. What is the precise nature of this action cannot be said ; but the nearest approach to a rational explanation appears to me to be that which considers it sedative to the functions under the control of the organic nervous centres, but irritant to the alimentary mucous membrane, and per- haps to the mucous membranes generally. This is similar to the poisonous action of tartar emetic, which depresses the circulation, while it irritates the lining membrane of the stomach and bowels ; and the case of disease, which, within my observation, has approached nearest to the collapse of cholera, and which resembled it so closely as to have been mistaken for it at first by a practitioner who had much experience in the complaint, occurred in a female who had taken a poisonous dose of that antimonial. By many, the epidemic cholera is believed to differ from ordinary cholera only in its violence. There is undoubtedly considerable resemblance between the two affections; but I nevertheless believe them to be distinct. In cholera morbus the evacuations are generally bilious, in epidemic cholera they are rarely so. This difference has been ascribed to the greater severity of the latter complaint; and it is stated, in support of this view, that bile often ap- pears in the discharges of epidemic cholera, when it begins to moderate. But the distinctive sero-albuminous character of the dejections in this affection is observed even in very mild cases, which yield readily to treatment, and which are certainly less violent than the higher grades of cholera morbus. Were the two affections identical, there ought to be a point, in their respective grada- tions of severity, in which they should exactly coincide. Though I have seen much of cholera morbus, both in public and private practice, I have not met with a case exhibiting exactly the rice-water evacuations ofthe epidemic dis- ease. There is often great and sometimes fatal prostration in the former affection ; but the blue skin, the shrivelled extremities, the universal shrink- ing away of the flesh, and the peculiar mental apathy, are generally, if not always wanting; and the neuralgic and spasmodic symptoms, if present, are so in a much less degree. The differences in the seasons at which they oc- cur, and the persons they attack, the situations they respectively affect, their cause, course, and termination, are other reasons for considering them as essentially distinct affections. Prognosis.—Treated in the forming stage, while yet in the state of diarrhoea or cholerine, the disease can almost always be arrested. Even when com- pletely formed, if not advanced to the stage of collapse, it terminates favour- ably, under appropriate management, in the vast majority of cases. But in the collapsed state, with the fluttering or absent pulse, the cold and leaden sur- face, the suspended capillary circulation, the sunken and inexpressive features, and complete mental apathy, the patient is already in the grasp of death, and medicine can be of little avail. Very few rise out of this condition, when completely formed ; and the danger is in proportion to the degree in which it is approached. From the rapidity of the disease, and the destitute state of many of those most exposed to it, the patient is very often reduced to this condition of collapse before medical aid can be obtained. Hence the great mortality of this fearful epidemic. The published reports of cholera often have reference to the disease as witnessed in hospitals, or other public insti- tutions, where the worst cases are crowded together, and not unfrequently in the last stage. The inmates of these institutions are, moreover, very fre- quently of the classes least able to resist the complaint; such, namely, as are already debilitated by age, disease, want, excessive fatigue, or intemperance. Among these, cholera has always made terrible havoc. It is not surprising, therefore, that the published records give a fearful proportion of fatal cases! CLASS III.] EPIDEMIC CHOLERA. 731 In some instances, almost all seized with the disease have perished. Out of 1,381 patients at Dantzic, during the first epidemic, only 377 recovered. Of those attacked in the Polish army more than one-half died. The same was the case in the hospitals of Paris. During the epidemic of 1854 in London, 46 per cent, of the recorded cases died. In New York, the ratio of deaths was one-half, in Philadelphia, one out of two and a half. (Am. Journ. of Med. Sci, xi. 292.) But this gives an unfair view ofthe mortality, at least as the disease prevailed in the United States; for a great number'of mode- rate cases which recovered were not reported. From my own observation, and the published statements of others in relation to their private practice, I should infer that the proportion of recoveries, even from well-marked cases of the disease, was vastly greater than that above given. In almost all instances, the amount of fatality was greatest at the commencement of the epidemic, and gradually declined with its continuance. It was no uncommon circum- stance for almost every individual to perish of those who were first attacked. The rate of mortality in subsequent epidemics has been, on the whole, very nearly as in the first. In forming an estimate of the probable result, in any particular case, all these circumstances are to be considered. In the early stages, before the symptoms of collapse have come on, in a young or middle aged, previously healthy and robust individual, and especially if the case occur in the decline or towards the close of the epidemic, a favourable termination may be rea- sonably expected. If, during the collapse, the pulse begin to rise, the skin to become warm, and the secretion of bile and urine to return, there is hope for the patient; though, in giving an opinion, it is necessary to bear in mind the great dangers of the state of reaction. When the attack is violent, and hastening into collapse, or this condition has already occurred, and when the seizure has taken place at the commencement of the epidemic, in an individ- ual more than fifty years old, or previously much debilitated from any cause whatever, the most serious consequences are to be apprehended. Dryness of the cornea, ecchymosis of the conjunctiva, and a perfect stasis of blood in the capillaries, as indicated by the want of any change of colour in the gums or inner surface of the lips upon pressure with the finger, are certain signs of approaching death. Treatment.—The plans of treatment which have been employed in epidemic cholera are almost as numerous as the combinations of which remedies are susceptible ; and, judging from the reports upon a great scale, there seems to have been little difference in the results; for the proportion of deaths has generally varied from one-half to one-third, no matter what was the locality, or what the means of cure resorted to. This apparent uniformity has no doubt arisen in part from the circumstances, that, of the cases reported, a very large proportion was utterly beyond the reach of remedies, and that, in any particular place, the favourable and unfavourable results of the different modes of treatment pretty nearly counterbalanced each other. When, however, a discriminating view is taken of the whole ground, and the published results of individual practitioners or individual institutions, in connection with the treatment employed, are compared, we still find insuperable difficulties in coming to a just conclusion as to the most effective plan; great success being often claimed for the most different, and even opposite remedies, by their respective advocates. In deciding, therefore, for himself, the physician is necessarily thrown off of the ground of general experience upon that of prin- ciple, and his own individual observation. I shall first give a sketch of the plan of treatment suggested by a judgment formed upon this basis, and after- wards a detail of various other plans, recommended by their apparent merits, or the testimony in their favour. 732 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. In the absence of any certain pathology of the disease, the efforts of the practitioner should be directed to the correction or removal of obvious disor- der of the functions, and thus to put the system as nearly as possible into its normal condition. The indications of treatment, in the first and second stages of the disease, deducible from the obvious phenomena, are to arrestthe evacuations from the stomach and bowels, to relieve irritation of the gastro- intestinal mucous membrane, to restore the suspended secretions, especially that of the liver, to equalize the circulation, to relieve the nervous disturb- ance, and to support, when necessary, the general strength. Of these, the most important is to arrest the alvine evacuations; for it is by their continu- ance and increase, that the fatal condition of collapse is generally induced. But the measures best calculated to answer this indication are such as will meet, to a certain extent, most of the others also; as the evacuations, if not the result of the irritation, are probably promoted by the sanguineous con- gestion which it induces; and the restoration of the suspended secretions, and the equalization of the circulation, must have a tendency to diminish this congestion. Among the remedies best calculated to meet the above indications are opium and calomel, in small and frequently repeated doses, combined, when the discharges are copious, with acetate of lead, and, in addition, if this should prove insufficient, with tannic acid, kino, catechu, or the extract of rhatany. Very large doses of opium are considered, and probably are injurious, by ob- tunding the nervous system below the point of necessary impressibility, and thus inducing torpor and even coma, and favouring congestions of the brain and other great internal organs. In moderate doses, on the contrary, it proves highly useful by checking exhalation into the bowels, determining to the sur- face, relieving pain and allaying irritation, and sustaining a gentle, general, diffusive excitement. Minute and frequently repeated doses of calomel have the effect of stimulating the hepatic secretion, without irritating the stomach. It is, indeed, highly probable that they have a tendency directly to allay gas- tric irritation; and, if the general mercurial influence is induced, it may prove useful not only by changing the existing morbid action, but also by obviating, in some degree, the danger of inflammation in the fourth or last stage. The mercurial pill may often be advantageously substituted for calomel, in equiva- lent doses. Acetate of lead acts by the combination of astringency with a directly sedative influence upon the mucous membrane; tannic acid, kino, catechu, and extract of rhatany, by their astringency alone. The mutual re- action of these substances, though resulting in the formation of new com- pounds, does not by any means necessarily imply a therapeutical incompati- bility. In relation to the combination and exact dose of the above remedies, the practitioner must be guided by the degree of severity, and the peculiar circumstances of each particular case. In the mildest cases, opium and calo- mel may be employed alone; in those of a higher grade, the acetate of lead should be added; and in the most obstinate, all should be given simultane- ously. The dose should be such as to admit of repetition every half hour or hour, during the height of the disease; after which the interval may be gradu- ally lengthened.* From one-twelfth to one-half of a grain of opium, from .* The following are convenient formulae. R—Opii pulv. gr. j; Hydrarg. Chlorid. Mit. gr. ij ; Acacise pulv., Syrup., aa q. s. Fiant pil. no. xii. S. One every half hour, or every hour. R._Opii pulv. gr. j; Hydrarg. Chlorid. Mit, gr. ij ; Plumb. Acetat. gr. xij ; Acacise pulv., Syrup., aa q. s. Fiant piluloe no. xij. S. One every half hour, or every hour. R—Opii pulv. gr. j ; Hydrarg. Chlorid. Mit. gr. ij ; Plumb. Acetat. gr. xij; Kino pulv. £j ; Acacise pulv., Syrup., aa q. s. Fiant pil. no. xxiv. S. Two every . half hour, or every hour. It should be recollected, as stated in the text, that, in urgent cases, a larger dose than any above indicated must be given at first, so as to produce a CLASS III.] EPIDEMIC CHOLERA. 733 one-sixth of a grain to one grain of calomel, from one-third of a grain to two grains of acetate of lead, and from two to five grains of kino or extract of rhatany are suitable quantities; and they are best given in the pilular form. The first dose or two of opium may be larger, say from half a grain to a grain or more in threatening cases, in order to produce a prompt impression, which may be afterwards sustained, if necessary, with the smaller doses. During the administration of the above remedies, the patient may be al- lowed to swallow frequently very small quantities of cold carbonic acid water, which tends at the same time to relieve the burning thirst, and allay the vomiting. If this cannot be had, small doses of the effervescing draught may be substituted. A little very cold water every now and then, or small pieces of ice, will be found very grateful to the patient. Whatever liquids are administered should be cold, as heat increases the thirst, and already in- tolerable burning of the stomach. Lime-water and milk are sometimes useful in allaying the gastric irritation ; and some of the aromatic waters may be employed for the same purpose. In cases requiring stimulation, the aromatic spirit of ammonia will often admirably answer both indications. At the same time, a sinapism of pure mustard should be applied over the epigastrium; and the effects of opiates given by the mouth should be aided by enemata of from forty to sixty drops of laudanum, with mucilage or thin starch. I wish particularly to impress on the young practitioner the importance of an early resort to the sinapism and anodyne enema, as here advised. To equalize the circulation and nervous excitement, efforts should be made to bring about action upon the surface of the body. For this purpose, dry heat, and moist heat by means of the warm bath or vapour bath, have been recommended. These may sometimes be advantageous in the earlier stages; but, at a more advanced period of the disease, when they would seem to be yet more strongly indicated, experience has not pronounced in their favour. Though the surface maybe cold, the patient has not unfrequently an opposite feeling, and suffers greatly from hot applications. These, moreover, are apt to increase the perspiration, already in many instances exceedingly abundant, and thus to aid the alvine evacuations in the exhaustion of the serous portion of the blood, and consequently to hasten the collapse. Hot pediluvia, ren- dered stimulating with mustard, Cayenne pepper, or common salt, maybe used in all cases in which the extremities merely are cold. The best mode of effect- ing a centrifugal excitement is by moderate frictions over the surface, either by the hand alone, or with flannel, coarse towels, or a flesh-brush, or in con- nection with rubefacients. Care must be taken to avoid injury to the skin by the violence of the friction. This remedy often affords great relief to the cramps. Frictions over the whole surface of the body with mercurial oint- ment, mixed with half its weight of camphor, and one-quarter of its weight of Cayenne pepper, urged to salivation, were employed with the happiest re- sults by Dr. Lee, of New York. (Am. Journ. of Med. Sci, x. 544.) Peculiar circumstances may require additional remedies. In those rare cases in which the pulse is full and strong, especially if connected with con- vulsive symptoms, blood should be taken from the arm. Leeching to the epigastrium is indicated in the earlier stages, when there is tenderness with burning pain in the stomach. Prostration must be obviated by the diffusible stimulants, especially in intemperate persons, though little good can be ex- pected from these remedies in the state of collapse. Tincture of camphor, aromatic spirit of ammonia, and the ethereal preparations are among the best. prompt impression, which is afterwards to be maintained by the smaller doses. Thus, the first dose or two may consist of half a grain or a grain of opium, with two grains of calomel. The blue mass may, in either of the formulae, be substituted for the calomel in three times the quantity; but it is generally less efficient. 734 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. Sound port wine or brandy diluted with cold water, and impregnated with mint or other aromatic, may also be used, though with caution. The cam- phorated tincture of opium is admirably adapted to mild cases of the disease, or to its earliest stage. The cramps may sometimes be relieved by steady and firm extension of the affected muscle. The above remedies must of course be graduated to the severity of the case; and, in the forming stage, while the disease is yet in the state of diarrhoea or cholerine, it may not be necessary to resort to any other remedy than an opiate, with or without calomel or the blue mass, according as the hepatic secretion is or is not deficient. It is, however, of the utmost importance to arrest the dis- ease in this stage, and the simple measures necessary for this purpose become highly valuable remedies. When the stools retain the natural colour, a tea- spoonful of the camphorated tincture of opium three or four times a day, or from five to ten drops of laudanum with a few drops of tincture of camphor, repeated as often, will very frequently be sufficient, along with a proper regi- men, to check the preliminary diarrhoea, and thus ward off an attack of the cholera. Should the stools be white, or very light coloured, the mercurial should be conjoined with the opiate in alterative doses. Should the stomach be loaded with undigested food during the forming stage, the treatment may very properly be commenced with a gentle emetic of ipecacuanha. Should costiveness follow the use of the means requisite for checking the disease, it should be corrected by the mildest possible measures; and rhubarb is perhaps the best laxative for the purpose. In the stage of collapse, the same indications are presented as in the pre- vious stages, with two additional; namely, to check the excessive sweats, and to supply the loss of watery fluid and salts which has been sustained by the blood. There would seem to be even a stronger call for active stimulation; but experience has shown that this measure should be employed with some reserve. In the existing state of the circulating fluid, it can be of little avail, and, when carried too far, it has the effect of still further aggravating the danger, by increasing the already excessive sweats, and exhausting the little remaining excitability of the system. It cannot possibly restore the lost epi- thelium of the bowels, and may possibly sometimes aggravate the inflamma- tion which must necessarily ensue. The stimulants, however, already men- tioned, may be used in small and frequently repeated doses, and continued if found productive of no ill effects. The efforts to restrain the evacuations from the stomach and bowels, if these continue, should not be abandoned; and, though external heat has been found productive of little good, attempts should still be made to excite the surface by frictions and rubefacients. Si- napisms may be applied to the abdomen and extremities, and Cayenne pep- per and brandy, oil of turpentine, tincture of camphor, liniment of ammonia, &c, over the surface of the body. Hot baths, rendered stimulating by com- mon salt, mustard, capsicum, &c, have been recommended. To close the cuta- neous exhalant orifices, astringent solutions may be employed, as of alum; and for the same purpose, as well as indirectly to excite the skin, frictions with ice or iced-water have been strongly recommended, and are often very grateful to the patient. Under the reaction from the cold application, the blueness of the surface gives way to a glowing redness, the temperature is elevated, and the pulse, which may have been quite wanting at the wrist, sometimes returns; but the improvement is too often only temporary. To repair, as far as possible, the loss of water and soluble salts by the blood, the patient should be allowed to drink frequently of carbonic acid water with bi- carbonate of soda in solution, weak animal broths with salt, iced-water, iced brandy and water, gum-water, barley-water, &c.; and enemata of salt water CLASS III.] EPIDEMIC CHOLERA. 735 with laudanum may be occasionally thrown up the bowels. With the same object, saline baths have been employed by some. When reaction has begun the stimulants should be moderated or with- drawn, and attention confined chiefly to the correction of the quality of the blood by the continued use of suitable drinks, and to the obviating of any local irritations which may appear. When reaction is established, the treatment must be made to conform to the variable morbid conditions presented, and must be guided by the general principles applicable to other affections. One fact, however, must be borne in mind, that the inflammations which are apt to occur cannot, in consequence of the previous exhaustion, be treated with the same activity of depletion as under ordinary circumstances. Blood must be cautiously abstracted, and cupping or leeching is in general preferable to the lancet. Reliance must be placed chiefly upon fomentations, blisters, the mercurial impression, and a properly regulated regimen. If a typhoid state of disease appear, it may be necessary to have recourse to tonics and stimulants, as sulphate of quinia, serpentaria, carbonate of ammonia, wine-whey, oil of turpentine, &c, as em- ployed in ordinary typhoid fever. Attention to the diet is very important. In the preliminary diarrhoea, while the appetite continues in a greater or less degree, the food should be of the least irritating and most digestible kind. Stale bread, crackers, boiled rice, milk, cream, light broths, and boiled meats of easy digestion (see Dys- pepsia), may be employed. When the disease is established, the diet should consist of mucilaginous and farinaceous liquids, or very weak chicken or mut- ton water. Milk, in very small quantities, with lime-water, sometimes proves useful both as food and medicine. During convalescence, the utmost caution should be observed to avoid indigestible, flatulent, or irritating substances. The farinaceous preparations, and the lighter kinds of animal food, should be preferred. The dietetic rules given in dyspepsia and chronic gastritis are applicable here.* Much may be done by proper prophylactic measures to avoid the disease or render it milder. The diet should be such as to preserve the digestive or- gans, and the general system, in the soundest possible state, so that they may be neither over-stimulated nor depressed. It should consist of a mixture of vegetable and animal food, avoiding indigestible, flatulent, acid, and irritat- ing substances, but admitting the more digestible fruits, when not forbidden by an already debilitated or irritated condition of stomach. They are useful by obviating costiveness, and the consequent necessity for the use of cathartic medicines. All those drinks should be shunned, which have been mentioned as exciting causes of the disease. Habits of temperance both in eating and drinking are all-important; but, for an individual accustomed to the use of stimulating drinks or food, there might be some danger in a sudden change. A moderate elevation of the vital functions is preferable to their depression; and hence the use of gentle stimulants, such as ginger, mustard, black and Cayenne pepper, in moderation, may prove serviceable. An equable state of mind should be preserved as far as possible; and excessive fatigue, sensual * In the Report on the different Methods of Treatment pursued in Epidemic cholera, pre- sented to the British Parliament in 1855, by the "treatment committee" of the Board of Health it is stated, as the result of an examination of aU the returns, that, of the different modes of treatment, the alterative with opium and calomel, and the astringent with chalk and opium, were the most successful, the latter of these two methods being more successful than the former. I cannot but find this result very satisfactory; as the practice which I have always followed and recommended, as given in the text, is mainly a combination of these two methods, though the astringent remedies recom- mended are acetate of lead and kino, instead of chalk. (See B. and F. Med.-Chir. Rev., Am. ed., July, 1855, p. 108.)—Note to the fifth edition. 736 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. indulgences, exposure to sudden changes of temperature, and especially to the damp night air, should be avoided.* In relation to the various plans of treatment, not included in the above statement, a very general sketch must suffice. Bleeding in all stages of the disease, even in that of collapse, has been the remedy chiefly depended upon by some practitioners. Others have placed great reliance upon emetics of ipecacuanha, mustard, or warm brine; and even purgatives have found their advocates. Nitrate of silver in solution, by the mouth and the rectum, is said to have proved highly beneficial in some cases. It has been given in the dose of one, two, or even three grains, dissolved in one or two fluidounces of water, in cases of approaching collapse, with the apparent effect of arresting the dis- ease. Great success has been claimed for the officinal diluted sulphuric acid, of which twenty minims may be given with a little aromatic addition, in a wineglassful of Water, and repeated after each act of vomiting, or each copious stool, or at intervals of four hours. A mixture of sulphuric and nitric acids has been used, under the name of the Austrian specific. Strychnia, admin- istered in the collapse, is said to have great power of producing reac- tion ; and, though most of the patients die subsequently, yet a more than usual proportion of recoveries from that condition takes place. Thus, out of 22 cases to which this medicine was administered, 19 reacted, and of these only 9 died. (Archives Gen., Aug. 1854, p. 234.) In the East Indies, and subsequently in some parts of the United States, calomel in large doses, with or without opium, has been a favourite remedy; and the quantities adminis- tered with impunity, in certain cases, would seem scarcely credible, were they not well authenticated. Frequent draughts of hot water have been highly lauded, as constituting the most effectual treatment, by one practitioner; while another has spoken, with equal confidence, of the almost exclusive use of cold drinks and cold water, or ice applied externally. Some have relied upon opium, brandy, and other stimulants; the school of Broussais, on the contrary, upon cool and demulcent drinks, leeches to the epigastrium, and the external use of fomentations and rubefacients. Great success has been claimed for a treat- ment, in which the prominent measure was the application of irritants over the spinal column; ammonia, oil of turpentine, or a heated flat-iron being employed for the purpose. Dr. W. H. Lyne, of Livonia, Louisiana, in a communication to the N 0. Med. and Surg. Journ. (xii. 24), states that, having noticed tenderness upon pressure on the spinal column, in a case of cholera, he had subsequently seen about 100 cases, of which only one was without this symptom, and all recovered under a treatment consisting mainly of cupping over the spine, with the subsequent application of sinapisms. The doctrine of Stevens, that the salts of the blood are essential agents of its arterialization, taken in connection with the supposed loss of these salts by the evacuations which occur in cholera, has led to the use, by some prac- titioners, of the non-purgative salts, such as bicarbonate of soda, chloride of sodium, chlorate of potassa, &c, as the main remedy. From the same idea of restoring to the blood the constituents lost during the disease, originated the practice of injecting into the veins, during the collapse, large quantities of warm water, holding common salt and carbonate of soda in solution, in the * Dr. Mitchell, of Trinidad, states that, when the cholera prevailed in that island, the people living near the "pitch lake" La Brea, escaped altogether; and that in the town of San Fernando, the only persons who escaped were inmates of a house around wliich a quantity of asphaltum had been thrown. The immunity in these instances was as- cribed to the protective influence of the odorous emanation from the bitumen. It is an obvious inference that the vapours from coal-tar might prove equally protective. (Charleston Med. Journ. and Rev., x. 559, from the Dublin Med. Press.)__Note to the fifth edition. CLASS III.] CnOLERA INFANTUM. 737 proportion in which these salts are found in the serum of the blood. The happiest effects seemed for a time to result from this remedy; the pulse re- turning, the surface assuming its natural colour and fulness, and the patient reviving into the appearance of convalescence; but the evacuations recurred, and collapse generally ensued, followed by speedy death. The general result of experience as to this plan of treatment has been, that, though in a very few instances recovery has taken place under it from a state of collapse, yet these instances have scarcely exceeded the proportion in which nature un- aided has effected cures, under similar apparently desperate circumstances. Besides the above plans of management, particular articles of the Materia Medica have acquired a more or less diffusive credit with the profession or the public. Among these may be mentioned, chloroform, used by inhalation, Persian naphtha, wood naphtha or pyroxylic spirit, terchloride of carbon, solution of chlorine, tincture of camphor, charcoal, sulphate of quinia in very large doses, valerianate of ammonia, cajeput oil, nitrous acid, gallic acid, and galvanism. But, as before observed, experience has not pronounced so favourably in relation to any of these remedial means, as to obviate the necessity of a recourse to general principles. The author has already given his views as to the course of treatment which these principles appear to him to suggest; and his own experience, so far as it has gone, is in its favour. Article III. CHOLERA INFANTUM. Syn.—Summer Complaint of Children. This affection, though not unknown in Europe, is comparatively so rare as to have escaped the special notice of most of the writers of that continent, and, when it occurs, is merely ranked among the cases of gastro-enteric irri- tation or inflammation to which infancy is subject. Its frequency and great fatality in this country make it an object of strong interest; and both among the profession and the people at large, it is universally considered as merit- ing a distinct designation. The complaint usually affects children between the ages of three months and two years, though instances sometimes occur before the first, and after the last of these two periods. It is exclusively a disease of the warm season, commencing with the first heats of summer, and ceasing upon the occurrence of cool weather in autumn. It is confined, moreover, almost entirely to cities and prevails most in those of largest size, and most densely peopled. Symptoms.—The attack of cholera is often preceded, for a longer or shorter time by diarrhoea; but sometimes the vomiting and purging commence simul- taneously In fatal cases, of short duration, the vomiting usually continues to the end; but when the disease terminates favourably, oris much pro- tracted it very often subsides considerably, or ceases altogether, leaving only the diarrhoea behind. Occasionally the disease is exceedingly violent and rapid; the vomiting and purging are almost incessant; the stomach rejects everything swallowed, even cold water; the intervals are marked by great languor and distress, with more or less spasmodic pain of the stomach and bowels; and, if relief is not afforded, prostration comes on, with a cool and clammy skin pallid and shrunken features, half closed eyes, insensibility amounting at length to coma, and death in three or four days, or sometimes even within twenty-four hours. Much more frequently, however, the attack is attended with febrile symp- vol. i. ^ 738 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. toms, and the case protracted to one, two, or three weeks, or more. In such instances, the pulse is frequent, small, and weak or corded, the mouth is hot, the tongue somewhat furred, and the surface ofthe body irregularly heated; the head and trunk being often above the healthy standard of temperature, while the extremities are cool. Writers in general describe the fever as re- mittent, and state that the exacerbation occurs in the evening. It is some- times attended with delirium or stupor. The abdomen, though usually flat or sunken, is sometimes swollen and painful on pressure. In fatal cases, the vomiting occasionally continues un- abated to the close, with the symptoms already mentioned; but more fre- quently it diminishes or ceases, leaving a diarrhoea, which runs on for several weeks, and gradually wears out the patient. In the progress of the com- plaint, the child emaciates rapidly; the flesh becomes soft and flabby; the skin hangs loosely about the neck; the features shrink greatly; the eyes are sunken; and the whole surface becomes pale, and either cool and clammy, or harsh and dry. In the more advanced stages, various morbid phenomena are presented. The abdomen is tumid or much sunken; the mouth is moist and aphthous, or brownish-red and dry; petechia? occasionally appear upon the surface of the body, and a small vesicular eruption on the breast; the skin sometimes assumes a dull dirty hue, and the conjunctiva appears blood-shot; the emaciation is extreme; the circulation is in the lowest state of languor; the child is often exceedingly restless, rolling the head from side to side and tossing the body in various directions, with moans and plaintive cries; at length coma sets in, and the scene is closed not unfrequently with convul- sions, or apparently hydrocephalic symptoms. Throughout the complaint, the child generally sleeps with the eyes more or less open; there is almost always thirst, which is sometimes insatiable; the appetite is variable and capricious, sometimes wanting, sometimes rapa- cious, and again seeking the most unusual articles of food. The discharges are in a high degree various in character. At first, they consist of the pre- vious contents of the stomach and bowels; and the matter vomited is always liable to be modified by substances swallowed, being frequently mingled with milk, either liquid or in various states of coagulation. The discharge of curdled milk is popularly viewed as an unfavourable sign, but is in fact the reverse, as it indicates the continued possession of a degree of digestive power by the stomach. After the discharge of the ingesta and feculent mat- ter, the evacuations are for the most part thin and copious, sometimes colour- less, but usually more or less tinged green, yellow, or brown, and not unfre- quently deep-green. Along with the more liquid parts, the stools often con- tain concrete or semi-concrete matter, yellow, green, white, or translucent or of these different characters variously combined, and not unfrequently tinged with blood. Sometimes they consist chiefly of slime. At an advanced period they are often copious, and dark-coloured or reddish, like the washings of putrefying flesh. Throughout the complaint, they are either inodorous, or sour, putrid, or otherwise offensive, but seldom if ever have the healthy fecal smell. When the disease has degenerated into a lingering diarrhoea it very commonly happens that more or less appetite remains, without the power of digestion; and the ingesta pass from the bowels little if at all changed. Worms either dead or alive are not unfrequently discharged by stool, or even from the stomach. Dr. Dewees considered the passage of live worms as a very unfavourable sign. The duration of the disease varies from a few hours to weeks or months. When terminating in a diarrhoea, it often runs on for a long time, sometimes improving under treatment, or with the diminished temperature' of the air, and then again relapsing when the favourable circumstances change, until at CLASS III.] CHOLERA INFANTUM. 739 length the system is worn out, or the permanent return of cool weather turns the scale in favour of health. The struggle is often one of time; the aim of the physician being to keep the enemy at bay, until he can receive the aid of the advancing autumnal season. There is scarcely any condition of the disease so desperate as to forbid all hope ; recoveries having occasionally taken place under the most unpromising circumstances. Perhaps the most alarming symptoms are those of hydrocephalus occurring in the advanced Btages. A general subsidence of the morbid phenomena affords, of course, ground for a favourable prognosis; but one of the most cheering signs is a return of the discharges to the healthy condition. Increased liveliness on the part of the child, a regular appetite, and diminished frequency of the evacuations, are also very favourable signs. Anatomical Characters.—According to Dr. Condie, if death takes place early, an unusual paleness of the mucous coat, and more or less hepatic con- gestion, are often the only morbid appearances discoverable. (Diseases of Children, p. 219.) Dr. Hallowed states that there is "undue development of the follicles, both of the stomach and intestines, or of one of those organs, without inflammation of the mucous membrane." (Am. Journ. of Med. Sci, N. S., xiv. 42.) At a more advanced stage, there is generally some indica- tion of inflammation; the mucous membrane of the stomach and bowels ex- hibiting more or less redness in points and patches, and an increased develop- ment of the glandular follicles. Dr. W. E. Horner found the mucous follicles in great numbers enlarged, and even ulcerated, both in the small and large intestines; and in one case he observed small ulcerations of the surface of the membrane in the jejunum. (Am. Journ. of Med, Sci, iii. 253.) The large intestine was in some degree inflamed and softened in almost all the cases examined by Dr. Hallowed. The gastric mucous membrane is some- times very soft, so as to be readily scraped off by the nail. Livid or purple spots have been observed upon the exterior surface of the stomach and duo- denum. The bowels usually contain green, yellowish, or colourless mucus. Dr. Horner noticed pus in considerable quantities in the colon in one case ; and retained feculent matter is sometimes found in the large intestines. The liver is usually large and congested ; and the gall-bladder contains a liquid, which is sometimes dark-green, and sometimes pale or nearly colourless. The brain has also been occasionally found congested ; and serous effusion in the ventricles or upon the surface, and thickening and opacity of the arachnoid have been observed. In cases which have exhibited hydrocephalic symptoms before death, the brain is either generally or partially softened. Dr. Lindsly found the bladder, in several cases, quite empty and much contracted. (Am. Journ. of Med. Sci, xxiv. 306.) Causes.—The main cause of cholera infantum is undoubtedly a combina- tion of heat of weather and the impure air of cities. Neither of these causes is alone sufficient; for the disease does not occur at an equal or even greater elevation of temperature in country places ; nor in cities during cold weather. The peculiar condition of the air generated in a crowded population appears to be essential; as even miasmatic districts in the country are exempt. It is true that miasmata have been supposed to favour the disease; but this is contrary to the personal observation of the author; and it is a well-known fact, that our autumnal fevers, which are universally believed to be of mias- matic origin, scarcely ever penetrate the densely built portions of our cities, where cholera infantum is most rife. It is a fact of constant observation, that this disease is most frequent and most virulent in crowded lanes, courts, and alleys, where population is thickest, and ventilation most imperfect. It is indeed' one of the greatest scourges of our large cities. According to Dr Condie 357 6 children died of it in Philadelphia during a period of 20 740 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. years, and Dr. Lindsly states that, of 201 deaths in Washington, during the three summer and first two autumnal months of the year 1838, fifty-five, or about one quarter, were of cholera infantum. But there are other causes which produce a predisposition to the disease, or call an already existing predisposition into action. Among these may be mentioned the process of dentition, unwholesome food, worms, and exposure to cold in a relaxed state ofthe skin. Dentition, though probably not alone capable of producing it, very much favours its production, and greatly aggra- vates the danger. Most of the fatal cases occur during this process, and few after its completion. Hence, children are universally considered as having passed the period of greatest danger, when the second summer is over. That diet has much influence upon the origin and severity of the complaint is proved by the fact, that children fed by the bottle, or the spoon, are more frequently and dangerously affected than those nourished at the breast. Nature.—From the symptoms of the disease, and the appearances upon dissection, it may be safely inferred to consist essentially in an irritation or inflammation of the alimentary mucous membrane, directed especially to the mucous follicles, and associated with a congested and torpid state of the liver, probably depending upon the same cause. The morbid phenomena connected with other organs are probably secondary or accidental. Treatment.—The first indication in the treatment of cholera infantum is obviously to remove the causes. While these continue to act, the most judi- cious efforts of the practitioner will for the most part be either quite nugatory, or but partially successful. The patient may be relieved, may even be appa- rently cured ; but the disease will often return under less favourable circum- stances of constitution, than at first; and, though a partial restoration may be again effected, and this alternation of relief and relapse may occur several times, yet there is great danger that the powers of vital resistance may be quite broken down, before the morbid cause shall cease with the hot season. The child, therefore, should be promptly removed into the pure air of the country. In general, the happiest change in the disease speedily follows this change of atmosphere. With a proper attention to diet and clothing, the child will almost always recover, even without medicine, or with such only as may be entrusted, by the medical adviser, to the judgment of the mother or nurse. The author has always been in the habit of pursuing this course, and, during the whole period of his practice, recollects only one fatal case, where the child has been sent into the country in the early stage of the disease. When the complaint is of longer standing, and the irritation of the bowels has had time to deepen into inflammation, the success of the measure is less striking, though even then it will be found the most effectual, especially when judicious medical advice can at the same time be obtained. Cases often occur, in which, under apparently the most desperate circumstances, the child, upon leaving the city, almost immediately begins to revive, and advances rapidly to convalescence. Should circumstances render a removal impracticable, the patient should be carried daily into the country, or into one of the open and most airy spots of the city, and kept there as long as possible ; and great care should be taken to have the apartments at home well ventilated and perfectly clean and dry. It is also highly important to examine the mouth of the infant at once, and, if the gums are swollen and painful, to lance them freely. Should the inflammation of the gums be extensive, from the pressure of several teeth, it may be advantageous, in addition to the lancing, to apply a few leeches to the cheeks, and a pair of blisters behind the ears. Under the same head may be considered the diet and dress of the patient; as errors in these respects are among the common exciting causes of the dis- CLASS III.] CHOLERA INFANTUM. 741 ease. The food of the infant should be the mother's milk, or, if she be dis- eased, that of a healthy wet nurse ; and the child should not be weaned during the existence of the complaint. The best substitute for this diet is perfectly fresh cow's milk, diluted with water. The farinaceous liquids prepared from barley, rice, sago, tapioca, arrow-root, wheat bread, water-crackers, kc, may also be used ; but care must be taken that these substances are entirely free from mustiness. When there is much fever, solution of gum arabic, infusion of benne leaves, or other mucilaginous fluid may be substituted. The caution should always be observed, whatever nutritive drink may be used, to give it in small quantities, so as not to irritate the stomach; and the disposition which the child often evinces, in consequence of its thirst, to suck freely should be restrained. To quiet the excessive thirst, very cold water, or cold solution of gum arabic, given frequently in small quantities, is preferable to more nutritious fluids. Pounded ice, confined in linen or gauze, so as to prevent it from being swallowed undissolved, will often be found useful. In the advanced stages of the disease, when the system is much enfeebled, it will be proper to allow a portion of animal food, such as weak chicken or mutton broth; and the child may be permitted to suck a piece of ham, dried salt beef, salt fish, &c, if these upon trial should be found grateful. It occasion- ally happens that the little sufferer exhibits a peculiar longing for some article of diet, which may not be thought suitable. Should this disposition be per- manent, it should be attended to, as the voice of nature; and the desired article should be allowed, with such caution, however, at first, as to insure against serious evil. The clothing should be such as to preserve an equable temperature of the surface, without oppressing the child. Yery thin flannel should generally be worn next the skin, and the feet and legs should be pro- tected by light woollen stockings. Iu relation to the medical treatment, the indications appear to be, to remove sources of irritation from the alimentary canal by laxatives and antacids; to promote the hepatic secretion, and thereby remove portal congestion, by calo- mel or some other mercurial; to divert excitement externally by diaphoretics, and by measures addressed to the surface; to relieve irritation by anodynes, and inflammation, when of a decided character, by direct depletion; to check excessive evacuations, in the advanced stages, by astringents; to modify the morbid state of the affected membrane by alteratives; and finally, to support the patient by suitable stimulants when greatly debilitated. In the early stage, attention should be first directed to the means for allay- ing the excessive vomiting. For this purpose, rubefacients should be applied to the epigastrium, so as to excite a very decided irritation upon the surface. Mustard, diluted with an equal quantity of rye-meal, is perhaps the most ef- fectual application ; but bruised mint steeped in brandy, or cataplasms made of the different spices, such as powdered black pepper, ginger, cinnamon, cloves, &c, separate or mixed, may be employed. At the same time, very small and repeated draughts of fresh and cold carbonic acid water; or tea- spoonful doses, repeated every quarter or half hour, of lime-water and fresh milk, mixed in equal proportions; or some one of the aromatic waters or in- fusions, such as mint-water, and fennelseed tea; or camphorated tincture of opium, in the dose of five or ten drops sufficiently diluted, may be given in- ternally, one of them being preferred to another according to the particular circumstances of the case, as, for instance, the degree of vascular action, the presence or absence of acid, «te. Dr. Dewees recommended, for the same purpose, a teaspoonful of strong coffee without sugar or milk every fifteen minutes, and an injection of a gill of warm water holding a teaspoonful of common salt in solution, which may be repeated when the vomiting is severe. The latter he considered as the most prompt and certain remedy that could be 742 LOCAL DISEASES.—DIGESTIVE SYSTEM. [l'ART II. employed. (Phys. and Med. Treat, of Children, 4th ed., p. 420.) Dr. Condie speaks favourably of the oil of turpentine, and of a solution of camphor in sulphuric ether, and, when everything else has failed, generally succeeds with a solution of acetate of lead, in doses containing about one-sixth of a grain, repeated every hour or two. (Diseases of Children, p. 223.) When the vomiting is excessive, and other means fail in arresting it, an anodyne injec- tion may be resorted to, containing from three to six drops of laudanum in a little thin starch. Indeed, opiate enemata will be found highly useful through- out the complaint, when the irritation of stomach is considerable, and no symptoms of cerebral disease exist. They may be repeated in suitable cases every day, and, if given at night, will be found very useful by enabling the child to rest. Care, however, must be taken not to employ too lar^e a dose; a mistake often made in infantile cases. When the stomach becomes retentive, medicines should be given to evacu- ate the bowels. Combinations of rhubarb and magnesia usually answer well. They may be given in powder; but the syrup of rhubarb, and the solution of carbonate of magnesia in carbonic acid water, are perhaps preferable. A teaspoonful of the syrup, with twice that quantity of the solution, may be given every two hours until they operate. The operation of the rhubarb may be known by its colour in the stools. The magnesia is peculiarly suit- able, when a sour smell and green colour of the evacuations indicate acid in the bowels. Advantage will often arise from administering these medicines in some aromatic vehicle. When the discharges are small, mucous, and at- tended with pain, castor oil should be substituted. But probably, upon the whole, the most effective cathartic in these cases is calomel. In children two years old or upward, I have seen it act most happily in numerous cases, in doses of two grains repeated at intervals of two, four, or six hours, until evi- dences of its operation were presented in the passages. Employed in this way, it often puts an almost immediate end to the disease, if given early. Another mode of exhibiting calomel, which is much employed, and is adapted to any age, is in doses of from one-sixteenth to one-quarter of a grain, re- peated so that from one to two grains may be given in the course of twenty- four hours. This plan is peculiarly useful when the stomach is irritable, and the secretion of bile suppressed or greatly deficient. The calomel may be administered mixed with a little powdered gum arabic, in syrup or on the surface of a teaspoonful of milk, or simply introduced into the mouth of the infant with a little sugar. A good plan is to give the mercurial one day, and the syrup of rhubarb or other laxative on the next, and thus alternate them until the stools become bilious; or the two may be alternated upon the same day, or even given conjointly, at the discretion of the practitioner. The laxative plan should be continued until the discharges assume a more natural appearance, unless there may be reason to think that it aggravates the com- plaint, or that no benefit accrues from it. Occasionally, from half a drop to a drop or two of laudanum may be usefully added to the laxative. It quiets pain, and relieves spasm of the bowels, without preventing the cathartic ac- tion. It may thus be combined with syrup of rhubarb or castor oil. This latter cathartic, given in the form of oleaginous mixture, made with gum arabic, loaf sugar, mint or cinnamon-water, and laudanum, may be used with peculiar advantage in the advanced stage, if the intestinal irritation approach the dysenteric form. When the complaint has the character of diarrhoea from the beginning, or assumes that character in its progress, and there is little or no irritability of stomach, but still deficiency of biliary secretion, the minute doses of calomel may be very happily associated with the powder of opium and ipecacuanha, which quiets irritation of bowels, and gives a direction to the skin. Under CLASS III.] CHOLERA INFANTUM. 743 these circumstances, also, the cretaceous preparations should be substituted for magnesia, especially if fever is absent, and the debility considerable. They are, like it, antacid, but rather astringent than purgative; and the indication is less to promote than to check the alvine evacuations. The mercurial pill, or mercury with chalk, may be substituted for calomel. These remedies may often be advantageously given in combination, as in the formula below.* If ipecacuanha should be objectionable, laudanum may be substituted for the Dover's powder in equivalent proportion. Mixtures made in the same way with carbonate of soda, or carbonate of potassa, as an antacid, are also occa- sionally used, but are less efficient. Cinnamon-water may be substituted for that of peppermint; but, if the officinal preparation be used, it should be diluted with from two to four parts of water. This plan should be continued until the stools assume a healthy colour. In a still more advanced stage, when the continuance of the evacuations threatens to exhaust the patient, it becomes necessary to attempt to arrest them by astringents. For this purpose, kino, catechu, or extract of krameria may be added to the cretaceous mixture above directed, from which the mer- curial may be omitted, if no longer requisite. The decoction of logwood, or of cranes-bill (geranium, U. S. Ph.) may also be used; and, if a combined tonic and astringent effect is desired, that of the blackberry root or dewberry root. Some of the mineral astringents are perhaps still more efficient, espe- cially acetate of lead, which has been highly recommended, and is certainly very useful in many cases of the diarrhoea following cholera infantum. The late Prof. Chapman, in his lectures, spoke favourably of alum. These reme- dies probably operate as much by an alterative impression on the mucous membrane, as by their astringency. They may in general be usefully com- bined with an opiate, and sometimes with ipecacuanha. Dr. Lindsly speaks, in strong terms, of the efficacy of a combination of acetate of lead and Dover's powder. The mineral acids sometimes prove useful as alteratives and tonics, These also should be combined with an opiate. The nitromuriatic acid is perhaps to be preferred. I have employed nitric acid, in the form of Hope's mixture (see page 633), with decided benefit. Nitrate of silver was employed by Dr. Skinner, of N. Carolina, in one almost desperate case, with the hap- piest result. The salts of iron may be resorted to in cases of obstinate diarrhoea connected with ana?mia. Other substances sometimes used as alteratives are oil of turpentine, copaiba, and creasote. In great debility it may be neces- sary to resort to wine-whey and the ammoniacal preparations; and the vege- table tonics will often prove useful in hastening a protracted convalescence. When, in the course of the complaint, there- is much tenderness of the abdomen, and the patient is not greatly exhausted, leeches, followed by warm fomentations or emollient cataplasms, should be employed; and, if these do not relieve the inflammation, they should be succeeded by a blister. In some rare cases, in which there is tension of pulse connected with gastric, intes- tinal, or cerebral inflammation, recourse may be had to the lancet. Should symptoms of meningeal inflammation occur early in the disease, they must be counteracted by local and general depletion, carried as far as circumstances will warrant, by cold applications to the head, and by blisters. Throughout the complaint, remedies should be employed in reference to a direct impression upon the surface. In the early stages, the simple warm- bath, and, in the more advanced, the warm salt or mustard bath, may be tried, and if found beneficial may be repeated every day. Great advantage may be expected from the salt-bath, especially when the disease has ternii- * ft._pil. Hydrarg. gr. vj : Pulv. Ipecac, et Opii_gr. ij; Cretae, vel Testa) Ppt. ^i; Aeaciaj pulv. sjj; Sacchari 3j; Aquae Menth. P. fgij. S. A teaspoonful every two hours, or pro re nata. 744 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. nated in diarrhoea. Baths of oak bark may also be tried under similar circum- stances. When heat is deficient in the extremities, the equilibrium should be restored by frictions, and by rubefacients applied to the legs and arms. Oil of turpentine, liniment of ammonia, or warm tincture of Cayenne pepper, may be employed. Blisters to the extremities, under these circumstances, are also indicated. Rubefacient applications to the abdomen should be oc- casionally used, and the effects of a flannel bandage in the advanced stages have been much praised. Prophylactic measures should always be resorted to in cases in which a predisposition to this disease exists. The rules already given in relation to country air, ventilation, dentition, diet, dress, and exposure to sudden changes of temperature, are applicable here. The late Dr. Joseph Parrish used strongly to urge the propriety, when the predisposition is very strong, of for- tifying the stomach and bowels by a digestible animal diet, and the use of aromatics, particularly the infusion of ginger, during the period of danger. Article IV FLATULENCE. Syn.—Eructation.—Crepitus.—Borborygmus —Tympanites.—Meteorism. Gases of different kinds are always found in the stomach and bowels, where their presence appears to be a provision of nature to sustain an equable dis- tension of the abdominal cavity, under the constantly varying quantity of its liquid and solid contents. It is onlywhen they are produced so abundantly, or accumulate so much as to become a source of decided inconvenience, that they can be considered in the light of morbid phenomena. In most instances, flatulence is a mere result of other morbid affections, and is to be regarded rather as a symptom than as a disease. But it is sometimes an original affec- tion, without any appreciable organic or functional derangement, other than that which its existence necessarily implies, and, like dropsy, deserves to rank as a distinct disorder. Symptoms, Course, Diagnosis, &c.—The symptoms of flatulence are such as depend either upon a too copious evolution of gas in the alimentary pas- sages, or upon its undue detention in these passages, or upon these two con- ditions united. A sense of distension, or of other uneasiness is experienced in the stomach or some portion of the bowels, which is soon followed by the expulsion of air either upward through the mouth, producing belching or eructation, or downwards through the anus, not unfrequently with a loud report, which, however, the patient has it generally in his power to suppress. These discharges are often brought about by the voluntary contraction of the abdominal muscles and diaphragm; but sometimes they are quite involuntary, and depend solely on the contraction ofthe muscular coat of the alimentary canal, or the elastic force of the confined gases. They are sometimes exceed- ingly copious, the air rushing from the stomach or bowels, or from both to- gether, in an almost continuous torrent, and constituting a very annoyino- affection, which has been called by some writers the dry cholera. Flatulence is often also attended with a disagreeable rumbling or gurgling sound in the bowels, called borborygmus, which is produced by the passage of the air from one part to another, and its intermixture with the intestinal fluids as it passes. Besides the sensation of distension or pressure, provoking and re- lieved by the discharges, the patient is often affected with pains, which are CLASS III.] FLATULENCE. 745 in some cases moderate and fugitive, in others distressing and almost con- stant, and in others again severe and spasmodic, amounting even to the most violent colic. Occasionally also acute pain is felt in various other parts, sympathetically connected with the stomach and bowels. Thus, it is not very uncommon for the spasmodic pain of gastric flatulence to shoot upward into the breast and throat, and even to ascend to the head. Meteorism, or tympanites is another distressing affection connected with flatulence. This consists in a distension of the bowels so considerable as to become visible. Perhaps the term meteorism may be appropriately applied to the slighter degrees of distension, and tympanites to that condition in which the abdomen is very much swollen, so as to be quite tense and sonorous. Sometimes the swelling is local, so as even to have given rise to the suspicion of the existence of solid tumours; sometimes it is equable over the abdomen. In its higher grades it is often very injurious. The muscular coat of the bowels, when greatly distended, loses its power of contraction; and thus, not only is the collection of gas allowed to go on increasing, but the passage of the liquid and solid contents of the canal is impeded, and obstinate constipa- tion results. Sometimes, however, diarrhoea attends tympanites. Another injurious result is the derangement of function in the neighbouring parts, pressed upon by the expanded bowels. The respiration especially suffers in this way, in consequence of the upward pressure of the diaphragm. A case is recorded by Dr. Ashmead, of Philadelphia, in which death resulted from a cessation of respiration, consequent upon an enormous tympanitic distension of the bowels. ( Transact, of Col. of Phys. of Philad., Jan. 4,1842.) Another fatal accident, sometimes proceeding from the same cause, is the rupture of the stomach or intestines by the expansive force of the confined air. In some rare cases of tympanites, the air is accumulated in the cavity of the perito- neal sac, instead of in the alimentary canal. There is nothing determinate in the course of flatulence. It may come on suddenly and as suddenly disappear, or it may continue, with various fluctua- tions, for a great length of time. In the form of meteorism, or tympanites, it often lasts for years with little abatement or alteration. In some cases, it disappears spontaneously, in consequence apparently of the absorption of the gas; in others, it yields with greater or less facility to remedial measures; and, in others, again, it obstinately resists all the means employed, and ceases only with life. The part of the alimentary canal in which the evolution of gas takes place, may sometimes be inferred from the point whence the ascending or descend- ing current of flatulence seems to the patient to proceed, from the period intervening between the introduction of some flatulent substance into the stom- ach and the first appearance of the symptoms, and, in the case of meteorism or tympanites, from the particular position of the tumefaction. Flatulent dis- tensions of the abdomen may be distinguished from liquid accumulations by the absence of the feeling of fluctuation produced by the latter, when the palm of the hand is placed on one side of the abdomen, and a gentle blow given to the other; from solid tumours, by the flat sound emitted by these upon per- cussion, instead of the clear resonance characteristic of confined air. From the contiguity of the stomach and colon it is sometimes difficult to decide by percussion in which the flatulence may be situated. In such a case, if the patient be examined after a full meal, or be told to drink freely, dulness on percussion over the stomach would evince that the morbid accumulation was in the colon. It is not always possible to determine, whether the gas occupies the bowels or the peritoneal cavity. The former position, however, may be inferred, when the distension was, in its forming stage, or continues to be unequal, when a gurgling sound on auscultation indicates a mixture of 746 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. liquid and air, and when the tympanitic sound elicited by percussion is par- tial ; the latter, when the same sound is uniform over the whole abdomen. The air evolved or confined in flatulence is generally a mixture of different gases, among which oxygen, nitrogen, and carbonic acid are the chief. Not unfrequently inflammable air escapes, consisting probably of hydrogen, or its gaseous compounds. Sometimes the flatulent discharges are without odour and perfectly bland, sometimes they are loaded with offensive exhalations from the alvine contents, and sometimes they are acrid and burning. Little, how- ever, is precisely known upon this subject. Causes.—Flatulence has its origin either in the character of the ingesta, or the condition of the alimentary canal, or in the two sources combined. Food not digested, or but imperfectly digested in the stomach, is liable to a chemical decomposition, resulting in the evolution of gaseous fluids; and the quantity thus evolved from a very small portion of solid or liquid matter is sometimes enormous. This result may take place in a perfectly healthy condition of the digestive organs, if food be employed of a nature not adapted to the mode of living, or peculiar constitution of the individual, and consequently to his strength of digestion. Certain kinds of food and drink are peculiarly apt to evolve gases in the prima? via?, and, on this account, are called flatulent. Such are cabbage, unripe fruits, melons, tough or fibrous roots, and fermenting or fermentable liquids. These will often evolve gas copiously in a healthy stom- ach. But, when the powers of digestion are morbidly enfeebled, the effect takes place in a much greater degree, and substances become flatulent, which, under ordinary circumstances, are easily dissolved in the gastric liquor. Any cause, therefore, which is capable of debilitating digestion, may act as a cause of flatulence. (See Dyspepsia.) The ordinary contents of the healthy bowels, consisting of the residuary alimentary matter and various secretions, are also liable to chemical reactions, which extricate gases, especially when they are confined too long in the intestines; and constipation thus becomes a cause of the disorder. When these secretions are unhealthy, in consequence of dis- ease of the secreting organs, they are often highly flatulent. Bile appears to have an antiseptic influence on the contents of the intestines; and, when it is deficient or wanting, these are apt to undergo putrefaction, with the evolution of sulphuretted and carburetted hydrogen, and possibly other offen- sive gases. It is, moreover, probable that the chemical changes, which take place when the heterogeneous contents of the small intestines are converted into chyle, are often attended with the production of aeriform substances, even when the processes of digestion and of secretion are perfectly healthy. There is reason to believe that a direct exhalation of gas often takes place from the mucous membrane. We know that such an exhalation occurs into the cellular tissue, constituting emphysema, and into the various closed serous cavities; and the alternation which has sometimes been observed between emphysema and flatulence of the bowels, leads to the inference, that the latter may be produced in the same manner. (Diet, de Med., xxi. 132.) The occa- sional sudden substitution of tympanites for diarrhoea is another evidence of a similar character. But positive proof is not wanting. Portions of intes- tine entirely emptied of their contents, and inclosed between two ligatures, have been observed to become distended with gas, especially when inflamed by some stimulant application. (Am. Journ. of Med. Sci, N. S., iv. 403.) What is the particular pathological condition of the mucous membrane which leads to this result is not known. It seems to be in some measure connected with defective or deranged innervation; for flatulent accumulations in the stomach and bowels, not attributable to any other known cause, are frequent in nervous affections, such as hysteria, hypochondriasis, and strong mental emotion. Some have supposed the globus hystericus to be a suddeii distension CLASS III.] FLATULENCE. 747 of portions of the oesophagus by air, confined by spasmodic constrictions above and below it. Cold drinks taken too freely, during a heated state of the body, sometimes produce sudden attacks of flatulence, originating probably in exhalation or secretion. Another cause of flatulence is the habit which some acquire of swallowing air, and which may become a morbid condition, analogous to certain mental perversions ranked under hypochondriasis or monomania. The form of flatulence denominated meteorism or tympanites, is produced by some cause preventing the discharge of the air contained in the bowels. This cause, whatever it may be, is itself sufficient to occasion the affection, without any unhealthy production or evolution of gas ; for the air taken in with the food, and that which, as before stated, is always extricated to some extent in perfect health, must become morbidly accumulated, if any accidental excess of it be prevented from finding an exit. The effect, however, is much greater, when the causes of production or evolution, above enumerated, co- operate with those of detention. Among the latter are debility or atony of the muscular coat, impairing its contractile power ; rigidity of the sphincter muscles of the oesophagus, pylorus, and rectum; spasmodic closures of the intestinal tube at other points; fecal accumulations; and mechanical obstruc- tions of all kinds, as by tumours, permanent strictures, and foreign bodies. Tympanites is most commonly an attendant upon other diseases, especially enteric or typhoid fever, peritonitis, malignant dysentery, and the different forms of colic and obstruction of the bowels. In its chronic forms, it is often associated with hypochondriacal, hysterical, and uterine disorder. When dependent upon accumulation of air in the peritoneal cavity, it usually pro- ceeds from perforation of the stomach or bowels, perforation of the diaphragm (Arch. Gen,, ieser., i. 471), or decomposition of the peritoneal membrane. It may, however, in this, as in other serous cavities, and in the cellular tissue, be the result of a secretory or exhaling process. Flatulence is most common in infants and young children. Treatment.—The indications are to cause the removal of the air already accumulated, and to prevent its evolution and accumulation in future. The first indication often requires prompt and energetic treatment, in consequence of the sufferings of the patient. The object may frequently be effected by the use of stimulants calculated to act directly on the alimentary mucous membrane, and thus indirectly to excite the muscular movement. Such are the medicines denominated carminatives. To this set belong most of the aromatics. These may be variously employed, in substance, hot infusion, or tincture ; or the volatile oil of the aromatic may be substituted for the medi- cine ; and they may be given separately or differently combined, to suit the taste of the patient, or the views of the practitioner. Among those most employed are peppermint, spearmint, fennelseed, cardamom, caraway, cin- namon, cloves, allspice, black pepper, ginger, and calamus. Twenty drops of the tincture of oil of peppermint, or oil of spearmint (essence of pepper- mint or spearmint), dropped on sugar, will often afford prompt relief. Com- pound spirit of lavender, and compound tincture of cardamom, are agreeable preparations, and may be given in the dose of a fluidrachm. Hot ginger tea will be found especially useful when there are colicky pains. Fennelseed tea, given both by the mouth and by injection, is well adapted to infants. Re- course may also be had to various stimulants, which do not belong to the aromatics. Oil of turpentine is a powerful carminative. Cayenne pepper, od of juniper assafetida, camphor, ammonia, and ethereal oil, may also be occa- sionally used with advantage. Aromatic spirit of ammonia is an excellent preparation when there is a depressed condition of the system. Assafetida and compound spirit of ether (Hoffmann's anodyne) are peculiarly use- 748 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. ful when flatulence is complicated with hysteric or other nervous disorder. Prompt relief is often procured, when severe stomachic pain depends on flatulence, from a fluidrachm of camphorated tincture of opium. When the bowels are affected with flatulence, the aromatics may often be advantage- ously combined with mild cathartics. The free use of lime-water does good in some cases, probably by combining with and neutralizing carbonic acid. Friction over the abdomen, agitation of the bowels by the hand with the body in a bent position so as to relax the abdominal muscles, jumping, jolt- ing in a rough vehicle, or a ride on horseback, will aid much in the expulsion of the confined air. Compression by a flannel roller or otherwise, stimulating embrocations, and galvanism, have also been recommended. In meteorism or tympanites, injections of oil of turpentine or assafetida should be given, in connection with other means ; and, if the symptoms are severe, attempts should be made to draw off the air by the introduction of a long gum-elastic tube, through the rectum, far into the colon. Life has probably been saved in this way. When the danger is very imminent from the vast distension of the abdomen, and relief cannot be obtained by the ordinary measures, it may become a question, whether it would not be the duty of the practitioner to puncture the ca?cum, or other part of the intestinal tube. In cases of exces- sive tympanites with irremovable obstruction of the bowels, the operation has been occasionally performed with the effect of affording relief; though the cases afterwards terminated fatally, in consequence of the obstructing disease. (See Am. Journ. of Med. Sci, N. S., xxiv. 543.) To prevent the morbid collection or evolution of air, it is necessary to remove or obviate the cause. Flatulent food and drink should be avoided, and the diet should be made to conform as nearly as possible to the digestive powers of the patient. Should, however, flatulent substances enter into the diet, their effects may be somewhat corrected by associating them with stimu- lating condiments, as Cayenne and black pepper and mustard. If the com- plaint originate in, or be associated with, debility of stomach and bowels, this should be corrected by tonic medicines, and other means indicated under the head of dyspepsia. Constipation should be obviated by a proper regu- lation of the diet, and if necessary by laxatives; but, in the choice of means for this purpose, care should be taken to shun those disposed to occasion flatulence. Among the most appropriate are bran bread, as an article of diet, and rhubarb or aloes as a cathartic. Magnesia may be employed in connection with these, when acid exists in excess in the prima? via?. Un- healthy secretions into the bowels, and especially deficiency of the biliary secretion, should be corrected; and the blue pill will often be useful for this effect, by its alterative action on the liver. When there is reason to believe that the gas proceeds from a secretory or exhaling act of the mucous membrane, tonics and astringents are indicated. Infusion of galls with fennelseed has seemed very useful in my hands, under these circumstances ; and I have repeatedly known the affection to yield to the free use of sulphate of quinia. Strychnia or nux vomica has also been recommended, and is among the most effective remedies in cases which may depend on atony ofthe muscular coat. Dr. Graves strongly advocates the use of acetate of lead in tympanites; and Dr. Baddeley, of Chelmsford, has employed both this salt and sulphate of zinc, in conjunction with an opiate, with success in very bad cases. (London Lancet, Jan. 8, 1848, p. 44.) As flatulence is often dependent upon other diseases, care should be taken, in all instances, to discover its source, and apply remedies to this, instead of wasting time in a direct combat with the flatulence itself. Particular atten- tion should be paid to nervous derangements, which frequently occasion or aggravate it. CLASS III.] PERITONEAL INFLAMMATION. 749 Great advantage will often be derived from combining, in the same pre- scription, medicines calculated to meet different indications. Thus sulphate of quinia, as a tonic, may be united in mixture with assafetida and one of the aromatic volatile oils, as carminatives ; and such a mixture is often highly useful in the cases of infants subject to flatulence.* Magnesia maybe asso- ciated, in mixture, with the aromatic oils, camphor-water, and a little lauda- num when there is pain. Rhubarb or aloes may be given in pill, with quinia or a bitter extract, and with assafetida, black pepper, or a volatile oil. Such combinations may be multiplied indefinitely, and often with great advantage, by a practitioner who possesses an adequate knowledge of medicines, and the modes of preparing them. Article V. PERITONEAL INFLAMMATION, or PERITONITIS. The protection which the peritoneum gives to the alimentary canal is, per- haps, its most important function; and its diseases may, therefore, be very ap- propriately associated with those ofthe digestive organs. Inflammation of the peritoneum is susceptible of division into several varieties ; but may be most conveniently considered under the two heads of the acute and the chronic. I. ACUTE PERITONITIS. Symptoms, Course, &c.—A chill is sometimes the first symptom of peri- tonitis ; but perhaps more frequently the disease begins with pain; and occa- sionally the occurrence of the two phenomena is simultaneous. The pain is sharp and very severe, and usually commences in the lower part of the abdo- men, in the hypogastric or one of the iliac regions, whence it gradually ex- tends over the whole cavity. Sometimes it is changeable, occurring now in one spot and then in another; and not unfrequently is attended with a sense of heat or burning. The abdomen is always tender to the touch. The slightest pressure by the hand occasions exquisite pain, and whatever gives rise to contraction of the abdominal muscles has the same effect. Hence, the patient suffers much from vomiting, the act of defecation, the discharge of urine, and straining of all kinds. A deep inspiration is often very painful. The motions of the abdominal walls in respiration are diminished, if not sus- pended ; and the expiratory act was observed by Dr. Sibson to be shorter than the inspiratory, a phenomenon noticed in no other complaint exterior to the thorax. (Ballard.) Movements of the body in or out of bed are also pain- ful ; and even the weight of the bedclothes is often insupportable. Hence, the patient usually lies motionless upon his back, with his knees drawn up, so as at once to relax the abdominal muscles, and take off the weight of the covering. Another object of the supine position appears to be, to obviate in some degree the pressure of the bowels upon the parietal peritoneum. But this posture is not so universal as might be inferred from the description of most medical writers. The author recollects that, in one of the worst cases of peritoneal inflammation he ever witnessed, the favourite position of the patient was upon his left side, with the knees so much drawn up as to be almost in contact with the abdomen. Most frequently the tenderness is * J£.—Quinke Sulphat. gr. ij ; Assafoetidae gr. iv; Acacias pulv., Sacchar., aa, ^ss; Aq. Cinnamom. I3J. Misce. S. A teaspoonful for a child one year old, four times a day. 750 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. general, but in some instances is greatest in particular spots, and in others is confined altogether to one spot; indicating, in the latter case, the local position of the inflammation. From near the commencement, there is gen- erally a feeling of hardness, tension, and elasticity in the abdominal parietes; and very soon a tumefaction begins, which increases with the progress of the complaint, and towards the close assumes the character of tympanites. In some cases, however, there is little swelling; and in others, none at all; the abdomen being sometimes even drawn in by the constriction of the muscles. The swelling is for the most part uniform, but is sometimes irregular, giving to the hand the sensation of a tumour or tumours in the abdomen, which may be either permanent or changeable. Percussion evinces at first a resonance healthy, or greater than that of health ; but, as the disease advances, the sound becomes dull, especially in the depending parts. After the complaint has lasted a short time, the abdomen frequently offers, under auscultation, a friction sound, like that observed in pleurisy, and like it arising from the rub- bing together, during respiration, of the opposing surfaces of the serous membrane, roughened by the effused coagulable lymph. Besides the above phenomena, there are many others, either sympathetic, or depending on a direct propagation of the irritation to contiguous parts. Nausea and vomiting, thirst, constipation, and scanty or suppressed urine are very frequent symptoms. The vomiting is exceedingly distressing. The constipation is obstinate, in those cases in which the muscular coat of the bowels becomes involved in the inflammation; but it is not a constant symp- tom, and sometimes gives way to diarrhoea. The face is pale, contracted, and marked by an expression of deep distress and anxiety, characteristic of the disease. The respiration is short. The pulse is usually very frequent, from 110 to 130 or more in a minute, small, and tense ; though, in some rare cases, it is full and but little accelerated. The tongue is usually moist, and covered with a whitish or yellowish fur; but sometimes it is red and dry, and some- times nearly natural. The patient is very often wakeful. The chill with which the attack commences, or which follows the occurrence of pain, is usu- ally succeeded by febrile heat of surface, which, however, soon subsides ; and, during the greatest severity of the complaint, the skin is often but little warmer than in health. The march of peritonitis is in general rapid. In fatal cases, death sometimes occurs within twenty-four hours, and generally in about a week; but occa- sionally the disease runs on for three or even four weeks. An aggravation of the pain, tenderness, and other symptoms marks its advance; but, when the fatal termination approaches, the pain often suddenly subsides, or ceases altogether; and this maybe considered as one of the most unfavourable signs, when not attended with a marked amelioration of the disease in other respects. At this stage, the pulse is extremely frequent and feeble; the extremities are cold, and sometimes purplish or livid; the countenance is sunken and ghastly; the abdomen is either tympanitic, or soft and flaccid ; a troublesome hiccough often occurs; and a green or blackish matter is thrown up from the stomach, rather by regurgitation than vomiting, and sometimes flows from the mouth ofthe patient without his consciousness. Occasionally the bowels give way, and a similar dark matter is discharged per anum. Coma, or convulsions, or both, sometimes precede the fatal issue. A favourable termination is indicated by a gradual subsidence of the pain, tenderness, and tension of the abdomen, a cessation of the vomiting, a dimin- ished frequency of pulse, and a less anxious expression of countenance. Oc- casionally a copious discharge from the skin, bowels, or kidneys, attends the solution of the disease. In some cases, the symptoms entirely disappear, and the recovery is perfect. In others, a greater or less degree of pain and ten- CLASS III.] PERITONEAL INFLAMMATION. 751 derness in the abdomen and frequency of pulse continues long after the danger is over; and sometimes a hard tumour in some part of the cavity remains for a considerable time. Again, the acute may subside into the chronic form of the disease; and the result thus be long postponed, and quite uncertain. In a few cases, the pus poured out by the inflamed membrane, and confined within sacs formed by the organized coagulable lymph, makes its way by ulceration either into some one of the hollow viscera, as the stomach, intes- tines, or bladder, or to the surface ofthe body, and is discharged. In some of these cases, recovery takes place, especially when the pus has found an outlet through the skin. Various modifications of peritonitis as above described occasionally take place, and require notice. Thus, it is sometimes entirely local, affecting some one portion of the peritoneum only; and this is apt to be the case when the disease proceeds from a local cause, such as mechanical violence, or the in- flammation of an invested organ. In such cases, it frequently happens that, though the inflammation is not propagated to any great extent continuously, it affects the portion of membrane opposed to, and in contact with that in- flamed. The inflammation is thus more likely to be confined to one spot, when a fixed than when a movable organ is affected. Any part of the abdo- men, where there is peritoneum, may be the seat of the affection. It is scarcely necessary to say that, in these cases, all the symptoms, both local and constitutional, are less violent than in general peritonitis. The local character of the affection is marked by the limited extent of the pain and tenderness, though it must be confessed that, in some instances, it would be very difficult to establish a certain diagnosis. The symptoms are much modi- fied by the position of the inflamed membrane, and by the organ which it may invest. Thus, when the inflammation occupies the peritoneal covering ofthe liver, it not unfrequently happens that the skin, eyes, and tongue, are more or less yellow, in consequence of an extension of irritation into the substance of the organ. Great epigastric pain and tenderness, with severe constitutional symptoms, mark the peritoneal inflammation of the stomach; obstinate constipation, with a lower seat of pain, that ofthe bowels; painful irritation with tenderness in the hypogastric region, and great pain in mic- turition, that of the bladder. The omentum may be separately inflamed, in which case the pain extends over the front of the abdomen, and effusion into the folds of the membrane may occasion circumscribed swellings, perceptible to the touch, and liable to be mistaken for enlarged spleen, or ovaries, or scirrhous tumours of different portions of the bowels. Andral mentions, as characteristic of pelvic peritonitis, pain above and behind the pubcs, and ex- tending backwards towards the loins, tenderness in the hypogastrium, slight fever, sweats, and the formation of tumours in the cavity, which press on the neighbouring organs, as the rectum, vagina, and bladder, materially inter- fering with their functions. Examination by the vagina or rectum may be necessary to determine the seat of the inflammation in this case. Another frequent seat of partial peritonitis is the right iliac region. This, however, is almost always secondary, depending either upon the propagation of inflam- mation from the exterior cellular tissue, or from the ca?cum or appendix, or upon the direct irritation of matters which have escaped from these portions of the alimentary canal by ulceration. It is marked by great tenderness and tumefaction over the head of the colon, and by obstinate constipation, and frequently terminates in an abscess, which makes its way to the surface, either anteriorly or in the lumbar region. Other instances of local peritonitis are those in which the inflammation depends upon strangulation of the bowel, whether from hernia, intussusceptio, or other cause. Iu these cases, the symp- toms of inflammation are always preceded by those of obstruction in its earlier 752 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. stages, and subsequently associated with those of the same affection in its advanced stages, such as almost insuperable constipation, and vomiting of stercoraceous matter. Partial inflammation sometimes becomes general, and may thus prove very dangerous; but, when confined to its original seat, it generally yields to proper treatment, unless complicated with some other more serious affection. As in the general disease, it occasionally gives rise to col- lections of pus, which is retained by adhesions between opposite surfaces of the membrane, and makes its way by ulceration either to the surface of the body, or into some one of the hollow viscera, occasionally producing, in its passage, much destruction of the organs with which it may come in contact. I have known sudden swelling of the scrotum, with great pain and tender- ness, to come on in the course of peritonitis, consequent upon the extension of the inflammation to the tunica vaginalis of the cord, and that altogether independent of the existence of hernia. Though for the most part an exceedingly painful disease, peritonitis some- times comes on very insidiously, with little pain, and no great degree of ten- derness, and runs its whole course, even to a fatal termination, without being suspected. This form of the disease is most apt to occur in persons of feeble health, and as a complication of other acute diseases, which serve to mask it. Affections of the brain, which diminish the ordinary sensibility, are perhaps most liable to this dangerous complication. In all these cases, when a sudden and unaccountable increase of disease takes place, with the peculiar counte- nance and pulse of peritonitis, even without abdominal pain, a close exami- nation should be instituted; and, if tenderness is found to exist generally through the abdomen, or in some one part of it, the existence of this disease may be suspected. Severe rigors, followed by some febrile reaction, with nausea and vomiting, and distressing sensations of sinking at the epigastrium, which can be traced to no other cause, should lead to the suspicion of perito- nitis. In all doubtful cases, the observation of the friction sound in auscul- tation would very much aid the diagnosis. Peritonitis, like all other inflammations, is sometimes connected from the commencement with a typhoid state of system, marked by feebleness of the circulation, general prostration, a dry and dark tongue with sordes about the teeth, a tendency to hemorrhage from the mucous surfaces, and various ner- vous symptoms, as delirium, subsultus tendinum, coma, &c. Sometimes ner- vous symptoms attend it without evidences of typhoid disorder. Headache, active delirium, subsultus, convulsions, sudden alternations in the violence of the ordinary symptoms, restlessness, wakefulness, and great general distress, are among the characters of this form of the disease. Andral states that he has known the disease to recur regularly for some time with the paroxysms of an intermittent, disappearing entirely in the in- tervals, until at length it became permanently established and continuous. (Clinique Medicate, Se ed., ii. 639.) Not unfrequently the symptoms alter- nately diminish and increase, in the manner of a remittent disease. Another modification of peritonitis is that resulting from the perforation of a hollow viscus or cavity, and the escape of its contents into the perito- neal sac. The inflammation is in this case most frequently general, though it may be local. It is usually preceded by symptoms of some other disease of longer or shorter duration. The commencement of the peritonitis is marked by the sudden occurrence of severe pain, without preceding chill, usually in some one point, from which it rapidly spreads over the abdomen. In a very short time, all the symptoms of the disease in its most violent form are de- veloped, and death ensues generally in two or three days, and sometimes even in a few hours. This form of peritonitis is generally fatal. But occasionally, when the perforating orifice is small, and in a neighbourhood where the intes- CLASS III.] PERITONEAL INFLAMMATION. 753 tine is not movable, the inflammation is limited to a small extent, the effused matter becomes isolated through the agency of adhesion, and the affection ends in an abscess, which pursues the same course with those alluded to in preceding sections, and with the same result.* Puerperal peritonitis is still another variety of this affection. It attacks women in child-bed, usually within three or four days after delivery, and sometimes within twenty-four hours. The pain sometimes comes on gradually and almost insensibly, sometimes suddenly and with severity, and in many cases is subject to exacerbations, resembling after-pains, with which it has often been confounded. It almost always commences in the hypogastric and lumbar regions, and, after the whole abdomen has become involved, is apt to be felt most severely in those parts. The tenderness on pressure is also at first confined to the region of the uterus. The lochia are diminished or sup- pressed ; the mamma? become flaccid; and the secretion of milk either is not established, or is suspended if it had commenced. The abdomen is soft and flaccid at first, and, though it ultimately swells and becomes tympanitic, the parietes have none of that elastic tension, which is found in ordinary peri- tonitis, probably owing to their great distension in advanced pregnancy. The effused liquid is often copious, so that fluctuation in the abdomen is readily perceived. It is unnecessary to repeat an account of the general symptoms, which are essentially the same as those of ordinary peritonitis, though usually more severe. The pulse is more frequent, the respiration more hurried, the countenance more deeply affected, the prostration of strength greater, and the inarch of the disease more rapid and fatal. Severe pain in the head, vertigo, and delirium are more frequent, and cough is a common attendant of the puerperal affection. Death, which in the severe cases occurs in the course of a few days, and sometimes in less than twenty-four hours, is preceded by symptoms of great prostration; an extremely rapid and feeble pulse, cold skin, a brown and dry tongue, sordes about the teeth, tympanitic abdomen, and discharges of black or dark-green matter by vomiting and stool. There is reason to believe that puerperal peritonitis is sometimes a second- ary affection, in the same manner as erysipelas, being dependent upon or at * It is sometimes impossible to decide with certainty, before an external communica- tion has been effected, as to the existence of perforation of the bowel, in those cases in which, adhesion having taken place between the intestinal and parietal peritoneum, the alvine matter seeks an outlet by means of ulceration. The following sketch of a case which occurred to me, in the Pennsylvania Hospital, in the autumn of 1847, may prove useful, by putting the young practitioner upon the proper track in similar cases. The patient, who was a man short of the middle age, complained at first of pain in the left lumbar region, which had been treated as rheumatism before I saw him. I found him with fever, diarrhoea, tympanites, and a dry tongue; and should have been disposed to consider the case as one of enteric or typhoid fever, but for the absence of the rose- coloured eruption, and of the characteristic countenance of that affection. At length a tumour was perceived in the back, wliich gradually increased, and, after a considerable time, presented an obscure fluctuation, with a diffused erysipelatous redness, and swell- ing of the subcutaneous areolar tissue for a great extent. Thinking that it might, pos- Bibly, have some connection with the bowel, I directed it to be opened. An offensive sanious fluid escaped, with a decided feculent odour. But extensive gangrene of the cel- lular tissue came on, under which the patient sank. Examination after death disclosed the existence of an ulcer of the colon, near the sigmoid flexure, communicating with the exterior abscess. Except at this one spot, the colon appeared healthy; but there was inflammation of the mucous membrane of the ileum for the extent of more than a foot from the ileo-caacal valve, though without ulceration, and without special disease of the glands of Peyer. With the light which dissection thus afforded, I should, in a similar case be disposed to make an early and deep incision into the tumour, in the hope that the intestinal contents might thus find an easy escape, and the patient be spared the gangrenous destruction of the cellular tissue, which was the probable cause of death in this instance. (Note to the second edition.) 754 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. least associated with a malignant febrile state of system, of which one of the characters is a depraved condition ofthe blood. In such cases, the general actions are feeble almost from the commencement, and the state of system is similar to that which occurs in malignant typhus. This form of the disease, the only one to which the name of puerperal fever can be attached with pro- priety, is most apt to result from epidemic influence. Peritonitis is always a dangerous disease; but, when it occurs in a person of good constitution, and without complication, generally yields to early and efficient treatment. That form of it which depends on perforation is the most fatal. Next, perhaps, in degree of danger is the puerperal peritonitis. The inflammation is least dangerous when it is partial, and, as a general rule, when it results from external injury. Anatomical Characters.—These are such as inflamed serous surfaces gene- rally present, (See page 57.) They will not, therefore, require a very par- ticular notice in this place. If death has occurred very early, the membrane may offer no other morbid appearance than redness. In cases of longer dura- tion, there is almost always more or less of a fibrinous exudation upon the surface of the membrane, and of free liquid in the cavity. At first it is often in the form of a thin, viscid, almost colourless layer; but it soon becomes more copious, and is then soft, of a dull-white, yellowish, or greenish-yellow colour, and generally more or less organized, forming false membrane, which connects together the opposite peritoneal surfaces, agglutinating the folds of the intestines, and causing the different viscera to adhere to one another, or to the sides of the cavity. This layer is, in advanced cases, several lines in thickness, and has an irregular surface, which gives rise to the friction sound observed in auscultation during life. The degree to which it is orgauized depends on the character of the inflammation, and the stage of the d'sease. In some cases, little tendency to organization is shown at any stage; in others, it appears to have commenced a few hours after exudation. The liquid is found in the interstices of the intestinal convolutions, and more largely in the pelvis and iliac fossa?. It is sometimes colourless and limpid, or whey-like, with fibrinous flakes floating in it; sometimes yellowish and turbid; sometimes milky, sero-purulent, or bloody; and sometimes composed of nearly pure pus, or of blood. In consequence of the adhesions formed by the false membrane, it is often contained in sacs, which appear like so many abscesses, and now and then occasion irregularities, observable upon the sur- face of the abdomen during life. In some instances, pus is formed without the peritoneum. Gangrene is very seldom observed in the membrane, except in cases in which the bowel has been strangulated. The dark spots occasion- ally noticed, resulting from effused blood in the submucous tissue, have pro- bably been mistaken for mortification. If the disease has depended upon the perforation of the alimentary canal, gas generally escapes upon the opening of the peritoneum, and is more or less fetid as the perforation has been lower down in the canal. The character of the liquid in the cavity varies with the organ perforated, and sometimes serves to designate the organ. Thus, portions of undigested or partially digested food have probably come from the stomach; a yellowish or brownish fetid liquid from the bowels ; solid fecal matter from the colon ; a yellowish- brown, or green inodorous liquid from the gall-bladder or biliary ducts ; and liquid of a urinous smell from the bladder. Stones of fruit, calculi, and biliary concretions are sometimes found. By taking the upper portion of the bowel between the fingers, and compressing it steadily towards the lower extremity, the escape of gas or liquid will sometimes indicate the point of perforation, which might otherwise escape attention. In the typhoid cases of peritonitis, especially the puerperal, little or no CLASS III.] PERITONEAL INFLAMMATION. 755 fibrinous exudation is found; the effusion consisting of a serous, milky, or bloody fluid, with only a few flakes of cbagulable lymph here and there adher- ing to the membrane. Though vomiting is so frequent a symptom of peritonitis, the mucous mem- brane of the stomach is only in exceptional cases found to have been the seat of any considerable inflammation. Causes.—Peritonitis may arise from the ordinary causes of inflammation, such as vicissitudes of temperature, excessive use of stimulating food or drink, suppression of habitual discharges whether healthy or morbid, retrocession of cutaneous eruptions, and translation of gout or rheumatism. It is, however, more frequently the result of local violence, as of blows, falls, and bruises of all sorts, and of wounds penetrating the peritoneal cavity, including various surgical operations, among which may be mentioned that for strangulated hernia and for tapping, and the Cesarian section. Sometimes it is secondary to other diseases, especially to inflammation of the organs which receive a complete or partial covering from the peritoneum. Inflammation of the womb, whether occurring from violence to that organ, or injury received in the process of parturition, is said frequently to extend to the peritoneal membrane. The disease is an ordinary result of strangulation of the bowel, both internal and external, when not relieved. A frequent cause of it is perforation of the different hollow viscera of the abdomen, or of morbid cavities, allowing the escape of their contents into the peritoneal sac. This perforation may be produced by ulceration, by mortification and the separation of sloughs, or by mechanical rupture depending upon an extraor- dinary distending force within the cavities, or weakening of* their parietes. Thus, perforation of the stomach, bowels, gall-bladder, biliary ducts, urinary bladder, kidneys, and ureters ; the opening of abscesses in the substance of the organs, or in the cellular tissue without the peritoneum ; the discharge of tubercles; the rupture of distended cysts or of aneurisms, may all occasion peritonitis. The perforation of the alimentary canal is most frequent in the course of typhoid fever and of phthisis, in both of which ulceration of the mucous membrane of the bowels is not uncommon. It is also not unfrequently produced by foreign bodies lodged in some portion of the canal, especially in the ca?cum and appendix, where they occasion inflammation, ulceration, and ultimately perforation of the coats of the bowel. Peritonitis sometimes comes on in the course of other affections, particularly those of a febrile character, without any assignable cause; and is not uncommon at the close of long-con- tinued and exhausting diseases, which it brings to a fatal issue. Of the variety of peritonitis denominated puerperal, the cause is probably, in many instances, a propagation of inflammation of the uterus itself to the peritoneal covering, or the direct participation of that covering in violence done to the organ. The disease may also arise from irregularities of diet, vicissitudes of the weather, &c, as any other inflammation. But very often also it arises from a peculiar epidemic influence, or, as some believe, from con- tagion; and, as thus originating, assumes not unfrequently its most malignant form. Of this character is the puerperal peritonitis of hospitals and lying-in establishments, which has often proved so fatal, and so little under the con- trol of remedies. It has been asserted that peritonitis in the male has some- times also occurred epidemically. Diagnosis.—When the disease is well developed, and attended with the dsual symptoms, without complication, there can be little difficulty in its diagnosis. From colic of all kinds it may be distinguished by the great ten- derness upon pressure, the more persistent and less paroxysmal pain, and the almost constant supine position of the patient; from mucous gastritis and enteritis by the sharper pain and greater tenderness, the elastic tension of the 756 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. abdomen, the supine position, the greater tendency to constipation, the small and very frequent pulse, the sunken arid anxious countenance, and generally the deeper impression upon the constitution; from inflammation of the mus- cular coat of the bowels, by the more decided colicky symptoms of this affec- tion in its earlier stages, its excessively obstinate constipation, and the fecal vomiting which attends its close; from inflammation of the liver, bladder, and other parts more or less invested by the peritoneum, by the absence, in these affections, of the symptoms which characterize peritonitis, while, if the membrane is inflamed, the acute pain, tenderness, abdominal tension, position, pain upon movement, &c, serve to indicate the fact; from rheumatism of the abdominal muscles, which bears to it the closest local resemblance, by the vomiting, the febrile symptoms, the peculiar expression of face, and the difference in the pain which attends motion in the two cases; the pain in rheumatism being much* severer from voluntary movements, which call the muscles into contraction, than from passive movement, while both occasion severe suffering in peritonitis. The distinction between inflammation of the peritoneal investment of an organ, and of the substance of the organ itself, is often rendered difficult by the fact, that the functions of the organ are almost always more or less deranged, when the investing membrane only is inflamed; and, in fact, the two affections are often simultaneous; but an accurate diagnosis is of less consequence, as the treatment required by the peritoneal inflammation would in general involve that required by the inflamed organ, and, when the symptoms are violent and the diagnosis doubtful, the measures required by the more dangerous affection should be adopted. There is sometimes danger of confounding with peritonitis a peculiar nervous affection of the contents of the abdomen and pelvis, occurring es- pecially in females. This is often attended with severe pain, tenderness, tumefaction, vomiting, and frequent pulse. But the pain is less constant; and, though aggravated by slight pressure, is sometimes alleviated when the pressure is strong. It is, moreover, often quite paroxysmal. The patient is liable to various nervous derangements of an hysterical character; and is able and disposed to change position in bed. The pulse and countenance are less disturbed; the urine, instead of being scanty, is usually copious and pellucid; and not unfrequently pressure upon the spine, by the suffering it occasions, at once discloses the nature of the disorder. In all abdominal affections, a friction sound under auscultation may be con- sidered as a sign of peritonitis; although it does not always occur. Treatment.—In ordinary peritonitis, prompt and copious bleeding is the most important remedy. The pulse cannot be relied on as a guide. The heart appears to be cramped in its action by the violence of the local affec- tion ; and the pulse, though often corded, is generally small and very fre- quent, and well calculated to mislead an inexperienced practitioner. Indeed, it often becomes more developed under the loss of blood, and this result may always be considered as a proof that the remedy was properly applied. Neither should paleness of face, and absence of febrile heat upon the surface, deter from venesection, when the evidences of inflammation are unequivocal, and the patient is seen early in the attack. The quantity of blood with- drawn must be regulated by the apparent constitution of the patient, the stage of the disease, and the effects produced by its loss. In a tolerably vigorous individual, soon after the attack, from fifteen to thirty fluidounces may generally be taken with propriety ; and the bleeding may be repeated once and again, if the symptoms remain unabated, and no decided evidences of exhaustion be observable, though the amount abstracted at the second and third operation should not generally be so great as at first. It may some- times be necessary to repeat the bleeding within twenty-four, and even CLASS III.] PERITONEAL INFLAMMATION. 757 twelve hours. Faintness, or decided sinking of the pulse, occurring during the flow of blood, is a sign that sufficient has been taken for the time. ^ After the first bleeding, from five to fifteen grains of calomel should be given, followed in six or eight hours by castor oil, or sulphate of magnesia, or infusion of senna with salts, whichever maybe most easily retained by the stomach, so as to produce a thorough evacuation of the bowels. The irrita- tion of accumulated feces, and the injurious but vain efforts at movement in the muscular coat ofthe bowels which they tend to sustain, are thus avoided, and at the same time a wholesome revulsion effected towards the inner intes- tinal surface, and congestion of the portal system in some measure relieved by secretion from the liver and mucous membrane. Calomel is peculiarly appropriate, because better retained than most other cathartics, and for the reason, moreover, that it serves as an early basis for mercurial treatment, should this be ultimately advisable. But, after the ffrst thorough evacuation of the bowels, it is not desirable to push purgative medicines actively. I am convinced that any benefit they might produce would, as a general rule, be more than counteracted by the disadvantage of the continued friction of the inflamed serous surface ofthe intestinal convolutions. It is considered ofthe utmost importance to keep the opposite surfaces of an inflamed synovial membrane at rest. Why not also those of the inflamed peritoneum ? It is true that this objection is of less force when the inflammation is confined to the abdominal parietes, or to the investment of an immovable viscus; and, in such cases, when the diagnosis can be clearly made out, it may be proper to keep up an active purgation. In general, however, it will be quite suf- ficient to procure one or at most two soft evacuations daily, by the use of the mildest laxatives, aided by enemata. In the selection of the laxative, regard should be had to the irritable state of the stomach. Small doses of the effer- vescing Seidlitz powder, or of Rochelle or Epsom salt dissolved in carbonic acid water, or of infusion of tamarinds with cream of tartar, may be employed early in the day, and rendered effective by a laxative enema in the evening. These often allay vomiting, and also act usefully as refrigerants. Castor oil may sometimes be given in very small quantities, when acceptable to the stomach ; and some authors speak highly of a combination of this with oil of turpentine. Should these laxatives prove irritating to the stomach, they should be suspended, and reliance placed upon enemata alone. After one or two large bleedings, and a full evacuation of the bowels, re- course should be had immediately to leeches, which should be very freely applied, especially over those points of the abdomen where the pain and ten- derness are greatest. From fifty to one hundred and fifty American leeches should be applied at once; and the application may be subsequently repeated, if required by a persistence of the symptoms. The leeches should be followed by warm fomentations, or, what is better, if the patient can support their weight, by light emollient cataplasms, as of mush, oatmeal, flaxseed-meal, &c, large enough to cover the whole surface of the abdomen. These cataplasms should be kept on steadily for several days. Laudanum may sometimes be advantageously added to them. Instead of warm emollient applications, some recommend cold water, or even ice to the abdomen; but I have not tried this remedy, and confess that I should be afraid of it. Opium may be used very early in this inflammation. After free bleeding and leeching, and the full evacuation of the bowels, there is no occasion for further delay. At first, the best plan is to give the narcotic at night, so as to secure rest to the patient, and quiet to the inflamed membrane. Calomel should generally be added to it in small quantities. This is useful by pre- paring for the easier evacuation of the bowels on the following day, but still further, by facilitating the mercurial impression, should this be afterwards 758 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. determined on. One or two grains of opium, with from two to four grains of calomel, may be given in one dose ; or two grains ofthe narcotic and four of the mercurial may be made into four pills, two of which may be adminis- tered at once, and one every hour or two afterwards until the patient feels the anodyne influence. A direction to the surface of the body may be very usefully given by the addition of a grain or two of ipecacuanha to the mix- ture, should it not prove offensive to the stomach. In the same stage, advantage will often be found from the effervescing draught, given every two hours through the day. It acts favourably by quieting the stomach, and producing diaphoresis; two effects which are strongly indicated. Other anti-emetics that may be employed are small draughts of cold carbonic acid water, and creasote when there is no reason to suspect mucous gastritis. If the vomiting should be obstinate, it may sometimes be relieved bj copious draughts of warm chamomile tea, or simply warm water, aided, if necessary, by a small dose of ipecacuanha, which serve to wash out the stomach, and remove any offending matter that may be present. Anodyne enemata may also be resorted to In order to favour diaphoresis, the warm bath is sometimes beneficial, especially in the cases of children; but in adults, on account of the difficulty and pain of motion, it is better dispensed with, unless it can be applied without disturbing the relative position of the different parts of the body. As the disease advances, the fomentations or cataplasms may be superseded by rubefacient applications, especially hot oil of turpentine, or by blisters, which, in general peritonitis, should be made sufficiently large to cover nearly the whole anterior surface of the abdomen. Should the complaint not exhibit evident signs of yielding in the course of three or four days, recourse should be had to the mercurial impression. For this purpose, from two to four grains of calomel may be given every four or six hours, combined with from a quarter of a grain to a grain of opium ; and, in very urgent cases, the doses may be increased, or the interval be- tween them diminished. If the system do not quickly respond to the calo- mel thus employed, mercurial ointment may be applied by friction to the inside of the limbs, and as a dressing to the blistered abdomen. The patient almost always recovers from ordinary peritonitis when ptyalism is induced. In the advanced stages, it sometimes becomes necessary to counteract de- bility by tonic or stimulant remedies. For this purpose, wine-whey, carbo- nate of ammonia, and nutritious liquids may be used ; but perhaps the best remedy is a combination of oil of turpentine with laudanum or one of the salts of morphia. Sometimes it may be necessary to have recourse to milk-punch, or eggs beat up with sugar, and with wine or brandy and water. During the activity of the inflammation, the diet should consist exclusively of liquids, and these should be taken in small quantities at a time. Lemon- ade, orangeade, infusion of tamarinds, solutions of the various syrups made from fresh fruits, orgeat and water, gum-water, barley-water, and the like, while they serve as drink, afford sufficient nutriment for the patient. Ice-water and cold carbonic acid water may also be taken to quench thirst. Rennet- whey may be used, when it is considered desirable to make the diet somewhat more nutritious. Animal broths may become proper before the close. The patient should be perfectly quiet in bed, and not allowed to rise to evacuate either bowels or bladder. The bedclothes should be prevented from pressing on the abdomen by crossed segments of hoops, or other means. Cases of partial peritonitis are to be treated upon the same plan precisely, though with less energy. It is not necessary to take so much blood from the arm, and calomel should, as a general rule, be more sparingly employed. If the complaint occur in constitutions previously enfeebled by other dis- CLASS III.] PERITONEAL INFLAMMATION. 759 eases, or if it be complicated with an adynamic or typhous state of system, it will not admit of the same active depletion, and in some very low cases, will scarcely admit of depletion at all. Where any doubt exists upon the point, it will be best to employ leeches, to the exclusion of the lancet. The remedy upon which reliance is chiefly to be placed is mercury combined with opiates. Stimulants may sometimes become necessary. Peritonitis dependent upon perforation of the alimentary canal or other cavity, requires a somewhat peculiar treatment. Depletion maybe pushed as far as the strength ofthe patient will permit; but, as this has generally been much impaired by preceding disease, the remedy is in most cases inadmissi- ble, and must always be used with caution. Local bleeding by leeches should be preferred to the lancet, if it be deemed advisable to have recourse to either. A large blister may be applied to the abdomen. But the prominent indica- tion is to keep the bowels perfectly at rest, in order that the effused matter may be prevented from travelling, and that the formation of adhesions may serve to limit the disease. This is to be effected by the use of opium in large and repeated doses, so as to maintain the system completely and constantly under its influence. The opium, while it thus puts the bowels, as it were, in splints, answers another excellent purpose, by rendering the system at large less sensible to the shock ofthe disease. The body of the patient should be kept absolutely at rest, and drinks forbidden, or at least admitted only in such quantities as may insure them against passing through the pylorus. Thirst maybe allayed by washing the mouth out with cold liquids, and allow- ing small pieces of ice to lie upon the tongue. Under any plan of treatment, the case must be considered as almost desperate; but the one described affords some chance of a favourable issue. One case was successfully treated by Dr. Stokes, of Dublin, upon the opiate plan; and another, probably of this character, already referred to as occurring in convalescence from enteric fever, ended in recovery under the care of Dr. Gerhard and myself. Two other cases of peritonitis, occurring under similar circumstances, have been subsequently reported as having ended in recovery under the opiate treatment. (See note, page 361.) But there can be no positive certainty that these were really cases of perforation. They may have been simply examples of the disease supervening upon other affections in their advanced stage, an event already stated not to be uncommon. Still, the important therapeutical inference may be drawn from them, that, as the opiate plan is the only one under which peritonitis thus occurring has been cured, this remedy should be employed in all cases supposed to be connected with perforation. Indeed, we may go further, and consider it as our main reliance in all cases of the disease, supervening upon others, in an exhausted state of the system. Puerperal peritonitis is to be treated upon the same plan as the ordinary form of the disease ; but being, as a general rule, more rapid and violent, it requires, in a proportionate degree, more prompt and energetic interference. It is unnecessary to particularize the remedies, which are absolutely identical with those already mentioned. Attention should be additionally paid to the state of the uterine discharges. The lochia, if suppressed, should be pro- moted by fomentations or emollient applications to the external genitals ; and acrid discharges, if any such exist, should be removed as they appear, while the vagina is carefully washed out by emollient injections. It is also ad- vised, by some writers, to favour the flow of milk by similar applications to the breast, and by resorting to the efforts of the infant, or of some young sucking animal, as a puppy. In the adynamic form of this disease, bleeding is not well borne ; the loss of a few ounces sometimes producing great faint- ness, from which the patient scarcely rises. Still it is generally proper to try blood-letting ; for the diagnosis is sometimes difficult, and the effects of bleed- 760 LOCAL DISEASES.—DIGESTIVE SYSTEM. [PART II. ing, and the quality of the blood drawn, are among the most characteristic marks of the affection. Should the pulse become very feeble, and the patient very faint from the loss of a little blood, while the blood which has been drawn is dark, and yields a loose and easily broken coagulum, the inference is, that the case is one of a malignant adynamic character, and the plan of direct depletion should be abandoned. Leeches may often be usefully sub- stituted for the lancet. Considering the favourable effects of the opiate treatment in the form of peritonitis ascribed to perforation, it is highly pro- bable that it may be found among the most efficient in this variety also of the disease. Stimulants and a nutritious diet are often necessary. It is probably to cases of this nature that oil of turpentine, so highly recommended by Dr. Brenan, of Dublin, is especially applicable. Both sound medical reasoning and experience are, I think, adverse to its employment in the cases of ordi- nary inflammation of the peritoneum, whether occurring in puerperal women or others. II. CHRONIC PERITONITIS. There are two varieties of chronic peritonitis, differing entirely in their origin, and much in their degree of fatality, which are nevertheless so similar in their symptoms, that it is not always easy to distinguish them. In one, the inflammation is of the ordinary character, and originates in the ordinary causes; in the other, it depends upon tubercles disseminated in the mem- brane, and serving as a constant source of irritation. I shall first describe the former, and then point out those additional symptoms which may be sup- posed to indicate the existence of the latter. Symptoms.—The disease is sometimes original, but, when the inflammation is of the ordinary character, is more frequently a mere sequel of an ill-cured acute attack. In the former case, its commencement is often very obscure, a little pain being sometimes felt in the abdomen, with derangement of diges- tion, and alternations of constipation and looseness of bowels, which exist for a considerable time without attracting much attention. At length the gene- ral health is affected, a little febrile excitement is experienced towards even- ing, the patient loses flesh and strength, and the disease becomes fully de- veloped. When the result of an acute attack, it exhibits the characteristic phenomena immediately after the subsidence of the primary symptoms. It is sometimes difficult to decide, whether the disease began in its acute or chronic form; for even in cases which might be considered as belonging to the latter, the pain is severe at first, and afterwards diminishes; and the fact is that there is no distinct line of division between the two varieties. When the complaint is fully formed, there is usually slight pain in the abdomen, which in many instances is scarcely felt unless under direct pres- sure, or on the occasion of some shock or jar, such as that produced by a false step, or the motion of a carriage, or some effort on the part of the patient, such as coughing, straining, &c, which causes a sudden concussion or com- pression of the abdominal viscera. Sometimes the pain and tenderness are confined to one spot, sometimes are diffused or variable. There is occasion- ally a sense of heat in the epigastrium. The abdomen is sometimes swollen in consequence of effusion into the cavity ; but, when this is not the case it may be even flatter than in health, in consequence of the tension of the muscles. In the former case, there is dulness on percussion, often more or less fluctuation, and sometimes an edematous condition of the feet and legs. In the latter, the abdomen is firm and elastic to the touch, and often more or less unequal, from the irregular formation of adhesions, and the development of tumours or of sacs within the folds ofthe peritoneum. Occasionally the CLASS III.] PERITONEAL INFLAMMATION. 761 abdominal effusion is so great as closely to imitate ascites, if not to consti- tute a variety of that disease. The appetite is feeble or irregular, and the digestion impaired. In most cases, there is nausea with occasional vomiting, and the bowels are irregular, being either constipated or affected with diarrhoea. Food produces a feeling of weight in the stomach, and, in some instances, causes pain in a particular portion of the abdomen, occurring at a certain interval after eating. The stools are often light-yellow or clay-coloured. The state of the tongue is variable ; but generally it is either slightly furred, or smooth, red, and more or less chapped. The pulse is frequent; the urine scanty ; the skin usually dry, unless in the latter stages when hectic fever has been developed; and the face pale and expressive of anxiety. The progress of the disease is usually very slow. Strength gradually fails ; and the patient, worn out by the con- stant irritation, as well as by the failure of digestion and nutrition, sinks into a state of extreme debility and emaciation, which terminates at length in death. The fatal issue is sometimes accelerated by the supervention of an acute attack of inflammation. The disease is sometime* complicated in its course by functional disorders of various organs, the action of which is in- terfered with by adhesions, or tumours formed in the peritoneal cavity. Thus, jaundice may result from pressure upon the gall-ducts, and obstinate constipation from pressure on the bowels. Sometimes the disease is quite latent until near its close. It is not always easy to determine, during life, whether the disease is or is not connected with tubercles of the peritoneum. Whenever it is protracted and very obstinate, resisting the curative measures employed, and when its origin cannot be traced to a preceding acute attack, to local injury of the ab- domen, or to chronic affections of the abdominal viscera, there is strong reason for believing it to be tuberculous. In this form of the disease, a close exam- ination of the abdomen will often detect small tumours consequent upon enlargement of the mesenteric glands; and the external lymphatic glands, especially in the groin, are also occasionally enlarged. The simultaneous ex- istence of tubercles in the lungs, or an obstinate diarrhoea, indicating tuber- culous ulceration of the bowels, would be further evidence of the nature of the affection. Some aid in the diagnosis may also be drawn from the general habit of the patient, and his hereditary tendencies. The disease is always dangerous, and, in the tuberculous form, probably quite incurable. When partial, or dependent on a curable disease of neigh- bouring organs, or consequent upon an acute attack, and unconnected with tubercles, there is reason to hope that it may yield to remedies. Anatomical Characters.—Not uncommonly there is almost universal ad- hesion ofthe peritoneal membrane, in consequence ofthe effusion and organ- ization of coagulable lymph. Occasionally small spots of lymph are observed thickly strewed over the surface of the peritoneum, which at first sight might be mistaken for tubercles, but are distinguishable by their less regular form, and by being easily scraped from the membrane, while tubercles, being situ- ated in the subserous tissue, are not thus removable. In those cases in which the false membrane covers the peritoneum, it is usually very thick, of a gray- ish, reddish, or dark colour, often rough, and of an areolar appearance upon the surface, and sometimes of an almost cartilaginous hardness. Sometimes the intestines are so agglutinated as to form tumours sensible externally, and now and then, in consequence of partial adhesions of the peritoneum, sacs are formed, which arc filled with liquid, and give an irregularity to the outline of the abdomen. The liquid effusion is variable in quantity, position, and appearance ; being in some cases very scanty, in others more or less abund- ant • sometimes anterior to the bowels, which are compressed into the back 762 LOCAL DISEASES.—ADSORBENT SYSTEM. [PART II. part of the abdomen, and sometimes, as before mentioned, partially collected in sacs ; occasionally nearly colourless and limpid, with fibrinous flakes, occa- sionally more or less opaque, and of a yellowish, brownish, blackish, or red- dish colour, from admixture of pus or of blood. In some instances, it consists exclusively of pus. In cases complicated with tuberculous deposition, this is found either in small distinct granulations, or in masses formed by their aggre- gation, more or less extensively diffused over the peritoneum, and generally attended with false membrane and adhesions. The tubercles exist in all stages of development. They are usually solid, but are sometimes met with in the softened state, and even opening into the peritoneal cavity. Instances have occurred in which tuberculous matter, deposited in the adhering coats of two intestinal convolutions, has produced ulceration in both, and thus formed a communication between them. Treatment.—The remedies to be chiefly relied on are rest, occasional leeching, fomentations or emollient cataplasms, warm bathing, blisters, and the constitutional impression of mercury and of iodine. Rubefacient applica- tions to the abdomen, pustulation by tartar emetic, and setons or issues on the inside ofthe thighs, have also been recommended. Mercury may be used both internally and externally ; the ointment being applied by friction over the abdomen, or as a dressing to the blistered surface. Iodine may be used in the same way. Attention should be paid to the state of the bowels, con- stipation being obviated by laxatives, and diarrhoea by opiates combined with cretaceous preparations. Dover's powder, or the extract of hyoscyamus, may often be usefully given at night, especially in connection with the mercurial preparations. Diuretics may be employed to promote the absorption of the effused fluid. The diet should be regulated by the circumstances of the case. In the more active stage, it should consist exclusively of vegetable matter; when the strength fails under this rigid course, milk may be added ; and cir- cumstances of debility and exhaustion may occur, requiring the use of richer animal food. In the tuberculous cases, the diet, as a general rule, should be more nutritious than in those of uncomplicated inflammation. In these cases, moreover, a preference should be given to iodine over mercury; and the ne- cessity of counteracting the tendency of general debility to produce tubercu- lous deposition, may render a resort to bitters, chalybeates, cod-liver oil, and moderate exercise of a passive character, desirable. Should abscesses form with an apparent external direction, their tendency to the surface should be favoured by emollient poultices. SECTION II. DISEASES OF THE ABSORBENT SYSTEM. The absorbent system, besides sharing in the general susceptibility of the body to morbid influences, is, from the nature of its office, peculiarly exposed to certain causes of disease. Receiving not only the effete matters of the general organism, but also the alimentary product of the digestive process, and, possibly, numerous bodies from without, of every degree and variety of noxious power, it must, in many instances, experience the first evil effects of morbid agents ; and not unfrequently, it is probable, experiences such effects exclusively; as there is reason to suppose that the glands have a modifying influence over the substances absorbed, which often brings them into har- mony with the susceptibilities ofthe system, and thus prevents their injurious influence beyond the structure, into which they have penetrated. The absorb- ents, moreover, seem, beyond all other vessels, to be possessed of that contin- CLASS III.] INFLAMMATION OF THE ABSORBENTS. 763 nous sympathy, which transmits an impression from one part to another of the same structure ; so that an irritation at their origin is very apt to be transmitted for a considerable distance along their course. A slight general sketch of the derangements of which they are susceptible, will be a proper introduction to the more detailed account of those few of their diseases which appear to merit a separate description. The absorbents, as the result of irritation, may act more energetically than is compatible with health, and may thus produce general emaciation, or the wast'ng of particular parts or organs.* They may fall into the opposite state of depression or debility, and, failing to execute their legitimate function, may giva rise to morbid accumulation of fluids, constituting dropsy, or of solids, constituting obesity, and various local excesses of growth. As a consequence, also, of deficient action, they may fail in their office of assimilation, and thus allow noxious matters to enter the blood, wliich might otherwise be rendered innocent, or at any rate be very favourably modified. They are subject to inflammation in all its grades and stages. To scrofulous or tuberculous dis- ease they are peculiarly liable. Involved, as they almost always are, at their origin, in every specific local disease to which the frame is subject, they serve as channels by which the affection spreads to neighbouring or distant parts, or pervades the system, and consequently are themselves the first to suffer. Hence, the absorbents or absorbent glands become the seat of syphilis, of car- cinoma, of epithelioma, of fibroid disease, and of other less strictly defined and understood degenerations. They may become enlarged or varicose, and diminished in their caliber or strictured. Their channel may be entirely closed, giving rise to accumulations behind the strictured point, and consequent rup- ture of the vessel. Their coats are sometimes ossified, and like other parts are liable to excessive and deficient growth. But most of these affections are very obscure, and scarcely discoverable during life. Some of them must, from the very nature of the case, be, in any particular instance, hypothetical, or at best conjectural. Others again are completely lost in the ravages which the disease produces in parts more immediately vital. Of the various complaints, therefore, to which this system is incident, a few only merit a separate notice. Those here treated of are inflammation of the absorbent vessels and glands, and scrofulous or tuberculous disease of the glands. Article I INFLAMMATION OF THE ABSORBENTS. Syn.—Angeioleucitis.—Lymphangeitis. Of inflammation of the laeteals, as distinct from that of the glands which they permeate, and of the lymphatics of the viscera, whether of the chest or abdomen, little can be known during life. Though probably of no very un- frequent occurrence, and sometimes possibly very serious in its results, there are no symptoms by which it can be distinguished from other inflammations, with an approach to accuracy; and the practitioner must content himself with treating the affection according to the visible indications. But inflammation of the external lymphatics is in general sufficiently obvious. Symptoms, Course, die.—If the superficial layer of absorbents only is * It must not be considered that it is the mere vessels or tubes to which the author has reference, when treating of this system of parts, but the whole apparatus con- hecte.l with the absorbent process, including, of course, the cells by which proper ab- sorption is supposed to be effected. 764 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. affected, as usually happens when the disease originates in a wound, ulcer, or inflamed point of the surface, pain, increased by pressure, is usually felt along the course of the lymphatics, and simultaneously, or soon afterward, one or more reddish streaks may be observed, commencing at the originating point of disease, or at a greater or less distance from it, and running towards the centre of circulation. These streaks are sometimes straight and sometimes crooked, often interlace with each other, so as to form irregular meshes, and, when examined by the fingers, feel like hard cords. The redness often extends to some distance on each side of the cord, being gradually shaded off into the natural colour of the skin. It is generally of a rather bright tint; but is sometimes dark. Not unfrequently distinct patches of redness occur, irregular and obscurely defined, but usually connected by the lines alluded to. The inflammation travels rapidly until it reaches the lymphatic glands, which become enlarged and painful; and often extends beyond these, spreading as it advances, and giving rise, in some instances, to a diffused erysipelatous redness. The cellular tissue also becomes inflamed, and the whole neighbour- ing parts swollen and hardened. The hardness, however, occurs rather in nodules than diffusively. The patient now suffers greatly with soreness and burning pain. When the more deeply-seated lymphatics are exclusively affected, the pain is at first without redness, is deep-seated and shooting, and gradually extends along the course of the vessels. Slight pressure on the surface has little effect, but strong pressure increases it considerably. There is much swelling; and deep-seated irregular hardness may be felt upon a close examination. The surface at first retains its natural colour; but at length becomes red- dened ; the redness occurring not in lines, but irregularly in patches, and having a pinkish or roseate hue. Both sets of vessels are sometimes simul- taneously inflamed; and then, the symptoms of the two are united. Most frequently the symptoms are much less severe than those enumerated; and often only a few red lines are observable, which are sore to the touch; and give rather a feeling of stiffness than of acute pain. Occasionally, the inflammation of the vessels is so slight that it could scarcely be recognized, but for the swelling and soreness of the glands towards which they run. The mild cases generally terminate in resolution, under suitable treatment The severer often run on to suppuration. The pus is generally in separate small abscesses, occupying the seats of previous hardness ; but sometimes it is diffused through the cellular tissue, or forms large collections, from which the matter flows copiously when the cavity is opened. Mortification rarely occurs, unless in the very old, or in persons of worn out constitution. Occa- sionally, however, the cellular tissue sloughs as in erysipelas. In some rare instances, the inflammation appears to assume a chronic form. The constitutional symptoms vary with the severity of the local disorder. When this is very slight, the system at large is not affected; when intense, the general disturbance is sufficient to involve life in danger. The phenomena are usually those of ordinary symptomatic fever; at first rigors, followed by heat of surface, a frequent and full pulse, furred tongue, thirst, loss of appe- tite, restlessness, and want of sleep; then, after suppuration, a relaxed skin, often sweats at night, diminution of the strength but not the frequency of the pulse, with a continuance of other symptoms. Sometimes there is nausea or vomiting, and sometimes slight delirium. In bad cases, especially those which result from wounds in dissection, the fever assumes in its progress a typhoid character, with a very frequent and feeble pulse, a dry or gashed tongue, great restlessness and anxiety, subsultus, delirium, &c. Death seldom occurs, unless in constitutions enfeebled by intemperance, or previous disease, or in cases dependent upon the absorption of some poisonous agent. CLASS III.] INFLAMMATION OF THE ABSORBENTS. 765 Most parts of the body are liable to this affection; but it is more frequent in the extremities than elsewhere, especially in the upper, because these are most exposed to the accidents in which it is apt to originate. When it occu- pies the arm, it runs up, on the inside, to the glands of the axilla, and often spreads to the chest before, behind, and below the arm-pit; producing, in bad cases, extensive erysipelatous inflammation, and subsequent suppuration in these parts. It sometimes Occurs, usually in a mild form, in the neck ; and has been found by dissection to have existed in the lungs, abdominal viscera, uterus, and thoracic duct, though no symptoms during life can reveal it with certainty in these parts. Anatomical Characters.—The coats of the lymphatics are thickened, the cellular tissue about them infiltrated and tender, the internal coat sometimes softened though not reddened, and the cavity often filled with pus. Some- times the caliber is distended with pus, so as to offer the appearance of an abscess; and Amussat details the examination of a chronic case, in which a large abscess in each groin, communicating with the abdomen through the crural arch, proved to be nothing more than distended lymphatics. In this case, the thoracic duct, and the lymphatics of the abdomen, were also found loaded with pus. The neighbouring cellular tissue is in some parts healthy, in others hardened, and in others again destroyed by purulent infiltration. Causes.—The cause of this affection is, in the great majority of cases, either inflammation in a particular spot, with or without solution of continuity, or the introduction of some acrid or poisonous matter through a wound, ulcer, or abrasion of the skin, or a combination of the two. Thus, the inflammation produced in the toe by the pressure of the nail, is apt to extend up the lym- phatics of the limb. Very small wounds, particularly punctured wounds, even the pricking of a thorn or briar, and the bites and stings of insects, will occa- sionally give rise to the disease. In the last case, the irritation of a poisonous matter is superadded to that of the wound. Among the most common causes is the exposure of a finger or hand, in which there has been some slight wound or abrasion, to the action of irritant animal matter, either in the dead or living body. The author once attended an accoucheur, affected with this dis- ease in consequence of an examination per vaginam with a slightly wounded finger. The effect of dissection, whether of a putrefying or sound body, in producing the disease is well known. Ulcers, and various eruptive affections of the skin also frequently induce it. Thus, impetiginous ulcers of the head and face, and the sores so common behind the ears in children, often give rise to inflammation of the lymphatic glands of the neck, and the intervening ab- sorbents. The deep-seated absorbents may become inflamed in consequence of a contusion, fracture, or deep penetrating wound, and from communicating with collections of various acrid secretions. It has been observed, however, that the latter result rarely takes place, unless the matter has undergone de- composition, and acquired irritating properties by exposure to the air. Simi- lar causes may produce inflammation of the visceral absorbents, and those of the intestines are peculiarly exposed to it, from the frequent existence of in- flamed points and ulcerations on their inner surface. In all cases, the vessels are affected either by a propagation of the inflammation from the original point, through what has been called continuous sympathy, or by the absorp- tion of acrid matter which comes in direct contact with their inner surface. But these causes often exist without inducing inflammation of the lymphatics ; and the inference is admissible, that there must be at the same time some peculiar condition of system, acting as a predisposition to the disease. This condition is seldom appreciable; but it is highly probable that bad living, sedentary habits, and other agencies calculated to deteriorate the character of the blood, may have some effect in producing it. 766 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. Diagnosis.—The only disease likely to be confounded with inflammation of the external lymphatics, is phlebitis or inflammation of the veins. But in this the inflamed cords are larger, of a darker redness, and less disposed to inosculate ; the lymphatic glands do not participate in the inflammation; and the redness upon the surface is less apt to have the diffused character of ery- sipelas. The progress of the disease, too, is more rapid; suppuration occurs more speedily; and the constitution is in general more profoundly affected, in consequence of the passage of pus into the circulation. Treatment.—The first indication is obviously to remove the cause, if it continue to act. Hence it is necessary to remove any existing source of irri- tation from the wounded or inflamed point, and to correct the inflammation by cooling applications, or emollient poultices. In poisoned wounds, as, for example, those which happen in dissection, the application of nitrate of silver is often useful. Might not the tincture of iodine, or a strong watery solution of chlorine, prove advantageous, by chemically decomposing any organic poison existing in the wound ?* If the pulse is full and strong, the patient vigorous, and the local disease considerable, blood should be taken from the arm; but caution is necessary; as the nature of the cause, and the constitution of the patient, sometimes give a tendency to a low form of disease, and it becomes, under such circumstances, important to husband the strength. Bleeding can scarcely ever be proper after suppuration has begun. Leeching along the course of the absorbents is a very valuable remedy. Solution of acetate of lead in the proportion of two drachms to the pint, or the officinal diluted solution of the subacetate, should be applied by means of linen cloths to the inflamed surface. Laudanum or acetate of morphia may be added to either solution. Blisters may sometimes be useful; but they seldom remove the disease. I have employed them chiefly to prevent the spread of the cutaneous and subcutaneous inflammation, by applying them at the outer limits of the erysipelatous surface, partly on the inflamed and partly on the sound skin. For the same purpose, as well as for the removal of the erysipelatous inflammation, recourse may be had to the local application of tincture of iodine, or a strong solution of nitrate of silver. Mercurial ointment may also be used; and, if it affect the mouth, will prove so much the more efficacious. When suppuration has begun, it should be favoured by emollient poultices. Blisters sometimes hasten it. When pus has accumulated, free openings should be made for its escape; and care should be taken to assist the discharge, if necessary, by pressure with the hand or otherwise, once or twice a day. If this precaution be neglected, the pus may spread through the cellular tissue, and extend the mischief. Properly grad- uated pressure, by means of bandages and compresses, is often highly useful in diminishing the cavities, promoting the healing process, and causing the absorption of the edematous effusion. Internally, the saline cathartics and refrigerant diaphoretics should be given in the early stages. The neutral mixture or effervescing draught, and the antimonials, when there is no nausea, may be selected. Spirit of nitric ether should be added, when the fever is attended with nervous symptoms. After due depletion, opium and ipecacuanha should be given, especially at bedtime ; and, if the disease is obstinate, they may be very usefully combined with calomel. When suppuration has taken place, it may become necessary to support the system by quinia, the mineral acids, wine-whey, ale or porter, &c. Nervous symptoms occurring in this stage may be counteracted by infusion of serpentaria and valerian, camphor, and compound spirit of sul- * This suggestion was made in the first edition of this work, published in 1847. The plan has since been submitted to trial with favourable results. CLASS III.] INFLAMMATION OF THE ABSORBENT GLANDS. 767 phuric etheri and opiates should be continued. If the tongue is dry, very small doses ofmercurial pill, combined or not with opium and ipecacuanha, may be given at short intervals until the mouth is slightly affected. The oil of turpentine is also sometimes useful under these circumstances. If the case should be typhous or adynamic from the commencement, it may be necessary to begin early with the tonic and stimulant plan. The diet should consist, in the early stages, chiefly of farinaceous or muci- laginous liquids, to wliich, in the more advanced stages, it may be necessary to add rennet-whey, milk, and animal broths and jellies, according to the degree of support required. When there is no fever, and the appetite is not affected, it is sufficient to confine the patient to a vegetable diet. Article II INFLAMMATION OF THE ABSORBENT GLANDS. Sy n. —Lymphadenitis. This affection may occur wherever there are absorbent glands, whether superficial, deep-seated, or within the great cavities; but, as it conies under observation, it chiefly affects the external glands, especially those ofthe neck, groin, and axilla. The bronchial glands may be occasionally attacked by common inflammation, and we know that those of the mesentery very often become more or less inflamed in consequence of ulceration or inflammation in the mucous membrane of the small intestines; but we have no means of ascertaining this point certainly during life; and, so far as the treatment is concerned, we must be guided by general principles. The following descrip- tion has reference to the external glands. Symptoms, Course, &c.—The affected gland becomes at first swollen, hard, painful, and tender to the touch. If near the surface, it forms an obvious tumour, which is usually oval, with a rather definite outline, and generally somewhat movable. The inflammation, in most cases, soon extends to the neighbouring cellular tissue, thus greatly increasing the tumefaction, wh'ch is now less precisely bounded, while the gland becomes fixed. Not unfre- quently several glands are inflamed at the same time, thus producing irregu- larity in the surface of the tumour, perceptible especially by the touch. If the disease is not arrested, in a period varying from one to two weeks, sup- puration commences; the skin becomes thinner under the distension, and assumes a dark-reddish or somewhat livid hue ; and one or more prominent points in the tumour are observable, where fluctuation may be perceived. The pus is contained sometimes in one, sometimes in several distinct cavities. Occasionally it is confined to the gland, in which case the tumour is circum- scr.bed and somewhat movable; occasionally to the surrounding parts, when the boundary of the swelling is quite indefinite; and not unfrequently occu- pies both situations. The skin at length ulcerates; and the abscess or ab- scesses open, discharging a homogeneous healthy pus, sometimes in small quantities, sometimes copiously; and then gradually heal, leaving almost always more or less swelling and hardness, which last for a long time, but ultimately in general disappear. Sometimes the tumour, before suppuration has commenced, or has made any considerable progress, ceases to increase, becomes less painful and tender, but at the same time harder and more circumscribed, and continues thus for a long time in a state of chronic inflammation, with a slight feeling of heat and soreness. The inflammatiou sometimes takes on at the beginning the 768 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. chronic form. In this case, the gland slowly enlarges and hardens, con- tinuing circumscribed and movable, with a deep, dull pain; and thus remains, until either some accidental cause induces an acute inflammation which hastens the result, or the tumour, after a long time, passes gradually into the state of resolution or suppuration. When the latter event occurs, the sub- stance of the gland is ultimately destroyed, and its place occupied by the pus, which is confined within its exterior envelope, forming a single cavity. The pus, both in the acute and chronic forms, is destitute of that tuberculous or cheesy matter which characterizes scrofulous disease of the glands. Acute inflammation of the glands is generally accompanied with more or less febrile disturbance, which differs in nothing from ordinary symptomatic fever. Chronic inflammation, on the contrary, seldom brings the system into sympathy. The prognosis of this disease, in the external glands, is almost always favourable. When treatment is applied early, before any appearance of sup- puration, resolution is very often effected. But, when the skin has begun to assume a reddish or purplish hue, or the slightest fluctuation can be perceived, it is generally futile to attempt to backen the disease, and the practitioner should confine his efforts to the hastening of the suppuration. Anatomical Characters—In the early stage of the inflammation, the tissue of the gland is firm, dense, and homogeneous, and presents upon the cut sur- faces, numerous dark-reddish points, which mark the orifices of the divided vessels. In the more advanced stage, it is dark-red, easily torn, and infil- trated more or less with effused blood. When suppurating, it is softened, and exhibits at first minute cavities containing a viscid serous fluid, which are gradually enlarged, and at length filled with a yellowish uniform pus. The cellular structure about the gland exhibits, when it has partaken in the disease, the usual evidences of inflammation in that tissue. (See page 36.) Causes.—The causes of inflammation of the lymphatic glands are so exactly those of inflammation of the lymphatic vessels, that it is unnecessary to re- peat them here. (See page 165.) If there is any difference, it is, perhaps, that the glands are more liable than the vessels to the influence of the ordi- nary causes of inflammation in other parts. It not unfrequently happens that the gland is inflamed, in consequence of an irritation or irritant carried to it by the vessels, while the latter exhibit no signs of being themselves affected. Treatment.—General bleeding may be employed when the disease is vio- lent, the constitution of the patient vigorous, and the inflammation at a stage which admits of resolution. Leeching is often very useful, ana may be re- peated once or oftener, if it be considered very desirable to arrest the pro- gress of the disease, and prevent suppuration. The cold poultice, made with crumb of bread and lead-water, may afterwards be applied with a similar object. Saline cathartics should be given in the early stages, and the patient confined to a vegetable diet. Should suppuration have commenced, or appear inevitable from the prominence of the tumour and discoloration of the skin, all these measures should be abandoned, and the new process promoted by emollient poultices. After an abscess has clearly formed, and fluctuation become distinct, a free opening should be made by the lancet. By allowing the abscess to open itself, the practitioner endangers, in some instances ex- tensive injury of the cellular structure, and such a thinning of the skin, as to cause great destruction of this tissue, and consequently a large ulcer, and ultimately a deforming cicatrix. If pus appears to exist in distinct cavities, each one of them should be freely opened. In cases disposed to assume the chronic form, or in those originally of that form, after due depletion by leeches, repeated blisters will often be found use- ful. Various other discutient applications may also be resorted to, such as CLASS III.] EXTERNAL SCROFULA. 769 the compound galbanum plaster, the ammoniac plaster, the mercurial plaster, the mercurial ointment, and various unctuous preparations of iodine, as the simple or compound ointment of iodine, the ointment of iodide of potassium, and that of iodide of mercury. The most effectual applications are those of mercury and iodine. Article III. SCROFULOUS INFLAMMATION OF THE ABSORBENT GLANDS, or EXTERNAL SCROFULA. Syn.—Scrofulous Adenitis. All the absorbent glands, whether external or internal, are liable to scrof- ulous inflammation. But there is so much difference, both in the symptoms and progress of the disease, according as it occupies the glands within or those without the great cavities, that it requires a distinct consideration in these two positions. I shall treat of it under the present head, as it occurs in the external glands, constituting ordinary external scrofula. Symptoms, Course, &c.—The first symptom which usually calls attention to the existence of the disease is an enlargement of one or more of the glands, which has come on almost imperceptibly, and increases for the most part very slowly. The tumour is hard, somewhat elastic, usually oval, pretty well de- fined, and more or less movable, especially when near the skin. When seve- ral neighbouring glands are affected, though isolated at first, they often become aggregated as the disease advances, forming a large, irregular mass, with an uneven, slightly lobulated surface. In the early stage, they are iu general nearly or quite free from pain, and from the other marks of inflammation, with the single exception of tumefaction. Sometimes, without any obvious cause, they cease to advance, becoming indolent, and remaining in this state for months or even years, and then again resume their activity. Not unfrequently, under proper treatment, the tumour or tumours gradually disappear, leaving in some instances no traces, but in the greater number, perhaps, slight glandular enlargements, which continue during life. When allowed to pursue their own course, they generally proceed to suppuration; and this often happens even under the best treatment. A higher grade of inflammation now supervenes, extending frequently to the neighbouring cel- lular tissue, and sometimes producing considerable pain, heat, and even febrile symptoms. The tumour becomes less movable in consequence of adhesion to the neighbouring cellular tissue, and to the skin, which is warm, tender to the touch, and often reddened. Fluctuation is now evident, and is felt equably over the tumour, or in distinct points, according as the pus is contained in one, or several cavities. At length one or more openings are produced, and a liquid is discharged, which is sometimes true pus, sometimes a puruloid serum mixed with a curdy matter, considered identical with the tuberculous deposit. Frequently, pus first escapes, and afterwards a mixture of viscid serum and the curd-like matter alluded to. The latter very generally appears when the substance of the gland suppurates. Occasionally the cellular tissue is the exclusive seat of suppuration; in which case, the liquid may consist of genuine pus alone. The resulting abscess is usually very slow to heal, con- tinuing for a long time to discharge its characteristic matter, and sometimes forming an obstinate fistulous sore, with the skin about its orifice, smooth, shining, and of a purplish or violet hue. vol i. 49 770 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. It often happens that the skin over the abscess ulcerates, leaving an open sore, of an unhealthy, characteristic aspect. The edges are irregular, often undermined, sometimes hard, swollen, and obtuse, sometimes thin and flabby, and dull-red or purplish. The bottom is uneven, light-red or grayish, with soft indistinct granulations, giving rise to a copious serous discharge, with curd-like flakes. The ulcer is often very obstinate, and frequently changes its form, in consequence of partial cicatrization, or the extension of ulceration, or of both these processes going on at the same time in different parts. It is very uncertain in its progress, sometimes appearing as if about to heal, and then again breaking out, in consequence frequently of inappreciable changes in the state of the system. It is seldom attended with much pain. Upon healing, it is apt to leave an irregular, rugged, and unsightly cicatrix. The superficial glands of the neck are most frequently affected, and next, those of the axilla, groin, and mamma?. The disease sometimes also attacks the more deeply seated glands. It is apt to run from gland to gland, along the course of the absorbents in which it originates. In the neck, there is sometimes a chain of diseased glands extending from the ear to the clavicle, and even within the chest. Sometimes both sides are affected, sometimes only one. In the former case, the tumours are apt to be larger on one side than the other. The diseased superficial glands are distinguishable from the deep seated by their greater prominence and mobility. The constitutional symptoms vary with the stage. Even before the appear- ance of the tumours, a certain disordered condition of the system is often obvious to a close inspection, especially in very severe cases; and peculiar physical characters, even in the healthy state, are thought to mark a predis- position to the disease. These have been detailed sufficiently under the head of tuberculous or scrofulous disease. (See page 116.) The incubative stage, or that which precedes the tumefaction, if open enough to be observed, is marked by a greater or less degree of languor and dejection, defective or irreg- ular appetite, loss of colour and of flesh, occasional erratic pains in the bones and joints, and slight febrile paroxysms. Certain local symptoms are some- times also observable. The mucous membranes are apt to become inflamed, especially that of the nostrils, which discharges a thin excoriating fluid, and is attended with swelling about the nasal orifices, so as to impede the entrance of air. The upper lip is often swollen and chapped in the middle. In some cases, the conjunctiva is irritated or inflamed, and the edges of the eyelids be- come affected in such a manner that the eyelashes drop out. The fast joints of the fingers are occasionally swollen, and a disposition in the nails to curve forward at their extremities has often been noticed. In many cases, however, the tumours occur in the midst of apparent health, and, as before observed, are generally the first symptom which attracts attention. When constitutional symptoms precede them, they usually become ameliorated after the glands have begun to enlarge. But, as the disease advances, especially when severe, the system sympathizes with the local affection, more or less fever is often experienced, and the appetite and strength, which had improved for a time, again begin to fail. In the last stage, when suppuration has been established, and the patient labours under the exhausting and irritating influence of large abscesses or ulcers, hectic symptoms often occur, with various nervous de- rangements, and, in the adult female, with disorder of the uterine functions. In very mild cases, however, the disease may run its whole course, with little if any observable disturbance of the constitution. When the scrofulous tendency is strong, the local development is not always confined to the glands. Indolent swellings occur in the subcutaneous cellular tissue, in various parts of the body, which ultimately become abscesses, or ulcers, with pus similar to that found in the glandular tumours. Abscesses CLASS III.] EXTERNAL SCROFULA. 771 also sometimes form under the fascia?, or in the cellular tissue between the muscles. _ The skin occasionally ulcerates in consequence of a morbid condi- tion of its own tissue, forming open sores of a very intractable character. Certain obstinate cutaneous eruptions, which sometimes attend the complaint in its progress, are supposed to have their origin in the scrofulous taint. Chronic inflammation of the conjunctiva and eyelids is not unfrequent; and the mucous membranes generally are more or less subject to the same vitia- tion. Disease of the joints, periosteum, or bones, may complicate the gland- ular affection; though more frequently, when the morbid tendency finds a vent through these avenues, it leaves the glands untouched. External scrof- ula is also sometimes associated with a similar condition of the internal glands, and with those fatal derangements which result from the deposition of tuber- culous matter in the vital organs, or the serous tissues investing them. It occasionally happens that the internal alternates with the external disease; and, though the two are, as before stated, sometimes associated, it may be considered true, as a general rule, that, in cases of a strong tuberculous or scrofulous diathesis, a direction to the external glands serves as a safeguard, in some measure at least, against the much more dangerous affections of the lungs, brain, peritoneum, and mesenteric glands. The duration of external scrofula varies exceedingly. Sometimes, in slight cases, it begins to retrocede almost immediately, under proper treatment, and finishes its course in a few weeks; while, in other instances, it resists all treat- ment, and runs on for many months, and even for years. Generally, how- ever, it sooner or later terminates favourably, unless complicated with or re- placed by disease of the bones or joints, phthisis, tabes mesenterica, or some other internal tuberculous affection. The disease is most frequent in children, from the close of the first denti- tion to the period of puberty. It is said to be more frequent in females than males; and the negro, or person of mixed blood between the negro and white, is much more subject to it than the pure white. The attack usually com- mences in the winter or spring, and the symptoms are often ameliorated during summer, to resume their original violence upon the return of cold weather. Anatomical Characters.—In the first stage, there is merely an enlargement of the gland, without any striking alteration of the tissue, unless that it may be somewhat redder and firmer than in health. As the tumour advances, it becomes still harder, exhibiting a granular structure, and a grayish colour. Tuberculous matter is then deposited either in the form of distinct granula- tions, or of irregular infiltration, or of roundish masses, isolated or aggluti- nated. The proper tissue of the gland is now more or less absorbed, and sometimes wholly disappears. In the advanced stage, abscesses are observed, sometimes only one or two, sometimes several, containing pus, or tubercu- lous matter in various states of softness. Causes.—There can be no doubt that a peculiar state of system often ex- ists, either inherited from the parent, or derived from the circumstances of early infancy, which constitutes a predisposition to this complaint. There is, I think, as little doubt, that a similar predisposition may be created in indi- viduals, previously free from any peculiar morbid tendency, by the operation of certain causes wliich lower the grade of the vital forces, and vitiate or im- poverish the blood. Such causes are a meagre and unwholesome diet; con- fined and contaminated air, especially that of crowded apartments; sedentary occupations; long exposure to cold, especially after a previous habitual ex- posure to heat, as in those who remove from a warm to a cold climate; a damp atmosphere; excessive and exhausting indulgences; continued mental depression; and finally, the influence of various diseases, as smallpox, scarlet fever measles, syphilis, &c. The state of system which may be considered, 772 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. in some cases, as merely predisposing to the disease, often becomes absolutely morbid by an excess of the influence which produced it, and thus passes di- rectly into the disease itself. The agencies above mentioned as predisposing, thus become immediate causes. In other instances, the predisposition is called into action by exciting causes, among which the most prominent are those which give rise to inflammation. It is very certain that this affection has a strong tendency to develope scrofulous disease, where the predisposition exists. The complaints above alluded to as sometimes co-operating, by the debility induced, in establishing a predisposition, oftener operate as exciting causes. Upon the whole, the most frequent sources of external scrofula are probably inheritance, and the combined influence of a cold, damp, and variable atmo- sphere, with depressing habits of life. The disease is most common in tem- perate latitudes, where the vicissitudes of weather are most experienced, and sufficiently effective measures are not resorted to, as in the extreme north, in guarding against the cold. It is less frequent in the United States than in Europe, because the mass of the population in this country enjoy more abund- ant means of physical comfort. Nature.—The nature of scrofula has been discussed under another head. (See page 116.) It will be sufficient here to observe that a question has been made, whether the original local affection is a peculiar inflammation leading to the deposit of tuberculous matter, or whether the deposit of this matter con- stitutes essentially the first step of the disease; the inflammation resulting from its presence, as from that of any other foreign substance. In answer to this, it may be stated that dissection often shows the existence of a low grade of inflammation before any tuberculous matter has been formed; while, in some cases of scrofula, inflammation of the same slow and obstinate character as that ofthe tuberculated glands sometimes occurs, in one part or another ofthe body, without the obvious production ofthe characteristic cheesy or curdy substance. The inference is, that, in a system predisposed to scrofula, the occurrence of inflammation often leads to the tuberculous deposition, which forms the peculiar feature ofthe complaint; and that the existence ofthe predisposition which leads to this deposition, is capable of impressing a peculiar character upon in- flammation arising from any ordinary cause. But it would be altogether premature to state that a low grade of inflammation necessarily precedes the tuberculous deposit. There is, on the contrary, reason to believe that this matter is often eliminated, whether in consequence of a species of vascular irri- tation, whether from the state of the blood, immediately from the blood-vessels, without the slightest preceding inflammation; and the truth probably is, that the state of system which leads to this deposit, is capable also, without the deposit, of giving a somewhat peculiar character to the inflammatory process. But, whatever may be the origin of the tuberculous matter, there can be no doubt that, when once deposited, it serves, like a foreign body, as the cause of the subsequent inflammation, suppuration, ulceration, &c, which are necessary for its discharge; and that, as it is the chief source of the obstinacy and danger of the case, it must also be the chief object of solicitude. Diagnosis.—Scrofulous inflammation of the glands is distinguished from ordinary chronic inflammation of the same parts by the greater hardness of the tumours, their less degree of tenderness upon pressure, their longer con- tinuance and greater indisposition to yield to treatment, their frequent com- plication with other scrofulous affections, and by the state of system which precedes or attends them. The practitioner will also be influenced in form- ing his judgment, by the hereditary or family influences, which may have served to create a peculiar predisposition in the patient. When, upon the occurrence of suppuration, the curdy matter above referred to is discharged there can be no doubt as to the scrofulous nature of the case. CLASS III.] EXTERNAL SCROFULA. 773 Treatment.— The point that should be first aimed at is the correction of the peculiar state of system in which the tuberculous deposit, and the other characteristic morbid phenomena of scrofula, originate. While this condition remains, our efforts to correct the local disease will at best be useless, and may be very injurious. Either the tumours will resist our remedies, or, if they yield and disappear, the diathesis will exhibit itself in disease of some other and more dangerous part. It is no uncommon event for the recession of scrofulous swellings upon the neck, or in other external situation, to be followed by pulmonary consumption. Instances of this kind have come under my own notice. The late Dr. Jos. Parrish, of Philadelphia, whose expe- rience in this form of disease was ample, had so much dread of such transla- tions, that he employed measures calculated immediately to discuss scrofu- lous tumours with great caution, and generally preferred leaving them entirely alone, addressing his remedies solely to the system. That the swollen glands are sometimes relieved by local means, and with impunity, only proves that, in mild cases, the morbid tendency may exhaust itself by the first demon- stration, and cannot be admitted as a justification for a similar course, in cases where the tendency may be much stronger and more permanent. In order to correct the state of system, it is of the utmost importance to remove the causes which may have produced, and may still be sustaining it. The patient should be surrounded with circumstances most favourable to the production of sound health, without undue excitement. The vital forces should be invigorated, and the vital actions moderately supported; but care should be taken not to stimulate the latter beyond the healthy standard. Fresh, pure air at all times, and exercise within the limits of fatigue, are among the most efficient remedial measures. If the patient be compelled to labour for a livelihood, he should, if possible, select an avocation in which the muscles generally are called into action, and which does not require confinement to close, and especially to crowded apartments. Among the worst situations for a scrofulous patient are the crowded wards of an ill-con- ducted, and over-peopled hospital. The diet should in general be simple, digestible, and nutritious, but not stimulating. Farinaceous substances, the more easily digested fruits and vegetables, milk, meats in moderation, and especially boiled meats, may be employed. Should the patient find himself over-stimulated by animal food, he should diminish the quantity, or abandon it for a time. But, in relation to diet, reference must be had to the stage of the disease, and the state of the system. Should the local inflammation be considerable, or any febrile excitement exist, as sometimes happens in the earlier stages, it would be proper to confine the patient to vegetable food. In the stages of debility, on the contrary, the more stimulating kinds of ani- mal food become advisable, and sometimes necessary. The clothing should be such as to preserve the temperature of the surface as nearly equable as possible; and for this purpose garments of wool should be worn next the skin. The mind should be kept in a state of moderate and agreeable occu- pation, neither overworked on the one hand, nor allowed to prey upon itself by utter idleness on the other; and efforts should be made to produce and sustain a cheerful flow of spirits, or at least a feeling of placidity and con- tentment. The injurious influences of climate should be obviated, as far as possible, without sacrificing the all-important requisite of exercise in the open air. Many of these conditions may be fulfilled by a sea voyage, or by travelling on land, especially if the course of the patient be directed towards a warm climate during winter. Where long journeys are impracticable, excursions, within the means of the patient, to watering-places, or to the sea-shore, should be recommended; and great advantage will sometimes ac- crue in the case of adults, from their performance on horseback. The waters 774 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. of many of the springs, employed both internally and externally, will be found to add to the various other advantages of these excursions; and few remedies are more efficacious in scrofulous affections, where the lungs are not involved or suspected, and especially in the cases of children, than sea- bathing and a residence by the sea-side. Experience has shown that such an exposure is peculiarly unfavourable to persons consumptively disposed, and to such persons, even though affected with external scrofula, the sea- shore should not be recommended. In addition to the measures above advised, care should be taken to keep all the functions as nearly as possible in their healthy state. If any one of the secretions be deranged, deficient, or excessive, it should be corrected by the appropriate remedies. Constipation should be obviated by means calcu- lated not to injure the tone of the bowels, or depress the general strength. Excess of acid in the stomach, or elsewhere, should be neutralized by lime- water, or one of the alkaline carbonates. Excitement should be equalized by supplying its deficiency in particular parts by artificial measures. Thus, if the feet and hands are habitually cold, and the surface of the body ha- bitually pallid, frictions, shampooing, gentle slapping upon the skin, rube- facient liniments, and warm stimulating pediluvia or baths, as of common salt, mustard, nitromuriatic acid, &c, should be resorted to. Internal in- flammations should be counteracted, as far as may be, without exhausting the resources of the system. Hence, local depletion, counter-irritation, the antimonials and other refrigerant diaphoretics, and the saline cathartics, should be preferred to free depletion by the lancet. The same rule is ap- plicable to the treatment of any febrile excitement that may attend the de- velopment of the tumours. The state of the blood should be attended to, and, if a deficiency of red corpuscles be observed, as may not unfrequently happen, it should be supplied by means of animal food and the use of the chalybeates. The preparations of iron are, indeed, among the most efficacious remedies in scrofulous affec- tions. They act directly by their tonic power, and indirectly by increasing the richness of the blood. Those should be preferred which are at the same time least irritating to the stomach, and most readily enter the circulation. The pills of carbonate of iron ofthe Pharmacopoeia, the powder of iron, the tincture of the chloride, and the solution of the iodide, may be employed. Some recommend also highly the wine of iron, which owes its chalybeate virtues to the tartrate of iron and potassa. There are very frequently, in scrofula, a laxity of tissue and general de- bility, which call for the use of astringents and tonics. One of the most agreeable and useful of these is pipsissewa (chimaphila, U. S.), which com- bines a mild astringent and tonic power, and may be given very freely and for a long time with impunity. I have been in the habit of using this remedy largely, and have had reason to be satisfied with its effects. The decoction should be given to the amount of half a pint or a pint daily to an adult, and proportionably to children. In many cases, I have found no other medicine necessary than this, in connection with a saline cathartic twice or three times a week, during the increase of the tumours. The same indication is met by walnut leaves, which have recently been introduced into use, in Europe, as a remedy in scrofula, and are highly lauded by some French practitioners. (See U. S. Dispensatory.) Some of the products ofthe oak have long been used for a similar purpose. In Germany, coffee made from roasted acorns is a favourite remedy; and baths of a decoction of oak bark are likely to be useful, particularly in children. The simple bitters, such as gentian, quassia, and columbo, may be given in cases of general debility with enfeebled diges- tion ; and, in the latter stages of the complaint, when a more powerful tonic CLASS III.] EXTERNAL SCROFULA. 775 impression is required, to support the patient under the exhaustion of the puruloid discharges and colliquative sweats, sulphate of quinia, or some other preparation of Peruvian bark, may be advantageouslv substituted, in connec- tion with wine or the malt liquors The mineral acids, too, are highlv useful under these circumstances, being peculiarly adapted to cases in which night sweats are associated with want of appetite and weak digestion. Nitromu- riatic acid is thought, in addition to its tonic effects, to exercise a beneficial alterative influence -. and it has appeared to me to be more effectual than the other acids, in the condition referred to. Phosphoric acid has also been highly recommended. The diluted acid of the London Pharmacopoeia may be given in the dose of twenty or thirty drops three or four times a day. Cod-liver oil has been found by experience among the most efficient, if not the most efficient corrective of the scrofulous diathesis. It probably acts by improving the character of the blood, and favourably modifying the nutritive process. It may be given in the dose of a tablespoonful three times a day, and should be persevered in for months, or intermittingly eveu for years, if the patient continue to improve, and such a perseverance seem necessary to eradicate the morbid tendency. Still another indication, frequently presented in external scrofula, is to relieve the nervous irritation, the pains, restlessness, want of sleep, and various vague uneasinesses, which attend the advanced stage of the disease. This is to be accomplished by means of narcotics and antispasmodics, especially co- nium, hyoscyamus, belladonna, and stramonium. The extracts of these medi- cines may often be advantageously combined with the laxatives, chalybeates. and other tonics employed. The preparations of hops, from their combina- tion of narcotic and tonic properties, are useful under the same circumstances. Opiates, in consequence of their constipating property, should be employed only when the other narcotics fail, or when they may be indicated for the sup- pression of diarrhoea. A remedy well adapted to the debilitated and irri- tated condition of system, incident to the advanced stages of the disease, is the cold infusion of wild-cherry bark, which is at the same time tonic to the digestive and nutritive functions, and, through its hydrocyanic acid, sedative to the nervous and circulatory systems. Various remedies have been introduced into the treatment of external scrofula, with a view to their alterative effect. Some of these, probably, owe their reputation to the circumstance, that the disease frequently runs a certain course, and. in the end, subsides spontaneously, without the employment of remedies. Now, in cases having this disposition—and the category probably includes all those in which the causes of the disease are not incessantly acting —the medicine last employed, before the spontaneous amendment, gets the credit of the cure. It can scarcely, however, be doubted that some of these alteratives are highly efficient iu the cure of the disease. Among them, the most important, bevond all comparison, is iodine. The efficacy of this medi- cine has been too'variouslv and abundantly tested to admit of reasonable question. It may be employed in all forms and stages of the complaint, unless, perhaps, when it is attended with febrile excitement. The prepara- tions which may be most advantageously employed, as a general rule, are the compound solution of iodine, the compound tincture, and iodide of potassium. One of these mav be preferred to another, according as it is found, upon trial, to agree best with the patient. Upon the whole, iodide of potassium may be considered the safest to commence with. If chalybeates are at the same time indicated, the iodide of iron may be preferred -. if mercury, the iodide of that metal. Whichever preparation is given, it should be employed at first in moderate doses, and persevered in steadily for a long time, unless some local or general irritation should appear to be occasioned by its use, when it should 776 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. be suspended. When it cannot well be administered internally, resort may be had to ointments, lotions, or baths; and this mode of application is often usefully combined with the internal. For the modes of exhibiting iodine, the reader is referred to the U. S. Dispensatory. Bromine and its prepara- tions have properties closely allied to those of iodine, and may, perhaps, be substituted for it occasionally without disadvantage. Other substances which have enjoyed considerable reputation in the treat- ment of scrofula, are the chlorides of barium and calcium, and various vege- table alteratives, as sarsaparilla, guaiacum, and mezereon. The compound syrup and compound decoction of sarsaparilla are still occasionally used, and probably with advantage, in cases in which it is desirable to sustain a gentle excitement of the various secretions, and particularly that of the skin. The two chlorides mentioned, though probably not wholly destitute of efficacy, have been almost entirely superseded by the preparations of iodine. Sea- water, taken internally, has been thought useful, through the chlorides which it contains. Mercury has been highly recommended; and, so far as concerns the removal of the tumours, may sometimes prove effectual, especially in the early stages. But at present its use is generally considered hazardous, and has been abandoned by prudent practitioners, at least in reference to its sialagogue action. It is thought, when pushed thus far, to interfere with the healthy processes of the system, and thus to favour the scrofulous diathesis; so that, though the glandular affection might be relieved, there would be danger of tuberculous deposition in other and more vital parts. There may, however, be complications, which would justify the moderate use of mercury in external scrofula; as, for example, when this disease is associated with chronic hepatitis, or secondary syphilis. In such cases, it may be used with caution, and the iodide of mercury is a convenient form for exhibition. Small doses of corrosive chloride of mercury, with the preparations of sarsa- parilla, have been much used, in cases of combined scrofula and syphilis. Phosphate of lime has been recommended by Dr. Beneke, a German phy- sician, in ulcerous and rickety affections, of a scrofulous character, upon the ground that, as it is essential in the formation of cells, it is likely to prove useful where there is deficiency in cell-growth. The remedy is an old one in rickets, and had been generally abandoned as inert, until brought forward under these new auspices. Since the publication of Dr. Beneke's observa- tions, it has acquired a certain popularity, especially in connection with other phosphates, as of iron, soda, and potassa; but, when it is considered that there is an abundance of phosphates in our food, and that much of them is constantly thrown off from the system, even in scrofulous affections, as the result of the disintegration of the tissues, the inference seems fair that it is not so much these salts that are wanting, as the power to make use of them. Very advantageous impressions may often be made in scrofula by different kinds of bathing. When there is a depressed state of the system, and yet vigour enough to insure reaction, the cold bath, employed daily or less fre- quently, will often prove an excellent tonic. Hence, in part, the virtue of sea-bathing already alluded to; but it is probable that the saline contents of the water of the ocean, such as the chlorides and iodides, are additionally advantageous, both by a stimulant action on the skin, and an alterative action on the system. Sea-bathing may be imitated by the use of cold baths impreg- nated with these salts artificially. When, instead of requiring a tonic impres- sion, the system is in a febrile state in consequence ofthe local inflammation, the warm bath, as one of the mildest and at the same time most efficacious sedatives that can be employed, should be substituted for the cold bath. Sul- phur-baths have been useful as an alterative in external scrofula, and especially when consisting of the natural sulphurous waters, such as those of the springs CLASS III.] EXTERNAL SCROFULA. 777 m the mountains of Virginia, of the Blue-lick springs in Kentucky, and the Avon and Sharon springs in New York. Dr. Simpson, of Edinburgh, having observed that persons working in wool-factories are seldom affected with scrofula or phthisis, and ascribing the exemption to the oil with which their skin comes incessantly into contact, proposes the external use of oil as a remedy and prophylactic in these affections. In the treatment of external scrofula, reference must always be had to the stage of the disease, and the state of the system. In the early period, when tonic medicines are indicated, those of the mildest character should in general be selected. If, as often happens, there should be some excitement of the pulse, gentle purgation with sulphate of magnesia, or other saline cathartic, given twice or three times a week, is not only well borne, but often proves highly advantageous by diminishing the excitement, and at the same time sustaining a moderate and safe revulsion from the seat of the disease to the long course of the bowels. Should the excitement be considerable, and the general vigour of the system little impaired, a combination of jalap and bitar- trate of potassa may be substituted for the less active cathartic. Under this treatment, especially when combined with the use of the decoction of pipsis- sewa, the patient often gains instead of losing flesh. In the more advanced stages of the disease, or at any period, if the debility is considerable, rhubarb, aloes, or some mild laxative which is without the property of materially in- creasing the intestinal exhalation, such, for example, as sulphur, should be preferred. It is to the last stages, when the system has become much ex- hausted, that the more actively tonic and stimulant plan of treatment is adapted. Cod-liver oil and the preparations of iodine may be employed at any stage, unless the system be in a state of inflammatory excitement. Local Bemedies.—For reasons already given, local measures should always be employed with caution. When inflammation is considerable in the gland, and especially when it extends to the surrounding cellular tissue, leeches and the saturnine applications may be resorted to. In the more indolent states of the tumour, if its dispersion be considered advisable, lotions or ointments of iodine, iodide of potassium, or iodide of lead; mercurial ointment; common salt, applied in solution or in the form of cold poultice ; ammoniacal liniments; a plaster of iodide of iron (see U. S. Dispensatory, 11th ed.), and plasters ofthe stimulating gum-resins, as ammoniac and galbanum, maybe used with some effect, especially if applied in the earlier stage, before the deposition of tubercle. When suppuration appears inevitable, it should be favoured by emollient poultices; and the abscess, when formed, should be opened by the lancet. Should the abscess degenerate into a fistulous sore, the sinuses should be excited by stimulating injections, or distended by sponge-tent, or laid open by the knife. When ulcers are formed, they should at first be treated with mild dressings. If indisposed to heal, they may be stimulated by resin cerate, the ointment of red oxide or subnitrate of mercury more or less diluted, that of iodide or biniodide of mercury, weak nitric acid, and other similar appli- cations. The ointment of iodide of lead has also been very strongly recom- mended. When the ulcer is flabby, and disposed to form fungous granulations, chalk, dried alum, nitrate of silver, the vegetable astringents, Peruvian bark, &c, may be resorted to. If fetid and gangrenous, chloride of soda or of lime, creasote, and the fermenting poultice are suitable applications. Should acute inflammation supervene, it should be corrected by emollient poultices. To obviate the danger arising from the cure of the local affection, it has been recommended to establish a steady external revulsion, by means of setons or issues in the arms or legs. Prophylactic Treatment.—In persons known or strongly suspected to have the scrofulous predisposition, it is of great importance to prevent the develop- 778 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. ment of the disease by suitable prophylactic treatment. The measures to be employed are identical with those already mentioned as calculated to obviate the causes of the disease, and need not be again enumerated. But the care of the physician should extend even beyond these. When a scrofulous female is likely to become a mother, or even when the defect lies upon the side of the male parent, the utmost care should be employed, during pregnancy, to keep her in a sound state of health; and the same care should afterwards be ex- tended to the period of lactation. If the mother positively labour under the disease, she should relinquish to a healthy and vigorous wet nurse the nourish- ment of the child. The child should be weaned at the end of a year, and then fed with milk, farinaceous substances, and a portion of light animal food; and these should be commenced with, even before the breast has been relin- quished. Attention should be paid to the clothing of the child, who should be kept perfectly clean, exposed freely to the fresh air, and early accustomed to active exercise. The mental precocity, which is a not unfrequent attendant of the scrofulous diathesis, should rather be repressed than encouraged. The physical rather than the mental education should engage the solicitude of the parent; and, when the time comes for the choice of an occupation, the atten- tion should be directed to some one, which must lead necessarily to frequent or habitual exercise in the open air. Article IV DISEASE OF THE BRONCHIAL GLANDS. These glands, from ten to twenty in number, are seated about the bifurca- tion of the trachea, and its bronchial ramifications, which they accompany for some distance into the pulmonary tissue. It should be recollected that, though reddish in early life, and afterwards grayish, they ultimately often assume a black colour, which is not to be considered an evidence of disease. The absorbents of the lungs pass through them; and the change in their colour corresponds with a similar change that takes place, to a certain extent, in the lungs themselves. The bronchial glands are liable to all the diseases which affect the same structure in other parts of the body. They may be affected with inflamma- tion, acute or chronic, may become scrofulous or tuberculated, and may be the seat of cancerous growths. But their diseases generally offer no signs by wliich they can be certainly recognized during life ; and are often first re- vealed by dissection. The glands may be considerably swollen, and indeed sometimes attain a great magnitude, without producing any material embar- rassment of respiration. Even when pressing upon the air-passages, they do not always occasion difficulty of breathing, probably in consequence of the gradual manner in which their encroachments take place. Another circum- stance which prevents an accurate diagnosis is the very frequent coexistence of other diseases, the symptoms of which completely mask those of the glandular affection. Sometimes, however, these tumours do produce dyspnoea by com- pressing the windpipe or bronchia, and, according to Dr. Carswell, even give rise to symptoms of obstructed circulation, by diminishing the caliber of the great blood-vessels. Andral relates a case in which he ascribed great feeble- ness of respiration, observed upon one side of the chest, without the loss of sonorousness on percussion, to the probable compression of one of the prin- cipal bronchia by a mass of tuberculated glands. (Clinique Medicate, iv. 250.) Dr. Williams states that he has seen tumours of these glands " push- CLASS III.] DISEASE OF THE BRONCHIAL GLANDS. 779 ing out the sternum or the ribs on one side, and causing dulness at those parts, and symptoms of displacement of the lung further down." (Lect. on the Physiol, and Dis. of the Chest.) When there is cough and more or less dyspnoea, together with dulness upon percussion in the interclavicular space, or over the upper dorsal vertebra?; when the upper part of the sternum and the neighbouring ribs are unnaturally prominent; when over the upper part of the chest a harsh or tubal sound is heard in inspiration, seeming as if it came from the trachea or one of the primary bronchia, without consolidation of the lung beneath; and when, along with these symptoms, is an absence of the signs of aneurism, or other known organic diseases of the chest, the existence of enlargement of the bronchial glands may be reasonably suspected, especially if the patient be very young. But, even should there be conclu- sive evidence of such enlargement, which is scarcely possible, it would still be difficult to determine the character of the affection ; and any inference upon this point must be more or less conjectural. The few remarks which follow will be confined to the subject of inflammation and tuberculous disease of the glands; as other affections are so uncertain, that nothing could be profitably said in relation to them. Inflammation of the Bronchial Glands. This may be acute or chronic, and is probably, in the greater number of cases, the result of inflammation of the bronchial mucous membrane. At least, in those post-mortem examinations in which the glands were found in- flamed, Andral states that he generally observed redness of that membrane; and such a result is in accordance with the general fact, that irritation is apt to be propagated to the absorbent glands which lie in the course of the lymphatics running from the part affected. But the disease does not always arise from this cause. It is sometimes original, advancing even to suppura- tion, with discharge of pus into the trachea or one of the bronchia, without any evidence of preceding or attending bronchitis. Should a case occur, presenting pain beneath the upper part of the ster- num, or deep in the chest towards the corresponding portion of the spine, together with the symptoms before mentioned as indicative of enlargement of the glands ; should there also be fever, cough, and expectoration of puru- lent matter, followed by a disappearance of the symptoms, without the evi- dences of inflammation in any other part of the chest, and without the pecu- liar signs of a strumous state of system, there would be reason to suppose that the disease had consisted in acute inflammation ofthe bronchial glands. A moderate degree and longer duration of these symptoms, with the same termination in suppuration and recovery, would mark a chronic affection of the same kind. Should the same symptoms be presented, with the exception of the purulent discharge, and should they yield to the ordinary antiphlogis- tic treatment, there would be grounds for believing that inflammation had existed, and terminated in resolution. _ The affection is more common in children than in adults; and it is not im- possible that some of those cases, not very unfrequent in infants in which pain and oppression of chest, with fever of longer or shorter duration have been followed by a sudden expectoration of pus with consequent relief and which have been considered as abscesses in the tissue of the lungs, may have in fact been instances of inflamed bronchial glands. The treatment of this disease, when supposed to exist should be conducted on the general principles applicable to inflammation wherever seated. De- ptetion general and local, refrigerant cathartics and diaphoretics, revulsion bv means of blisters or rubefacients, the antiphlogistic regimen, anodynes to allay cough and ultimately, should other means fail, mercury, or, in chronic 780 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. cases, the preparations of iodine internally and externally, would be the pro- per remedies; care being taken to adapt them in degree to the severity ofthe local disease, and the general condition of the system. Scrofulous or Tuberculous Bronchial Glands. The name of bronchial phthisis has been given to tuberculous disease of the bronchial glands. In phthisis, these glands are often inflamed and enlarged, but not necessarily tuberculated. The bronchial and pulmonary inflammation associated with tubercles gives rise to a sympathetic inflam- mation in these glands, which may or may not be attended with a deposition of tuberculous matter. The former result is much more apt to take place in children than in adults. In infants of a strumous constitution, whatever pro- vokes inflammation of the absorbent glands is apt to awaken in them the scrofulous action. Thus, while in adults, tuberculous ulceration of the bow- els, or of the lungs, may be accompanied with common inflammation of the absorbent glands with which these parts respectively communicate, it not unfrequently happens that, in infants predisposed to scrofula, common enteric or bronchial inflammation gives rise to a tuberculous affection of the same structures. Hence, the complaint of which we are now treating is incom- parably more frequent in young children than in persons of mature age. The disease is so frequently associated with phthisis, the symptoms of which cover and conceal those of the glandular affection, that it can seldom be re- cognized until after death. Occasionally, however, it occurs without any preceding or simultaneous development of tubercles in the lungs; and, even when these exist, they are sometimes much smaller in amount than the tuber- culous deposit in the glands, and cannot be considered as the source of the latter affection. When the physical signs indicative of enlarged bronchial glands are observed, with little or no pain in the part, with occasional fever, night sweats, emaciation, cough, and dyspnoea, which have come on gradu- ally and persisted for a considerable time; when along with these symptoms are marks of a scrofulous constitution, such as swellings of the cervical glands, occasional epistaxis or spitting of blood, tumefaction of the abdomen, &c.; and especially when the patient is under the age of puberty ; it is rea- sonable to suspect the existence of the disease in question; and, if no physi- cal signs can be discovered of tubercles in the lungs, it may be inferred that the affection is exclusively that of the glands in question. The diagnosis, however, is always more or less uncertain. The disease is various in its progress, being sometimes rather rapid, but generally slow, and occasionally quite stationary for a considerable time. The tumours now and then attain a very great magnitude, filling the whole posterior mediastinum, or protruding, in young subjects, the bones of the thorax. Pressing upon the air-passages, they occasion inflammation, adhesion, and ultimate absorption of their parietes, thus opening a way for the dis- charge of the softened tuberculous matter they contain into the trachea or its branches. In this way, there is reason to believe that the diseased glands are sometimes ultimately restored to health. Occasionally also the tubercu- lous matter deposited in them appears to be absorbed, and, in some instances, its place to be supplied by chalky matter, as happens in certain cases of pul- monary tubercles. But unfortunately the affection is so often complicated with pulmonary consumption, tabes mesenterica, or other fatal tuberculous disorder, that its favourable termination can seldom have any considerable effect upon the general issue. Death has occurred from suffocation conse- quent on the opening of the glands, and the discharge of their contents into the air-passages. The complaint has been found on dissection in every stage of development, CLASS III.] DISEASE OF THE MESENTERIC GLANDS. 781 including mere tumefaction of the glands, solid tuberculous deposit in their substance, softening of this tuberculous matter, absorption in various degrees of the structure of the air-passages, openings into these passages, and cavities resulting from the evacuation of the softened matter. The glands, moreover, have been observed shrunken, hardened, and chalky, or even bony. Andral states that he never met with perforation of the trachea or bronchia from this cause in adults; while the chalky deposition was most frequent in middle and advanced life. He had generally observed redness or other marks of existing or former inflammation of the bronchial mucous membrane, but not always. The treatment of this disease, when ascertained, is to be conducted upon the same principles as that of external scrofula. The most important point is to obviate the tuberculous tendency of the system by measures calculated to support the general health and strength, without producing undue ex- citement ; for the danger is much greater from an extension of the disease to the lungs, than from that already existing in the glands themselves. Article V. DISEASE OF THE MESENTERIC GLANDS. Of the absorbent glands of the abdomen, the mesenteric are most frequently diseased ; after these, probably, the mesocolic, and next the lumbar; but all are liable, in a greater or less degree, to the various morbid affections to which the lymphatic ganglia are subject in other parts of the body. The remarks which follow, though directed especially to the mesenteric glands, are, in great measure, applicable also to the others. They are confined to the simple inflammation, and the scrofulous or tuberculous degeneration of the glands. Inflammation of the Mesenteric Glands. This is a very frequent attendant upon inflammation and ulceration of the mucous membrane of the small intestines, and especially of the ileum. Andral states that, whenever he had found the intestines exanthematous or ulcerated, the mesenteric glands were seriously affected, being enlarged, of a reddish or brownish colour, softened, and sometimes charged with small collections of pus Those were most diseased which corresponded with the most diseased portion of bowel. (Clin. Med., i. 600.) Louis found them more or less altered in size, colour, and consistence, in all instances of typhoid fever, m which their condition was examined after death. Those were affected which corresponded with the inflamed or ulcerated elliptical patches of the ileum; and the changes observed were the same as those above mentioned In one instance, a gland was completely converted into pus which was retained only by a thin sac, and must have been effused into the abdominal cavity, had death been postponed for a few days. (Becherches sur la gastro-enteriie.) Even the enteric inflammation and ulceration which attend phthisis, not un- freauentlv ffive rise to common inflammation of the mesenteric glands. Thus, Louis states that, when the glands were not found tuberculated in these cases, they were often increased in size, and more or less reddened. That thev are also subject to ordinary chronic inflammation may be inferred from the fact, that, in cases of tabes mesenterica, they are sometimes observed upon dissection, to be enlarged, compact, and hardened, though less indurated than in scirrhus, and without tuberculous deposit (Guersent,Dwt de Med vi 439 ^ It appears that any inflammation existing in the bowels is liable to be propagated to these glands, through the lacteals by which the two parts 782 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. are connected. It is possible, also, that they may be originally inflamed; but little seems to be known upon the subject. Either the affection is very rare, or so mild as seldom to lead to serious results. The diagnosis of ordinary inflammation of the mesenteric glands is very uncertain. The disease may be inferred to exist, should a patient, without any scrofulous symptoms, complain of pain, increased by strong pressure, in the central parts of the abdomen, or towards the right iliac region, and at the same time one or more roundish tumours be felt in the same part, by means of a very careful examination. In consequence, however, of the depth of the mesentery, the want of considerable magnitude in the tumours, and the frequently swollen state of the abdomen, this could very seldom happen. The tendency of the disease appears to be towards resolution, or, if suppuration commences, the pus is generally absorbed. The only danger to be apprehended is, that an abscess may form, and open into the peritoneal cavity. There is reason to believe that this event has sometimes occurred. But, more frequently, the pus would probably find a safer outlet into the bowel by means of adhesion and ulcerative absorption. Where the diagnosis is so vague, little need be said of the treatment. Fortunately, the measures calculated to relieve the enteritis in which the affection generally originates, are all that will be required. Scrofulous or Tuberculous Disease of the Mesenteric Glands.— Tabes Mesenterica.—Scrofula Mesenterica.—Atrophia Mesenterica. This disease is confined to no period of life, having been observed in the foetus of six or seven months, and in old age; but it is most common in child- hood. By far the largest proportion of cases occur between the ages of one and ten years. The complaint is not common in this country, at least as a distinct affection. It is more frequent in Europe. Guersent states that, in the Hopital des Enfans at Paris, where no one is admitted under one year, or over sixteen, the proportion of tuberculous mesenteric cases to the whole number of deaths, may be for boys five or six, for girls from six to eight per cent. (Diet, de Med., vi. 436.) But this was under circumstances, both as regards age and situation, most favourable to the disease. Bayle gives the general proportion at scarcely four in the hundred. (Ibid.) The disease is associated, in the great majority of cases, with other results of the tuberculous diathesis, which are often much more serious than itself, and not unfrequently completely mask its symptoms, so that it is first dis- covered upon dissection. Louis found the mesenteric glands more or less tuberculated in 23 out of 102 cases of pulmonary consumption. (Becherches sur la phthisie.) Chronic inflammation and ulceration ofthe bowels, so com- mon in the advanced stages of this complaint, are very frequent complications of the mesenteric affection; and it is occasionally associated also with tubercu- lous peritonitis, chronic hydrocephalus, scrofulous disease of the spine, rickets, tuberculated bronchial glands, and various other forms of scrofula. In most of these cases, it is either altogether secondary, or at most of little compara- tive importance. Occasionally, however, the scrofulous diathesis appears to expend itself chiefly if not exclusively upon the mesenteric glands, in which case the disease may be distinct and prominent. Symptoms.—The symptoms which ordinarily attend a case of tabes mesen- terica are very ambiguous. As a general rule, the greater number belong to the associated diseases, and comparatively few to the proper affection of the mesenteric glands. Nevertheless, as they actually occur in this association, it is important that they should be presented in one view. The following are those usually enumerated. The appetite is irregular, sometimes feeble, and sometimes voracious or perverted. Occasionally there is vomiting of CLASS III.] DISEASE OF THE MESENTERIC GLANDS. 783 glairy matter. The bowels are either costive, or affected with diarrhoea; and the discharges are usually unhealthy, being raucous, bloody, or otherwise dis- coloured, and sometimes of a clayey or chalky appearance. There is frequent abdominal pain, which is sometimes acute and colicky, sometimes dull and continuous, and is usually increased by pressure. But perhaps the most prominent symptom, and the one generally regarded as most characteristic, is tumefaction and hardness ofthe abdomen, with general emaciation, evinced especially in the extremities. The features are also shrunken, the surface pale, and the strength greatly depressed. A livid appearance may sometimes be observed beneath or around the eyes. The secretions are often perverted; the breath being offensive, the exhalations from the surface sour or otherwise disagreeable, and the urine scanty and of a whitish or milky colour. The child is usually dull and indisposed to exertion. The pulse is almost always more or less accelerated, especially towards evening, when there is often an accession of febrile symptoms, which are followed by perspiration early in the morning. Cough is a frequent symptom. At length hectic fever sets in, the emaciation becomes extreme, effusion begins to appear in the extremities, and sometimes in the abdomen, and the patient dies exhausted, or is cut off by the supervention of some acute inflammation. But none of the symptoms above enumerated are absolutely characteristic of the mesenteric disease, and there are none wliich may not proceed from other causes. The deranged appetite, vomiting, irregular alvine evacuations, and abdominal pains, may be the result of chronic enteritis or intestinal ul- ceration, which are often present. The chalky stools, instead of consisting, as has been conjectured, of the chyle which is evacuated because unable to pass through the lacteals of the mesentery, are probably in general ascribable to a suspension or perversion of the hepatic secretion, and the milky urine to an excess of earthy phosphates. The swelling of the abdomen may depend on derangement of bowels, or chronic peritonitis, and probably does in general depend mainly on the first-mentioned cause. The emaciation, paleness, hectic, «fec, are abundantly accounted for by the extent of tuberculous disease, scat- tered over various parts of the system. The whole series of symptoms may exist without disease of the mesenteric glands. Nor is this complaint, when it does occur, necessarily attended with any of the enumerated symptoms. The mesenteric glands occasionally become tuber- culated, swell largely, and advance even to the stage of maturation, without perceptibly deranging the health; and the existence of the disease is first revealed by dissection, after death from some other cause. Striking cases of this kind are recorded by Bayle and Morgagni. In one of these cases, the patient is represented as having been very fat, showing that the chyle finds access into the circulation, notwithstanding the disease of the mesenteric glands. The emaciation has been usually ascribed to the non-absorption of the chyle, in consequence of obstruction of the lacteals; but the existence of cases such as the one just mentioned, and the fact that Boker, a German anatomist, was always able to inject the diseased glands with mercury, their absorbents being quite permeable (Cyc. of Pract. Med., Lond., 1835, iv. 149), throw some doubt upon this explanation. There is, in most cases, abundant cause for the loss of flesh in the coexistence of tuberculous disease in various organs, and the exhausting irritation of system which this occa- sions. In those instances of tabes mesenterica in which no symptoms are exhibited during life, the result is to be ascribed to the absence of inflamma- tion of the substance' of the glands, or of neighbouring parts, which, in active cases, always attends the tuberculous deposit. There is reason to believe that 'in some of these instances, the disease may run its whole course to health again, undiscovered; the tuberculous matter being absorbed after 784 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. maturation. But, when of considerable extent, it probably sooner or later becomes active, from the necessity of inflammation and ulceration to the escape of the foreign matter. In many cases, inflammation of the glands attends the disease from its very commencement, either preceding the tubercles or excited by them, and not unfrequently involving also the corresponding portion of the bowel or perito- neum. There may, at the same time, or may not be more or less ofthe com- plications before alluded to; and the symptoms will vary with the amount and nature of the associated affections. The whole train of phenomena above enumerated may be presented, or those only which indicate either enteric, peritoneal, or pectoral disease, besides the mesenteric, according as one or another of these complications may exist. But what are the symptoms which characterize the affection of the mesen- tery itself, and which may serve to point it out, whether isolated or connected with others ? These cannot be stated with certainty, because dissection very seldom affords the means of verifying the inferences drawn during life; fatal cases being almost always greatly complicated. Conjecturally, however, the following may be stated as characteristic symptoms; viz., a steady dull pain in the centre of the abdomen, extending to the back, and inclining towards the right iliac region; tenderness upon strong pressure either backward from the neighbourhood of the umbilicus or forward from the lumbar region; the increase of the pain by sudden jars of the frame, as by coughing, sneezing, jumping, &c.; and, finally, its perseverance for months or even years, with remission in summer and exacerbation in the autumn and winter. Besides these, a general acceleration of pulse, occasional fever, especially towards even- ing, loss of colour and flesh, and various sympathetic derangements of the neighbouring organs, such as constipation or diarrhoea, nausea and vomiting, disordered hepatic secretion, &c, might be reasonably expected. The pressure of the enlarged glands, moreover, sometimes occasions derangement in the functions of the contiguous viscera. Thus, according to Andral, by compress- ing the pylorus, they have simulated scirrhus of this passage, and, by operating in a like manner upon the biliary ducts, have induced jaundice. But the only unequivocal sign of the disease is the actual discovery, by the touch, of hard roundish, or knobbed tumours in the region of the mesentery. It not unfrequently happens that the glands become so much enlarged, especially at an advanced period of the complaint, as to be readily felt upon a careful ex- amination. When this evidence is joined to that of the symptoms above enumerated, and at the same time the patient exhibits signs of a scrofulous constitution, there can be no doubt as to the nature of the case. Hardened feces may possibly be mistaken for enlarged glands; but there can be little danger of such an error, if it be borne in mind that feculent accumulations of this kind are confined to the large intestines, and must occupy a seat different from that of the mesenteric glands. The progress of tabes mesenterica is very generally slow, often continuing for years. There is reason to believe that it not unfrequently terminates fa- vourably, when not complicated with other incurable affections. In fact, in almost all fatal cases, death is owing less to the disease of the mesentery than to pulmonary consumption, chronic peritonitis, tuberculous hydrocephalus, intestinal ulceration, or spinal disease, separate or more or less conjoined. When death results directly from the diseased glands, it must generally be in consequence of the discharge of their contents into the peritoneal cavity. But this is not a necessary consequence of the opening of the tumours, and the escape of their tuberculous and puruloid matter. Cases have occurred in which adhesion to the abdominal parietes was established, and the matter discharged externally by means of ulceration; and there can be little doubt CLASS III.] DISEASE OF THE MESENTERIC GLANDS. 785 «n« b/n!lhtbe S^nds are, in the early stages, red, swollen, and somewhat hardened; but sometimes they are entirely free* from marks of inflammation, and even paler than in health. The tuberculous matter exists in roundish or irregular granules, which are often more or less aggregated, or in sma 1 flat plates or layers ; and may be deposited either in the substance of the gland, or immediately exterior to it, beneath its perito- neal covering. It is especially apt to be found in the latter position in those cases which are unattended with inflammation. The substance of the gland pressed upon by the increasing tubercles, is either absorbed, or forced within smaller limits, and sometimes quite disappears; the glands being transformed into masses of tuberculous matter. These are isolated or connected and vary in size from that of a pea to that of a hen's egg, or, according to Portal, even the head of an infant. Sometimes the tuberculous matter is deposited in layers between the lamina? of the mesentery. This matter is generally, from the first, dull-white or yellowish, and is very seldom of that gray colour and transparency, which often characterizes the commencement of pulmonary tubercles. It undergoes the various stages of softening to which similar deposits are liable elsewhere, and is at length converted into a sero-puruloid liquid, with curdy flakes intermingled. But this condition of the glands is not often observed upon dissection ; as death generally occurs from other dis- eases before the period of complete maturation. Occasionally, glands are found filled with a calcareous or gypseous matter, which has probably taken the place of the tuberculous; and, in some instances, this matter has been observed surrounded by a bony shell. In relation to contiguous structures, the peritoneum is sometimes perfectly sound, sometimes inflamed to a greater or less extent, with small tubercles between it and the subjacent cellular tissue. The mucous membrane of the bowels may also be either sound, or variously diseased. It is sometimes red- dened, especially about the ca?cal extremity of the ileum, and frequently ulcerated, the ulcers being small or large, superficial or deep, and in various stages of progress. Not unfrequently the omenta are found inflamed and tuberculated, and the liver to a greater or less extent similarly affected. Causes.—The causes of this disease are essentially the same as those of external scrofula. The strumous diathesis necessary to its development may be inherited, or may be the result of various agencies calculated to impair the vigour of the system and impoverish the blood. (See page 111.) The milk of mothers or nurses, themselves scrofulous in fact, or in their constitutional tendencies, is said to predispose to the disease. As in many other affections, the causes which give rise to the predisposition are of themselves sufficient, by their long-continued action, to bring on the complaint; but it is, perhaps, more frequently hastened by exciting causes, and especially by such as irritate or inflame the intestinal mucous membrane. The exanthematous fevers, and repelled cutaneous eruptions are among these causes. In the same light may be considered the cure of external scrofula by local measures, which do not modify the general tendencies of the system. From the character of the causes, it would be inferred that the disease must be most frequent among the poor, and very apt to prevail in large hospitals crowded with children ; and such is really the case. It is comparatively rare in private families in affluent or comfortable circumstances. Treatment,—Of the treatment very little need be said; as it is almost identical, so far as regards constitutional measures, with that already detailed under the head of external scrofula. Any modifications that may be deemed vol. i. 50 786 LOCAL DISEASES.—ABSORBENT SYSTEM. [PART II. necessary would have reference generally to the state of the bowels and the liver, which are more frequently disordered in this form of scrofula than in that which attacks the external glands. Few causes are probably more influ- ential in awakening the scrofulous predisposition in the mesenteric glands than intestinal irritation or inflammation, and a torpid condition of the liver givinu rise to congestion of the whole portal circle. Hence the great im- portance of attending to the condition of these parts. Constipation should be obviated, acid or other irritating contents of the bowels should be neutral- ized or removed, vitiated secretion should be corrected, and the liver if torpid stimulated to increased action. These various indications may be met by the use of small doses of calomel, daily, every other day, or at longer intervals; combined or alternated with mdd cathartics, such as rhubarb, castor oil, mag- nesia, or one of the purgative salts; and aided by mUd tonics and aromatics, when called for by debility of the stomach or bowels. To correct acidity, one of the antacids may be conjoined with the tonics and cathartics; that one being preferred which may seem best adapted to the circumstances; as, for example, magnesia or its carbonate, when a laxative effect is indicated, chalk or other form of carbonate of lime in an opposite state of the bowels, and the alkaline carbonates or bicarbonates, when neither laxatives nor astrin- gents are wanted. It need scarcely be added that, should positive signs of intestinal or peritoneal inflammation exist, recourse should be had to anti- phlogistic measures, proportioned to the strength of the system, and to the violence of the local affection. General bleeding, however, will seldom be admissible. The warm bath, used frequently, will, under these circumstances, be found an excellent adjuvant to the other measures. Another point of treatment, in which this affection differs somewhat from external scrofula, is the greater attention which the local disease requires. In tabes mesenterica, it is of the utmost importance to prevent, if possible, the maturation of the tumours, and to favour the absorption of the tubercu- lous matter. Especial care should, therefore, be taken to correct any acute inflammation of the glands, which accelerates the march of the tuberculous affection, if it do not call it into action. When signs of such a condition exist, leeches or cups should be applied to the abdomen, if the strength ofthe patient permit, and these should be aided by fomentations, emollient cata- plasms, and blisters. In purely chronic states of inflammation, gentle and long- continued friction over the abdomen, rubefacient liniments, stimulating plas- ters, or pustulation by tartar emetic or croton oil, will be preferable. To promote absorption of the tumours, nothing will be found so efficient as the free application of ointment of iodine to the belly, persevered in for a con- siderable time. Great advantage may also ensue from the use of iodide of potassium internally, in doses as large as the system of the patient will sup- port. This remedy is preferable to mercury, from the circumstance, that, while iodine acts as a general tonic, and rather tends to support the vital functions than otherwise, the mercurials, though they may correct existing in- flammation of the glands, if pushed to salivation, leave a condition of de- bility behind highly favourable to the increase of the scrofulous diathesis, and consequently to the deposition of tuberculous matter. The use of mercury should be restricted to its purgative action, and its alterative influence on the functions, especially that of the liver. For whatever else is requisite in the curative, palliative, or prophylactic treatment of this complaint, the reader is referred to the article upon external scrofula. (See page 773.) In its earlier stages, much may be expected from appropriate treatment; and, even when the glands have become so much enlarged as to be felt through the parietes of the abdomen, there is no reason to despair. One cause, probably, of the frequent failures is, that the circum- CLASS III.] AUSCULTATION. 787 stances of those affected are often such as to prevent the employment of mea- sures best calculated to obviate the diathesis, such as exercise, fresh air, wholesome and nutritious food, and whatever tends to cheer the mind, and invigorate the bodily functions. When the disease has advanced to suppu- ration ; and hectic fever, with emaciation, night sweats, and colliquative diarrhoea, has set in, little else can be expected from remedies than simple palliation. r SECTION III. DISEASES OF THE RESPIRATORY ORGANS. Previously to entering upon the consideration of the individual diseases of these organs, it will be necessary to call attention to certain means of dia- gnosis,-which, being applicable to many of the affections in common, cannot be appropriately treated of in connection with any one of them exclusively. These may be included under the heads of auscultation, percussion, inspec- tion, manual application, and measurement, which are here mentioned in the order of their importance. Auscultation. By this term, in its technical sense, is meant the act of listening to the sounds of the interior of the body, by means of the ear applied to the sur- face, either directly, or through the intervention of an instrument denomi- nated the stethoscope. The proper methods of practising auscultation are sufficiently explained elsewhere. (See page 209.) It is here to be considered only in its application to respiratory complaints. It may be proper to observe, preliminarily, that the sounds heard in aus- cultation, or developed in percussion, vary in quality, intensity, and pitch, independently of those differences which depend on duration and succession. By the quality of sound is meant its peculiar character, that by which it may be distinguished from all other sounds, however similar they may be in the other properties referred to. Intensity has reference to the degree of strength, pitch to that of elevation. Differences in these respects often have important significance in diagnosis. In employing this method of diagnosis, it is often advisable to examine the chest in different stages, and states of respiration ; because the sounds are materially modified in these varying conditions ; and occasionally a sound is evolved in one condition which might not be heard in another, or might be heard so imperfectly as to lead to incorrect inferences. Thus, the patient should be first examined while breathing in the ordinary manner, and should afterwards be directed to breathe quickly or forcibly, to take a long breath, or to exhaust his lungs more or less completely, to hold his breath for a time after inspiration or expiration, to speak, to cough, or in fine to make any other modification of the respiratory act, which may be thought capable of furnishing more precise materials for judgment. As the sounds produced even in perfect health vary greatly in different individuals, so that what would be morbid in one might be quite normal in another, it is proper to compare each individual with himself; in other words, to examine the chest at different periods, and especially to examine the two sides of the chest at correspond- ing points, so as to detect any difference that may exist between them. Should one side yield results decidedly different from the other, allowance being made for the very few natural diversities, the existence of disease may be considered as highly probable. The sounds connected with the function of respiration, which are the sub- 788 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. jects of this process, are, first, those directly resulting from inspiration and expiration, and secondly, those of the voice, including coughing. 1. In the healthy state of the lungs, two distinct sounds are sensible in auscultation ; one called the vesicular, because supposed to depend upon the passage of air from the ultimate ramifications of the bronchia into the air- cells ; the other bronchial or tubal, because generated in the bronchial tubes, and probably caused by the air impinging upon their sides in its movement through them. The vesicular sound, sometimes designated as the respiratory murmur, is heard over those parts of the chest where the proper structure of the lungs comes into contact with its walls. It is produced chiefly during inspiration, and results probably in part from the vibrations occasioned in the minute tubes and cells by the impulse of the air, and in part from the dilatation of the cells themselves. During expiration, though of the same character, the sound is very faint, and sometimes scarcely perceptible, owing probably to the circumstance, that the motion of the air now commences in the cells, and is at first too feeble to give rise to other than very feeble vibrations. Between the murmur of inspiration and that of expiration, the interval is almost too short to be appreciated, and the two may practically be considered as con- tinuous. In relation to the character of the sound, it is a soft, diffused mur- mur, which has been compared to the sighing of a gentle breeze among green leaves, but is best appreciated by applying the ear to those portions of the chest, where it exists in greatest purity. It does not appreciably differ in corresponding points upon opposite sides of the thorax. It is purest in the lateral and lower portions, where the bronchial tubes are finest. The sound varies considerably within the limits of perfect health. It is increased in intensity by whatever increases the rapidity and force of respiration, and is prolonged by a full breath. Thus, when naturally feeble, so as to be per- ceived with difficulty, it may be rendered sensible by directing the patient to breathe rapidly, or to cough; the inspiration which follows the latter act being usually quick and forcible. Its intensity varies much in different indi- viduals. It is proportionate, in some degree, to the amplitude of the chest, and the thinness of its walls. Hence, the sound is usually more distinct in thin and lank persons, than in those who are fat or muscular. It is above the general average in hysterical women, and men of excitable nervous con- stitution, in consequence of their rapid breathing. In women the sound is usually louder than in men, and in children much more so than in adults. Hence, the respiration is said to be puerile, wherever met with, when the vesicular murmur is very loud. In old age, the sound becomes much weaker, while its duration, which is diminished during inspiration, is increased in ex- piration. Hence, breathing of this kind is called senile. But sometimes, also, even when all circumstances are apparently similar, the respiratory mur- mur may vary greatly in different individuals, being loud in some and very feeble in others, without any appreciable cause. When, in the same person, the sound is much weaker on one side than at the corresponding part of the opposite side, or when two points on the same side materially differ in this respect, there is good reason to suspect the existence of disease. The bronchial or tubal sound has a blowing character, such as may be produced, out of the body, by causing air to pass quickly through a tube. It may be imitated, in its different degrees, by voluntary modification of the ca- pacity of the rima glottidis, and greater or less rapidity of inspiration or expiration, so as to produce audible breathing. It is harsher and of higher pitch than the vesicular, and quite distinct from it. The part at which it may be heard in its greatest intensity is over the trachea, and in that situa- tion it is sometimes called tracheal; but this differs only in degree from the CLASS III.] AUSCULTATION. 789 sound yielded by the bronchia, and therefore scarcely merits a distinct name. It is perceived, in a somewhat lower degree, over the bronchia where they enter the root of the lungs, and, from that point, gradually diminishes, as the tubes ramify and penetrate more deeply into the pulmo- nary structure, until it is at length entirely lost. The bronchial sound is heard characteristically at the upper portion of the sternum, and may be distinguished for some distance upon each side, under the clavicle anteriorly, and between the scapula? posteriorly. It is more distinct, both before and behind, on the right side than on the left, owing to the greater caliber of the tube proceeding to the right lung. That it cannot be heard over the whole chest, is owing to the intervention of the soft spongy structure of the lungs, which deadens the sound, so that it is inaudible unless the tube is large, or very near the surface. It differs strikingly from the vesi- cular in the circumstances, that it is nearly as loud and long-continued in expiration as in inspiration, and sometimes more so, and of a higher pitch, and that instead of being nearly continuous in these two acts, it suffers a distinct interruption between them. The reason of these differences is ob- vious. In any given space from which the bronchial sound can reach the ear, the entering and returning currents, being of about equal velocity, and acting through an equal extent of tube, produce about an equal amount of vibratory movement and consequently of sound, both as regards intensity and duration; while, as the entering column is arrested before the returning movement commences in the cells, it is obvious that a certain time must elapse, after the cessation of the sound of inspiration, before the impulse which produces that of expiration can reach the part. Both of these cir- cumstances are wanting at the point at which the current of air begins to return, or, in other words, at the place in which the vesicular sound is gene- rated. In parts of the chest in which the vesicular structure of the lungs exists, while the bronchial respiration is still audible, the two sounds are sometimes so commingled as to be with difficulty distinguished, and the kind of respiration is produced which has been called rough, harsh, or rude. One of the most characteristic marks of this mixed respiration, is a prolonged expiratory sound, with an appreciable interval between that and the inspira- tory. Dr. Austin Flint attaches considerable importance to the higher pitch of the expiratory sound, as a sign of this kind of respiration, for which he proposes the name of broncho-vesicular, as more expressive than that of rude respiration. The sounds of the chest hitherto treated of are those of healthy respira- tion. They should be well studied on the living subject, in order to serve as points of comparison with the same sounds modified by disease, or with new ones which may arise from morbid states of the chest. The vesicular sound is liable to various changes. In the first place, it may become morbidly loud and prolonged, the latter alteration taking place more especially during expiration. Whatever has a tendency, by impairing, sus- pending, or destroying the respiratory function in one part of the lungs, to throw an increased duty upon the remainder, will be likely to render the sound in the latter portion more intense. Hence, tight bandages around the lower part ofthe chest occasion a louder vesicular murmur in the upper. The same effect is produced by obstructions in the bronchial tubes, excluding the air from a portion of the lungs ; by consolidation of the pulmonary structure; by compression from tumours, effused liquid in the pleural cavity, or from other causes • and even by dilatation of the air-cells, so considerable as to interfere with the performance of their duty. Whatever, too, produces a general morbid increase in the frequency and force of respiration, will give greater intensity, other things being equal, to the vesicular murmur, which 790 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. thus becomes a pathological sign. On the other hand, the sound may be morbidly weakened or altogether suppressed, in any particular part of the chest, by a partial or complete obstruction to the entrance of air into the cells, whether this obstruction exists in the tubes conveying the air, or arises from a filling up, compression, or want of expansibility of the cells themselves. Nor is a mere increase or diminution of intensity the only change to which this murmur is liable. It is occasionally deranged in various ways, in refer- ence to its duration and continuity. Sometimes it is not audible at the com- mencement of a respiratory movement, but becomes so before its close ; and again, though audible at the beginning, it ceases before the inspiration is completed. The former irregularity may be ascribed to an impediment which is capable of resisting for a time the entrance of air into a portion of the lungs, but is overcome by a continuance of the inspiratory movement, as in bronchitis partially closing the bronchial tubes, and in pleuritic effusion press- ing with a certain but not irresistible force upon the lungs; the latter, to some obstacle which, though it admits a certain amount of air to pass, resists a full inspiration, as in spasmodic asthma, and certain cases of fixed compres- sion of the air-cells short of obliteration. Sometimes the murmur, instead of being thus abbreviated at the commencement or close, is interrupted or jerk- ing, coming to the ear in successive irregular fragments, owing to some cause, such as pleurisy or pleurodynia, which renders inspiration painful, and breaks its continuity. Not unfrequently the murmur is wavy rather than interrupted, as if there were a remittent resistance to the inspiration, sufficient to diminish without checking it. Still another irregularity is the occurrence of a decided and readily appreciable interval between the sounds of inspiration and expi- ration, attributable to some impediment in the bronchial tubes interfering with the ready exit of the air, or possibly, in some instances, as has been supposed, to permanent distension of the air-cells, as in emphysema. It may be proper also to state, in this place, that agitation of the patient, at the commencement of an examination, sometimes induces temporarily a condition of the respi- ratory passages, in which, though the muscles of respiration may act, air does not enter the cells freely, and the vesicular murmur is not heard. To avoid false inferences, under such circumstances, it is always proper to make an- other examination after the agitation alluded to has subsided. The character of the vesicular sound is sometimes morbidly altered. It has before been stated that, in certain parts of the chest where the bronchial and vesicular sounds are both heard in the healthy state, the two become mingled, forming what has been called the rough or rude respiration. This frequently occurs, as a result of disease, in other parts of the chest. It usually depends on a certain degree of condensation in the pulmonary tissue, which renders it a better conductor of sound, without an obliteration of the air-cells. The bronchial respiration thus becomes audible, and modifies the vesicular, which may either be feeble or increased, according as the cells are more or less affected. It is in expiration that this change is more especially observable; the expiratory murmur being increased in intensity and duration, and having more of the harsh blowing character of the proper bronchial sound than the murmur of inspiration. This modification of the pulmonary sound is often of considerable value, as one of the signs of incipient tubercle, pneumonia, or pleurisy. The bronchial sound also is liable to morbid irregularities. Very fre- quently, in consequence of disease, it is heard without the accompaniment of the respiratory murmur, in parts of the chest where it is usually quite inau- dible. Under these circumstances, the respiration is said to be bronchial. The sound does not materially differ from that which is heard in health, near the root of the lungs. The sounds of inspiration and expiration, however, CLASS III.] AUSCULTATION. 791 are for an obvious reason less distinct from each other and more continuous. The bronchial respiration may depend upon a consolidation ofthe pulmonary tissue, and an obliteration, tempdrary or permanent, of the air-cells. The air is admitted into the larger tubes, but not into the minute ramifications, or into the pulmonary vesicles. It is in consequence of the greater solidity of the intermediate structure, that the sound is conveyed to the surface. Some- times the blowing sound is even louder than over the trachea, probably owing to the greatly increased surface of contact with the air, consequent upon the multiplication of the tubes; and also to the fact, that, in addition to the sound made by the movement of the air in the smaller tubes, that also of the larger tubes, and even of the trachea, is brought to the ear, being con- veyed downward through the ramifications, and thence to the surface through the solidified lung. The blowing character of respiration may also be induced by dilatation of the tubes, without condensation of the pulmo- nary tissue; but in this case the vesicular murmur is mixed with it. The strongest effect is produced by dilatation of the tubes, existing jointly with consolidation of the tissue. In violent dyspnoea, the bronchial respira- tion may sometimes be heard over the whole chest without any change of structure. Bronchial respiration may be diffused equably over a considerable extent of lung, and proceed apparently from a great number of smaller tubes; or it may be limited, as if proceeding from the larger tubes only, the smaller rami- fications being filled or consolidated along with the air-cells. In the latter case, the medium being denser, is a better conductor of the sound, which is therefore more distinct, louder, and of a metallic character, as if produced in a brass pipe. In this state, the respiration may be called tubal or tubular. Another modification is the cavernous respiration, produced by the passage of air into a cavity of moderate size. The sound is hollow, blowing, metallic, circumscribed, and less rapid than in the other varieties. When the cavity is very large, with dense and firm walls, the sound is still more metallic, and resembles that produced by blowing into an empty glass bottle. The respi- ration is in this case denominated amphoric. It is heard both in inspiration and expiration, unless the opening into the bronchia is very small, in which case the expiration is not distinctly audible. It is probably in this condition that the amphoric sound may become sensible through strong inspiration, when not heard in ordinary breathing. These sounds often pass into each other by such insensible gradations that no accurate line can be drawn be- tween them; and the cavernous respiration is denied by Skoda to be in any degree distinct from the bronchial. It is certain that there are none of these sounds, except the amphoric, which may not be produced without a cavity in cases of consolidation of the pulmonary tissue ; yet it is no less certain that, as a general rule, excavations in the lungs do give a somewhat modified cha- racter to the bronchial sound, which, though it cannot be relied on as sure evidence of a cavity, may, in conjunction with other not more certain signs, render its existence extremely probable. The cavernous respiration is of a lower pitch than the bronchial; and, according to Dr. Flint, differs from the latter also by the relative lowness of pitch in expiration when compared with that of inspiration. (Physical Exploration, &c, p. 205.) There does not therefore, seem to be sufficient reason for abandoning, at least in the pre- sent state of 'our knowledge, the nomenclature of Laennec in this respect. The morbid sounds hitherto treated of are modifications of those of health. But others of a distinct character are generated by disease, and are highly important as signs. These are called rales by the French, ronchi by English authors I prefer the former word, as susceptible of being adopted into our language- while ronchus,with its plural ronchi, must always remain foreign 792 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. to it. These rales may entirely supersede the healthy sounds of the chest, or may more or less mingle with and mask them. They result from the passage of air through altered tubes, or through liquid or semi-liquid matters con- tained in them, or from the friction of contiguous surfaces, or the flexion of abnormal tissue, in the respiratory act. Those formed in the air-passages have been divided into the dry and the moist. The dry rales are formed by the passage of the air, with more than the ordinary rapidity,through por- tions of the bronchial tubes, narrowed either by inflammatory thickening, adherent secretions, spasmodic contraction, or exterior pressure. The chief varieties of this sound are the sibilant and the sonorous rales. The moist rales are produced chiefly by the passage of air through a fluid in the bronchia of greater or less tenacity, causing the formation of a succession of bubbles, the bursting of which occasions the sound. They include the mucous rale and its varieties, the crepitant, and the subcrepitant. Each of these requires a brief description. a. The sibilant rale is a low whistling sound, heard both in inspiration and expiration, or in either exclusively, sometimes short and sharp, ceasing almost immediately, sometimes prolonged and of a lower tone, and produced usually in the smaller bronchia, though it may occur in the larger when their caliber is very much diminished. b. The sonorous rale is a musical sound, of a deep or grave tone, and has been compared, in its different varieties, to the snoring of a man, the hum- ming of a gnat, the plaintive cooing of the wood-pigeon, and the bass notes of a violin. It varies greatly in intensity, being in one extreme so low as to be just audible, and in the other so loud that it may be heard at some dis- tance from the chest, without the aid of an instrument It may occur during either inspiration or expiration, or may accompany both these movements, but is more common in the latter. It is sometimes of short duration, in consequence of the sudden removal by coughing or otherwise of the obstruct- ing cause, sometimes persistent, though generally occurring interruptedly, and seldom with every successive respiratory movement. It arises in the larger bronchial tubes, which alone are capable of producing the grave tone by which it is characterized. It is occasionally associated with the sibilant and mucous rales. A modification of this sound, sometimes called the dry mucous rale, is produced by a portion of tough mucus obstructing a tube, and yielding to the air, during each inspiration, at short, successive intervals, so as to occa- sion a ticking or crackling noise, which, during very rapid and forcible breath- ing, becomes continuous, and passes into the proper sonorous rale. c. The mucous rale is heard in bronchial tubes of the size of a crow's quill or larger, and is formed by the bursting of bubbles of liquid, whether mucus, pus, or blood, of considerable, but unequal size. It accompanies both inspiration and expiration. When prevalent over a considerable portion of the lungs, it may often be heard at some distance from the chest. It is familiar to most practitioners, as the sound which attends bronchitis after secretion has become established; and, in the stage of transition from the dry to the secretory state of the membrane, is often mixed with the sibilant and sonorous rales, forming a singular combination of sounds, which have been compared to the various notes of different birds, singing or chirping together. In the smaller tubes, in which the bubbles are necessarily more minute, and the sound weaker, it is sometimes designated as the submucous rale, an example of which is afforded in the early stages of pulmonary tubercles, which keep up a slight inflammation in the small tubes in their vicinity. When the air passes into a pulmonary cavity, or into morbidly enlarged bronchial tubes contain- ing liquid, the sound is still looser and coarser than the mucous rale, assuming a gurgling and sometimes hollow character, which has entitled it to the name CLASS III.] AUSCULTATION. 793 of cavernous rale. This is usually more circumscribed, and confined to nar- rower limits than the mucous rale, though, when owing to enlarged bronchia, it may extend over a considerable portion of the chest. d. The crepitant rale is a very fine, regular, crackling sound, with minute, sharp equal crepitations, and resembles very closely that made by rubbing a lock of hair between the thumb and fingers, near the ear. It has been compared also to the crackling of salt, and to that produced by the burning of a very small train of moist gunpowder. It is confined exclusively to the minutest bronchial tubes, and to the air-cells, and may depend on the suc- cessive bursting of very minute bubbles of the tenacious secretion which occurs in pneumonia, of which affection this sound is characteristic, or, as suggested by Dr. Carr, of Canandaigua, New York, upon the separation of the walls of the cells, agglutinated by the plastic exudation. (Am. Journ. of Med. Sci, N. S., iv. 360.) One of its peculiarities is, that it is heard only during in- spiration, and this fact corresponds with the explanation of Dr. Carr, as it is only during the expansion of the air-cell that the necessary condition for its production exists. Or, the peculiarity may be owing to the passage, which has been opened by the entering air, remaining open for a time, in conse- quence of the stiffness of the secretion, and permitting the returning air to escape without resistance, and consequently without sound. When this rale is once perceived, it remains for a considerable time, and is not removable, like the mucous rale, by coughing, and thus clearing out the bronchia. Two varieties of the crepitaut rale may be distinguished, one fine as above, the other coarser, more irregular, and often heard in expiration. The latter approaches to the subcrepitant. e. The subcrepitant rale is intermediate between the two preceding. The sound is bubbling, but the bubbles are finer, more crackling, and more regu- lar than in the mucous, or its modification the submucous. It has been com- pared to the sound of a liquid in moderate effervescence. It is heard both in inspiration and expiration, and is probably formed in the minutest bronchial tubes, in consequence of a liquid more or less tenacious contained in them. Variations in the force and fulness of respiration materially affect the sounds above described. Some that are heard in ordinary breathing, cease when the lungs are fully expanded, because the passage for the air is now free. On the contrary, when the bronchial fluids are so abundant as to close the smaller tubes, and thus entirely to prevent the passage of air, a forcible and deep inspiration will open them, and thus enable the respiratory sounds to be gen- erated. Sometimes the different sounds are audible at the same time in different parts of the lungs, and two or more occasionally in the same part. Not unfrequently also the rales are combined in greater or less proportion with the healthy respiratory sounds; and very often much experience and a patient examination are necessary, to enable the practitioner to distinguish them satisfactorily. It must be recollected that, in consolidation of the pulmonary tissue, the various rales above referred to may be heard, in like manner with the bron- chial respiration, in parts ofthe lungs distant from their point of production, being conveyed through the bronchial tubes into the consolidated lung, and through that to the ear. Metallic tinkling is another morbid sound requiring notice. It is quick and sharp, and resembles that produced by striking a pin, or other small me- tallic body, gently against a glass vessel. Different opinions have been held as to its cause. The only necessary condition of parts, universally admitted, is the existence of a cavity of considerable size, with firm walls, containing air. Laennec supposed the simultaneous presence of air and a liquid in the cavity essential to its production. It has been ascribed to the passage of a 794 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. bubble of air through the liquid, to the bursting of the bubble on the surface of the liquid, and to the falling of a drop of fluid matter from the walls of the cavity, through the air, into the liquid. But Dr. Williams is probably correct in considering it as resulting from any sudden vibration of the air in the cavity, which is reflected from side to side of the walls. Hence, not only may any one of the above causes occasion it, but the voice, the respiratory act, and the different rales, may have the same effect; nor is the conjoined presence of air and liquid absolutely necessary, as it has been produced in cavities filled only by air, and having no external communication, by the mere concussion of the voice and cough, carried through condensed pulmonary tis- sue. (Tweedie's Syst. of Pract. Med., art. Pneumothorax.) In pulmonary cavities, having an external communication, it frequently attends and alter- nates with amphoric respiration, which owes its existence to a similar condi- tion of parts. A sufficiently correct idea of the sound may be obtained by ausculting over the stomach, when it contains a certain amount of air and liquid; and an analogous sound is produced by placing the palm of the hand over the ear, and then giving the back of it a sharp tap with the end of the finger. Friction sound is a name given to the noise produced by the rubbing to- gether, during respiration, of the pulmonary and costal pleura, roughened by an irregular deposition of coagulable lymph upon the surface. It is of course entirely morbid, never being produced in a healthy state of the membrane. It consists usually of a succession of quick, jerking sounds, not very nume- rous, superficial in position, developed over an uncertain but limited extent of surface, and exceedingly variable in intensity, being sometimes scarcely audible, sometimes very loud, and, in the latter case, often attended with vi- brations of the walls of the chest, perceptible to the hand, and even felt by the patient himself. Sometimes the friction sound, when not occasioned by ordinary breathing, may be developed by a deep inspiration, or by coughing. In its slighter varieties, it sometimes closely resembles the subcrepitant rale, from which it may be distinguished, according to Dr. Gerhard, by less regu- larity in the component sounds, and by not following so closely the passage of the air. Though usually most observable during inspiration, it is gene- rally heard during both movements, but rarely, if ever, according to Walshe, in expiration alone. The friction sound is not confined to the pleura during respiration ; but is produced by whatever causes two contiguous surfaces of a serous membrane to move upon each other, when roughened by the exudation of coagulable lymph. It sometimes arises from the movements in the inflamed pleura, occasioned by the contraction and dilatation of the heart; and may be clearly perceived over the abdomen, in cases of peritoneal inflammation with plastic effusion, when the walls are made to move upon one of the solid viscera, or upon an abnormal tumour, as during a deep inspiration, or by a change of position. Under the same name may be included the creaking sound made by the movement, during respiration or the pulsations of the heart, of the consoli- dated layer of coagulated lymph, after adhesion between the opposite sur- faces has taken place. It is obvious that the proper interrupted friction sound may pass by degrees into the more continuous creaking sound, as the surfaces gradually coalesce. The friction sound is attended with vibrations of the thoracic walls, which may generally be perceived by the hand; and sometimes are sensible to the patient himself. 2. The vocal resonance is also a subject of auscultation. This obviously in- cludes cough; for all sound formed in the larynx, above that of the breath, is CLASS III.] AUSCULTATION. 795 voice, whether articulated or not. It will be most convenient, as in the respi- ratory sounds, to treat first of the healthy sounds, and afterwards of their modification by disease. If the stethoscope be applied over the trachea, in front of the neck, or at the top of the sternum, the voice will be heard loudly, and words will reach the ear through the tube with tolerable distinctness. This sound is sometimes called tracheophony. For a short distance on each side of the upper part of the sternum, below the clavicle, between the scapula? behind, and in the axilla, the voice is still heard, but less loud and distinct, and with a very imperfect and confused articulation. The sound is, in these situations, called bronchophony. It does not extend below the third rib in front. Over the remainder of the lungs, the voice is either not heard, or produces only an obscure, confused, thrilling sound, which maybe distinguish- ed by the name of pectoral resonance, and is often accompanied with a slight vibration of the walls of the chest, sensible to the hand laid flatly against them. The cause of this difference is, that, in the former case, little besides the walls of the chest intervenes between the bronchia and the ear, while, in the latter, the tubes are enveloped in a mass of spongy pulmonary tissue, that intercepts the sound, which, moreover, is weakened by its ramification with the air-passages. The bronchial sound is a little stronger on the right side than on the left, below the clavicle, and in the space between the spines of the scapula? behind. In other parts, allowance being made for the heart, the two sides of the chest have a pretty accurate correspondence. The general vocal resonance is stronger in the upper than in the lower portions of the chest, and in front than behind, except in the interscapular space. It differs greatly in different individuals. A thin chest transmits the sound better than one which is fat or very muscular; and a voice with a high key penetrates more deeply into the lungs than a low or bass one, in consequence of the more ready entrance of its small vibrations into the smaller tubes. But, as the bass voice is usually the strongest, it is more apt to produce a general vibra- tion of the chest. Hence, the pectoral resonance and sensible tremor of the walls of the thorax are more marked in men; while articulate sounds extend further in women and children. The difference between individuals, in rela- tion to the degree and extent of these sounds, is so great, that pathological inferences are deduced, less from their general character in any particular case, than from their want of correspondence on opposite sides of the chest. The vocal resonance may be morbidly diminished or suppressed, in conse- quence of collapse of the lung, or the intervention of a badly conducting medium, as of a large quantity of liquid in the pleural cavity. It is, how- ever, much more frequently increased, often becoming, in diseased lungs, much louder and more extensive than in health; so that, in parts ofthe chest where naturally only a feeble sound is heard, it may approach or equal that ordinarily perceived over the larger bronchia or the trachea. When bronchophony is perceptible in other parts of the chest, besides those above pointed out as the seat of it in health, it is in general a sign of disease. It usually results from the intervention of a denser medium than the normal structure of the lungs between the bronchia and the ear, and may indicate either consolidation or compression of the lungs, or effusion of liquid into the air-cells, the interlobular tissue, or to a certain extent into the pleural cavity. It may also depend upon morbid enlargement of the bronchial tubes, with thickening and consolidation of their walls. It is a valuable sign in diagnosis; but the fact before referred to must be borne in mmd, that persons differ much in the degree to which it naturally prevails, and that it may be audible in one individual without deviation from health, in parts in which it would in others be unquestionably morbid. To obtain correct inferences, therefore, it is proper to examine both sides ofthe chest; and, if the sound be louder on 796 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. one side than at the corresponding spot on the other, or if it be heard only on one side, allowance being made for the naturally greater resonance at the top of the right than of the left lung, the presumption will be strong of the exist- ence of disease.* Mgophony is a name given to a modification of bronchophony, supposed to be produced by the intervention of a moderate layer of liquid between the side of the chest and the lung. The voice, transmitted through the compressed lung to the liquid, imparts to this a vibratory movement, which causes the sound as it passes to the ear to assume a tremulous irregular character, com- pared to the bleating of a goat, from which this variety of bronchophony derived its name. When the lung is at the same time consolidated, the reso- nance is louder than when dependent solely on the presence of effused liquid. But the same sound is sometimes produced without liquid in the pleural cavity, and Skoda asserts that it is occasionally heard in the healthy lung, in the interscapular space; at least it has been noticed in cases in which there was compression of the trachea, or larger bronchia. It cannot, therefore, depend solely on the movement of the liquid, as supposed by Laennec. Skoda ascribes it to the impinging of one solid body against another, or of a solid against a liquid or aeriform body. Pectoriloquy is another variety of morbid vocal resonance, in which not only the sounds of the voice, but the articulated words seem to proceed from the walls of the chest directly into the ear, resembling tracheophony almost exactly. It differs from bronchophony in the distinctness of the articulation, and in the circumstance that the resonance is usually more circumscribed, and limited in its extent. It is produced by the articulated voice entering a cavity which communicates freely with the bronchial tubes. When the cavity is near the walls of the chest, the voice is still louder and more distinct. But it may also be produced in the bronchial tubes of solidified lung tissue without a cavity, of which, therefore, though it may in general indicate the existence, it cannot be considered as a pathognomonic sign. As articulation takes place only in the fauces and mouth, it is obvious that the vibrations which give rise to pectoriloquy must be conveyed from above the larynx into the chest. Amphoric resonance is the sound produced by the voice in a large cavity communicating with the bronchia by a small aperture. In this case, the voice is not articulated as in pectoriloquy, and does not seem to enter the ear as in bronchophony, but reverberates through the cavity, and has a ringing * Skoda, the celebrated professor of Vienna, denies that the bronchial sound is con- veyed more readily through consolidated pulmonary tissue than through the same tissue in a healthy state. He ascribes the sound heard under such circumstances to conso- nance, by which the vibrations produced by the voice in the larynx, and conveyed through the air of the bronchial tubes, are repeated by the walls of those tubes in the consoli- dated lung, and thence reach the ear; the only effect of the consolidation being to give increased firmness to the walls of the bronchia, and thus enable them to vibrate more freely. He extends the same views to the respiratory bronchial sound, which he believes to be formed not in the tubes of the solidified lung, which scarcely expand or contract in respiration, and into which, therefore, air does not enter, or enters only in small quan- tity, but in the larger bronchia above, from which it is conveyed downward through the contained air. Skoda is no doubt correct in ascribing both bronchophony and morbid bronchial respiration to a conveyance of the sound from above into the tubes of the diseased lung, though in this he has stated nothing new; but he has not proved that the walls of the tubes do not transmit the vibrations as well as the contained air, nor that these vibrations do not reach the surface more readily through the solidified lung than they would do through the healthy sponge-like tissue. It is an established law in physics that solids transmit vibrations more readily than air, as in the well-known ex- ample of a rail, in which a slight scratch of a pin at one end is distinctly heard at the other. Is it probable that a piece of loose sponge would transmit vibrations producing sounds so readily as the same sponge infiltrated with wax? A similar relation the healthy pulmonary tissue bears to the same tissue uniformly consolidated by plastic exudation. (Note to the fourth edition.) CLASS ILT.] AUSCULTATION.—PERCUSSION. 797 metallic sound, similar to that produced by speaking into a hollow broad- mouthed vessel. The cough, which in health yields to auscultation a short, dull, indistinct sound, undergoes, in morbid states of the lungs, modifications analogous to those produced upon the ordinary voice. It is called bronchial under circum- stances which produce bronchophony, cavernous under those which produce pectoriloquy, and amphoric in large cavities with firm walls and narrow outlets. The sound of whispering, though little or not at all heard over most of the chest in health, is conveyed to the ear in the same morbid conditions as bronchophony, and may often be heard more or less articulated in cases of solidified or excavated lung. The signs of respiration and vocal resonance generally correspond, as they result from the same physical modifications of structure. Thus, rough respi- ration and increased resonance, bronchial respiration and bronchophony, cavernous respiration and pectoriloquy, and finally amphoric respiration and amphoric resonance usually go together, and lend to each other a mutual support, as means of diagnosis.* As a general rule, all the sounds given forth in morbid states of the respi- ratory organs are heard in those parts of the walls of the chest which corre- spond most nearly with the part affected ; but it is necessary to bear in mind, in order to avoid false inferences, that they are sometimes conveyed to a con- siderable distance from their true seat, by the intervention of abnormal solid or liquid matters, which have a greater conducting power than the healthy pulmonary tissue. Thus, gurgling from a cavity in the upper part of the lung may sometimes be heard low down in the organ when solidified ; and cardiac murmurs, usually most distinct at points nearest the valves producing them, are, under similar circumstances, sometimes audible over large portions of the chest. Indeed, any sound made in the larger air-tubes may thus be conveyed to distant parts, as the bronchial, cavernous, and, perhaps, even the amphoric, and without care, may be mistaken for evidences of a cavity im- mediately beneath the ear. It sometimes happens that the abnormal bronchial sounds, arising from consolidation of the lung on one side behind, are heard to a certain distance on the opposite side of the spine, in the healthy lung. This is ascribed by Prof. Fenger, of Copenhagen, to a sort of echo; but, whatever the cause, re- quires caution, lest it should be mistaken for evidence of disease on the sound side. The sounds, however, are less distinct than on the diseased side, and are not attended with dulness on percussion. (B. andF. Med.-Chir. Bev., Oct., 1856, p. 245.) Percussion. For the methods of performing this operation, and for the principles of the * The voice of the operator, in auscultation, may be used as a means of diagnosis. When a person, with his ear applied to the chest, speaks aloud, the tone of voice varies according to the condition of the parts beneath, being lower or more bass with greater resonance when the lung is solidified, as by tubercles or by inflammation, than when in the healthy state; higher or shriller, and also more resonant, when there is a large cavity filled with air; and quite flat, and without resonance, when the lung is com- pressed as by pleuritic or dropsical effusion. Now it must be obvious that a person who has rendered himself familiar with the effects of these and other conditions of the chest upon his own voice, will be able to detect them with some certainty by simply speaking aloud in the act of auscultation. The name of " heautophomcs" has been pro- posed by Dr R. G. Latham, for this mode of diagnosis; and some attempts have been made bv Mr G Corfe, of the Middlesex Hospital, to apply it to the study of particular pectoral affections. It is scarcely probable, however, that sufficient precision can be eiven to rules upon the subject, to render it anything more than a subordinate aid to ordinary auscultation. (See Braithwaite's Retrospect, xvn., 65; from Med. Times for January and March, 18i8.)-Note to the second edition. 798 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. process, the reader is referred to the general observations on the modes of exploring disease. (See page 206.) It is only its application to diseases of the respiratory organs that is to be considered in this place. Mediate percus- sion, or that performed by tapping with the ends of the fingers upon a small solid body applied closely to the chest, such as a piece of caoutchouc, ivory, or wood, or, what is still more convenient, one or more fingers of the left hand, is exclusively referred to in the following remarks. The sound produced by percussion over the chest in health, wherever the proper structure of the lungs comes into contact with its walls, has a certain degree of depth and clearness, indicating the presence of air within, and strikingly different from the dull flat sound, yielded by a perfectly solid structure as the thigh. This clearness, however, is much less than that of a large cavity containing air alone, or air and liquid, as, for example, the stom- ach and intestines when empty of solid food. The peculiarity of the sound is owing to the spongy structure of the lungs, in wliich air is distributed into an immense number of minute cells, around which are solids and liquids intimately intermingled. Its precise character can be appreciated only by making frequent percussion upon the healthy chest, and familiarizing the ear with the sounds thus produced. The sound varies considerably in certain parts of the lungs, with the force of percussion. When this is slight, the vibrations reach only the superficial structure, which, therefore, gives character to the sound ; when it is strong, they penetrate more deeply, and evolve the sonorous peculiarities of the parts there situated. Thus, over the lower part of the right side, where the liver projects into the thorax, but with a thin layer of lung between it and the outer wall, a slight percussion yields the clear sound of the pulmonary tissue, a strong one, the dull sound of the hepatic. The sound is even affected by the material upon which the patient may lie, being deadened by a feather bed more than by a hard mattress. But it is best that the examination should be made in the erect or sitting posture. The state of the thoracic parietes also affects the character of the sound, which is resonant in proportion to their thinness and elasticity. Hence, during the examination, the patient should keep his chest moderately tense, but without contracting the muscles in the part percussed. If examined in front, he should have his head erect; his shoulders thrown backward, and his arms either hanging loosely by his side, or thrown over the back of the chair; if upon the side, he should place his hand upon the top of his head ; if upon the back, he should bend a little forward, and fold his arms over the breast. Both sides of the chest should always be examined, so that the sounds yielded by their corresponding parts may be compared. The natural sound is different in different individuals, and what is morbid in one may be per- fectly healthy in another. But the opposite sides yield the same sounds, with some few exceptions; and any difference in them, allowance being made for these exceptions, may be considered as indicative of disease. The per- cussion, moreover, should be performed under similar circumstances in refer- ence to respiration; as the sound after full inspiration is considerably more resonant than after full expiration, especially in certain parts of the chest. Hence, it is important, in making a comparison of the two sides, not to examine one in one stage of respiration and the other in another. The patient should be directed, if possible, to hold his breath until the corre- sponding places on the opposite sides shall have been percussed; or, at any rate, the practitioner should seize the same point in successive inspirations or expirations, for his trials. Care should also be taken that the finger, or other object employed as the pleximeter, should be in the same direction, and upon the same structure on the opposite sides; that it should not, for example, be CLASS III.] PERCUSSION. 799 in the intercostal space upon one side, and on the rib upon the other, or in a perpendicular direction on one, and a horizontal on the other. In order to appreciate the morbid changes of the pectoral sounds, it is necessary to be acquainted with their modifications in the healthy chest. The results of percussion vary considerably in different individuals, in con- sequence of difference in the relative size of the lungs, and the relative mag- nitude and position of the neighbouring viscera. The following probably approaches, as nearly as may be, to the general average. In the whole upper portion of the chest, anteriorly and laterally, the sound has the ordinary pul- monary character, and does not differ materially on the two sides. As we descend, the sound is modified by the presence of the liver upon the right side and in front, by the heart and stomach in front and on the left side, and by the spleen further to the left. Over the liver, heart, and spleen, the sound becomes duller, shorter, and flatter; over the stomach either very flat, when that organ is full of food, or very resonant, and of a peculiar tympanitic character, when it contains only air and a portion of liquid. But the change of the sound from the pulmonary character to that of the organs above men- tioned is not abrupt. In consequence of the convexity of the diaphragm, the abdominal viscera project further into the thorax towards the middle than at the edges of the cavity, where they are to a considerable extent overlapped by the lungs; and the thickness of the pulmonary layer, intervening between them and the walls of the chest, diminishes gradually in the downward di- rection until the lung ceases, and the viscera press directly against the ribs. In like manner, the lung overlaps the greater portion of the heart, with a gradually diminishing thickness as it approaches the uncovered part of that organ. It follows that the clearness of the pulmonary sound gradually diminishes from the outer limits of the heart, liver, and spleen, up to the line where the lung ceases, when it yields entirely to the flat sound afforded by these organs; while, in the transition to the stomach, it changes into the strikingly different resonance of that organ if flatulent, or into its perfect dul- ness if full. On the right side, the sound begins to become somewhat duller below the fourth rib in front, and the sixth rib in the side, and gradually increases in dulness as far as the sixth rib in front, and the eighth in the side, below which the pulmonary is superseded by the hepatic, and, to a cer- tain extent, towards the epigastrium, by the stomachic sound. Behind the middle of the sternum, and on the left side behind the third rib in front, a very slight diminution of clearness may be observed, in consequence of the presence of the heart, which is here, however, covered by the lung. Behind the intercostal space between the fourth and fifth ribs, for an extent of one or two square inches, bounded by the middle of the sternum on the right, and stretching towards the nipple on the left, which, however, it does not reach, there is dulness in consequence of the contact of the heart with the chest. With this exception, the left lung reaches to the seventh rib in front, and to the eighth on the side, where the pulmonary gives place to the stom- achic, and perhaps slightly in front to the hepatic sound, and further to- wards the left to the splenic. Besides these variations anteriorly, there are others in the upper part of the chest. The sternal extremity of the clavicle gives a very clear sound, which becomes somewhat duller towards the middle of the bone, and is much duller at the humeral extremity. Above the cla- vicle percussion is less resonant than below; and the sound on the right side under the clavicle is said by Dr. Gerhard to be in a slight degree less clear than on the left. In the back of the chest, the sound is much affected by the masses of muscle, and the presence of the scapula. It is very dull above the spine of the scapula, somewhat less so upon that bone beneath the spine, and still less so upon the spinous processes of the vertebra?. In the space 800 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. between the scapula and spinal column it is rather clear, but is clearest below the scapula, until we reach the region of the liver on the right side, and that of the stomach or colon and spleen on the left, which is somewhat lower than the same line anteriorly. This infra-scapular region is peculiarly clear in children. The sound is remarkably clear in the lateral portions of the chest in consequence of the absence of muscle. The pulmonary sound generally is clearer in children than in adults, and in these than in old per- sons. In women it is affected in front by the mamma?, which render it dull, unless under pretty strong percussion. But the limits above designated are much affected by a full inspiration, which causes the lung to descend about one rib lower, and almost entirely to cover the surface of the heart; so that the boundary of the proper pulmonary sound is thus much extended, while the sound itself becomes clearer. A full expiration, on the contrary, somewhat narrows its limits, and extends those of dulness, at the same time diminishing somewhat the general clearness of the sound. But it has been observed by Williams that either a full expiration or inspiration, by giving greater firmness to the walls of the chest, quickens their vibrations, and renders the key higher. It must be recollected, too, that the degree of clearness in those parts of the chest where the lungs overlap the heart, liver, &c, depends in some measure on the force of percussion ; a slight impulse evolving only the sound proper to the superficial parts, and conse- quently a clear one, while a strong impulse brings the hepatic and cardiac dulness to the surface. The limits between the lungs and stomach cannot be so easily detected, in consequence of the hollow resonance of the latter organ, which swallows up the slighter pulmonary sound, though a very feeble per- cussion may sometimes elicit the latter, without the former. The morbid states revealed by percussion are those in which the pulmonary sound becomes flatter, or is altogether superseded, and those in which it acquires additional clearness and sonorousness. The former effect is produced by whatever increases the density of the pulmonary tissue, or substitutes a denser substance in its place ; the latter, by whatever increases the relative amount of air, whether in the air-cells, in morbid cavities, in the cavity of the pleura, or in the external cellular tissue. The special changes of the sound will be more conveniently treated of under the several affections upon wdiich they depend, and which they serve to indicate. It will be sufficient here to state that percussion is said to be tympanitic when it produces a drum-like sound, as over a cavity containing air with moderately tense walls ; tubular when made over the trachea or one of the larger bronchia with solid or liquid intervening between it and the wall of the chest; and amphoric when at- tended with a certain musical intonation similar to that of amphoric reson- ance and respiration, and usually indicative of a large cavity with firm and thin walls, and lying near the surface. These sounds do not differ from the vesicular percussion sound simply in intensity or loudness, but in character; for the tympanitic sound may be quite characteristic, and yet really feebler than the vesicular. One of the elements of this distinctive character is a higher pitch. Consolidation or hepatization of portions of the lungs, oedema of these organs, compression by fluids in the pleural cavities, solid tumours, encroach- ments of the neighbouring organs, as the heart, liver, stomach, and spleen, emphysematous distension of the air-cells, and the presence of air within the pleura, are among the pathological conditions which percussion may assist in pointing out. But it is inadequate to the detection of very slight changes, especially if deeply seated, and it seldom happens that it is alone sufficient precisely to define the character of the complaint. It is highly im- portant, however, by calling attention to the existence of disease within the CLASS III.] PERCUSSION. 801 chest, and in connection with other methods of diagnosis, often serves to give a certainty scarcely attainable otherwise. In relation to the existence of fluid in the pleural cavity, it is often of itself sufficiently diagnostic. If dulness upon percussion is observed in the lower part of the chest, and if this dulness materially varies with the position of the patient, being absent or present according as the operation of gravity ought, in the change of posi- tion, to bring the level of the surface of a fluid in the pleura below or above the point of examination, the evidence is conclusive that such a fluid exists in the cavity. An important fact, ascertained by Skoda, is, that great tension of the walls of a cavity containing air, contrary to what was formerly believed, causes dul- ness on percussion. This is probably owing to a degree of immobility of the particles, which prevents the ready transmission of vibrations to or from the air beneath; so that it is only the sound of the surface percussed, and not that of the air which is heard. It has been noticed that, when one of the pleural cavities is partially filled with liquid, or one of the lungs partially consolidated, the portion of lung above the liquid, or the part of it not consolidated, becomes more resonant upon percussion. This, it appears to me, must depend upon the same cause as the louder respiratory murmur under the same circumstances; that is, upon a greater expansion of the air-cells, in consequence of the greater amount of duty they have to perform; the cavity of the chest locally expand- ing in the same proportion as the cells. Sometimes too percussion evolves a tympanitic sound when the structure immediately beneath is more or less so- lidified; but this may be explained by the extension of the vibrations, through the solidified structure, to some neighbouring cavity containing air; as to the stomach or colon, or to large bronchial tubes. A peculiar sound of a somewhat tympanitic character is sometimes evolved by percussion, in certain states of the lungs, called, from its resemblance to that made by a cracked metallic vessel when struck, the cracked-metal, or cracked-pot sound, or, as the French name it, bruit de pot file. This is closely imitated by striking the two hands, loosely clasped together, upon the knee. It is probably produced by vibrations of air, driven by percussion from a limited space, in various directions, through different outlets. Hence it is elicited when percussion is made over a pulmonary excavation communicating freely with several bronchial tubes, the mouth being open during the opera- tion. At one time it was considered as an almost certain sign of a cavity; but either the sound itself, or something very similar to it, may be elicited in various morbid states of the lungs, in which a portion of spongy structure, communicating with bronchial tubes, is surrounded by consolidated tissue; and it has frequently been produced in the lungs of children in health, owing, probably, to the large proportion of air contained in them, and to the flexi- bility of the thoracic walls. Nevertheless, it may still be considered as among the most decisive signs of a cavity, but'requiring other confirmatory evidence to render it certain. It is best brought forth by making a rather sharp and quick percussion; the patient being directed to keep his mouth open, and to look towards the operator, so that the vibratory wave may proceed imme- diately to his ear. This last direction is considered important by Dr. R. P. Cotton, of the Brompton Hospital for consumption, who considers the sound as highly diagnostic of a cavity, and states that he has never heard "the true cracked-pot sound as a pathological condition, except in cases of pulmonary excavation." (Lancet, Am. ed. June, 1857, p. 479.) Independently of the diversities of sound evolved by percussion, this method also affords useful indications by the impression made upon the sense of touch. When percussion is made with the finger as a pleximeter, a certain sense of vol. i. 51 802 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. resistance is perceived, the degree of which may serve as a measure of the condition, in relation to elasticity, ofthe parts percussed; and inferences can thus be drawn as to the condition of the lungs, which may serve to confirm or correct, in some instances, those deducible from the sound. The sense of re- sistance is inversely proportionate to the elasticity. Inspection. This is nothing more than an examination by the eye of the shape, size, and movements of the chest; and the object is to ascertain the existence of any deviation from health, in either of these respects. The patient should be viewed in front, behind, in the direction of his length, and from side to side. During the inspection, the chest should be naked, or, as in females, covered with a thin closely fitting garment; and the position of the body should be in one uniform plane, whether lying, sitting, or standing. In order that a good longitudinal view may be obtained, the patient may lie evenly on his back, while the practitioner stations himself at the foot of the bed, and directs his eye along the surface of the chest; or, what is perhaps better, the patient may sit, and the practitioner, standing behind him, may bend over his shoulder and look from above downward. In a perfectly well-formed chest, the sides are symmetrical. The general shape of the chest is that of an irregular cone, truncated at top, larger below than above and from side to side than from front to back, somewhat depressed above the clavicle, rather less so immediately below it, and gently convex from the second rib downward, as far as the base of the lungs, where a slight de- pression or flatness may often be observed surrounding the chest, immediately above the bulging produced by the abdominal viscera, during inspiration. Attention has been called by Dr. Edward Harrison to this line of depression, as the boundary between the lungs above, and the liver, stomach, and spleen below. The chest is often slightly prominent over the heart. Behind, it is somewhat convex from above downward, and there is a sulcus on each side of the spine. The ribs, except in fat persons, are somewhat more prominent than the intercostal spaces. But a perfectly formed chest is rare. Derange- ments, either congenital or acquired, are very common, without any want of health in the contents of the thorax. This must always be taken into con- sideration in forming a judgment; and it will seldom be proper to depend on the shape of the chest, without confirmatory evidence from other signs. But this is valuable as an aid in diagnosis; and, when any considerable deviation from the normal shape, and especially when any striking want of conformity in the opposite sides is visible, it should lead to the suspicion of disease, and to other modes of examination. In inspiration, the chest is at the same time expanded and elevated; in expiration contracted and depressed; the intercostal spaces being somewhat widened in the former, and diminished in the latter. The ribs rise upward, and project outward, at their central portions during inspiration, and fall during expiration, having at the same time a somewhat rotatory motion. In health these movements are all regular, and those of the ribs correspond in all parts with those of the chest in general. The walls of the abdomen also expand regularly with every inspiration, in consequence of the descent of the diaphragm. The number of respirations in health is from sixteen to twenty in a minute. Between inspiration and expiration there is scarcely any appre- ciable interval, and their duration is nearly equal. The chest may exhibit derangement to the eye by a general morbid expan- sion, or local bulging; by the contrary state of general contraction, or local depression; by inequality in the size of the two sides; by changes in the rela- tive position of its parts in reference to their elevation; by lateral curvatures; CLASS III.] APPLICATION OF THE HAND. 803 by an increased or diminished frequency, or irregularity of respiration; by changes in the relative duration of inspiration and expiration; and by an increase, diminution, or entire cessation of visible expansion in the act of breathing, whether in the whole chest, or only a part of it. Sometimes fluctuation is visible when there is liquid in the pleura, and the intercostal spaces are much bulged. Irregularities in the movements of the abdomen connected with respiration are also observable upon inspection. The indica- tions of these various abnormal phenomena will be given under the individual diseases in which they are observed. It will be sufficient to mention here that collections of liquid or air in the pleura or pericardium, enlargement or expan- sion of the lung itself, or of other organs in its immediate vicinity, as the heart, liver, stomach, or spleen, and tumours of various character, either in the lungs or their neighbourhood, may occasion projections, general or partial, in the walls of the chest, which may be obvious to the eye, and which are much more frequent and extensive in the lower than the upper part of the thorax. Contraction or depression may result from permanent compression of the lung, produced by fluid in the pleura, which is afterwards absorbed, and from whatever destroys the substance of the lung, or produces shrinking in its tissue. Application of the Hand. By applying the palm of the hand to the chest, in a healthy state, during the act of speaking, we are sensible of a very slight tremor, which is most observable in persons with a strong bass voice, and diminishes in proportion as the voice is feeble or high-toned. Thus it is scarcely ever felt in children, and is often wanting in women. It is more perceptible in thin chests than in those covered with fat, in the horizontal than in the erect position, in front than behind, and upon the right than the left side. In disease, the tremor is increased by whatever consolidates the lung without obliterating the bron- chial tubes, because the pulmonary structure thus becomes a better conductor of sonorous vibrations. The impression produced upon the hand in this way is sometimes very strong, when there is a considerable extent of consolida- tion. The intervention of liquid or air between the sides of the chest and the lungs, or an emphysematous expansion of the air-cells, has, on the con- trary, the effect of checking or intercepting the vibrations, so that the tremors will not be felt. The thrill imparted to the chest by the friction of the oppo- site surfaces of the inflamed pleura may sometimes be perceived by the hand, as may also the vibrations which attend a sonorous rale of great intensity. In the same way, fluctuation in the pleura or lungs may occasionally be de- tected ; the fluctuating movement being produced either by strong agitation of the chest in certain morbid states of respiration, or artificially by shaking the patient, or by a sharp tap with the fingers upon one of the intercostal spaces in the neighbourhood. The act of respiration also gives rise to it, in cases of large pulmonary cavities partly filled with liquid. In examining the chest in reference to these parietal vibrations, it is generally proper to apply the two hands to corresponding portions of the opposite sides, so that the effects produced may be compared. If found less or greater upon one side than the other it gives ground for reasonable suspicion of disease. The appli- cation of the hand sometimes aids in the detection of a want of correspondence in the movements of the opposite sides of the chest, and even of different parts of the same side The immobility of a portion of the walls of the chest, thus detected, may become under some circumstances a valuable sign The beating of the heart, after full expiration, is felt between the cartilages of the third and fifth ribs, and at the neighbouring part of the sternum. After 804 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. full inspiration, it is either quite lost, or felt as low as the sixth rib. When the lungs are extensively consolidated, even though the heart itself may be healthy, the impulse is sometimes felt to a considerable distance. Measurement. The modes of effecting measurement have been elsewhere described. (See page 208.) The object of the process is to detect differences in the dimen- sions of the two sides, or in those of the whole chest at different times. It should be recollected that the right side of the chest is usually rather larger than the left, owing probably to the greater development produced in the whole of that side by exercise, though the liver may also have some effect in causing the difference. The amount of difference varies with the degree in which the causes operate. On the average it is about half an inch. In left- handed persons it is said that the two sides are equal, or that the left is some- what larger. Care must be taken, in making comparative measurements, that the lungs should be in the same condition in reference to the respiratory movement; and, therefore, it may be best that the patient should hold his breath during the examination. Among other points ascertained by measure- ment, is the increase or diminution of fluids in the cavity of the pleura. Under this head may also be considered the measurement of the respiratory movements, and of the quantity of air respired. It is often desirable to know how, and to what extent, the motions of the thorax and abdomen are inter- fered with by disease; and diagnosis is aided, in several important points, by the decision of this question. In order, however, to have some standard of comparison, it is necessary to determine the mean amount of movement in health. In ordinary respiration in men, the walls of the chest are but slightly expanded; inspiration being mainly effected by the descent of the diaphragm. The forward movement of the chest, therefore, is very slight, while that of the abdominal parietes is considerable, and readily observable by the eye. In women, it is different; the thoracic movement being much more distinctly observable, and that of the abdomen less so. According to Dr. Sibson, the forward movement of the sternum, above the seventh rib, in a robust man, in ordinary healthy respiration, is from the fifteenth to the fourteenth of an inch, that of the abdomen about one-quarter of an inch. In forced respiration, these dimensions are greatly altered. An extreme in- spiration will advance the sternum from one to two inches; whde the greatest movement of the abdomen is from half an inch to an inch and a half. In the fullest possible inspiration the abdomen projects very little, because the ex- pansion is now effected mainly by the ribs, and comparatively little by the descent of the diaphragm. The expansion of the chest, as indicated by its circumference, in a healthy male adult, at the level of the sixth cartilage, in an ordinary inspiration during calm breathing, is on the average about one- quarter of an inch. In a forced inspiration it amounts to from one and a half to three inches, being somewhat greater on the right than the left side. The difference between the extremes of a forced inspiration and a forced expira- tion, varies from two and" a half to five inches. In the abdomen, in the greatest possible inspiration, the increase is only about one-quarter of an inch, being less than that which occurs in ordinary breathing; though, by a volun- tary effort of the individual, directing the inspiratory movement rather to the diaphragm than the ribs, the result may be very different. Any considera- ble deviation from the above measurements may be looked upon as suspicious, and should lead to further investigation. Two instruments have been invented which greatly facilitate the mensuration of the chest while in motion. One of these is the "chest measurer" of Dr. Sibson, the other the " stethometer" of Dr. Quain, the former of which indicates the change of diameter, the latter CLASS III.] MEASUREMENT. 805 that of circumference.* In relation to the measurement of the quantity of air respired, it is extremely difficult to arrive at any satisfactory results; and the reports of different experimenters have been so various and conflicting, that little reliance can be placed on them for practical purposes. An instru- ment, however, invented by Mr. Hutchinson, affords a very convenient method of measuring the amount of expired air; and some conclusions have been attained by means of it, which are not without practical value. An account of this^instrument, which is called the "spirometer," and of its application, is given in a note below, f * The "chest measurer" of Dr. Sibson consists of a small round case with two dial- plates, supported at the end of a rod, which at the other end is connected, in a manner to admit of free movement upward and circularly, with a second rod rising perpendicu- larly from a long narrow plate, upon which the body rests when examined. From the interior of the case projects a short movable rack, which, as it rises or falls, causes the index hand on the face of the dial to revolve in a circle, each revolution representing an inch of movement in the rack, and each subdivision the hundredth of an inch. When applied, the end of the rack is brought into contact with the surface of the chest or abdomen, the elevation or depression of which, at the point of application, is exactly measured by the movement of the rack, and, of course, by the change of the index on the dial. For a particular account of the instrument and its uses, the reader is referred to Dr. Sibson's paper, in the London Medico-Chirurgical Transactions (xxxi. 355). The stetkometcr of Dr. Quain is a simpler instrument. Upon the surface of a case re- sembling a watch, is a graduated dial with an index, moved by means of a silk cord a foot or more in length, that enters the side of the case. The instrument being applied by the fingers of one hand to any given point of the chest, the cord is carried over that part of the surface the movements of which are to be measured, or, if deemed advisable, quite round the thorax, and, being fixed by the other hand, acts with each expansion or elevation of the thoracic wall upon the index, a complete revolution of which indicates an extension of the cord, and consequently an increase in that part of the circumference measured, equal to one-fourth of an inch. The instrument and its uses are particularly described in the London Medical Gazette for January, 1851, (page 127), and in Braith- waite's Retrospect (Am. ed., xxii. 157).—Note to the third edition. Another instrument for measuring the expansion of the chest in respiration has been invented by Dr. G. Nelson Edwards, of London. It is a modification of the common callipers, in which the legs are continued beyond the joint, and made to act upon an index, which measures the amount of movement between the ends of the callipers. For a full description see the London Med. Times and Gaz. (Dec. 1856, p. 640).—Note to the fifth edition. f Mr. Hutchinson's spirometer, as modified by Dr. Pereira, consists essentially of a reservoir of water, in which is suspended an inverted glass receiver, so arranged that, by breathing through a tube entering into the receiver from below, this is made to rise in proportion to the amount of air admitted, which is measured by a graduated scale affixed to the upper end of the receiver. As each degree of the scale represents a cubic inch, it follows that the number of degrees through which the receiver rises indicate the number of cubic inches of air expired. From the various circumstances which modify respiration, it is almost impossible to measure with accuracy the results of that process as ordinarily performed. Rut the greatest amount of air that an individual can possibly expire, after the fullest possible inspiration, gives a certain measure of capacity which can be ascertained, and, being compared as found in the same individual under different circumstances, or in different individuals as nearly as may be under the same circumstances, may lead to inferences of some practical value. To this quantity Mr. Hutchinson gives the name of "vital capacity." Now, from the examination of a vast number of individuals. Mr. Hutchinson seems to have established the curious law, that the vital capacity is proportionate in health directly to the height of the body, without reference to the depth or breadth of the chest, or to its absolute capacity when at rest. It is, however, somewhat affected by the weight and the age of the individual, and allowance must be made for these modifying influences in forming any practical conclusions The mean vital capacitv for a man from five feet to five feet two inches, at a temper- ature of 00° was found to be 175 to 17D cubic inches. For convenience of calculation it may be stated at 174 cubic inches for the stature of five feet one inch. For every inch of increased height, eight cubic inches are to be added to the vital capacity. In reference to the effect of weight, it has been ascertained that the vital capacity in 806 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. SUBSECTION I. INFLAMMATION OF THE RESPIRATORY PASSAGES. Inflammation may occupy distinct portions of these passages, terminating in the same part in which it began, or it may affect several portions succes- sively or simultaneously, forming one continuous disease. Thus, we have inflammation of the nostrils, of the larynx, of the trachea, and of the bronchial healthy men is not materially altered below the mean weight; but is diminished in a certain ratio with any increase amounting to more than 7 per cent, above the mean. The mean weight of a man in England, from five feet to five feet one inch in height, is said to be about 115 pounds. For every additional inch of height, the mean increase of weight may be stated roughly at 5£ pounds. From these data the mean weight for any height above five feet may be readily ascertained. Add to this weight 7 per cent.; and then, for every additional pound, one cubic inch is to be deducted from the vital capacity. These are only approximations to the numbers which have resulted from positive experiments as presented by Mr. Hutchinson; but they are sufficiently near for practical purposes, and are useful on the score of simplicity of calculation. The effect of age is next to be considered. Up to 35 years, the vital capacity, accord- ing to the table of Mr. Hutchinson, is somewhat augmented with age, but not sufficiently so to render the increase an object of consideration. From 35 years to 65 there is a de- crease of 45 cubic inches, or exactly 1J cubic inches for every year. In estimating the vital capacity, therefore, this number must be deducted for every year above 35. With these data, the normal vital capacity of any individual may be readily estimated; and, if this considerably exceed the result given by the instrument, the inference drawn would be unfavourable as to the healthy condition of his respiratory function. General debility, muscular fatigue, rheumatism or other disease of the respiratory muscles, and various abdominal affections, as well as disease of the lungs, have the effect of lowering this capacity; and the decision as to the precise cause must be left to other modes of investigation. It is obvious that the spirometer affords an admirable means of estimat- ing any change in the capacity of the lungs of the same individual whether for better or for worse. To illustrate the operation of the above rules let a case be imagined, and the result deduced in accordance with them. What is the healthy vital capacity of a man five feet ten inches high, weighing 160 pounds, and 45 years of age ? Starting from 174 cubic inches, which is the vital capacity for the height of five feet one inch, and adding 8 cubic inches for each inch of stature, we shall have 246 cubic inches as the vital ca- pacity in reference to the stature alone. The mean weight at five feet one inch is 115 pounds, to which b\ pounds being added for every inch, gives the mean weight at 164J pounds, or less than 7 per cent, beyond the supposed weight. No allowance, therefore, is to be made on this score. The age being 10 years beyond the standard of 35, and 1£ cubic inches being the mean diminution for each year, 15 altogether are to be de- ducted from the 246 cubic inches, which represent the vital capacity in reference to height alone. There will then remain 231 cubic inches as the healthy vital capacity under the circumstances referred to, and as that which the spirometer should indicate. (See, for Mr. Hutchinson's paper, London Medico-Chirurgical Transactions, xxix. 137.) In using the spirometer, with the view of ascertaining the vital capacity, the individual should loosen his dress, stand erect, and then, having inspired to the utmost extent of his power, apply his mouth to the tube, and empty his chest as completely as possible into the receiver. (Note to the third edition.) Since the introduction of Mr. Hutchinson's spirometer into use, it has been found that various other influences materially vary the respiratory capacity, besides those for which allowances are made in the above statement. Thus, it is considerably lessened by a full stomach, and is therefore greater before a hearty meal than immediately after. Prof. Frederick Arnold, of Germany, says that modes of life and occupation have con- siderable influence; persons of sedentary habits, and unaccustomed to muscular exer- tion, having less capacity than the active and laborious, especially those much in the open air. Between the first class, and the latter section of the second there is an average difference of 25 cubic inches of capacity, other things being equal. The vital capacity also increases with the circumference and with the mobility ofthe chest; and if these are greater or less than the mean for a given height, allowance must be made. From the fifteenth to the thirty-fifth year of age, the capacity increases about 10 cubic inches. In women the capacity is proportionably less than in men. Certain CLASS III.] CORYZA. 807 tubes, constituting severally coryza, laryngitis, tracheitis, and bronchitis, and inflammation of all these parts successively or conjointly, as in catarrh. It will be most convenient to consider the first set of these complaints in the first place ; and, after the more local affections have been described, then to treat of such as embrace various parts of the structure, either at once or during their course. Article I INFLAMMATION OF THE NOSTRILS. In the nostrils we consider as included the neighbouring sinuses, as those of the superior maxillary and frontal bones, all of which are lined by con- tinuations of the same mucous membrane, and all are liable to become in- flamed, though the whole surface is probably seldom affected at once. I. ACUTE INFLAMMATION OF THE NOSTRILS, or CORYZA. Syn.—Cold in the Head.— Gravedo. Symptoms.—The first sensations are usually those of dryness, fulness, and tickling or other irritation in the nostrils, with sneezing. These are in gene- ral soon followed by a copious discharge of a thin, colourless, acrid fluid, which still further irritates the membrane, while it often inflames and even exco- riates the skin about the nasal orifices, and on the upper lip. The nostrils are at this time not unfrequently either partially or wholly closed by the tume- faction of the inflamed membrane, which causes the voice to assume a nasal tone. There is often a considerable degree of dull pain or aching, with burn- ing heat in the nasal passages ; and now and then severe stinging sensations are experienced from the irritation of the acrid fluid. The eyes become red and watery, either from sympathy, or by the continuous extension of irritation along the lachrymal passages; and sometimes these passages appear to be closed, so as to occasion an overflow of the tears. A similar extension of the disease to the frontal sinuses produces pain in the forehead. The maxillary sinuses are sometimes involved, with consequent pains in the face; and hard- ness of hearing in a greater or less degree is not uncommon, from swelling and closure of the eustachian tubes. Even the external parts occasionally participate in the inflammation, and the nose and cheeks are swollen and tender. The sense of smell, and in a less degree that of taste, are almost always blunted or lost. In many instances, the constitution does not seem to sympathize with the local affection; the pulse and skin remaining in their ordinary state, and the appetite unimpaired. Very frequently, however, febrile symptoms make their appearance, especially when the inflammation is of a high grade, and affects the whole of the nasal passages. Chilliness and pains in the limbs are followed estimates have been made for these modifying influences by Dr. Arnold, by which the healthy vital capacity of any individual may be estimated with an approach to accuracy. (See B and F. Med.-Chir. Rev., July, 1856, p. 61.) But, with all due allowances for these known influences, there are so many exceptions to the general rule, as very much to vitiate the results obtained by the spirometer, from the want of an accurate and re- liable standard • so that the instrument is more useful in comparing an individual with himself at different times, and thus showing the progress or decline of disease, than in enabling us to form a just opinion of a case when examined for the first time. (Note to the fifth edition.) 808 LOCAL DISEASES.---RESPIRATORY SYSTEM. [PART II. by a hot skin, excited pulse, furred tongue, loss of appetite, and severe head- ache. The fever sometimes shows a tendency to exacerbations and remissions. The complaint usually attains its height in three or four days, after which the symptoms begin to subside. The uneasiness in the nostrils and adjoining parts diminishes; the secretion becomes less copious, thicker, more opaque, and less acrid; and sometimes assumes a yellowish, or greenish-yellow, puru- loid appearance; the fever gradually subsides ; and the recovery is usually complete in from five to seven days, unless the disease is kept up by improper management, or renewed by a repetition of the cause. In this case, it some- times becomes chronic, and may then run on for weeks, months, or years. In a few instances, it retains a sort of acute character, with a thin acrid dis- charge, for a considerable time, probably in consequence of fresh attacks before the old have ceased. This watery secretion, so characteristic of the disease, and which has given it the name of coryza, is not invariably present; the inflammation being sometimes dry at the commencement, and remaining so until thick mucus, or muco-purulent secretion takes place. Tery frequently the inflammation travels downward into the bronchial tubes, constituting catarrh; but frequently also it does not extend beyond the nostrils, and immediately adjoining parts. Sometimes it affects one part only, being confined to a portion of the nostrils, or to one of the sinuses. When it affects the frontal sinus, the symptoms are heaviness and pain in the middle of the forehead, extending frequently to the superciliary ridges and the eyes, with a disposition to more copious discharge from the nostrils wrhen the pa- tient rises, after having for some time maintained the horizontal posture. It is more especially to this condition of the complaint that the name of gravedo has been attached. In the maxillary sinus, the disease is usually indicated by pain and tenderness, with some swelling of the corresponding cheek, a similar condition of the gums on the affected side, and soreness of the teeth. A copious discharge from the nostrils, when the patient turns upon his side, is another characteristic symptom. Sometimes, however, the orifice into the nostrils is closed by inflammation, which, if not relieved, may end in abscess of the antrum, requiring the aid of the surgeon. Coryza is sometimes regu- larly intermittent. In new-born or very young infants, this disease is attended with some peculiar effects which require notice. In consequence of the stop- page of the nostrils, they have great difficulty in sucking, and may suffer from the want of nourishment. On attempting to take the breast, they sometimes become black in the face from suspended respiration, and are said occasion- ally to be thrown into convulsions by the same cause. In its severest forms, the complaint is asserted to have sometimes proved fatal. Another pecu- liarity in children is the tendency to exudation of coagulable lymph from the membrane, which forms solid layers upon the surface, as in diphtheritic in- flammation of the fauces, which this affection sometimes accompanies. Such cases are always serious, and not unfrequently fatal, from the extension of the same kind of inflammation to the larynx or lungs. They may be known by the fetid odour of the discharge, the occasional ejection, in coughing or sneezing, of portions of the false membrane, and the appearance of the ex- udation either near the anterior nasal orifices, or in the fauces. Causes.—The most frequent exciting cause of coryza, beyond all compari- son, is the partial application of cold, as to the back of the head or neck, to the feet, &c.; and the effect is especially apt to be produced after perspira- tion from heat or exertion. Hence, the complaint is most common in winter. In some instances, it is probably induced by the breathing of a warm air after previous exposure to cold, in the same manner as chilblains. Some persons are much more liable to be affected in this way by cold than others. This greater susceptibility is frequently ascribable to a want of the habit of expo- CLASS III.] CORYZA. 809 sure ; but it is often also constitutional, and inexplicable. Individuals are occasionally met with, who are liable to attacks of the complaint periodically, at a certain date, once a year, without reference to the state of the weather at the time. Others are attacked at the commencement of winter, and are scarcely entirely free from the complaint until warm weather returns. Coryza is also frequently epidemic, being a very general attendant upon the influ- enza. It is very common at the beginning of measles, and sometimes accom- panies other exanthemata in their earlier stages, especially smallpox, and scarlet fever. Occasionally it is produced by the direct application of acrid vapours, or irritating powders, to the nostrils. Treatment.—Most cases of this disease are so mild as not to require me- dical treatment, and scarcely to interrupt the avocations or pleasures of the patient. Even in those in which the physician is consulted, the gentlest measures only are in general required. When there is no fever, it is usually sufficient to direct a dose of sulphate of magnesia, abstinence from animal food, and the avoidance of exposure to cold or wet. Should the patient be under the necessity of leaving his house, he should clothe himself warmly, take care especially to keep his feet dry, and protect his nostrils by a hand- kerchief against the cold. Should the symptoms be more severe, and fever present, the treatment, in addition to the above measures, may consist of hot pediluvia made more stimulating by the addition of common salt or mustard, and the use of refrigerant diaphoretics, as citrate of potassa, acetate of am- monia, nitre, and tartar emetic, variously combined to suit the circumstances of the case. The patient should be confined to bed, and should lie with his head raised by pillows. When there is much headache, with a full strong pulse, and the symptoms have not yielded to the above treatment, with addi- tional purgation by one of the neutral salts, a little blood may be taken by the lancet from the arm, or, in case of inflammation of the frontal or maxillary sinuses, by leeches from the forehead or cheek, or from within the nostrils. Various measures have been recommended to relieve the local symptoms, which are often very distressing. Dr. Physick was in the habit of advising the frequent inhalation, through the nostrils, of the vapour from a mixture of laudanum and Hoffmann's anodyne. Mr. Harrington, a dentist of Philadel- phia, has found the affection, in several instances, to disappear at once and completely under the inhalation of chloroform. (Med. Examiner, N. S., iv. 295.) A lump of camphor held near the nostrils sometimes affords relief. I knew an individual who derived prompt relief from snuffing up powdered cloves. Powdered cubebs have been recommended in the same way. Steam- ing with the vapour of hot water, snuffing powdered gum arabic up the nose, the injection of oleaginous liquids with some narcotic ingredient, and the direct application of the vapour of acetic acid, are also among the measures occasionally resorted to. M. Deschamps has found a solution of extract of opium, made in the proportion of about a grain to a fluidounce of water, and drawn into the nostrils by inspiration, promptly effectual. One nostril is to be closed with the finger, and the liquid drawn in through the other, until felt to be about to enter the fauces, when it is to be allowed to flow out again. The application may be made every two hours if necessary; but seldom requires to be more than once repeated. (Journ. de Pharm. et de Chim xi 370.) Dr. J. H. Douglas, of New Orleans, cures the severest coryzas by causing the patient to snuff a little laudanum up the nostrils, tak- ing care that none is swallowed, and following this measure by a brisk ca- thartic (N 0 Med. and Surg. Journ., ix. G04.) Another mode of using opium is to heat a grain or two on an iron plate held over a lamp, and to snuff up the fumes as they arise. Dr. John A. Lockwood has found a solu- tion of nitrate of silver, containing eight or ten grains in the fluidounce, 810 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. applied by means of a camel's-hair pencil to the mucous membrane of the nostrils, at the beginning of the attack, a sovereign remedy. (Am. Journ. of Med. Sci., N. S., xviii. 21.) Injections of a solution of sulphate of zinc, of the strength of two or three grains to the fluidounce, have also been used. Still another plan is to close the external nostrils entirely by strips of some adhesive plaster, so as to prevent the access of air from without. The pa- tient will derive comfort from applying some stiff, mild, fatty matter, as suet or spermaceti cerate, to the upper lip and nasal orifices, in order to pro- tect them against the irritating secretion. He should employ a soft linen handkerchief. Dr. Williams strongly recommends an almost total abstinence from liquids, as an effectual cure for coryza. The secretion is arrested by the deficiency of the watery portion ofthe blood, and the inflammation speedily subsides, when no longer aggravated by the discharge. The coryza begins to disappear at the end of a day, and in the course of thirty-six or forty-eight hours the cure is generally completed, so that, after that time, the patient may resume the moderate use of drinks. After the commencement, and before the comple- tion of the cure, a single copious draught may bring back all the symptoms. When there is fever, Dr. Williams precedes his dry plan by an aperient and an antimonial. If care be taken to keep the surface warm, exercise in the open air is rather beneficial than otherwise by promoting secretion from the skin; and any other dry method of favouring the healthy secretions contri- butes to the cure. The food should not be heating or saline so as to excite thirst, and the solid matters used may be moistened with liquids. Though "total abstinence from liquids is most effectual, yet taking about a teaspoon- ful of tea or milk with breakfast and the evening meal, and a wineglassful of water on going to bed, does not prevent the success of the plan, whilst it diminishes its discomfort." As, according to Dr. Williams, the plan pro- duces no injurious effects, the patient may well be allowed to choose between its discomfort, and that of the disease under ordinary treatment. When, after the subsidence of the acute symptoms, the complaint continues obstinate, with a copious mucous or muco-purulent discharge, a speedy cure may sometimes be effected by a return to a nourishing food, and free exercise in the open air. Sometimes violent exercise will of itself throw off an attack, in its earlier stages, by promoting perspiration. If the complaint have the intermittent form, it may be readily cured by sulphate of quinia. In infantile cases, it is necessary to feed the child by means of a spoon. Relief may sometimes be afforded by holding a sponge wet with warm water upon the nose. Dr. C. D. Meigs recommends strongly, as a very effectual remedy, to cover the head with a closely fitting flannel cap. ( Trans, of Col. of Phys. of Phil, iii. 63.) In severe cases, when the head is threatened, it will be proper to apply leeches, to administer a calomel purge, and to blister behind the ear, or at the back of the neck. In pseudo-membranous cases, it may become necessary to apply a solution of nitrate of silver by means of a camel's-hair pencil to the parts, or to blow powdered alum up the nostrils. When an individual is subject to the complaint in its severer forms, and especially when previous experience suggests that it is likely to be the pre- cursor of a protracted disease of the chest, it is important to be able to set the attack aside at its very commencement. This may often be done by a full dose of opium. More than forty years ago, the author heard this plan suggested by the late Dr. Chapman, of the University of Pennsylvania, in his lectures, and he has had frequent opportunities of verifying the statements of Dr. Chapman as to its efficacy. From one to two grains of opium, or from ten to twenty grains of Dover's powder may be given at bedtime; and the CLASS III.] OZ.EXA. 811 patient will often awake in the morning free from the disease. An aperient may sometimes be advisable to correct the constipating effects of the opium. Another mode of obtaining the same end is to produce a copious diaphoresis by soaking the feet in hot water, and administering copious draughts of some hot herb-tea, as of balm, sage, horehound, &c, at bedtime. The plan will be still more efficacious, if some nauseating diaphoretic be added, as ipecacu- anha or tartar emetic. A hot infusion of eupatorium combines these advan- tages. If it operate as an emetic, the success will be still more certain. Care, however, must be taken by the patient not to expose himself to the cold air next day. I have known severe pneumonia result from a neglect of this pre- caution. Sometimes a rich supper, with a due accompaniment of stimulants, will set aside a commencing coryza; but the plan is hazardous ; as, if not successful, it may cause a great aggravation of the symptoms, and render serious what would otherwise have been a trivial disease. It is very desirable to be in possession of a prophylactic against this trou- blesome affection. I know of none so effectual as the daily habit of washing the head and back of the neck in very cold water ; or, where wet feet are the ordinary cause, to dip them in ice-cold water every morning. It is best to begin with this plan in warm weather, and persevere through the winter. The cold shower-bath is also recommended. II. CHRONIC INFLAMMATION OF THE NOSTRILS, or OZ^ENA. Chronic inflammation of the nostrils is sometimes dry, being attended with little if any increase, or even with a deficiency of the usual amount of secre- tion. There is a feeling of uneasiness, heat, and stiffness in the nostrils, which are often closed, on one or both sides, from the thickening of the mem- brane, so as to impede the passage of air; and this is generally the greatest inconvenience experienced. When it affects the posterior nares, there is a frequent disposition to clear them out by sudden and forcible inspirations of air through the nostrils. In other cases, there is a copious secretion of a whitish somewhat opaque mucus, or of a yellowish muco-purulent matter, with little uneasiness. Again, the discharge is occasionally quite purulent, and of a yellowish or greenish colour, or it is sanious and frequently tinged with blood ; and, in both cases, has an odour generally more or less disagreeable, and sometimes intolerably offensive. In this form, the disease is called ozsena, and is one of the most obstinate and disagreeable affections which the physician has to encounter. In some instances, the breath of the patient is so revoltingly offensive as almost to isolate him from society, and to render him an object of disgust even to himself. There is reason to believe that this affection sometimes occurs without any violation of the integrity of the mucous mem- brane ; but more frequently it is associated with ulceration, and sometimes with caries of the bones, or necrosis. In the latter case, pieces of bone some- times escape with the pus or sanies. Large solid flakes of excessively offen- sive matter are occasionally discharged along with blood. These are probably plastic exudation, or hardened mucus, from the surface of the ulcers. The sense of smell is almost always much impaired, if not lost. Whatever may be the form of chronic inflammation of the nostrils, it often runs on for months or years, sometimes even for many years, and, in the form of oza?na, is, in certain old cases, quite incurable. Billard relates the case of an infant, of seventeen months, who died ofthe disease after a year's illness •the immediate cause of death being suffocation. Causes.__In many instances, the chronic disease results from a continua- 812 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. tion or frequent repetition of the acute. It is often also original. The cause is generally obscure. In some cases, it depends on foreign bodies in the nos- trils, acting as nuclei for the deposition of" solid matters from the secretion. In others, it appears to be associated with a scrofulous or gouty diathesis, with a tendency to scaly cutaneous eruptions, or with that disordered state of the digestive organs which so often gives obstinacy to chronic inflammation of the fauces. In the form of oza?na, when not ulcerous, it may depend upon some impediment to the free discharge of mucus from the nostrils or sinuses, which, consequently accumulating, becomes putrid and excites inflammation. In ordinary chronic inflammation, the accidental retention of the secretions may thus superadd the putrid character of oza?na. The offensiveness of the discharge, however, in some cases, cannot be traced to this cause, and is quite inexplicable, except upon the vague supposition of peculiar morbid constitu- tional tendencies. When associated with ulcers, it is most frequently de- pendent on a syphilitic, scrofulous, or scorbutic taint. Treatment.—In simple chronic inflammation, cures may very often be effected by the injection into the nostrils of solution of acetate of lead, sul- phate of zinc, sulphate of copper, or nitrate of silver. I have usually prefer- red sulphate of zinc, beginning with two grains to the fluidounce of water, and rapidly increasing, as the nostrils are found to bear the impression, to ten, fifteen, or even twenty grains to the fluidounce. The injection should be repeated daily or twice a day, and continued perseveringly for months if necessary. It is important that, by a proper direction of the instrument, and position of the head, the fluid should be made to reach the seat of disease, whether this occupy the whole of the membrane, or, what is much more fre- quent, some comparatively small portion of it, in the nasal passage or the sinuses. Sometimes the part can be reached by a camel's-hair pencil, in which case, this is the best means of applying the solution, as the sound por- tions of the nostrils may thus be avoided, and a stronger solution may be em- ployed. When the discharge is offensive, solutions of creasote, or of chloride of soda, potassa, or lime, will do much towards correcting the fetor, and may prove useful as alteratives to the mucous surface. Dr. Jackson, formerly of Northumberland, informed the author that, in a case of this complaint, he had found an injection of Fowler's solution, much diluted, completely to re- move the fetor, and much to diminish the discharge. Caution, of course, is necessary not to allow the solution to be swallowed. Sometimes advantage will result from the mere washing out of the retained mucus, two or three times daily, by injections of warm water. When an ulcer exists, and is within reach, it maybe treated by the direct application of the solid nitrate of silver, or by a saturated solution applied by means of a camel's-hair pencil. Inhala- tions through the nostrils of diluted chlorine, and of the vapours of creasote, tar, and vinegar have been recommended. Blisters often repeated behind the ears, or at the nape of the neck, or on the arm, and issues or setons be- tween the shoulders, may sometimes prove useful, especially in cases which may have followed the disappearance of cutaneous eruption. Remedies should also be addressed to the constitution. Their character must depend upon the peculiar diathesis, or general morbid condition which may exist. Syphilis, scrofula, and scurvy have their appropriate treatment, which should of course be applied when these constitutional affections exhibit themselves in this form. Even when the complaint can be traced to no par- ticular morbid predisposition, still, good may occasionally be expected from alteratives, such as mercury, iodide of potassium, arsenic, and compound de- coction or syrup of sarsaparilla. Arsenic is especially applicable, when the disease has followed, or is associated with scaly eruptive affections of the skin. Tonics, and, in general, measures calculated to give vigour to the system, will CLASS III.] ACUTE LARYNGITIS. 813 be likely to prove useful. Among these may be mentioned a wholesome nu- tritious diet, exercise, fresh country air, sea bathing, long journeys, and a sea voyage. Article II INFLAMMATION OF THE LARYNX, or LARYNGITIS. The larynx, though most commonly involved in inflammation of other parts of the respiratory passages, is sometimes exclusively, and often chiefly affected. By some English writers laryngitis is considered as among the most danger- ous, perhaps the most dangerous, of inflammatory diseases. But they restrict the term to a highly aggravated form of laryngeal inflammation, excluding altogether the milder forms of that affection. With as much propriety might we restrict the name of bronchitis or pneumonia to the very highest grades of these complaints, and then proclaim them as eminently dangerous. The truth is, that inflammation of the larynx is not uncommon, and is in general very manageable ; though in a few instances, when very intense, or attended with an unusual degree of serous effusion into the submucous tissue, it be- comes very alarming and even fatal. Its great danger, under these circum- stances, is owing to the narrowness of the passage through the chink of the glottis, which is closed by the swollen state of its walls, aided probably by spasm of the muscles, against the admission of air; so that the patient dies of true asphyxia. There is no other portion of the respiratory passages, in which an equal extent of inflammation is capable of producing the same fatal results. As in most other inflammations, the disease may be acute or chronic. I. ACUTE LARYNGITIS. Of the acute form, several modifications exist, according to the grade of action, the part attacked, or the character of the extravasated matter. Some- times it is very superficial, affecting only the mucous tissue, and perhaps only the surface of the membrane. Sometimes it extends to the submucous cel- lular tissue, involving that and the mucous membrane at the same time, thus greatly increasing the tumefaction, and consequently the danger. Again, the inflammation, which is usually attended with mucous secretion, occasionally gives rise to an exudation of coagulable lymph, which lines the larynx with false membrane. Finally, the submucous tissue may be swollen simply as in ordinary acute inflammation, or may be distended with serum in a degree greatly disproportionate to the grade of inflammatory action, presenting in- deed an edematous condition. These varieties may be conveniently con- sidered under the three divisions of 1. mucous laryngitis, affecting the mu- cous membrane especially, and attended with mucous secretion; 2. sub- mucous laryngitis, in which the submucous tissue is also involved, and sometimes chiefly so, as in the proper edematous variety; and, 3. pseudo- membranous laryngitis, which is characterized by the formation of false membrane These are dangerous in the order in which they have been men- tioned But it must not be supposed that they are always distinct. On the contrary they often run together, or differ only by almost insensible shades, so that they cannot be distinguished by the symptoms. _ 1 Mucous Laryngitis.—In its mildest form, this is marked by a slight hoarseness without pain or difficulty of respiration, and often with little or no comrh unless complicated with catarrh. It passes oft in a few days, frequently without medical interference. When of a somewhat higher grade, in addition to the hoarseness, there is a feeling of soreness in some part of the larynx, 814 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. together with tightness or stricture, a dry husky cough, and often a slight difficulty of inspiration. If the fauces are examined, they will frequently be found in a greater or less degree reddened. Under proper treatment, these symptoms speedily subside. Not unfrequently the inflammation descends into the bronchia, with relief of the laryngeal affection. But, if neglected, it may take on the character of a still higher grade of laryngitis. In this, the voice is from the beginning very hoarse or stridulous, and, in the progress of the disease, is almost or quite suppressed, so that the patient cannot speak above a whisper. There is almost always pain, sometimes severe, sometimes moderate, increased by speaking and coughing, and occasionally by external pressure. The patient often has the sensation as of a foreign body in the larynx. Inspiration is difficult, and often stridulous or tightly sounding, while the patient feels a distressing constriction of the throat, and exhibits some anxiety or apprehension about his ability to get breath. The cough is hoarse or muffled, and of a peculiar character, commencing as it were in the larynx, and obviously intended to remove some obstruction at that point. It is either dry, or attended with the discharge of a little tough mucus. In some instances, it comes on paroxysmally, and is almost convulsive. There is often some difficulty in swallowing, arising from coexisting inflammation of the fauces, from the pressure of the alimentary bolus upon the tender larynx, or simply from the motion of this structure in deglutition. Paroxysmal at- tacks of great oppression and dyspnoea are sometimes experienced, arising from spasm of the muscles of the glottis, such as occurs in croup. There is generally some degree of fever, which may have come on simultaneously with the local symptoms, or not until they had existed for some time. It cannot be doubted that there is in these cases considerable swelling of the mucous membrane; and it is not improbable that the submucous tissue is often in some degree involved. Redness of the epiglottis may generally be seen by strongly depressing the base of the tongue, and inducing the patient to cough, or make the motion of swallowing. The attack gradually subsides under proper treatment, and goes off in from four to six days, sometimes by mere resolution, but more frequently with a secretion of mucus, which is at first transparent, but gradually becomes thick and opaque, if not purulent. Should the inflammation travel into the lungs, severe bronchitis is apt to ensue. 2. Submucous Laryngitis.—Edematous Laryngitis.—Cynanche La- ryngea.—This differs from the preceding rather in degree than in cha- racter. It may be considered as the highest grade of acute laryngitis, extending to the subjacent areolar tissue. It is not many years since this was first noticed as a distinct disease. Washington is supposed to have died of it; and his case is said to have been the first recorded in detail. According to Cheyne, the disease was not generally understood until after the publication of a paper by Dr. Farre, in the third volume of the Medico- Chirurgical Transactions. When originating in the larynx, and not the result of some direct violence, this form of laryngitis usually commences with a distinct chill, or with chil- liness alternating with flashes of heat, which is followed by fever, with a full strong pulse, a hot skin, aud flushed face. At the same time, some soreness of the throat is felt, the voice is hoarse, and a sense of tightness, stricture, or pressure is experienced, as if there were some mechanical impediment in the larynx. To remove this the patient coughs, but brings up nothing, or only a little clear viscid mucus. The cough is painful, and its sound is harsh and stridulous. Great difficulty of breathing soon comes on. The inspira- tion is prolonged, wheezing, whistling, or otherwise sonorous, and requires a considerable effort on the part of the patient. The expiration is performed more easily and silently; as the swollen membrane of the glottis acts like a CLASS III.] ACUTE LARYNGITIS. 815 closing valve against the entrance of the air, but opens readily for its exit. Lpon examining the fauces in the manner described above, the epiglottis may sometimes be seen of a bright or deep-red colour, erect, and much swollen, so as to be unable to descend and close the glottis during deglutition. The external parts about the larynx are also often much swollen, though not in- variably so._ Deglutition is difficult, partly from inflammation of the fauces, but chiefly in consequence of the swollen state of the epiglottis, which pre- vents it from closing accurately over the orifice of the windpipe, and thus allows the substances swallowed to enter the glottis, where they excite in- tense irritation, and give rise to vehement paroxysms of coughing, with the most distressing dyspnoea. Dr. Watson relates a case in which, after laryn- gotomy, a portion of anything swallowed appeared immediately at the wound. (Lect. on Princip. and Pract. of Med.) Should the case continue to advance, all the symptoms are aggravated. The voice becomes wheezing or whispering, or is quite extinguished; the cough of which the sound is scarcely above the breath, is agitating, often convulsive, and very painful; inspiration is exceedingly difficult, and is ac- complished only after violent efforts, with great distress and anxiety, and a feeling as of impending suffocation. The patient is in general extremely restless, sometimes starting up suddenly in bed, walking about the chamber, putting his hands to his throat, showing the greatest eagerness for fresh air, and expressing in his countenance an almost fearful anxiety, apprehension, and distress. He is unable to sleep longer than a few minutes at a time, being roused by the necessity for voluntary effort to get breath. The blood now begins to exhibit signs of deficient aeration, which rapidly increase in intensity. The lips have a bluish or purplish colour; the face becomes of a livid paleness ; and a dark circle forms about the eyes, which are sometimes protruded and watery. The surface is cool, and the pulse frequent, irregular, threadlike, and very feeble. In the midst, however, of this exhaustion, the patient makes the most violent efforts ; his shoulders rise ; his whole chest heaves; his countenance assumes a staring and ghastly expression; his skin is bathed in a cold sweat; and he sinks at last into a drowsy or comatose state, often preceded by delirium, and quickly followed by death. The fatal effects depend upon the want of air to support respiration, and the consequently carbonated and poisonous state of the blood, wliich no longer affords the due stimulus to the vital functions. Sometimes this con- dition of the blood is sufficient to cause death, even though respiration should be restored. Thus, patients not unfrequently die in the intervals of violent dyspnoea, when air is no longer excluded from the lungs, and some- times even after the operation of tracheotomy, though the lungs themselves are not embarrassed. The nervous system is unable to recover from the depressing influence of the black blood. Death may, therefore, occur either suddenly, from complete closure of the passage; or gradually from a partial and insufficient supply of air, causing a change of blood, the effects of which a subsequent return of respiration cannot always obviate. The disease is very rapid ; generally, when fatal, ending in from three to five days, and sometimes much sooner. Death has been known to occur in seven hours. Sometimes, however, the complaint is protracted for several weeks. Its duration depends in general upon the degree of internal tumefac- tion in the larynx, though it is probable that life is sometimes suddenly ter- minated by the supervention of spasm of the glottis. I have seen a case, in which spasm of this kind recurred frequently at short intervals, each time attended with complete suspension of respiration, and partial insensibility from asphyxia, during the relaxation of which, air again entered the chest, 816 LOCAL DISEASES.---RESPIRATORY SYSTEM. [PART II. and thus prevented immediate death. This case ultimately recovered under copious depletion, and tobacco cataplasms. Occasionally the attack is very sudden; the dyspnoea and all the other bad symptoms occurring in the course of a few hours. In other cases, it is gra- dual. The disease varies also much in the grade of inflammation. Some- times this is very violent; sometimes it is comparatively moderate, and the danger depends rather upon a copious serous effusion into the submucous tissue than ordinary inflammatory tumefaction. Cases of the latter kind are distinguished by the name of edematous laryngitis, or oedema glottidis. The effusion, in these cases, is chiefly within the folds of membrane extending from the epiglottis to the aritenoid cartilages, and, by the swelling produced, acts as a kind of valve, which closes the chink of the glottis upon an attempt at inspiration. There is little pain in the throat, or tenderness upon pres- sure, and little or no febrile disturbance. If the epiglottis can be seen, it is observed to be much swollen, but rather pale or livid than of a bright- red colour. The symptoms, however, arising from closure of the rima glot- tidis, are not less urgent, and the disease is perhaps even more fatal, because it does not so well tolerate antiphlogistic treatment. Cases are said to have occurred, in which this oedema was strictly dropsical; but such cases are, to say the least, exceedingly rare. In most instances, the effusion undoubtedly depends upon a low grade of inflammation ; and the peculiar result is pro- bably owing in general to peculiarity of the constitution or of the blood, predisposing to serous effusion under inflammatory action. Dr. Stokes says that this variety of laryngitis is sometimes consequent upon the inflammatory swelling in the vicinity of the parotid, which occasionally follows continued fever. It seldom if ever occurs in children, in whom the areolar tissue about the glottis is not so loose as in adults. In all its varieties, the disease may exist either alone, or in connection with inflammation of the fauces and tonsils, of the trachea, or of the bronchial tubes. The diagnosis is sometimes a point of much importance. It is very neces- sary that the complaint should not be confounded with diseases ofthe chest, which are sometimes attended with severe dyspnoea, and similar constitutional symptoms. But, in the latter, either the disease is chronic, or is accompanied with such obvious symptoms of pectoral disorder that there can scarcely be room for mistake, if due examination be made. Besides, in affections of the larynx, the change of the voice, the feeling as of a foreign body in the throat, the laryngeal cough, the seat of pain, tenderness, and constriction, the great difference between the facility of inspiration and expiration, and the results of local inspection, point beyond all doubt to the true seat of disease. Some of the French practical writers speak of the introduction of the finger into the posterior fauces, and the perception of a cushion formed by the tumefac- tion of the border of the glottis (Valleix, Guide Med. Prat., 2e ed., i. 240); but this mode of examination must be difficult, and might possibly aggravate the inflammation. Aneurism of the aorta, by pressing on the windpipe, has given rise to symptoms which have been taken for those of laryngitis ; but auscultation would render such a mistake impossible. Abscesses near the larynx may sometimes simulate laryngitis so far as to lead, upon superficial examination, to an erroneous diagnosis; but a close inspection of the parts would correct the error, and it is only necessary that the attention of the practitioner should be awake to its possible occurrence. To one of the forms of croup, laryngitis bears a close analogy; but, in the former, spasmodic con- traction of the muscles of the glottis, in the latter, swelling of the lining membrane or the parts beneath it, is the prominent and characteristic phe- nomenon. More will be said upon this subject under croup. With mere spasm of the rima glottidis, unconnected with inflammation, it is scarcely CLASS III.] ACUTE LARYNGITIS. 817 possible to confound it, even leaving out of consideration the fact, that this affection is rare in adults, and confined chiefly to hysterical women. This form of laryngitis is considered by many writers as exceedingly fatal. By far the larger proportion of persons attacked with it are thought to perish. But it is very certain that individuals, attacked with symptoms in all appear- ance identical with those of submucous laryngitis, often recover. It is true that they cannot be positively proved to have had effusion in the submucous tissue, as the evidence of dissection is wanting. Judging from my own ob- servation, I should say that, when the disease makes its attack in the form of open and decided inflammation, in a person of tolerably vigorous constitution, and not previously labouring under chronic disease of the larynx, it may generally be cured, if attacked in its early stages, before the powers of the system have begun to give way under the depressing influence of the black blood. After this deterioration has commenced, the chances of saving the patient are very much diminished. Of the cases published a large propor- tion have proved fatal; because, in consequence of the difficulty of adducing positive proof of the character of the affection from the symptoms alone, it is chiefly the fatal cases that have been brought before the public. When the disease supervenes upon chronic laryngitis, as not unfrequently happens, it may be considered as extremely dangerous ; as too little vigour of system remains to support the requisite treatment. For the same reason, it is more than ordinarily dangerous in its edematous variety, which is most likely to occur in persons of feeble health. 3. Pseudomembranous Laryngitis.—This is exceedingly rare in adults. In severe cases of inflammation of the larynx, patches of coagulable lymph may sometimes be found upon the surface of the mucous membrane after death ; but these are not sufficiently extensive to be of themselves a serious source of danger. Sometimes an extension to the larynx of a pseudomem- branous condition of the fauces has taken place in adults, with fatal results; but even such cases very seldom occur, so that many practitioners in exten- sive business have probably never seen an instance. In children the disease is not uncommon, and in them it constitutes a variety of croup. To the article upon that disease the reader is referred for all that is deemed requisite to be said upon this form of laryngitis. (See Croup.) Besides the forms of acute laryngitis above described, another has been noticed in which the perichondrium appears to be the seat of the inflamma- tion. It is very rare, but has been known occasionally to attend or follow smallpox and typhoid fever; and to occur originally from direct injury, and exposure to cold. I know of no symptoms by which it could be certainly distinguished during life. After death, pus has been found bathing the car- tilaginous surfaces. Appearances after Death.—The mucous membrane lining the larynx is gorged with blood, softened, and thickened, while the subjacent cellular tissue is distended with bloody serum or a sero-purulent fluid. This tumefaction affects especially the epiglottis, and the upper part of the larynx, extending often no further than the ventricles. It seldom reaches the trachea, of which, however the lining membrane often shows an increased vascularity. The thickening is so great about the glottis, that the chink is almost closed, so that when held up to the light only a few rays can penetrate through it. The surface of the membrane is usually covered with mucus, and sometimes ex- hibits patches of coagulable lymph, which is also occasionally found effused in the submucous tissue. In the edematous variety, there is little injection of the mucous membrane, but great sweUing, in consequence of the effusion of serum beneath it. . # (jauses,__The most frequent cause of laryngitis, in all its forms, is proba- VOL.I. 52 818 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. bly partial exposure to cold, or to cold and wet, especially when in a state of perspiration from heat or exercise. There is in some individuals a peculiar predisposition to be affected by this disease ; so that when any general cause of inflammation acts, it is almost certain to affect the larynx. Persons simi- larly predisposed to tonsillitis, are said to be also peculiarly susceptible to laryngitis; the force of the morbid influence falling sometimes on one part, and sometimes on the other. A continued, frequent, and powerful exertion of 4he voice sometimes produces the complaint, and often predisposes to it Other causes are such as produce direct injury to the larynx. Among these are scalding water or corrosive liquids, which an individual may accidentally attempt to swallow; flame or hot air inhaled during exposure to fires; cor- rosive irritating gases, vapours, or powders taken in with the inspired air, and arrested in some measure at the glottis; the unskilful insertion of in- struments ; and external violence. The author has witnessed a very severe case resulting in a child from smelling at a bottle of chlorine. Another source of the disease is the propagation of inflammation from neighbouring parts. Inflammation of the fauces is very apt to extend to the larynx, and to retain in the latter the character which it had in its original seat. Thus, if confined to the mucous membrane in the fauces, it is apt to be similarly limited in the larynx; if pseudomembranous in the former, it is also pseudo- membranous in the latter; if submucous in the one, it retains the same re- lative position in the other. Hence, when tonsillitis is propagated to the larynx, the disease sometimes assumes the worst forms of submucous laryn- gitis. Mercurial stomatitis, according to Cheyne, sometimes extends into the larynx. Erysipelas, and the sore-throat of scarlet fever, sometimes prove fatal by reaching that structure, and giving rise to submucous or pseudo- membranous inflammation. Measles, catarrh, and smallpox also occasionally give rise to some form of laryngitis. The affection occurs as an accompani- ment or consequence of typhoid fever. Aneurism of the aorta may produce it, by the propagation upward of the bronchial inflammation which it causes. Cheyne considers intemperance as a predisposing cause of the complaint. It is said that the disease is most common in middle and advanced life, and very rare in infancy. This is true of the submucous variety. The other forms of laryngitis are not uncommon in the young; but in these they are apt to assume the form of croup. Treatment.—In slight cases, a dose of sulphate of magnesia, a vegetable diet, and, if the weather be cold or damp, confinement to the house for one, two, or three days, are the only remedies required. Should the fauces, upon examination, be found reddened, a solution of alum may be employed twice a day as a gargle. These simple measures will often avert a serious increase of the inflammation, or its propagation to the bronchia. When the disease is more severe, with febrile action and a strong pulse, blood should be taken from the arm once or oftener, in quantities proportion- ate to the violence of the symptoms, and the apparent vigour of the patient After the first bleeding, from five to fifteen grains of calomel should be admin- istered, either in connection with or followed by another cathartic, to insure its action on the bowels. These should afterwards be kept freely open, throughout the complaint, by saline aperients if required. If the disease do not yield, the purgative should be followed by tartar emetic or ipecacuanha, in diaphoretic or nauseating doses, given at short intervals, together with the neutral mixture or effervescing draught, if the skin be hot and dry. With these measures may also be combined hot and stimulating pedduvia. From the beginning, the throat may be enveloped in an emollient poultice, contain- ing a very small proportion of mustard, sufficient merely to produce a feeling of warmth upon the skin. When bleeding from the arm seems to be no IIL] ACUTE LARYNGITIS. 819 longer called for, leeches may be applied freely over the larynx, and will often be found at once to cut short the disease. Should spasm ofthe glottis accompany the inflammation, the antimonial maybe given in an emetic dose, and the system afterwards be kept moderately under its influence, in con- junction with tincture of lobelia, which exercises a powerful influence over this affection. In case of failure by these means, a cataplasm of tobacco should be applied to the throat, due caution being exercised to prevent a too prostrating influence from this powerful sedative. I have witnessed the hap- piest effects from this remedy in very alarming cases. Should the skin be denuded, from any cause, in front of the neck, the cataplasm may be applied to the back of the neck or between the shoulders. In the more advanced stages, syrup of seneka and syrup of squill, or the same medicines in other forms, are often of advantage in conjunction with antimonial or ipecacuanha wine; and at this period, small doses of opium or hyoscyamus will often be found useful by allaying cough, without the objection to which the former remedy especially is liable in the early stage, in consequence of checking secretion. A blister to the neck will also chime in happily with these reme- dies. If the disease still remain unsubdued, recourse should be had to the mercurial influence, which will seldom fail, in cases of ordinary inflammation, at this stage. During the whole treatment, the patient should avoid using his voice altogether, or speak only in a whisper, and should suppress the cough as much as possible. Rest and low diet are also requisite. In the violent cases described under the title of submucous laryngitis, it is of the utmost importance to employ active remedies promptly. If postponed until the purple lips and livid paleness of the face indicate an insufficiently aerated blood, they will be of little avail. In the early stage, if not forbid- den by the debility of the patient, blood should be taken very freely. In a robust adult, from twenty to thirty ounces may be drawn at the first bleed- ing, and the operation repeated once or oftener if necessary. The loss of blood should stop short of syncope. The obstruction to the respiration con- sists in an internal tumefaction of the larynx, which is not at once removed by the bleeding. A certain amount of muscular force is necessary to over- come the resistance in the glottis; and, if the patient be bled to fainting, there might be some reason to fear that his returning powers would be insuf- ficient for that purpose, and consequently that the syncope might be fatally prolonged. Nor is this copious bleeding applicable to the edematous cases, attended with but a moderate degree of inflammation, and little or no fever. It might prostrate the patient below the point of reaction. Moderate vene- section, however, is both tolerated and required. In the highly inflamma- tory cases, the lancet should be aided by the very free use of leeches to the throat. From fifty to one hundred American leeches may be applied in robust cases. Apprehension has been expressed lest they might increase the difficulty, in consequence of the superficial inflammation they excite pro- ducing subcutaneous extravasation. But the danger is from effusion within and not without the larynx, and if the latter should result from the leeches, it might act usefully by revulsion. It could scarcely be injurious. Nor should the leeches be delayed in these cases. Take blood once from the arm, and as soon afterwards as the patient's strength will permit, apply them. Should they not be attainable, cups may be substituted, to the side or back of the neck or between the shoulders. Next to the loss of blood, calomel is the most important remedy. It should be given in the full dose at once, and afterwards in smaller doses, at stated intervals, until the system is brought under its influence. For this purpose, two grains may be given every two or three hours, either alone, or combined with opium and ipecacuanha, should these not be contraindicated. Mercurial 820 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. frictions to the inside of the extremities may also be employed to hasten the effect on the system. As soon as any soreness of the gums is perceived, the mercurial should be moderated or suspended ; as there might be some danger from its excessive action. Small doses of Dover's powder are a useful addi- tion to the calomel, when given with a view to its general effects, by pre- venting it from running off by the bowels. They are also useful in moderat- ing the cough, which is itself a source of mischief by still further irritating the inflamed parts. The opiate, however, should not be carried to the stupe- fying point; and, if the disease should be complicated with bronchitis, ought not to be used in the early stage. Some practitioners place great reliance upon the antimonials in this affec- tion. Dr. Stokes considers them even more important than calomel. They may be used as auxiliaries, but care should be taken to avoid vomiting; as the matter discharged would be very apt to enter the glottis, and provoke the most vehement and distressing paroxysms of cough and dyspnoea. The measures recommended for the milder forms of laryngitis may also be employed, as occasion may seem to call for them; but the chief dependence must be placed upon the heroic remedies above mentioned. Should a blister be employed, it should be placed upon the sides or back of the neck rather than in the front, where it would be in the way of laryngotomy. The strong solution of ammonia would, in some cases, be preferable to cantharides, in consequence of the rapidity of its action. In the asthenic cases, which will not bear bleeding, reliance must be placed upon leeching, blistering, and the prompt and efficient use of mercury. The only circumstance, under which the last-mentioned remedy is contraindicated, is the complication of the disease with chronic tuberculous or scrofulous laryngitis. When bleeding and mercury fail, the only remedy upon which much re- liance can be placed is the opening of the larynx or trachea. As soon as the system begins to exhibit a depravation of the blood, and a disposition to sink, this remedy should be at once resorted to. It may even be employed in the earlier stages when the danger of suffocation is imminent. The only condi- tion which positively forbids it is the existence of extensive pulmonary disease, which would render death certain at all events. It is highly important that it be not postponed too long; for, in the advanced stages, death sometimes takes place in consequence of the state of the blood, even though air be freely admitted into the lungs. Nevertheless, the remedy should not be omitted. Recoveries have sometimes taken place, through its instrumentality, under apparently desperate circumstances. Well authenticated cases are on record, in which patients have been restored after respiration had ceased, and the pulse could no longer be felt at the wrist. In such instances, it might be proper to resort to artificial respiration, after the opening has been made. The effect of the operation is to admit air into the lungs, and it is surprising how speedy and complete is the relief sometimes afforded. The patient, ex- hausted by wakefulness, suffering, and the labour of respiration, sinks into a calm slumber almost immediately after the opening has been effected. Respi- ration is afterwards maintained for some time through the artificial passage. The laryngeal inflammatiou may now be cured at leisure by proper remedies. It will indeed generally subside of itself, with a secretion, more or less copious, of muco-purulent matter. The performance of the operation belongs to sur- gery. Laryngotomy is generally recommended ; and the opening should be made between the cricoid and thyroid cartilages. Some advise the upper part of the trachea as the seat of the operation. If not liable to surgical ob- jections, the latter position would appear to be preferable, on account of the danger of augmenting the laryngeal inflammation, by the introduction of the CLASS III.] CHRONIC LARYNGITIS. 821 tlilbe "eJessaryto keeP tQe opening pervious. The inner extremity of the tube should be prevented from projecting into the cavity, beyond the level of the mucous^ surface. Sir Charles Bell sometimes keeps the wound open by blunt- hooks, inserted^ in each side, and fastened behind the neck. Some attention to the opening is necessary after the operation. As much mucus is often dis- charged, it is advisable that the patient should facilitate the coughing neces- sary for its expulsion by placing his finger, after inspiration, on the orifice of the tube, and retaining it there until the effort of expiration has acquired force enough to drive the air vigorously through the opening. The patient should be carefully watched during sleep, so that the mucus which accumu- lates, and might possibly suffocate him, may be removed. After the subsi- dence of the inflammation, the glottis again opens; and, the patient being now able to breathe by the natural passage, the tube should be removed, and the opening allowed to close. The voice, which is lost for a time after the operation, returns with a restoration of the larynx to its healthy state. Dr. Gordon Buck, of New York, found decided benefit from incisions in the edges of the glottis, and in the epiglottis, by means of a guarded bistoury, in a case of oedema of the glottis. (Annalist, July 15, 1837.) As the effusion is mainly, or at least most dangerously, in the ariteno-epiglottidean fold of the mucous membrane, the operation of Dr. Buck is clearly indicated in this variety of the disease, and should always be resorted to in very threatening cases. Dr. T. R. Varick, of New York, applied a solution of nitrate of silver, of the strength of two scruples to the fluidounce, by means of a sponge affixed to a curved bougie, to the inner surface of the larynx, in an apparently almost desperate case of acute laryngitis, from which the patient afterwards re- covered ; and, though other active treatment was employed, the cure was ascribed chiefly to this measure. (N Y. Journ. of Med., x. 12.) This remedy is especially indicated in the pseudomembranous variety. II. CHRONIC LARYNGITIS. Syn.—Laryngeal Phthisis. Like the acute inflammation of the larynx, this differs much in degree and in danger, being in its mildest and simplest form nothing more than a chronic hoarseness, which is scarcely inconvenient and not at all dangerous; while, in its higher grades and with certain complications, it is one of the most serious diseases to which the human frame is liable. In the earlier stages, however, it is often impossible to discriminate between cases of the most opposite tendencies; as the most fatal frequently commence with the same symptoms as the most trivial; so that the affection, even in its mildest form, always merits attention. So long as the mucous membrane, though inflamed, maintains its integrity, there is comparatively little inconvenience. It is only when ulceration takes place, that the case begins to present a very alarming aspect. Now, in ordinary inflammation, without any peculiar morbid consti- tutional tendency, neither the mucous membrane nor any other constituent of the larynx has a disposition to ulcerate ; and the disease, after a longer or shorter duration, almost always gets well under appropriate treatment. Upon the occurrence of ulceration, there is generally reason to suppose that some morbid complication exists, calculated to render the disease in the highest degree obstinate and dangerous. This complication is almost always either a tuberculous tendency of the system, or syphilis. In some very rare instances, it mav be cancer or other malignant local disorder. In by far the greater number of cases it is the first-mentioned cause that renders chronic laryngitis 822 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. dangerous. In fact, this complaint, in its severer forms, is very generally associated with tubercles of the lungs. It is a very common incident in the course of phthisis, and, when it occurs originally, is generally attended with the formation of pulmonary tubercles, and complicated, before its close, with the symptoms arising from their ordinary progress. There appear, how- ever, to be cases in which the mucous follicles become the seat of ordinary inflammation, and in which ulceration may take place, without complication either with the scrofulous diathesis or syphilitic disorder. It is highly pro- bable that certain protracted cases owe their obstinacy to the same condition of system which occasions obstinate cutaneous affections, such as psoriasis, and chronic eczema. The disease, when not consequent upon an acute attack, generally begins with hoarseness, a little uneasiness in the throat, and a slight laryngeal cough, which is often rather a clearing up of the throat or hawking than a proper cough, such as occurs in pulmonary affections. In this condition, with occasional aggravations and remissions, it may continue for months, and ulti- mately disappear, especially upon the occurrence of warm weather. Fre- quently, however, the symptoms are less mild. Various morbid sensations are felt in the larynx, such as heat, dryness, constriction, itching or tickling sensations wliich provoke cough, and sometimes dull, smarting, or even acute pain, increased by coughing or any strong exertion of the voice, and occasion- ally by pressure. But, in a large portion of cases, even those of a fatal kind, there is little or no pain through the whole course of the complaint. The voice is always in some degree altered, being generally hoarse or husky, some- times stridulous or squeaking, and sometimes whispering. The change of voice is more perceptible when the patient attempts to speak loudly or to sing. The cough is at first usually short and dry, but becomes loose as the com- plaint advances, and is attended with a mucous or muco-purulent discharge. It is apt to be excited by speaking loud, or by the inhalation of cold air or irritating substances. If the fauces be examined, they will sometimes be found to exhibit the appearances of chronic inflammation, and among others, enlargement of the mucous glandules, as described under pharyngitis. All the symptoms above enumerated may occur without ulceration, though not inconsistent with it; for ulcers do not always give evidence of their exist- ence, and not unfrequently occur before they are even suspected. But, gene- rally speaking, the ulcerative stage is marked by some of the following pheno- mena. In cases attended with follicular inflammation of the fauces, the follicles within view exhibit signs of ulceration. There is often a pricking sensation in the larynx, as if from a sharp or pointed body, especially when the patient speaks. Deglutition is not unfrequently painful, and sometimes, in consequence of ulceration of the epiglottis, occasions violent paroxysms of coughing, with sensations as of suffocation, and a return by the nostrils of what the patient attempts to swallow. In some instances, however, there is no difficulty of swallowing from the beginning to the end of the case. The voice is still more altered than in the earlier stage, and is very variously affected, being hoarse, or whistling, or hollow, or quite lost, in the last case indicating ulceration of the rima glottidis, and partial destruction of the vocal ligaments. The cough undergoes analogous changes, being hoarse, croupy, stridulous, or altogether without sound above the breath. Sometimes, in the last stage, it has a peculiar loose, continuous character, ascribed by M. Trousseau to inability to close the glottis. The discharge is now purulent, and occasionally bloody and fetid. Sometimes patches of coagulable lymph are detached from the membrane and thrown up, with at least temporary relief to the symptoms. Instances too are mentioned, in which portions of the cartilages, sometimes ossified, and calcareous concretions, are found among the matter discharged. The respira- CLASS III.] CHRONIC LARYNGITIS. 823 tion is often difficult, though occasionally somewhat relieved after free suppu- ration, in consequence probably of the removal by ulceration of tumefactions, which may have narrowed the passage. It maybe wheezing, hissing, or other- wise noisy, and is sometimes merely tight, as if the air was drawn through a narrowed passage. The difficulty is sometimes continuous, but is more fre- quently in some measure paroxysmal, being brought on by attempts to swallow, by bodily exertion, or by irritations of any kind provoking spasm of the glottis. Sometimes the patient dies in one of these paroxysms. In other cases, he is carried off by the supervention of submucous effusion as in acute laryngitis. Still more frequently the general health gives way. Debility, emaciation, night sweats, frequency of pulse, oedema of the extremities, loss of appetite, occasional nausea and vomiting, and obstinate diarrhoea, mark the approach- ing close ; and the patient dies in a state of hectic exhaustion. It is not always easy to distinguish the different varieties of chronic laryn- gitis. If the symptoms indicating the existence of ulcers are wanting, if the chest is perfectly sound, and the general health of the patient unimpaired, there is reason to suppose that the inflammation may be of the ordinary kind, and to hope that it may yield to treatment. But if the disease has continued long and gradually increased, if a pricking pain is felt in the larynx, if the matter discharged is purulent, bloody, sanious, or fetid, if deglutition provokes paroxysms of cough and dyspnoea, if the voice has become broken or extinct, and the cough nearly aphonic, if the larynx crepitates under pressure, and the epiglottis can be seen ulcerated or deformed, if these or some of these symp- toms are present, and at the same time the general health appears impaired, the probabilities are that the laryngeal disease is of a scrofulous or syphilitic character. Should evidence of tubercles in the lungs be afforded, or the pa- tient in other respects show any signs of a scrofulous or tuberculous habit of body, the complaint may be considered as of the former kind. The pre-exist- ence of syphilis in other forms, and the absence of the ordinary local signs of phthisis, would determine in favour ofthe latter. It is said that laryngeal phthisis has sometimes occurred, and proved fatal, without tubercles in the lungs or elsewhere, and without suspicion of syphilis. This may possibly be the case; but the instances are very rare. In such cases, we may ascribe the obstinacy of the local disease, at our pleasure, to the peculiar circum- stances of the structure in which it is situated, or to a scrofulous or other concealed vice of constitution. We have no means of deciding the question. In relation to the prognosis in these several cases of ulcerative laryngitis, it may be stated that, when the disease is connected with pulmonary con- sumption, the two together are almost necessarily fatal; that the syphilitic variety may generally be cured in its earlier stages, and is seldom quite despe- rate ; and that, when neither of these complications exists, and no other serious depravation of the general health can be discovered, we may entertain a reasonable hope of making a favourable impression on the complaint Appearances after Death.—If the patient happens tobe carried off in the ear- lier stage the mucous membrane is found red, thickened, softened or indurated, and often'rough from the enlarged follicles. At a more advanced period, ulcers are found in various situations, most frequently between the vocal ligaments and epiglottis, sometimes superficial, sometimes deep, penetrating through the mucous membrane to the cartilages, and occasionally even through these. Dissecting abscesses meander among the different structures, and sometimes result in external fistulous openings. The cartilages themselves are changed, beinir sometimes ossified or encased in bony matter, and sometimes partially in a state of caries or of necrosis, with the dead portions surrounded by ulcera- tion and bathed in a fetid pus. The epiglottis is sometimes irregularly con- tracted ulcerated, and partially or wholly destroyed; as are also the vocal 824 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. ligaments. The submucous tissue is infiltrated with serum or pus, or thick- ened and indurated ; and the ventricles are sometimes obliterated from this cause. The muscles of the larynx are wasted, hardened, or otherwise degene- rate, and the ligaments contracted and distorted. Excrescences of various kinds appear on the surface of the mucous membrane, especially in syphilitic cases. It is said that, in syphilis, ulcers are apt to form on the anterior surface of the epiglottis, while in scrofulous cases they occupy the posterior surface. Louis states that he has not found tuberculous granulations upon the surface, or in the substance of the epiglottis or larynx. They do, how- ever, sometimes occur; and a case is recorded by Dr. Metcalfe, of New York, in which there was copious tuberculous deposit, which had softened, and pro- duced considerable loss of tissue. (N Y. Journ. of Med., July, 1857, p. 81.) Causes.—The ordinary causes of acute laryngitis may produce also the chronic form, when operating with less force, or upon less susceptible subjects. Among these the most common are cold, an excessive use of the voice in speaking or singing, irritating substances inhaled, propagation of inflamma- tion from the fauces above and the bronchia below, foreign bodies in the larynx, mechanical violence, the retrocession of cutaneous eruptions, and sometimes probably gout and rheumatism. The disease appears to be occasionally con- nected sympathetically with chronic gastritis. It is often the result of inflam- mation propagated from the fauces to the larynx. The abuse of sensual pleasure is thought to predispose to the complaint, which is said to be very common among drunkards and prostitutes. The scrofulous diathesis consti- tutes a predisposition to it. Polypous excrescences, warts, and other tumours in the larynx or its vicinity, may also be counted among the causes. The chronic disease occasionally succeeds the acute. It is said to be rare in infancy and old age, and most common between the thirtieth and fortieth year. Men are more frequently affected than women. Treatment.—In the early stages, moderate depletion, rest as complete as possible to the organ, and revulsion by means of a steadily sustained external irritation, are the chief remedies. It may sometimes be proper, during an access of excitement, to take a little blood from the arm ; but this is seldom required. Leeching is safer and more effectual. Cups may also be applied to the side or back of the neck. In order to rest the larynx, the patient should abstain from speaking aloud, and from singing; and cough should be allayed by opium, hyoscyamus, lactucarium, extract of hemp, or some other narcotic. It has been recommended to rub unctuous preparations of hyoscya- mus, belladonna, &c, over the larynx; and plasters of opium and of bella- donna have been used with the same view. For revulsion, a perpetual blister, pustulation by croton oil or tartar emetic long sustained, or a seton to the back of the neck, may be employed. The patient, if exposed to the inhalation of irritating substances, should be protected against them, by means of a fine gauze veil, or respirator. The diet should be nutritious but not stimulating, and should consist chiefly of vegetables, farinaceous preparations, and milk, with little or no meat. In the somewhat advanced stages, seneka may some- times be found useful; but the most effectual remedy, when other means fail, is mercury pushed to a very moderate ptyalism. This will often cure chronic inflammation, of the ordinary, or the syphilitic character. It is not adapted to scrofulous cases. In these, more reliance should be placed on the prepara- tions of iodine, especially iodide of potassium; and iodine ointment may be rubbed upon the throat. Tonics should also be employed to support the general health, such as wild-cherry bark, and the chalybeates; and, in these cases, the diet may contain a larger proportion of animal food, especially when the disease is far advanced into ulceration and suppuration. Cod-liver oil is a most valuable remedy in this form of the disease. When there is any sus- Iri'] CHRONIC LARYNGITI8. 825 picion that the affection may depend on the condition of system which gives rise to obstinate cutaneous diseases, small doses of one of the arsenicals may be employed, as in the scaly affections of the skin. (See Psoriasis.) Local applications to the diseased surface are very important. The smoking of stramonium leaves, belladonna, hyoscyamus, and tobacco, has been recom- mended ; as have also inhalations of the vapour of heated water impregnated with chlorine, iodine, camphor, turpentine, tar, creasote, or ether with extract of hemlock. Liquids and powders have also been applied to the larynx, and sometimes with great asserted advantage. For this purpose, solutions of cor- rosive sublimate, nitrate of mercury, sulphate of copper, and nitrate of silver, and powders of subnitrate of bismuth, red oxide of mercury, calomel, sulphate of zinc, sulphate of copper, alum, acetate of lead, and nitrate of silver, all variously diluted with sugar, have been employed by M. Trousseau.* Of these substances, nitrate of silver is upon the whole the most manageable and efficacious. It was commonly employed by M. Trousseau dissolved in distilled water, in the proportion of one part of the nitrate to two or four parts of the menstruum, forming a strong caustic solution. Others have used a much weaker solution, containing only fifteen or twenty grains in the fluidounce. Nitrate of silver has the great advantage of combining superficially with the tissues, and thus affecting only the surface, so that little danger need be apprehended of extensive mischief, if the application be properly made. Various plans have been proposed. One of the simplest is to introduce a drop of the solution into the glottis, by means of a slender roll of stiff paper, bent downward at the extremity; the base of the tongue being strongly de- pressed and somewhat drawn forward, and the patient directed to make the motion of swallowing, so as to raise the larynx. Another mode is to apply quickly to the same part, similarly brought within reach, a small piece of sponge, firmly secured to the end of a piece of bent whalebone, and saturated with the solution. A third method of Trousseau's was to inject into the glottis the solution mingled with air, by means of a small silver syringe, like that of Anel, with a long tube bent at the end, and having an orifice at least one-quarter of a line in diameter. The syringe was to contain three-quarters of air, and one-quarter of the solution, and the two, mingled together, were to be forced by a quick descent of the piston into the glottis, in the form of a fine shower. A convenient plan, proposed by Mr. Cusack, of Dublin, is to sew a small piece of lint to the end of the finger of a glove, and, having fixed this upon the right fore-finger, to moisten the lint with the solution, and bring it into contact with the glottis. In whatever mode applied, the solu- tion occasions a violent paroxysm of coughing, and sometimes even vomiting, which, however, subside in a short time without serious consequences. To decompose the portion of nitrate which may not unite immediately with the tissues, it is recommended to rinse the mouth and throat with a solution of common salt, of which the patient may also swallow a portion. The powders above mentioned may be applied by means of a tube, into which they have been introduced, and through which, placed deeply in the mouth with one end projecting, the patient should be directed to inspire forcibly. Dr. Horace Green, of New York, applies a strong solution of nitrate of silver directly to the laryngeal mucous membrane, and with the best results. He employs a solution of the crystallized nitrate, of the strength of from two to four scruples of the salt to a fluidounce of distilled water, and makes the * The proportions employed by Trousseau were subnitrate of bismuth undiluted; calomel with twelve parts of sugar; red precipitate, sulphate of zinc, and sulphate of copper with thirty-six parts; alum with two parts; acetate of lead with seven parts; and nitrate of silver variously with seventy-two, thirty-six, and twenty-four parts. (Diet, de M6d., xvii. 566.) 826 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. application by means of a piece of curved whalebone, with a sponge attached to the end of it, as recommended by M. Trousseau. Before attempting to penetrate the glottis, he accustoms the membrane to the irritant impression by applying the solution daily, for several days, to the parts immediately about the opening. When the sensibility of the lips of the glottis is thus somewhat blunted, he passes the sponge, saturated with the solution, through the rima glottidis into the cavity of the larynx. He recommends that the patient, upon opening his mouth, " should take a full inspiration, and then breathe gently out, at the moment in which the sponge is introduced." This is carried over the top of the epiglottis, along the posterior surface of this car- tilage, and then suddenly pressed downward and forward through the aperture. A momentary spasm of the glottis takes place, by which the sponge is com- pressed, and the fluid forced out of it. The application should generally be made every other day for the first two weeks, after which it may be repeated two or three times a week, until a cure is effected. ( Treatise on Dis. of the Air-Passages, kc, N. Y., p. 199, &c.)* Dr. Cotton, of London, employs a pair of curved forceps, with flattened blades, to the end of one of which a small piece of sponge is firmly attached. This being saturated with the solution, the instrument is introduced into the fauces, and the blades are closed, so as to compress the sponge, and cause the liquid to fall directly into the larynx. (Lond. Med. Times and Gaz., June, 1852, p. 579.) In the closing period of the disease, it sometimes becomes necessary, in consequence of the difficulty and danger of swallowing, to support the patient by the introduction of food through a stomach tube; and occasionally it may be necessary to perform the operation of tracheotomy, in order to avert im- mediate death. Article III INFLAMMATION OF THE BRONCHIA, or BRONCHITIS. In a pathological account of the several portions of the air-passages, it might be thought that the trachea should receive a separate consideration; but it is very seldom exclusively affected, offers no symptoms when inflamed which are not observed in other localities, and requires absolutely nothing peculiar in the treatment. The nomenclature which gives the title of tra- cheitis to croup, is founded on a false assumption in relation to the especial seat of that complaint. It is true that the trachea is generally affected in croup; but it is almost never exclusively affected; nor are the peculiar fea- tures of the disease essentially connected with that part of the respiratory passages. (See Croup.) The symptoms and treatment of tracheitis are almost always merged in those of laryngitis and bronchitis. The term bronchitis is applicable to any case of inflammation of the bron- chial tubes, whatever may be its grade, character, or precise locality. It will be here considered under the two heads of acute and chronic bronchitis. * To penetrate the glottis in the manner described by Dr. Green is a difficult opera- tion, and in the hands of many has proved unsuccessful. Indeed, its possibility has been denied; and it has been asserted that the instrument, when supposed to have penetrated the larynx, has in fact only entered the oesophagus. There is no doubt that this mistake has often been made; but there is, I think, as little doubt that the glottis has often been penetrated by Dr. Green and others, with the advantageous effects claimed. The operation should not, however, be attempted by the unskilful; and the less so, as its benefits may be more safely obtained in one of the methods mentioned in the text, by which the solution is applied to the top of the glottis, and enters with the air when the patient inspires. (Note to the fifth edition.) CLASS III.] ACUTE BRONCHITIS. 827 I. ACUTE BRONCHITIS. This designation has been restricted by some writers, without any very obvious propriety, to the higher grades of inflammation of the bronchia. The author considers it applicable to every case of short duration. In this sense of the term, acute bronchitis is one of the most common diseases to which man is liable. It varies very greatly in degree, and somewhat in character. The inflammation begins very frequently in the nostrils, fauces, or larynx, and thence descends into the bronchia; and is very apt to retain, in the last- mentioned position, unless modified by treatment, the grade of severity which characterized it at the outset. In its mildest form, acute bronchitis is a very slight disorder, commonly called a cold, or a cold in the breast. It usually comes on with a little hoarseness, followed by a moderate cough, and slight feelings of heat or soreness in the chest. The cough is at first dry, but is soon attended with expectoration, and then gradually subsides, causing little inconvenience to the patient, and seldom requiring the interference ofthe physician. Between this form of the disease, and the higher grade next to be described, there is every shade of difference. A common form of bronchitis is one formerly known as catarrh fever, and still frequently so called. Beginning with coryza, sore-throat, or hoarseness, and sensations of lassitude, weariness, aching in the limbs, and chilliness, followed by febrile reaction, it soon exhibits the characteristic signs of bron- chial inflammation. There is a feeling of diffused heat and uneasiness in the upper and anterior part of the chest, and often of tightness, stricture, weight, or soreness, but without acute pain, unless sometimes in coughing. In se- vere cases, these sensations are distressing, and attended with feelings of oppressed breathing, and occasionally with some difficulty of inspiration. Cough is usually among the first, and soon becomes one of the most promi- nent symptoms. It is at the commencement short and dry, or accompanied with but a slight expectoration; and is often very painful, producing sensa- tions as of scraping, tearing, or rending, behind the sternum. It has some tendency to occur in paroxysms, especially in the morning after waking, when a little viscid mucus is occasionally discharged with temporary relief. At this stage, the patient is usually affected with frequency of pulse, heat and dryness of skin, flushed face, headache, furred tongue, scanty and high- coloured urine, sometimes nausea or vomiting; in short, with all the symp- toms of fever. There is generally a remission of fever in the morning, and an exacerbation in the evening. In some rare instances, the symptoms above enumerated gradually subside, without any material increase of the bronchial secretion; but, in the great majority of cases, after a duration of from some hours to two or three days, the patient begins to expectorate a transparent, ropy, and often frothy mucus, of a saline taste, and sometimes streaked with blood, which is thrown up with painful, and occasionally almost convulsive coughing. This expectorated matter gradually increases in quantity, and at the same time in consistence, and, instead of being colourless and transparent as at first, becomes opaque and white, and ultimately yellowish or greenish, and at the same time quite bland to the taste. Sometimes this altered secre- . tion is mixed with the thinner transparent matter, at others is exclusive, f Along with the change in the mucous secretion, there is usually an ameliora- tion of the other symptoms. The cough is easier, the soreness and tension are diminished, and the fever abates. In some instances, after such an amendment the mucous discharge again becomes thinner and more transpa- rent and the symptoms generally undergo a corresponding change for the 828 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. worse, indicating a temporary increase of the inflammation. At length, how- ever, the disease gives way; the expectoration becomes free and easy^with an opaque, often puruloid discharge; the skin becomes moist; the urine is increased in quantity; the fever subsides; and the patient returns gradually to health, but often with a slight cough, which remains for a considerable time. The attack varies in duration generally from four to ten days, though it sometimes runs on for two or three weeks, and sometimes assumes the chronic form. When the patient recovers, with a cough remaining, he is liable to relapse from slight causes. Occasionally, after the subsidence of the acute symptoms, a condition is left approaching in character to hectic, with frequent pulse, copious purulent expectoration, night sweats, emaciation, and debility. The system is too feeble to recover from the blow which it has received, and, unless supported by appropriate treatment, sinks into a dan- gerous or even fatal exhaustion. The grade of action throughout the com- plaint varies much. Generally it is sthenic, with a strong, full pulse, and bears depletion well. Occasionally it is low or asthenic, in consequence of the peculiar state of the constitution, or peculiar influences of a depressing character to which the patient may be subjected. This distinction is occa- sionally important in practice. In the grades of bronchitis above described, the disease is very seldom fatal, unless in old persons, or in those debilitated by chronic complaints, in whom there is insufficient strength to throw off the copious bronchial secre- tion, wdiich, therefore, overwhelms the lungs, and literally drowns the patient But cases of a much severer and more dangerous character are not unfre- quently met with. In those already treated of, the inflammation is compara- tively moderate in degree, and confined chiefly to the larger tubes. In those now alluded to, the inflammation is more intense, sinks more deeply into the bronchial membrane, perhaps even to the submucous tissue, or penetrates further into the tubes, so as even sometimes to reach their ultimate ramifica- tions. In these cases, without a materially greater amount of pain or sore- ness, there is much greater oppression and difficulty of respiration. When these arise from mere intensity of inflammation, the air sometimes enters with difficulty through the thickened or contracted tubes, producing a blowing sound audible at a considerable distance ; and the patient suffers with feel- ings of impending suffocation. When the cause of difficulty arises from the extent of the inflammation, respiration is hurried, the dyspnoea extreme, the pulse exceedingly frequent, and the general strength speedily exhausted. This condition of the disease is most common in infants, and is sometimes quickly fatal. Occasionally, in these severer forms of bronchitis, the attacks of dyspnoea are exceedingly sudden and violent, destroying life in the parox- ysm unless relieved. The expectoration is sometimes thick and glutinous, even at the beginning, more like the adhesive secretion of pneumonia than the mucus of ordinary catarrh. It is also occasionally fibrinous, and small quantities of false membrane are coughed up with the mucous secretion. The danger may arise partly from the shock of the inflammation upon the nervous system; but much more commonly it proceeds from the interference of the disease with the access of air to the cells, and consequently with the due aeration of the blood. Dark blood, therefore, flows through the arteries, and produces its depressing effects upon the brain and all the dependent functions. The face becomes pale, or somewhat livid or purplish, the sur- face cool, the pulse frequent and very feeble, the dyspnoea excessive, and the countenance expressive of great anxiety. The vital powers give way, the skin is cold and clammy, the patient complains of intense thirst, and death soon takes place, preceded by coma, delirium, or convulsions. Those who most frequently perish of this disease are the very young and the old CLASS III.] ACUTE BRONCHITIS. 829 and debilitated. The swelling of the tubes, and the secretion into those of smaller dimensions, cause an obstruction to the entrance of air, which the feeble muscular power of the patient is unable to overcome. Sometimes it is the blocking up suddenly of one of the larger bronchia which supplies a con- siderable portion of the lung, that occasions sudden death. Besides, the bronchitis not unfrequently becomes complicated with pneumonia, which greatly increases its danger. An occasional variety of bronchitis is one in which the inflammation is obviously accompanied with spasm of the bronchial tubes. Paroxysms like those of spasmodic asthma come on at irregular periods, and threaten the patient with immediate suffocation. In other respects, the cases do not differ from the forms of the disease above described. There is another variety, in which, instead of mucus, or in connection with it, coagulable lymph is secreted upon the inner surface of the bronchia, form- ing tubes of false membrane, which greatly obstruct the passage of air. This happens chiefly in infants, constituting a feature in the worst forms of croup. (See Croup.) It is very rare in adults, at least to any considerable extent. Occasionally, in persons of full age, a small portion of one of the bronchia becomes thus affected, and fibrinous tubes are expectorated with complete relief to the symptoms. There is not necessarily, in these cases, any consi- derable amount of constitutional disturbance. Indeed, the disease is some- times of so limited an extent as not even to occasion fever. The patient is harassed with an obstinate cough, perhaps spits up blood consequent upon a partial separation of the false membrane, and some time later, after severe efforts, expectorates the offending cause. In some rare cases the affection has been much more severe, attended with much dyspnoea, violent coughing, and the frequent expectoration of masses of fibrinous matter, which the mi- croscope shows to consist mainly of casts of the bronchia, often ramifying, and sometimes laminated, as if thrown out in successive layers. Like ordi- nary bronchitis, this variety sometimes passes into the chronic state. Bronchitis is sometimes complicated with bilious and gastric symptoms, such as a yellow tinge of the eyes and skin, a loaded tongue, nausea or vomit- ing, and tenderness in the epigastrium and right hypochondrium. These may arise from portal congestion, gastric or hepatic inflammation, or from the influence of miasmata, adding remittent fever to the bronchial disease. When bronchitis invades the smaller tubes, it has a strong tendency to pass into the air-cells, especially in infants, and thus to constitute pneumonia. It is not always easy to determine the limits between the two affections; nor is it a point of much practical importance ; as their treatment in these situa- tions is essentially the same. Pneumonia may always be suspected in bron- chitis, when, along with the loose fluid secretion of the latter complaint, the tough, rusty-coloured, yellowish, or greenish, adhesive matter, characteristic of the former, is thrown up.* * The microscopic appearance of the expectorated matter varies with the degree, seat, and stage of the inflammation. In the earlier stage, and in mild cases, it differs little from that of healthy mucus, showing effete epithelial cells with their cilia, mucous corpuscles which are epithelial cells in different stages of development, patches of ad- hering cells, and others of basement membrane with attached nuclei, all of which are contained in a transparent liquid. In severer cases, when the whole thickness of the mucous membrane may be supposed to be affected, there are in addition irregular masses of fibrinous exudation, with fibrils and exudation corpuscles in different stages, and, if the small tubes have been affected, minute cylindrical casts of fibrin. At a later stage, pus corpuscles are intermingled with the other ingredients, and increase until they be- come the prominent constituent. These are probably the result of the degradation of the mucous and exudation corpuscles. Resides these, crystals of uric acid and oxalate of lime have been noticed, with urate of ammonia, and amorphous sulphate of lime. (C. Black, Ed. Month. Journ. of Med Sci., vii. 294, 297, &c.) The first transparent 830 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Under the names of peripneumonia notha, suffocative catarrh, and catar- rhus senilis, affections have been described by practical writers which have not always been sufficiently defined; and it is probable that very different diseases have sometimes been confounded; such, for example, as congestion or apoplexy ofthe lungs, pneumonia supervening upon old catarrhs, and proper bronchitis. There is a condition of the last-mentioned disease, which may be considered perhaps as representing the greater number of these cases. It is characterized by the sudden occurrence of dyspnoea, often in paroxysms, with a copious and early secretion of mucus, and consequent wheezing respiration. The patient speaks with difficulty, is often unable to lie down, gasps for breath, and coughs violently and incessantly to free the lungs from the matter which threatens to overwhelm them. The expectoration, if not free at the onset of the disease, soon becomes abundant, and is frothy from the violence of the cough. It is sometimes also tinged with blood. An almost universal mucous rale may be heard over the chest, while percussion is occasionally dull in some parts, in consequence of the accumulation of mucus, or the existence of pulmonary congestion or collapse. Febrile symptoms sometimes appear at the com- mencement; but they do not usually continue long. Those consequent upon deficient aeration of the blood soon occur, and are very striking. The face is pale or livid, the lips are purple, the extremities cool, and the circulation very feeble. The disease is very dangerous, the more so as it has a tendency to run into pneumonia. But its fatality is owing chiefly to the circumstance of the previous bad health of the patient, who, long balanced between life and death, is precipitated by comparatively slight causes to the fatal issue. The sudden inability of even a small portion of the lungs, to perform its duty, in consequence either of congestion, mucous accumulation, or the ob- struction of one of the larger bronchial branches by a clog of concrete matter, is thus sufficient to endanger or destroy life. Physical Signs.—The characteristic signs of bronchial inflammation are clearness upon percussion in all parts of the chest, sometimes diminishing a little as the disease advances; the dry or sonorous and sibilant rales in the earliest stage ; afterwards the moist or mucous rales more or less mingled with the dry; and the respiratory murmur still audible, though frequently weakened, especially when the disease is seated in the smaller tubes. It is not in every case of bronchitis that the dry rales are heard ; for not unfrequently the disease is so mild as not to produce sufficient narrowing of the tubes to give the requisite physical condition for these sounds. Nor are the two sounds heard always under the same circumstances. Both arise from the diminished caliber of the bronchia, consequent upon inflammatory thickening or exudation, or spasmodic constriction. But the sonorous rale is heard in the larger, and the sibilant in the smaller tubes. It sometimes happens that the caliber of one of the larger bronchia is so much contracted as to occasion the hissing or whistling sound ; and this may be known by the persistence of the sound during the whole period of inspiration and expiration ; for in the small tubes the air is not so long in its passage as in the larger; but, gene- rally speaking, when the sibilant rale is heard, and especially when it extends over a large surface, the evidence is strong that inflammation exists in the small tubes. According to the extent of the chest over which these sounds mucus of bronchitis would appear to be the result of a more rapid formation of epi- thelial cells with their liquid product; the white opacity which follows may be ascribed to the abundance of undeveloped cells or mucous corpuscles, which are produced and thrown off under the excitement of the inflammation ; the greater tenacity and dusky hue frequently noticed evince the presence of fibrinous exudation, resulting from a higher grade or deeper seat of the inflammation; while the gradually increasing yellowness of the sputa, as the affection advances, is owing to the formation of pus, consequent on the failing vital forces of the tissue. (Note to the fourth edition.) CLASS III.] ACUTE BRONCHITIS. 831 prevail, is in general the extent of the inflammation; but it must be borne in mind that the sonorous rale, from its loudness, may often be heard at a considerable distance from its actual seat, sometimes even over the whole of one side of the thorax; and, if any part of the lungs is consolidated by pneumonia, all the rales, whether dry or moist, may be conducted to the ear from a considerable distance. There is always great reason for apprehension, when the hissing sound, as sometimes happens in infants, is audible over a great portion of the chest. The dry rales are seldom entirely pure, even when first distinguishable by the ear; as secretion generally begins before the membrane has become so thickened as to cause them. Occasionally, however, they are so ; and it is asserted that they have continued two or three days without admixture of the mucous rales, and that they have even subsided altogether without the occur- rence of the latter sounds, or of expectoration. In the great majority of cases, there is, almost from the beginning, more or less of the mucous bubbling or crepitation; and it is only the predominance of the dry sounds that deter- mines the stage of the disease. Not unfrequently, the mucous rale ceases for a time after expectoration. At length, when the stage of secretion is fully established, the moist sounds predominate, though the dry are still frequently heard. All of them are variable, often shifting about from one part of the chest to another, with the varying condition of the tubes and the secretion. The moist sounds themselves vary according to the size of the tubes, and consequently of the bubbles formed in them. The mucous rale is perceived in the larger, the subcrepitant in the smaller. When, therefore, the fine crepitation of the latter is observed, and especially if in connection with it is the sibilant rale, the evidence is conclusive that the disease is seated in the smaller bronchial ramifications; and, should the respiratory murmur be super- seded by these sounds, it would be inferred that the disease is very extensive. Under such circumstances it might be difficult to distinguish bronchitis from pneumonia, especially if some congestion of the lung, producing a degree of dulness on percussion, were connected with the former; but the absence of the crepitant rale, of the rusty sputa, of bronchial respiration, and of bron- chophony, and the temporary duration of the dulness, would be sufficient to prove the absence of pneumonic inflammation. Sometimes the mucus is so thick and tenacious, in the advanced stages of bronchitis, as to narrow the passage by adhering to the sides of the tubes, and thus to occasion the sono- rous and sibilant rales; which, however, under such circumstances, cease after coughing. Such a condition of the mucus occasions also a sort of ticking sound, in consequence of the greater tenacity and consequent less frequent rupture of the bubbles. An important point among the physical signs of bronchitis is, that the respiratory murmur, though usually heard over the whole lung, yet some- times ceases to be audible in one or more parts, thus leading to the suspicion that consolidation of the lung has taken place from inflammation or other cause. But percussion relieves the apprehension by proving that the part affected continues sonorous, and consequently contains air. The phenomenon is owing to the obstruction of one of the bronchial tubes by a plug of mucus, or by inflammatory thickening. In the former case, it is often removed by coughing, which displaces the obstruction, and allows the air again free admission and exit. Dr. Gairdner has shown that, as a consequence of ob- struction in the bronchial tubes in bronchitis, a collapse of that portion of the lung supplied by the tube affected is not unfrequent; giving rise of course, when extensive, to more or less dulness on percussion, as well as to absence of respiration. „,,..., . -, ■, , Anatomical Characters.—The bronchial mucous membrane is reddened, 832 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. thickened, sometimes softened, occasionally rough and destitute of its natural polish, and, in some very rare cases, ulcerated or gangrenous. The redness is sometimes diffused, but more frequently in patches, points, streaks, or arborizations. In slight cases, the redness is often confined to the larger bronchia ; in the severer, it extends into the smaller ramifications. Under the microscope, the surface of the membrane may sometimes be seen deprived of its epithelium, and the fibrous layer covered with a fibrinous exudation in place of it. The tubes contain mucus in various states, sometimes blood, and not unfrequently pus. In cases which appear to have proved fatal from the abundance of the undischarged secretion, the lungs refuse to collapse upon the admission of air into the pleural cavities. The bronchia are some- times dilated. Dr. Gairdner, of Edinburgh, has demonstrated that, in certain cases of local condensation of lung in the adult, previously ascribed to limited inflam- mation of the pulmonary tissue, the result is in fact owing to collapse of the air-cells, consequent on the obstruction of the bronchial tubes leading to the parts affected, and that the phenomenon is one not of lobular pneumonia, but of bronchitis. The same observation had been previously made by MM. Bailly and Legendre iu relation to the supposed lobular pneumonia of infants. The state of the lung is similar to that imperfect expansion of the lungs of newborn infants, denominated atelectasis. This seems to be proved by the fact that, in cases of such condensation, before the parts have become altered in structure by length of time, the portion of lung affected can frequently be restored nearly to its natural condition by forcible inflation. Dr. Gairdner describes two conditions of this collapse, one diffused, and the other of the lobular form. In both, the colour is usually of a dark violet on the surface, and brownish-red within ; the crepitation is diminished or quite lost; and, when the collapse is complete, portions are found to sink readily in water. The cut surface is nearly smooth, having somewhat the appearance of mus- cular flesh, and without any trace of the granular aspect characteristic of the hepatization of pneumonia. In the diffused variety, the state of collapse may affect considerable portions of one or both lungs, especially the posterior part, and gradually passes into the healthy structure; in the lobular, the con- densed part has an abrupt boundary, being accurately limited by the inter- lobular septa. These collapsed portions may have been affected with bron- chial inflammation, in which case small abscesses may sometimes be observed in them, from the size of a hemp-seed to twice or three times the volume, bearing when incised no inconsiderable resemblance to softening tubercle. These are lined with false membrane, and communicate with the bronchial tubes. Dr. Gairdner considers them as strictly bronchial, but they probably arise from distension of the air-vesicles with pus. They sometimes occur in adults ; but are more frequent in infants, being a common attendant on acute infantile bronchitis of a severe character. (See Ed. Monthly Journ. of Med. Sci., Aug. & Sept. 1850.) Dr. Gairdner ascribes this local collapse of the lung in bronchitis, partly to an excess of the expiratory over the inspiratory power, which causes the air to be expelled with greater force than it can enter through the impediment in the bronchia, partly also to the mechanical action of the plug of mucus, which with the inspiration is forced into a con- stantly diminishing passage, and with the expiration into one constantly en- larging, so that air necessarily passes outward more readily than inwards. The latter is probably the true cause. The collapse, if permanent, is followed by atrophy of the part, which leaves in the place of pulmonary structure, nothing but a little fibrous tissue with specks of carbonaceous matter. Causes.—Cold is beyond all comparison the most frequent cause of bron- chitis. It is most apt to produce the disease when applied partially to some CLASS III.] ACUTE BRONCHITIS. 833 one portion ofthe frame, as to the back ofthe neck, feet, &c, or to the body previously heated by exercise, and in a state of perspiration; and it is always most injurious when combined with moisture. The disease appears sometimes to result from reaction in the bronchial mucous membrane, upon entering a heated apartment after having breathed an intensely cold air. It is most fre- quent in the latter part of autumn, in winter, and spring, when the atmospheric changes are frequent and great, and the air is often loaded with condensed moisture. But it occurs from the same cause in summer, and sometimes, when protracted, ceases upon the occurrence of the clear cold weather of winter. Other causes are heated air, acrid gases or vapours, and irritating powders inhaled into the lungs. In some persons, the disease is produced by peculiar exhalations which do not affect men in general. Thus, the powder of ipeca- cuanha occasionally excites violent bronchial inflammation when inhaled. English writers speak of a peculiar catarrhal affection, called in Great Britain "the hay asthma," which occurs in some susceptible individuals about the period of mowing in May and June, and is ascribed to the exhalation from a certain kind of grass when cut. The complaint is often very severe, involving the whole of the air-passages, and requiring removal from the sphere of the supposed cause in those exposed to its attacks. Bronchitis occurs periodically in some individuals once a year, and at the same time of the year, without any assignable cause. Among my patients, for a long time, was an elderly gentleman, who was attacked with the disease regularly at a certain time in August. He resided in the city of Philadel- phia, and, so far as could be learned was never exposed at that season to the influence of any peculiar cause. He died ultimately of phthisis at an advanced age, and had probably for thirty years been subject to occasional attacks of ha?moptysis. Two other persons, of gouty families, have occasionally con- sulted me for a similar affection, occurring about the same time every summer. I think it not improbable, that such cases are often gout affecting the respi- ratory passages. They usually begin with a severe coryza, and run on for six weeks or two months, when they subside spontaneously. Epidemic influence is a powerful and not unfrequent cause of bronchitis. (See Influenza.) The disease is a frequent attendant upon many other complaints, as measles, smallpox, scarlet fever, hooping-cough, asthma, enteric or typhoid fever, and acute inflammation of the lungs, pleura, pericardium, and liver. It also affords us one of the first intimations of the deposition of tubercules in phthisis. Treatment.—In the very commencement of one of these bronchial affections, while there is yet but a slight coryza, soreness of throat, or hoarseness, and the irritation is but just beginning to show itself in the chest, the disease may often be entirely subverted by a dose of opium at bedtime, a copious perspira- tion induced by hot teas or strenuous bodily exertion, or even by a full sup- per of stimulating food and drink. But it is only in cases where previous experience justifies the apprehension of a severe attack from these slight beginnings, that such treatment would be desirable; and the stimulating plan is altogether too hazardous for ordinary use, as, if it fail, it will be liable greatly to aggravate the subsequent symptoms. For further particulars the reader is referred to the subject of coryza- (See page 810.) In a mild case of bronchitis, with little or no fever, nothing more is required than a saline cathartic, confinement to the house, a vegetable diet, demulcent drinks and small doses of one of the antimonials. I usually direct an adult patient, after having been purged by an ounce of sulphate of magnesia, to drink daily in smalf portions at a time, a pint of flaxseed tea with two fluid- drachms of antimonial wine. Other demulcents maybe employed if preferred by the patient; as solution of gum arabic in the proportion of an ounce vol. i. 53 834 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. to the pint, infusion of slippery elm, decoction of marsh-mallow, and decoc- tions of the dried fruits, sweetened and flavoured with lemon or orange-juice. To allay the cough, demulcent substances may be held in the mouth, and swallowed as they slowly dissolve. Such are gum arabic, liquorice, jujube paste, solidified molasses, and gum pectoral, consisting of a mixture of gum and sugar dissolved together and evaporated. Should considerable fever exist along with the pectoral symptoms, the patient ought to soak his feet in hot water, go to bed, and take every two or three hours a dose of the neutral mixture, effervescing draught, solution of acetate of ammonia, or nitre, with a small proportion of tartar emetic, or one of the liquid preparations of ipecacuanha. In infantile cases in which the nervous system is often disordered, spirit of nitric ether may be added to the diaphoretic medicines. The air of the room should be kept warm, and the patient should use his voice as little as possible. When there are headache, oppressed breathing, and considerable pain or soreness in the chest, or any one of these symptoms, in a high degree, along with a strong and excited pulse, blood should be taken from the arm, to the amount, in robust persons, of sixteen ounces; but generally less bleeding is required than in the serous inflammations, and the great majority of cases do very well without it. Occasionally, but not often, the bleeding may be re- peated. In relation to the loss of blood, it is highly important to have refer- ence to the constitution of the patient; and the discharge should always be stopped, however little may have been lost, when the pulse begins to fail. In feeble patients, it is of the utmost importance to reserve sufficient strength for the expectoration of the pulmonary secretion. When bleeding is of doubt- ful propriety, should the local inflammation seem to call for depletion, leeches or cups should be applied to the breast or between the shoulders, or wherever the sibilant rale may be most heard ; and, in all cases, these are admirable adjuvants to the lancet. Sometimes, when there is considerable debility, dry cups may be applied with benefit. In severe cases, a full purgative dose of calomel should be given at first, and followed by depletion and diaphoretics as above. Some advise, as an adjuvant to the lancet, or as a substitute for it in cases in which it may be of doubtful propriety, tartar emetic in doses as large as can well be tolerated by the stomach without emesis, as one-quarter, one-third, or one-half of a grain, every hour or two. When the first violence of the inflammation is over, medicines should be given calculated to favour expectoration. Squill or seneka, in connection with tartar emetic, ipecacuanha, or sanguinaria, is now a suitable remedy. Some strongly recommend the alkaline carbonates, as having the property of thinning and rendering of easier expectoration the viscid bronchial secre- tion. I have little confidence, however, in the latter remedies. It is more desirable to associate with the expectorants, substances calculated to allay the cough and quiet restlessness. Opium, however, which, under favourable cir- cumstances, is best adapted to these ends, cannot be used with propriety in this stage of bronchitis, at least as a general rule, in consequence of its ordi- nary effect of restraining mucous secretion, and therefore of shutting up the inflammation in the membrane. Recourse, then, may sometimes be had, where the cough is peculiarly violent, to the preparations of hyoscyamus, conium, or hydrocyanic acid. Either of these medicines may be advanta- geously given in liquid mixtures, along with some demulcent substance, as liquorice, gum arabic, or sugar. Every practitioner can make a cough mix- ture out of these materials to suit his own views, and the circumstances of the case. It is generally preferable to employ the liquid preparations of the medi- cines recommended, as the syrup of squill or seneka, the wine or syrup of CLASS III.] ACUTE BRONCHITIS. 835 ipecacuanha, and the tincture of sanguinaria. Tartar emetic may be used in aqueous or vinous solution; and the narcotics in the form of tincture or extract. The proportions should be so arranged that a dose may be given every two, four, or six hours, according to the urgency and acuteness ofthe symptoms.* After expectoration has been fairly established, opiates come in with great propriety, and not only add vastly to the comfort ofcthe patient, but tend to promote a cure. The salts of morphia are probably preferable to any other preparations of opium in cough mixtures, from the circumstance that they tend less to restrain the secretions. The camphorated tincture, or paregoric, which is much employed both popularly and by physicians, is less suitable to acute than to chronic cases, in consequence of its stimulating properties. The opiate may in general be most conveniently administered, in small doses, in connection with the expectorant mixtures. Sometimes, when the cough is very troublesome, and productive of wakefulness at night, the opium is best given in full doses at bedtime, conjoined with an equal or double weight of ipecacuanha. Should bronchitis be indisposed to yield to suitable depletion, and the symptoms be of an urgent character, there should be no delay in resorting to mercury, with a view to its peculiar influence on the system. It may also be used, with great advantage, in some dangerous cases, in which the debility of the patient may contraindicate the lancet. In the advanced stage of the disease, when it appears to be verging to a chronic form, I have found nothing so effectual, with the exception of mer- cury, as a decoction of seneka with tartar emetic. An ounce of the bruised root, and the same quantity of liquorice root, may be boiled in a pint and a half of water to a pint, and one grain of tartar emetic, and an ounce or two of sugar, added to the decoction. The dose is a tablespoonful every two hours, or a wineglassful, if the patient's stomach will bear it, twice or three times a day. I prefer the former mode of exhibition. The compound pills of squill, consisting chiefly of squill and ammoniac, are also an excellent remedy. Assafetida is capable of doing great service in certain cases, espe- cially in infants, in whom the nervous actions are often irregular, and the system needs support, under the exhausting action of the disease. When there is considerable debility, with difficulty of expectorating the bronchial secretions, carbonate of ammonia, in doses of three or five grains every hour or two, often answers an admirable purpose. Local measures are also important. After the application of cups or leeches, in severe cases, large emollient poultices are often useful, kept steadily applied for days together. After due depletion, sinapisms and blisters are highly beneficial. The latter are, indeed, among the most effectual means that can be employed at a certain stage. Yery early in the disease, they often fail to arrest the inflammation, while they aggravate the fever. It is after the vio- lence of the diseased action has begun to subside, that they are most usefully employed In this condition of the disease, they sometimes put an immediate end to it. Occasionally, in very threatening cases, when a very speedy action is required, the strong solution of ammonia maybe employed as a rubefacient * A mixture may contain in each dose, for an adult from fl^x to f^ss of Antimonial or Ipecacuanha Wine or Tincture of Sanguinaria, or from f3ss to f^j of Syrup of Ipeca- cuanha ; combined with from Hlx* to ITL^f Syrup of Squill, or Wx to Wxx of Vinegar or Tincture of Squill, or from f3ss to !# of Syrup of Seneka ; and with from f^ss to ffc of Tinct. of Hyoscyamus or Conium, or Ulij to Hliv of Officinal Hydrocyanic Acid. In ' ,, i. J •„♦„„ f„- thp above narcotic tinctures may be substituted, in each XT f"m m u"^ f Lludtum HI- to f3ss of Solution^ Sulphate of Morphia, or fis to f?}of Camphorated Tincture of Opium It will be convenient to prescribe 01 13SS to i^j 01 v * f f2 j with 3U 0f Gum Arabic, and gij of Sugar or Sq^oScf ta Soh q«.nSrthft aVblespoonful of the mixture shall contain the doses above mentioned. 836 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. and vesicatory. In mild cases, especially in children, rubefacient liniments, made of solution of ammonia or oil of turpentine, mixed in various propor- tions with olive oil, with the occasional addition of tincture of camphor, and certain aromatic oils, as those of rosemary, origanum, and horsemint, are sometimes preferable to blisters. Towards the period of convalescence, plas- ters of Burgundy or Canada pitch, or the warming plaster, may hasten per- fect recovery, and guard against relapse. Inhalation of the vapour of hot water is recommended by some writers, as a kind of emollient application to the inflamed surface; but I believe that it will be found to aggravate, quite as frequently as to alleviate the discomfort of the patient. It is probably better applicable to cases complicated with spasm of the bronchia, than to pure acute inflammation. There is a point in the progress of some cases of acute bronchitis, when it becomes highly important to abandon all depletory methods, and resort to a supporting treatment. The pectoral stricture and pains have ceased, expec- toration has been fully established, the skin has become soft or moist, and the matter discharged has assumed an opaque and perhaps puruloid appearance; but the cough continues severe and harassing, the pulse is often frequent, and the patient suffers greatly from feelings of debility and general uneasi- ness. Every experienced practitioner must have seen such cases recover rapidly, as if by a charm, under a nutritious diet, a little malt liquor or wine, and exercise in the open air. When purulent expectoration, night sweats, and a hectic circulation are observed, there should be no hesitation in resort- ing to tonics, among which sulphate of quinia is the most efficient. Should this produce constriction ofthe chest, the infusion of wild-cherry bark should be substituted, with the addition of one of the mineral acids. Throughout the case, the patient should avoid speaking long or loudly, should wear flannel next the skin, and should not expose himself to vicissi- tudes of temperature. Certain special cases require, in some degree, special modes of treatment In infants, leeching is often in the highest degree efficient, emetics are some- times beneficial, and the warm bath proves a useful adjuvant. Full purga- tive doses of calomel frequently produce in children the happiest effects. In the advanced stage of the disease, when the strength begins to fail, the re- spiration to become hurried, and the nose and cheeks to feel cool to the hand, assafetida produces immediate amendment, and sometimes speedily rescues the little patient from great apparent danger. The syrup of onions, and the syrup of garlic, have the same effect in a less degree ; and advantage some- times accrues from applying garlic poultices to the feet, and bathing the chest with a tincture of the same substance made extemporaneously by heating it in brandy. When the disease is seated in the smaller bronchia, and occupies a large portion of the chest, the treatment should be especially active. General and local bleeding pushed as far as the strength will permit, free and early blis- tering, and the use of mercury, are the chief remedies. When the inflammation is complicated with spasmodic paroxysms of an asthmatic character, emetics of ipecacuanha during the paroxysms, and the steady use of tincture of lobelia, in such doses as slightly to nauseate without vomiting the patient, wdll be found highly useful additions to the ordinary antiphlogistic measures. Tincture of lobelia and syrup of seneka answer well together in such cases. In relation to the variety of bronchitis called in Great Britain the hay asthma, independently of the measures ordinarily employed in catarrhal affec- tions, Mr. Gordon, who appears to have paid particular attention to the subject, states that he has found lobelia the most speedy and effectual remedy, CLASS III.] CHRONIC BRONCHITIS. 837 and the cold shower-bath and a combination of the sulphates of quinia and iron the most effectual preventives. ( Watson's Lect. on Princip. and Pract. of Physic.) A contributor to the Boston Medical and Surgical Journal (lvi. 316) states that he has found pills consisting of two grains of sulphate of quinia and one of sulphate of iron, given three times daily, commencing eight or ten days before the expected attack, and continued three or four weeks at least, to be invariably successful in preventing the disease. Dr. Elliotson has obtained signal relief, in three out of four cases, by diffusing chlorine in the patient's apartment, by means of the chloride of lime or of soda, placed in saucers or other convenient vessel. (Tweedie's Syst. of Pract. Med.) The tincture of nux vomica, in the dose often drops, gradu- ally increased to twenty, three times a day, has produced the best effects in the hands of Mr. Gream. At the same time he applies to the nasal membrane, as high up as possible, an ointment made by mixing a drachm and a half of solution of subacetate of lead with two ounces of sperma- ceti cerate, and a few drops of oil of bergamot (London Lancet, June 8, 1850.) Dr. F. W. Mackenzie, of London, has found arsenic peculiarly use- ful, and gives the Fowler's solution in doses of from one to five minims. (Lond. Journ. of Med., July, 1851.) Dr. D. Lavis, of London, gives, during the stage of coryza, a scruple of powdered guaiac in a cup of warm tea at bedtime, for six successive nights, and afterwards depends mainly on tinc- ture of lobelia. He thus shortens its duration to three weeks from the ordi- nary period of two months. (See Bost. Med., and Surg. Journ., lvi. 528.) Under the impression that this affection sometimes partakes of the gouty character, I have employed colchicum in its treatment. When bronchitis is associated with hepatic disease, calomel should be early given as a purge, and the system brought quickly under the mercurial influ- ence. If associated with miasmatic fever, especially in its intermittent form, it will generally yield to quinia, after due depletion. The treatment adapted to the variety ofthe disease denominated peripneu- monia notha, depends very much upon the strength of the patient. In vig- orous individuals, and cases not complicated with chronic disease, active de- pletion by the lancet and by local means should be employed. In the old and feeble, who are much more frequently the subjects of attack, blood must be taken cautiously; and more reliance should be placed upon cups or leeches, blisters, and expectorants than on general bleeding. The choice of expecto- rants will also be influenced by the symptoms; the antimonials and ipecacu- anha being adapted to the more open inflammatory cases; squill, seneka, ammoniac, assafetida, and carbonate of ammonia, to those in which the bron- chial secretion is too abundant, and the muscular powers of the patient too feeble for its expectoration. In intermediate cases, the two kinds of expec- torants may be very properly combined. II. CHRONIC BRONCHITIS. Of chronic inflammation of the bronchia there are, perhaps, as many grades and varieties as of the acute. It often occurs in a very mild form, with no other observable symptoms than a slight cough and moderate expectoration, which after lasting a considerable time, either gradually cease, or become aggravated so as to excite the solicitude of the patient. Such coughs are apt to diminish or disappear during the summer, and, when the predisposition is stronir to return again in the winter ; and in this way they not unfrequently continue for many years, especially in elderly people. Severer cases are not uncommon, in which there is a troublesome cough, usually attended with expectoration, sometimes scanty and difficult, some- 838 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. times easy and copious, of a thick, somewhat tenacious, opaque mucus, whitish, yellowish, or greenish, sometimes streaked with blood, and frequently mixed with larger quantities of a thinner and more transparent, ropy liquid, probably the result of more recent inflammation, either supervening upon the old, or occupying a different part of the lungs. In some instances, small, whitish, opaque, solid particles are mixed with the sputa, which have by some been considered as tuberculous matter, but which, according to Andral, are nothing more than the concrete secretion of mucous follicles in the fauces. In certain rare cases, the expectoration has a very offensive odour, referrible possibly to the condition of the blood. The cough is usually most severe, and the expectoration most abundant in the morning. It is occasionally at- tended with pain, soreness, heat, and some degree of tightness in the chest; but these symptoms are not common, unless as consequences of new accessions of inflammation. Sometimes the patient is affected with hurried respiration or dyspnoea, and these are much more apt than in health to occur after mus- cular exertion. In general, there is no fever ; but it is not uncommon to find the pulse somewhat quickened; and sometimes a slight febrile paroxysm may be observed to form every day. The complaint may run on for a very long time with little modification, except, perhaps, a diminution in warm weather, which, indeed, not unfrequently co-operates with proper remedial measures in putting an end to it. Unless relieved, it is apt in time to take on the fol- lowing more aggravated form. Either as a consequence of an acute attack, or from the increase of a milder chronic form of the disease, the symptoms sometimes exhibit a for- midable character. There is copious purulent expectoration, with occasionally a little blood, shortness of breath much increased by exercise, debility, ema- ciation, a frequent pulse, sweats at night, and, in fact, all the obvious symp- toms of phthisis; so that the complaint was formerly, and is still occasionally denominated catarrhal consumption. Such cases not unfrequently terminate fatally, either by gradually wearing out the patient, or by the supervention of acute inflammation of the bronchia or other portion of the respiratory organs. In some instances, however, such acute attacks appear to supersede the chronic, and, if they do not carry off the patient, leave him better than they found him. When chronic bronchitis of this or the milder form has lasted for many years, it is sometimes dangerous to suppress it, especially in very old people. The system, so long accustomed to the discharge, cannot accom- modate itself to the new condition consequent upon its cessation ; and serious or fatal congestion or inflammation is apt to occur in some one of the vital organs. Frequently, in the course of chronic bronchitis, there is a mixture of acute with the chronic symptoms, in consequence either of the supervention of fresh inflammation in the parts before inflamed chronically, or of new parts becom- ing affected; and this possible complication should always be borne in mind in the treatment. A test of the occurrence of acute symptoms, suggested by Andral, is the appearance of transparent, amidst, or in the place of previously opaque sputa. The sign is generally, but not universally true. A variety of chronic bronchitis called by Laennec pituitous catarrh, by Williams bronchorrhcea, and by the older writers humoral asthma, is charac- terized by paroxysms of severe dyspnoea and coughing, followed by the copious expectoration of a ropy, glairy, transparent, and more or less frothy mucus, which has been compared to the white of egg beat with water, and allowed to stand. Several pints are sometimes discharged in twenty-four hours. The paroxysms occur daily, and, in some cases, several times a day, are exceedingly variable in their duration, are seldom accompanied with fever, and sometimes begin with coryza. Upon auscultation, the dry morbid sounds are first heard, CLASS III.] CHRONIC BRONCHITIS. 839 which are very soon followed by the mucous rale, showing that the attacks commence with a congestion and consequent tumefaction of the mucous mem- brane, which is afterwards relieved by secretion. The chronic disease consists in a peculiar condition of the bronchia, which renders them liable to conges- tive attacks from slight irritation; while the tissue does not possess energy enough to take on acute inflammation. The complaint is apt to occur in old gouty individuals, and those labouring under chronic disease of the stomach, liver, and especially of the heart. It sometimes also attends the develop- ment of miliary tubercles throughout the lungs. The paroxysms are induced by cold, irritating vapours or powders, and by other causes which ordinarily produce catarrh. The disease is sometimes speedily fatal in old persons, who die in one of the paroxysms, suffocated by the excessive secretion which they cannot discharge. Generally, however, it continues for a long time, in some instances for many years, wearing out the strength of the patient, who is apt to become dropsical, and dies at length from exhaustion or suffoca- tion. The excessive secretion sometimes relieves complaints of the heart by removing congestion. Laennec describes, under the name of dry catarrh, a variety of chronic bronchitis, with a very troublesome cough, sense of oppression in the chest, and either no expectoration, or only of small, semi-transparent, pearl-gray pellets, of the consistence of pitch. A sibilant rale is heard. The disease is apt to attack the gouty and hypochondriac, the inhabitants of the sea-coast, persons subject to cutaneous diseases, and those enfeebled by excesses. Physical Signs.—These are the mucous rales, occasionally mixed with the sonorous and sibilant, occurring in various parts of the chest, and often shift- ing. It is sometimes only by physical signs that the chronic catarrh can be distinguished from phthisis. The diagnostic symptoms of the former are equa- ble resonance upon percussion, the absence of the signs of consolidation in any portion of the lung, as bronchial resonance and respiration, and of the signs indicating a cavity, as amphoric resonance or respiration, and pectoriloquy. When these signs are absent, and at the same time there is copious purulent expectoration, the evidence is almost conclusive that the disease is bronchial. But, when the bronchia are themselves much enlarged, and contain pus, it is sometimes difficult to make an accurate diagnosis. The signs, however, of preceding consolidation of the lungs, characteristic of ordinary tuberculous deposits, are wanting in this case. (See Phthisis.) Prognosis.—In its worst forms, chronic bronchitis is a dangerous affection, though it often continues for many years, and is occasionally prolonged from middle life into an advanced old age. It is not so often directly fatal, as in- directly, by so far debilitating the system, and deteriorating the lungs, as to cause the patient to sink under the supervention of acute inflammation whether of the bronchia or other part of the respiratory apparatus. One of the first effects of these acute attacks is to produce a suspension or diminution of the discharge from the bronchia, which is, therefore, a bad sign in chronic bron- chitis Patients with this disease also frequently die of complaints of the heart which are sometimes the cause, and sometimes probably the result of the bronchial affection. The coexistence of much enlargement of the bronchia with chronic inflammation is an unfavourable sign. The supervention of an attack of spasmodic asthma upon an old catarrh occasionally adds greatly to its danger In determining as to the degree of danger from chronic bron- chitis, it is very important to ascertain whether it may not be dependent upon some more serious disease. . Anatomical Characters —The mucous membrane is thickened, sometimes Dartiallv indurated, sometimes, though rarely, softened or ulcerated, in some cases of a deep-red, violet, or brownish hue, in others grayish, whitish, or only 840 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. of a slightly reddish tinge, and generally lined with puruloid mucus or well- formed pus. The extreme tubes are not unfrequently distended with the pul- monary secretion; and the bronchial glands enlarged and softened. In the dry catarrh of Laennec, the minute bronchial ramifications are reddened, and so much thickened as often to obstruct the passage, and, when this is not the case, are apt to be blocked up by a thick, tenacious matter, in globules of the size of millet seeds. The tubes are occasionally found dilated, either singly or in numbers, sometimes throughout the whole extent of a branch and its ramifications, sometimes in isolated portions of the tube. In the former case, the parietes are generally thickened, and the result is probably owing to a kind of inflammatory hypertrophy; in the latter, they are thinned, sometimes very much so, owing, undoubtedly, to distension from the extraordinary im- pulse given to the air in coughing and respiration. Constriction of the tubes is sometimes observed, in such a degree as completely to close them, arising from thickening of the mucous membrane, or of the entire wall of the tube. In some cases in which all the signs of chronic bronchitis exist during life, the tubes are found to all appearance perfectly healthy after death. (Andral, Bayle, dec.) More or less emphysema of the lungs is almost always found in fatal cases of chronic catarrh. Causes.—The greater number of cases of chronic catarrh are the conse- quences of acute attacks. But not unfrequently they come on gradually from the slight and continued or frequent application of causes of irritation, such as ordinarily produce the acute disease, when more intense, or acting on more susceptible subjects. Irritating powders are apt to produce this effect when inhaled; and hence, stone-cutters, workers in metal, and those employed to cleanse feathers, hair, &c, by beating them, are liable to the disease. There is a peculiarity, moreover, of constitution, which predisposes certain individu- als to chronic bronchitis; and such a peculiarity often exists in persons of a rheumatic or gouty habit of system, and those subject to cutaneous eruptions. The disease is a frequent accompaniment of other pectoral complaints, espe- cially phthisis, in which, when fully developed, it is never absent. Disease of the heart frequently causes it, in consequence of the irregular distribution of blood in the lungs which it produces, and, when not the cause, tends to aggra- vate the complaint, and to render it much more obstinate. It frequently fol- lows measles and hooping-cough; and appears sometimes to depend upon the suppression of habitual discharges, especially the menstrual and hemorrhoidal. Treatment.—General bleeding is seldom required or admissible, to any considerable extent. In some cases, when the symptoms, under temporary influences, assume a more acute character, a few ounces of blood may be taken with advantage from the arm; but it should always be done with cau- tion. Local bleeding, by cups or leeches, is both safer and more efficacious. It may be resorted to occasionally, and in moderation, when there is some pain or stricture in the chest, with sufficient strength of pulse. The expectorants are, upon the whole, the medicines best adapted to this complaint. In the choice of them, the practitioner must be guided by the symptoms. Should some excitement of the circulation exist, with deficient expectoration, and some degree of constriction, the least stimulating articles of the class should be used, such as tartar emetic in aqueous or vinous solu- tion, ipecacuanha wine or syrup, tincture of sanguinaria and of lobelia, and wine of colchicum; of which a dose should be given four or six times a day, and so regulated as to be kept just within the nauseating point. If, as com- monly happens, there is little or no evidence of general excitement, or active inflammation, one or more of the above-mentioned expectorants may be con- joined with syrup or tincture of squill, or syrup of seneka. I have found no com- bination more efficacious than the decoction of seneka and liquorice root, with CLASS Hi.] CHRONIC BRONCHITIS. 841 tartar emetic, described under acute bronchitis. (See page 835.) It has hap- pened to me to see many very obstinate cases of cough yield to this remedy. Ihe seneka appears to exercise an alterative influence over the bronchial mucous membrane, independent of its expectorant power. The compound squill pill of the Pharmacopoeia, containing chiefly squill and ammoniac, is an excellent combination. Recourse may also be had to the balsams of Tolu and Peru, the compound tincture of benzoin, and to copaiba. The last- mentioned medicine often proves serviceable in chronic catarrhs. The expec- torants should generally be given in mixture, with small doses of one of the narcotics to allay cough. When there is tightness of the chest, and want of bronchial secretion, hyoscyamus, conium, stramonium, belladonna, hydro- cyanic acid, or chloroform should be preferred to opium; and tincture of camphor, or camphor-water, may sometimes be usefully added to the other ingredients. Under other circumstances, one of the opiates should be pre- ferred, as more effectual than the medicines mentioned in allaying cough. The salts of morphia are probably the best preparations of opium for use in bronchial disease. The camphorated tincture of opium is a very agreeable preparation, well adapted to cases without any vestige of acute inflammation. Black snake-root, or cimicifuga, sometimes exerts a happy influence in the relief of chronic coughs. Sulphur, in the dose of half a drachm or a drachm, two or three times a day, is also said to be useful. Cough mixtures of almost infinite diversity may be prepared from the above materials, in the choice and association of which the practitioner has ample opportunity for the exercise of a discriminating judgment. Gum arabic, liquorice, and. sugar, are useful demulcent additions to the expectorants. If the expectorant treatment fail, aided by local measures, such as will be detailed immediately, and should the case exhibit no peculiar tendency to tuberculous disease, recourse should be had to a mercurial impression, which should be maintained moderately for weeks, if not sooner effectual. For this purpose calomel or the mercurial pill should be employed; and advantage will often accrue from the addition of a narcotic, such as extract of hyoscya- mus or conium, or opium with ipecacuanha when not contraindicated. Muriate of ammonia is highly esteemed and much employed by German practitioners under similar circumstances. It has also been used with great asserted advantage by inhalation. The salt may be volatilized in a suitable vessel by means of a spirit lamp, and the vapours inhaled as they escape, due caution being observed that they are not too concentrated. Dr. Gieseler has found the remedy thus used, two or three times daily, to cure chronic catarrhs in a few days, and on no occasion to be quite useless. (B. and F. Med.-Chir. Bev., July, 1856.) Should febrile action supervene upon chronic bronchitis, it may usually be relieved by a saline aperient, the neutral mixture, and tartar emetic in small doses. External irritation should be sustained by blisters to the chest frequently repeated, pustulation by tartar emetic or croton oil, and setons or issues be- tween the shoulders. To do permanent good, these must be long persevered in. The irritant should be applied as near as possible to the seat of inflam- mation, as indicated by auscultation. In mild cases, it may be sufficient for the patient to wear a plaster of Burgundy or Canada pitch, or a warming plaster. Frictions to the chest are also useful, and especially with rubefacient liniments composed of some ofthe stimulating volatile oils, as of turpentine, rosemary' origanum, or monarda, sufficiently diluted with olive oil. When the disease is connected with a repelled eruption, it is important to endeavour to restore the cutaneous affection by irritation to the part in which it had previously existed; and croton oil is an excellent irritant for this purpose. 842 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Inhalations are also very useful in some cases of chronic bronchitis. The vapours of tar are especially beneficial. The air of pine forests is thought to be peculiarly wholesome in this complaint. The fumes of common resin, de- composed by heat, have been employed with advantage. Copaiba, and an ethereal solution of balsam of Tolu have been recommended. To these, anodyne additions may be made with advantage, as opium, conium, and some one of the preparations containing hydrocyanic acid. Other substances, occasionally administered in this way, are chlorine and the vapour of iodine. The former may be breathed with the air in apartments, in which solutions of chloride of lime, potassa, or soda are placed; the latter is most conveniently applied by means of an inhaler, along with the vapour of water, and that of tincture of conium, hyoscyamus, opium, ether, or Hoffmann's anodyne. In old or prostrate cases of chronic bronchitis, with copious purulent ex- pectoration, night sweats, &c, it is in many instances highly important, in addition to the treatment above detailed, to employ measures calculated to invigorate the system. The chalybeates, combined with the bitter tonics, may be used, the former to improve the character of the blood, the latter to promote digestion. The infusion of wild-cherry bark, long and freely used, is an excellent remedy under these circumstances; and may often be advan- tageously associated with one of the mineral acids, especially the aromatic sulphuric acid, or the nitromuriatic. Decoction of Iceland moss has been much used, and it is said sometimes very efficaciously, as tonic, demulcent, and nutritive. Sulphate of quinia may be given when the disease is accompanied with chills and hectic paroxysms. Porter and other stimulant drinks must be called in requisition when the debility is great. Dr. Alison, of Edinburgh, has found great advantage from tannic acid, in doses of from one to three grains, two or three times a day. It diminishes the secretion and the cough, and increases the general strength. Should gastric or hepatic disease exist, the treatment must be modified accordingly, and, in cases of vomiting with gastritis, the stimulant plan should be suspended if possible. Exercise should be taken freely in warm dry weather; but exposure to cold and wet should be avoided. Hence the importance, if the patient be a resident of cold and austere climates, that he should remove during the winter to warm and equa- ble latitudes. The interior of one of our most Southern States, or one of the West India islands may be recommended. A sea voyage is itself often beneficial, and, if long enough, will not unfrequently effect a cure. A change of residence, even without any considerable obvious change of climate, is sometimes beneficial. A resort to the Sulphur Springs may be advised, in the hope of good from their waters. Warm clothing, and flannel next the skin are important. Advantage will often accrue, during the severe cold of our winters, from wearing wadded cotton or lamb's wool over the breast or shoulders. General frictions to the surface are sometimes useful. The diet should vary with the circumstances of the case. Ordinarily, it should be nutritious without being stimulant, consisting, for example, of milk, the lighter meats in moderation, fish, farinaceous preparations, and vegetables. When there is any degree of acuteness in the symptoms, meats should be forbidden, and the patient confined to milk and vegetables, or the latter alone. Stimulating drinks should not be allowed unless in cases of considerable debility. In the form of bronchial disease denominated pituitous catarrh, bronchor- rhoza, or .humoral asthma, the treatment should vary according as it is applied to the paroxysm or the interval. At the accession of the attacks, hot pediluvia, hot baths, sinapisms over the epigastrium, and, if the strength permit, an emetic of ipecacuanha, may be employed, followed by small doses of the same medicine or of tincture of lobelia, every hour or two, so as to CLASS III.] CATARRH. 843 sustain a slight nausea. During the excessive expectoration, stimulants some- times become necessary to support the strength, and aid the patient in the discharge of the mucus. For this purpose, carbonate of ammonia, Hoff- mann's anodyne, or ether may be employed. Strong coffee has also been re- commended. In the intervals, efforts should be directed towards obviating the tendency to bronchial congestion. The indications, therefore, are to give tone to the bronchial vessels, and to maintain a moderate secretion from them. For this purpose, the stimulant expectorants already enumerated as remedies in chronic catarrh should be employed, and should be given with small doses of one of the preparations of antimony or ipecacuanha, or some other nause- ating expectorant. Blisters to the chest are also useful. The functions should all be carefully attended to, and corrected if deranged. Disease of the liver and stomach, if existing, should be removed, the bowels should be kept regular, and gouty tendencies obviated by suitable remedies In relation to diet, exercise, fresh air, an equable temperature, and warm clothing, the same remarks are applicable as to chronic bronchitis in general. III. CATARRH. This name was formerly applied to diseases of the mucous membranes generally, attended with increased secretion. At present, however, when not connected with some epithet fixing its locality elsewhere, it is confined to inflammation of the respiratory passages. Each portion of these passages gives a distinct name to the inflammation with which it may be affected. Hence we have coryza, angina, laryngitis, and bronchitis. But it often hap- pens that, in the same attack, all these parts are successively or simultaneously the seat of inflammation, which, therefore, may be said to constitute one dis- ease. For this, in its full extent, we have no other name than catarrh. Some writers consider catarrhal inflammations as peculiar or specific, " character- ized by slightly increased vascularity, afflux of the circulating fluids, and aug- mented secretion." I have never been able to discover anything specific in its character. The inflammation, which begins with increased secretion in the nostrils, very often becomes dry when it reaches the throat or bronchial tubes; and yet it can hardly have changed its nature. There is a certain grade or stage of inflammation in the mucous membranes, in which they are disposed to copious serous or thin mucous secretion ; and what these writers designate as catarrh differs from other examples of inflammation only in this respect. The disease usually begins in the nostrils with coryza, then invades succes- sively the fauces, larynx, trachea, and bronchia, and finally loses itself in the ramifications of the last-mentioned tubes. Sometimes, especially in children, it penetrates to the vesicular structure of the lungs, and constitutes pneumo- nia. Not unfrequently, also, the inflammation commences in the fauces or larynx, and runs downwards; and, in some instances, making its first appear- ance in the bronchial tubes, it extends upwards as far as the nostrils, giving rise to coryza. The grade of inflammation is apt to be nearly the same throughout this course unless modified by treatment. If the coryza or angina be light, the chances are that the bronchitis will be light also ; and vice versa. Some of the worst cases of bronchitis begin as intense inflammation of the fauces, ex- tending to the submucous tissue. When the disease reaches the chest, and is attended with febrile symptoms, it is called catarrh fever It is unnecessary to treat of the symptoms of catarrh. They vary with the part or parts affected, and have been sufficiently described under the preceding heads When severe, the complaint is almost always attended with fever, 844 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. and, even though slight, is not unfrequently thus attended, if it occupy simul- taneously a great extent of the respiratory passages. The treatment has been already fully detailed. Thus, when the disease occupies the nostrils, it must be treated as coryza; when the fauces, as an- gina ; when the larynx, as laryngitis; and, finally, when the bronchia, as bronchitis. It is only necessary to state here, that it is often highly important to arrest the disase, or diminish its violence, in its earliest seat, so that it may either not reach the bronchia at all, or reach them in a milder form. Hence the propriety of attacking inflammation of the nostrils and fauces more efficiently than if the complaint were to be confined within these limits. Attention to this suggestion may often prevent a long-continued, if not se- rious attack of pectoral disease. In the cases of individuals subject to frequent and severe attacks of catarrh, it is sometimes very desirable to meet the disease upon the threshold, and turn it aside if possible. This is true in whatever portion of the air-passages it may make its first appearance. The means calculated for this purpose are, chiefly, a large dose of opium at bedtime, and the production of a copious and continued flow of perspiration. For the modes of carrying these mea- sures into effect, and the cautions necessary, the reader is referred to the article on coryza. IY. INFLUENZA. Syn.—Epidemic Catarrh.—Grippe (Fr.). The name influenza, adopted from the Italian, has been applied exclu- sively, though with no great propriety, to an epidemic disease which usually takes on the character of catarrh. The first epidemic of this kind, of which we have any distinct medical record, occurred in the year 1510. There can be little doubt, however, that it has occasionally visited mankind from the earliest ages. Since the year mentioned, we have numerous records of its occurrence, at irregular intervals, down to our own times. The epidemic appears to have been altogether irregular in the periods of its occurrence. Sometimes returning in two or three years after its disap- pearance, it has, in other instances, postponed its return for seven, ten, or even twenty years. Nor does it appear to have observed any certain course in its progress. In general, however, its tendency is to proceed from the east towards the west, and it probably marches more frequently from the south northward, than in the contrary direction. On the old continent, it has sometimes commenced in Russia, advanced westward through Poland and Germany, then crossed into Britain, and afterwards visited successively France, Spain, and Italy. On other occasions, it has begun in the south- east, and entering France and Spain from Italy, has thence proceeded to England, and swept round the north of Europe. In this country, it has sometimes proceeded from the Northern States towards the Southern; on other occasions, has commenced in the latter, and marched towards the north. Its spread is usually so rapid, that it not unfrequently appears throughout vast extents of territory almost simultaneously. Oceans seem to oppose no obstacle to its course. It has leaped over from Europe to North Ame- rica, has been observed in solitary islands in the midst of the ocean, and has attacked the crews of ships far out of reach of any communication from the land. It appears sometimes to have made the circuit of the whole globe. There is a considerable resemblance in its course to that of epidemic cholera, the march of which it has both immediately preceded and followed. At the moment of invasion, it seizes almost simultaneously on great num- CLASS III.] INFLUENZA. 845 bers, and before its departure sometimes involves almost the whole popula- tion. Its average duration, in each neighbourhood, is about six weeks; though the cause appears to linger after all the susceptible material for its action has been exhausted; for strangers arriving in the affected region, after the disease has apparently ceased, are not unfrequently attacked. The in- ferior animals appear to suffer as well as man. Many instances are on record, in which horses, dogs, sheep, and even birds have been seized by the epi- demic. Some persons are much less susceptible to the morbid influence than others, and some appear to be altogether insusceptible. No obvious cause exists for this discrepancy. All ages, both sexes, and every variety of tem- perament and occupation, are equally liable to attack. It has been estimated that from one-half to three-quarters of the whole community are in a greater or less degree affected. The disease exhibits, on the whole, a remarkable uniformity of character, though it has occasionally differed much in its grade of severity, in different times and places. In general it is very mild ; but, on some occasions, and in certain localities, it has proved extremely fatal. Thus, during the epi- demic of 1850, nine thousand persons are said to have died ofthe disease in Rome. It is probable that other epidemic influences may occasionally com- bine with and modify it in certain situations. It may, for example, be con- ceived that, if it should appear in a neighbourhood already tainted with a typhoid influence, this might fearfully increase the mortality. In many of the epidemics, authors have recorded unusual changes in the temperature, moisture, and weight of the atmosphere ; but the same state of the weather has not been observed in different places attacked; and not un- frequently there has been nothing uncommon noticed. It appears that the disease has prevailed in all climates, at all seasons, and in every possible thermometrical, hygrometrical, and barometrical variation. It has sometimes occurred in summer, though more frequently in the colder seasons. Symptoms.—Influenza usually appears with the ordinary symptoms of catarrh, upon the whole, in a rather aggravated form. In many instances, however, it is very light, without fever, and scarcely regarded by the patient. It usually begins with coryza or sore-throat, and the common preliminary symptoms of fever, as feelings of lassitude and weariness, pains in the limbs, chilliness, rigors, &c, which are followed first by heat of skin, headache, and excited pulse, and soon afterwards by cough, uneasiness in the chest, and other signs of pectoral disease. But the symptoms of nervous derangement are in general much more prominent than in ordinary catarrh, and there is greater muscular debility. Disorders of sight and hearing, giddiness, pains in the back and limbs, general uneasiness, and depression of spirits are not uncommon in this disease. The headache is often severe, sometimes affecting equally the whole head, but more frequently concentrated in the forehead, and especially in the region of the frontal sinuses. Not unfrequently the pains extend to the back of the neck, in the form of rheumatism, and to the cheeks and temples, which are very sore and painful. Disorders of stomach, such as nausea and vomiting, are more common than in ordinary catarrh. But the most distinguishing feature of the disease is the debility which attends it. Almost all writers are agreed upon this point In some of the epidemic attacks, it seems to have been less striking than m others, and in a few instances the pulse is said to have been strong, and to have not only borne but imperiously demanded depletion. But, in the much greater num- ber of instances, it is described as having been feeble; and in some, the de- bility was extraordinary, so that the disease would not at all bear the loss of blood and death was in numerous cases ascribed to bleeding. So great was the prostration of strength, that the patient fainted merely upon attempting 846 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. to sit up. Another striking circumstance is, that the debility often continued for a considerable time after the cessation of all other symptoms. I cannot say that I have observed this extraordinary debility in the epidemics which it has been my lot to witness; but the testimony to the fact is too strong and united to admit of denial. As in ordinary catarrhal fever, there is generally a remission of the febrile symptoms in the morning, and an exacerbation towards night. The degree of intensity in the nasal, throat, and pectoral symptoms is extremely variable. Sometimes the affection of the mucous membrane scarcely exceeds the point of irritation or congestion; and, even when the cough is considerable, auscultation does not always detect the signs of bronchial inflammation. But the effects of this epidemic influence do not necessarily appear in the shape of catarrh. In some instances, its force has been spent upon the brain; and violent headache, flushed face, delirium, and fever have been the promi- nent symptoms. Sometimes the digestive organs have been affected, and the disease has been evinced chiefly by 'epigastric pain and tenderness, nausea, vomiting, &c. Occasionally it has appeared in the form of colic, diarrhoea, or dysentery, which have either existed alone, or as complications of the catarrhal affection, especially towards its close. Inflammations of the lungs, pleura, and pericardium have always been frequent during the prevalence of influenza, and have undoubtedly been dependent upon the same cause as that of the respiratory passages. Sometimes inflammation has appeared in these situations as an original affection, and sometimes as an attendant upon the bronchial disease. Abscesses of the frontal sinuses were noticed by Rush among the forms of influenza. Ha?moptysis not unfrequently occurs in per- sons predisposed to it. Authors speak also of inflammation of the urinary organs among the effects of the epidemic cause. Epidemic catarrh has usually the same course and duration as the disease from ordinary causes. It generally terminates favourably by perspiration, copious mucous secretion from the bronchia, or increased discharge of urine, which deposits a sediment on standing. Pustular eruptions, erysipelas, and scarlet rashes, are enumerated among the phenomena which occasionally occur at the close of the complaint. The duration of the disease varies from two or three days to one or two weeks; and a cough is frequently left after the other symptoms have disappeared. The fever, probably in most cases, goes off about the fifth day, with copious sweating or expectoration. A catarrhal epidemic, in which the disease assumed, in frequent instances, a regular intermittent character, with paroxysms occurring daily at a par- ticular hour, and which yielded to the sulphate of quinia, is described by Dr. Samuel Webber, of Charlestown, N. Hampshire. (Boston Med, and Surg. Journ., xxxviii. 149.) Epidemic catarrh cannot be considered as a dangerous disease. It is scarcely ever fatal, unless complicated with inflammation of the brain, lungs, or heart, or in persons debilitated by old age, or previous maladies, such as chronic catarrh, phthisis, and organic cardiac affections. It occasionally also proves fatal in infants. But, though thus mild in its character, it affects so large a number of individuals, and so many persons in every community are just tottering on the brink of the grave, that it proves the immediate cause of numerous deaths whenever it prevails. Thus, in some places, it is asserted to have proved more fatal in reference to the community at large than even cholera, in consequence of the vastly greater number of persons affected. It has been estimated that, of those attacked by influenza in its different forms, about two out of every hundred perish. Causes.—The peculiar nature of this epidemic influence has been a subject of much conjecture and discussion, but has not yet been satisfactorily explained. CLASS III.] INFLUENZA. 847 Some have supposed that it might consist in those atmospheric vicissitudes which have often been observed to accompany the epidemic; but this notion is contradicted by the fact, that the disease has occurred under all possible varieties of appreciable atmospheric condition, at all seasons, in all weathers, and at the same moment in distant places, differing wholly in climate, and the state of the atmosphere at the time. The ascription of the disease to a peculiar electrical state ofthe air is equally unsatisfactory; for no such state has been shown to exist in connection with it. That the cause cannot be an exhalation from the earth is proved by its rapid passage from one country to another, from the immense extent of its prevalence, and from the fact, that it acts in the midst of the ocean, which no such exhalation would be apt to reach. The notion of some uncertain telluric influence is too vague to require refuta- tion. Nor does the idea of contagion, though entertained by so high an authority as Cullen, appear to deserve a much more serious notice. It is alto- gether beyond modern credulity, that a disease which sweeps like a tempest over nations, and prostrates whole communities almost at the same moment, should be propagated by communication from individual to individual. That, though occurring epidemically, it may still have contagious properties, like measles and scarlatina, is another matter, and not so obviously absurd. But there is no good reason even for this modified belief. A contagious disease usually attacks some one individual in a family, and after a certain interval extends to others. The influenza commonly seizes at once upon the whole family. The vicinity of the sick has not been shown in any degree to favour the occurrence of the disease. Contagious affections communicated through the atmosphere usually occur but once. An attack of influenza is no security against subsequent attacks. Contagion lingers long after the epidemic has passed. Influenza leaves few or no straggling cases behind it; unless those of individuals who may suffer relapses from cold or other cause. It is said that the disease has been observed to commence in certain places after the arrival of strangers from infected neighbourhoods, and to spread from the point of arrival. This might happen fifty times, and yet be purely accidental At present very few believe that the disease is in any degree contagious. The last notion which has been advanced as to the nature of the epidemic cause, is that it is organic, consisting of innumerable animalcules or vegetable micro- scopic fungi, which have the power of propagating rapidly in the atmosphere, but run a brief course of existence There is some plausibility in this idea. It explains many of the extraordinary movements of the epidemic, and ac- counts for the asserted fact of individuals from infected districts becoming the centre of a new prevalence elsewhere. They may bring about their persons, or in their baggage, organic germs, which may soon fill the atmosphere with their progeny. But this hypothesis is wholly destitute of proof; for the asser- tion that immense swarms of visible insects sometimes appear during the catarrhal epidemic, even if its truth be admitted, goes but a very little way towards proving that the epidemic cause consists in insects that are invisible. It is best then at once to confess our ignorance on this point, and to wait patiently until wo can obtain new light. Treatment.__In relation to the treatment it is necessary to say but little. The disease must be managed in the same way essentially as common catarrh. (See coryza, laryngitis, and bronchitis.) There is one prominent difference, however, which requires notice. Almost all writers agree that the influenza does not so well tolerate depletion. Bleeding is not borne well, or if borne, is said to be less effective. In abstracting blood, therefore, it is proper to be cautious, and always carefully to examine the pulse. If this begin to falter, the bleeding should be immediately checked. As a general rule, unless the symptoms of inflammation are decided, it is best to avoid venesection alto- 848 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. gether, and to trust chiefly to the diaphoretic plan. Even active purgation is scarcely admissible. Eupatorium, or boneset, has long been recommended in this disease. Dr. Peebles (Am. Journ. of the Med. Sci, N. S., vii. 365) spoke in the highest terms of its utility. He employed it in many cases ex- clusively, and found it useful by its sudorific, laxative, and emetic properties, when administered early in the complaint, in the form of warm infusion; and by its tonic powers, when given in cold infusion in the advanced stage. When diarrhoea occurs in the latter stages, it may be arrested by means of opium and ipecacuanha. When the debility is considerable, it is often necessary to support the system by tonics, aromatics, and even more powerful stimulants. Should the disease assume a regular periodical character, sulphate of quinia would be indicated. Y. CROUP. Syn.—Cynanche trachealis.—Angina trachealis.—Tracheitis.—Hives. This is a disease almost peculiar to infancy and childhood. The name of croup, by which it is usually designated, is of Scottish origin, and is said to be derived from roup, a word used in some parts of Scotland for the sound made by a chicken with the pip. No correct scientific name has yet been adopted, embracing all the varieties of the disease. Cullen's cynanche trachealis, and the more modern tracheitis are objectionable; as they lead to false notions of the pathology of the affection. Croup is not essenti- ally inflammation of the trachea. It may exist without disease of that part of the respiratory passages; and inflammation of the trachea often takes place in infants, as in their catarrhal affections, without producing the symptoms of croup. The complaint may be confined to the larynx ; though it generally embraces also the trachea, and not unfrequently extends deeply into the bron- chial tubes. It may, therefore, occupy one or several divisions of the respi- ratory passages. If any one part is necessarily affected, it is the larynx; for a case would scarcely come under the designation of croup, in which this organ should not be disordered, at least in its functions. To constitute croup two circumstances are essential. One of these is inflam- mation or high vascular irritation of the laryngeal, or laryngo-tracheal mucous membrane. But that inflammation alone does not constitute the disease is proved by the fact, that it often exists without the peculiar croupal pheno- mena, as in measles, catarrh, smallpox, &c. The additional circumstance, not less essential than inflammation, is spasm of the interior muscles of the larynx. It is this which distinguishes the croup of children from the similar inflam- matory affections of adults, occupying precisely the same structure. Some have supposed that a variety of croup exists which is purely spasmodic. It is certain that the muscles of the glottis sometimes contract spasmodically, without inflammation or vascular excitement; but the phenomena are different from those of croup, and belong to a different pathological condition. Definition.—Croup, therefore, may be defined to be a disease, in which in- flammation or high vascular irritation of the laryngeal, or laryngo-tracheal mucous membrane, is combined with spasm of the interior muscles of the larynx, giving rise to peculiar modifications of voice, cough, and respiration. Varieties.—Under the name of croup are usually confounded two forms of disease, materially different in their character, and greatly so in their results. This will scarcely admit of contradiction, when we consider that, of the cases commonly called croup, both popularly and professionally, in this country, a vast majority are very manageable, yielding with great facility and with con- CLASS HI.] CROUP. S49 Biderable certainty to the early application of remedies; while the disease, a? described by most European writers, is stated, under precisely the same treat- ment, to be exceedingly fatal, even when attacked in the earlv stage, and almost necessarily so in the advanced stage. Without having the support of statistics, I do not think I shall greatly err in stating, that not one in fifty patients dies of ordinary croup in this country, when properly treated ; while European writers inform us, that formerly the proportion of deaths was four out of five, and at present, when the treatment is better understood, is not less than one-half. The two forms of the disease differ essentially iu the product ofthe inflammatory action. In the more curable variety, the mucous membrane, if it secrete at all, yields mucus, pus. or a muco-purulent fluid, according to the degree and stage ofthe inflammation. In the more danger- ous form of the disease, fibrinous exudation takes place upon the inner sur- face of the air-passages, giving rise to the formation of false membrane. In the former, the inflammation is exactly analogous to that which takes place in catarrh, and, as in that affection, may be of every grade, from the slightest and most trivial, to the severest and most dangerous. The disease differs from catarrh only in cousequence of the addition of spasmodic symptoms. In the other form of croup there is something peculiar, either in the character of the diseased action, or the state of the blood, which induces the peculiar exudation. The nature of this exudation has nothing to do with the violence of the inflammation; for the false membrane is often produced when the in- flammatory action is only moderate, as proved both by the phenomena during life, and the results of dissection. The milder form of the disease will be distinguished in this treatise by the name of catarrhal croup, the more dan- gerous, by that of pseudomembranous croup. But, while making this distinction in the general character of the two varieties, I admit that the catarrhal form may run into the pseudomembran- ous ; in other words, that a case beginning with the symptoms of the former may terminate with those of the latter. Indeed, in the earliest stage, before secretion has commenced, it would be impossible to determine, with certainty, which form the disease was about to assume Again, there may be cases in which the two forms shall be combined; that is, in which one portion of the membrane shall secrete mucus, and another exude fibrin; and the relative amount of the secretion and exudation would determine the position of the case in one or the other division. From these facts the important practical inference is deducible, that, in every case in which the symptoms of croup appear, efficient remedies should be promptly applied; for, if carefully em- ployed and properly guarded, they can do little serious injury; whde the neglect of them may possibly lead to the most deplorable consequences. No rule in medicine is more certain, than that every case of croup, whatever mav be its apparent character, should be treated promptly and efficiently. L Catarrhal Croup. — False croup. — Stridulous laryngitis.— Stridulous angina, —Spasmodic laryngitis. — This is sometimes called spasmodic croup; but the name is improper, as both forms ofthe complaint are more or less spasmodic. In giving it the name of catarrhal croup, I wish to be understood merely as indicating that the inflammation is of the same general nature as that which occurs in catarrh. Symptoms, Course, &c— The disease commences variously. >ot unfre- quently the child is affected for some time with the symptoms of common catarrh such as coryza, sore-throat, bronchial irritation, cough of an ordinary character and perhaps fever, before those peculiar to croup are developed. Yery often a croupy cough and some hoarseness precede the attack for some hours or even davs ; and this state of things, though always suspicious, some- times passes away spontaneously, without the occurrence of the fully formed VOL. L bi 850 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. disease. Either after the prevalence, for a shorter or longer time, of the symptoms just referred to, or altogether without premonition of any kind, the child is attacked with a paroxysm of coughing and dyspnoea, having certain peculiar and highly characteristic features. In the majority of instances, this occurs in the night, and more frequently in the early part of it than towards morning. The paroxysm differs greatly in severity in different cases, being sometimes very slight, sometimes violent and alarming, and of every inter- vening grade between these two extremes. The following description applies to one of a very decided character. The child usually starts out of sleep with a peculiar dry, sonorous, ringing cough, sounding, according to Cheyne, as though it came through a brazen trumpet; but in fact comparable to nothing else in nature, and to be appre- ciated only by being heard. When once heard, it will always afterwards be easily recognized. So characteristic is it of this disease, that, when met with in other affections, as sometimes happens, it is called the croupy cough. It is occasioned, in all probability, by a certain spasmodic rigidity of the vocal cords, giving an almost metallic tension to the sides of the rima glottidis. Im- mediately succeeding the cough there is often a shrill, stridulous sound, pro- duced during inspiration; and the two sounds together, that of the cough and of the inspiration, have been compared to the barking of a small dog, or the crowing of a young cock, though the resemblance is not very obvious. Along with the cough, which is frequently repeated, the child is affected with dys- pnoea, which is often severe and very distressing ; the respiration being dry, wheezing, and often sonorous, as if the air entered through a narrowed pas- sage, with firm vibrating walls. If the child attempts to speak, the voice is usually more or less rough and hoarse, though very rarely quite extinct or whispering, and scarcely ever more than temporarily so. This is an important point in the diagnosis of the two varieties of croup. So long as the voice is so- norous, even though occasionally suppressed during a paroxysm of laryngeal spasm, there is good reason to hope that the case may not prove to be pseudo- membranous. The distress of the little sufferer during the paroxysm is often very great. He sits up or tosses himself about in bed, supports himself on his hands and knees, or lies on his back with his head extended, so as to give as great a permeability as possible to the trachea; puts his hands to his throat as if to remove some difficulty there, or holds them out imploringly for aid from his attendants ; and, as if conscious of threatened suffocation, has upon his countenance an alarmed, anxious, and affectingly beseeching expression. Sometimes, when able to speak, he complains of tightness or pain in his throat; but his voice, and his piteous attempts to cry, are often stifled by the cough, and increase the violence of the paroxysm. At first the countenance is usually flushed, the skin warm, and the pulse frequent and febrile; but, unless the paroxysm subside, especially when it is very severe, the effects of the impeded respiration begin to be experienced in the state of the blood, which is insufficiently aerated. The lips assume a pur- plish or livid hue; the face becomes pale, the extremities cool, the pulse very frequent, feeble, and irregular; and a condition takes place approach- ing to asphyxia, during which the spasm relaxes, and the air is allowed again to enter the lungs. The violent symptoms are now moderated, and the paroxysm gradually subsides, so that the child falls to sleep, and upon awaking is found to have been greatly relieved. In some extraordinary cases, complete and fatal asphyxia may occur in the paroxysm; but this is exceedingly rare, under suitable treatment. Yery generally the symptoms are much more moderate than as above de- scribed. They are said to be less severe when the attack occurs in the day- time. The duration of the paroxysm varies from a few minutes to several IIL] CATARRHAL CROUP. 851 hours. In the morning the patient often appears nearly well, except that an occasional cough may be heard, the croupy sound of which gives warning that the disease is not yet gone. There may also be some hoarseness of the voice and, if the fauces are examined, they may be found somewhat red- dened. Should proper treatment be adopted, there may be no return of the paroxysm of dyspnoea; and the child may be restored to health. This result sometimes takes place even without treatment. But in general the cough and dyspnoea return, occasionally during the day, but more frequently in the following night, and often with symptoms more violent than at first. A similar course is run, though perhaps with a less complete subsidence of the symptoms ; and for two, three, or four days, the disease continues, with oc- casional exacerbations and remissions, and with a more or less threatenino- aspect, according to the degree of the accompanying inflammation. If this is moderate, it gradually yields, and along with it the spasmodic paroxysms, which become milder and milder, and at length cease to recur; the child being left with nothing but a catarrhal cough, which soon disappears. But often, especially when not properly cared for in the beginning, the course of the disease is less favourable. Sometimes the symptoms of pseudo- membranous croup supervene, indicated by a huskiness of the voice, gradu- ally increasing until no sound can be uttered above a whisper. But this is rare; and the greater violence of the disease depends simply on the greater severity or extent of ordinary inflammation of the air-passages. This fre- quently affects the bronchia ; and then, along with the peculiar phenomena of croup, are those of catarrhal fever, such as a hot skin, an accelerated pulse, rapid respiration, frequent cough, and often pain or soreness of the chest, indicated by the crying of the infant after every paroxysm of cough- ing. When the laryngeal or tracheal inflammation is severe, there are pain and soreness upon pressure, with occasional swelling of the external parts, and constant difficulty of breathing, with sonorous or even sibilant inspira- tion, dependent partly upon swelling of the mucous membrane, and partly upon spasm of the muscular fibres. But the voice, though hoarse, is not suppressed; and the cough is sonorous. In connection with these symp- toms, which are constant, the paroxysms of dyspncea return with greater frequency and violence than in milder cases. The slightest cause, such as crying, attempts at speaking, drinking, mental emotion, &c, brings on the most distressing difficulty of breathing, with a suffocative cough, and occa- sionally vomiting, probably from the irritating movements of the fauces. If not relieved, the patient may go off in one of these exacerbations; or, after suffering inexpressible agony, may perish of a slower suffocation, with a cold skin, clammy sweats, a feeble vanishing pulse, and ultimate coma. If he survive, a new train of symptoms commences, which may be con- sidered as the second stage of the disease, and usually makes its appearance at the end of two or three days. It is the stage of secretion. The cough now sounds loose and more broken, especially towards the end of a paroxysm; and a portion of mucus is often thrown up, clear or tinged with blood. Should the attack be disposed to terminate favourably, the paroxysms of coughing become shorter and less severe, the inspiratory sounds acquire a mucous character, the cough loses its harsh ringing tone and becomes quite loose, and if the child be old enough to expectorate, mucus is discharged freely, at first clear then whitish and opaque, and ultimately purulent, exactly as in catarrh 'The fever subsides, the croupy symptoms quite disappear, and the child recovers completely, in a length of time varying from three or four days to two weeks from the commencement Sometimes, however, an excess of secretion beyond the ability of the patient, already greatly weakened, to throw off from the lungs, added to the embarrassment of the respiration from 852 LOCAL DISEASES.--RESPIRATORY SYSTEM. [PART II. the laryngeal and tracheal disease, brings on a fatal defect of ha?matosis. Not unfrequently, too, the bronchial symptoms become mingled with those of pneumonia, which adds greatly to the danger. Indeed, though the child occasionally perishes in a spasmodic paroxysm, death is generally occasioned, in this disease, by supervening or accompanying bronchitis or pneumonia. Throughout the complaint, the stomach is usually remarkably insensible to emetic impressions, and the bowels are rather torpid than otherwise. After recovery, relapses are remarkably frequent. The physical signs are not very distinct. The stridulous respiration, ac- cording to Williams, may be detected by the stethoscope applied directly to the throat, before it becomes sensible in the ordinary manner. The sounds of the chest are obscured by those of the larynx; but, if the patient be ex- amined after the subsidence of a paroxysm, or during the relaxation which follows the operation of an emetic, the peculiar signs of bronchitis or pneu- monia may generally be detected, if existing in a marked degree. Dissection shows redness ofthe mucous membrane ofthe larynx, trachea, and bronchia, either in patches or continuous, with occasional swelling of the submucous tissue from inflammatory infiltration, and more or less mucus in the air-passages, which, if death has taken place early, is scanty, viscid, and adherent to the sides of the tubes, if in the more advanced stages, is more abundant and often purulent Occasionally patches of adhering false mem- brane may be detected, but insufficient to have had any agency in the fatal result. In some rare instances, no signs of disease are discovered in the mucous membrane, and the patient has probably died of spasm, consequent upon high vascular irritation or active congestion, the marks of which dis- appear with life. The prognosis in this variety of croup is almost always favourable, if treat- ment has been commenced early, and no complications exist. In the vast majority of cases, the disease may be quickly arrested by proper curative measures in the first stage. Indeed, it is often treated successfully in domes- tic practice; and very numerous cases occur to which the physician is never called. But, if the patient is neglected until the inflammation has penetrated into the ultimate ramifications of the bronchia, or into the pulmonary tissue, or if the disease assume the pseudomembranous form, the issue is much more uncertain, and not unfrequently fatal. 2. Pseudomembranous Croup. — Pseudomembranous pharyn- go-laryngitis, or true croup. (Guersent)—Pseudomembranous laryngitis. (Rilliet and Barthez.)—Laryngeal diphtheritis.—This variety of croup is, compared with the former, in this country at least, a very rare disease. It is, however, the form usually described by European writers under the name of croup; and it is important to bear this fact in mind in estimating the value of their statements. That such is really the case, will be inferred from the exceedingly fatal character which they assign to the disease. That, by some of the best English authors, the two affections have been more or less con- founded in description is true; but they must have had their eye fixed on the more dangerous variety, if we are to judge from their prognosis alone. Possibly, the disease may present a somewhat different aspect in Great Bri- tain from that which it offers with us, and may in all cases have a tendency to the more dangerous form. Some recent French and German writers recog- nize the distinction clearly, and treat of our common disease under a distinct designation. Guersent calls it false croup. Symptoms, Course, &c.—This affection begins variously. In some in- stances, it has the pseudomembranous form from the very commencement • the occurrence of the inflammation and of the exudation being, so far as can be observed, quite simultaneous. This is not owing to any peculiar violence CLASS HI.] PSEUDOMEMBRANOUS CROUP. 853 in the inflammatory act; for the grade of inflammation in these cases is, in fact, often feeble, and sometimes, in the beginning, scarcely sufficient to in- duce fever. It is, as before observed, to the peculiar character of the inflam- mation, or of the blood, that the result is to be ascribed. I once attended the case of a little girl, who, when first visited, was running about the apart- ment with no other apparent disease than a whispering voice, and perhaps some little difficulty of respiration; yet she was, at that moment, almost as surely condemned to death as though she had been in the last stage of the disease; for the membrane was already formed, and no efforts could prevent its fatal progress. The disease may be suspected, in such cases, when the voice cannot be raised above a whisper, when the cough is as it were muffled, when some wheezing in inspiration can be detected, and especially when an examination of the fauces reveals patches, or a continuous coating of fibrinous exudation on the soft palate, half arches, or pharynx. But very frequently inflammation exists, and makes itself evident, before any considerable amount of plastic exudation has taken place. Indeed, the symptoms are sometimes at first exactly those ofthe catarrhal croup, and the difference is not detected until the voice begins to become whispering, and the cough to exchange its peculiar ringing or sonorous character for a husky sound. It may be said that, in these cases, the disease is the same, with the single exception, that a plastic instead of diffluent exudation takes place. But it is this plasticity of the secretion that constitutes the very essence of the affection; and the vast importance of the consequences certainly justifies us in ascribing to it the rank of .at least a distinct variety. The occurrence of the changes above mentioned in the voice and cough, though not certain signs, should always lead to the suspicion that false membrane is forming. Often, instead of being either fully formed at the outset, or of beginning like ordinary catarrhal croup, the complaint has an intermediate character. There is more or less cough, which is rough and hoarse, or hollow and of a grave tone, but not peculiarly sonorous. It may even differ in no respect from a common cough, when the disease does not happen to begin in the larynx. The voice, too, is hoarse; as in a common cold in an adult. But the symptoms soon become more characteristic. The voice gradually sinks into a whisper, above which it can scarcely be elevated by any efforts of the patient, The cough altogether loses whatever sonorousness it may have pos- sessed, and becomes husky, and as it were stifled in the throat Each effort of coughing is often followed by a short whistling or sibilant sound in inspi- ration. The cough sometimes occurs in spells or paroxysms, and, though often frequent, is sometimes rare and at distant intervals. At length the breathing becomes difficult; every inspiration has more or less ofthe sibilant character, or sounds as if the air were forced through a narrowed and rigid passage. The voice is now whispering or quite extinct, and the effort to speak often excites paroxysms of a muffled cough, attended with pain in the throat and upper part of the chest, with great dyspnoea, swollen and darkened features, anxiety, restlessness, jactitation, and feelings as of impending suffo- cation. ' These symptoms, though never absent, relax for a time, to return with equal or increased violence from the slightest cause, and often without apparent cause The child is afraid to speak lest he may thereby induce a paroxysm Sooner or later, there is always some febrile action, and, when the inflammation is severe or extensive, it is very high. In all cases, the pulse is frequent and towards the close excessively so. The respiration is also quickened sometimes to between forty and fifty in a minute. In the intervals of the paroxysms, the patient is disposed to sleep. Cases now and then occur in which the spasmodic character is nearly wanting, and the dis- ease marches directly onward to suffocation, almost without paroxysms. 854 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Should the case now take a favourable turn, the cough, instead of being perfectly dry and tight, sounds loose or broken, as if from the presence of liquid in the bronchia. Sometimes it produces on the ear an impression as if there were a concrete substance with one end loose, moving backward and forward with the motion of the air. If the child is old enough to expecto- rate, some viscid mucus is coughed up, either transparent or opaque, and occasionally mixed with flakes or patches, or even tubes of concrete fibrinous matter. It is not always, however, that this membranous substance is thrown up, even when it exists in the tubes. It is probably sometimes dissolved by the mucus or muco-purulent matter, and sometimes gradually absorbed, as we see the similar matter disappear, which is now and then thrown out upon the surface of the fauces. This sort of expectoration is said to appear in scarcely one-third of the cases. (Billiet and Barthez.) It occurs especially after the action of powerful emetics. Sometimes the discharge of the false membrane gives great relief; and the patient goes on recovering with a gra- dual, or even sudden amelioration of all the symptoms, though suppression of the voice, more or less complete, for a considerable time after recovery, is not uncommon. In other cases, however, after a partial amendment, the symptoms return with all their former violence; the false membrane is re- newed, or penetrates more deeply into the respiratory passages, and the little sufferer passes into the last and fatal stage of the disease. I have seen a relapse of this kind, after the discharge of a tube about two inches long. The symptoms of the last stage occasionally come on very early, even within twenty-four hours from the commencement of the attack. More fre- quently, however, they are postponed for three or four days, and sometimes considerably longer. This stage is characterized by the excessive difficulty of respiration. Along with complete suppression of the voice, and a perfectly tight and dry, though now comparatively infrequent cough, the inspiration is wheezing and sonorous, so that it may be heard at a considerable distance. The child uses his utmost efforts to expand the chest, and the respiratory muscles are thrown into almost convulsive action. The shoulders rise, the breast heaves, the nostrils expand and contract, the head is thrown back- ward, and the intercostal spaces may be observed to be pressed inward by the weight of the air, which finds the ordinary entrance almost closed against it. The force of the respiratory effort is sometimes so great as to rupture the air-cells of the lungs, and even to make a rent between the rings of the windpipe. The child appears in an agony of distress. He throws himself about in bed, or jumps up and runs to the window for air, his face bearing, meanwhile, a most anxious, alarmed, and imploring expression. At length the powers of the system fail. The pulse becomes exceedingly quick and feeble, the skin cool and bathed in sweat, the cheeks pale and cold, the lips livid; and the former agitation at first alternates with, and then gives way to drowsiness or stupor. The brain and heart, no longer stimulated by arterial blood, cease to act, and the patient sinks gradually and quietly away • or the nervous system rouses itself for a last struggle, and death takes place in the midst of convulsions. Not unfrequently, however, the patient is cut off, at an earlier stage, by suffocation in one of the paroxysms of dyspnoea. In- stances of recovery from the last stage are very rare. It has been suggested that death may sometimes be the immediate result of the formation of a clot in the heart, consequent partly on the peculiar condition of the blood, and partly on the stasis of the circulation in the last stage. The duration of the disease varies from less than a day to one or two weeks. The symptoms vary at the outset with the portion of the air-passages first affected. When the larynx and trachea are first seized upon, the phenomena of the disease are as above described. But sometimes it begins in the bron- CLASS III.] PSEUDOMEMBRANOUS CROUP. 855 chia and travels upward ; so that the symptoms of bronchitis precede those peculiar to the croup. In other instances, the starting-point appears to be in the fauces, or posterior nares, as we frequently see in ordinary catarrh. In such cases, there is sore-throat and some pain in swallowing, for a longer or shorter time antecedent to the laryngeal symptoms; and, if the fauces be inspected, a white or yellowish membranous exudation may be seen, diffused or in patches, upon the soft palate, half arches, and pharynx. Sometimes the whole fauces are thus covered. The first sign of the disease having reached the larynx is usually hoarseness of the voice and cough; and, after the occurrence of these, the development proceeds as above described. Bre- tonneau and Guersent believe that the disease begins in this way in the great majority of cases. It may be so in France ; but is not so in this country, so far as my observation has extended; and does not appear to be so in Great Britain, from the accounts of British writers. We have occasionally severe cases of croup, occurring during epidemics of scarlet fever; and now and then cases of diphtheritic sore-throat, such as were formerly called ul- cerated or malignant sore-throat, which depend upon some epidemic cause, and possibly sometimes on contagion, and occasionally end in pseudomem- branous croup. But these affections differ from ordinary croup, whether catarrhal or pseudomembranous, both in their origin and in some of their symptoms. They are generally attended with a low, typhoid, or adynamic state of system, not unfrequently with a fetid breath, and sometimes with strongly malignant symptoms. Their cause is usually either epidemic influ- ence or contagion, neither of which produces ordinary croup, unless perhaps when it attends influenza. In fact, their only resemblance to this affection is the presence of a pseudomembranous exudation in the larynx. They come under the head of what some European writers call secondary croup, though, as appears to me, not very appropriately; for ordinary pseudomembranous croup often follows an attack of catarrh, and might, under such circum- stances, with equal propriety be called secondary. After all that has been said, however, there is no doubt that ordinary croup of this variety occasion- ally begins by pseudomembranous inflammation in the fauces; but such cases are the exceptions, and not the rule. Diagnosis.—The loss of voice and the extinction of the sound in cough- ing, the appearance of albuminous or fibrinous exudation in the fauces, and the expectoration of patches or tubes of false membrane, are diagnostic symptoms of this variety of croup. The only certain one, however, is the last. The suppression of the voice is sometimes met with in catarrhal croup, and false membrane in the fauces is often absent in the disease, at least as it occurs in this country; nevertheless, when the former symptom occurs at a somewhat early stage, and afterwards perseveres, with a steady march of the disease towards a state of extreme danger, there is little reason to doubt its pseudomembranous character. Barth and Roger state that a trembling vibratory sound may often be heard in auscultation, during the ingress and egress of the air through the larynx and trachea, denoting the presence of floating false membrane. This sign may be of some value in the diagnosis. It has been stated as essential to the constitution of croup, that the larynx should be more or less involved. Pseudomembranous inflammation some- times attacks the trachea, without in any degree involving the larynx. This is tracheitis but not croup. There are fever, cough, pain, and soreness m the trachea' and gradually increasing difficulty of respiration ; but, although the patient'may speak low from pain, there is no extinction of the voice, nor croupy sound of the cough, nor whistling sound of inspiration such as follows the cough in genuine croup. The patient may expectorate a portion of false membrane and recover, or the disease may descend deeply into the bronchia, 856 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. and bring on fatal suffocation. Sometimes the disease attacks the bronchia exclusively. The symptoms are then those of severe bronchitis, wdth more of stricture and suffocative sensation than in ordinary cases, and with the oc- casional discharge of pseudomembranous matter after violent fits of coughing. Anatomical Characters.—False membrane is always found somewhere upon the free surface of the mucous membrane of the air-passages. According to Guersent, it is never entirely absent in the larynx. It is sometimes confined to the glottis, sometimes lines the whole interior of the larynx, including the ventricles, and not unfrequently extends throughout the trachea, and for a greater or less distance into the bronchial tubes. I have seen a case in which it lined the upper portion of the bronchia, the whole trachea and larynx, and the pharynx as low down as the oesophagus. It occasionally reaches even the remote ramifications of the bronchial tubes. Sometimes the deposit forms perfect tubes, which, when removed, bear no inconsiderable resemblance, as suggested by Dr. Cheyne, to macaroni boiled in milk. More frequently, however, it is in patches, or long narrow ribbons, and occasionally, especially in the earlier stages, has a granular aspect, with the red mucous membrane appearing in the intervals of the imperfectly connected grains. In some in- stances, it adheres firmly, especially in the upper part of the tube ; but it is frequently loosened by intervening mucus or muco-purulent secretion, in which the lower extremity sometimes floats loosely. The false membrane is sometimes thin and delicate, more frequently thick, opaque, white or yellowish-white, and smooth on both surfaces. It varies much in consistence, being in general tough and almost leathery, in some in- stances soft, and in some nearly diffluent towards the lower extremity. In the larynx, it is said to be less firm than in the trachea. In chemical nature, it is closely analogous to the fibrin of the blood, and the exudation which takes place upon inflamed serous surfaces. It is dissolved by alkaline solu- tions and strong acetic acid. It has been questioned, whether this matter is susceptible of organization. Generally, the false membrane shows no sign of such a condition. It is said to have been found partially organized in some rare cases; and certain red points and lines upon its adhering surface, which cannot be washed off, have been thought, though probably on insuffi- cient grounds, to be the commencement of vascularity. In the cases associated with other diseases, as smallpox, scarlet fever, &c, and in the epidemic diphtheritic cases, the false membrane is usually yellow- ish or grayish, of an unpleasant odour, less firm than in the original cases, less adherent, and often associated with considerable mucus or pus. It sel- dom extends, unless in small quantity, below the larynx. When the deposit is removed, the mucous membrane beneath it, though sometimes quite healthy in appearance, and seldom exhibiting the marks of severe inflammation, is commonly reddened either partially or generally ; and the red points and streaks correspond with those upon the separated surface of the false membrane. Sometimes, though rarely, the mucous membrane is softened, and still more rarely thickened. The bronchial tubes are usually somewhat reddened, and contain an opaque, whitish, greenish, or yellowish puriform mucus, sometimes in large quantities. Signs of lobular pneumonia, and an emphysematous condition of the air-cells, are not unfrequent. Causes of Croup.—The most common cause of this disease in all its forms, certainly in its ordinary catarrhal form, is cold, or cold combined with damp- ness. The disease is said to prevail most in moist places. It is frequently brought on by a sudden passage from hot to cold air, and in infants is pro- bably often occasioned by sleeping in very cold chambers, after having been all day in hot rooms. Irritating substances inhaled into the lungs have some- times caused it. Foreign bodies lodged in the larynx give rise occasionally to closely analogous symptoms. ni-] PSEUDOMEMBRANOUS CROUP. 857 , Among the predisposing causes, age appears to have the greatest influence. The disease is not positively confined to any period of life ; but it is exceed- ingly rare in adults, and is seldom seen in very early infancy. From one to seven years is the age at which it is most prevalent; though cases are not very uncommon at any period before puberty. The catarrhal variety usually occurs at an earlier age than the pseudomembranous ; and the cases in infants less than a year old are generally of the former kind. The pseudomembranous cases which have come under my observation have almost always been be- tween the second and sixth year. It is probable that the change of diet, after weaning, may contribute to render the blood more favourable to the plastic exudation. The structure of the larynx in children probably disposes to the spasmodic phenomena; but we are to look for the main cause of these rather in the more excitable condition of the nervous system generally at that age, than in any local cause. When persons in advanced life are attacked with croup, it is generally of that variety which attends the diphtheritic disease of the fauces, and is produced by epidemic influence. Sex appears to have some causative influence, at least as relates to pseudo- membranous croup; for this has been observed to be much more common in males than females. The disease sometimes appears to run in families. All the children of certain parents, are peculiarly predisposed to it, while those of others escape. Yigorous and fleshy children, with rosy complexions, are said to be most frequently affected. The disease has also been ascribed by some writers to epidemic and con- tagious influence. But, if we except the cases which are apt to occur during the prevalence of epidemic catarrh, it is only to the diphtheritic disease of Bretonneau that this remark is applicable. Original, uncomplicated croup is probably never either epidemic or contagious. Certain febrile diseases strongly predispose to one or the other form of croup. The influenza and measles are often attended with the catarrhal variety ; scarlatina and smallpox with the pseudomembranous. Treatment of Catarrhal Croup.—The treatment in this disease should always be prompt and decided. It is impossible, from the first symptoms of croup, to determine, in any case, that it will be harmless. Should it be mild in its tendencies, it will probably yield at once to the moderate measures which are first employed in all cases, and no injury can result. Should a dis- position to pseudomembranous effusion exist, a prompt interference affords, in many instances, the only chance of safety. So soon as croupy cough and dyspnoea occur, an emetic should be admin- istered without hesitation. In this disease it is often difficult to vomit, and larger doses are usually required than under ordinary circumstances. The choice of the emetic should depend on the degree of violence in the symptoms. When these are mild, with little or no fever, ipecacuanha should be given; when they are severe or decidedly febrile, tartar emetic is preferable. One of these will generally answer the purpose. To a child two years old, from four to six grains of ipecacuanha, or from one-quarter to one-third of a grain of tartar emetic, may be given diffused or dissolved in water, every fifteen, twenty or thirty minutes, until vomiting is produced. Tartar emetic is the more efficient of the two, because more nauseating and consequently relaxing, more sedative, and more powerfully revulsive. It should always be preferred in doubtful cases, or at least should be combined with the ipecacuanha. Should the emetic not be at hand in substance, one of its officinal preparations may be resorted to ; as the wine or syrup of ipecacuanha, in the dose of a fluidrachm of the former and two fluidrachms of the latter, or antimonial wine in the dose of a fluidrachm. I have seldom had occasion to employ any other emetic than these in the early stages. Others, however, are occasion- 858 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. ally used. Dr. Archer, of Maryland, recommended seneka, urged so as to produce emesis. There is no doubt that this medicine exercises a powerful alterative influence over the respiratory mucous membrane, and is, therefore, capable of doing good independently of its merely emetic property ; but, in reference to this alterative power, I have always considered it more applica- ble to the advanced than to the earliest stages. Nevertheless, seneka com- bined with squill and tartar emetic, in the form of the officinal compound syrup of squill, more commonly named, after its original inventor, Cox's hive syrup, is much and advantageously employed, both in regular and do- mestic practice, in all stages of croup. Thirty or forty minims may be given to a child two years old, and repeated at short intervals till it vomits. Dr. Hubbard, of Hallowed, in Maine, strongly recommends turpeth mineral, which, while scarcely less efficient than the antimonials, he considers safer, as less prostrating, and less disposed to act on the bowels. He gives two or three grains to a child of two years, and repeats the dose every fifteen min- utes till it operates. (Trans, of Phil. Col. of Phys., A. D. 1845, p. 332.) Should the emetic not be disposed to act, it will be much aided by a warm bath, in which the whole body should be immersed, the water being warm enough to relax, but not so hot as to stimulate. About 98° to 100° will be a suitable temperature. The immersion should continue fifteen or twenty minutes, or even half an hour if necessary. Great care must be taken that the skin of the child be not exposed to cold air during the process. When removed from the bath, he should be wrapped for a time in a warm blanket, and wiped dry with a heated towel. Even after emesis, if the symptoms should not have given way, the bath may be resorted to; and in all stages of the disease, except the last, it constitutes one of the legitimate means for overcoming spasm in the paroxysms. After vomiting, the child is often greatly relieved. The spasm relaxes, the breathing becomes easy and quiet, the voice loses much of its hoarseness, and the patient falls into a gentle sleep, from which he awakes much improved, if not well. In mild cases, the cure is now frequently accomplished. From my own observation, I should say that the great majority of cases will yield to this simple treatment; nothing more being subsequently necessary than to open the bowels, if not already loose, by a dose of castor oil, and to sustain a slightly nauseating or expectorant effect by small doses of antimonial or ipecacuanha wine, or the compound syrup of squill, given at intervals of two, three, or four hours, and continued till the croupy cough ceases, and the danger of another paroxysm is passed. But a caution is necessary, to inex- perienced practitioners, in relation to the use of tartar emetic under these cir- cumstances. If too largely given, or too long continued, it may produce great and even fatal prostration. I have witnessed a case of death in an infant, resulting from repeated doses of antimonial wine, directed by a prac- titioner after a paroxysm of croup, without any reference to the time or cir- cumstances of its omission. The parents continued to repeat the dose until the child was prostrated beyond recovery. The stools were in this instance white, as in malignant cholera. Directions should always be left to omit the antimonial if it purge, or otherwise prostrate much, and whether or not, pro- vided the croupy symptoms quite disappear. But, in many instances, the spasmodic symptoms resist the action of an emetic, or return after a shorter or longer interval of comparative relief. This is very apt to be the case when there is considerable inflammation. In such instances, if the pulse is full and vigorous, it is proper to bleed from the arm. The quantity of blood taken should be regulated by the effects produced. It is desirable that the pulse should be reduced, but not to the point of syn- cope. From two to five ounces may be taken from a child two years old, and m-] PSEUDOMEMBRANOUS CROUP. 859 somewhat less than an ounce be added for each year. Dr. Cheyne recom- mends bleeding from the jugular vein, in very young children. Should the bleeding not afford the requisite relief, the emetic with or without the warm bath may be again resorted to. Should this fail, an efficient remedy remains in tobacco, which may be applied, in the form of fomentation or cataplasm made from the leaves, upon the front of the throat. I have seen this of great use in severe cases of laryngeal spasm. But it is necessary to be cautious, especially in children, and to remove it as soon as its relaxing effects have been obtained. Dangerous prostration may result from a neglect of this pre- caution. The remedy is one which should never be employed in domestic practice, and should generally be applied under the immediate superintendence of the physician. It should never be placed upon a blistered surface. The internal use of lobelia is here also highly serviceable; and, when a powerfully relaxing effect is required, it may be combined, in powder or tincture, with one of the emetics already mentioned The above treatment is adapted to the paroxysm. It scarcely ever happens that this does not give way, however violent, if the case be not pseudomem- branous, to some one of the remedies mentioned, or some combination of them. After the spasmodic paroxysm has been subdued, or has subsided, the treat- ment must be guided altogether by circumstances. If the croupy phenomena have disappeared, and only a cough with moderate catarrhal symptoms re- main, the treatment before mentioned as proper after the subsidence of the paroxysm may be adopted. But it often happens that, though the violent spasmodic symptoms give way, there are yet considerable inflammation and fever, with some cough and dyspnoea, threatening a return of the paroxysms. Under these circumstances, it will be proper to administer a full purgative dose of calomel, which should be followed in a few hours by castor oil. Few remedies are more efficient in the relief of infantile catarrh than this. The patient may at the same time be kept moderately under the influence of anti- mony, ipecacuanha, or seneka, or combinations of them; and advantage will occasionally accrue from warm poultices to the feet, made of bruised garlic, mixed with the bread and milk or flaxseed-meal cataplasm. If, in connection with the cough and febrile symptoms, there should be considerable difficulty of respiration, a hoarse or sibilant sound during inspi- ration, or evidences of pain in the throat or chest, leeches are an admirable remedy. It is always best to make use of our native leeches, as there is with them less subsequent bleeding, and we are better able to regulate the quantity of blood lost. Dangerous and even fatal prostration has sometimes resulted from the difficulty of arresting the hemorrhage, consequent upon the bite of the European leech, in very young children. The leeches should be applied upon the throat, or upper part of the chest, according to the apparent seat of the severest inflammation. Great care should be taken, during their applica- tion, that the skin of the child be not chilled by wet and exposure. In young infants, leeches may be employed as a substitute for the lancet. In a child of two years from twelve to twenty-four leeches may be applied, so as to take from two to'four ounces of blood. After leeching, an emollient cataplasm should be applied to the chest or throat, or to both. This is often highly useful in inflammation of the air-passages. Should paroxysms recur with the original or increased violence, it will be necessary to go through the same routine of remedies as at first; viz an emetic the warm bath, bleeding once more if the pulse will permit, and the tobacco cataplasm; recourse being had to the latter remedies only when the former fail Bleeding in this stage must be used with more caution than at fi t It is scarcely probable that the bronchial inflammation can be resolved without a great increase of secretion; and there may be danger that the 860 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. strength may be reduced so far as to disable the child from coughing up the mucus, which would thus overwhelm the lungs, and produce suffocation. After the subsidence of the more violent inflammatory symptoms, counter- irritation to the throat and chest, by means of blisters or active rubefacients, will often be useful in removing the remains of the inflammation, and the tendency to a recurrence of the spasm. Rubefaction may be produced by mixtures ofthe oil of turpentine or solution of ammonia, or both, with olive oil, spirit of rosemary, camphor, &c, or by means of a cataplasm containing a proportion of mustard or garlic. If flies are used for blistering, they should not be allowed to remain in contact with the skin longer than three or four hours, and should then be followed by a poultice. If a powerful and very speedy impression is desired, it may be made with the strong solution of ammonia, which, however, should be used with great caution. If the physician should not be called until the disease has entered into its advanced stage, and the peculiar symptoms should then be more or less con- tinuous, such as dyspnoea, the croupy cough and voice, high fever, and signs of considerable or extensive inflammation in the respiratory passages, he should at once take blood as freely as the pulse and general strength may allow, and, if doubtful about bleeding, should substitute leeching, with the same caution. Emetics, the warm bath, calomel as a purge, and the steady use of antimonials in moderate doses, repeated at short intervals, should fol- low successively; and, in case of severe spasm, tobacco externally, and lobelia with decoction or syrup of seneka internally, may be superadded. After the employment of the above remedies unsuccessfully, an attempt should be made without hesitation to bring the system under the influence of mercury, and, for this purpose, one grain of calomel may be given every two hours, united, if it purge, with a little Dover's powder; and mercurial fric- tions may also be made to the inside of the upper and lower extremities. It very seldom happens that a patient with catarrhal croup may not be rescued by some of the above remedies, if timely applied. But it may hap- pen that no medical aid is obtained until the disease is already in its last stage; or the means may have been inefficiently employed ; or finally, in some few instances, the tenacity of the complaint may have been such as to resist the best directed measures. The system is now too much enfeebled by the carbonaceous state of the blood, and the exhausting influence of the disease, to admit of depletion. The lungs are overwhelmed with the mucous or purulent secretion, which the sufferer is unable to discharge, and suffocation is threatened every moment. Now it is that the nervous stimulants, and stimulating expectorants are to be employed, while our antiphlogistic efforts must be confined to external revulsive measures. Decoction of seneka, as- safetida by the mouth and rectum, carbonate of ammonia, valerian, musk, oil of amber, wine-whey, animal broths, and sometimes a little weak milk-punch, may be employed; the activity of the remedies being graduated according to the debility of the patient. An emetic may sometimes be employed ad- vantageously even in this stage. It proves useful by aiding in the expecto- ration of the pulmonary secretion. But some substance should be selected which operates without producing prostration. Mustard, sulphate of zinc, or sulphate of copper, will best answer this indication. Externally, garlic and brandy may be applied warm to the breast and spine ; and liniments or cataplasms of oil of turpentine, mustard, Cayenne pepper, ammonia, &c, may be resorted to, if necessary, to aid in the support of the system, until the offending cause is removed, or reaction established. Dr. Fithian, of Woodbury, New Jersey, treats croup successfully by cold water, applied by means of towels to the throat and upper part of the chest. The symptoms of the paroxysm are relieved, and, if they return, again give CLASS III.] PSEUDOMEMBRANOUS CROUP. 861 way upon a repetition of the application. (Report, &c, by Dr. J. G. Garrison, N J. Med, Beporter, iii. 249.) The external application of tincture of iodine has been strongly recommended. Dr. Tracy, of Worcester, Mass., has found great advantage from keeping the patient in a warm dry atmosphere, at 80° or 90° F., and thinks he has successfully treated many cases in which false membrane had formed mainly by this remedy, though he conjoined the use of emetics and rubefacient liniments. (Bost. Med. and Surg. Journ., xiv. 374.) Treatment of Pseudomembranous Croup.—In the forming stage of the disease, when it is still doubtful what may be the nature of the secretion, the treatment differs in no respect from that above detailed as applicable to the catarrhal variety. It is here only necessary to treat of the measures to be employed, after it has become obvious that the case is truly pseudomem- branous. In the first place, if, upon the occurrence of hoarseness and other symptoms of commencing croup, the fauces should be found covered with a coating of false membrane, recourse should be had immediately to cauteriza- tion by nitrate of silver, powdered alum, or muriatic acid, as recommended by Bretonneau. (See Pseudomembranous Inflammation of the Fauces, p. 551.) The nitrate of silver is generally preferred, and a solution may be employed, varying in strength from two scruples to two drachms to the fluid- ounce of distilled water. The weaker solutions must be used several times a day, the stronger require to be applied once daily The application should be extended to the borders of the glottis, which may be effected by means of a small piece of sponge fixed to a slender stick of whalebone, somewhat curved near the end. There may be some hope of arresting, in this way, the inflammation as it passes downward. It was formerly thought that, after the exudation had formed in the larynx, it would be useless to attempt the cure by cauterization; but experience seems to have shown that this cavity may be penetrated, even in the infant; and cures have been effected apparently by this measure in several instances.* Depletion, in this variety of croup, is much less efficient than in the ca- tarrhal. The nature of the exudation does not depend upon the violence of the inflammation, but upon its peculiarity, or that of the blood, and this pe- culiarity is not modified by bleeding. This remedy has no effect in removing the false membrane already formed. The utmost that can be effected by it is to moderate the severity of the inflammation, and thus possibly diminish the amount of effusion. But there are many cases in which it is borne very badly Such are those associated with scarlet fever, and epidemic diphthe- ritis or pseudomembranous angina. The inflammatiou is here decidedly peculiar, and is scarcely diminished by bleeding, which, besides, endangers fatal prostration. The rule for the use of bleeding, in pseudomembranous croup is to proportion it as exactly as possible to the violence of the inflam- mation, and the vigour of the patient; regard being always had to the pre- servation of sufficient strength for those efforts, which will be necessary for the discharge of the offending matter from the air-passages, without which recovery can seldom take place. It should never be employed in ow cases, nor in the last stage of the disease. Leeching is generally preferable to bleeding; as an equal amount of blood taken in this way lias a greater in- fluence on the local affection. I have seen bleeding pushed far m this variety * See communications by Dr. Wm. N. Blakeman in the A'. Y. Journ. ofMed.,jm. 209 -by Dr. Charles E. Ware, in the Boston Med and Surg. Journ. xxxvn. 41, ; and by Dr James Bryan, in the »^«^ IJr. JamesB.p", -- ■— Dr nark. and in the same> xxii 85> by Dr g D ^sel Su^essful cases have since been recorded by Dr. Chapman,^Brooklyn, N Y (N Y. Journ. of Med. Sci., JN. h. Journ. of Med. Sci., N. S., xxiv. 281.) 862 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. of croup ; but never, after the membrane had been clearly formed, with any obvious effect in ameliorating the symptoms. If it is to do good, it must be resorted to before the exudation has become extensive. Nor can much benefit be expected from blisters, except sometimes to the chest, in order to moderate bronchitis and prevent pneumonia. In the diphtheritic variety, the blistered surface is much disposed to slough. The indications in the treatment of pseudomembranous croup, are, to prevent the further formation of false membrane ; to effect the dissolution, absorption, or separation of that already formed; and to favour its expul- sion. The most effectual method of meeting the first indication, after any violence of inflammatory excitement that may exist has been moderated by bleeding, is, beyond all comparison, to bring the system as speedily as possi- ble under the mercurial influence. This, more than any other known means, modifies the peculiar nature of the inflammatory process, and consequently the character of the secretion, which, from being plastic, becomes mucous or puruloid and diffluent. This plan of treating croup originated with American practitioners. Dr. Rush recommends the use of calomel freely, in his Me- dical Inquiries. It has subsequently been pushed to an enormous extent in some parts of Europe. Three hundred grains are said to have been given in twenty-four hours. But this heroic practice is quite unnecessary. Only a certain amount of the medicine, after entering the stomach, can find access into the general system; and the remainder lies inert, or nearly so, in the bowels. It will be sufficient to administer to a child from two to four years old, first a purgative dose of four or six grains, and afterwards to follow this by from one to three grains every hour or two. I am not certain that the end would not be better accomplished, after effectual purgation by the first dose or doses, by giving a fraction of a grain, say one-quarter, or one-half of a grain every half hour. It would thus be less apt to purge, and more apt to be absorbed. After the production of green stools by it, further pur- gative effort should be avoided; and, should it then disturb the bowels, it should be combined with minute doses of the powder of ipecacuanha and opium. Its operation may be aided by mercurial frictions. Should any effect upon the mouth or salivary organs be observed, the remedy should be sus- pended. In young children, however, it very seldom salivates. It is said, in some cases, to have produced gangrenous ulcers in the mouth, and necro- sis of the jaw-bones. I have not witnessed these effects; but, in cases of the desperate character of pseudomembranous croup, a remedy must not be rejected on account of some hazard from its use. It should be employed with great caution in children of very feeble health, or of a scrofulous habit. Theory as to its mode of action is useless, in the present state of positive knowledge on the subject. It not only so modifies the secretory process as to prevent the production of false membrane, but, by causing a liquid secre- tion, favours the separation and possibly the solution of that already exist- ing, and thus meets the second indication. It may even promote the absorp- tion of the adhering exudation. There is every reason to believe that this process occasionally takes place; for cases having all the characters of pseudomembranous croup get well, without the expectoration of false mem- brane ; and dissection sometimes shows that portions of the exudation have been removed. We can sometimes even see the process going on, in the diphtheritic disease of the fauces. Along with the mercurial, expectorant medicines should be given freely, to promote the loosening of the false membrane. Of these, tartar emetic and seneka are the most efficient; and they should be pushed as far as the pa- tient's strength will admit. To meet the same indications, the alkalies have been strongly recommended CLASS HI.] PSEUDOMEMBRANOUS CROUP. Mi 3 by some writers. They have been thought to dispose, like mercury, to mucous rather than to fibrinous secretion, and even to dissolve the false membrane. as they are known to do out of the body, Sulphuret of potassium, proposed by the author of a prize essay upon croup in France, had at one time the reputation almost of a specine"; but has fallen into neglect. Cures, however. asserted to have been effected by it. are on record. It may be given in doses of from one to four grains every three or four hours. In overdoses it purees and vomits, and may produce dangerous effects. In reference merely to alka- line properties, the carbonate or bicarbonate of potassa, soda, or ammonia would be preferable. I cannot speak of the effects of these medicines in croup from my own observation. Dr. J. D. Gris.om. of Philadelphia, relates a case in which iodide of potas- sium, given in the dose of two and a half grains every three hours, to a child between two and three years old, and continued for several days, had the ap- parent effect of modifying the plas:ic exudation, so that a gradual amendment took place, and the child ultimately recovered. (Trans, of Col. of Ph,<. of Phil., N. S. ii. 164.) Bromine, or bromide of potassium, is considered by M. Oznaman, of France, as a specific in pseudomembranous affections, and has been employed by him successfully in two cases of croup. (See Bos:. Med. and >urg. Journ., Iv. 23G.) Mr. E. F. Sankey, of Sussex, England, relates a case in which similar advantage was supposed to be derived from chlorate of potassa. (Med. Times and Ga:., July, l>o2. p. 99.) Dr. Wm. Budd, of London, has obtained very encouraging sueeess by keeping the child con- stantly immersed in warm vapour of from 75° to M'° F., and at the same time using emetics. (Ibid., June. 18-3:2. p. 614.) Dr. Watson, of New York, fol- lowing the suggestion of Dr. Ware, has added opium to the treatment with vapour, with decided advantage, giving two grains of Dover's powder every three hours to a child of three years old. (A. Y. Journ. of Med., May, l>3f>, p. o>4.) Dr. E. Macfarlan, of Williamsburg, New York, has employed sul- phate of quinia with marked advantage in some cases, giving a grain every half hour or hour until the sedative effects on the circulation are exhibited, and afterwards at longer intervals until the cure is effected. (Ibid.. Nov. 1S54, p. 3i.'«4.) Dr. E. R. Mayer, of Wilkesbarre, Pa., has found benefit from the frequent application of glycerin to the glottis; the tongue being drawn for- ward, and pressed down by the fingers, and the liquid introduced by means of a large camers-hair brush. (Am. Journ. of Med. Sci.. April, 1n3>. p. 340.) Dr. John D. Shelton, of Jamaica, New York, recommends the application, by friction, in front of the trachea, of a mixture of extract of belladonna and mercurial ointment. (Ibid., p. 341.) To favour the expulsion of the membrane, which is the last indication, emetics are the most efficient remedies. Of these, ipecacuanha, tartar emetic, sulphate of zinc, and sulphate of copper, have been proposed. When the strength is considerable, the action decidedly sthenic, and the inflammation of aTii'-h irrade. tartar emetic is the best : but. in the advanced stage, when the >nen ■ t'n has begun to fail, sulphate of copper, or perhaps turpeth mineral, as proposed by Dr. Hubbard, would be preferable. Sulphate of copper has been highly applauded bv some German practitioners, both as an emetic and alterative." It was introduced into use in croup by Hoffmann. I have seen it apparently very effectual in promoting the diseharge of the false membrane. The dose a-" an emetic, for a child two or three years old, is half a grain or a erain repeated everv fifteen minutes till it operates, after which one-quarter of a grain may be given everv two hours. Alum, originally proposed by Dr. C D Mei^ as an emetic in croup, is strongly recommended by his sou Dr. J For^vth Meigs, upon the faith of frequent and advantageous trial. A tea- .poouful of the salt, in powder, is to be given in honey or syrup, every ten or 864 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. fifteen minutes till it operates. It is rarely necessary to give the second dose. One prominent advantage is that the emetic effect may be obtained several times a day, without exhausting the patient. (Practical Treatise on the Dis- eases of Children, by J. Forsyth Meigs, p. 46.) In relation to the general results of the emetic treatment in pseudomembranous croup, it is stated by M. Valleix that, of fifty-three cases treated upon this plan, fifteen were cured; whilst of twenty-two cases in which emetics were omitted, or parsimoniously used, only one recovered. Of thirty-one treated by energetic emetics, twenty- six discharged false membrane through the effort of vomiting, and fifteen were cured. (Billiet and Barthez.) Sternutatories have been proposed in order to favour the expulsion of the false membrane, and may be tried. The same end is asserted to have been successfully attained by the affusion of cold water upon the whole posterior surface of the trunk. The remedy was proposed by Harder, and has been recommended by other German practitioners. It operates by the shock pro- ducing a powerful reaction. It is, however, applicable only to desperate cases. The water should be of the temperature of 53° to 55° F. Reference has already been made to the cauterization of the larynx by so- lution of nitrate of silver. After an unsuccessful employment of other means, the practitioner would certainly be justified in resorting to this measure.* In the last stage, when the strength has become exhausted, our hopes must rest upon stimulants. The only chance for medical treatment is now to sup- port the strength, in the hope that the false membrane may be spontaneously loosened and discharged. The remedies to be used are carbonate of ammonia, wine-whey, weak milk-punch or egg beat with wine, and spirituous fomenta- tions externally. To quiet the extreme agitation of the patient, and give the other means employed opportunity to act more efficiently, it will be proper to place the system under the influence of antispasmodic and anodyne remedies, such as assafetida and opium, which may be conveniently given by injection. This practice was successful in the hands of the late Dr. Isaac Parrish, of Phi- ladelphia, in an extreme case. (Trans, ofthe Col. of Phys. of Phi lad.,\\. 277.) As a last resort, in cases otherwise desperate,tracheotomy maybe employed. It is especially applicable to cases in which there is good reason to think that the false membrane does not extend into the bronchial tubes. This operation has been frequently performed in France, with considerable success. Of twenty cases, Bretonneau saved six; and out of one hundred and twelve operations performed by Trousseau, twenty-seven were successful. But M. Trousseau recommends that the operation be performed so soon as it is satisfactorily es- tablished that the false membrane has formed in the larynx; and, in such cases, many cures might be cited which have been effected by medical treatment. It is, therefore, very difficult to determine the real value of the operation. * The difficulty of penetrating the larynx, according to the method used by Dr. Green, has led M. Loiseau to try the following plan, which he has found successful, and which has met the approval of M. Trousseau. The child is placed on the lap of an assistant, with the head firmly held against his shoulder by another assistant. The operator pro- tects the metacarpal phalanx of his left index finger with a metallic ring, about an inch in breadth, and, having opened the mouth of the child with a spoon, plunges his finger quickly to the bottom of the fauces. After this, taking a laryngeal tube, while he causes the extremity of the index finger to glide over the base of the tongue till it meets the glottis, and holds the epiglottis erect, he passes the tube along the finger, by which it is guided, so as to reach its extremity, and then straightens the instrument, and easily causes it to penetrate the glottis. Through the tube thus introduced liquids may be injected, powders blown into the larynx, or a whalebone or gum-elastic sound intro- duced, armed with a scraper or a sponge, so as either to apply a liquid substance to the interior surface, or to detach false membranes by which it may be lined. (Archives Generates, Oct., 1857, p. 4S9.)—Note to the fifth edition. CLASS III.] PSEUDOMEMBRANOUS CROUP. 865 If postponed until the case is otherwise quite desperate, it offers comparative- ly slender chances of success; if performed at an earlier period, it saves life, but possibly may do no more than can be accomplished in an equal or greater proportion by other means. Besides, in order to obtain its best results, a degree of skill in operating is required, not possessed by practi- tioners generally. M. Trousseau finds necessary to success the application of topical remedies, such as the solution of nitrate of silver to the trachea, through the opening made into it, and moreover employs mechanical means to aid in removing, through the opening, the membranous matter which may exist in the windpipe. For detailed information on all points relating to tracheotomy in croup, the reader is referred to memoirs by M. Trousseau in the Dictionnaire de Medecine (ix. 381), and in the treatise of MM. Rilliet and Barthez, on the diseases of infants (i. 367.) In two out of three cases re- corded by Dr. J. F. Meigs, in which the operation was performed by Dr. Jos. Pancoast of Philadelphia, it was successful. In one of these, it afforded the only chance of safety. Instead of making a slit in the trachea and introduc- ing a tube, Dr. Pancoast removed a small piece of the trachea itself, thereby superseding the necessity for the canula, and avoiding irritation from that source. (Am. Journ. of Med. Sci, N. S., xvii. 307.) Dr. B. W. Richardson, of London, has suggested that one cause of the frequent failure of the opera- tion, in the last stage, is the formation of fibrinous coagula in the heart, in which case the patient dies from syncope, and cannot be saved by admitting air into the lungs. (Med. Times and Gaz., March, 1856, p. 230 )* General Points of Treatment.—The patient with croup should be confined to bed, should have flannel next his skin, and should be kept in the same temperature day and night Great caution should be exercised, in the use of fomentations, cataplasms, leeches, and the warm bath, not to expose the skin while moist to the air. The diet should be farinaceous and mucilaginous, in the stage of highest excitement; when strength is wanted, milk may be em- ployed ; and, in the lowest cases, animal broths, jellies, &c. To prevent relapses, the clothing should be warm, and the child should not be transferred from a warm room in the day to a cold one at night. The custom of leaving the arms and breasts of infants uncovered is too great a sacrifice to fashion or to vanity. In children predisposed to the disease, the plan may be tried of * Since the publication of the last edition of this work, the results of the operation of tracheotomy in croup have been given to the world from various sources. M. Trous- seau has found it increasingly successful. Out of 24 cases in which the operation was performed by him in four years, there were 14 cures; and during the last of these years he operated 9 times with 7 cures. Such results entitle to close attention the various cautions which he considers important for success. I shall notice the chief of these, as given in a paper published by him in the Archives Gtneralcs, for March, 1855 (p. 25* )■ In the first place, he never operates in those diphtheritic cases, in which the constitution is greatly involved, and the danger is rather from the general disease than from that of the larynx; but, when the local lesion constitutes the chief danger, it is never too late to operate. The operation should not be too rapidly performed. He insists on the neces- sity of dividing the tissues by successive layers, removing out of the way the vessels and muscles, and laying bare the trachea before opening it He has never seen too great slowness the cause of any serious accident, but often the'reverse. The necessary instruments are a straight or curved bistoury another furnished with a button a dila- tor two blunt hooks, and a double canula with as large a diameter as compatible with its easv introduction into the trachea. It is of little consequence how the trachea is entered provided hemorrhage be avoided But the after treatment is all-important. 5C first thine to be attended to is that the child be well nourished, without hrinirover fed Milk, eggs, cream, chocolate, and soups are the proper articles. All morlirine^ such as may have been deemed necessary before the operation, are to be meuiniic.-, ghieU1 of waxed snk or of caoutchouc, should intervene between the avoiaeu. prevent the sides ofthe instrument and the strings which hold it in 8l"n from irritating the wound. The neck of the child should be surrounded with a PaCe'VOL.I. 55 866 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. gradually accustoming the skin to the impression of cold, by washing the shoulders and breast with water of the temperature of the air, beginning in the warm season, and continuing into winter, and taking care to prevent any unpleasant effect by wiping the part dry with a towel, and bringing about re- action if necessary by friction. When families are predisposed to the more fatal form of croup, it may be advisable to remove to a mild and dry climate. SUBSECTION II. NERVOUS OR FUNCTIONAL DISEASES OF THE RESPIRATORY PASSAGES. Article I LARYNGEAL NERYOUS DISEASE. 1. Infantile Spasm Of the Glottis.—Laryngismus Stridulus (Good).—Crowing Disease.—Inward Fits.—Spasmodic Croup.— Thymic Asthma.—Miller's Asthma.—This disease, though similar to catarrhal croup in some of its symptoms, is essentially distinct in the circumstance, that it scarf of knit wool, or with a large piece of muslin, so that the child may breathe into this tissue, and inhale the air warmed and moistened by its own breath. This is an important precept, and, before the plan was adopted, many patients were lost by catar- rhal pneumonia. For the first four days, all the cut surfaces should be daily cauterized by the nitrate of silver, so as to prevent a diphtheritic affection of the wound. The sooner the canula can be removed the better. It can rarely be removed before the sixth day; and should seldom be allowed to remain beyond the tenth. Nevertheless, the larynx sometimes continues closed much longer; and of course the canula must remain till the natural passage is opened. At the end of a week, the canula should be with- drawn, care being taken not to alarm the child, or cause it to cry. There is often a paroxysm of fright in consequence of the slight difficulty of breathing through the natural passage, which should be quieted by the mother or nurse as soon as possible. If the air pass easily through the larynx, the wound is closed with strips of English court-plaster, if not, a piece of open lint spread with cerate is placed over it, and the closing of it is postponed to the next day. If now the air does not pass, the canula is again introduced ; and another trial is to be made two or three days later. As soon as the breathing becomes natural, the dressings are to be removed two or three times daily. Usually the opening in the trachea closes in four or five days. A difficulty in swallowing sometimes occurs, which requires attention. In the passage of liquids over the glottis, a portion sometimes enters, and creates so much irritation that the child instinctively refuses food, and may even die of starvation rather than attempt to swallow it. To avoid this, the food should in such instances be given in a soft solid state, and liquids should never be allowed. The accident seldom occurs before the third or fourth day after the operation, or later than the tenth or twelfth day. In England the operation of tracheotomy has been much less successful than in France. Of the cases in which it has been tried in pure croup, almost all have proved fatal; at least the recoveries have been relatively very few. The same, to a con- siderable extent may be said of our experience in the United States. I have always been in the habit of ascribing this difference not so much to difference in the skill of the operators, as to the circumstance that the disease in France is much more fre- quently confined to the fauces and larynx, than either in Great Britain or the United States. At least I am quite confident that, in a very large portion of the fatal cases which have come under my personal notice, death was owing much more to the disease in the bronchia and lungs than to that of the larynx, and that no operation could pos- sibly have saved them. It has been stated in the text, that one of the forms of croup is associated with an epidemic or contagious diphtheritic disease. In this the exudation takes place generally in the fauces, and becomes croup by descending into the larynx. This may be an ordinary form of the disease in France. With us, and in England, it is comparatively rare. Nevertheless, as the operation with us now and then saves life, it is I think justifiable, if not obligatory, as a last resort, when no proof exists of an amount of pectoral disease which must necessarily render it abortive. (Note to the fifth edition.) CLASS III.] SPASM OF THE QLOTTIS. 867 is purely nervous, and altogether independent of vascular irritation or inflam- mation of the larynx. There is much unfortunate confusion in its nomen- clature. The description by Dr. Good of his laryngismus stridulus, though the name has been adopted by several writers for the disease in question, obviously also embraces catarrhal croup in some of its less inflammatory forms. The name of spasmodic croup is altogether inapplicable, as the dis- ease is not croup at all. Asthma, however qualified by epithets, is equally inappropriate; as that is the name for a pectoral affection, while this com- plaint resides in the larynx. Inward fits is a vulgar title of the disease. The affection is usually characterized by a shrill sound in inspiration, some- what like the crowing of a cock, which has given origin to the name of crow- ing disease. The sound is supposed to be owing to a spasmodic contraction of the chink of the glottis; and the complaint is confined to infancy and very early childhood, occurring at any time from a few days after birth to the end of the third year, but most frequently during the first dentition. Hence the name at the head of this article. Symptoms.—The attack is sudden, and may occur at any time, though it is most frequent during sleep, from which the child awakes with a start, and in great apparent alarm. He is seized with inability to inhale the air; and the first symptoms are those of a struggle for breath, with the head thrown back, the breast elevated, the nostrils expanded, the mouth open, and all the muscles of inspiration in almost convulsive action. The veins of the neck and head are distended; and the countenance is flushed, swollen, and pur- plish, or of a pale cadaverous hue, with an expression of extreme anxiety and distress. At length, but occasionally not until symptoms of asphyxia appear, the spasm of the glottis somewhat relaxes, and the air rushes in, with a shrill, whooping sound. The child then usually begins to cry, and, after a short period of hurried breathing, returns to his previous health. But the stridulous sound during inspiration is not absolutely essential; for it some- times happens that the spasm, instead of yielding partially, relaxes at once and completely, so as to allow the air to enter quietly. Not unfrequently, along with the difficulty of inspiration, there is a spasmodic contraction of the fingers and toes; and the paroxysm is sometimes followed by general convulsions. When the attack is over, the child is free from all symptoms of disease of the throat Occasionally only a single paroxysm occurs at first, aud the disease does not return for weeks. But the interval is often much shorter; and, in bad cases, the attacks take place several times a day, in- creasing in duration and frequency, until they occupy a quarter or half an hour at a time, with sometimes a scarcely appreciable interval. The complaint is usually unattended with cough, fever, bronchial disease, or inflammation of the larynx or trachea. By the absence of these affections it may be readily distinguished from croup. Though often a trifling disease, it is sometimes far otherwise. In some instances the child perishes with asphyxia from the persistence of the spasm. The interruption of respiration, when the fits are frequent, gives rise to a degree of cerebral congestion, which sometimes produces convulsions, or other serious morbid phenomena. But in general the complaint, when alarming, is so merely as a sign of serious disorder elsewhere. It is often rather a symptom than itself a disease. Though said by some writers to be frequent, it hcas been rare within the observation of the author. M Herard who saw much of the disease in the Children's Hospital at Paris asserts'that no characteristic morbid condition can be discovered after death'- the emphysema, which he uniformly noticed, being an effect and not a ' Kv this writer spasm of the diaphragm is considered as sometimes forming an essential part of the affection. {Med. Times, Nov. 6, 1847.) 868 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. Causes.—The disease appears sometimes to depend upon a general morbid excitability of the nervous system, directed especially to the muscles of the glottis, which contract spasmodically from slight causes, such as the sudden contact of cold air, any quick unexpected movement, or vivid mental emotion, especially fright. Hence infants are sometimes attacked with it, when tossed playfully in the air. The act of swallowing occasionally brings on a paroxysm. This morbid nervous irritability is most frequently owing to dentition; but it may also be produced by other causes which deteriorate the general health, such as impure and confined air, and unwholesome food. Attacks may be brought on by sources of irritation in the intestines, including undigested food, acidity, acrid secretions, and worms. Disorder in the alimentary canal is, indeed, believed by some to be its most frequent cause; and hence it is apt to occur in infants fed by the hand. In some instances, the disease is associated with, and probably dependent on, affection of the brain, and has been considered as one of the earliest signs of hydrocephalus. It has also been ascribed to inflammation of the cervical portion of the spinal marrow, and to tumours pressing on the par vagum, or the recurrent nerve, wliich regulates the movements of the glottis. Thus, it has appeared to arise from enlarged cervical glands; and the thymus gland has been found of unusual size in some fatal cases. Some authors consider the latter as among the chief sources of the complaint, which has therefore been named thymic asthma. Treatment.—It is sometimes highly important to relax the spasm of the glottis at the commencement of the paroxysm, so as to prevent asphyxia, This may generally be accomplished by dashing cold water upon the face or shoulders, gently slapping the back, breast, or nates, blowing into the face or ear, or exposing the patient to a current of cool air at an open window. When the spasm recurs frequently, it may often be prevented by the warm bath, nau- seating medicines, and antispasmodics injected into the rectum. Should the symptoms be alarming, tobacco should be applied to the throat in the form of a cataplasm. It is said also to have proved very effectual in the form of enema, prepared with five grains of the tobacco and a fluidounce of hot water. Dr. F. Collins, of Wanstead, England, has employed the inhalation of chlo- roform, in several cases, with unfailing success. (Lond. Med. Times and Gaz., April, 1853, p. 380.) But the practitioner must bear in mind the hazardous character of this remedy. Inhalation of the vapour of ether was effectual in a very bad case, recorded by Mr. Image, of the Suffolk Hospital, England. It was applied by means of a sponge held to the mouth and nostrils, at the commencement of each recurring paroxysm, which was thus instantly set aside; and at length the disposition to a return of the paroxysms ceased entirely. (Prov. Med. and Surg. Journ., June 2, 1847.) Should the danger of death from asphyxia appear imminent, and no other remedy have proved availing, recourse should be had to tracheotomy, which could scarcely fail to rescue the patient for the time. But it must be very rarely requisite. Arti- ficial respiration is recommended by Dr. Reid. The general nervous excitability in which the complaint sometimes origi- nates, should be controlled by the nervous stimulants, which have the pro- perty of equalizing the excitement. For this purpose, assafetida or valerian may be given internally, and garlic applied in the form of cataplasms to the feet, or with hot brandy to the spine. Alusk would probably act powerfully in these cases in relaxing the spasm, and the tincture of artificial musk is said to have been used with great success. Narcotics may also prove useful, when the brain is not diseased, by diminishing the sensibility to exciting causes. Tonics and the cold bath, when the latter does not induce the spasm by the alarm it occasions, are also useful by giving strength to the nervous system. Of the tonics, sulphate of quinia and the preparations of zinc are probably most to be depended on. CLASS III.] SPASM OF THE GLOTTIS.—APHONIA. 869 Attention should always be paid to the gums, which should be lanced if swollen and painful. When the dentition is peculiarly diflficult and painful, blisters may be applied behind the ears, or at the nape of the neck. The bowels should also be scrupulously attended to. If the stools are white, or otherwise disordered from deranged biliary secretion, minute doses of the mercurial pill or calomel should be given, or mercury with chalk if there is diarrhoea. Acidity must be corrected by the usual remedies. Should a tendency to constipation exist, it must be counteracted by rhubarb, mag- nesia, castor oil, or other mild cathartic, so as to obtain one or two stools daily. The diet should be very carefully regulated, and all indigestible or acescent food forbidden. The mother's milk is usually the best food under the year, and cow's milk with arrow-root, ground rice, &c, and animal broths in moderation afterward. The child should be clothed warmly, and made to breathe a free and pure air. Especial care should be taken to avoid all frights, and other sudden or violent emotions. Should there be reason to suspect disease of the brain, or tumours pressing upon the par vagum or its recurrent branch, as the cause of the complaint, the remedies should be addressed to these affections. 2. Spasm of the Glottis in Adults.—Occasionally the glottis is spasmodically affected in adults, independently of inflammation. The same phenomena to a certain extent occur as in children. There is first difficulty with laborious effort in inspiration, then the shrill, whooping sound arising from the entrance of air through the somewhat open but still contracted pas- sage, and occasionally a croupy cough. The spasm may be excited, and some- times fatally, by a foreign body in the larynx or pharynx. Choking is in such cases not mechanical; but arises from involuntary contraction of the laryngeal muscles, consequent upon irritation of parts supplied with branches of the same nerves. The affection results more frequently from an unstable and excitable condition of the nervous system, and is merely one of the pro- tean forms in which hysteria exhibits itself. Sometimes it appears to have its origin in spinal, sometimes in cerebral irritation. It may also be produced by tumours pressing upon the recurrent nerve, as aneurism of the aorta and its primary branches. It is much more common in women than in men. The treatment must be directed to the cause, and is for the most part such as is adapted to cases of hysteria. Antispasmodics, narcotics, tonics, the cold or shower-bath, a proper regulation of the intestinal and uterine func- tions, counter-irritation to the spine, an appropriate diet, and exercise in the open air, are the chief remedies. 3. Suppression of the Voice, or Aphonia.—Allusion is here made only to affections of the voice of a nervous character, independently of inflammation or organic alteration of the larynx. Changes of the voice of this kind are not uncommon. Sometimes it becomes acute, or of a higher key though feeble. The voice of a man is thus rendered feminine, or puerile. Sometimes the alteration is of an opposite character, the voice becoming low, or hoarse, or croaking, so that a child or a woman will speak like a man. In many instances, it is entirely suppressed. No sound is formed above that of the breath, and speech is in whispers. The attack may be sudden or gradual, and brief or of long and indefinite duration Causes —These are numerous. Among the most frequent is the irregular distribution of nervous influence consequent upon general debility, as after long-continued or exhausting diseases. The affection is often nothing but a form of hysteria Sometimes it depends upon debility of the laryngeal mus- cles alone-as where these have been overstrained by protracted and excessive efforts in speaking or singing. Occasionally an attack .^ brought on by a sudden -ind strong mental emotion, as of joy, anger, or fright. Quick changes 870 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. from a warm to a very cold air have induced it. In some instances, it appears to depend on sympathy with intestinal irritation, or disease of the sexual organs, whether in man or woman. It has attended the poisonous action of lead, and has been brought on by powerful narcotics, as belladonna and stra- monium. Another frequent source of it is disease affecting the par vagum, recurrent, or spinal accessory nerve, or one of the nervous centres. Hence it may attend aneurisms in the upper part of the chest, and, in the form of partial or complete palsy of the larynx, may depend upon congestion or effu- sion in the brain, or other organic cerebral disease. Treatment—When the disease depends on general debility, the obvious plan of cure is to restore strength by tonics, the cold bath, nourishing food, and exercise. When a mere form of hysteria, it is to be treated like spasm of the glottis from the same cause. If the central or spinal nervous centres are in fault, our remedies must be addressed to those parts, and must vary with the nature of the affection. Should there be reason to suspect active congestion or inflammation, antiphlogistic remedies must be used, including local depletion and repeated blistering to the back of the neck. Nux vomica or strychnia may be employed, when there is reason to suspect a paralytic state of the muscles of the glottis, without sufficient active congestion or in- flammation ofthe nervous centres to contraindicate its use. Aphonia arising from temporary causes often disappears spontaneously. When produced by cold, it is cured by hot teas, or warm stimulating drinks, given so as to pro- duce perspiration. If the result of lead poison, it may be treated .by mer- cury or iodide of potassium, and by measures calculated to stimulate the organ. Such measures are also obviously proper in all cases, where the modification of the voice depends on debility of the laryngeal muscles. Under such circumstances, we may employ gargles of alum and other astrin- gents whether vegetable or mineral, stimulating inhalations, electricity or galvanism, external irritation by means of sinapisms, blisters, croton oil, or a seton, and strychnia applied to a blistered surface, or taken internally. Inha- lation of the vapours of benzoin has been found effectual. Dr. Pancoast, of Philadelphia, has related two cases in which the voice was restored by inha- lation of chlorine. (Trans, of Am. Med. Association, iii. 136.) The vapour of ether with balsam of Tolu has been recommended. Solution of nitrate of silver has been applied directly to the internal surface of the larynx, with suc- cess in several cases, by M. Trousseau; but the operation requires dexterity, and should be tried only by a skilful hand. 4. Laryngeal and Tracheal Pains.—Neuralgia of the Larynx and Trachea.—Severe pain sometimes attacks these parts, without any evi- dence whatever of inflammation. It is felt along the anterior part of the throat, and beneath the upper part of the sternum. Like other forms of neuralgia, it may occur in paroxysms, or may be continuous for a considerable time, and varies greatly in degree. It may or may not be accompanied with spasm of the muscular fibres. The most frequent cause of it is probably rheumatic or gouty irritation, in constitutions of a nervous character. It may arise also from other causes of neuralgia elsewhere, as general debility, or irritation existing in the nervous centres, or in the course of the nerves sup- plying the parts. In persons predisposed to the affection, it is sometimes excited by breathing cold air. The remedies are the same as for neuralgia generally. Those especially applicable in this case would be the inhalation of warm aqueous vapour, either unmixed or impregnated with the vapours of narcotic and anodyne substances, such as opium, camphor, and conium ; the smoking of tobacco or stramonium; and the application of a blister over the seat of pain, and the sprinkling of morphia upon the blistered surface. When apt to be induced by cold air, it may probably be best prevented by CLASS III.] HOOPING-COUGH. 871 the habitual use of the cold shower-bath, or the frequent application of cold water to the neck and breast. An attack may sometimes be averted by holding a silk handkerchief to the mouth and nostrils, upon entering the open air. Article II. HOOPING-COUGH, or PERTUSSIS. Syn.—Chin-cough.—Convulsive Cough of Children.—Tussis convulsiva, spasmodica, stran- gulans, Sec. This is a contagious disease, characterized by frequent paroxysms of coughing, in which the expiration is broken into numerous short, rapid, and spasmodic movements, and the inspiration is long, and frequently sonorous. It most frequently affects young children. Medical writers usually divide it into three stages; 1. the catarrhal or forming stage, 2. the spasmodic stage, or that of progress and maturity, and 3. the declining stage. The limits of these several stages are not always well defined, nor do they all exist in every instance of the disease. Something like them, however, is very generally observable; and the division enables the symptoms to be conveniently grouped in description. Symptoms, Course, eve.—The disease generally begins, like a common cold, with coryza, red and watery eyes, sneezing, irritation of throat, a dry cough, and sometimes febrile symptoms; and it is often impossible to distinguish it, with certainty, at this period, from catarrh. The cough, however, is usually more paroxysmal; and this circumstance, in connection with the fact that the disease is prevalent at the time, is sufficient to fix suspicion upon the case, and put the practitioner upon his guard. This stage continues, in most cases, for one or two weeks, before decided spasmodic symptoms appear. Sometimes, however, its duration is shorter, and sometimes longer. Instances, indeed, now and then occur, in which the characteristic symptoms appear at the out- set ; and it is occasionally observed, during the prevalence of hooping-cough, that catarrhal affections run a corresponding course, as if dependent upon the same cause, though destitute of the spasmodic phenomena. But, in most cases, at the end of eight or ten days, the cough begins to change, gradually assuming the proper character of pertussis; and the disease passes into the second stage. This, when fully formed, presents the follow- ing symptoms. At irregular intervals through the day and night, the child is seized with an irresistible disposition to cough. But the sound, instead of occupying continuously the whole time of expiration, as in ordinary com- plaints of the chest, is broken into a number of short coughs, which succeed each other with an almost convulsive force and rapidity; and the inspiration that immediately follows is long, difficult, and often attended with a shrill or whooping sound, which has given its common name tothe complaint This succession of spasmodic cough and shrill inspiration is repeated again and again, thus constituting a paroxysm, which lasts variously from thirty seconds to fifteen minutes, or even longer. During the paroxysm the face is flushed, swollen and sometimes purplish or livid, the veins of the neck and temples distended the eyes prominent, and the countenance expressive of much dis- tress The child if lying, starts up into the sitting posture, and, if standing, aire's some person or object near him for support. In violent cases, the blood sometimes escapes from the nose mouth, or ears, or is extravasated in the coniunctiva; and the urine and feces are discharged involuntarily. The paroxysm usually terminates with the expectoration of transparent mu- 872 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. cus, and not unfrequently in vomiting, which appears to relax the spasm, and thus proves serviceable. Occasionally, however, no discharge takes place from the lungs or stomach, and the paroxysm ceases with the exhaustion of the patient. For a short time after it is over, the child appears feeble and perhaps trembling, with hurried pulse and breathing; but he soon recovers, and seems as if nothing had happened, resuming his play or occupations with his ordinary cheerfulness, and often showing an eager desire for food, especially after vomiting. If asleep when seized with a cough, he lies down when it is passed, and is soon asleep again. The successive broken coughs, so characteristic of the disease, are obviously the result of short and quick spasms of the muscles of expiration. This symptom not unfrequently occurs long before the whooping sound, which, in some few instances, is very seldom or never heard throughout the complaint. The sonorous inspiration, or whooping, is owing to the difficult passage of the air through the contracted and rigid chink of the glottis, as happens also in croup, and the crowing disease of children. The expectoration is probably produced, not by inflammation of the bronchial mucous membrane, but in consequence of the violent agitation of the lungs, which induces an increased afflux of blood and consequent increased secretion, exactly in the same man- ner as prolonged fits of laughter. The vomiting arises from the disturbed movements of the fauces, and seems to be a provision of nature for a solution of the paroxysm. There is no previous or subsequent sickness of the stomach. The paroxysms recur quite irregularly, sometimes without apparent cause, sometimes from slight causes, such as exposure to cold air, sudden or rapid movements, crying, attempts at swallowing, fits of passion, irritating inhala- tions, and even the sight of others labouring under an attack. The period of their recurrence is very different in different cases. In some, there is only an interval of a few minutes between them, in others, they occur not oftener than eight or ten times in twenty-four hours; and there is every intervening degree of frequency. Authors do not agree upon the point, whether they occur oftener during the day or night; from which it may be inferred that there is no great difference in this respect. The patient is often sensible, for some time previously to the seizure, that it is about to take place. A tickling sensation in the larynx and upper part of the trachea, pains in the breast, and increased frequency of the pulse and respiration, often precede the par- oxysm ; and the child appears to dread its approach, and to repress the dis- position to cough as long as possible. The paroxysms increase in frequency and violence until the complaint is at its height, which is usually in four or five weeks from the commencement of the attack, though the time may be considerably shorter or longer. The dis- ease then appears to remain stationary for about two or three weeks, after which it begins to decline, and the third stage commences. The spells of coughing now gradually become less frequent and severe, and more catarrhal, being attended with the expectoration of opaque whitish or yellowish matter, and losing much of the spasmodic or convulsive character. At length the broken expiration and the whooping sound cease entirely; and the patient is either well, or affected with a slight ordinary cough, which in its turn ceases. But not unfrequently the termination is much less regular. Sometimes the symptoms, after having ceased, reappear for a time. Frequently, after resto- ration to health, if the patient acquires a cough from any cause, it is apt to exhibit more or less of the characteristics of pertussis. Occasionally the dis- ease seems to assume a chronic form, and is'indefinitely protracted. Its dura- tion is quite uncertain. Sometimes it has disappeared in a month or six weeks, while in other cases, it is asserted to have run on for two years. It will probably be no great deviation from the truth to state that, in its ordi- CLASS III.] HOOPING-COUGH. 873 nary course, the disease occupies about three months; six weeks being allowed for its formation and progress, two or three for its highest elevation, and three or four for its decline. A. remarkable fact, stated by Dr. G. D. Gibbs, is that the urine in hooping- cough is generally saccharine; the quantity of glucose being usually small, sometimes a mere trace, but occasionally considerable, so as to give a high specific gravity to the secretion. (Lond. Lancet, Am. ed., April, 1858, p. 345.) Small ulcers on the fra?num of the tongue are said to be a common symp- tom of the disease; and Dr. Gamberini, of Milan, ascribes them to the fre- quent impinging of the part against the teeth, in the paroxysms of coughing. They lessen as the complaint declines, and disappear along with it. (Arch. Gen., Feb. 1855, p. 191.) As above described, hooping-cough is in its simple uncomplicated form. Except the catarrhal symptoms at the commencement, it does not necessarily show any signs of bronchial inflammation. The patient runs about, often with a good appetite, and, except during the paroxysm, suffers little. There is no fever, or only an occasional slight accession, dependent probably on some temporary irritation of the bronchial or alimentary mucous membrane. Aus- cultation may sometimes detect the dry or mucous rales; but very often, as asserted by Blache from personal observation, it reveals no morbid sounds whatever in the chest. (Diet, de Med., ix. 27.) It is a curious fact, that, during the paroxysm, the respiratory murmur cannot be heard. The air does not enter the air-cells, either from the deficient quantity allowed to pass the glottis, or from spasmodic closure of the small tubes. Immediately after the paroxysm, the ordinary sound of respiration is heard distinctly. The force of the disease varies much even in its simple form. In some instances, it is so slight that it can scarcely be determined, after recovery, whether the child has had hooping-cough or not. In others again it is very severe, with frequent and violent paroxysms, which seem to threaten suf- focation. By the pressure upon the brain, fatal convulsions are sometimes brought on ; and death may also take place from asphyxia during the parox- ysm. A case of death is recorded from emphysema of the neck and medias- tinum, consequent upon a violent paroxysm of coughing. (London Lancet, Aug. 1849.) In protracted cases, great emaciation and debility sometimes ensue, and the patient may die of exhaustion. But these results are compa- ratively rare. The simple form of the disease almost always terminates favourably. It is, however, liable to complications, which are very often dangerous, and not unfrequently fatal. Of these complications the most frequent are probably bronchitis and pneu- monia When the child becomes steadily febrile, one of these affections may be suspected. It is not uncommon for the peculiar symptoms of pertussis to be diminished during their continuance, and to reappear upon their decline. A certain degree of bronchial inflammation is not unusual in the early stage, and for some time even after the spasmodic symptoms have appeared But this is not often serious. That from which danger is most to be apprehended occurs at an advanced period of the disease. It may affect the larger tubes exclusively or may penetrate into their minute ramifications. 1 he symptoms and physical signs are the same as in bronchitis from other causes Pneu- monia very seldom occurs early in the complaint. Rdhet and Barthez state that they have not observed it in children who have perished before the twenty-seventh day. (Malad. dest Enfants, ii. 216.) Convulsions are another frequent complication of hooping-cough. They nre most ant to occur during the period of dentition. They may be owing Smr.lv to an excessively excitable condition of the nervous system, induced by the two affections jointly. In this case, they are not necessarily dangerous. 874 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. A more serious form of them is that which occurs from congestion or effusion within the cranium, indicated by a rolling of the head, contracted or dilated pupil, squinting, paralysis of some portion of the body, and comatose symp- toms. Occasionally they are the mere expression of a hydrocephalic condi- tion of the brain; in which case they are almost necessarily fatal. Croup sometimes complicates pertussis, and, if pseudomembranous, is great- ly to be dreaded. Still another complication is inflammation of some portion of the alimen- tary canal, indicated by fever of a remittent character, furred tongue, ten- derness and sometimes swelling of the abdomen, diarrhoea, &c. The hepatic secretion is not unfrequently deranged. When any predisposition to tubercles exists, these are very apt to be de- veloped. Dropsical effusion sometimes attends pertussis. Yarious other diseases have been enumerated as occasional accompaniments, but their pre- sence is in general merely accidental. When all the complications of pertussis are considered, it must be regarded as a disease calculated to excite solicitude, and a careful watchfulness. Great numbers die of it in every epidemic. It is most fatal in children under two years, probably in part because then combined with dentition.* From results stated by Dr. Condie, it appears that the average deaths from hooping- cough, in our Atlantic cities, are about one in 70 of the whole number of deaths from all diseases; while in various countries of Northern Europe mentioned, it is nearly one in 34. (Diseases of Children, p. 325.) Anatomical Characters.—After death, the morbid appearances, besides occasional signs of congestion of the brain, are, according to Dr. G. Hewitt, of London, a viscid muco-purulent fluid in the bronchia, patches of collapsed lung, as in atelectasis, and some dilatation of the air-cells in the parts neighbouring to those collapsed. An organic lesion, long since noticed as a common attendant on the advanced stage of fatal cases, is dilatation of the bronchial tubes. This, however, was not met with by Dr. Hewitt in any one of nineteen cases examined by him. In some instances, he found minute abscesses at the termination of the bronchia, such as will be hereafter more particularly noticed under vesicular pneumonia, but not true bronchial dilata- tion. (Edinburgh Med. Journ., Nov. 1855, p. 448.) Supposing this lesion sometimes to occur, its production, as well as that of the dilated air-cells, may be ascribed to the existence of collapse, as noticed by Dr. Hewitt. Under the expansive force of the dnspiratory muscles, the air contained in the vesicles and bronchia must have a tendency to dilate them, to supply the want of expansion in the collapsed parts. Of course any supervening dis- ease must leave its peculiar lesion behind it. Dr. Hewitt met with instances of the hepatization of pneumonia, pleuritic adhesions, and tubercles. Causes.—One of the most common causes of pertussis is certainly epidemic influence. But this is not so sweeping in its range, nor so rapid in its pro- gress as the cause of influenza. Epidemic hooping-cough is more commonly somewhat partial in its prevalence, like measles and scarlatina, affecting only certain districts or cities, or even parts only of these, to the exclusion of other parts. Sometimes the disease attends an epidemic of measles, and is occasion- ally associated with the influenza in certain localities. It is altogether ir- * From a statistical table prepared by Dr. Ed. Smith, of London, and published in the Medico-Chirurgical Transactions (xxxvii. 227), it appears that, in England and Wales, of the deaths from hooping-cough, 40-4 per cent, are under one year, 27-4 be- tween one and two, 13-8 between two and three, 7-7 between three and four, and 4-7 between four and five, leaving only 6 per cent, for all ages above five. In the London district, during a period of ten years, the deaths from this disease were about one- thirtieth of the whole number of deaths. (Note to the fifth edition.) CLASS III.] HOOPING-COUGH. 875 regular in the periods of its recurrence. Its fatality is said to be much greater in some epidemics than in others. It is not confined to any season, though perhaps more frequent in cold than in warm weather. The disease *\™°re favourable in sPrinS than in autumn, because its latter stages, in which there is greatest danger of pectoral inflammation, are brought into the summer instead of the winter. Occasionally the complaint is sporadic. Different opinions have been entertained of its contagious nature; but the great majority of writers are united in believing that it is propagated from individual to individual; and it does not appear to the author possible to resist the weight of evidence in favour of this view. It is probably most contagious at the period of its highest development. As a general rule, the disease occurs only once in the same person. Ex- ceptions occasionally happen to this rule, as in all other contagious diseases. It is confined to no age, sex, or condition of life. Persons advanced in life are sometimes attacked, and Dr. Watson mentions a case in which a child was born with it. For a very obvious reason, however, it occurs chiefly in early childhood. Being frequently prevalent and highly contagious, it attacks most persons early in life; and adults escape because they have once had the disease. It is said to affect infants less frequently before than after the commencement of dentition. But may not this be owing to the fact, that, upon the whole, very young infants are less exposed to the cause ? Nature.—Very different opinions have been advanced as to the nature of hooping-cough. Some consider it as essentially a variety of bronchitis; but this opinion is not tenable ; because the best evidence exists, both from the physical signs during life and examination after death, that the bronchia are often wholly free from inflammation. Others again ascribe the phenomena to cerebral disorder, considering this to be the essential feature of the disease. But this opinion wants the support of facts. No proof whatever is afforded by the symptoms that the brain is chiefly disordered. It seems to the author very clear that the complaint is not wholly and exclusively either inflamma- tory or nervous. The cause appears to be capable of giving rise to inflam- mation of the air-passages directly; for this is often the first observable effect; and, when not sufficient immediately to induce inflammation, it strongly predisposes to that condition, as proved by the frequency of bronchitis and pneumonia in the latter stages. But it is not less certain that the same cause gives rise immediately to nervous disorder of the respiratory passages; for this not unfrequently exists without any inflammation whatever in the second stage of the disease, and, in a few instances, is the first effect produced. Usually the catarrhal and spasmodic, in other words the inflammatory and the nervous effects, exist in the same case, and not unfrequently conjointly; but the cause may operate exclusively in either of these directions; for cases occur in which the peculiar spasmodic phenomena are uncomplicated, while others have been observed, in all probability ascribable to the same epidemic cause, which have been catarrhal throughout. Some have ascribed the com- plaint to inflammation of the pneumogastric nerve, and have even found that nerve inflamed after death; but other close observers have searched in vain for this condition of things, through a long series of dissections. Treatment.—In simple cases of hooping-cough, without violent symptoms, little treatment is requisite. It is probable that, in the majority of cases, the disease runs its course to a favourable termination, with very little, if any, interference on the part of the physician. In its severer forms, however, treatment is often highly useful in alleviating the symptoms, and, in compli- cated cases, is frequently indispensable to safety. In the early stage, if the catarrhal symptoms are moderate, it will be suffi- cient to give a mild cathartic, as castor oil, magnesia, or sulphate of mag- 876 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. nesia, and afterwards small doses of ipecacuanha or antimonial wine, at short intervals. But, should fever be present, with signs of bronchial inflammation, it will be proper to administer a full purgative dose of calomel; three or four grains, for example, to a child two or three years old, to be followed by castor oil, if it should not operate freely. This cathartic may be repeated in a few days, if the febrile symptoms do not abate. When the bronchitis is very decided, with some pain in coughing, difficulty of breathing, and the sonorous or sibilant rale under auscultation, blood may be taken from the arm, or locally from the breast by leeches, or from both, according to the severity of the symptoms, and the age of the patient. But the practitioner should always remember, while depleting in this disease, that the loss of blood cannot check its course, and that sufficient strength should be preserved to bear the patient through. He will, therefore, take less blood than in cases of original inflammation having the same seat, and the same grade. When the spasmodic symptoms appear, other remedies are required. They may be either such as by stimulating the nervous system tend to equal- ize its actions, and thus obviate the irregular distribution of influence which causes spasm, or such as diminish the sensibility of the nervous centres, and render them less susceptible to the exciting or irritating cause. Hence, the nervous stimulants or antispasmodics, and the narcotics, have been found use- ful. The former are, perhaps, upon the whole, preferable, as less likely to promote any pre-existing disposition to cerebral disease; but the two may often be happily conjoined. The use of these should not, as a general rule, be commenced with, until any existing fever or bronchial inflammation shall have been removed. When these symptoms linger in connection with the spasmodic, it will be preferable to precede the antispasmodics and narcotics by occasional emetic doses of ipecacuanha, in violent cases every day or every other day, with smaller closes every two or three hours in the interval, so as to sustain a very slight degree of nausea. Should the bronchitis be conside- rable, and especially if croup should coexist, or be threatened, tartar emetic may be preferred to ipecacuanha, in reference both to its emetic and nause- ant action. Lobelia, too, may be employed in the latter case with great propriety. The daffodil (Narcissus pseudo-narcissus), which has been re- commended in hooping-cough, probably acts in the same way. Emetic medi- cines are useful by relaxing the spasm, depressing general arterial excitement, and promoting expectoration. They may be aided by the frequent use of hot pediluvia or the warm bath. When fever has disappeared, and the pro- per paroxysms of hooping-cough only remain, recourse may be had to the antispasmodics; and, if there be any doubt upon the point, the use of these may be combined with that of the emetic medicines. By far the best of the nervous stimulants that I have employed is assafe- tida. It should be given in emulsion, in the dose of one or two grains to a child two years old, repeated three or four times a day, or, in severe cases, as often as every two or three hours. Though disagreeable at first, it soon ceases to be so ; and it is not at all uncommon to see the little patient anxious for the repetition of his dose. It has been recommended also by injection, and, in the form of tincture, as an application to the spine; but these modes of administration are unnecessary, when it is supported well by the stomach. Garlic may be employed as a substitute for assafetida, when this is not at hand, or may from any cause be forbidden. Strong coffee is said to have proved very serviceable. Other antispasmodics, which have had more or less reputation in the complaint, are musk, artificial musk, castor, valerian, camphor, ammonia, oil of amber, Dippel's animal oil, and cochineal. Of the narcotics, belladonna has the highest reputation. It appears, in- deed, from much highly respectable testimony, both of European and Ame- CLASS III.] HOOPING-COUGH. 877 rican practitioners, to exercise a very powerful influence over the disease. .Little good, however, can be expected from it until it has given some obvi- ous sign of its action, as dryness of the fauces, vertigo, or dimness of vision ; and it should therefore be pushed to this point. Dr. Samuel Jackson, late °l fiorthumbe.rland, in Pennsylvania, now of Philadelphia, who was one of the first physicians to employ the remedy in this country, and has found it very successful, insists upon the necessity of giving it so as to dilate the pupil. The dose for a child two years old is from the twelfth to the sixth of a grain of the extract, twice or three times a day to begin with, and gradu- ally increased, if necessary, until it produces its peculiar effects. The uncer- tainty and occasional great strength of the extract render it advisable to begin with a very small dose. The same effects may be obtained from the external as from the internal use of the medicine. The most convenient mode of apply- ing it is in the form of a plaster between the shoulders, I have seen a plas- ter of this kind act like a charm in relieving the symptoms of pertussis ; but alarming convulsions came on ; and, though these ultimately yielded, and the patient recovered, I have since been very cautious in the employment of the remedy. The connection, however, in this case, may have been merely accidental.* Yarious other narcotics have been employed in hooping-cough. Among them are opium, hyoscyamus, conium, extract of Lactuca virosa or lactucarium, and dulcamara. Opium is undoubtedly the most efficient in allaying cough; but is liable to the objection of being apt to check mu- cous secretion, and consequently to prevent expectoration. Still, it may be occasionally used with advantage in connection with ipecacuanha or tartar emetic, and other expectorants. It has been recommended, in the form of one of the salts of morphia, as an endermic application to the throat. Hy- drocyanic acid has been very highly praised. It does, in fact, appear to exercise a favourable influence in the disease; but its strength is so uncertain, and it is so dangerous in overdoses, that it is scarcely an advisable remedy, especially when we have so many others much safer, and not less effectual. Cherry-laurel water, which is identical in effect with hydrocyanic acid, has been used in Europe, both by the mouth, and by inhalation. The tonics which often prove efficient remedies in the purely nervous af- fections, have enjoyed some reputation in the treatment of this, especially at a somewhat advanced period, when the system has begun to be exhausted by the continuance of the disease. The mineral tonics have usually been pre- ferred. Of these, oxide of zinc, in the dose, for a child two years old, of from half a grain to two or three grains every three or four hours, subcarbon- ate of iron in the quantity of from ten to fifteen grains in twenty-four hours, iodide of silver in the dose of one-quarter of a grain three times a day, and nitrate of silver in that of one-fifth of a grain daily, have been especially commended. Nitric acid, recommended by Dr. Arnoldi, is affirmed by Dr. G. D. Gibbs, in his treatise on hooping-cough, to " shorten the disease almost as effectually as quinia does intermittent fever." (See Lond. Med. Times and Gaz., July, 1854, p. 118.) It is stated by Dr. Gibbs that, when glucosuria attends the disease, it disappears under the use of this acid. (Lancet, Am. ed., April, 1858, p. 345.) Among the substances which have enjoyed more or iess reputation, sulphate of quinia has also been considerably employed, and probably quite as effectually as the mineral tonics. We should perhaps be no great losers, were we to confine ourselves, in the treatment of the first two stages of hooping-cough, to the remedies already * See a paper by Dr. Hiram Corson, of Montgomery Co., Pennsylvania, in which this remedy is asserted to be extremely efficacious in shortening the disease, and numerous ca«es are adduced in proof of the fact. (Am. Journ. of Med. Sci., >\ S., xxiv. 353.) 878 LOCAL DISEASES.--RESPIRATORY SYSTEM. [PART II. enumerated. The practitioner will select from among them those which he may deem most efficient, and variously combine them to answer different in- dications. Thus, in the earlier stages, when the catarrhal symptoms linger, the emetics may be combined with the antispasmodics and narcotics; in the latter stages, when debility has supervened, tonics may take the place of emetics; and in all stages, should the bowels be confined, and the medicines employed to meet other indications not have the effect of opening them, lax- atives should be added to the other remedies. On the whole, of the emetics I should prefer ipecacuanha, of the antispasmodics assafetida, of the narcotics hyoscyamus, belladonna, or opium, of the tonics sulphate of quinia, nitric acid, or one of the chalybeates, and of the laxatives, castor oil, rhubarb, or magnesia. In connection with this course of medicines, occasional recourse may be had with advantage to the antacids, when the stomach or bowels are disordered; and hence the preference given to magnesia as a laxative. But, when laxatives are not required, the carbonates or bicarbonates of soda and of potassa should be used. These have had much reputation in hooping-cough independently of their antacid properties, and have been considerably used in liquid mixtures with cochineal. If to the above measures we add the use ofthe warm bath, for half an hour, an hour, or even two hours at a time, in bad spasmodic cases, when the paroxysms are very frequent and distressing, we shall have completed the round of remedies. Nevertheless, it will be proper to allude to others which have been strongly commended; as some of them may undoubtedly be occasionally useful, and the practitioner may know where to resort, when he has ineffectually ex- hausted the usual remedies. Among those of mineral origin may be men- tioned, solution of arsenite of potassa, iodide of potassium, acetate and sub-acetate of lead, alum* sulphur, and sulphuret of potassium; among the vegetable, tannic acid, the misletoe of the oak in the dose of ten or twelve grains for a child, and nux vomica; and of the animal, cod-liver oil, and tincture of cantharides. Dr. P. J. Hynes, of Nottingham, Eng- land, states that he invariably cuts short the disease, in the course of a few days, by tincture of cantharides, given so as to produce and maintain a moderate strangury. (Lancet, July, 1856, p. 87.) Local irritation by blis- ters, tartar emetic, &c, has had strenuous advocates, though in general it is in little favour, unless in cases of obvious inflammation, whether pec- toral, encephalic, or abdominal. Pustulation by tartar emetic is hazardous, and a case of death from this cause, consequent upon sloughing and ulcera- tion, is recorded. (Diet, de Med., ix. 41.) Inhalations have also been re- sorted to, and promise some temporary benefit. The substances used in this way, among others, have been cherry-laurel water, added in the quan- tity of a fluidrachm to the warm water employed, camphor, tar, benzoin, galbanum, and nitrous acid vapours. Ether and chloroform have recently been recommended, and the latter is stated to have been used with great advantage; but it requires much caution, and, in consequence of the occa- sional fatal results of inhalation, should not be resorted to unless to save life. Dr. E. Watson, of Glasgow, recommends the application of a strong solution of nitrate of silver to the interior of the larynx, as in chronic laryn- gitis ; having cured the complaint, in several instances, by this remedy. (Ed. Month. Journ., Dec. 1849, p. 1290.) Vaccination appears to have exercised a decided influence in modifying or arresting the disease, and may be resorted to, in cases in which the child has not yet undergone this process. Dr. R. L. * Drs. J. F. Meigs and D. F. Condie, in their respective works on the diseases of children, speak very decidedly of the efficacy of alum. Dr. Meigs has found it more efficacious in moderating the violence of the disease than any other remedy that he has used. (Note to the fourth edition.) CLASS III.] HOOPING-COUGH. 879 Madison, of Petersburg, Ya., believing the disease to originate in irritation ot the spinal cord, near the orifices of the pneumogastric and phrenic nerves, treats it with a blister to the back of the neck, and finds this remedy speedily and permanently effectual. In most cases, a single application is sufficient to effect a cure. (N J. Med. Beporter, v. 124, from the Western Lancet.) In the declining stage of the disease, the same remedies may be employed as previously, in gradually diminishing quantities, as the peculiar symptoms decline. Should a troublesome cough remain in this stage, it may be treated with the stimulant expectorants, combined with opium or hyoscyamus, as in chronic bronchitis. Debility must be counteracted by the moderate use of tonics. But what is chiefly required is care to avoid causes of inflammatory attacks, to which the child is now very liable. Should convulsions occur in the course of the complaint, without fever, heat of head, or other signs of dangerous cerebral disease, assafetida should be given by injection, garlic poultices applied to the feet, frictions with garlic and brandy made along the spine, and the body immersed, if necessary, in a warm bath. Should they be simply threatened, the same use may be made of garlic, while assafetida or Hoffmann's anodyne, with or without a little laudanum or paregoric elixir, may be given by the mouth. If the convulsions are connected with symptoms of cerebral congestion, it will be necessary to apply leeches to the temples, cold to the head, a blister to the back of the neck, and stimulating applications to the feet. In such cases, narcotics must be avoided. A bolder practice would be indicated, should the symptoms threaten an attack of meningitis. (See Meningitis.) Severe bronchitis or pneumonia must be encountered by the remedies demanded by these affections occurring originally; except that bleeding should be less freely employed. The most efficient remedy, under these circumstances,'next to a due amount of depletion, is calomel given in purgative doses, daily, every other day, or twice a week, according to the severity of the symptoms. In cases of fever connected with irritation or inflammation of the prima? via?, leeches to the abdomen, emollient cataplasms, refrigerant diaphoretics, warm baths, demul- cent drinks, mild aperients, as rhubarb and magnesia, and sometimes small doses of calomel, are suitable remedies. Throughout the complaint, there are various points of regimen and man- agement which require attention, independently of the use of medicines. One important rule is, that, when very young, the patient should be sedulously watched; as there might be danger of strangulation in the paroxysm. The infant, as soon as the cough begins, should be raised to the upright position; and, at the close of the paroxysm, the nurse should remove by her finger the mucus which is thrown up into the fauces. The violence of the paroxysm may sometimes be abated by inducing the child to drink a little cold water, or some cool demulcent beverage; and, when suffocation is threatened by the violence of the spasm, this may often be relaxed by dashing a little cold water into the face, or, according to Williams, by blowing into the ear. The bowels should be carefully regulated, and the biliary secretion, if deranged, corrected by appropriate means. During dentition, the gums should be carefully at- tended to. If swollen, they should be lanced freely; and, if they still remain inflamed and painful, a few leeches may be applied near the angle of the jaws, and blisters behind the ears. The diet should vary with the stage and the decree of excitement. It should consist, in the early stage, chiefly of vege- table substances with or without milk; at a more advanced period, of the same materials with milk freely, and a little of the lightest kind of meat, as the boiled breast of fowl, soft boiled egg, &c; and, in the end, when the patient is debilitated, of the most nutritious food. Whatever is taken should be of easy digestion. Should inflammation at any time supervene, the diet 880 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. should be strictly vegetable. The child should be clothed with flannel next the skin. In the catarrhal stage, he should be confined to a uniform tempera- ture ; but, when the disease has become purely spasmodic, frequent exposure to fresh dry air, even in winter, is not only allowable, but often highly useful. Damp should always be avoided. In protracted cases, or those with a tedious convalescence, the cure is promoted by a change of residence, as from town to the country, or from one part of a town to another; and, in the winter, great good may be expected from removal to a warm climate. Article III. NERYOUS COUGH. Now and then we meet, both in children and adults, with a cough which cannot be referred to any recognized disease. It is not attended essentially with any of the symptoms of catarrh. There is no evidence whatever of inflammation, or even vascular irritation in any part of the respiratory pas- sages. None of the morbid sounds, whether of the dry or moist character, are necessarily detected in the chest. It is obviously a purely nervous affec- tion ; but it does not run the course, and is seldom attended with the pecu- liar symptoms of hooping-cough. It is the characteristic, and sometimes only observable sign of a peculiar morbid condition of the respiratory nerves, or their centres, and deserves to be ranked among diseases. The cough is almost always dry, unless in instances in which, after a vio- lent paroxysm, some •mucus is thrown up, consequent upon the excitement of the respiratory organs, in the same way as expectoration results from a paroxysm of laughter. In other respects, it is liable to all possible varia- tions. It is sometimes single, short, and at uncertain and distant intervals. Sometimes it is almost incessant, leaving the patient scarcely any rest for days and weeks together, except when interrupted by sleep. I have known a young lady affected with it in this form for months, with occasional inter- vals of brief duration. In this case, it had a uniform character, continued evenly onward, sometimes almost as regularly as the breathing, and had a peculiar loud, hollow sound, which could often be heard in the adjoining house. In such cases, it is occasionally interrupted by any cause which strongly engages the attention, or excites the feelings. It is even checked for a time by eating. In other instances, the cough assumes a paroxysmal character, sometimes closely resembling that of hooping-cough. When of this form, it is apt to occur in the night, and I have known it to prove exceedingly troublesome by interrupting sleep. Not unfrequently it bears so close a re- semblance to the cough of the earlier stages of catarrh, as to be distinguished only by the absence of the other characteristic symptoms of that affection, and by resisting the remedies to which it very generally yields. The cause is not always evident. The disease is most common in women and children, though it may occur also in adult males. It is often, no doubt, the result of an hysterical condition of the nervous system, and I have seen it associated with tenderness of the spine between the scapula?. I have seen it also apparently the result of gouty and rheumatic irritation. Yery fre- quently such a cough proceeds from gastric or other abdominal disorders, probably in consequence of the nervous connections of the abdominal viscera with the larynx, through the medium of the par vagum and sympathetic. Sometimes it probably depends upon primary or secondary organic disease of the par vagum, recurrent, or spinal accessory nerve. But there are many cases in which the cause of it cannot be traced. ILI-] NERVOUS COUGH.—ASTHMA. 881 When not associated with any other disease, it almost always either sub- sides spontaneously in the end, or yields readily to remedies. In the uncom- phcatedaffection, I have found nothing so effectual as assafetida. To this remedy it will often give way immediately, after having long resisted all the treatment usually applied to catarrhal affections. The other antispasmodics are also more or less efficient; and musk, so powerful as a remedy in hiccough, may be expected to be very useful here. Garlic, externally and internally, may be used advantageously, especially in the cases of young children. The narcotics may also be appealed to, and the warm bath will be found beneficial in cases of a spasmodic nature. Leeches or cups to the spine, followed by blisters or antimonial pustulation, are most to be depended upon in hysterical cases; and wine of colchicum with morphia, in those of a rheumatic or gouty origin. When the cough is a mere attendant upon dyspeptic or other ab- dominal disease, it yields with the cause which produced it. General debility, if existing, must be corrected by the usual means. Article IV ASTHMA. Syn.—Spasmodic Asthma. Asthma, as the term is here employed, is a disease characterized by great difficulty of breathing, occurring in paroxysms, and depending on spasmodic constriction of the bronchial tubes, without the necessary accompaniment of fever, or organic disease of the lungs or heart. The name has been very indefinitely applied. It would seem often to have been used synonymously with dyspnoea; but this use of it is clearly incorrect. Dyspnoea is not a disease; but a mere symptom, which may occur in various diseases ; and, indeed, is occasioned by whatever interferes, in any way, with the due arterialization of the blood in the lungs. Compression of the air-cells, as in pleuritic and pericardial effusion; solidification of the pul- monary tissue, as in pneumonia; excess of liquid secretion in the bronchial tubes, as in bronchitis ; loss of the substance of the lungs, as in phthisis; mere congestion of the lungs, as in cardiac diseases; and even deficient in- nervation, as in various malignant affections, may all produce it. Frequency of the pulse is as much a disease as difficulty of breathing. The latter, there- fore, is not asthma. Formerly, in consequence of defective means of diagno- sis, many cases of dyspnoea could not be traced to their origin in organic dis- eases of the chest, and were thrown together into the same category with true asthma, because it was not known where else to place them. This diffi- culty is now removed ; and we are enabled, by auscultation and percussion, to refer difficulty of breathing, not truly asthmatic, to its proper source, and thus to give greater precision to our conceptions of this disease. The pathological condition proper to asthma, is that constriction of the bronchial tubes which sometimes occurs independently of inflammation or other organic lesion, and even of congestion, and which, though not positively demonstrated to depend upon muscular contraction, is generally believed to do so and is therefore considered as spasmodic. But every case of constriction of this kind is not included in asthma. Bronchial spasm is a frequent and subordinate attendant upon other diseases of a much more serious character, as in cases of severe bronchitis. The inflammation is here the prominent affection- the one from which danger is apprehended, and to which treatment is directed It would be as inappropriate to rank such cases with asthma, as vol. I. 56 882 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. to give the name of colic to every painful spasm of the bowels, attendant upon enteritis. It is only when the spasm, whether in the respiratory or alimentary passages, is the predominant affection, that it is entitled to rank as a disease, and take the name, in the one case, of asthma, and in the other, of colic. Those cases, therefore, even of spasmodic and paroxysmal dys- pnoea, in which bronchial inflammation is the most important constituent, are not, in this work, treated of as examples of asthma, but are referred to bronchitis. (See Bronchitis.) In some instances, there is reason to believe that asthma is purely nervous or functional, and quite independent of any other disease ; but it is probably more frequently associated with some degree of bronchial inflammation or other organic affection, which serves to call it into action. In the latter case, it does not lose its claim to be considered as the disease, so long as the exciting cause is merely subordinate. Symptoms, Course, etc.—The asthmatic paroxysm is often preceded, for a longer or shorter time, varying from a few hours to several days, by certain premonitory symptoms, which warn the experienced patient of its approach. Among these symptoms are languor, heaviness of the head, drowsiness or headache, flatulent distension of the stomach, loss of appetite, stricture across the lower part of the chest, and sometimes the copious discharge of limpid urine. In some instances, however, the attack is sudden and without warn- ing. It occurs generally in the night, most frequently between bedtime and two or three in the morning. The patient starts out of sleep into an erect posture, with a feeling of tightness or compression of the chest, and great difficulty in breathing. The air seems as if excluded from the lungs, and violent and even convulsive efforts of the muscles of inspiration are made in order to expand the chest. A peculiar wheezing noise is made in breathing, which can be heard at a considerable distance. Yet, notwithstanding the expansive efforts of the muscles, the chest sometimes appears contracted in consequence of the shrinking of the lungs, and a hollow in the epigastrium is produced by the unusual elevation of the diaphragm. Expiration is much less difficult and painful than inspiration. Under a sense of impending suffo- cation, the patient is irresistibly impelled to seek for cool and fresh air, and the least semblance of restriction in this respect is insupportable. He insists that every avenue for the entrance of air should be opened ; and often rushes to the door or window, and even leans over the window-sill with his head and trunk projecting, in the vain search of breath. It is surprising how long the body is sometimes thus exposed, very imperfectly covered, to the cold air of winter, without any injurious consequence. But a similar impunity is well known to attend exposure, under other forms of great nervous excitement. The countenance of the patient, and his general movements express an inde- scribable anxiety and distress. It seems to him as though he could not possibly live. A common and characteristic position is with the elbows upon the knees, and the head between the hands. There is occasionally an attempt to cough ; but it is imperfect, in consequence of impeded respiration. Speak- ing is equally imperfect and difficult. The pulse is often small, feeble, irre- gular, and frequent, with palpitations ofthe heart; but occasional] v both the pulse and the actions of the heart are nearly or quite healthy. The face is either pale or flushed, or one and the other alternately; the eyes are promi- nent ; the extremities often cool; and the head and breast covered with a cold sweat. The urine, during the paroxysm, is pale and abundant, but, at its close, becomes scanty and high-coloured, and sometimes deposits a copious sediment. The bowels are, in some instances, suddenly relaxed at the befin- ning of the attack. After two, three, or four hours, the symptoms gradually subside, usually with a copious expectoration of mucus, though sometimes without this accompaniment. In the latter case, the disease is sometimes CLASS III.] ASTHMA. 883 called dry asthma, in the former, when the expectoration is abundant, humid or humoral asthma; though the latter name is more frequently applied to a variety of chronic bronchitis already described. (See Bronchorrhoea, p. 838.) After the subsidence of the paroxysm, the patient usually falls into sleep, and upon awaking in the morning, feels himself comparatively well. But the symptoms do not wholly disappear. Soreness ofthe muscles, and occasionally neuralgic pains are experienced. Some feeling of constriction, and perhaps a little wheezing, continue through the day; and the dyspnoea is greatly increased by muscular exertion, and by the horizontal posture. The patient often complains of weight and distension of the stomach after eating, and of other dyspeptic symptoms. In the following night, another paroxysm occurs with the same symptoms as the first, and with the same declension towards morning. This alternation of exacerbation at night and remission in the day is repeated for several days, usually less than a week; when the paroxysms, which have been gradually abating, cease altogether, and leave the patient in his ordinary health. There is still, however, some occasional dyspnoea; or at least this condition is brought on by causes which do not affect other persons, showing the existence of a morbid predisposition. Early in the course of asthma, there is often no return of the phenomena above described for a long time. A year, or even several years may elapse, before the patient experiences another succession of paroxysms; but more frequently they return at the end of six, four, or two months, and sometimes recur monthly, though the interval is seldom regular. In general, they in- crease in frequency with the duration of the complaint; till at length, in some instances, they are brought on by the slightest causes, and the patient is never free from the danger of an attack. In relation to the physical signs, percussion is usually clear throughout the chest during the paroxysm, when there is no complication; but, notwithstand- ing the violent efforts at inspiration, the ear applied to the thorax is sensible of little sound from the entering air; only a faint respiratory murmur, and occasionally a degree of sibilant or wheezing sound being heard. Towards the end of the paroxysm, a temporary relaxation of the constriction appears now and then to take place, during which the respiratory murmur is heard as in health, but it soon becomes faint again. My friend, Dr. Fitzwilliam Sargent, informs me that, in several cases of asthma, he has observed that, towards the close of inspiration, or even after this has apparently ceased, sibilant and sonorous rales begin to be heard, and soon spread all over the lung, denoting that the spasm of the smaller tubes has yielded to the pressure of the air; and the same sounds are continued through the expiration. Ac- cording to Laennec, if a patient be induced to hold his breath for a short time, or to count aloud as many numbers as possible without stopping, and then quietly to commence breathing again, the spasm appears to be in a man- ner surprised into relaxation, and the air can be heard entering all parts of the lungs for the next breath or two, after which the ordinary state of things returns. This phenomenon may be considered as characteristic of spasmodic constriction of the bronchia. Forbes states that, during expiration, sound is perceptible over the whole chest, even in the extreme points of the lungs; not the sound of healthy respiration, but a loud sibilant or dry sonorous rale, corresponding with the wheezing noise usually heard in the paroxysm. (Cyclop of Pract. Med.) According to Williams, the same diminution of respiratory sound is found in the intervals as during the paroxysm, though in i less marked degree; and a similar relaxation, upon holding the breath, shows that the affection is still spasmodic. (Tweedie's Syst. of Pract. Med.) When asthma is uncomplicated, it often continues for a great length of time without materially impairing the health in other respects; and patients 884 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. sometimes carry the disease into extreme old age. It has, indeed, been thought by some to contribute to longevity by warding off other affections; but this may well be doubted. Yery often it is associated with organic dis- eases, either accidental, or standing towards the asthma in the relation of cause or effect. The most frequent of these are diseases of the heart, and emphysema of the lungs. It is easy to understand how either of these may be the result of asthma. The pulmonary circulation being impeded by the constricted state of the bronchia, the blood accumulates in the right cavities of the heart, which may thus suffer dilatation and hypertrophy. As to em- physema, the expansion of the chest, under the convulsive action of the mus- cles of inspiration, while the constriction of the bronchia lessens the general bulk of the lungs, and impedes the entrance of air from without, causes that contained in the vesicles to expand, and thus to produce their dilatation. When, in asthma, near the commencement of the disease, the intervals be- tween the paroxysms are free from dyspnoea, should emphysema come on, it may be safely considered as a result of the spasmodic affection. Appearances after Death.—It is asserted that, in many instances, no lesions have been found after death in asthmatic patients, which could account for the disease. But, as the uncomplicated cases scarcely ever prove directly fatal, there is little opportunity for making the requisite examination, unless in instances in which the patient is carried off by some other accidental malady. Hence it happens that, in persons reported to have died of asthma, a great variety of lesions have been observed, of which it is often impossible to say whether they had any essential connection with the disease, or if so, whether the connection was that of cause or of effect. The only organic affec- tions which must be regarded as direct causes of the asthmatic symptoms, are lesions of the brain, spinal marrow, or par vagum, either original or conse- quent upon neighbouring tumours. All these are occasionally observed. Causes.—A peculiar predisposition is generally necessary to the production of asthma by the ordinary exciting causes. These causes may operate in equal degree upon great numbers of individuals, and yet occasion asthma in but a very few. What is the nature of this predisposition, it is not easy to determine. The most that can be said is, that it consists in some inapprecia- ble modification of the nervous constituents of the bronchial tubes, or of the par vagum, or of one or more of the nervous centres, the influence of which is extended to the respiratory apparatus. The predisposition is sometimes hereditary. The congenital shape of the chest, or of the glottis, has been supposed to have some influence in its pro- duction. I believe that it is often connected or identical with the gouty or rheumatic diathesis; and that the paroxysm is nothing more than an attack of nervous gout or rheumatism, affecting the respiratory organs. A certain general mobility or excitability of the nervous system, such, for example, as occurs in hysteria, may be supposed to be favourable to the production of an asthmatic predisposition. Indeed, asthma is sometimes probably nothing more than hysteria in the lungs. It may occasionally be traced pretty clearly to spinal irritation, indicated by tenderness upon pressure of one or more of the spinous processes. A similar condition of the nervous system may possi- bly be induced by causes of an exhausting or debilitating nature, such as ex- cessive venery or masturbation, habitual mental depression, habitual indulgence of any of the stronger passions, profuse evacuations, protracted illness, and the different forms of dyspepsia. It is said that persons much exposed to irritating inhalations whether in the form of gas, vapours, or dust, are pecu- liarly liable to asthma. I suspect that, except in cases in which the predis- position has existed, the result of these causes has rather been bronchitis attended with more or less bronchial spasm, than true asthma. Another • CLASS III.] ASTHMA. 885 predisposing cause is said to exist in those professions which require in their exercise violent and continued respiratory efforts; but, with the same excep- tions as above stated, it is highly probable that the dyspnoea is in these cases ascribable to emphysema of the lungs. It is difficult to determine how much influence climate may have in the production of the asthmatic predisposition. The disease would seem to prevail most in moderately cold and moist regions; though it is said to be frequent also in very cold and very hot climates. But the accounts of writers are somewhat contradictory on this point. All ages are liable to the disease; but it is most common in middle age, rarely attacks young children, and, though occasionally found in the old, sel- dom originates in advanced life. It is more frequent in men than women, except in old age, when it is said to prevail about equally in both. Of the exciting causes, the most frequent is probably cold. Hence, the paroxysms are most frequent in winter. Exposure to a very hot air, and the hot bath sometimes induce them. It is said that asthmatic patients are peculiarly apt to suffer from dyspnoea immediately before a thunder-gust, when the atmosphere is highly charged with electricity. Patients are sometimes affected by what appear to be whimsical causes. Thus, the change from light to darkness, the removal from one apartment to another not obviously differ- ent, an alteration in the direction of a journey, the shutting of a door, the very alarm of an expected paroxysm, are said to have induced attacks. With one patient a cold dry air agrees best, with another a damp air; some can breathe only a pure atmosphere, others prefer the smoky and contaminated air of cities. There can be no doubt that the imagination has much to do in directing the agency of various reputed causes. Irritating substances, whether aeriform or solid, may excite the paroxysms when inhaled. In pe- culiar idiosyncrasies, certain odours, as that of ipecacuanha, and of new-mown hay, produce violent attacks of dyspnoea, which are sometimes of the asthma- tic character. Anything capable of irritating the bronchial mucous membrane may excite a paroxysm. The suppression of hemorrhages or other habitual discharges, the sudden disappearance of cutaneous eruptions, the retrocession of gout or rheumatism, and various derangements of stomach consequent upon dyspepsia, especially flatulence, are enumerated among the causes. True asthma is occasionally found associated with organic diseases of the thoracic viscera. More frequently these induce ordinary dyspnoea, with or without some spasm of the respiratory passages. In order that they may cause asthma proper, they must act on a predisposition to that complaint. Perhaps not one case in one hundred of the difficulty of breathing consequent upon pulmonary diseases deserves to be called asthma. In producing this disease, they must act either by a direct irritation of the bronchial mucous membrane or the nerves which supply it, or by producing congestion in the membrane, and thus secondarily acting upon its peculiar nervous susceptibili- ties. Tubercles and other tumours in the lungs may operate in the former mode, diseases of the heart in the latter. It has been already explained how emphysema of the lungs, which is a frequent accompaniment of asthma, may be the result of that affection. We may easily conceive how it may occasion dyspnoea; but it is not so easy to understand how it can give rise to the asthmatic paroxysm. When the two complaints, therefore, are associated, if there be any relation of cause and effect between them, the probabilities are altoo-cther in favour of asthma as the cause. Bronchitis is another complaint veryoften connected with asthma; and is perhaps the most frequent accom- paniment. The same cause which excites the one, will be very apt also to excite the other; and their coincidence is, therefore, not remarkable. It is not at all unlikely that the inflammation, once established, may have a ten- dency to sustain the spasmodic constriction of the bronchia, and thus far act 886 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. as a cause of asthma in the predisposed. Should the inflammation be very violent, it would constitute the main disease ; should the spasmodic symptoms preponderate, they would class the case under asthma; and there are occa- sional instances in which the two are so nearly balanced, that it would be impossible to decide in which category the particular case should be placed. It is impossible not to be struck with a strong analogy, in certain respects, between asthma and gout. Their apparently constitutional nature, the dispo- sition of the attacks to recur at distant but gradually diminishing intervals, the division of each attack into nightly paroxysms with marked remission in the day, the duration of the early spells for several days or a week, and the general incurability of the two diseases, are circumstances calculated to in- duce the suspicion that they are often identical; in other words, that asthma may often be simply nervous gout. Prognosis.—Asthma is occasionally cured, and more frequently relieved; but, in the great majority of cases, after being once established, it continues with more or less frequent recurrence of the paroxysms until the close of life. When uncomplicated, it is almost never fatal, notwithstanding its apparent violence ; but it is not unfrequently associated with fatal diseases ; and there is reason to believe that it sometimes produces them, and is thus the remote cause of death. A judgment, therefore, as to its results, in any particular case, must be founded on the character of the attendant diseases. Treatment.—There are two prominent indications in the treatment of asthma; one to relax the spasm, the other to correct the predisposition. The former is presented in the paroxysm, the latter in the interval. The symptoms of the asthmatic paroxysm so strongly suggest the idea of congestion and inflammation ofthe lungs, that blood-letting is apt to present itself to the mind as a necessary remedy. Should the disease be associated with considerable bronchitis, and a strong excited pulse, this remedy may be employed with propriety; but, in the absence of inflammation, or of decided congestion, and when the pulse is at the same time rather feeble than strong, it should be avoided as rather injurious than beneficial. One of the most effectual means of producing relaxation is the use of emetic substances. These may be given so as to vomit, or merely to sustain a considerable degree of nausea. Ipecacuanha is much employed. It may be given in the full emetic dose, and afterwards, if deemed necessary, in small doses, so as to nauseate. Lobelia, too, has great reputation, and is certainly in some instances very effectual, though it fails, as every remedy is liable to do, iu others. I think I have derived more advantage from it than from any other single remedy. Tartar emetic and squill have also been employed. Colchicum administered so as to produce moderate nausea, is especially applicable to gouty cases. The emetic and nauseating treatment generally is best adapted to the disease, when associated with a degree of bronchial inflammation. Antispasmodics are often very useful in the purely spasmodic cases. Ether, assafetida, and musk, are among the most effectual; and they are often usefully associated with one of the salts of morphia. They are es- pecially beneficial in hysterical cases. Strong coffee is also much employed, and is often serviceable. It should be saturated, and a cupful taken every twenty or thirty minutes. As it loses its effects somewhat upon repetition, it is a good plan to abstain from its habitual use at meals. Certain narcotics have been much and beneficially employed. Some cau- tion, however, is requisite in their use. When the asthma is associated with hypertrophy of the heart, and a tendency to cerebral congestion, or when the affection has resulted from translated gout, especially in persons of an apo- plectic habit, they may prove dangerous by making the brain the centre of irritation, and consequently of an afflux of blood. The death of asthmatic CLASS III.] ASTHMA. 887 patients has been ascribed, in repeated instances, to the use of narcotics. Stramonium is the one which enjoys the highest reputation. It is employed almost exclusively by smoking the dried leaves or stems, like tobacco. The relief which it affords is sometimes great and immediate. It is most efficient when used at the commencement of the paroxysm. But it not unfrequently fails, and has sometimes proved highly dangerous and even fatal in its effects, by inducing coma. It should, therefore, always be used with due reference to the cautions above given, and should be omitted as soon as it produces vertigo or nausea. The smoking of tobacco also occasionally affords great relief. Chloroform, administered by means of inhalation, sometimes com- pletely resolves the paroxysm ; but care is required to prevent a too power- fully depressing effect. It would probably be safer to administer it in con- nection with ether; and these same remedies may be given in combination by the stomach. Opiates are very useful in the purely spasmodic cases, without tendency to cerebral disease. The salts of morphia are perhaps preferable to the other preparations. They may often be usefully associated with the other medicines employed, as with ether and colchicum. Hydrocyanic acid has been recommended; but, to produce a decided impression, it must be em- ployed in quantities which may readily become hazardous. Besides the three classes of medicines above mentioned, many other reme- dies have been used with greater or less advantage in the paroxysm. The application of electricity or electro-magnetism has occasionally arrested it. The same may be said of cold water, dashed in the quantity of a pailful over the shoulders. The simultaneous use of cold drinks and hot pediluvia has been recommended. Sinapisms or other powerful rubefacients to the chest some- times afford relief; but there is danger that some of the more volatile sub- stances of the class may increase by their vapours, the sense of suffocation Insufflation of the lungs by a pair of bellows, is among the means which are said to have been used with advantage. The inhalation of the fumes of burn- ing paper, previously impregnated with a saturated solution of nitre and dried, is asserted to be sometimes very effective. It is best that the paper should have been dipped a second time into the solution and dried. It may be either burned in the chamber, or smoked by means of a pipe, or in the form of a cigar. M. Collidoni cures the disease by causing the patient to smoke sarsa- parilla, by means of a pipe. (Bulletin Gen., Aug. 1850.) M. Rayer applies solution of ammonia, by means of a roll of lint moistened with it, to the velum pendulum palati, for a few seconds, and with almost uniform advantage. The patient is at first seized with a feeling of suffocation, which is followed by couching and copious expectoration, and soon afterwards by great relief. (See Am. Journ. of Med. &•/., N. S., xiii. 165.) Dr. A. M. Johnson, of Illinois, has administered sulphate of quinia in a single dose of twelve grains in the paroxysm with success in several cases. (See Wood's Quart. Betrosp., w. 2.) Dr OS Stilwell of Sag Harbor, N. Y., has obtained extraordinary effects from iodide of potassium, given in the dose of five grains three times a day. (Bost Med. and Sury. Journ., lvi. 158.) In cases attended with spinal ten- derness cups or leeches should be applied over the tender vertebra?, and fol- lowed in due time, by strong ammonia, a fly blister, or tartar emetic ointment. The apartment should be well aired, all articles of dress that m any degree restrain the movements of the chest should be removed, as few assistants as will answer the purposes of attendance should remain in the room, and smoke and other exhalations should be carefully avoided. In the interval our efforts should be directed to the removal ofthe morbid tendency■ and for this purpose, every discoverable deviation from health should be'corrected as far as practicable. It is impossible to particularize all the remedies that may be employed. The attention should be directed 888 LOCAL DISEASES.—RESPIRATORY SYSTEM. [PART II. particularly to the state of the stomach and bowels. Dyspeptic symptoms may require antacids, carminatives, and tonics; constipation, laxatives; de- ranged hepatic secretion, the mercurial alteratives. In the female, the men- strual function should be kept in order. In gouty cases, moderate doses of colchicum may be found beneficial. Ana?mia and general debility must be counteracted by tonics and a suitable regimen. Dr. T. S. Hopkins, of Bethel, Georgia, has found special advantage from nitric acid. (Am. Journ. of Med. Sci., N. S., xx. 549.) If chronic bronchial inflammation exist, it should be treated with- local depletion, blistering, the stimulating and nauseating ex- pectorants, &c. Any remains ofthe spasm, connected with the inflammation, may be advantageously treated wdth tincture of lobelia, associated with ipe- cacuanha wine or syrup, the tincture or syrup of squill, or the syrup of seneka. In some cases, the metallic tonics which prove useful in nervous affections, as chorea, epilepsy, hysteria, and neuralgia, have the effect of interrupting or postponing the paroxysms. For this purpose may be employed, subnitrate of bismuth, oxide and sulphate of zinc, ammoniated copper, nitrate of silver, and the chalybeates, which may sometimes be conjoined with small doses of opium. Dr. nuss, of Sweden, has found the disease to yield promptly to chloride of platinum, given in the dose of half a grain, three or four times daily. When the paroxysms occur at precisely regular intervals, with com- plete intermission, there is some chance of interrupting them by sulphate of quinia. Strong moral or physical impressions of any kind will sometimes avert them. Dr. Lefevre, a French physician, who published a paper on asthma, used frequently to set aside a paroxysm, in his owm case, by having his bed heated, or heating himself before a fire. (Valleix, ii. 564.) The diet should be easy of digestion and nutritious, yet not stimulating. Caution should be particularly observed not to overload or distend the stom- ach. Alcoholic drinks, as well as the habitual use of tea and coffee, should be forbidden. Advantage will sometimes accrue from the daily use of the shower-bath, or sponging the chest with cold water or salt and water; but these means should not be employed unless followed by immediate reaction. Exercise is highly useful, especially on horseback. The place of abode should be chosen in reference to the particular experience of the patient, that being preferred which is found to suit him best. As a general rule, a mild, equable climate, neither very moist nor very dry, is the most favourable. Travelling is sometimes highly advantageous. In this as in other habitual nervous affec- tions, it is useful to surround the patient with entirely new circumstances, so that a new set of impressions may be made on his nervous system. A long voyage, or a protracted journey abroad, would offer some hope of a perma- nent cure, should no organic disease exist. ncT H ^ •W^V-*. *"-" - - '*• v - -J . V.v.r -c\-xv.v. • -«k v. •Skv'.v.,vav'V