UNITED STATES OF AMERICA FOUNDED 1836 WASHINGTON, D. C. GPO 16—67244-1 rN~ /. T* /Cj* r'i>; /'x//'"«) 0/ » "---■ Boston Medical* Library Association, 19 BOYLSTON PLACE, /- Receiv^f.... / Gift of.. > %S(kN*~* iiO-MiU c^vOi«VM A TREATISE ON THE PRACTICE OF MEDICINE. BY JOHN EBERLE, M.D., *»• PROFESSOR OF MATERIA MEDICA AND BOTANY IN THK OHIO MEDICAL COLLEGE: MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY; OF THE ACADEMY OF NATURAL SCIENCES OF PHILADELPHIA J AND CORRESPONDING MEMBER OF THE MEDICO-CHIRURGICAL SOCIETY OF BERLIN, IN PRUSSIA, &C. &C. IN TWO VOLUMES. VOL. II. FOURTH EDITION, REVISE!! ASD. GED. SUAGCON GCIMAl-£ Of FICE I $MlatoIj)M&_ GRIGG & ELLIOT, 9 NORTH FOURTH STREET. 1838. t' > < -- \\ :b em-t 183? v. 2. Entered according to the act of Congress, in the year 1831, by John Eberle, M. D. in the clerk's office of the district court of the United States, in and for the eastern district of Pennsylvania. ,fH!;-:-,}« Philadelphia: T. K. & P. G. Collins, Printers, No. 1 Lodge Alley. CONTENTS OF VOLUME II. CHRONIC DISEASES. CHAPTER I. Of Chronic Nervous Diseases. Page. General Observations, ---..... 7 Sect. I. Apoplexy, ----_.... 10 Sect. II. Paralysis,.........30 1. Hemiplegia, .......32 2. Paraplegia, --...... 34 3. Paralysis Partialis,......35 Sect. III. Epilepsy,.........47 Sect. IV. Catalepsy, --.......70 Sect. V. Chorea, -.........77 Sect. VI. Convulsive Affections of Infants,.....89 Sect. VII. Hysteria, -........100 Sect. VIII. Puerperal Convulsions, ------ 114 Sect. IX. Tetanus,.....- - - - 119 Sect. X. Hydrophobia, -- - -- - - - 134 CHAPTER II. Chrontc Nervous Affections, in which Intellectual and Moral Faculties are Disordered. Sect. I. Mental Derangement, ------- 148 1. Mania,.........159 2. Monomania, -------- 161 3. Dementia, -------- 163 4. Idiotism, -------- 164 Sect. II. Delirium Tremens, -------- 172 CHAPTER III. Local, Chronic Nervous Affections. Sect. I. Neuralgia,.........180 Sect. II. Amaurosis, ---------- 198 IV CONTENTS. Page. CHAPTER IV. Chronic Affections of the Respiratory Organs. Sect. I. Asthma, ------"" Sect. II. Whooping Cough, ------ Sect. III. Asphyxia, .-----" Sect. IV. Pneumo-Thorax, ------"" CHAPTER V. Chronic Diseases of the Heart. Sect. I. Of the Diseases of the Heart,......249 1. Hypertrophy of the Heart,.....257 2. Dilatation of the Ventricles,.....258 3. Aneurism of the Aorta, ------ 260 Sympathetic Affections of the Heart, - 265 Sect. II. Angina Pectoris, -------- 268 CHAPTER VI. Chronic Diseases of the Alimentary Canal. Sect. I. Indigestion, --------- 275 Sect. II. Diarrhoea, --------- 291 Sect. III. Cholera,.......- - 301 Cholera Infantum, -------- 204 Sect. IV. Colic,..........315 1. Flatulent Colic,.......315 2. Bilious Colic,.......318 2. Colica Pictonum,...... - 323 Sect. V. Heus,..........330 Sect. VI. Constipation, -------- 335 Sect. VII. Intestinal Worms,.......337 Sect. VIII. Haemorrhoids, -------- 348 Sect. IX. Jaundice, --------- 361 CHAPTER VII. Chronic Diseases of the Urinary Organs. Sect. I. Diabetes Mellitus, -------- 373 Sect. II. Diabetes Insipidus, ------- 337 Sect. III. Lithiasis, --------- 393 1. Lithic Acid Diathesis, ------ 394 2. Phosphatic Diathesis. ------ 397 Sect. IV. Ischuria Renalis, -------- 402 Sect. V. Retention of Urine, ------- 406 Sect. VI. Dysury,.........418 Sect. VII. Enuresis,.........420 CONTENTS. y CHAPTER VIII. Page" Chronic Diseases of the Serous Exhalent Vessels. HydroPS,.........425 1. Ascites, -------- 431 2. Hydrothorax,...... 432 3. Anasarca, ---.....434 CHAPTER IX. Chronic Affections of the Lymphatic System. Sect. I. Scrofula, --._......4gg Sect. II. Bronchocele, --------- 459 CHAPTER X. Chronic Disorders of the Assimilative Functions. Sect. I. Scorbutus, --------- 479 Sect. II. Chlorosis, --------- 435 CHAPTER XI. Chronic Diseases of the Sexual Organs. Sect. I. Gonorrhoea, -- - - - - - - . 491 Sect. II. Syphilis, --------- 502 Buboes, .........523 Sect. III. Amenorrhoea, -------- 526 Sect. IV. Dysmenorrhea, -------- 532 Sect. V. Leucorrhcea, --------- 539 APPENDIX. Cholera Asphyxia—Spasmodic Cholera,.....546 1* A TREATISE ON THE PRACTICE OF MEDICINE. CHRONIC DISEASES. CHAPTER I. OF CHRONIC NERVOUS DISEASES. General Observations. The nervous system gives to organised matter all the peculiar functions of animal life, and in its higher states of development, ren- ders it a fit recipient for the powers of reason and moral feeling. In a state of health, or freedom from irritation, it qualifies man for the enjoyment and communication of happiness—when disordered, it may render him the most deplorable and abject of created beings. Exalted mental endowments, equanimity, and benevolence, may be converted into imbecility, waywardness, and misanthropy; meek piety into the vvildness and intolerance of fanaticism; confidence into universal mistrust, and friendship into hatred, by morbid con- ditions of this component of the human organisation. The chronic diseases of the nervous system may be divided into two classes—viz: 1. Those in which the sensorial or muscular func- tions are morbidly affected, either separately or conjointly; 2. Those in which the intellectual and moral powers are disordered. The first of these classes comprehends a great variety of affections —characterised either by a perversion, or a morbid activity, or abolition of one or more of the sensorial functions; or by spasm, or convulsion, or paralysis, of a greater or less portion of the mus- cular system. The examples of singularly perverted sensorial function are nu- 8 GENERAL OBSERVATIONS. merous. Reil mentions a case in which the whole surface of the body was insensible to heat or cold, and incapable by the touch ol distinguishing hardness from softness in bodies. Dufour gives an account of a similar case.* Sauvages relates the case of an individual who always heard two voices, one an octave higher than the other, when any one spoke to him. Individuals have lost the power ot distinguishing colors; and some have been much harassed by vari- ous visual allusions. Instances of very distressing morbid increase of sensorial power are frequently met with. The sense of hearing has become so ex- ceedingly acute, that the weakest sounds gave rise to pain and un- easiness, and the same has been observed with regard to the other sensorial powers. In some cases, nervous disorder manifests itself by excruciating pain in some part of the body, as in the various forms of neuralgia. The sensorial functions may also be weakened or entirely de- stroyed, by affections seated in the nervous system. When such affections are local, one sense alone maybe obliterated; but when the disorder implicates the whole of the sensorium commune—the brain—all the sensorial powers will be suspended. This general state of nervous oppression or inactivity is attended with manifest respiration and arterial action, and constitutes what is termed coma; a condition which must not be confounded with syncope, or as- phyxia. These latter affections are not accompanied by any per- ceptible respiratory and arterial actions, and although like coma, the immediate consequence of impeded cerebral function, yet they are manifestly dependent on different conditions of the encephalic circu- lation. The pathology in relation to this subject, however, will be illustrated hereafter. When the nervous irritation passes upon the muscular system, it gives rise to irregular, spasmodic, or convulsive actions, either in one, or in several, or in the majority of the muscles of the body. These convulsive or spasmodic muscular contractions, are divided by au- thors into tonic and clonic. In the former the contractions are per- manent, as in tetanus; in the latter they occur in quick alternation, with relaxations, as in hysteria and epilepsy. There exists, however, no essential difference between these varieties of convulsive muscular action. They indeed often occur at the same time in the same indi- vidual, some muscles remaining in a state of firm contraction, whilst others are alternately relaxed and contracted. In general, however, convulsions of the clonic form are attended with less danger than those of the rigid or tonic spasmodic affections. The former are frequently the result of a mere temporary sympathetic irritation of the brain, from causes of a transitory character, or susceptible of be- ing removed; whilst the latter usually depend on a more intimate affection of the nervous system, from causes over which we have * Reil, Fieberlehre, bd. iv. p. 64. GENERAL OBSERVATIONS. 9 little or no control. Convulsions, or general spasmodic affections of the voluntary muscles, must, therefore, be regarded as the external manifestations of certain morbid actions or conditions of the brain and nerves. The brain, or spinal marrow, is the immediate source of the muscular irritation; and the violence, duration, character, and extent of the convulsive affection, depends on the nature of the cause, and the constitutional habit of the patient. In some instances, the cerebral affection which gives rise to the convulsive muscular contractions, is so great as to produce a temporary suspension of consciousness, and of the sensorial functions. In others, as in tetanus and chorea, the mind and sensorial powers remain unaffected until the disease becomes inveterate. Spasmodic contractions are often confined to one part, and indeed frequently to a single muscle. Of this kind are, tonic spasm of the muscles of the eyes, producing strabismus; or convulsive action of these muscles, giving rise to rolling of the eyes (hippus;) spasm of the muscles of the lips and face, (sardrosis, risus sardonicus,) giv- ing an expression of malignant laughter to the countenance; tonic contraction of the muscles of the jaws (trismus;) spasmodic affec- tion of the oesophagus; convulsive action of the diaphragm, produc- ing hiccough (singultus;) tonic spasm of the erector muscles of the penis, giving rise to painful, and sometimes protracted priapism; tonic or clonic spasmodic contractions of the abdominal muscles;* and other local spasms or cramps of the voluntary muscles, are among the most common affections. The involuntary muscles also are subject to spasmodic affections; but these appear to depend more frequently on some local irritation, than upon a reflected cerebral impression. The whole arterial sys- tem is sometimes affected with clonic convulsive action. This is particularly apt to occur from sudden and violent mental agitation; from gastric irritation; and from organic affections of the heart, (angina pectoris, palpitation.) The stomach, the intestinal tube, the common gall duct, the urethra, uterus, &c. are all particularly liable to painful spasm. The second class of nervous diseases, those in which the cerebral irritation produces mental derangement, presents a variety of modi- fications, both in relation to the degree, and the particular character of the hallucination. In some instances, there is a general derange- ment of all the intellectual faculties, with violent excitement of the passions; occasional exacerbations of raving delirium and agita- tion, (mania.) In other cases, the insanity is only partial—the patient retaining the regular powers of his understanding on all but a few, or a single subject, (monomania.) Sometimes the reasoning powers become defective or imbecile, and the memory weak or ob- * Whytt mentions the case of a young woman who was affected with constant convulsive action of the abdominal muscles during the day, though free from them at night when in bed. 10 APOPLEXY. literated, (dementia,) a state of mind which is most frequently met with in very old people, and in such as have suffered frequently from convulsive affections, as epilepsy, chorea, or apoplexy. In some instances, almost every trace of intellectual power is wanting, either from a congenital defect in the cerebral organisation, or from diseases or accidental causes affecting the brain. These varieties of mental disorder sometimes pass into each other, and present an al- most infinite diversity in their particular phenomena. They may arise from causes acting directly on the brain, and from impressions conveyed sympathetically to this organ from remote visceral affec- tions. Whatever be the nature of the remote cause, however, in- sanity of every variety is always the immediate consequence of some peculiar dynamic or organic disorder of the sensorium com- mune. Under the particular head of these affections, I shall enter more fully into the etiological consideration of this subject. Sect. I.—Apoplexy. Apoplexy may be defined, a sudden loss or suspension of the animal functions, with a slow and full pulse, laborious breathing, generally attended with stertor; whilst the organic or vital functions continue with little or no perceptible disturbance. In some instances, the apoplectic attack comes on suddenly with- out any precursory indications of its approach. Occasionally, indeed, patients feel unusually well for some time previous to an attack of this affection, and this is most apt to be the case in individuals of a gouty habit. (Richter.) Much more frequently, however, various pre- monitory symptoms, indicative of cerebral disturbance, precede the attack; and amongst these the following are the most common: ver- tigo; a dull and deep-seated pain, or sense of weight in the head, particularly on stooping or suddenly turning the head round; a tur- gid state of the veins of the head; throbbing of the temporal arteries; ringing in the ears; inability to articulate distinctly ; dimness of sight; transient obtuseness of hearing; sparks and flashes of light before the eyes; bleeding of the nose; drowsiness; confusion of ideas, manifested by incoherent talking; disturbed and heavy sleep; loss or unusual weakness of the memory; general sluggishness, both of body and mind; irregular spasmodic contraction of the muscles of the face; and, occasionally, transient pains in the pit of the stomach, and nausea. In some instances, a numbness is felt in the fingers or in one side of the body shortly before the attack super- venes. In general, the symptoms which announce the approach of an apoplectic attack, indicate an unusual determination of blood to the head. Of these symptoms, however, vertigo, ringing in the ears, dimness of sight, and pain and heaviness in the head, are by far the most common precursors of an attack of this disease. The duration of these symptoms is extremely various. In some cases, they do not continue more than a few hours before the attack APOPLEXY. 11 ensues; in others, they occur with occasional remissions or intermis- sions, for several weeks or months, and even years. Occasionally, the most alarming of the foregoing symptoms occur and continue for a longer or shorter time, without terminating in an attack of this disease. The premonitory symptoms often become considerably aggravated immediately before the apoplectic attack supervenes. The fulness, weight, and pain in the head, become suddenly very severe; a sense of tension and drawing is felt in the muscles of the back of the neck; and, in some instances, pain in the epigastrium, with nausea, occurs just before the attack. In some cases the apoplectic attack comes on by a sudden depri- vation of all sensorial power and motion; the patient sinking almost instantaneously into a state of profound stupor, resembling deep and heavy sleep, from which it is impossible to rouse him in the slightest degree. This mode of seizure constitutes what authors term perfect or strong apoplexy, (apoplexia perfecta, apUepsis, sideratio;) and generally terminates fatally in a very few hours, and sometimes in less than an hour. In other cases, the patient is seized with sudden deep-seated pain in the head; tremor of the extremities; confusion of ideas; nausea or vomiting; and vertigo. He then becomes insensible, and sinks down as from syncope; in a short time however, he recovers suffi- ciently to converse, and, perhaps, to walk about, but still complains of pain and other unpleasant sensations in the head, with confusion of the mind and giddiness. In the course of a few hours after this temporary recovery, the brain becomes gradually more and more oppressed, until complete insensibility is induced, and the patient lies in a state of deep coma. Sometimes paralysis of one side suddenly occurs, with loss of speech; pain in some part of the head; slowness and confusion of the mind; and vertigo;—the sensorial functions and consciousness remaining. By degrees, however, the brain becomes more oppress- ed, and the sensorial powers gradually decline, until profound apo- plectic stupor ensues.* In whatever way the apoplectic attack comes on, the following phenomena attend its course, and serve to distinguish it from the other forms of soporose affections. Immediately after the accession of the fit, the pulse and respiration are weak and often scarcely per- ceptible. Both, however, soon recover from the first shock; the pulse becomes full, slow, regular, and often hard; and the respiration slow, oppressed, interrupted or irregular, and generally stertorous. Some writers contend, that in true apoplexy, stertorous breathing is invariably present; but this is not confirmed by general experi- ence.t In violent instances, expiration is attended with a puffing * Abercrombie. Edin.,Med. and Surg. Journ. vol. xiv. p. 554. f I have seen a case of fatal apoplexy, in which the breathing was throughout free from stertor. On post mortem examination, a coagulum of extravasated 13 APOPLEXY. motion of the lips, and a frothy saliva is blown out with a sputtering noise. The face is sometimes livid and of a turgid appearance; more frequently, however, it is pale and somewhat bloated. In some instances, the eyes are blood-shot; in others, they are dull, glassy, and fixed, or rolling about in their sockets. In general, the pupils are considerably dilated; and in some cases they are permanently contracted. Dr. Cook states, that he has seen instances in which the pupils were almost entirely closed. The extremities are usually below the natural standard of tempe- rature, but the skin about the body, and particularly of the head, is warm. The jaws are generally spasmodically closed; sometimes they remain widely open. The power of swallowing is occasionally, in very violent cases, entirely destroyed; but in most instances, though greatly impeded, it remains to a degree sufficient to enable the patient to swallow small portions of fluids. In all instances, very considerable torpor of the bowels exists; and this is sometimes so great as to resist every effort to evacuate them by cathartic reme- dies. Clammy sweats usually break out about the head and neck, and the same sometimes occurs on the extremities. In moderate cases, the temperature of the skin, and appearance of the countenance, do not differ from their natural condition; and in such cases, the power of deglutition is generally sufficiently strong to permit the easy administration of medicines by the mouth. This is most apt to be the case in what is termed apoplexia hydrocephalica, or the apoplectic stage of hydrocephalus. Towards the termination of fatal cases, the pulse becomes small, irregular, and frequent; and the respiration slow, short, and interrupted by long intervals. If the disease does not end in death, it may terminate:— 1. In the perfect restoration of all the suspended functions, and the enjoyment of good health. This favorable issue may be ex- pected when the various organs gradually resume their respective functions, more especially if consciousness and a command over the voluntary muscles gradually return. The tongue is often the first organ that obeys the commands of volition; after this the upper extremities, then the inferior ones, resume their power of motion; the muscles of the face being in general the last to return to their regular action. Not unfrequently, during the progress of recovery from an attack of apoplexy, general and pretty free perspiration, or diarrhoea, and in some instances active vomiting, occurs. Some- times sanguineous evacuations attend the favorable termination of the disease; such as epistaxis or haemorrhoidal and menstrual dis- charges.* 2. In paralysis of certain parts of the body, with a restoration of health in all other respects. More or less paralysis, indeed, re- blood was found in the centre of the right anterior lobe of the brain, and blood was also effused into the lateral ventricle of that side. * Richter's Specielle Therapie, Bd. viii. p. 711. APOPLEXY. 13 mains after the majority of apoplectic attacks. In some instances the palsied muscles soon resume their natural power; in others, they slowly recover a certain degree of power, without, however, ever regaining their natural state of activity; whilst in some cases little or no perceptible diminution of the paralytic affection ensues—the affected muscles remaining permanently palsied. In most cases in which permanent paralysis is left by an attack of apoplexy, the mind becomes very perceptibly weakened. The power of comprehend- ing complex ideas and the memory are often almost entirely oblite- rated in persons who recover from a severe apoplectic seizure. Paralysis from apoplexy is usually of the hemiplegiac variety; but in some instances, the palsy is confined to a single member or to certain muscles, more especially to such as derive their nerves im- mediately from the brain, as those of the face. 3. The apoplectic fit may terminate in a general febrile condition after the sensorial oppression has passed off. In some instances, strong synochal fever is developed in proportion as the nervous functions are restored; in others, fever of a typhoid character, with manifest gastric irritation, ensues. Several years ago, I was called to a gentleman who a few minutes before had been seized with a fit of strong apoplexy. Under the usual treatment he gradually re- covered so as to be able at the end of the fourth day to sit up and converse without difficulty. On the next day strong febrile reaction, with a hot and dry skin supervened, and notwithstanding the most vigorous antiphlogistic measures, violent delirium ensued, and con- tinued for several days before it subsided. The patient eventually recovered. Diagnosis.—The diagnosis of apoplexy is not, in general, at- tended with difficulty. Where a loss of consciousness of the senso- rial functions and voluntary motion suddenly come on, and continue with an active state of the pulse and full respiration, the case must be regarded as apoplexy. From syncope and asphyxia, this form of soporose disease is distinguished by the absence or almost imper- ceptible action of the pulse and respiration in the two former affec- tions. It is sometimes difficult, however, to distinguish apoplexy from deep intoxication. The habits of the individual, the smell of his breath, and the general relaxation of all the muscles, particularly those of the jaws and the sphincters, will generally lead to a correct diagnosis on this point. Dr. Cook observes, that " as the treatment for true apoplexy would not be improper for intoxication, a mistake respecting the cause would not be hurtful to the patient." This is no doubt correct in reference to mistaking intoxication for apoplexy; but if a case of apoplexy were mistaken for intoxication, the conse- quence might be very injurious to the patient; for under this mistake the case would probably not be subjected to any efficient medical treatment whatever. Prognosis.—Apoplexy is always to be regarded as a highly dan- gerous affection. When the sensorial functions are completely abol- Vol. II.— 2 14 APOPLEXY. ished and the respiration is strongly stertorous, intermitting, and attended with a sputtering discharge of saliva from the lips, distor- tion of the mouth, immobility of the pupils, and an entire loss of the power of swallowing, no reasonable hope can be entertained pf a recovery. Nevertheless, patients do sometimes, though indeed extremely seldom, recover from this affection, after the most pro- found coma, stertorous respiration, and foaming of the mouth have supervened.* In general, however, if an appropriate and energetic tretment do not soon make a favorable impression upon the disease in its violent form, the case may be regarded as hopeless.t The duration of the apoplectic attack varies from a few minutes to two or three days. In some instances, death almost immediately follows the apoplectic seizure. This indeed has been doubted by some. Dr. Cook thinks that the cases of sudden death which have been ascribed to apoplexy, depended, probably, on some affection of the heart or large vascular trunks within the chest. There is good reason for believing that this has sometimes been the case; but it is by no means improbable, that sudden and extensive extravasations of blood into the substance of the brain, particularly in that part of this organ which gives rise to the respiratory nerves, may suddenly abolish, not only the sensorial powers and voluntary motion, but also the action of respiration, and thus produce speedy death.J Death from this affection, however, seldom takes place before the second or third hour from the attack. In most instances, indeed, from twenty to thirty hours, and in some cases five or six days pass, before the fatal termination occurs. Besides the unfavorable symptoms mentioned above, there are various others which are said to indicate especial danger. When the attack commences with sudden severe pain in the head,§ or with vomiting,j| or a general spasmodic rigidity of the muscles, the ut- most degree of danger is to be apprehended. General, clammy, and profuse perspiration, with a small and frequent pulse, is also a pecu- liarly unfavorable sign. Hippocrates says that the supervention of fever in apoplexy is favorable; but Richter observes that this ob- servation can only be regarded as generally correct when the fever is of the synochal grade and commences early, for when it super- * Portal, Observations sur la Nature et le Traitement de l'Apoplexie, p. 404. | Cook on Nervous Diseases, p. 113. Boston edition. % A case is related by Dr. Abercrombie, in which death from apoplexy occur- red in the space of five minutes. The patient had long complained of headach. While sitting in a crowded meeting, apparently in good health, she suddenly fell down in a state of insensibility, and expired in a few minutes after. On dissection, a thin but extensive (layer of extravasated blood was found on the surface of the brain; and small coagula were found also in the substance of the anterior right lobe. § Cheyne. y Richter, Specielle Therapie, Bd. viii. p. 773. APOPLEXY. 15 venes at a late period, and assumes a typhoid character, it never fails to increase the danger. (Loc. cit. 774.) The prognosis is also influenced by the character of the exciting cause, and still more by the presence or absence of that corporeal habit, which experience has shown to predispose especially to this affection. When there are evident manifestations of some degree of sensi- bility remaining; such as contraction of the pupils from the stimulus of light; some power of swallowing, &c, together with free and regular respiration, without stertor or discharge of saliva from the lips; a warm and general perspiration; the occurrence of sanguineous discharges, particularly from the nose or haemorrhoidal vessels; diar- rhoea, or a copious flow of urine; reasonable hopes may be entertain- ed of a favorable issue of the case. It was formerly supposed that apoplexy from the rupture of a vessel, and extravasation of blood into the substance of the brain, is always necessarily fatal. This opinion has, however, been satisfac- torily controverted by the experience of many of the ablest patholo- gists of the present day.* The observations and dissections of Riobe, Rochoux,t Cruvelhier, Bricheteau, and Serres;J and we may add, of Baillie and Sir Astley Cooper,§ place the occasional recovery from strong apoplexy beyond all doubt. From the numerous dis- sections made in the Parisian hospitals by the French pathologists just mentioned, we learn, that when sanguineous extravasation into the substance of the brain does not soon terminate in death, a mem- branous, vascular structure is formed around the coagulum, and that the coagulum is afterwards absorbed by the vessels of this membrane or cyst. In the progress of time, this cyst itself becomes absorbed, and leaves a yellowish cicatrix, or laminated, cellular structure, which in some instances is found to contain a small portion of red- dish serum. (Rochoux.)|| Sir Astley Cooper thinks, that in apoplexy from sanguineous extravasation, " the blood never becomes absorbed, but that the brain gradually acquires the power of bearing its pressure, and that thus the general symptoms which are produced at the first moments of * Recherches sur l'Apoplexie. f Considerations et Observations sur l'Apoplexie. X Nouvelle Division des Apoplexies. Annuaire Medico-Chirurg. vol. i. § Cook, loc. cit. p. 129. || " After the absorption of the extravasated coagulum," says Rochoux, " the sides of the cavities approximate, and unite into a kind of cicatrix by the inter- vention of a cellular and vascular structure, forming various areolae, between which a reddish serous fluid is found. These parietes are much more dense than the rest of the brain, about a line or two in thickness, and of a yellowish brown color. He asserts that these caverns are invariably found after apoplexy terminating in paralysis, and that their number constantly corresponds with the number of previous attacks." 16 APOPLEXY. extravasation gradually diminish."* That the brain is capable of accommodating itself in some degree to unnatural pressure from ex- travasation, or other causes, cannot be doubted. I knew an instance of considerable depression of a small portion of the superior and la- teral part of the os frontis from a fall. The child remained in a state of apoplectic insensibility for about twelve hours, and very gradually recovered a state of perfect consciousness in about three days. The depression still continues, and, with the exception of occasional headach, no inconvenience appears to remain from the accident. The numerous and well attested facts that have been brought to light by the authorities already mentioned, are nevertheless sufficient testimony to establish the truth of the occasional absorption of san- guineous effusions in the brain. Bricheteau and Riobe have reported numerous dissections, " all proving, not only the resorption of the effused fluid, but a reunion of the lacerated surfaces afterwards by a kind of cicatrisation.t Causes.—A variety of circumstances, both in relation to the constitutional habits of individuals, and extraneous influences, appear to predispose to this affection. Of these predisposing causes, the following are the principal:— 1. A peculiar conformation of the body; consisting in a large head; thick short neck; broad shoulders; ample chest; florid, and full face; short stature; globular abdomen, with a tendency to ple- thora and obesity. Such individuals are often subject to haemorrhage from the nose, as well as to sensations of weight and fulness in the head, particularly on stooping, or making strong corporeal exertions. When they sleep with the head lying low, they are restless, dis- turbed with dreams, and the respiration is heavy and sonorous. Such a corporeal structure constitutes, no doubt, in many instances, the hereditary predisposition to this disease, noticed occasionally in particular families.^ It is to be presumed also that a peculiar con- dition of the intimate organisation may, in some cases, establish a constitutional tendency to inordinate determinations to the head, and to the consequent occurrence of apoplexy and other cerebral affections. 2. Age.—The observation of Hippocrates, that apoplexy occurs chiefly between the fortieth and sixtieth years of age, (Aphor. sect. vi. Aphor. 27.) still holds good at the present day. Instances of apoplexy occur indeed at a much earlier period of life, particularly between the thirtieth and fortieth years; but in a general estimate it will be found that a very large majority of cases happen after the * Cook on Nervous Diseases, p. 129. f Med. Chir. Rev. June, 1820. X Dreysig (Handworterbuch der Med. Klinik. B. i. p. 450) mentions some remarkable cases of this kind. Portal and Van Hoven also state that they have known families in which a hereditary predisposition to this disease was manifested. APOPLEXY. 17 age of forty. Rochoux states, that out of sixty three cases of this disease, two occurred between the ages of twenty and thirty—eight between thirty and forty—seven between forty and fifty—ten be- tween fifty and sixty—twenty between sixty and seventy—twenty- three between seventy and eighty—and one between eighty and ninety years of age. It would appear from this statement, that apo- plexies occur more frequently after the age of sixty than at any pre- vious period; and this corresponds with the sentiments of Cullen and Portal. The greater liability to apoplexy at an advanced period of life, cannot be referred to a mere increased tendency to a preter- natural determination of blood to the head; for in infancy this ten- dency is acknowledged to be generally greater than at any subsequent period of life; and yet apoplexy at this early age is an extremely rare occurrence. Some other circumstances, therefore, connected with advanced age, must be the cause of this greater aptitude to the dis- ease. Many pathologists have ascribed this increased tendency to apoplexy in old people, to an ossified state of the cerebral vessels; but this opinion is not verified by post mortem examinations. Others, with more plausibility, have supposed that it may depend on a weakened state of these vessels, similar to that morbid condition of the arterial coats which favors the occurrence of aneurism. It is probable, however, that this predisposition depends on various cir- cumstances of a general character connected with old age, indepen- dent of a morbid condition of the cerebral vessels. 3. Whatever tends to produce general plethora, or to keep up a preternatural determination of blood to the brain, increases the liability to apoplexy. A full and nourishing diet; the habitual use of stimulating drinks, particularly in connection with an inactive and sedentary course of life, are especially calculated to increase the pre- disposition to this disease. Immoderate venereal indulgences at an advanced age; frequent, and long-continued warm bathing; a sudden change from an active or laborious to a quiet or indolent course of life; intense and protracted study; and the free use of strong coffee, are mentioned among the predisposing causes of this disease. 4. Various organic affections, such as aneurism of the aorta; hy- pertrophy of the heart; visceral indurations; and tumors about the neck, increase the liability to apoplexy. The exciting causes of apoplexy are very numerous. In general, whatever produces inordinate determinations of blood to the head, or impedes its free return from the brain to the heart, may give rise to this disease. Over-distension of the stomach by immoderate eating, more espe- cially if the ingesta are stimulating and of difficult digestion, and the digestive powers weak, is one of the most common and powerful exciting causes of apoplexy. The intemperate use of spirituous liquors, violent exertions in lifting, much straining in evacuating the feces, strong fits of coughing, sneezing, and great exertions in de- claiming, playing on wind instruments, singing, laughing, or speak- 18 APOPLEXY. ing, by causing sudden and strong determinations of blood to the head, may produce this disease in individuals predisposed to it. Ex- posure to the direct rays of the sun in warm climates, gives rise to that sudden and fatal affection called stroke of the sun, and which is generally regarded as apoplexy. Extreme cold also is capable of producing this affection, by diminishing the circulation in the exter- nal vessels, and causing strong internal congestions. Violent and sudden mental excitement, rage, excessive joy. terror, and deep sor- row, have been known to produce this disease. . The suppression of habitual discharges, whether sanguineous or serous, may give rise to apoplexy. This is particularly the case with habitual haemorrhoi- dal discharge or epistaxis in plethoric subjects. The healing up of old ulcers has a tendency also to produce this disease in persons otherwise predisposed to it, (Schmucker's Vermisch. Schriften. B. iii. p. I49;)and the neglect of customary venesection in full habits may tend to the same effect.* Stoll mentions the sudden disappear- ance of oedema of the feet as an exciting cause of apoplexy, (Ratio. Medend. Pars. iii. p. 305.) Women in the puerperal state, "arein some degree liable to apoplexy." Dr. Davis, of London, states that he has met with four or five apoplectic seizures and consequent hemiplegia, in puerperal women. In all these cases, the habitus apoplecticus mentioned above was present.t Tumors or visceral indurations in the abdomen, by pressing on the aorta, may give rise to this disease. Morgagni relates an instance which was produced apparently by an enlarged spleen pressing on the aorta. Apoplexy may also occur in consequence of the repulsion of chronic cutaneous diseases; and it is frequently the result of metas- tasis of gout. Authors mention also translations of rheumatism, erysipelas, and of other exanihematous affections among the exciting causes of this disease. I knew an instance in which it appeared to be brought on by a very severe attack of mumps. Violent rigors or chills, particularly the severe and protracted chills of internrnttents, sometimes give rise to apoplexy. I have known several fatal in- stances of this kind. In one rase, I stood by the patient when he was seized with the chills; in about ten minutes after they com- menced he became insensible; feil into convulsions, and quickly passed into a profound apoplectic stupor, from which he did not re- cover. The patient was an old, corpulent, and very plethoric man. Intestinal irritation may also cause so strong a determination of blood to the brain as to give rise to this affection.J * Vogel. Praelectiones Academ. § 558. f Dr. Davis. Medico-Chirurg. Rev. April, 1825. X There is, indeed, much reason to believe that gastro-intestinal irritation is a very common exciting cause of apoplexy. Thilenious, (Medicin-Chirurg. Be- merkungen, p. 66.) Also Schroder, (De Jlpoplexix ex pnecordior. vitiis Origine. Analecta in Opusc. vol. ii. p. 388,)—as quoted in Jahn's Klinik der Chronischen Krankheiten. Bd. i. p. 340. APOPLEXY. 19 Besides the foregoing causes, which operate apparently by causing undue determinations to the vessels of the brain, apoplexy may also be produced by causes that impede the free return of the veinous blood from the head to the heart. Stopping, or other situations in which the head remains in a depending position; wearing tight cra- vats, and turning the head round to look back, by which the jugular veins are in some degree compressed; impeded circulation through the lungs; organic diseases of the heart;* tumors on the neck, or in situations where they may press upon the veins which convey the blood from the head, are the principal of these causes. Authors mention also excessive evacuations among the occasional causes of this disease. Boerhaave states, that he knew an instance of apoplexy apparently produced by an excessive haemorrhage from the nose. The tendency of excessive sanguineous evacuations to produce soporose or cerebral oppression very similar to apoplexy, has already been adverted to under the general head of haemorrhages. The work of Marshall Hall, referred to in that place, gives some very interesting observations on this subject. It is certainly a very remarkable circumstance, and not accordant with the present received pathology of apoplexy, that entire insensibility, with stertorous breathing, sometimes results from profuse haemorrhage.t Diabetes sometimes terminates fatally, under symptoms strongly resembling apoplexy; and the same termination has been noticed in excessive diarrhoea and cholera. (Richter.) Peculiar atmospheric constitu- tions have also been ranked among the exciting causes of apoplexy; and from causes of this kind, this disease has at times prevailed epi- demically.:}: Besides the authorities referred to below, we have also the more recent testimony of Weikard, (Vesmich. Schriften, st. i. p. 292. st. ii. p. 65,) and of Jahn, (Klinik d. Chronish. Krankheit. B. i. p. 333,) in confirmation of this fact; and Baglivi mentions the epidemic occurrence of this affection. Richter states, that a humid, cold, and variable state of the atmosphere, appears to be most favor- able to the occurrence of apoplexy. It is not improbable, however, that such a condition of the atmosphere depends more upon its elec- trical and barometrical state, than on its relative degrees of humidity and temperature. This atmospheric tendency to produce or favor the production of apoplexy, is sometimes limited to a few days of continuance. Thus Thilenius states, that in the course of a few days, nine persons were seized with apoplexy in one district. Bemerk. B. i. p. 67— Richter.,)§ * See Medico-Chirurg. Rev. January, 1820. p, 343 and 345. j- For an interesting example of this kind, see Mr. Brown's case of uterine haemorrhage, reported in the London Medical and Physical Journal—1827. \ Agathias. De Bello Gothico, in Hugo Grotii. Histor. Gothorum. p. 568. See also, Lepecq. de Clotiere. Anleit. f. Aerzte, Epidem. Krankh. Zubeobacht. p. 412. Fr. Hoffman. Medic. Ration. System, torn. ii. p. 11. s. 11. p. 529— as quoted by Richter, Specielle Therapie, vol. viii. p. 755. § Vide Macullough on Malaria. 20 APOPLEXY. Various organic affections of the brain and its meninges, and the narcotic poisons, are also enumerated among the exciting causes of this disease. Gregory doubts whether these latter can, with pro- priety, be considered as exciting causes of apoplexy. As they tend, however, to cause strong congestion in the vessels of the brain, they may, no doubt, excite this affection in persons otherwise pre- disposed to it, as other causes do that strongly determine the circula- tion to the head. Pathology.—What is the immediate cause of the abolition of sensorial power and voluntary motion in apoplexy? Pathologists are far from being unanimous in their answers to this question. Some maintain, that pressure on the cerebral mass is always the immediate cause of the characteristic phenomena of this disease; others suppose that they depend not on pressure, but simply upon interrupted cir- culation in the brain;* whilst some believe that the encephalic ef- fusions are the consequence of a previous morbid change in the brain, (Rochoux,) upon which the loss of sense and motiou depends. Some pathologists confine the term apoplexy strictly to sanguineous extravasation within the brain; others include serous effusions among the immediate causes of the disease; and many believe, and correctly too, that mere vascular turgescence, without effusions of any kind, frequently produces apoplexy. From a careful examination of much of what has been written on this subject, as well as from my own observations, it appears to me clear that the opinion which assigns the characteristic phenomena of apoplexy to pressure of the brain, is the correct doctrine on this point. Post mortem examination detects in those who die of apoplexy one or more of the following phenomena:—1, vascular turgescence of the brain; 2, sanguineous extravasation into the substance of the brain; 3, serum effused into the ventricles or upon the surface of the brain; and 4, no cognisable cerebral disorder whatever. Of these four conditions, the first only ought, I think, to be considered as primary or essential; the others being consecutive, and not immedi- ately concerned as a cause in the apoplectic seizure. When blood flows more rapidly into the arteries of the brain than it can be returned by the veins, preternatural distension of the cere- bral vessels must be the consequence; and this general vascular turgescence must exert an unusual degree of pressure on the cere- bral mass. That such vascular engorgement and consequent pressure on the brain is capable of producing all the peculiar symptoms of apoplexy, admits of no doubt. In some instances of fatal apoplexy, the ves- sels of the brain are found so much engorged with blood, as to render even the smallest branches very conspicuous, and to give a more or less deep red tint to certain portions of the cerebral mass without * Abercrombie. Researches on the Pathology of the Brain in Apoplexy. APOPLEXY. 21 any sanguineous or serous effusions.* Richter says that an ex- tremely congested state of the cerebral vessels is sometimes the only morbid condition visible within the head, t Bricheteau also observes, " that we often find a general turgescence of the cerebral vessels, which congestion causes a general pressure on the encephalic mass, sufficient to extinguish the nervous influence, and destroy life."J Morgagni has related a case in which he found, on dissection, the whole vascular system of the brain extremely engorged with fluid blood. Dr. James Johnson, in commenting on this case observes— " that apoplexy is frequently produced by turgescence of the vessels alone, was believed in ancient times as well as in modern. It is, in- deed, reasonable to suppose, that in the majority of apoplectic re- coveries, congestion only had taken place in the vessels of the brain. But if congestion gives rise to the most favorable cases, it appears capable of producing the most desperate and instantaneously fatal ones also."§ Dr. Fouquier also, has reported a case of fatal apo- plexy, which was manifestly the result of mere sanguineous engorge- ment of the brain. " The exterior vessels of the brain and those of the choroid plexus were much engorged with blood;" and the in- terior of the cerebral mass, when sliced off, presented a multitude of red points. Neither serous nor sanguineous effusion was present.|| Strong and sudden sanguineous engorgement of the cerebral ves- sels is, probably, always one of the first morbid conditions in the occurrence of apoplexy—the immediate result of diminished vital resistance in the vessels of the brain, and a preternatural afflux of blood to these vessels. (Johnson.) This vascular turgescence may pass off again under proper remediate measures; or it may terminate speedily in sanguineous extravasation into the brain; or continue, finally, without any effusions, until it terminates the patient's life. What is usually termed serous apoplexy is perhaps only one of the terminations of apoplexy from vascular turgescence. A sudden vio- lent determination of blood to the brain, and consequent cerebral compression, may immediately destroy all sense and voluntary mo- tion. If the vessels be not relieved by extravasation or by immedi- ate applications, they may, in the course of some hours, relieve themselves by serous effusion, as they do in hydrocephalus acutus; and this effusion must then become a secondary but permanent cause of cerebral compression. It is unnecessary here to adduce any argu- ments in support of this pathology of serous apoplexy. We often meet with striking examples of sudden serous or lymphatic effusions from vascular engorgement. Every one has heard of the affection usually called apoplexy of the lungs. Sudden and often fatal effu- * Portal. Resultats de l'Ouverture des Corps. f Specielle Therapie, Bd. viii. p. 718. X Journal Complimentaire du Diet, des Scien. Med. p. 296. § Medico-Chir. Rev. June, 1820, p. 9. || Annuaire Medico-Chirurgicale, vol. i. p. 376. 22 APOPLEXY. sions of this kind occur into the substance of the lungs from violent engorgement of its blood-veseels. It appears highlv probable, therefore, that strong vascular tur- gescence of the encephalic, mass, constitutes the primary pathological condition of apoplexy. This state often terminates almost immedi- ately in sanguineous extravasation, or at a later period in serous effusion; and both these consequences constitute, of course, additional causes of cerebral compression.* To this view of the pathology of apoplexy, it has been objected, that cases sometimes occur in which the brain on dissection exhibits no traces whatever of vascular congestion, nor any other obvious lesions. Petzold has related instances of this kind, which he ascribes to inanition of the cerebral vessels, and in which not the slightest unnatural appearances were discovered on dissection, except an empty and collapsed state of the vessels of the brain.t Such cases are, however, extremely uncommon; and do not, upon proper inquiry, militate against the doctrine advocated above. Upon this point Dr. Johnson observes, " that there is nothing more certain than that the vascular turgescence in the brain may so far subside, in the interval between death and dissection, as to leave no trace of its previous existence. This, in fact," he continues, " we consider to be the natural and true solution of the difficulty respecting the cause of apoplexy in those cases where the scalpel cannot detect deviations * M. Serres contends that both sanguineous and serous affections are always the effect, and not the cause of apoplexy. He denies that pressure, in any case is capable of producing either this disease or hemiplegia. He thinks, that what is usually termed serous apoplexy depends on disease of the meninges; apoplexy with paralysis, he says, is the immediate consequence of an altered state of the cerebral structure, attended generally with sanguineous extravasation as a secon- dary result. His reasons for denying the agency of pressure in the causation of this affection, are derived from the fact, that fatal apoplexy sometimes occurs without any effusion or extravasation, or even vascular turgescence appearing on dissection: and from some experiments which he made on animals, in which the cranium was opened, and a vessel wounded, and the blood carefully confined within the head by closing up the external opening. Although much blood was thus extravasated and lodged into the great interlobular scissure and upon the surface of the brain, no comatose or paralytic affections ensued. These views, so far as cerebral pressure is concerned in the production of the disease, are, however, directly contradicted by the results of some experiments made in rela- tion to this subject by Portal. This pathologist trepanned the cranium of a dog. By different degrees of pressure made on the brain through the openino- with the finger^or a piece of wood, he could at pleasure produce convulsions, or coma, and apoplectic stertor; and Sir Astley Cooper obtained the same results from similar experiments made on a dog.(a) j- Dissert, de apoplexia ex inanitione vasorum cerebri, Goett. 1785. (a) Cook on Nervous Diseases. APOPLEXY. 23 from the healthy structure."* There is, however, another objection that has been urged against the doctrine of cerebral compression as the exclusive cause of apoplexy, which, though plausible, possesses no real weight. It is stated, and correctly, that all the external mani- festations of strong apoplexy are sometimes the immediate result of excessive haemorrhage. I have already referred to the case reported by Mr. Brown, in which entire insensibility and stertorous breathing were the immediate consequences of excessive uterine haemorrhage, and which were removed by transfusing blood from another person into the patient's veins.t Dr. Denman has also related an instance of apoplectic symptoms supervening on very profuse haemorrhage,:}: and many more cases of this kind might be collected. In relation to such cases it is to be observed, that great losses of blood are pe- culiarly favorable to extraordinary determinations to the brain, or as Marshall Hall expresses it, " to increased action and fulness of the cerebral vessels."§ The experiments of Kellie, on animals show that serous effusion within the head, is a pretty constant con- comitant or consequence of excessive sanguineous depletion; and the experiments of Dr. Seeds go to establish the same fact.|| The sanguineous extravasations are usually found in the corpus striatum, or in the thalami nervorum opticorum. Out of forty-one dissections, Rochoux met with but five or six instances of extravasa- tion in other parts of the brain: and the observations of Morgagni give nearly the same result.IT Extravasation of blood into the cere- bellum is an extremely rare occurrence. According to Rochoux it hardly happens once in fifty cases; and Morgagni reports only one instance of this kind. " Blood is rarely effused, in the first in- stance, into the ventricles. During ten years observation in the different hospitals, M. Bricheteau saw only two cases of this kind. The fluid is generally extravasated in the neighborhood of the ven- tricles, and bursts into them by a ragged opening." (Med. Chir. * Med. Chir. Rev. June, 1820, p. 8. f Lond. Med. and Physical Journal, 1827. X Trans, of a Soc. for the Improv. of Med. and Surg. Knowledge, vol. iii. p. 315. § Medical Essays, p. 68. || M. Seeds, in six experiments performed on animals which he bled to death, found the contents of the cranium and spinal canal so engorged with blood, that it might at first sight have been thought that blood-letting would have saved the animals.—Medico-Chirurg. Jour, and Review, vol. i. If In explanation of this fact, M. Bricheteau observes, " an attentive study of the vascular system of the brain shows us that a number of arteries penetrate directly into these parts—the corpus striatum, &c. without dividing themselves in the pia mater, as the other vessels do which serve to nourish the brain. In consequence of this they are without any additional membranous support in the middle of the cerebral mass, the consistence of which is but illy calculated to support them against the impulse of the blood."—Loc. cit. 24 APOPLEXY. Rev. loc. cit.) Occasionally blood has been found effused on the surface of the brain. Rochoux relates a case of this kind; and Rich- ter states that sometimes the brain, on removing the cranium, appears dark, brown, or blackish, through the membranes, from extravasated blood underneath. (Loc. cit. B. viii. p. 719.) The old division of apoplexy into sanguineous and serous, possesses no importance in a practical point of view. I have already stated that the effused serum sometimes found within the head on dissection, is very probably not the immediate cause of the apoplectic seizure, but one of the results of the vascular engorgement, upon which the apoplexy depends. There are, nevertheless, some circumstances connected with this dis- tinction which it may be proper to notice. Thus, it appears, from the observations of M. Serres, that when the apoplectic attack is complicated with hemiplegia, we may infer that there is extravasa- tion of blood into the cerebral substance. When, on the other hand, the disease is accompanied with paralysis, we may presume that the substance of the brain remains uninjured, and that more or less serum, or sero-sanguineous fluid, is effused by the congested and irritated meninges upon the surface, or into the natural cavities of the brain. The former variety—that is the complicated or paralytic form of the disease—M. Serres calls cerebral apoplexy, from the cerebral mass itself being the principal seat of the morbid changes. The latter, or uncomplicated variety, he denominates meningeral apoplexy, on account of the manifest traces of vascular irritation and congestion, discovered by dissection, in the meninges. It ap- pears from the observations made in the Parisian hospitals, that meningeal or serous apoplexy occurs chiefly before the fifteenth and after the sixtieth year of age; and that females are more liable to this variety of the disease than males. When blood is extravasated into one hemisphere of the brain, the consequent paralysis occurs almost universally on the opposite side of the body. The paralysis is occasionally general—both sides of the body being equally affected. In such cases the mouth is not drawn to either side, and the patient dies as from asphyxia; or as ani- mals do which have the pneumo-gastric nerves of both sides divided, The extravasation, in cases of this violent character, takes place into the substance of the tuber annulare, or bursts from thence and spreads along the basis of the skull. (Serres.) The existence of hemiplegia may, in general, be readily detected by the distortion of the mouth; for, however profound the apoplectic stupor may be, more or less deviation from the natural position of the mouth is almost universally present. Treatment.—The main object to be kept in view in the treat- ment of apoplexy, is the removal of the vascular turgescence within the head. This fundamental indication is to be answered by a prompt reduction of the general mass and momentum of the blood; and by the employment of means calculated to lessen the determination of the blood to the brain, and to derive it from the cerebral vessels. APOPLEXY. 25 In the actual paroxysm of apoplexy, the patient should be imme- diately removed to an airy and cool situation, and placed in a posi- tion which least favors the flow of blood to the head. All ligatures, particularly those about the neck, should be speedily removed, and his head and shoulders supported in an elevated position. In this posture, a large orifice should be made into a vein, and the blood suffered to flow until a very decided impression is made on the pulse, at the same time that cloths, wet with cold water, are applied to the shaven scalp, and warm or stimulating applications—such as fomen- tations, sinapisms, or frictions with tincture of capsicum—made to the legs and feet. Cups may also be very beneficiallly applied to the temples and back of the neck, conjointly with the means just mentioned. Some advise bleeding from the temporal artery or the jugular vein in preference to brachial venesection; but others do not regard this preference as founded on good grounds. It is neverthe- less very probable that blood promptly drawn from the jugular veins or temporal arteries, will have a more direct and speedy effect in diminishing the sanguineous congestion in the brain, than if it be taken from the arm; and as the accomplishment of this effect consti- tutes our chief purpose in the employment of blood-letting, we may with propriety adopt this mode of depletion. In whatever way the blood is drawn, little or no advantage will be obtained, unless a sufficient quantity is abstracted to produce a very obvious impression on the action of the pulse; and this effect can seldom be produced without the loss of from thirty to forty ounces of blood at once. If in the course of an hour the pulse resumes its activity, a second venesection should be practised, and repeated afterwards at longer or shorter intervals, as long as the pulse indicates the propriety of further depletion. It is sometimes necessary to abstract a vast quan- tity of blood before the disease begins to subside. " From six to eight pounds of blood have been taken from a person by no means robust, before the disease began to yield."* I have myself drawn five pounds of blood from an apoplectic patient in the course of six hours after the seizure with entire success. In the employment of blood-letting wo may suffer ourselves to be guided by the pulse, as has just been stated. Nevertheless, the judicious practitioner will regulate the extent to which this evacuation is carried, not only by its effects on the pulse, but by an attention also to the age and con- stitutional habit of the patient. I have met with a case of apo- plexy which ultimately proved fatal, in which the loss, of thirty ounces of blood produced, almost immediately, much feebleness of the pulse. The patient was a female, beyond the seventieth year of age. Leeching is of no service beyond what may result from the gene- ral diminution of the circulation. Cupping, however, is a most im- * Cheyne. Vol. II.—3 26 APOPLEXY. portant auxiliary.* After an efficient venesection, the application of cups along the temples and back of the neck, or to the shaven scalp, will sometimes speedily rouse the patient from his stupor.t The application of ice, or very cold water to the scalp, is one of the most useful remedies in this disease. This was a favorite mea- sure with Thilenius,J and his praise of its powers, though great, can scarcely be deemed extravagant. Its efficacy will be much en- hanced by the simultaneous application of warmth, or stimulating frictions to the legs and feet. Of course, where the pulse is feeble, and the countenance pale, cold must be cautiously applied, but stimu- lating and warming applications to the lower extremities are always proper. Formerly, blood-letting was regarded as of very doubtful propriety in this affection; but at the present day its usefulness, or rather its indispensableness, in every case of genuine apoplexy, is universally acknowledged. Active purgatives also are among our most efficient remedies in this affection. As the advantages derived from them depend, no doubt, in most instances, chiefly on the tendency they have to direct the circulation more particularly to the intestines, and to excite a free secretion from their internal surface, and consequently to di- minish the afflux of blood to the head, it is evident that the more rapidly they operate, the more beneficial will be their influence. On this account, as well as from the great intestinal torpor which prevails in this affection, it is necessary to employ the most active articles of this class of medicines. It is, however, often extremely difficult, and in violent instances, sometimes impossible to admin- ister cathartics by the mouth, from the paralysed state of the organs of deglutition. Where the power of swallowing is wholly destroyed, we may introduce a purgative fluid into the stomach through an elastic stomach tube. Calomel and extract of jalap are recommended by Sir Gilbert Blane as the best purgative in this affection. Calomel and colocynth form also a suitable purgative. I have used the oil of croton, rubbed up with a little gum arabic and water, with excel- lent effect in two instances of apoplexy. This article generally acts * I very much admire the mode of cupping recommended by Mr. Wallace, (a) It is as follows: A cupping-glass having been exhausted in the usual way, is applied to the surface until the skin is sufficiently raised. A very sharp gum lancet is then to be lightly and rapidly drawn over the skin, so as to make super- ficial incisions about the sixth of an inch from each other, over the whole surface raised by the exhausted cup. These incisions should be so slight as to be scarcely visible. The moment the cupping-glasses are reapplied, the blood will be found to stream from them with surprising rapidity. f Dreysig, loc. cit. p. 481. X Medicinische und Chirurgische Bemerkungen, p. 62, et seq. (a) A Physiological Inquiry into the Action of Moxa, &c. By Mr. William Wallace M. R. I. A. Surgeon of the Charitable Infirmary of Dublin, &c. &c. p. 62. APOPLEXY. 27 with much energy, and from its small bulk and fluidity, is more easily introduced into the stomach than other remedies of this kind. Castor oil with turpentine, also forms an excellent purgative in this disease. At the same time that cathartics are given by the mouth, active purgative enemata should be repeatedly administered. For this purpose we may use a solution of aloes in warm water, in the proportion of from thirty to forty grains to the pint of water; or a strong infusion of senna. Richter advises a solution of tartar emetic for this purpose. Where the vascular reaction is vigorous, this so- lution may be peculiarly serviceable, by the nausea and consequent reduction of arterial excitement which it is apt to produce, as well as by its evacuant effects on the bowels. Purgatives are particularly useful where the bowels are in a loaded condition. Dr. Abercrombie relates some instances of this disease, in which blood-letting afforded but very little advantage. As soon, however, as the bowels were freely evacuated, a very obvious im- provement took place. Where the inordinate flow of blood to the brain is caused or supported by intestinal irritation from accumula- tion of feculent matter, or the presence of vitiated secretions, it would seem in vain to expect decided benefit from bleeding or any other remedy, unless the bowels are freely moved; and it is in such cases especially, that cathartics are of primary importance. Formerly emetics were much extolled for their remediate powers in apoplexy. Van Helmont, Riverius, Stoll, and Burserius, placed much dependence on them in the treatment of this disease.* Since the time of Cullen, however, they have been generally abandoned, as much more calculated to do mischief than good.t Unquestionably, as a general rule, emetics must be regarded as hazardous remedies in apoplexy; for the tendency of vomiting to propel the blood to the head is always very considerable. Nevertheless, this disease may occur under circumstances of gastric irritation, which may not only render emesis useful, but absolutely indispensable to success. When the apoplectic seizure occurs soon after taking a very full meal of stimulating food, an emetic ought undoubtedly to be given. But even under the most urgent indications for the exhibition of an emetic, a copious and efficient abstraction of blood should always be premised. A few years ago, I met with a striking instance of the usefulness of emetics in apoplexy, under the circumstances just men- tioned. A robust man, about fifty years of age, fell down in a fit of apoplexy about an hour after he had taken a very full meal of animal food, with several glasses of brandy and water. The coma was pro- found and the respiration stertorous and sputtering. He was imme- diately bled to the extent of about forty-eight ounces, but although the pulse was considerably reduced, no perceptible improvement * Burserius. Inst. Med. Pract. vol. iii. § 131, p. 106. X See Lond. Med. and Phys. Jour. vol. v. and vi. for an ample discussion on this subject 28 APOPLEXY. ensued. Twenty grains of sulphate of zinc were with difficulty introduced into his stomach, and free vomiting ensued in about ten minutes after. Almost immediately after the contents of the stomach were thrown off, he became better; and by the use of purgatives, enemeta, and cups to the head, he recovered without any further difficulty. Dr. Gregory says, " in certain cases vomits are proper; but they should never be given till after large evacuations by blood- letting. They are most proper where the disease proceeds from a surfeit; and in serous habits vomits are very efficacious."* Authors generally advise the mildest emetics in cases where they are indi- cated. Heberden gave a weak infusion of chamomile; Cheyne used lukewarm water with hartshorn; and others recommend warm water with mustard. It is very questionable, however, whether any peculiar advantages attend the use of these milder emetics. Indeed, the system is almost always so insensible to the impressions of medi- cines, that nothing but the most active articles in large doses, will procure emesis. Where there are indications present to justify the exhibition of an emetic, the more promptly the stomach is evacuated the better. Richter, who speaks very favorably of the employ- ment of emetics in cases of this kind, advises the most active arti- cles of this class.t Blisters do not appear to afford any advantage in apoplexy, unless the pulse is weak, small and quick, which, though rarely, is some- times the case, in old and enfeebled persons of leucophlegmatic habits. At all times, however, it is better to apply them to the ankles and wrists than to the head or back of the neck. It is scarcely necessary to say. that stimulants are decidedly im- proper in the early period of apoplexy. Where, after copious eva- cuations, some degree of consciousness and a power of voluntary motion returns, with much prostration and a feeble pulse, some be- nefit may perhaps be obtained from the cautious exhibition of the carbonate of ammonia or camphor, (Richter,) in the form of a mu- cilaginous mixture. The prompt and judicious employment of the foregoing means, embraces every thing that may be deemed efficient in the remediate management of apoplexy. From whatever cause the disease may arise, our whole efforts should be directed to the removal of the in- ordinate vascular action or turgescence within the head. Some modifications in the mode of employing the measures mentioned, according to the general constitutional habit, the age, and the cha- racter of the exciting causes, will of course be necessary. Thus, in cases which succeed the sudden suppression of habitual hemorrhoidal discharge some peculiar advantage may perhaps be gained from the application of leeches to the anus; if the healing up of old ulcers on the lower extremities appears to have given occassion to the apo- * MS. Lecture as quoted in the Med. Chirurg. Rev. June, 1820, p. 26. \ Med. Chir. Bemerkungen. B. ii. p. 109. APOPLEXY. 29 plectic seizure, blisters, issues, or sinapisms to these parts will be proper; and I have already adverted to the usefulness of emetics when the attack takes place soon after a surfeit, and the indispensa- bleness of cathartics when the bowels are loaded with feculent and other irritating matters. During convalescence from apoplexy, nothing but the lightest un- irritating diet should be allowed; and unless great prostration exists, all kinds of vinous liquors should be interdicted. The prophylactic management, in persons laboring under the usual premonitory symptoms of apoplexy, or constitutionally pre- disposed to this affection, constitutes a very important point of me- dical attention. A simple, abstemious diet, exercise in the open air, and the avoidance of all kinds of stimulating drinks, as well as of sudden and violent mental excitement, are among the most im- portant precautionary measures in cases of impending apoplexy. If the bowels are torpid, and cannot be brought to a regular state by vegetable diet, it will be necessary to use an occasional dose of some mild laxative, as castor oil, or small portions of rhubarb; and where there is reason to suspect hepatic torpor or derangement, three or four grains of blue pill with a few grains of pulvis antimonialis, taken occasionally at night on going to bed, will be useful. When alarm- ing premonitory symptoms come on, with an active, full, and hard pulse, blood should be immediately drawn to an extent sufficient to reduce considerably the momentum of the circulation, and a brisk cathartic administered. It should be recollected, however, that blood- letting affords only temporary benefit. A copious abstraction of blood may obviate an approaching attack of this disease, but frequent venesection will do little or no good in preventing that general ple- thoric habit which is so favorable to the occurrence of this affection. This must be done by abstemious living; and above all, by an active course of life. Persons predisposed to apoplexy from corporeal conformation, should be particularly careful not to interfere with, or check haemor- rhoidal discharges, unless they become excessive. The same pre- caution is necessary with regard to epistaxis in individuals of the apoplectic habit, as well as with other habitual evacuations. Drs. Oheyne* and Stokert recommend the internal use of small doses of James's powders, or pulvis antimonialis, where there is an habitual tendency to inordinate sanguineous determinations to the head. In one instance of this kind, I have known the daily use of two grains of James's powder, mornings and evenings, of unequivocal benefit. Green tea also is said to possess the power of diminishing or obviating cephalic congestions. Drs. E. PercivalJ and Stoker * Dublin Hospital Reports, vol. i. p. 315. X Dublin Medical Essays, anno 1806. Transactions of the Association of Fellows and Licentiates of the Queen's College of Physic. Dublin, vol. ii. X Dublin Medical Essays, vol. ii. p. 44. 3* 30 PARALYSIS. strongly recommend it for this purpose in comatose affections; and my own experience leads me to think that it possesses considerate powers in this way. Coffee, however, is decidedly injurious vvnere there is an apoplectic tendency. Some eight years ago, a gentleman in this city, of a strongly developed apoplectic habit, was seized witn an attack of this affection. He was in the habit of taking large quan- tities of very strong coffee twice daily. I advised him to leave otl taking this beverage entirely. He did so; and has not since expe- rienced even the ordinary premonitory symptoms of the complaint. Apoplectic subjects should be very careful not to bathe their feet in very cold water—more especially when they are subject to habitual perspiration from these/parts. The frequent use of the warm bath also is hazardous in persons of this habit; and excessive venereal' indulgence is equally apt to do injury. Sect. II.—Paralysis.—Palsy. Palsy consists in impaired or abolished power of voluntary mo- tion, or of sensation, or of both, in certain parts of the body, with- out coma, or a loss of consciousness. Cases in which both sensibility and the power of motion are at once destroyed, are however ex- tremely rare. Instances even occur in which the sensibility of the palsied part is morbidly increased. I have met with a case of this kind. The patient had lost all command over the muscles of the lower extremities; but the sensibility of the skin from the knees downwards was so great, that even moderate pressure with the fingers gave rise to considerable pain. An instance is related in a recent French journal, in which the surface of the paralysed limb was entirely insensible, but the muscles beneath were the seat of acute pain, which was always much increased by pressure.* In general the paralysed parts become soft and flaccid, and at last usually emaciated, or occasionally cedematous. Sometimes a peculiar ting- ling, or creeping sensation (formicatio) is felt in the affected parts, "as if small insects were creeping over them." The opinion gene- rally entertained, that the temperature of the palsied parts is lower than natural, does not appear to be founded on correct observation. It is true, we frequently find such parts cooler than the rest of the body; but this would seem to depend on the loss of power in the paralytic part to maintain its specific temperature; in other words, to resist the physical laws of the distribution of heat, in consequence of which, such part becomes cooler when exposed to a temperature below that of the human body, and warmer than natural, when ex- posed to a temperature above this point.t Patients sometimes com- plain of a severe sense of cold in the affected parts, although to the touch the temperature does not appear to be materially diminished. * Med. Chir. Rev. October, 1829, p. 168. X Dr. Abercrombie—See Cook on Nervous Diseases, p. 227. Boston, 1824. PARALYSIS. 31 In some instances the pulse is smaller and weaker in the paralysed limb, than in the healthy one; sometimes, however, it is fuller and stronger in the affected than in the sound side; and frequently no difference whatever can be perceived in this respect. When palsy arises from disease of the encephalon, it is generally attended with an evident impairment of the mental powers—amount- ing, in some instances, to complete imbecility. The memory, es- pecially, is apt to suffer in this affection; and sometimes in a very singular manner. Individuals affected with cerebral palsy, have lost the power of recollecting particular words, numbers, letters, locali- ties, or even their own names; whilst in other respects no material defect was manifested in this faculty. The natural temperament and disposition also sometimes suffer a total change from a stroke of palsy. Individuals of amiable and placid dispositions have become sullen, peevish, irascible; and persons of an irritable and passionate temperament have been rendered mild and simpering by a paralytic seizure. (Cook.) Paralysis has been known to occur periodically. A case of palsy is related by Musgrave, (Philosoph. Transact.) which regularly returned every eight days, and continued each time to the fourth day. A similar instance of paralysis is recorded by Dr. Battaille, of Paris, (Ann. de la Medecine Physiolog. December, 1829.) It was a quotidian hemiplegia, with perfect intermissions of five or six hours, and was cured by the use of quina. The duration of palsy is very various. Occasionally the affected muscles recover almost en- tirely their healthy powers in a few days; but the progress of amendment is much more commonly very gradual and slow. It is a singular fact, that the extreme parts of a paralysed limb are often the first that manifest any degree of returning muscular power. I attended a hemiplegiac patient about two years ago, for three weeks, without any apparent amendment; at last, however, he found that he could move his toes; by degrees he regained the power of mov- ing the foot, then the leg, and finally the thigh. The same progress of amendment occurred in the paralysed arm. The power of motion began in the fingers, and gradually extended upwards. When palsy occurs in the whole of one side of the body, it is termed hemiplegia; if both the inferior extremities, from the hips downwards, are paralysed, it is called paraplegia; and when only some one particular part is affected, it constitutes the paralysis partialis of authors. Paralysis, without coma, affecting the whole body, is an extremely rare occurrence. Cases of this kind, however, have been recorded. Avery curious instance of general palsy oc- curred lately in one of the Parisian Hospitals. The paralysis in this case commenced in the feet, and gradually ascended towards the body, when it had arrived at the knees, the palsy seized also upon the hands, and slowly passed upwards to the trunk; finally, every voluntary muscle, excepting those of the face, neck, and tongue, 32 HEMIPLEGIA. became paralysed. The patient's general health was good, and his intellect perfect.* Tissot relates an instance of a boy, who, ap- parently in consequence of a repelled scabby affection of the head, became paralytic throughout nearly the whole of the muscular sys- tem, attended with much torpor of the sensorial functions, and cental weakness, though wholly free from coma or somnolency.t M. Bre- tonneau has related a somewhat similar case. " A lady was seized with paralysis of the little finger of the left hand, which gradually extended to the whole of that side; the right became similarly af- fected, with the exception of the thumb and two fingers. The whole body was thus palsied—the tongue was motionless, and deglu- tition extremely difficult; but her intellectual faculties remained un- impaired.":]: Cook mentions a case, from a publication of M. Keratry, in which there was paralysis of the "arms, thighs, and of the whole exterior surface of the body, with the exception of the face." 1. Hemiplegia. This is by far the most common of those forms of palsy which depend on oppressed function of the sensorium commune. In its essential pathological character, it does not appear to differ materially from apoplexy; and it occurs frequently as an immediate concomi- tant of this disease. Hemiplegia is almost always ushered in with more or less distinctly marked apoplectic symptoms. Occasionally the hemiplegiac attack occurs suddenly, without any distinct manifestations of its approach. Much more frequently, however, some of the ordinary premonitory symptoms of apoplexy precede the attack for several days; and just before the seizure, strong symptoms of sanguineous determination to the head, and cerebral disturbance, are particularly apt to occur—such as flushed face; distension of the veins about the head and neck; vertigo; a sense of fulness, weight, and sometimes pain in the head; ringing in the ears; drowsiness; impeded articulation of words, or loss of speech; slight delirium, or confusion of the mind; loss of memory, and a change of habitual disposition. M. Serres states that he has noticed in cases that came on gradually, distortion of the mouth for several hours before the hemiplegia supervened; and immediately before the seizure, he has sometimes remarked, that in the act of respiration, one side of the chest was quiescent, whilst the other was very conspicuously dilated and contracted. The reproductive or vital functions are seldom much disturbed in the ordinary cases of hemiplegia. In some instances, however, the * Medico-Chirurg. Rev. Oct. 1829, p. 168. f Medical Works, vol. iv. p. 552. X Med. Chir. Rev. Oct. 1826, p. 604. Clinical Report of the Hospice de Perfectionnement. Rev. Medicale, 1826. HEMIPLEGIA. 33 whole track of the alimentary canal is extremely torpid, and it would appear that the liver is sometimes affected.* The counte- nance generally acquires a vague or fatuous expression; the mouth is drawn to one side; the lower lip on the palsied side hangs down, and suffers the saliva to dribble away. Articulation is always more or less difficult and indistinct, and deglutition is generally somewhat impeded and difficult—more especially on attempting to swallow liquids. It is in this form of paralysis, particularly, that the mind is apt to suffer from the long continuance of the disease. General impairment of the intellectual powers usually occurs; but the memory is most apt to become conspicuously enfeebled, and even wholly effaced. Very remarkable anomalous circumstances are sometimes con- nected with hemiplegiac affections. Cook has collected a great variety of curious cases of this kind. An instance is related, in which the arm of one side and the leg of the opposite one were palsied, (Fabricius;) another, where the sensibility, but not the power of voluntary motion, was destroyed in one leg, whilst in the other the power of motion was lost, with the sensibility unimpaired. (Ramazzini.) Cases are reported in the Memoirs of the Royal Academy of Sciences, in which there was an entire loss of sensibility, without any impairment of voluntary motion. In some instances the sensibility is morbidly increased. Falconer mentions a case in which cold bodies communicated the sensation of heat to the palsied parts; and in the case of Dr. Vieusseux, (Med. Chir. Trans, vol. ii. pp. 216, 217,) the right side was at first so insensible that it could be pinched or pricked without giving him pain; afterwards this insen- sibility seized on the left side. In the right side cold bodies excited the sensation of heat, and hot bodies that of cold, or only coolness. Dr. Cook has seen a case of hemiplegia, in which the muscles of the left arm, from the shoulder to the elbow, were much emaciated, and greatly impaired in activity; whilst those of the fore-arm were in a perfectly natural state, both as to fulness and power. The condition of the right arm was directly the reverse, the muscles of the part above the elbow were natural in size and energy, but those of the fore-arm were wasted and powerless. In some instances little or no improvement takes place, and the patient remains helpless, often for a-long time, and at last dies, either from gradual exhaustion, or suddenly from apoplexy. More com- monly, however, more or less amendment slowly occurs, until the patient is perhaps able to support himself with but little aid in a sit- ting posture, or even to walk about, with some assistance, without any further improvement. Occasionally the paralysis passes off almost entirely in a few days; but the progress of improvement is usually very slow and gradual, and rarely goes on at once equally throughout the whole of the paralysed part. * Morgagni, Epist. xi. art. xiv. 34 PARAPLEGIA. 2.—Paraplegia. The palsy, in this form of the disease, is confined to the lower half of the body—that is to the pelvis and the inferior extremities. When the immediate cause of abolished nervous function is seated in the upper parts of the spine, the paralysis will affect the superior parts of the body; but the term paraplegia is generally restricted to palsy of the inferior extremities, and parts about the pelvis. Paraplegia generally comes on gradually, and when it arises from an affection of the brain, is often preceded and accompanied in its course by pain in the head, giddiness, drowsiness, dimness of sight, and impaired memory. Sometimes a feeling of heaviness and numb- ness is felt in the upper extremities, as a precursory symptom of this form of palsy. At first the patient usually experiences a slight stiffness and awkwardness in the motions of the lower extremities, which gradually increase until the patient finds himself unable to maintain the due balance of the body without the aid of a cane. As the disease advances, " the stream of urine becomes more and more feeble, and at length dribbles off involuntarily." The bowels are generally constipated; but when the sphincter muscles of the anus become paralysed, the feces are evacuated without the consent of the will. I have met with an instance of paraplegia, in which retention of the urine took place, requiring the use of the catheter five or six days before any paralytic affection was experienced in the lower ex- tremities. Sometimes the palsy is complete, the patient being unable to maintain even a sitting posture; in other cases the power of mo- tion is not wholly destroyed so that with a little assistance, the patient may support himself in a sitting position. (Baillie.*) When paraplegia depends on disease or lesion of the spinal marrow, it usually approaches very gradually, unless it occurs as the immediate consequence of some mechanical injury of the spine. The patient at first feels a languor and weakness in the knees; after some time a difficulty in directing the feet occurs, and the legs in walking are involuntarily thrown across each other, causing frequent tripping or stumbling. By degrees the insensibility and loss of muscular power in the legs and thighs become more and more conspicuous, until, at length a total paralysis of these parts occurs. The loss of vitality is sometimes so great, that gangrene and sloughing of the legs ensue from the mere pressure of the parts against the bed. About six years ago, I met with a case of paraplegia in an adult, which, from the attending symptoms of cerebral disturbance, depended, 1 pre- sume, on some affection of the brain. In the course of about ten days after the accession of the paralysis, the heel first, and then * Observations upon Paraplegia in Adults. By Matthew Baillie, M. D., in the sixth volume of the Medical Transactions of the London College of Physi- cians. PARALYSIS PARTIALIS. 35 rapidly all the soft parts of the right leg, from the ankle to near the knee, became gangrenous, and sloughed off to the bones. Paraplegia from cerebral affection most commonly occurs after the forty-fifth year of age, and according to the observations of some more frequently in males than in females. That variety of paraple- gia which depends on disease or injury of the spine, is most common in childhood, and seldom comes on spontaneously after the age of puberty. Contrary to cerebral paraplegia, it occurs more frequently in females than in males.* 3.—Paralysis Partialis. Every sensitive and motive part of the animal system may lose either its power of feeling, or of motion, or of both. In some in- stances the palsy is confined to a particular organ, but when the muscles are the seat of the affection, it generally embraces either all the flexors or extensors, or both, of a part or the whole of a limb. Some, cases of partial paralysis are attended with loss only of sen- sorial power. Of this kind are the paralytic affections of the olfac- tory nerves; of the retina; of the gustatory nerves; of the auditory nerves; and of the nerves of general feeling or touch. In other cases the palsy is confined to a deprivation of the power of motion, with or without the loss of sensibility, in a particular part. In some instances a single muscle alone is paralysed. Abercrombie mentions a case of this kind, which continued for a long time without either extending to other muscles or becoming better. Paralysis of the muscles of one side of the face is by no means uncommon, and in some cases the under lip only becomes thus affected. The eyelids also sometimes become palsied; and a loss of the power of voluntary motion in the muscles of the hands, feet, fingers, wrists, legs, and thighs, is of frequent occurrence. The bowels, the oesophagus, the pharynx, the bladder, the different sphincters,and the erector muscles of the penis, are occasionally affected with palsy; and it is not im- probable that some of the secretory organs—particularly the kidneys and liver may sometimes be thus affected. Of the Causes of Paralysis.—The predisposing and exciting causes of those forms of palsy which arise from an affection of the common nervous centre, so far as they can be ascertained, do not differ from those which have already been mentioned under the head of apoplexy. In relation to the immediate cause of palsy, it would seem that so far as it is dependent on the state of the brain, it may be the consequence of a great variety of morbid conditions of this organ. It has been generally supposed that pressure on the brain is the * Dr. C. Meigs has reported an interesting instance of paralysis of the in- ferior extremitiss, occasioned by the sudden repulsion of crustea lactea by some drying ointment. (North Amer. Med. and Surg. Jour, vol, x. p. 376.) 36 PARALYSIS PARTIALIS. chief immediate cause of hemiplegia. That sanguineous or serous effusions, and other causes producing pressure on the brain, often give rise to paralysis, appears to be well established. " When the causes which produce cerebral pressure act generally and power- fully," says Dr. Cook, they seem to produce apoplexy, and to give occasion to palsy when they act partially or with less .violence; so that by an increase of power of the cause, palsy may terminate in apoplexy; and by a diminution of it, apoplexy may terminate in palsy." Hemiplegia is, indeed, a very frequent consequence of apo- plexy; and, on the contrary, paralysis very often terminates at last in an apoplectic attack. It is, nevertheless, equally well ascertained, that both general and partial palsy may arise from cerebral affections wholly unconnected with any circumstances that might be supposed capable of exerting any pressure on the encephalon. Reasoning, indeed upon the general nature of palsy, we would be led it priori, to suppose that every thing which is capable of greatly disordering the source of nervous power, might give rise to this affection. Dr. Powel, in an interesting paper on the subject of paralysis from sud- den exposure to cold, has adduced some cases which would seem to show that both general and local palsy sometimes depend on a mor- bid condition of the nerves alone, independent of any affection of the encephalic mass. So far, however, as post mortem examinations can throw any light upon the nature of the proximate cause of gene- ral paralysis, we have direct evidence that almost every variety of cerebral lesion and disorder may produce hemiplegia and other forms of palsy. We not only find this affection connected with sanguine- ous extravasation into the brain, but also sometimes with serous effusion; or with traces of recent inflammation and vascular turges- cence; with encysted suppuration; with induration of some portions of the cerebral mass; with softening of the brain, or with destruction and entire loss of a portion of it; and with other morbid conditions of this organ. (Abercrombie.) Willis states, that in cases of pro- tracted palsy, he found the corpora striata in a diseased condition; and Peyrous, in one instance, found a firm tubercle, about the size of a bean, in the middle of the corpus striatum. (Cook.) But the most frequent morbid appearance, discovered on dissection, is organic lesion or injury of the cerebral substance, particularly about the corpora striata, thalami nervorum opticorum, and in the medulla oblongata or its immediate vicinity. M. Serres mentions a case of apoplexy attended with palsy, in which every part of the brain was perfectly sound, except the tubar annulare, which was completely destroyed by a central cavity containing a clot of blood. Although some of these phenomena usually present themselves on the dissec- tion of paralytic subjects, yet each of these morbid conditions of the brain not unfrequently exists without any, or with but very slight manifestations of palsy. There exists also much diversity in the extent and particular form of the paralytic affections connected with apparently similar morbid states within the brain. In one patient PARALYSIS PARTIALIS. 37 a particular lesion or diseased condition of the brain will be attended with almost universal palsy; in another a similar state of cerebral affection, with regard to its location and general character, will be accompanied with hemiplegia; in a third patient, perhaps with para- plegia; and in a fourth one, with partial paralysis. It would appear, also, that in hemiplegia the immediate cause of the paralysis may be in the spine. Dr. Prichard has published some observations which render this opinion at least highly probable.* Notwithstanding, therefore, the light which dissection has thrown on the etiology of palsy, we are yet far from possessing any very satisfactory or pre- cise information on this interesting subject. The general fact, that pressure or organic lesion of the brain is often attended with para- lysis, and apparently its direct cause, is indeed sufficiently established; but the various and opposite results or phenomena just mentioned, assure us that our knowledge upon this subject, as in truth upon most other points of pathology, is but general and vague. What has been hitherto said relates chiefly to hemiplegia. It would appear that paraplegia also is frequently dependent on cere- bral disease. Paraplegia in adults, says Dr. Baillie, is by most pa- thologists considered as the result of some disease, "either in the bones or ligaments of the spine,, or in the cavity of the spine, most commonly at the loins, independently of any disease of the brain."t He denies the correctness of this opinion, and expresses his convic- tion, that like hemiplegia, this form of palsy "depends most com- monly in adults, in a great measure, upon disease affecting the brain itself." The same sentiments appear to be entertained by Mr. Earle, Mr. Halford, and Mr. Copeland;J and several recent French writers have expressed similar views. Dr. Baillie and Dr. Abercrombie relate cases of paraplegia, in which, on dissection, the cause of the disease was discovered in the brain. In a strongly marked case, the arachnoid was much thickened and opaque; the substance of the brain was considerably softer than natural, attended with vascular congestion of the pia mater, a large quantity of serum in the lateral ventricles, as well as in the theca vertebralis, and between the mem- branes of the brain. Dr. Baillie thinks that the serum which is sometimes found in the theca vertebralis in this affection, descends into it from the brain. We cannot doubt that paraplegia may some- times be entirely dependent on cerebral disease; yet observation renders it equally certain that disorder, lesion, or pressure upon the spinal cord, is even in adults very frequently the immediate cause of the paraplegiac affection; and in children this is unquestionably by far the most common source of the disease. In relation to the disease in adults, a great number of well authenticated dissections might be adduced, presenting unequivocal evidence of its spinal * Med. depository, No. 1. New Series. X Loc. cit. p. 17. X Med. Chir. Rev. December, 1820, p. 392. Vol. II.—4 33 PARALYSIS PARTIALIS. origin; and facts illustrative of this point, in reference to the disease in children, must be familiar to every one. It has already been ob- served, that paralysis depending on disease of the brain, occurs almost universally on the side opposite to that in which the cerebral affection exists. Some exceptions indeed to this fact have been noticed by pathologists, but these are extremely rare. Mr. Bayle has collected, from different authorities, eight cases in which palsy took place on the same side of the cerebral affection.* When para- plegia depends on disease seated within the head, the primary affec- tion extends probably to both sides of the brain. This opinion is at least strongly countenanced by the phenomena developed on post mortem examination. (Baillie.) Partial paralysis depends on a great variety of causes, both of a general and local character. It may depend on disease within the head, on spinal affections, and disease or local injury of a particular nerve. The latter source of this form of palsy is propably the most common. Local paralysis is sometimes excited apparently by intes- tinal irritation in children. In cases of this kind, the palsy is usually confined to one of the arms.t I have seen cases of palsy of the arm in young children, which appeared to have been occasioned by the irritation of worms in the bowels. Much attention has, within a few years past, been bestowed on local paralysis of the muscles of one side of the face. It appears from the researches of Shaw and Bell, that this variety of palsy depends most commonly on some injury of the portio dura of the seventh pair; and in some instances, also on a diseased condition of that part of the brain which gives origin to this nerve. J The occasional causes of this variety of palsy are, inflammation of the ear spreading to the portio dura; surgical operations about the ear and consequent injury of this nerve; disease of the temporal bone; tumors pressing on this nerve; sudden exposure to cold;§ injuries inflicted on the head; and disorganisation and other morbid conditions within the brain, implicating the portio dura. The paralysis in cases of this kind is not complete—the muscles of the face being deprived only of "the power of those actions which are to a certain degree involuntary, and to perform which it is necessary there should be a combination with the organs of respiration;" sensibility, and those actions which are derived from the trigeminus, namely, the action of the orbicularis oris, of the eyelids, of the buccinators, and of the muscles subservient to mastication remaining undiminished. Mr. Shaw remarks, that in the paralysis of the face after an attack of apoplexy, just the re- verse condition in this respect obtains—the actions just enumerated * Revue Medicale, Janvier, 1824. f C. Bell. See Cook's Treatise on Nervous Diseases, p. 268. X On Partial Paralysis. By John Shaw. Med. Chirurg. Transact, vol. xii. p. 1. § Dr. Powell. Transactions of the College of Physicians, vol. v. PARALYSIS PARTIALIS. 39 as depending on the fifth pair of nerves being abolished; whilst those which are influenced by the portio dura remain unimpaired. Among the exciting causes of partial paralysis, the poisonous in- fluence of lead is the most remarkable. The tendency of this article, in whatever way it may be brought to act on the system, to produce paralysis of the muscles of the fore-arm and wrists, is peculiarly strong, as is evident from the frequency of this affection in persons who work in lead mines, in plumbers, manufacturers of white lead, painters and glaziers. There exists, however, much diversity, with regard to the constitutional predisposition of different individuals, to become thus affected by this article. Some persons appear to enjoy almost an entire immunity from its poisonous influence, although much exposed to its operation; whilst others are peculiarly liable to its effects. Paralysis of the extensor muscles of the hands and wrists some- times occurs, apparently from pressure of the nerves which go to these muscles. Cases of this kind generally come on during sleep, and seem to be occasioned by a particular position of the arm, while the head is resting upon it, and compressing perhaps its principal ar- teries and nerves. I met with a case lately in a young gentleman who fell asleep while sitting at his desk. On awaking, he found that he could not extend the hand nor use the fingers; the palsy continued for four weeks before it yielded. Dr. Healy has published an interesting paper on this variety of palsy, in the third volume of the Dublin Hospital Reports. The question why the power of motion is often entirely destroyed whilst that of sensation remains undiminished, has at all times greatly perplexed physiologists. Galen supposed that, two sets of nerves were distributed to every part of the body—one to endow them with sensibility, and the other to give to the muscles the power of voluntary motion. What was thus alleged from mere theoretical vie ws by this very sagacious physician, has been recently demonstrated by M. Magendie and Mr. C. Bell. The nerves which originate from the spinal prolongation of the brain, and which supply the power of voluntary motion and sensibility, are composed of two packets of fibres, proceeding from distinct parts of the spinal marrow. It has been ascertained that, by dividing or compressing the posterior of the two fasciculi by which the spinal nerves originate, the sensibility of the part to which the nerves go is greatly diminished, whilst the power of motion remains unimpaired; and, on the contrary, if the anterior of these heads of the nerve be divided or materially injured, the power of voluntary motion is destroyed in the parts to which it is distributed, but the sensibility remains unaffected. This physio- logical fact throws much light on the curious phenomenon in ques- tion, and may be regarded as full an explanation of it as anatomical investigations are capable of furnishing on any subject. Treatment.—The prophylactic treatment of approaching hemi- plegia does not differ from that which is proper for warding off an 40 PARALYSIS PARTIALIS. attack of apoplexy. In the apprehension of a stroke of palsy, a lo diet, gentle exercise in the open air, and the avoidance ot all Kino of stimulating liquors, as well as of full and heavy meals, snouia De enjoined; and the bowels kept in regular motion by gentle laxative medicines. . , Where predisposition to apoplexy exists, and particularly wnen the ordinarypremonitorysymptomsof this affection occur frequently> a drain, by means of setons or issues established in the neighborhood of the head, will contribute materially in obviating the paralytic seizure. Much discrepancy of opinion has been expressed with regard to the value of blood-letting in hemiplegia. Some speak strongly in praise of its powers; while others condemn its use as often decidedly injurious. An attention to the various pathological conditions of the brain in cases of this disease, must at once show the folly of sweep- ing declarations either in favor or against this measure. We meet with cases, for instance, in which there are unequivocal manifesta- tions of sanguineous engorgement in the vessels of the head; and with others, in which the face is pale and shrunken, and the pulse small, weak, and irregular. The immediate cause may consist in vascular turgescence with sanguineous extravasation into the brain; or in a slow disorganisation of a portion of this organ, with little or no engorgement or inordinate action of the cerebral vessels. The pulse must be our guide in the employment of this evacuation. If the artery beats strongly and is full and hard under the finger, blood should be drawn freely and promptly as in apoplexy, until the momentum of the circulation is adequately moderated. When, on the other hand, the pulse is weak, the extremities cold, and the face pale and contracted, as it sometimes is in old, weak, and nervous individuals, blood-letting to any considerable extent is just as ob- viously contra-indicated. In a few cases, I have abtracted from forty to fifty ounces of blood in the course of twelve hours after the hemi- plegiac attack with decided benefit; but I have met with cases also, in which even a moderate bleeding brought on faintness and alarm- ing weakness, without any favorable impression on the paralytic affection. Of course, even where the state of the circulation indi- cates the propriety of this evacuation, regard must be had to the age of the patient, his constitutional habit, and the nature of the exciting cause. Purgatives are as useful here as in apoplexy. In no instance, whether the action of the pulse be strong or weak, can evacuants of this kind be properly omitted. "All writers," says Dr. Cook, " agree as to the propriety of keeping the body open in hemiplegia. The neutral salts and other purgatives of the refrigerant kind, may be given where there is much determination of blood to the head and in full habits; but in debilitated, leucophlegmatic, and dropsical cases the more stimulating purgatives, such as aloes, calomel, scammony, colocynth, jalap, &c, may with more propriety be administered." PARALYSIS PARTIALIS. 41 An excellent mode of giving purgatives in habits of this latter kind, is to administer them in combination with powdered mustard. From ten to twelve grains of calomel, mixed with about twenty grains of mustard, and succeeded in about three hours by a dose of infusion of senna, will rarely fail in such cases to procure free and copious evacuations. In relaxed and sluggish habits, cathartics will almost always operate with more certainty and force when given with a stimulant of this kind. I have frequently, under such circumstances, administered a small portion of Cayenne pepper with purgatives, with excellent effect. Emetics also are much recommended by some writers in the treat- ment of hemiplegia. In recent instances, ushered in by apoplectic symptoms, and particularly in robust and plethoric subjects, they are of doubtful propriety. When hemiplegia comes on during a dys- peptic condition of the stomach, or soon after taking food of difficult digestion, an emetic may, no doubt, prove very serviceable. At a more advanced period of the disease, when the momentum of the circulation is moderate, and no symptoms of cerebral congestion exist, emetics will occasionally do much good, and may be freely employed without risk of doing mischief. In addition to the general remedies already mentioned, revulsive applications constitute important auxiliaries in the treatment of this affection. In recent cases, blistering or cupping the nape of the neck and sinapisms to the ankles, will sometimes contribute considerably to the removal of the disease. Stimulating enemata also are highly recommended in this variety of palsy; and I have myself witnessed several instances of their good effects. In paraplegia, attended with symptoms of cephalic disorder, be- sides the local applications just mentioned, Dr. Baillie recommends the use of calomel, or the blue pill in union with squills, together with purgatives. He directs a grain of calomel, or five grains of the blue mercurial mass with one grain of dried squills, every night for several weeks, with an occasional dose of one of the neutral purga- tive salts. When all the symptoms of undue determination to the head have disappeared, or the disease has assumed a strictly chronic character, antiphlogistic and depletory remedies are no longer appropriate means. Exciting remedies must now be resorted to. Frictions, stimulating liniments, sinapisms, blisters, stimulating baths, cold affu- sions, electricity and galvanism, are the principal external exciting applications; and, under proper management, they often prove de- cidedly beneficial. Frictions with the flesh-brush or a piece of dry flannel, will sometimes answer better than the more irritating or ru- befacient applications. The frictions should be made twice or thrice daily, and continued each time at least half an hour. Along with dry frictions, the occasional application of blisters to the leg and wrist of the affected side may prove beneficial. Where the palsy is 4* 42 PARALYSIS PARTIALIS. complete, however, the sinapisms or blisters should not be left on too long, lest gangrene and sloughing be produced. A moderate rubefacient effect is all that it will, in general, be prudent to excite in cases of this kind. Cullen indeed observes, that when external stimulants produce violent inflammation, they are apt to do less good than when they act merely as rubefacients, or at most, create but a moderate degree of superficial inflammation. Anciently, the appli- cation of nettles was much recommended; and from the very pungent irritation they produce in the skin, they may, no doubt, be serviceable. I have known the application of dolichos pruriens lo a paralytic limb to be of manifest advantage. Electricity, being peculiarly adapted to excite the nervous system, has been much employed in the treatment of paralytic affections; and, under judicious management, it will sometimes do much good. I have known several cases of local palsy completely cured by this agent; and the records of medicine furnish us with no small number of instances in which it was successfully employed. It would appear, however, that it has sometimes proved injurious. Mr. Cavallo ob- serves, that electricity has often proved wholly inefficacious in para- lysis, and in some instances, pernicious and even fatal. It seems probable, however, that where it has been followed by unfavorable or fatal consequences, it was applied in too powerful a manner; for it is admitted, on all hands, that it proves most beneficial when it is moderately and repeatedly applied. Shocks should never be given. The electric fluid must be passed through the affected part, without * sparks, by means of wooden points; or, at most, by discharging very weak sparks into it from the prime conductor. Dr. Cook re- marks, that this agent " is only to be considered safe when its opera- tion is confined to parts somewhat remote from the head;" and that it is most apt to prove injurious when the disease depends upon disease or compression of the brain. Galvanism, also, has been recommended for the cure of this af- fection; and it is said to be safer, and in general, more effectual than electricity. Dr. Bardsly, from considerable experience with t^e use of galvanism in paralysis, concludes, that if no sensible benefit arise from a steady and well-regulated application of this influence, after a trial of a week or ten days, its use ought to be discontinued; that when the brain forms a part of the galvanic circle, it is to be very cautiously employed; and that when the activity and firmness of the pulse, as well as the temperature of the affected part are increased— the corporeal and mental feelings somewhat enlivened, and the se- cretions improved, we may persist in the application of this a"-ent, with the prospect of ultimate and permanent advantage. When the affected parts are so torpid as to render them insusceptible of the galvanic stimulus, the cuticle ought to be removed by a small blister and the metallic points applied to the raw skin. (Bardsly.*) * Medical Reports, p. 183. Cook, 1. c. p. 296. PARALYSIS PARTIALIS. 43 M. Rouxhas practised electro-puncturation with entire success in a case of paralysis of the inferior extremities. He introduced a very long needle (as in acupuncturation) into the spinal marrow, across the bodies of the vertebras, and then connected the needle with a Voltaic pile. This operation has, of late, been frequently performed for paralysis, chronic rheumatism, &c. Two needles may be intro- duced so as to bring the principal nerves, distributed to the affected part, within the galvanic circle, and bringing the needles in contact with the opposite poles of a weak galvanic apparatus. Moxa has been used with success in paralysis. Dupuytren has reported a case of general paralysis, in which moxa applied on each side of the spine, near the first and second dorsal vertebra, procured immediate benefit. Larrey mentions a case of palsy from disease of the spine, which was cured by thirty-two applications of moxa; and two other cases of paralysis of the fore-arm from gun-shot wounds yielded completely to this remedy. He also states, that he cured several cases of paralysis of the muscles of one side of the face from cold, by the application of moxa; but he observes that the application of moxa to this part is dangerous, unless the cones of cotton are small, and suppuration be prevented by the application of ammonia.* The instances on record of the successful application of moxa in paralysis are, indeed, sufficiently numerous to entitle this remedy to particular attention in the treatment of this affection. Internally a variety of remedies have been recommended for the cure of this disease. Among these the nux vomica, or its preparation strichnine, has of late years been a good deal used in palsy, and oc- casionally with decided benefit.t Mr. Purcell has recently reported a case of paraplegia, in which this article, in conjunction with the application of moxa, was successfully used. J Professor Giddings, of the university of Maryland, has also reported several highly in- teresting cases, which yielded to the influence of the strichnine. One of these cases was manifestly the result of sanguineous extrava- sation into the brain, as its acception was attended with decided apo- plectic phenomena. The second was a case of general paralysis, and the consequence, as was believed, of the injurious influence of lead. This article may be given in doses of from one-sixteenth to one- sixth of a grain, three times daily. The dose should, at first, be small, and gradually increased to as much as the system will bear. * Recueil de Memoires de Chirurgie, par le Baron D. L. Larrey, p. 94. f Decandolle, Husson, Dumeril, Lescure, Asselin, Magendie, Bricheteau, and Fouquier, have reported cases of palsy in which the happiest effects were produced by the use of this remedy. M. Fouquier gave the nux vomica to the extent of from four to twenty-four grains of the powder daily to an habitual drunkard affected with hemiplegia from apoplexy; and in the course of one month he was entirely cured. X Medico-Chirurg. Rev. November, 1829, p. 203.—Prov. Med. Gazette, No. XI, July, 1829. 44 PARALYSIS PARTIALIS. Since the last edition of this work was published, I have employed this powerful narcotic with complete success, in an obstinate and long standing case of hemiplegia. It is undoubtedly a remedy of excellent powers in paralytic affections. When the peculiar con- vulsive motions which result from the operation of this narcotic, ap- pear early in the palsied limb, in connection with transient tremors, formication, and free perspiration in this part, and particularly if these affections do not directly pass to the sound parts, the prospect of benefit from this remedy is said to be considerable. In paralytic affections connected with an inflammatory or congested condition of the brain or spinal marrow—and in hemiplegia from sanguineous extravasation into the cerebrum, this remedy cannot be employed without considerable risk of injurious consequences. From two to four grains of the nut may be administered three or four times daily, until spasmodic motions of the extremities ensue, or gastric distress is experienced. The extract is given in doses of from two to three grains; and of the strichnine, which has latterly been used, one- sixth of a grain may be exhibited thrice daily. Somewhat analogous to the nux vomica is the rhus toxicodendron in its occasional effects in paralytic disorders. This article was for- merly highly extolled for its remediate powers in affections of this kind, and in Germany it has lately again attracted considerable at- tention in this respect.* In two instances of hemiplegia, I prescribed the saturated tincture of the leaves of the rhus with unequivocal benefit. In a letter to me from professor Osann of Berlin, 1 am in- formed that the following mixture has been used with decided benefit at the Polyclinic Institute, in paralysis of the lower extremities: R.—Tinct. rhois. toxicodend. §ss. ----aconiti ■ ----guaiaci volat. aa gii—M. S. Take forty drops every three hours. The effects of this article are often very similar to those which * M. Dufresnoy, Professor of Botany at Valencia, was, I believe, the first who used the rhus toxicodendron in palsy. Mr. Alderson, an English physician, next published a small work on the medical effects of this article, in which he relates seventeen cases which were more or less benefitted by its use. Dr. Horsefield, in his inaugural dissertation on different species of rhus, published in this city in 1798, testifies to its usefulness in paralytic affections. Mangrat, (Journ. de Phys. Chim. d'Histoir. Nat. vol. Ii. p. 370.) Elz. (Dissert, de Toxicodend., 1800.) Hunold, (Piepenbrings' Archiv. f. Pharmacie. Bd. i. st. iii. p. 276.) Kok. Van Mons. Augustin, (Asklepeion, 1811, No. IV. s. 57.) Sybel, (Asklepeion, 1811, No. XXXII. p. 497.) Gisovious, (Rust's Magazine, Bd. xiv. s. 386.) D'Alquen, (Harles Rhein-Westphal. Jahrb. ect. Bd. x. st. i! s. 135.) Osann, (Hufeland's Biblioth. d. Heilkund, 1823, Mai, s. 324.) Buch- heim, (Allgem. Med. Annal. 1825.) Hennin, (Archiv. fur Med. Erfahr. V. Horn., ect. 1823. Nov. and Dec. s. 392,) have all published cases illustrative of the remediate powers of this article in different forms of palsy. PARALYSIS PARTIALIS. 45 result from the full operation of the nux vomica. In one of the cases in which I used it, the patient experienced occasional convul- sive actions in the muscles of" the palsied limb, with a sensation of tingling or prickling in the affected part. The powdered leaves may be used, commencing with half a grain, and gradually increasing it to four grains, three times daily. The effects of this article when given in large doses, are headach, vertigo, nausea, and sometimes profuse diarrhoea, and when these manifestations of its operation ensue, its use must be discontinued. The oil of turpentine is strongly recommended by Dr. Prichard, (Med. Repos. No. 1, new series,) in paralytic affections, after deple- tory measures have been adequately pursued. He gives it in doses of from one to two drachms, three times daily. Mr. Manson has related several striking instances of the successful use of iodine in paralytic affections.* The flores arnicse appear to have been frequently used with entire success in cases of this kind. They are said to be particu- larly useful in paralysis of the bladder,! and in local palsies of the organs of sense. Richter indeed says that they may be used with occasional success in almost every variety of palsy. Hufeland states that he cured a case of scrofulous deafness with this article, in con- junction with antimonials.f Within the present year I prescribed this remedy in an instance of hemiplegia, which came on very gradually in an elderly female, and its effects were very manifestly beneficial.§ The internal use of mustard seed, and of horse-radish, have also been recommended in paralysis; and I have known the former of these articles prescribed by the late Dr. Barton in the Pennsylvania Hospital with much advantage. A number of other remedies are said to have been employed with success in various forms of palsy. Cantharides in substance, "in the dose of one grain to a scruple of volatile salt, and gradually increased to two grains of the former and forty of the latter, every three hours," have been employed with great benefit. (Cook, Med. Comment, vol. xiii. p. 96.) Dahlberg and Kblpin speak highly of the effects of the tincture of colocynth,\\ in doses of ten drops every two hours, and gradually increased to sixty or seventy drops. This tincture is said to be particularly use- ful in paralysis of the inferior extremities, and of the bladder. Kiilpin declares that he has used this remedy with extraordinary success; and many other authorities of respectability might be cited, in favor of its occasional efficacy in this affection. (Horn's Archiv. * Medical Researches on the Effects of Iodine, &c.—Lond. 1825, pp. 87—90. X Hufeland's Journal, Bd. ix. st. iii. p. 95. X Ibid. Bd. xxxiv. st. v. s. 33. § The arnica is highly extolled for its virtues in paralytic affections by Junker, Colin, Plenk, and others. (Cook.) || Hufeland's Journal, Bd. ii. st. iv. p. 570. 46 PARALYSIS PARTIALIS. 1S04.) The chenopodium ambrosiodes is said to have produced excellent effects in aphonia from paralysis of the muscles of the larynx.* It is given in substance, in doses of from a scruple to half a drachm, twice or thrice daily. Jahn (Klinik. der Chron. Krank. B. i. p. 365,) says the belladonna is one of the most efficacious re- medies in paralysis. Besides the foregoing remedies, almost every active tonic and stimulant has been recommended in such affections— phosphorus, camphor, volatile salts, valerian, bitters, chalybeates, the essential oils, savin, &c. have all found advocates as remedies in paralytic affections, but they deserve little or no attention in this respect. In that variety of local palsy which arises from the poisonous influence of lead; the use of mercury, so as to produce moderate ptyalism; in conjunction with the repeated application of blisters, or other active, irritating substances to the wrist; and the use of the splint or battledore, recommended by Dr. Pemberton,t with mild aperients, and occasional warm bathing, constitute our most useful remediate means. Dr. Gregory is not willing to attribute any powers to mercury against this affection, notwithstanding the authority of Dr. Clutterbuck in its favor. I have met with one case in which gentle salivation, with local stimulants to the palsied parts, succeeded in removing the disease. It is not improbable, however, that the chief advantage in this instance was derived from the local irritating applications.^ In paralysis of the tongue, we may direct the patient to chew the root pyrethrum, or other irritating and purgent substances; such as cloves, senega, squills, pepper, calamus, aromaticus, &c. The oil of cajeput has also been recommended in this variety of local palsy. A few drops of it are to be put on the tongue three or four times daily. Blisters, or frictions with tartar emetic ointment under the chin and ears, may also be used; and a very moderate excitation of the tongue by the galvanic influence; which may be done by two flat pieces of silver and copper, the one applied to the upper, and the other to the under surface—the parts projecting from the mouth be- ing brought in frequent contact. In partial paralysis of the face, cupping, leeching, and blistering over the origin of the portio dura, mercurial purgatives, and a seton in the neck, may be accounted the most efficient remediate measures. Dr. Delafield, of New York has related several instances of this affection, which yielded under the employment of these remedies.§ I have known a case of this kind, * Borries—Ibid. Bd. xiv. st. ii. p. 201. X This consists simply in applying a carved splint to the inner side of the arm, so that the broad surface supports the hand. X A gentle mercurial action is recommended for the cure of this variety of palsy by Hunter and Dr. Clarke. Dr. Clutterbuck regards it as the most effec- tual means we possess in this affection. § New York Med. and Phys. Jour. Dec. 1824. EPILEPSY. 47 produced, or at least accompanied, with indurated swelling of the parotid gland, cured by the use of iodine. Sect III.—Epilepsy. Epilepsy, whether considered in its immediate phenomena or in its remote consequences, is unquestionably one of the most distress- ing and deplorable of human maladies. Its tendency to impair the understanding, to produce hebetude, and even total abolition of the rational powers, leads often to a condition infinitely more lamentable than death itself. So frightful and distressing a disease could not fail to attract the particular attention of the physicians of every age; and we accordingly find it minutely described, and its nature and treatment extensively discussed, in the works of the Greek and Ro- man physicians.* The soporose and convulsive affections are so closely allied to each other, both in relation to their general phenomena and their patho- logical character, that it is extremely difficult to give an unexcep- tionable definition of any one of them. Epilepsy may, perhaps, be defined a disease primarily seated in the nervous system, manifested by convulsions recurring at uncertain periods in paroxysm, accom- panied by a temporary loss of consciousness, sense, and voluntary motion, and terminating in somnolency. The epileptic attack sometimes comes on suddenly without any manifestations of its approach. More frequently, however, certain symptoms precede the occurrence of the paroxysm, and of these the following are the most common:—A peculiar confusion and distress- ing feeling in the head; an absent, wandering, and confused state of the mind; giddiness; dimness of sight; ringing and loud sounds in the ears; sparks and flashes of light before the eyes; distension of the veins of the head and neck; a trembling and feeling of restless- ness in the extremities; an anxious feeling in the precordial region; restlessness and starting during sleep; loss of the power of distinct articulation; complete temporary deafness; and drowsiness. In some instances, there is a manifest change in the moral disposition a short time before the accession of the attack. Sullen gloominess with an irritable temper is manifested by some patients. In some cases, the * Hippocrates describes epilepsy under the name of morbus sacer—a name which was g^ven to it from its supposed origin; it being generally regarded at his day, as ah infliction of the gods or of demoniac influence. Aristotle treats of it under the name of morbus herculius, because Hercules is said to have been afflicted with this disease. The most common appellation of this affection among the Roman physicians, however, was morbus conMialis. We neverthe- less find it mentioned also under various other names in their writings—such as morbus soniicus, morbus caducus, morbus puerilis, morbus insputatus, seleniacus, major, magnus, vitriolatus, mensalis, &c. In the sacred writings, epileptic per- sons are called lunaticos. 48 EPILEPSY. mind falls into a kind of revery from which it cannot be drawn, which terminates often speedily in total insensibility. Some epilep- tics evince an unusually timid disposition; others are spiteful, resent- ful, and mischievous, shortly before the accession of the paroxysm. Occasionally, spasmodic twitches of particular muscles, especially in those of the face, precede the attack. Richter states, that painful sensations in certain parts of the body, particularly spasmodic pains in the stomach, with a rumbling noise in the bowels, occur as the precursors of the epileptic paroxysm. The most remarkable of the premonitory symptoms of epilepsy, however, is that which is technically called aura. The sensation to which this term is applied, and which, I believe, occurs in no other disease, is compared by patients to the feeling which is communi- cated by a gentle stream of cool air directed on the part. This sen- sation generally commences in the feet or legs, and gradually ascends until it reaches the head, when the patient instantly becomes insensi- ble and epileptic. Some patients are enabled by this symptom to tell with accuracy the nearness of the attack, and to avail themselves of this intimation to place themselves in a situation in which they will be less liable to sustain injury during the attack. Spiculae of bones, tumors, and foreign bodies pressing upon and irritating some nerve, have been found to exist at the starting point of this singular sensa- tion.* The primary irritation is, however, almost invariably seated elsewhere, and transferred sympathetically to the part in which the aura commences. In many instances, the attack always occurs at night while the patient is sleeping. In this respect epilepsy differs conspicuously from chorea, the convulsive motions of which, however violent du- ring the day, are almost always wholly suspended during sound sleep. When the epileptic seizure occurs while the patient is sitting or standing, he suddenly falls down in a state of insensibility, and imme- diately becomes more or less violently convulsed. In some cases, the convulsive actions of-the muscles, particularly those of the face, are frightfully violent; the whole frame is violently agitated; the eyes roll about; the lips and eyelids are convulsed; the tongue often spasmodi- cally thrust from the mouth, which, with " the gnashing of the teeth, and foaming at the mouth, give the countenance a horridly wild ex- pression." Sometimes the teeth are firmly pressed together; at others, the jaws are widely and fixedly distended; the thumbs are almost invariably firmly pressed in upon the palms of the hands. The spasms are generally of the clonic kind; but in some instances, the muscles remain for a time rigidly contracted, the body being bent either backwards, forwards, or to one side, as in tetanus. Occasion- ally, the abdominal muscles are violently drawn in towards the spine. In many instances, there are strong erections of the penis, with spas- * Van Swieten's Commentaries, vol. iii. p. 419.—See also Medical Experi- ments and Observations by a Society, &c. at Edinburgh, vol. iv. p. 334. EPILEPSY. 49 modic retraction of the testicles, and occasional seminal discharge. (Richter.) The face is occasionally pale, but more commonly livid, with a turgid state of the veins of the head and neck. The heart palpitates rapidly; the pulse is usually contracted, irregular, and fre- quent;* and respiration oppressed, laborious, and, in violent cases, sonorous. About the termination of the paroxysm, a considerable quantity of frothy saliva usually flows from the mouth; and in some cases, the feces and urine pass off involuntarily. Sooner or later these spasmodic symptoms abate—generally gradually, but sometimes abruptly. The respiration becomes freer; the pulse fuller and more regular; the countenance more composed; and the patient finally falls into a state of stupor or deep sleep, out of which he awakens with a feeling of languor, and confusion and torpor of mind, which generally continues for ten or twelve hours. The countenance exhibits a va- cant and stupid expression, and the eyes are dull, staring, and wan- dering. In violent attacks the mind remains obtuse and fatuous, and the temper irritable and morose, for several days after the paroxysm. During this somnolent state, the patient usually perspires freely, particularly about the head, neck, and breast; and the perspiration has frequently a very peculiarly offensive smell.t The sweating has been known to be distinctly confined to one side of the body only.J Epilepsy does not, however, always assume the violent grade just described. Sometimes the attack supervenes suddenly, and after a few moments of partial convulsions of the muscles of the face and neck, quickly subsides, and restores the patient to consciousness. I once attended a girl affected with this disease, in so slight a manner, that the convulsions seldom lasted longer than a few minutes. In relation to the duration of the epileptic paroxysm, there exists great diversity. The convulsive stage generally continues from ten to fifteen minutes, sometimes for half an hour, and occasionally for several hours. The paroxysm is most apt to become protracted in children. In most instances one paroxysm only occurs at a time. Sometimes, however, they recur several times—the patient passing from one into another, with but a very short interval between them. In general, the first attacks are shorter than those which occur after the disease has continued for some time. The contrary, however, generally takes place when the first attack is caused by some sud- den and violent mental impression, as terror. With regard to the interval between the epileptic seizures, also, there exists the greatest diversity. In some cases the paroxysm re- turns almost daily; in others at various intervals, from a few days * Dr. Burnett relates a singular case of epilepsy, in which the pulse became so slow at times, as to beat only fourteen strokes in a minute.—(Med. Chir. Transact, vol. xiii. part i. p. 202.) Morgagni relates two similar cases. ■J- De Haen, Ratio Medend. torn. v. p. 123. X Voigtel's Handbuch der Patholog. Anatom. B. i. p. 70. Vol. II.—5 50 EPILEPSY. to a whole year. Many instances observe a more or less perfect periodicity in the recurrence of the fits; whilst others are quite irregular in this respect. Richter observes, that cases arising from gastric or intestinal irritation, and from catamenial irregularities, are most apt to assume a periodical character.* Occasionally the parox- ysms recur regularly at the periods of new or full moon. Nearly twenty years ago I treated a case successfully, in which for several years previously the paroxysms had returned regularly on the night of each full moon. Examples of this kind may, however, occur as mere coincidences, without any relation, as cause and effect, between the two phenomena.t Epilepsy seldom proves fatal, except through the intervention of apoplexy. When it recurs very frequently, however, the mental powers gradually fail, until at last a total imbecility or idiotism is induced. The most complete state of idiotism I have ever seen, was produced in less than two years, in a fine, intelligent boy, by the ferocious attacks of this malady. Post mortem appearances.—The morbid appearances discovered on dissecting subjects who die of epilepsy, are often similar to those which occur in apoplexy and palsy. No man has, perhaps, dissected so great a number of bodies that had died of epilepsy as M. Wentzel. Previous to the dissections of this indefatigable anatomist, it was generally thought that the cerebrum is the chief seat of the proxi- mate cause of epilepsy. M. Wentzel, however, in a very great pro- portion of heads he examined, found the cerebrum perfectly sound, whilst the cerebellum was uniformly in a diseased condition. The part of the cerebrum which he found most frequently affected, was the pineal gland. The cerebellum was generally of a dusky red, approaching to a blackish color; in some cases it exhibited a whitish or yellow hue, and in a few instances the posterior lobe was of a gray color. This portion of the encephalon was sometimes very soft; more frequently it presented a preternaturally hard and compact structure. In ten out of twenty-one cases, a morbid, yel- low, friable matter, was found between the lobes of the cerebellum, which in some instances not only separated the lobes, but caused also the destruction of a portion of their substance. Notwithstanding these observations of Wentzel, dissections made by other pathologists render it certain that the substance of the cerebrum is often mate- rially diseased in epilepsy. This indeed Wentzel does not deny, but his observations convinced him that this is much less frequently * Specielle Therapie, Bd. vii. p. 570. X For a full discussion of this point, the reader may consult Mead, de Imperio Solis et Lunae in Corpus Humanum; also, Balfour on Sol-lunar influence. That the moon governs the epileptic paroxysm, appears indeed to be a very ancient opinion. Galen, Aretasus, and Alexander Trallianus entertained this opinion. (Cook on Nervous Diseases.) EPILEPSY. 51 the case than we might be led to believe from the observations pre- viously published on this subject.* Both Greding,t and Roederer relate cases in which the cerebrum was disorganised to a greater or less extent. Some French pathologists have pointed out various morbid appearances of the mucous membrane of the intestinal canal as being intimately concerned in the causation of this disease. Causes.—Observation has informed us that in some cases of this disease the original exciting cause is seated within the head, or acts directly on the cerebral mass; whilst in others the cause is located in some other part of the system, and affects the encephalon second- arily, through the medium of the nerves. It is evident, therefore, that we may with propriety divide this malady into two general varieties—namely, into idiopathic and symptomatic. Experience has shown that the latter is in general much more apt to yield to remediate treatment than the former. In some individuals there appears to exist a constitutional predis- position to epilepsy; and it is, without doubt, in some instances, of hereditary origin. Boerhaave mentions an instance in which all the children of an epileptic father died of this disease^ and Stahl has related a similar occurrence.§ Tissot also mentions a remark- able instance of this kind. An epileptic man had eight sons and three grandsons all of whom, he says, became affected with this disease. (Cook.) Children, it has been observed, are much more liable to this dis- ease than adults; but the age at which there appears to exist the strongest predisposition to epilepsy is the period of puberty. Some writers assert that females are more subject to this affection than males; others, however, contradict this assertion. Probably hysteria has been frequently mistaken for epilepsy, which may have given rise to this opinion. Those who have once had this disease, and have been freed from it by remediate treatment, generally retain a particular predisposition to its recurrence. The exciting causes of epilepsy are exceedingly various. Of these causes some act immediately on the brain, and others make their impressions on distant parts, and affect the sensorium commune. secondarily through the medium of the nerves. The most common of the former variety of causes are: injuries and malformation of the cranium; exostosis from the internal surface of the bones of the skull; spiculae of bones driven in upon the brain; preternatural dis- tension of the cerebral vessels; various organic affections of the brain, and effusions of different kinds within the cranium. (Cook.) * Cook on Nervous Diseases, &c. p. 342. | Sammtliche Medic. Schriften. ii. Theil. X Praelectiones in Prax. Med. torn. v. p. 30. § De Hereditar. Dispos. ad Varios Affectus. Halle, 1706. p. 48. Also in his Dissertatio de Epilepsia Hereditaria Casum Exhibens, as quooted in Richter's Specielle Therapie, Bd. vii. p. 594. 52 EPILEPSY. Sudden and violent mental emotions frequently produce this dis- ease by a morbid excitement originating in the brain. Fear, terror, grief, and other disagreeable sensorial and mental impressions, have been known to give rise to epilepsy. I have met with three in- stances that were excited by terror. Locker states that six out of fourteen cases of this disease, which came under his care in the Hospital St. Mark at Vienna, were produced by terror. Many re- markable instances of epilepsy, excited by disagreeable and strong impressions on the senses, have been reported. Strong odors, sud- den and vivid light, loud and peculiar sounds, and certain colors, have produced this disease in weak and irritable habits. Weikart relates the case of an individual in whom the smell of red beets ex- cited epileptic paroxysms.* The odor of the garden ranunculus has also given rise to the disease;t and Cook quotes from Buchner an instance of an epileptic child in whom the sight of a vivid red color seldom failed to excite a paroxysm of the disease. Cases of this kind are of course connected with idiosyncrasies by which the influence of these exciting causes is peculiarly favored. This disease has frequently been excited by the sight of a person affected with the epileptic paroxysm. Dr. Rush mentions several instances of this kind. The principle of association exerts indeed a powerful influence over the actions of the animal economy; and in no disease has this been more strikingly exemplified than in'the pre- sent one. The mere recollection, or sight of the causes or circum- stances which attended the first attack of the disease, has re-excited the paroxysm.f Among the causes of this disease that act upon the brain through the general system, gastric or intestinal irritation is perhaps the most common. Epilepsy from this cause is most frequently met with in children. Worms, and indeed every other substance which is capable of producing an irritation in the nervous extremities of the mucous membrane of the alimentary canal, may give rise to this affection in weak and irritable subjects. A protracted case is re- lated, which ceased entirely after the expulsion of a tape-worm.§ Leeches swallowed into the stomach have produced epilepsy. (Gu- denklee.) The suppression of habitual evacuations, whether sanguineous or serous, is another powerful exciting cause of epilepsy. Suppressed or morbidly postponed catamenial discharge soon after the age of puberty, is particularly apt to give rise to this affection in individuals otherwise predisposed to it. || The healing up of old ulcers, setons, * Hufeland's Journal, Bd. xii. st. i. s. 174, f Acta. Natur. Curios. Dec. iii. Ann. ix. x. Obs. 92, p. 170. X Van Sweiten, Commentar. torn. iii. p. 414. § Mursinna's Journal, f. Chirurg. Arzneik. u. Gebershuife. B. i. st. ii. p. 306. (Richter.) || Falk, Dissert, de Epilepsia, s. Motib. Convuls. Virgin. See also the in- EPILEPSY. 53 issues, &c. may give rise to epilepsy. Richter mentions the sup- pression of habitual sweating of the feet as a strong exciting cause oi this and other convulsive affections. The repulsion or sudden drying up of chronic cutaneous eruptions, particularly the itch and tinea capitis,, also may produce epilepsy; and in the exanthemata, either just before the eruption is about coming out, or from its sud- den retrocession, this form of convulsive disease is by no means uncommon. Excessive evacuations are also among the exciting causes of epi- lepsy; and this is particularly the case with inordinate seminal evacuations, either from excessive venery or masturbation.* Various poisons, more especially of the narcotic kind, sometimes produce this disease. It is said that in Kamschatka, epilepsy is frequently occasioned by the use of an.indigenous species of toad- stool, which the inhabitants of that country are much in the habit of eating on account of its exhilarating effects.t The abuse of opium in children has a tendency to produce this malady; and among the mineral poisons, lead and arsenic are said to be most apt to excite it. Wendt mentions a case produced by lead, and Dr. Warren relates a fatal case produced by this poison. (Cook.) In the second volume of the Medico-Chirurg. Transactions, five cases are reported which arose from the reception of arsenic into the stomach. The habitual intemperate use of alcoholic liquors is a very common cause of epilepsy. It is probable that epilepsy from this cause pro- ceeds from the combined influence of hepatic disorder, and a constant preternatural determination of blood to the brain. Painful dentition, pregnancy, and parturition, occasionally excite the disease. Tissot relates three cases which arose evidently from pregnancy. In one case, the patient was affected with epileptic paroxysms almost every week, in three of her pregnancies, until quickening commenced. Irritation from biliary concretions, as well as from urinary calculi, has sometimes given rise to this affection. Dr. Cook refers to the works of Bertholini for examples of this kind. Habitual tendency to congestion or plethora of the vessels of the brain is perhaps one of the most frequent exciting causes of the epi- leptic paroxysm. This may be the result either of a constitutional habit, or of the operation of some one of the foregoing exciting causes, particularly intestinal irritation, and suppressed sanguineous and serous discharges. Atmospheric influences also have been sup- posed capable of exciting this disease. Great heat or cold, and sud- den vicissitudes of temperature, are mentioned as exciting causes; but their influence in the production of this affection is perhaps rather predisposing and exciting. teresting observations of Prichard on this subject in his Treatise on Nervous Diseases. * Zimmerman on Experience, vol. iv. chap. 10. t Langsdarf in d. Weterauschen Annalen. Bd. ii. bit. 2. (Richter, Spec. Ther.) 5* 54 EPILEPSY. On the subject of the proximate cause of epilepsy, a very great diversity of opinion has been expressed. Without entering into a detail of these opinions, all of which are hypothetical, and many01 them absurd, I shall content myself with a statement ol those cir- cumstances, which experience and observation appear to sanction in relation to the pathology of this affection.* 1. The immediate cause of the epileptic paroxysm, whatever its essential character may be, is always seated in the brain. 2 In the majority of fatal cases, organic and other obvious affec- tions of the brain, particularly of the cerebellum, or of the meninges, are found on dissection, and which, we may infer, contributed to the excitation of the epileptic paroxysms. 3. The cerebral affection is in some instances primary, and the result of causes that act directly upon the brain. In others, probably in the majority of cases, it is secondary, depending on primary irri- tations located remotely from the brain. 4. Immediately before the accession of the epileptic attack, it would seem that vascular turgescence takes place in the encephalon; and the pressure thus created, in co-operation with the general pre- disposition to the disease and the organic cerebral affection, where such disorder exists, is probably the immediate exciting cause of the paroxysm. It would be useless to enter into any discussion concerning the causes of the paroxysmal character of this affection, or of the occa- sional strict periodicity of its recurrence. The influence of habit has been adduced in explanation of these mysterious points of pa- thology. The term habit, however, in a physiological sense, can mean nothing else than a tendency to repeat an action, whether morbid or healthy, that has been produced by some exciting cause, without the presence or further co-operation of such cause. This, however, is merely expressing the general fact, and offers no expla- nation of it whatever. Diagnosis.—The affection with which epilepsy is most liable to be confounded, is hysteria, when this disease assumes the convulsive form. They may be distinguished from each other, however, by the following circumstances. In hysteric convulsions, the countenance is less livid and distorted than in epilepsy; and there is seldom any foaming at the mouth, or profuse discharge of saliva, nor does it terminate in heavy sleep, or in a confused and torpid state of the mind, so general at the conclusion of the epileptic paroxysm. In hysteria, too, there are always some concomitant phenomena which indicate its character, such as the globus hystericus, involuntary laughing or weeping, and in many instances a continuation of some degree of consciousness, &c. * Mr. Mansford, in a work published on Epilepsy a few years ago, gives it as his opinion, that the proximate cause of this disease consists.in an accumulation of the electric matter in the brain, or what he considers the same thing, a supera- bundance of the nervous power in the sensorium commune. EPILEPSY. 55 Prognosis.—Although the immediate danger of the epileptic pa- roxysm is not in general very great, yet in relation to its sanabilitv, the prognosis is always highly unfavorable. Even where a cure or suspension of the disease has been effected, the liability to a relapse is always considerable. When epilepsy depends on organic disorder within the head, no remediate management can effect a cure. Epi- lepsy, however unconnected with cerebral lesion, may sometimes be cured.* That variety of the disease which occurs in young fe- males about the age of puberty, from menstrual irregularities, is not unfrequently curable, and indeed sometimes passes off spontaneously after the catamenia begin to flow regularly. The longer the disease has continued, or rather, the more frequently its attacks have been repeated, the greater will be the difficulty, in general of effecting a cure; and when the mind has once become obviously affected or impaired by its attacks, all hopes of a cure may be abandoned. Ex- perience, too, has shown that those epilepsies which commence soon after birth, or during early infancy, rarely, if ever, yield to remedi- ate treatment. From the period of dentition to that of puberty, is the most favorable age for the cure of this affection. Hippocrates observes, that those who are attacked with epilepsy after the twenty- fifth year of age, will continue to have it as long as they live—an observation which though very generally correct, .is not confirmed by the experience of subsequent practitioners.! When the disease is the consequence of excessive venereal indulgence or masturbation, it may sometimes be removed, provided the mental powers have not as yet suffered considerably from its repeated attacks, or from the influence of its cause. The epileptic paroxysms, which sometimes occur in the exanthematous diseases, are seldom followed by serious consequences, and very rarely recur afterwards. When the premonitory symptoms consist of some affections in the * Dr. Dewees, in his work on the " Practice of Physic," has inadvertently expressed contradictory sentiments in relation to the curableness of this disease. Under the head of treatment, he asks, " What plan of treatment has ever suc- ceeded in curing epilepsy] Has epilepsy ever been cured?" Under the head of diagnosis, however, he says, " When the disease is symptomatic, it is occasion- ally curable;" again, " those attacked between the fourth and tenth year may be cured by proper treatment." Most assuredly this latter sentiment accords with the experience of the ablest of the profession of all ages. However appalling and really intractable this disease may in general be, perfect cures are by no means so uncommon as the doctor's interrogatories might lead one to suspect. I have known at least five distinctly marked cases cured'under my own observa- tion, two of .which were of more than two years standing, and one above six years. f He says, moreover, that when epilepsy commences before the fourteenth year, and is not connected with an hereditary predisposition to the disease, it frequently terminates spontaneously in after-life.—Aphor. xv. s. 7.—Aphor. vii. t. 5.—Aphor. xlv. s. 2. 56 EPILEPSY. head it may be regarded as more unfavorable than if they manifest themselves in remote parts of the body, particularly in the extremi- ties. Richter observes, that a long continuance of the sleep, and subsequent mental stupor and confusion after the subsidence of the paroxysm, is a very unfavorable sign. Epilepsy from moral causes, particularly from violent anger or grief, is said to be very rarely cured. (Jahn Klinik d. Chronisch. Krankh. Bd. i. p. 267.) It is also asserted, that those cases which come on at night during sleep, are in general more intractable than such as occur during the day, and are preceded by premonitory symptoms. (Richter.) It has been affirmed by men of great ex- perience, that epilepsy occasionally ceases spontaneously on a change of climate.* Treatment.—There is perhaps no disease in which medical treat- ment is so frequently purely empirical as the one now under consi- deration. The causes are so multifarious, and generally so obscure, or so wholly beyond our cognisance, that we are seldom enabled to *prescribe with any degree of reliance upon general and rational the- rapeutic principles. In this state of perplexity and uncertainty, we have often no other alternative left us, than to administer remedies, without being able to give any other reason for their use than that they have been occasionally successfully employed. True as this observation unquestionably is, we have nevertheless in some in- stances, at least sufficient lights in the symptoms and causes to lead us to a consistent and rational plan of treatment. When called to a case of epilepsy, the first object of the practitioner should be to in- quire into the nature of its exciting cause, its duration, the time and manner of the first attack, the general constitutional habit of the pa- tient, his age, previous or concomitant diseases, his habitual temper and disposition of mind, his manner of living, his probable hereditary predisposition, in short, into every thing which can throw light on the particular character of the disease, and on the constitutional or acquired habits of the patient. Authors assert, that when the premonitory sensation, termed aura, commences in one of the lower extremities, the epileptic paroxysm may sometimes be effectually prevented, when it is approaching, by compressing the limb firmly with a tourniquet or ligature above the part at which the aura may have reached. Dr. Cullen observes, " that a ligature upon the limb above the part from which the aura arises, should always in those cases be applied, both because the pre- vention of a fit breaks the habit of the disease, and because the fre- quent compression renders the nerves less fit to propagate the aura." Dr. Cook .mentions an instance from the London Medical and Phy- sical Journal,in which pressure made in this way prevented the parox- ysm. Richter states, that when compression is thus made on a limb, above the ascending aura, the patient generally experiences great * Lentin, in Hufeland's Journal, Bd. xiv. s. iii. p. 17. EPILEPSY. 57 anxiety of feeling in the praecordia, with extremely painful twitches in the compressed limb, accompanied sometimes with a sensation as if a heavy stone were thrown upon it. Brechstedt and Michaelis assert that the application of the tourniquet upon a leg has been known to put a speedy stop to the epileptic paroxysm after it had actually supervened.* In persons of robust and plethoric habits, prompt and efficient bleeding on the occurrence of the premonitory symptoms, has been known to keep off the epileptic attack. Active purgatives have also been recommended with the view of obviating or palli- ating the impending paroxysm, where the premonitory stage is protracted; but their tendency in this respect deserves little or no attention. Richter and other of the earlier German writers speak favorably of the employment of emetics with this intention. They cannot, however, be used without considerable risk in cases attended with strong congestion in the vessels of the head. Richter states that they are only adapted to those cases which continue to recur from habit, after the original exciting cause has ceased to act. It even appears from the observations of this writer, that a radical cure may be effected in this way. He states, that he cured a woman of this disease, by frequently suspending the paroxysms by the administra- tion of emetics a short time before the expected occurrence of the epileptic attack.t It must be observed, however, that many highly respectable authorities might be adduced against the use of emetics in this affection; and as a general rule, they are indeed to be re- garded as of very doubtful propriety. Jahn, in his excellent work on chronic diseases, says that a draught of cold water will occasion- ally do more towards keeping off an impending attack of epilepsy than any other means; and Dr. Busmann has published some cases tending to confirm this observation. J Some fifteen years ago, while practising in Lancaster, 1 knew an old epileptic patient who could generally keep off the paroxysm for some months by taking a large draught of cold water as soon as the premonitory symptoms came on. Without this precaution he seldom escaped having one or two fits a week. In the epileptic paroxysm, our principal object should be to di- minish the preternatural congestion of the cerebral vessels. The immediate danger of an epileptic fit arises chiefly from this condition of the cephalic circulation; for when death occurs during the pa- roxysm of this disease, it is almost invariably by apoplexy, from vascular turgescence, or sanguineous extravasation. When the patient is plethoric, and the signs of inordinate sanguineous congestion in the head are considerable, it will be prudent to abstract blood, and to remove every thing which may compress the veins of the neck, * De artuum ligaturis ad nonnullos morbos internos. Michaelis—in Medizin. Pract. Bibliothek. Bd. i. st. iii. p. 397—as quoted by Richter. X Specielle Therapie, Bd. vii. p. 630. X Hufeland's Journal, Bd. x. st. ii. p. 133. 58 EPILEPSY. or impede the free return of blood from the brain to the heart. It is very doubtful, however, whether any treatment, during the epi- leptic paroxysm, can materially mitigate its violence, or shorten its duration. It is almost exclusively with the view of protecting the brain, that remediate measures can be resorted to during the fit with a prospect of advantage. The most important part of the treatment of epilepsy, however, is that which is proper during the intervals of the paroxysms, for the purpose of effecting a permanent removal of the disease. 1 have already adverted to the importance of attending to the nature of the exciting cause in instituting a course of treatment for its radical cure. If our inquiries in this respect are successful, it will not be difficult to lay down an appropriate plan of treatment. Thus, if on a careful examination, it appears that the bowels are in a loaded and irritated state, and particularly if signs of intestinal irritation existed, in a very obvious manner, previous to the occurrence of the disease, it would be exceedingly unwise to neglect the state of the bowels, and to resort at once to some one of the numberless remedies usually recommended in the disease. Epilepsy from this cause is principally confined to infancy and childhood. It is in this variety of the disease that emetics have most frequently been found useful. When symptoms of gastric irritation—such as nausea, flatulency, dis- turbed sleep, and other manifestations of indigestion are present, in children affected with this disease, a course of emetics have been used with decided success. (Richter.) In a child which had been affected with occasional epileptic paroxysms for upwards of eighteen months, I succeeded in removing the disease entirely by a course of emetics, (ipecac.) administered every third day.* Dr. Clark recommends a solution of sulphate of zinc, in an aqueous infusion of ipecacuanha, to be given every six, eight, or ten days. Absorbents have also been recommended in the epilepsies of in- fants, attended with gastric disturbance; and when used in conjunc- tion with mild tonics, and an occasional aperient, they are some- times beneficial, particularly where there is much acidity in the primae viae.t Richter observes, that we have reason to presume that the remote cause of the disease is seated in the stomach when vomiting occurs at the close of the paroxysm. He mentions also a peculiar tremulous motion of the under lip, as a sign of gastric irritation, from vitiated * This case came on after an attack of ague, which was cured by Fowler's solution. j- The famous powder of Margrave, which is still a good deal used by some of the German practitioners in infantile epilepsy, owes whatever powers it pos- sesses to its absorbent, tonic, and aperient virtues. It is composed of one ounce of powdered misletoe, the same quantity of sugar, and half an ounce of the car- bonate of magnesia. The dose is a teaspoonful two or three times daily for a child under five years old.—Rkhter,s Spec. Therap. Bd. vii. p. 645. EPILEPSY. 59 secretions or other offensive matters. Van Swieten relates a case of epilepsy, the fits of which were always preceded by a remarkable tremor of the under lip. The case was treated by emetics and pur- gatives, and thereby permanently removed.* If symptoms of intes- tinal worms are present, anthelmintic remedies are decidedly indi- cated. Small and repeated doses of calomel, with an occasional dose of castor oil in union with a small portion of spirits of turpentine; or infusion of spigelia, followed with a full dose of calomel and jalap, will sometimes answer in such cases. In verminous epilepsy, full doses of powdered valerian with the elutriated oxyde of tin, has been successfully used. From one to two drachms of the former, with thirty to fofoy grains of the latter, may be taken three times daily. Should it appear that the disease arose in the first instance from sudden suppression of the perspiration, a course of diaphoretics, and whatever else may have a tendency to keep up a regular action of the cutaneous exhalents, should be resorted to. Frictions with dry flannel; the occasional use of the warm bath, rendered more stimu- lating by the addition of common salt; flannel worn next the skin; active exercise when the weather is dry; the internal use of diapho- retic remedies—such as the pulvis antimonialis; camphor in union with tartar emetic; the tincture of guaiacum; and sulphur, are appro- priate and occasionally beneficial remedies in such cases. When epilepsy arises from the repulsion of cutaneous eruptions, or the drying up of old ulcers, the manifest indication is to restore these affections; or, if this cannot be done, to establish others artifi- cially in their stead. For this purpose we may employ issues, setons, blisters, and particularly frictions with tartar emetic ointment, to- gether with diaphoretics, warm bathing, and stimulating frictions. Richter says, that in such cases, vomits are occasionally very useful; he also speaks favorably of the use of musk and camphor in epilepsy arising from causes of this kind. Prichard recommends mercury, given to the extent of producing ptyalism, in this variety of the dis- ease. One of his patients was perfectly cured by a copious salivation. In those cases which occur in young females, in consequence of an unsuccessful or imperfect menstrual effort, the indications are, to remove the preternatural determination to the head, and to establish or restore the natural determination to the uterine system, and thereby promote the regular performance of the menstrual function. This variety of the disease occurs chiefly in young females of sanguine temperament; and bleeding, therefore, can seldom be dispensed with. Indeed, in all cases of this kind I have met with, bleeding was deci- dedly indicated by the condition of the pulse, the occasionally flushed countenance, and sense of fulness in the head. Dr. Prichard, speak- ing of this variety of the disease, which he calls uterine, observes— "The immediate effects of blood-letting are generally relief of the pain and oppression of the head, and a subsidence of the carotid and * Comment. T. iii. p. 439. 60 EPILEPSY. temporal pulsations. Sometimes the use of the lancet is speedily followed by a restoration of the catamenia." He advises that the blood be taken while the patient is sitting up, and that it be suffered to flow until syncope begins to come on. In addition to bleeding in cases of this kind, the warm semicupium is a valuable remedy. We may also employ frictions about the loins, back, and pubic re- gion, and stimulating enemata, with advantage. Prichard recom- mends clysters composed of spirits of turpentine and castor oil, in such cases. An ounce of each may be occasionally thrown into the rectum. After the plethoric or phlogistic state of the system has been reduced by the foregoing measures, it will be proper to resort to emmenagogue remedies, if the menstrual evacuation has not al- ready been restored. The following pill may be employed for this purpose.t According to the experience of Dr. Prichard, the best emmenagogue we possess in uterine epilepsy is the oil of turpentine. It should be given in doses of from a half to two drachms once or twice daily. I used the turpentine in a case, about eighteen months ago, with complete success. Setons in the nape of the neck, or on the arms, or on the sacrum, have also been recommended. This variety of epilepsy is almost invariably suspended by pregnancy. In epilepsy from onanism, besides the proper moral influences, Richter strongly recommends the use of camphor in regular and full doses. That this article possesses the power of lessening the \ enereal propensity 1 am fully persuaded, and its general influence, independ- ent of this particular effect, renders it a suitable remedy in cases of this kind. Patients affected with epilepsy from this cause, should sleep on a hard mattress, rise early, take exercise in the open air, and use a mild and unirritating diet. The tepid shower-bath, and labo- rious occupations, will sometimes assist materially in removing the habit upon which the disease depends, and without the discontinu- ance of this habit, nothing useful can be expected from remediate treatment. Epilepsy from local injuries of the head has been cured by surgi- cal operations. Boerhaave, Thenier, Stalpart, and Van der Weil, re- late instances in which trepanning succeeded in removing the disease. Tissot also mentions several instances of this kind. Dr. Massie gives an account of a case of epilepsy which was produced by a blow on the head, and consequent depression of a portion of the cranial bones. After the disease had continued about four years, the patient was trepanned, and a spicula of the bone removed, after which the pa- roxysms returned no more. X Instances have also occurred in which epilepsy was cured by sur- * The bath, says Prichard, should be about the temperature of 96° or 98° of Fahrenheit's scale—Treatise on Diseases of the Nervous System. Lond. 1822. X R.—Extract, sabinae gii. G. aloes lace. ^i. Sulphat. ferri. gr. x.—M. Fiant pil. No. 40. Take one every six hours. X Philadelphia Med. and Phys. Jour. 1809, No. 35. EPILEPSY. 61 gical operations on other parts of the body than the head. Portal relates a case, where the paroxysms always commenced with violent pain in the index finger. This patient was cured by dividing the radial nerves.* The disease has sometimes terminated spontaneously after the removal of spiculoe of bones, balls, tumors, or other foreign bodies pressing upon particular nerves.t Dr. Dudley, of Lexington, succeeded in curing a case of epilepsy by removing a spicula of bone which had penetrated the substance of the brain to a considerable distance. Dr. Rogers of New York succeeded in a case by a similar operation; and an instance is related by Dr. Guild of Alabama, which was cured by the operation of trephining. This case is an extremely interesting one, and deserves to be consulted as a remarkable instance of successful trephining for this disease.^ Where we can ascertain the remote cause of the disease, we should always found the plan of treatment on the general indications which such a knowledge is capable of affording. In the majority of in- stances, however, we are wholly left in the dark with regard to this point, and very frequently indeed, all our efforts to cure the disease, under the guidance of what we may deem the most unequivocal curative indications, are unsuccessful. In this case we are obliged, if we wish to pursue our endeavors to effect a cure, to resort to some one, or many, by turns, of that long list of remedies which, according to the reports of eminent practitioners, or our own experi- ence, have occasionally succeeded in removing the disease, without our being able to give any other satisfactory reason why they are resorted to. The following are the most celebrated of these anti- epileptic remedies. Valerian.—This is one of the most ancient remedies employed in this disease. Aretaeus and Discorides recommend it as a valuable medicine in this affection; and it is favorably mentioned by many of the most celebrated of modern writers.§ It should be given in as large doses as the stomach will bear. From one to two drachms may be taken three times daily. This article is said to be most apt to do good in epilepsies from verminous irritation, suppressed cata- menia, terror, and repelled cutaneous eruptions. Quarin used it with success in epilepsy of infants. (Richter.|[) Biett generally * Cours d' Anatomie Medicale, T. iv. pp. 247. 272. f Memoires sur la Nature et le Traitement de Plusieurs Maladies. Par Ant, Portal, vol. xi. p. 229. (Richter.) X American Journal of Medical Science. October, 1829. § Hoffman, De Haen, Burserius, Haller, Murray, Selle, Tissot, Thilenius, Vogel, Hanneman, Horn, Quarin, and others, recommend it as a valuable remedy in epilepsy. On the other hand, Cullen, Home, Heberden, and Woodville, re- gard it as of but little value in this disease. || The famous anti-epileptic powder of Ragolai contains a large proportion of valerian. According to Knopfs analysis, this nostrum is composed of one drachm of valerian, one scruple of orange leaves, two grains of muriate of am- Vol. II.—6 62 EPILEPSY. employs the oil of valerian in this affection in doses of from 40 to 50 drops three times daily. (Casper. Charakter. d. Fanz. Med. p. 192.) The misletoe also is a very old remedy in epilepsy; and if we are to place any reliance on the testimony of Boerhaave, De Haen, Van Swieten, Hufeland, Stark, and Richter, we cannot doubt of its having proved effectual in removing this affection. Cullen admits that in large doses it may perhaps be useful; but he thinks it proba- ble, and with justice, that the reputation it once had arose in a great measure from its having been an object of superstition, and thus calling in the powerful aid of the imagination to whatever powers it may really possess of itself. Frazer, in a small work published on the powers of this article, asserts that he cured nine cases out of eleven with this medicine. He gave it in powder, in doses of from two scruples to two drachms, twice daily in a draught of camphor- ated emulsion. (Cook.) We have moreover the testimony of Fother- gill, and Dr. Willan in favor of this article as a remedy in epilepsy. Of late years, however, it has fallen into total neglect. I knew an empiric who succeeded in curing several old cases with this article. The animal oil of Dippel* also was formerly a good deal em- ployed in the treatment of this disease; and we have the testimony of Hoffman, Cullen, Bang,t Kortrum, Quarin, Werlhof, Thouvenel, Van Hoven, and others, in its favor. It is given in doses of from 20 to 50 drops three times daily. It is said by Richter to be most useful in epilepsies originating from metastastic gout, rheumatism, and from repelled cutaneous eruptions. The oil of turpentine has at present no inconsiderable reputation as a remedy in this disease. I have already mentioned its usefulness in epilepsy from menstrual disorder, on the authority of Dr. Prichard. It has also been successfully used in other varieties, particularly in monia, and a few drops of cajeput oil. Jahn thinks that it contains a portion of the powdered root of the convallaria majalis; and some assert that it consists of a mixture of valerian, agaric, and an ethereal oil. This remedy, according to the testimony of Richter and others, has cured obstinate and even inveterate cases of epilepsy. Richter succeeded in curing a case of four years standing, by a powder composed of one drachm of valerian, with three drops of cajeput oil, taken four times daily for six weeks. (Therap. Speciel. vol. vii. p. 672.) In this city the following composition has been used with complete success in some instances, and frequently with the effect of postponing the paroxysm for many months. R.—Pulv. zingeberis. ----fol. salviae. ----sem. sinapi aa gi—Dose. A teaspoonful three times daily I have myself employed this powder with advantage in a few cases, though never with complete success. * Dippel. Disquisitio de Vitae Animalis Morbis. p. 89. j Acta Societ. Med. Hav. vol. i. p. 500. EPILEPSY. 63 cases depending on intestinal irritation from worms and other offen- sive matters. Dr. Latham cured several cases of epilepsy with this remedy. Dr. Young has given an account of two cases which yielded under the use of this remedy;* and Dr. E. Percival relates three instances of its successful employment.! Dr. W. Money also testifies to the usefulness of this article in epilepsy; and Dr. Prichard assures us that of all other remedies which he has tried in this dis- ease, he has found none so frequently useful as the oil of turpentine. (loc. cit.) Biett is said to employ this oil frequently for the cure of epilepsy in the Hospital St. Louis. This article should be given in doses varying from a half to two drachms three times daily. Fresh milk is perhaps the best vehicle for administering it. The root of the pseony was anciently highly esteemed for its powers in this disease. It was a favorite remedy with Stark; and it is particularly recommended by Hufeland, Jahn,J and Thorn. Hufeland says, it is especially useful in the epileptic affections of children. The powder is given in doses of half a drachm three times daily, or an infusion of one ounce of the root to eight ounces of water, given in tablespoonful doses every two hours. Agaric us muscarius was first employed in this disease by Bern- hard. Wistling and Gruner afterwards published statements illus- trative of its powers in this affection. (Richter.) It is said to be most useful in cases originating from repelled cutaneous eruptions. The dose is from a scruple to a drachm three times daily. Artemisia vulgaris, or mugwort, has been lately much com- mended for its virtues in this disease by several eminent German practitioners. About eight years ago, Dr. Burdach, an eminent phy- sician and writer, published an account of the successful treatment of several cases of epilepsy by this root; and in a recent number of Hufeland's Journal, he has adduced further evidence of its usefulness in this disease. It is a remarkable circumstance, he says, that in nearly every case in which this article proved successful, an evident amendment of the disease took place from the first dose. It appears further from the experience of this physician, that in cases of epi- lepsy occurring in male subjects about the age of puberty, this reme- dy very seldom does any good. In young females about the same age, " its beneficial effects are often prompt and decisive." He oc- casionally found it very speedily successful in apparently very ob- stinate cases, while in others, seemingly quite similar, it was wholly inefficient. An interesting instance of the successful employment of this remedy, is related by Dr. Wagner, in Hufeland's Journal, (vol. for 1824.) And in the 12th Annual Report of the Berlin Polyclynic Institute, there is another case related which yielded under the use of the artemisia. It is usually given according to the * Transactions of the College of Physicians, Lond. vol. v. f Edinb. Med. and Surg. Jour. vol. ix. p. 271. X Klinik. d. Chron. Krankh. Bd. i. p. 282. 64 EPILEPSY. following formula.* This is not a new remedy. Ettmuiller men- tions its use in epilepsy; and Zwinger, speaking of this plant, says, mire in epilepsia valet. The internal ligneous part of the root is inert. The cortical portion alone is said to possess medicinal powers. The artemisia is indigenous to this country, particularly to Pennsyl- vania.! Of the narcotics, belladonna,:}: opium,§ camphor,|| and stramo- nium,1F have been most recommended in this affection. Some ot the antispasmodics also have been employed with benefit in epilepsy. Among these, musk, castor, and assafcetida, are generally supposed to be the most useful. Very commonly, however, no advantage whatever is to be derived from remedies of this kind; and they are often manifestly injurious, by their tendency of increasing preter- natural determination to the head. Of late years, phosphorus has been strongly recommended by some as a remedy in this affection. I gave it in one case about two * R.—Pulv. rad. artem. vulg. §ss. Pulv. sacch. albi ^i.—M. Of this, about a teaspoonful is to be taken four times daily; the dose being gradually increased. | Besides the foregoing remedies, a great many others of a similar character have been recommended in this affection. Veratrum Album, (Stark, Schulze, Greding.) The roots of the white lily, (Hufeland's Jour. B. xxxi. p. 30,) Phe- landrium aquaticum; faba St. Ignatii; the fresh juice of white onions, (Hufe- land's Annalem;) Radix meu (Jahn;) the juice of unripe grapes, (L. Frank, Loebstein-Loebel;) sedum acre (Zachorn, Hufeland's Jour. Bd. xl. p. 19;) folia aurantiorum, (Van Swieten, De Haen, Stoerk, Werlhof, Stark, Hufeland, Thi- lenius.) The carbonate of potash in large doses, is recommended in recent cases. (Hufeland's Jour. Bd. viii. p. 170.) X Stoll, (Ratio Medend. vol. iii. p. 406,) Hufeland, (Journal d. Prack. Heilk. Bd. ix.) Greding, (Vermischte Shriften,) and Jahn, (Klinik. d. Chron. Krank. B. i. p. 282.) speak favorably of this narcotic as a remedy in epilepsy. Rich- ter says, it should never be given to children—or in cases attended with habitual congestion of the cerebral vessels. § Tralles, (Usu Opii Salubris et Noxius, &c. p. 16.) Fothergill, (Med. Observ. and Inquir. vol. vi. p. 80,) asserts that opium may be very beneficially used in cases attended with a weak, irritable, and nervous habit of body; and in eases that arise from violent pain or mental excitement. Dr. Huxy relates an instance of the successful employment of opium in epilepsy; and Dr. Darwin tells us that in two cases in which the fit always occurred at night during sleepi a grain of opium given at bed time removed the disease completely. || Richter says, that camphor is sometimes particularly useful in cases that depend on onanism, or on the repulsion of chronic cutaneous eruptions. (Loc. cit. B. vii. p. 682.) fl This article is much praised as a remedy for epilepsy by some of the Swed- ish writers. Ohdelius speaks favorably of it; and Greding cured a few cases with its use. Hufeland asserts, that he has used the tinct. sem. stramon. with decided benefit in this disease. (Journal, Bd. ix. st. 3.) EPILEPSY. 65 years ago, and although it did not perform a cure, it suspended the paroxysm above three months beyond its usual period of recurrence. Four grains may be dissolved in half an ounce of sulphuric aether. Of this, from eight to ten drops should be given three times daily in some mucilaginous fluid.* This article cannot, however, be em- ployed with propriety, in cases attended with general plethora, or habitual congestions in the cephalic vessels. Where symptomatic epilepsy is connected with torpor of the vascular and nervous sys- tems, or general debility and relaxation, advantage may be expected from it. Loebstien-Loebel, Van Hoven, and Horn, relate instances of its successful employment. The oxyde of zinc is generally regarded as one of our most effi- cient remedies in epilepsy; and from the testimony extant in relation to its powers, as well as from facts which have come under my own notice, I am inclined to regard it as a medicine of considerable value in this aflection.t This article is generally given in much too small doses to do any good in epilepsy. It may be commenced with in doses of three grains thrice daily, and gradually increased to the amount of forty or fifty grains a day. Dr. Gutherie cured a case in which the paroxysms returned three or four times daily, with this article given to the extent of eight grains on the first day, and gradually increased to forty grains in twenty-four hours. (Duncan's Annals of Med. v. iv. p. 473.) It is generally given by itself; but it would seem that its powers may at times be enhanced by combin- ing it with bitter and laxative remedies. Lentin (Hufeland's Jour. Bd. xiv. st. iii. p. 13,) cured an inveterate case with a powder com- posed of fifteen grains of magnesia, from two to eight grains of oxyde of zinc, two grains of the extract of quassia, and two drops of cajeput oil, twice daily. Stroubel (Hufeland's Jour. Bd. 52. st. i. p. 40,) used .this metallic preparation, in union with misletoe, with complete success, in a case attended with much nervous irritability. The sulphate of zinc has also been occasionally used with suc- * In Horn's Archives of Medicine (Bd. x. hft. ii. p. 270,) the following for- mula is given for the administration of this article: R.—01. tereb. §ss. 01. olivar. ^iii. Phosphor, gr. ii.; put them into a half ounce phial, and digest it in warm water until the phosphorus is dissolved; then add mucilage of gum arabic §iv. Syrup of cinnamon ^ss.—M. Dose, a desert- spoonful every 3 or 4 hours. (Richter, 1. c.) X This remedy has been used with success by Bell and Percival, (Edinb. Med. Comment, v. i. p. 229, and v. ii. p. 316;) Beiries, Home, (Clinical Experiments, p. 223;) Ranoe, (Acta. Societ. Med. Hafn. vol. i. p. 451, 457;) Metzcher, (Ad- versar. Med. v. ii. p. 98;) Osiander, (Denkwuirdigk. Bd. ii. p. 188;) Hirschel, Richter, (Med. Chir. Nebenst. pp. 161, 190;) Shearman, (Lond. Med. and Phys. Repos. Sept. 1822;) P. Frank, (Prax. Med. Univ. Praec. II. torn. i. p. 409;) Dr. Hay garth, Dr. White, (Cook on Nervous Diseases, p. 398;) Van Hoven, (Handbucb, Bd. ii. p. 131.) 6* 66 EPILEPSY. cess in this affection. It is favorably mentioned, in this respect, by Lettsom, Weikart, Cullen, Ideler, (Hufeland's Jour. Bd. iv. p. 114.) Cuprum ammoniacum.—This was the favorite remedy in epi- lepsy with Cullen. I have given it in ten or twelve cases, one of which only derived any decided benefit from its use. This article is indeed a very old remedy in this affection. Aretaeus mentions it as a valuable anti-epileptic. Richter observes, that the cuprum ammoniacum is only calculated to do good in cases attended with a torpid, unirritable, and phlegmatic constitution, and a healthy state of the digestive functions, and when it is continued from habit.* According to Stark, it is especially beneficial in cases depending on verminous irritation, or on repelled herpetic eruptions. Haase, an eminent German writer, asserts that it is much better adapted to the cure of epilepsy in adults than in children; and he agrees with Richter in regarding unirritable and phlegmatic subjects as most apt to derive benefit from its use. The dose at first is from a quarter to half a grain, and gradually increased to one or one and a half grain three times daily, or until it creates considerable nausea and gastric disturbance. Dippel refers to a preparation of copper, consisting of a union of this metal with potash, ammonia, and oil of turpentine, which, he avers, has been used with the most decided benefit in epi- lepsy. (Richter, Specielle Therapie, Bd. vii. p. 701.) The mode of preparing this mixture is given by Durr (in Hufeland's Journal, Bd. xxviii. st. iv. p. 117.) Richter says, that when given in union with valerian, its effects are generally more beneficial. The nitrate of silver possesses at present more reputation as a remedy in epilepsy than perhaps any other remediate article. It would be an easy matter to collect a very considerable number of instances of its successful employment in this disease.t From the * Numerous authorities may be quoted in favor of the anti-epileptic powers of this preparation. The most celebrated are, Burserius, (Instit. Pract. vol. iii. p. 11, § 289;) Loebstein-Loebel, (Wesen, u. Heilung d. Epilepsie,p. 234; (Dun- can, Harles, (Jour. d. Auslaend Med. Liter. Bd. iv. st. 2;) Bland, (Medical Com- mentaries, vol. vii. p. 300;) Greding, (Vermischte Schriften, Bd. i. p. 103;) Michaelis, (Med. Pr. Bibl. 1785, B. i. st. 3;) Stark, (Handbuch Z. Erkennt, &c.;) /. Frank, (Praxeos Med. Univ. Praec. P. II. vol. i. p. 412,) Haase, (Chron. Krankh. Bd. ii. s. 103;) Thilenius, (Med. u. Chir. Bemerk.'Bd. i. p! 103;) Bally, (Duncan, Medical Annals, vol. i. Lust. p. 377.) f It has been used with success, in well marked and often long standing cases of epilepsy, by Sims, (Mem. of the Med. Societ. of Lond. vol. vi. p. 397;) Cappe, (Duncan's Annals, for 1798, p. 56;) Bostock, Hull, Heberd'en,'(Com- mentaries;) Sauchier, (Anna!, de la. Societ. de Med. de Montpell T vii 369, 384;) Valentin, (Ibid. T. viii. p. 182;) Heim, Nord, (Med. Nationalzeit! 1798;) Born, (Hufeland's Journal, Bd. xlv. st. i. p. 93;) Shaeffer (Ibid Bd xlviii. p. 43;) Pitschaft, (Ibid. Bd. !i. st. 3. p. 54;) Loebstein-Loebel, (Wesen u. Heil. d. Epilepsie, p. 243;) Portal, Fouquier, (Diet, des Sciences Med T xxxvii. p. 120;) Harrison, Baillie, Roget, Johnson, (Cook on Nervous Diseases EPILEPSY. 67 various and highly respectable testimonies we have in relation to its powers, it is, without doubt, entitled to much attention as a remedy in this affection. In order to obtain its beneficial effects as an anti- epileptic, this preparation should be given in as large doses as the stomach will bear. Dr. Powell observes, that the nitrate of silver may be taken into the stomach in much larger quantities without inconvenience in the form of pills than in solution. We may com- mence with one grain, and gradually increase the dose to three or four grains or more three times daily. Richter states, that this article seldom does any good unless the digestive organs are in a healthy and vigorous condition; and Dr. Harrison considers it par- ticularly adapted to those cases which are connected with a morbid irritability of the nervous system. I have given it in a number of cases—in one case only, however, did it prove permanently success- ful. Kruiger employed this article with success according to the following formula.* The nitrate of silver will sometimes manifest no beneficial effects until its use has been continued for many months. Toel (Horn's Archives, 1824,) relates a case in which the parox- ysms recurred regularly every month, at night during sleep, which yielded at last to this remedy after it had been regularly taken for more than a year and a half. It is a common practice to discontinue the use of this and other similar remedies, if no perceptible advan- tage is derived from it in the course of six or eight weeks. This, I am persuaded, is not unfrequently the source of defeat in our at- tempts to subdue this complaint. I once succeeded in curing a case of seven years' continuance, by persisting* with the same remedy for nine months. Tin.—This article has recently been strongly recommended in the cure of epilepsy. Dr. Shearman states, that in his hands the elutriated oxyde of tin has more frequently succeeded in curing this affection than any other remedy he has ever employed. He gave it in doses of from two scruples to one drachm, night and morning, for about four days. ,At the end of that time he ordered a purgative, and again gave this preparation, or not, according to its effects on the system.t The filings of tin, given in large doses, have been used with success in epilepsy from verminous irration by Richter, (As- klepeion, 1811, st. 67, s. 1060,) and Monro, (A Treatise on Med. p.394;) Barladini, (Omodei. Annal. di. Medic. 1826., p. 41;) Jahn, (Arzneinuttell, Bd. i. and Klinik d. Chron. Krankh. B. i. p. 283;) Kruiger, (Archiv. f. Med. Erfahr. v. Horn, Maertz, April, 1823;) Toel, (Ibid. 1824, Nov. and Decemb.;) Uiett, (Casper. Charakt. d. Franzoesish. Med. p. 191.) * R.—Nitrat. argenti. gr. vi. G. opii. gr. x. Extract, gentian, £i. Extract, aloes, 9 i.—M. Divide into two grain pills. Take one three times daily, increasing the number from time to time. f London Medical Repository. 6S EPILEPSY. and Pharm. Chem. vol. i. p. 289.) From the acknowledged an- thelmintic properties of this article, it is manifestly peculiarly adapted to cases which depend on irritation from worms. Lead.— The acetate of lead has been employed with entire suc- cess in a few instances of this disease. About sixteen years ago, I succeeded in curing a case with this remedy which had continued for upwards of seven years. The patient was a young man about 22 years old; and the disease was excited, in the first instance, by violent terror. The paroxysms returned regularly at each period of full moon. I prescribed three grains of sugar of lead mornings and evenings, commencing three days before the time of full moon, and continuing two or three days after this period. He took the medi- cine in this manner for nine successive lunar periods; but the dis- ease did not return after the fifth period from the time the treatment was commenced.* Dr. Rush gave this remedy in two grain doses with complete success in a case of this disease;! and Drs. Spence and Agnew employed it, in some instances, with decided benefit. Saxdorph also gave it with marked advantage. J Quarin (Animadv. Pract.) and Portal condemn its use in epilepsy, as being inefficacious in small doses and dangerous in large ones. Besides the foregoing remedies, many others have been used with advantage. Dr. Johnson speaks favorably of the internal use of cantharides; Dr. Kirkhoff has used the prussiate of iron with success; and Underwood has derived advantage from the use of savin.§ Mercury, with a view to its salivant effects, was formerly much recommended. Burserius speaks highly of the powers of cinnabar in this affection. Mercurials, particularly mercurial frictions, were used with success by Bang, Willis, Ettmuiller, J. Frank, Tissot, Locher, and others. Richter states, that the sulphuric acid sometimes produced the happiest effects in epilepsy. Advantage, however, is to be expected from its use only in cases attended with a general nervous irritability, and erethism of the vascular system. In such cases, from two to four drachms of the acid should be taken during the day. Zimmer- man, Tissot, and Hildebrand, (Hufeland's Jour. Bd. ix. p. 34,) com- mend the anti-epileptic powers of this acid. Various external remediate applications also have been recom- mended, and occasionally used with advantage in this affection. * New York Medical Repository, vol. ii. No. I. 1815. X New York Med. Repos. vol. ii. No. I. new series, 1813. X Osann. Dissertatio de Saturni Usu Medico, &c. 1809. § Dr. Ferrara, of Naples, has successfully treated an obstinate case of epilepsy in a young gentleman, by the employment of four or five grains of ipecacuanha every morning, and the same dose whenever any premonitory symptoms of the disease appeared. Dr. Gaetano Allegretti, another Italian physician, had re- course to this practice in four cases, in three of which a complete cure was ef- fected.—Jim. Jour, of the Med. Scien. vol. viii. p. 241. EPILEPSY. 69 Statements have been published which go to show that galvanism may occasionally be employed with benefit. It is said to be most efficacious in this disease when its influence is applied sometime be- fore the accession of the expected paroxysm, and (when the case is preceded by the aura,) if the positive current of the galvanic fluid is passed through the part where the aura commences.* According to the experience of Mansford, little or no advantage is gained from galvanism in epilepsy, unless it be applied steadily and constantly, and only with a weak power. He thinks that the negative point should be as near the brain as possible, and the positive one in some distant part of the body.t Electricity has also been recommended for the cure of epilepsy. Richter states, that this agent has been employed in several obstinate cases with great advantage. Both galvanism and electricity, how- ever, may, and have done unequivocal harm, particularly when ap- plied with much force. It is only in cases attended with a torpid and unirritable state of the nervous system, that these powers appear to be applicable with a prospect of benefit.^ Setons and issues were at one time much used in epilepsy. Hippo- crates cured a case by an issue on the crown of the head, (De. Morb. Sacro. § vii.;) and Tulpius relates a case cured in the same way. Mead used blisters on the back of the neck with success, (De Im- perio Solis et Lunae, cap. xi.) Fabricius cured an obstinate case with a seton in the nape of the neck, (Observ. et Epistol. Franc. cent. i. ob. 41.) The actual cautery has also been successfully applied in this disease. Van Swieten, Heister, Willis, De Haen, Larrey, and others, have related cases cured by this severe applica- tion. This remedy is mentioned by the ancients as a cure for epi- lepsy, particularly by Cselius Aurilianus. (Richter.) Larrey has published an account of some cases of epilepsy, in which local bleeding from the vessels of the head, and the subsequent application of moxas, blisters, and other counter-irritants, proved completely effectual. (Revue Medicale.) Of late years a good deal has been said in favor of pustulation with tartar emetic ointment, as a remedy in this affection. Mr. John Creighton has related six cases treated by frictions with this ointment, along the course of the spine, with very obvious benefit, though not with entire success in any one.§ More recently, Dr. Carter has .given an account of five cases of epilepsy, which go to show the usefulness of this application.|| * Walther. Uber d. Therapeutisch Indie, d. Galvanism. Richter, Specielle Therapie, Bd. vii. p. 716. X Galvanism is favorably mentioned as a remedy by Martens, (Answeis. Zur. Therapeut. Anwend. d. Galvanismus, p. 333;) Whitlam, (Med. and Phys. Jour. vol. xiv.) Burdach. X Electricity is particularly recommended in this disease by Albans, Stoll, Kuihn, Spengler, Wilhelm, and others. § Dublin Transactions, vol. iv. || Med. Chir. Rev. vol. ix. July, 1826. 70 CATALEPSY. Music has been employed to overcome this distressing malady. Quarin states, by means of this delicious power he succeeded in gra- dually weakening and finally subduing the epileptic paroxysms in one case. Whatever mode of treatment or remedies be employed, particular attention should always be paid to proper regulations in relation to the diet, exercise, and the action of the bowels. Sect. IV.—Catalepsy. We find this very remarkable and rare disease described in the books under a variety of names—such as stupor vigilans, congela- tio, extasis, catoche, or catochus, lethargus, carus catalepsia, &c. Catalepsy consists in a temporary suspension of consciousness, sen- sorial power, and volition—the body remaining in the precise posi- tion in which it was when the attack came on, without coma, mus- cular rigidity, or spasm; the respiration and circulation continuing. The attack generally comes on without any warning of its ap- proach. In some instances, however, symptoms, premonitory of the cataleptic seizure, occur, such as vertigo, cephalalgia, flushed face, a certain inactivity of mind and body, pain in the praecordium, a feel- ing of heaviness or tremor in the extremities, forgetfulness, flatulent pains in the bowels, yawning, sensorial obtuseness, depressed spirits; and in some instances a sensation similar to the aura epileptica. When the attack occurs, every part of the body remains in pre- cisely the same position in which it was at the moment of the seizure. If the paroxysm comes on while the person is in the act of doing any thing, as, for instance, drinking, the hand will be suddenly arrested with, perhaps, the glass near the lips and the mouth open. Even the expression of the countenance continues fixed during the cataleptic state, as at the moment of the attack.* The eyes are ge- nerally open, fixed and slightly .turned up. Sometimes they are spasmodically closed. One of the most remarkable circumstances of this affection is the wax-like flexibility (flexibilitas cerea) of all the members of the body, with sufficient tonic muscular action to cause an extremity, or the whole of the body, to remain in the exact position in which it is put by another person. Thus, if during the cataleptic state, the arm be raised up, or in any way extended or flexed, it will remain so until the paroxysm is over. To this, how- ever, the eyelids sometimes form an exception. When they are closed, they will not remain open when separated with the fingers; and when open, they immediately separate again, if forcibly closed, as soon as the force is removed. Van Swieten mentions an instance of the former,! and Heberden one of the latter.^ In complete cata- lepsy, all the sensorial functions are entirely suspended, and the * Richter's Specielle Therap. Bd. viii. p. 471. X Comment, vol. x. p. 183. X Comment, on the History and Cure of Diseases, p. 291. CATALEPSY. 71 patient, on recovering, remembers nothing either of his own internal sensations, or of what is done about him during the paroxysm. The period occupied by the attack is a perfect blank in the patient's existence; and if the paroxysm comes on while he is conversing, or in the performance of any other continuous act, he will resume the thread of the conversation, or even finish the half-pronounced word, or continue his acts, as soon as the paroxysm is over, as if no inter- ruption had taken place. Although voluntary motion is almost uni- versally suspended during the cataleptic attack, cases have occurred in which locomotion continued, without, however, the least con- sciousness in^the patient of its performance. Dr. Stearns* relates a case, in which if the paroxysm came on while the patient was walk- ing, the same pace was unconsciously continued. Dr. Good also relates a similar instance, in which the involuntary walking continu- ed during the attack.! Fernelius states, that he saw a cataleptic patient who, when pushed forwards, walked with a regular and firm step.f In cases less perfect, some degree of sensorial power remains, and the patient retains an indistinct recollection of what occurred during the paroxysm, on emerging out of it. But even in cases of this kind, all power of voluntary motion, or of manifesting, in any manner, a consciousness of their situation, or a desire for any thing, is wholly suspended. A case is mentioned by Galen,§ in which the patient, one of his fellow students, lay motionless like a log, with his eyes open; but he heard and remembered what occurred during the pa- roxysm. A remarkable case is related by M. M. Lenormand, seen also by Laennec and Recamier, in which there was complete immo- bility, rigidity of the whole body, pulse weak, expression of the countenance natural, and abolition of all the senses, except that of hearing; the patient (a young female) heard every thing that was said in her presence, but was totally unable to make the least sign, or utter the weakest sound. In the course of the third week, her hearing also failed, and her limbs became flexible, and readily as- sumed any position in which her attendants placed them. During the intervals of the attacks, she suffered much anxiety and pain in the pit of the stomach. || it is even stated that instances have occurred of catalepsy on one side only .IT In some cases the respiration and pulse become so feeble as to be imperceptible, and the whole surface is cold and contracted, as in death. The flexibility of the limbs, however, remains throughout— a circumstance which is never observed in dead subjects.** The duration of the cataleptic attack varies from a few minutes to * American Medical Register, vol. i. art. viii. X Study of Medicine, vol. iii. p. 387. X Patholog. lib. v. cap. xi. p. 70. § Liber i. Prorrhetic. p. 756. |J Rev. Medicale Juillet, 1825. \ De la Metrie, Abrege de la Theorie Chymique, &c. p. 278. (Van Swieten.) ** Fitzpatrick. Medical Commentaries of a Society, &c. of Edin. v. x. 72 CATALEPSY several days. A deep inspiration generally announces the return of consciousness, sensation, and voluntary motion. In many cases the paroxysm passes off suddenly, the patient recovering in an instant all his mental and physical powers. I saw a case lately with my friend Dr. Stadiger, which regularly recurred three or four times daily, and in which the paroxysms never continued longer than be- tween one and two minutes, and always came on and passed off sud- denly. In other instances, particularly in those of protracted dura- tion, the attack goes off gradually, the power of feeling and motion generally returning first in the fingers, then in the arms, and finally in the whole of the body. In transient cases, the patient experiences no unpleasant feelings, or sensible diminution either of the mental or corporeal powers, after the j>aroxysm; in others, a feeling of weight and fulness in the head, with slight cephalalgia, lassitude, and some degree of sensorial obtuseness, remain for some time after the attack has passed off. The cataleptic attacks in some instances recur with more or less frequency for months or even years; but it has very rarely been found to assume a strictly periodical character. Sometimes several attacks may occur in the course of one hour.* F. Hoffman mentions the case of a woman in which upwards of one hundred paroxysms occurred during the period of forty days.t Oc- casionally individuals will suffer a cataleptic attack, without ever afterwards becoming affected with it again.J Catalepsy sometimes succeeds, terminates in, or alternates or be- comes complicated with other affections. Dr. Lenormand's case, already referred to, was a most remarkable instance of this kind. The patient, a young girl, laboring under pains in the stomach and menstrual irregularities, passed successfully through nostalgia, fever, obstinate constipation, chorea, trismus, trismal catalepsy, complete catalepsy, chorea, a species of somnambulism, and finally hysteric symptoms, during the period of about eleven months. The disease v has been known to alternate or terminate in epilepsy, anomalous convulsive disorders, soporose affections, and mental derangement.§ It is sometimes modified by a very peculiar morbid excitability of the nervous system, giving it the character of cataleptic hysteria. In such cases, the patient will remain in a completely cataleptic state for some time, and then suddenly, without a recovery of conscious- ness, begin either to talk incessantly, or sing, or whistle, or declaim.|| Fleisch calls this modification of the disease, catalepsis loquax. (Richter.) Sometimes catalepsy is connected with a species of som- nambulism, the patient lying in what is familiarly called a trance. The diagnosis of catalepsy depends chiefly, if not wholly, on the * Behreus.—Baldinger's Neu Magazin. B. ix. p. 207. X Medic. Ration. System. T. iv. part iii. cap. iv. X Vogel. Praelectiones de Cognosc. et Curand. Morb. p. 569. § Hirschel Gedanken von der Starrsucht. p. 13. || Sauvages. Nosolog. T. ii. P. ii. p. 418. Richter, Specielle Therapie, B. vm. p. 477. CATALEPSY. 73 wax-like pliability of the extremities, and their maintenance of the position into which they are placed by extraneous force, together with the entire impossibility of the least voluntary motion. (Richter.) The affection described in the books under the name of ecstacy, though differing in some respects from catalepsy, as described above, appears to be only a modification of this latter disease, or at least not essentially diverse from it. In its general phenomena, ecstacy par- takes both of the character of tetanus and catalepsy. In ecstacy, the whole mind is concentrated, and as it were, fixed upon some par- ticular object, and the motific nervous influx is strongly and regu- larly determined upon the extensor and flexor muscles; so that no other impression can affect the mind, and the whole body remains rigid. Authors, however, differ in their statements with regard to the state of the muscular system. Good says, that in ecstacy "the muscles are thrown into a rigid and permanent spasm, not incurvat- ing the body as in the different modifications of tetanus, but main- taining it erect from an equal excess of supply (of nervous power,) to the extensor and flexor muscles." Richter, on the contrary, states that the limbs may be bent by extraneous force as in catalepsy; but they do not, as in this latter affection, continue in the position they are placed, but obey the laws of gravity.* The higher grades of ec- stacy are sometimes attended with visions, apparitions, &c. and may continue for many hours.t Osiander speaks of a variety of partial cataleptic affections, which sometimes attacks a single extremity in young females about the age of puberty. The limb swells suddenly, becomes insensible, incapable of voluntary motion, but remains plia- ble as in true catalepsy.J Causes.—This affection occurs much more frequently in females than in males. The period of life at which there appears to exist the greatest aptitude to catalepsy, is about the age of puberty. Persons of a nervous temperament, more especially when addicted to long and intense mental application, are said to be most subject to this affection. The exciting causes of catalepsy appear to be as various as those of epilepsy. The disease not unfrequentlv arises from the influence of mental affections, especially from disappointed love. Tulpius relates a case of this kind;§ and Schilling has collected similar in- stances. || Violent anger, protracted grief, hatred, and sudden terror, have produced this affection.IT Long continued and intense mental application has excited the disease.** Wepfer knew a young man * Loc. cit. Bd. viii. p. 481. f Braumer, de Differentia Ecstaseos et Catalepseos—as quoted by Richter. X Osiander, Denkwuirdigk, &c. B. i. § Observ. Medicar. lib. i. cap. xxii—as quoted by Van Swieten. || Disser. JEgrum ex Amore Catalepticum Factum Exhibens. (Richter.) Tf Richter, Speciell. Therap. B. ix. p. 488. ** The case already quoted from Galen was produced "by too much study," Van Swieten, 1. c. T. x. p. 193. Vol. II.—7 74 CATALEPSY. who always became cataleptic when he applied himself to mathema- tical studies.* Fernelius saw a case brought on by close study. Re- pelled cutaneous eruptions, particularly itch and tinea capitis, have been known to give rise to this affection.t Suppression or irregu- larities of the menstrual evacuation, appears to be one of the most common causes of catalepsy; yet the catamenial disorder, as Richter observes, is probably itself often only a concomitant occurrence, de- pending, as well as the cataleptic affection, upon some other morbid condition, particularly on intestinal irritation. That irritation in the stomach and bowels is often the direct exciting cause of the disease, is abundantly demonstrated by the cases that have been published. Van Swieten mentions the case of a woman seized with " true cata- lepsy," to whom he was called. While standing by her " she sud- denly vomited up two live round worms," and immediately the cataleptic affection ceased.f Similar cases are related by Thorn, Jawandt,§ Behrens, and others. A constipated and loaded state of the bowels also has been known to give rise to this affection. (Hirs- chel.) Catalepsy has been frequently found to occur in intermitting fever. Cases are related in which each paroxysm of this fever com- menced with a cataleptic state.|| Van Swieten quotes a case of this kind from Dodonoeus; and Richter refers to Fleisch and Hirschel for similar instances. Tissot has seen catalepsy produced by carbonic gas. It is said to have been excited by pregnancy.1T General plethora; organic affections within the head; masturbation, &c. are also enumerated among the exciting causes of this disease. It would be in vain to enter into any speculations concerning the proximate cause of this affection. We may indeed observe, that there appears to be a complete dissociation between the moral and corporeal elements of the human system, so that the former can no longer be affected through the latter, or vice versa. At the same time, however, that the mind is thus incapable of being excited, or of exciting the body, the brain continues to secrete and transmit the motific influence to the muscular system, although its distribu- tion is wholly beyond the control of volition. That the muscles are furnished with a regular influx of the nervous power, is evident from the fact, that the cataleptic patient, though enitrely without consciousness and sensorial power, will maintain not only an erect and firm posture, but support the extremities in positions in which they can be kept only by a regular and equilibrious action of the flex- or and extensor muscles. The metaphysician might draw interesting inferences from the phenomena of this disease, concerning the essen- * Observ. Med. Prac. de Affect. Capites, obs. 66. X Burserius Instit. vol. iii. p. 137. Dufour. Jour de Med. T. lxx. p. 418. X Loc. cit. T. x. p. 191. § Hufeland's Journal, B. iv. st. iv. p. 784. || Medicus Samml. u. Beobacht. B. ii. p. 372. (Richter.) ^ Osiander, Entwicklungs Krankheiten, &c. B. i. p. 182. CATALEPSY. 75 tial distinction between mind and the mere physiological functions of the sensorium commune. This, however, is not the place to in- dulge in speculations of this kind. The prognosis in this affection cannot, in general, be regarded as very unfavorable. Van Swieten observes, " I have both seen from practical observations myself, and it appears from undoubted observa- tions of celebrated physicians, that a great many have recovered from this disease and afterwards enjoyed a perfect state of health."* Tissot makes the same remarks from his own experience. It may, nevertheless, terminate in fatal apoplexy, or in epilepsy, coma, me- lancholy or mania, and occasionally, though very rarely, the catalep- tic paroxysm has been known to terminate fatally without the super- vention of any other affection. (Richter.) In protracted cases of catalepsy, the mind generally at last suffers more or less impairment of its powers; and in some instances, atrophy, emaciation, or dropsy, are its consequences. When the cataleptic paroxysm is succeeded by weakness and numbness in some part of the body—particularly of one or more of the sensorial organs, together with a sense of weight, fulness, and confusion in the head, or inactivity and absence of mind, the prognosis is particularly unfavorable with regard to its sanability; and the same remark applies to those cases which alternate with chorea, mania, or epilepsy. The occurrence of spontaneous sangui- neous discharges—as haemorrhois, epistaxis,or thecatamenia,has been known to put a stop to the further recurrence of the disease. Those cases which come on about the period of puberty, often cease spon- taneously after this stage of physical development has been fully passed over. Instances that depend on gastric irritating causes— such as worms, accumulated fecal matter, acrid secretions, or other moveable, offensive substances, are in general most easily cured. Treatment.—In general the treatment of catalepsy does not differ materially, either in its particular indications, or remediate measures, from that which has already been described under the head of epi- lepsy. When the paroxysm is protracted, small doses of sulphuric or acetic aether may be administered, if the power of deglutition remains, and there are no signs of cephalic congestion present. Great caution, however, is to be practised in the use of internal stimu- lants. Frictions along the course of the spine, fomentations or stimu- lating applications to the feet, and enemata, may sometimes contribute to the removal of the paroxysm. When evident signs of vascular congestion of the head are present, and the pulse is not very feeble, blood should be taken from the arm, or by means of cups from the temples or back of the neck, and sinapisms or warm applications made to the feet, together with the use of purgative enemata. If a purgative can be introduced into the stomach, it ought, by all means, to be done—more especially when there is reason to apprehend the presence of irritating matters in the intestinal canal. Reil states, * Commentaries, vol. x. p. 197. 76 CATALEPSY. that he once saw a girl affected alternately with mania and epilepsy, which instantly went off, on the expulsion of a number of lumbrici, by anthelmintics and enemata.* Galvanism and electricity, also, have been recommended in the cataleptic paroxysm; but they must not be applied in a strong degree. Richter refers to an instance, re- lated by Thorn, in which a young lady who was passionately fond of music, was roused from the cataleptic state by this delicious in- fluence. Hard tones produced no effect on her, but soft and melo- dious ones brought tears from her eyes, and roused her as from a dream. The treatment proper during the intervals of the cataleptic parox- ysms, with the view of preventing their recurrence, should accord with the character of the occasional cause, the patient's constitutional temperament, and the state of the vascular system. In the cases that occur about the period of puberty in females, active or exciting remedies will seldom do any good, but on the contrary, often prove decidedly prejudicial; and when such instances are connected with suppressed or irregular menstrual function, the active emmenagogues should be particularly avoided. (Richter.) A proper regulation of diet, country air, regular exercise, tepid bathing, sea-bathing, chaly- beate, and laxative mineral waters, will often do more in cases of this kind than any other course of remediate management. Where symptoms of gastric and hepatic derangement are present, the occa- sional use of four or five grains of blue pill, with a course of gentle laxative and tonic medicines, will often prove beneficial. A state of general plethora will require an abstemious mode of living, and ab- stractions of blood; verminous irritation demands anthelmintics; re- pelled cutaneous diseases call for external vesicating, pustulating, or irritating applications, with a gentle course of alterative and diapho- retic remedies; and a general excitable and weakened• state of the nervous system, requires tonics, with antispasmodics, the narcotic extracts, or camphor, exercise in the open air, and the use of the tepid shower bath. Stark cured a case of catalepsy by assafoetida, galbanum, and infusion of the bulb of pseony; the extract of hyoscy- amus, oxyde of zinc, valerian, musk, castor, and opium, (Grenier) have been successfully employed. Marx speaks very favorably of the powers of acorns in this affection. The sulphuret of iron, and belladonna, with the fetid gums, have been used with success; and Loebstien-Loebel recommends the use of phosphorus. In short, nearly every remedy that has already been mentioned, under the head of epilepsy, has been advised, and may perhaps be beneficial in certain varieties of this disease. The nitrate of silver, the elutri- ated oxyde of tin, flowers of zinc, mercury, cuprum ammoniacum, and the various antispasmodic and narcotic remedies have all been used, and sometimes, it is said with success. * Fieberlehre. Bd. iv. p. 72. CHOREA. 77 Sect. V.—Chorea.—St. Vitus''s Dance. The first distinct account which was given of this disease is to be found in the writings of Plater and Senertus, both of whom lived about the close of the sixteenth century.* Since that period it has been described under a variety of names, expressive of that peculiar saltant action of the extremities which characterises the disease, such as chorea St, Modesti; saltus viti; choreomania; ballismus; orchestromania; epilepsia saltatoria; dance de St. Guy. The name St. Vitus's Dance, by which it is now familiarly known, was derived, according to Horst, from the chapel of St. Vitus near Ulm, to which women laboring under a certain nervous affection were in the habit of resorting every spring, where they danced violently and unremittingly from morning to night, until they sunk down, completely exhausted, into a swoon, or kind of ecstacy, by which exercise they fancied themselves cured for one year. Some writers place its origin at a much earlier date, deducing, it from the very remarkable dancing mania which prevailed through- out Germany in 1374, and which, as it was thought to be the mali- cious doings of Satan, was generally treated by exorcism; and" it is said that the monks of the convent of Korbey were particularly for- tunate in casting out the fiend under the holy influence of their patron, Saint Veit. Chorea rarely, if ever, comes on suddenly. Its approaches are always gradual under a variety of premonitory symptoms, varying in duration from a few days to several months, indicative of a de- ranged state of the digeslive organs and nervous system. The most common of these symptoms are slight flatulent pains in the stomach or bowels, variable appetite, constipation, tumid and hard abdomen, occasional vertigo, anxiety and a feeling of oppression in the precor- dial region, slight tremors and heaviness of the extremities, op- pression in the chest, frequent palpitations, visual illusions, fulness in the head with temporary confusion of mind, a feeling of tension in the forehead, itching in the nose, cold feet, variableness of disposition fluctuating between gloom and cheerfulness, and in some instances a remarkable proneness to mischievous and unruly conduct. After some or perhaps the majority of these manifestations of de- ranged health have continued for a longer or shorter time, irregular muscular twitches or spasmodic contractions are observed in the face or one of the extremities. These spasmodic actions are, at first, slight and only occasional, and are particularly noticed on the sudden occurrence of any thing that flurries the mind. With more or less * It has been supposed that Hippocrates alludes to chorea in the following passage, according to the version of Fcesius. " Medulla spina affecta homo nee rrurum aut ventris officio potens est, nisi urgente necessitate; si vero morbus invaluerit turn aliquando praeter voluntatum mejit et egerit." 7* 78 CHOREA. rapidity, however, they become stronger and more constant, until, at times, almost every muscle of the body is in a state of continued involuntary action. Not unfrequently, the morbid muscular action is almost entirely confined to one side of the body; and this is generally the left side. (Richter.*) From ihe imperfect command of the will over the voluntary muscles, the patient, when he attempts to walk, has a starting, hobbling, and irregular gait, with an awkward dragging of one of the legs. Sometimes the involuntary muscular actions are so violent, and the empire of volition over them so com- pletely lost, that progression, and even an erect posture, are rendered wholly impossible.! The hands and arms too are in constant mo- tion; the patient is often entirely unable to direct them; and in all cases, various ineffectual efforts are made before the hand can be brought to the desired point. Thus, in conveying food or drink to the mouth, the hand is generally forced in almost every direction except the intended one, and is at last brought to the lips only after a number of unsuccessful efforts. The contractions of the muscles of the face are sometimes ex- tremely severetand irregular, giving a continually varying expression to the countenance, often of the most ludicrous cast, and occasion- ally truly frightful. The head is sometimes thrown from side to side, or backwards and forwards, the mouth suddenly widely opened and again forcibly closed, the tongue rapidly thrust out of the mouth and retracted, and the eyelids are in continued irregular motion. In violent cases, deglutition is much impeded, and, occasionally, for a short time entirely prevented, by the spasmodic action of the pha- rynx and oesophagus. Respiration also is often anxious and irregu- lar; the voice is altered, and articulation is indistinct and stuttering. Almost every voluntary muscle, in short, is at times in a state of uncontrollable and dissociated action. The authority and commands of volition are disregarded, and the whole muscular system is thrown into a state of revolt, its actions being irregular, lawless, and destructive to the welfare of the general constitution. At first the expression of the countenance, in the intervals of the spasmodic motions, "is that of good humor and contentment;" as the disease advances, however, the eyes lose their wonted lustre and intelligence, the face becomes pale, expressive of languor, and at last acquires a fatuous expression. Fleisch observes, that in many * Cases have been related, in which one leg and the arm of the opposite side alone were affected, (Woeltche, Observationes, Medicin. Fascicul. Richter.) X Occasionally all the muscles suddenly become completely relaxed; and in- stances have been known where the extremities have been so violently distorted as to dislocate some of the joints. (Bruickman. Enerratio Chorese St. Viti et Epilepsia per Fontis Medicatos Emenses Curatse. Hufeland's Journal, Bd. iii. st. iv. p. 612. Richter, Specielle Therapie, Bd. vii. p. 735.) A case is mentioned in Baldinger's Magazine, st. xii. p. 1095, in which the elbow-joint was dislocated, and in a few minutes again replaced by the violent contortions of this disease. CHOREA. 79 instances patients affected with this disease evince a peculiar and ap- parently irresistible propensity to creep into holes, boxes, or closets, so narrow that it is sometimes difficult to extricate them from their confined situations.* The temper and mind almost always become more or less affected in cases of a protracted character, more especially in very young subjects. I have seen several cases in which complete and perma- nent weakness of intellect was the consequence of this disease. In some instances, the patient occasionally lapses into a kind of ecstacy or somnambulism. (Richter.) Slight paralysis sometimes occurs on one side of the body. Nearly three years ago, I attended a child affected with this disease, in which incomplete hemiplegia and amau- rosis in both eyes took place; and it is only within the last ten months that these paralytic affections have wholly gone off. Sometimes chorea assumes very extraordinary forms. In some cases the patient is seized with paroxysms of violent dancing, leap- ing or stamping, accompanied with various antic contortions of the body; at others there is a rapid and forcible beating with the hands against some part of the body, particularly the knees; occasionally an irresistible propensity to leap upon chairs, tables, and to clamber up the walls of the room is manifested; and patients have been known to stand erect and turn round like a top on the toes. Fever is not a necessary attendant on chorea, but when the disease con- tinues long, the muscles become wasted and flaccid, and in cases of a very obstinate and protracted character, slow febrile irritation ensues. During sound sleep, when volition is in a state of temporary sus- pension, (with regard to its influence over the voluntary muscles) all the spasmodic motions which characterise this affection cease en- tirely. Indeed the efforts of volition during the waking state, often manifestly aggravate the involuntary action of the muscles. It would seem that the stimulus of the will is in some degree essential to the production of the irregular muscular motions. Chorea is a paroxysmal affection. In most instances several dis- tinct paroxysms occur daily at irregular periods, with little or no spasmodic action during the intervals. Sometimes, however, violent exacerbations take place once, twice, or oftener daily, with more or less of choreal action throughout the intervals. Occasionally, though indeed very rarely, the recurrence of the paroxysms is strictly pe- riodical.! There is much diversity also in relation to the duration of the paroxysms. Sometimes they do not last more than ten or fifteen minutes; more frequently they continue for an hour or two, and occasionally they commence in the morning and do not cease until the patient sleeps at night. Cases have occurred in which the * Handbuch der Krankheiten der Kinder, &c. B. iv. p. 419. Richter 1. c. p. 731. Wichmann, Ideen zur Diagnostick. B. i. p. 137. X Mead. Opera. Tom. i. p. 32. 80 CHOREA. paroxysms'continued with no obvious remissions for six or seven days.* The touch of iron is said sometimes to have a very extraordinary effect upon this disease. Wichmann,t Richter, and others, assert that the peculiar spasmodic actions of this affection either cease in- stantly, or become greatly aggravated, if the patient places his hands on a piece of cold iron during the paroxysm; and Stark says that he has often known the same effect produced by sprinkling cold water* on the patient, or merely by touching him with a cold hand.J Chorea appears to be very closely allied to the tarantismus of Apulia, an affection which has, indeed, by some, been regarded as a mere modification of this disease.§ The berberie of India, also, would seem to be somewhat similar to chorea; and that singular con- vulsive affection, described under the name of raphania, which, from the latter part of the 16th to the middle of the 18th century, appeared in frequent and extensive epidemics in various parts of Germany and France, bore, in many respects, a close resemblance, in its chronic form, to the present disease. Whether those remarkable nervous and spasmodic affections, which have been known to result from religious enthusiasm or frenzy, are to be regarded as instances of chorea, is very doubtful. Many very extraordinary examples of this kind have been related. Wierus gives an account of a choreal affection which occurred among the nuns of the convent of St. Brigitta. They were seized with occa- sional paroxysms of screaming, dancing, leaping upon chairs and tables, and various other ludicrous contortions and motions of the body.|| The same writer gives the history of a somewhat similar affection, which prevailed in 1564, among the nuns of the convent Nazareth, near Koelln; the paroxjTsms of which were attended with very un-nun-like actions. " Infima corporis parte," says Wierus, " succusata ad eum modum qui veneri solet ascribi, oculis interim clausis," and it was concluded that nothing but the malicious work- ings of Satan could produce such mortifying and uncongenial phe- nomena. Dr. Robertson, in his inaugural dissertation, states, that some years ago, an affection, resembling chorea, appeared among a religious sect in Tennessee, in consequence of an enthusiastic and noisy mode of worship, and was extensively propagated by the influence of imagi- nation, or moral sympathy.1T * Vogel, Stark, Richter. X Ideen zur Diagnostick. Bd. i. p. 153. X Handbuch zur Kentniss u. Heilung innerer Krankheiten & Th. iii. p. 164. § Swartz Dissert, de Tarantismo, &c. Richter. || J. Wieri. Lib. de Praestigiis. p. 378. If The Rev. Mr. Hoge, in a letter to the Rev. Ashbel Green, of this city, dated September 10, 1801, speaking of the methodist revivals, says: During worship the members of the meeting " drop down on every hand, shrieking, groaning, CHOREA. 81 Causes.—Chorea very rarely attacks persons beyond the 20th year of age;* and its occurrence before the 8th year is equally un- common. Sydenham, Wichmann, and Thilenius, never met witk this disease in children under ten years of age; but its occurrence even in early infancy is unquestionable. About three years ago I met with an instance of well-marked chorea in an infant less than nine months old. This case was seen also by Dr. Parrish. Hamil- ton^ Gregory, and other writers, assert that the disease attacks girls and boys indiscriminately. Judging from my own observations, I should infer that females are by far more liable to it than males; and this inference is supported by the observations of several eminent writers. Van Hoven makes the relative proportion of males and females affected with chorea, as about two to twenty. The constitutional habit, most favorable to the occurrence of this disease, is that peculiar excitable state of the common sensorium, constituting what is usually called the nervous temperament. It is said that a predisposition to chorea is sometimes hereditary; but this depends probably simply on the hereditary transmission of the ge- neral constitutional temperament. Cullen, Wichmann, and JahnJ state, that this otherwise not very common disease, has been known to occur with unusual frequency during particular years or seasons; and it has been supposed, from this circumstance, that certain atmos- pheric constitutions may create a predisposition to its attacks. The following are the principal exciting causes of chorea: 1. Mental emotions, particularly terror, fear, disappointed love, and religious enthusiasm. 2. Gastro-intestinal irritation from worms, accumulation of fecal matter, and other irritating substances lodged in the intestinal canal. Hamilton and other late writers consider this as by far the most common source of chorea. That the disease very frequently arises from causes of this kind admits of no doubt, Its origin from intestinal irritation is not, however, so common, I think, as is alleged by Dr. Hamilton. Certaip I am, that in the majority of instances that have come under my notice, the exciting cause did not appear to be located in the alimentary canal, and little or no advantage was derived from the remedies usually found bene- ficial in cases unequivocally dependent upon causes of this kind. Cases of chorea have been reported, which ceased almost immediately crying for mercy, convulsed; professors praying, agonizing, fainting, falling down in distress for sinners, or in raptures for joy! No spectacle can excite a stronger sensation. I am told by the subjects of it, that a tremulous benumbing sensation seizes the extremities, particularly the lingers, which rapidly spreads through the system, the knees become feeble, the heart violently compressed, and the person drops to the ground." * Dr. Powel knew an instance in which this disease occurred in a person in the 50th year of age. f On Purgatives, &c. X Klinik. der Chronisch. Krankheit. Bd. i. p. 245. 82 CHOREA. on the expulsion of worms—particularly the tape-worm.* 3. Re- pelled chronic and acute cutaneous eruptions. Bisset, an English physician, relates a case which came on in consequence of the repul- sion of itch. Wendt saw an instance produced by the imprudent drying up of tinea capitis; and other authors mention cases excited by repelled small-pox, and miliaria. (Richter.t) 4. The suppression of habitual discharges, more especially of the menses. A case of chorea, in a girl about fourteen years of age, terminated fatally in less than three weeks. On dissection, the whole body of the uterus was found as hard as cartilage, and completely scirrhous. J 5. Unsatis- fied or over-excited sexual propensities. Richter states that chorea has been frequently cured by marriage. 6. Vegetable and mineral poisons have also been known to produce this affection. Stramo- nium, (Comment. Litter. Norimburg. An. 1774;) mercury, (De Haen Ratio Medend. torn. iii. p. 202,) and lead, have excited parox- ysms of chorea. Dentition, pregnancy, parturition, and cold, are also mentioned among the exciting causes of this affection; and it appears frequently to depend upon rapid corporeal evolution, or that peculiar change of constitutional habit which occurs at the age of puberty. The pathology of chorea derives little or no light from anatomical examinations. There are good reasons, however, for believing that it is essentially a cerebral affection. Its frequent occurrence from mental excitement; the intellectual weakness which almost invaria- bly results from its protracted continuance; the suspension of the convulsive motions during sound sleep; and its exclusive confinement to the voluntary muscles, point directly to the sensorium commune, as the immediate source of the irritation upon which the spasmodic actions of the disease depend. Unquestionably, however, the cere- bral irritation is itself very frequently secondary, depending on a primary irritation, located in some remote part of the system, and frequently, perhaps, in the alimentary canal. In some cases which I have seen, it appeared to me that the irregular muscular motions were not so much the result of involuntary muscular actions, as of an irresistible volition to perform these peculiar motions. In those instances of [the disease, at least, that are characterised by leaping on tables, chairs, dancing, clambering up walls, and other similar actions, the propensity or will to do so appears to be irre- sistibly exerted; and we might, with some plausibility, ascribe the characteristic phenomena of the disease to a morbid action of the faculty of volition, depending generally on a sympathetic, and some- times an idiopathic irregular excitement of the brain. * Albers. Hufeland's Journal, Bd. i. p. 152.—Baldinger's Neues Magazin. Bd. ix. p. 189. j- A case of chorea, consequent upon scarlet fever came under my observation recently and slowly yielded to remedies. X Richter's Specielle Therapie, Bd. vii. p. 749, quoted from Wiegand's Ma- gazin. fur Geburtsh. 1808. st. ii. CHOREA. 83 Richter thinks that the proximate cause of chorea is seated in the system of ganglionic nerves, and particularly in the abdominal plexus. It is from this location of the primary irritation, he says, that the first manifestations of the disease generally occur in the feet; that gastric and uterine irritation so frequently constitute its exciting cause; and finally, that those remedies which act more especially upon the abdominal viscera, are usually the most beneficial. All these circumstances may, however, be adduced with equal plausibi- lity in favor of the cerebral pathology of this affection. Prognosis.—Chorea very rarely proves fatal, but it cannot be said to be entirely free from danger, as some writers have asserted.* I have known one instance to terminate fatally, by the supervention of a slow and waiting irritative fever. Occasionally it is converted into epilepsy, and may prove fatal through the intervention of this affection.t The duration of chorea varies greatly. It may continue only a few days, or several weeks, months, or even years. The more violent and protracted the paroxysms are, and the more the mind has become affected by its attacks, the more difficult, in general, will it be to effect a cure. When the disease becomes very protracted in its course, it rarely fails to weaken the intellect; and it has occasion- ally terminated in mental derangement, particularly in melancholy. Richter observes, that when chorea is complicated with other affec- tions—as chronic pectoral diseases, scrofula, fluor albus, and in gene- ral with a debilitated and shattered state of the nervous system, the prognosis is unfavorable. When it arises from the irritation of worms, or other substances in the alimentary canal, it is generally readily cured by proper remediate measures. It appears to be less apt to yield, when it has been excited by terror or other violent emotions of the mind. Instances that occur about the thirteenth or fourteenth year of age in girls, generally continue until the sexual development is completely accomplished. Cases of this kind, if left to themselves, almost universally terminate spontaneously after the regular establishment of the catamenia. When the disease is ar- rested by remediate treatment before the changes of puberty have been accomplished, it is apt to return, and to manifest itself at inter- vals until the period of adolescence is passed. Treatment.—The principal indications in the treatment of chorea, are, 1. To remove or counteract the exciting cause; 2. To invigorate the general system; and 3. To break up the train of associated actions by which the paroxysms are repeated or continued. As the ordinary cases of chorea are almost always devoid of dan- ger, and often terminate spontaneously, after having for a considera- ble time resisted remediate treatment, it is not in general advisable to resort at once to very energetic remedies or modes of treatment. This observation applies particularly to those cases which depend on * Wichmann, Baumes. X Weigand, Hamburg Magazin. Fuir. die Geburtsh. St. 1808. 84 CHOREA. that peculiar constitutional metamorphosis which occurs during the period of puberty; for we may calculate almost with certainty on the spontaneous termination of such cases as soon as this stage of corpo- real development is fully completed.* Every one knows how strongly purgatives are recommended in the treatment of this affection, by Dr. Hamilton of Edinburgh; and this practice has since obtained pretty general approbation in Eng- land and in this country.t Where the bowels are in a torpid state, with an accumulation of fecal matter, free and repeated purgation is, without doubt, a highly important measure; and in all cases, indeed, laxatives must be regarded as useful auxiliaries. That the power of this class of remedies as a curative measure, is, however, considerably overrated by Dr. Hamilton and others, I am much inclined to sus- pect. I have treated twelve or thirteen cases according to the plan laid down by this highly respectable writer, but have not, in more than two instances, derived the advantage from it that I was led to expect from his statements. As a preparatory and auxiliary mea- sure to tonic and other suitable remedies, moderate purging will rarely fail to do good; but I question much whether any decisive impression can be made on this disease by purgatives alone, except in cases depending on intestinal irritation from fecal accumulations or other irritating substances lodged within the bowels. Where the signs of gastric impurities, or of a loaded state of the bowels, are unequivocal, mercurial purgatives should be given daily, or every other day, until there is reason to believe that the offending matters are evacuated, and the biliary secretion improved.^ After the bowels have been freely evacuated, tonics should be used in alternation with laxatives. The quinine, or any of the ordinary bitter infusions, will answer for this purpose.— Whytt says that he has known the super- vention of diarrhoea to put a permanent stop to chorea; and the very remarkable case, reported by Dr. Watt, after active purgatives, and a great variety of other remediate means, had been ineffectually em- ployed, terminated at last, on the occurrence of profuse spontaneous diarrhoea. (Med. Chir. Transact, vol. v.) * The importance of attending to these circumstances is particularly insisted on by Richter. Specielle Therapie, Bd. vii. p. 755. f The employment of active purgatives for the cure of this disease, was strong- ly recommended long before the time of Dr. Hamilton. Stark speaks highly of the good effects of very active purgation in this disease. (Acten d. Kurfufstl. Aca- demieder Wissenshaften. 1776. p. 193.) Unzer also employed drastic'purges with success in chorea. Sydenham treated this disease by purgatives and bleed. ing on alternate days, with an opiate at night. (Schedula Monitoria de Novae Fe- bris Ingressu, an. 1655.) X Hamilton recommends full doses of calomel and jalap. I have generally preferred using the following pills: R.—Extract, colocynth. comp. gi. Calomel gss. Tart, antimonii gr. i._M. Divide into 20 pills. S. Take one, two, or three, according to the age of the patient, every other day. CHOREA. 85 In some instances, coming on from retained or suppressed men- strual evacuation, the general diathesis is manifestly phlogistic. Here, along with aloetic purges, it will be proper to bleed, and to put the patient on a mild vegetable diet, with an occasional dose of Dover's powder in the evening. About three years ago I attended a young lady who was seized with chorea, apparently in consequence of sup- pressed catamenia. Her pulse was small, sharp, and tense; the skin generally dry and warm, and the bowels constipated. 1 directed her to be bled to the extent of twelve ounces, and to take one of the pills, mentioned below,* every night, and a small dose of sulphate of magnesia every fourth day. In the course of two weeks she was bled four times, and the disease disappeared during the third week. The menses did not reappear until five weeks afterwards. When the disease attacks persons of a highly excitable state of the nervous system—or of a strongly marked nervous temperament, peculiar benefit may often be derived from the cautious exhibition of antispasmodic and narcotic remedies. Valerian, assafcetida in union ivith quinine^ musk, hyoscyamus, camphor, and opium, under judicious management, will sometimes do much good in cases of this kind. In cases depending on suppressed catamenial discharge, attention must, in the first place, be paid to the alimentary canal. Laxatives, a mild and simple diet, with a few grains of blue pill at night, must be employed until the bowels and liver are brought to a healthy condition. When this is effected, recourse may be had to remedies more directly calculated to promote the flow of the menses—parti- cularly to turpentine, warm pediluvium, cantharides, blisters over the sacrum; small doses of aloes!—and, where the general habit and pulse are languid, savin, and black hellebore. Richter says that in one instance of this kind, he gave twelve grains of borax three times daily, with speedy and complete success. It should be recollected, however, that retained or suppressed menstruation may accompany chorea, without having any agency in the production of this affection —the catamenial disorder being itself only a concomitant effect of some previous general morbid condition of the system. It will, * R.—Massae hydrarg. gi. G. aloes. 3ss. 1 Tart, antimonii gr. ii.—M. Divide into 20 pills. \ Within the present year I have seen very decisive advantage obtained from the use of the following pill, taken every four hours, after proper evacuations had been premised: R.—Sulphat. quinae ^i. G. assafcetid. Qii__M. Divide into 20 pills. X The compound tincture of aloes, in doses of from 15 to 20 drops three times daily, is one of the best aloetic preparations for this purpose. Small doses of hiera-picra, also, frequently answer peculiarly well, where there is considerable weakness of the stomach present. Vol. II.—8 86 CHOREA. therefore, be more accordant with correct principles of practice, to endeavor rather to remove that general morbid condition upon which both the menstrual irregularity and the convulsive disorder depend, than to make vain, and too often injurious, efforts to restore the menses with active emmenagogue remedies. When, therefore, re- laxation, debility, or a general leucophlegmatic state is present, tonics, particularly iron, a regulated diet, ventilation, and exercise by ges- tation, should be chiefly depended on : and, on the contrary, where the diathesis is phlogistic, the body plethoric, and the skin dry and warm, recourse must be had to depletion, purgatives, a vegetable or farinaceous diet, leeching about the pelvis, &c. When chorea arises in consequence of suppressed perspiration from cold, or the retrocession of cutaneous eruptions, antimonials, Dover's powder, camphor, warm aromatic ptisans,* the warm bath, blistering, rubefacient frictions, the internal use of sulphur, issues or setons, and a warm and equable temperature, are appropriate reme- diate measures. It is scarcely necessary to say, that where vermi- nous irritation is manifestly present, anthelmintics, should be used. In instances that are excited by mental emotions, musk and opium are said to be particularly calculated to do good. Considerable advantage may sometimes be obtained in the treat- ment of chorea, whatever be its exciting cause, from external appli- cations—such as dry frictions with flannel, or blistering, or rubefa- cients, along the course of the spine; stimulating baths; the cold shower-bath, and sea-bathing. The cold shower-bath, after a proper course of evacuants, and in connection with the internal use of tonics, will generally contribute materially to the re-establishment of health. Frictions with tartar emetic ointment over the region of the spine, has been resorted to with entire success in some very severe and protracted cases. Mr. Hunter of Glasgow, (Med. Recorder, vol. 8,) has reported an interesting case, which after many ineffectual trials with other remedies, was speedily subdued, by pustulation with this ointment on the scalp, and over the spinal column. Dr. Wharton, of Virginia, also, has related a case which yielded to this treatment. (Med. Recorder, No. 33.) In the fifth volume of the Amer. Journal of the Medical Sciences, Dr. Byrne, of Baltimore, has given an ac- count of two protracted and obstinate cases of chorea, in which pus- tulation along the course of the spine effected speedy cures. The first case had continued nearly two years—the mind was evidently impaired, " the appetite was bad, the tongue foul, and the bowels irregular, generally costive." The patient, a girl, was 13 years old, and had as yet never menstruated. The purgative plan of treat- ment was fully tried; afterwards, she was put on the use of tonics and antispasmodics, and finally subjected to a slight mercurial course. No advantage, however, was derived from these remedies. Strong * Infusions of elder blossoms, eupatorium perfoliatum, catnep, sage, rnarp- rum, balm, &c. will answer well for this purpose. CHOREA. 87 tartar emetic ointment was then rubbed in along the whole spinal co- lumn, and repeated three times daily. " On the evening of the second day the eruption began to appear, and from that time to the present, the patient has never been .affected with the slightest irregularity of muscular motion. Her mental faculties, in a short time, resumed their wonted energy, and her health was perfectly restored." If our endeavors to remove the disease, by a course of treatment founded on the indications furnished by the character of the exciting cause and the general state of the system, prove abortive, we may then resort to what the Germans, with strict propriety, call the em- pirical remedies, recommended in this affection. Among these, the flowers of zinc have perhaps been most fre- quently employed, and favorably mentioned, as a remedy in chorea. Burserius,* Hand, Richter,t Stark, and Alexander,^ relate instances of the successful employment of this article in chorea, and Dr Bed- dingfield asserts that thirteen out of fourteen instances of this disease, in which he gave this remedy, yielded permanently to its influence.§ In my own practice I have never obtained any decided benefit from this article. The sulphate of zinc, however, removed the disease speedily and permanently in one instance that came under my notice. The patient, a girl about twelve years of age, had already been affected with the disease for upwards of nine months, and undergone various modes of treatment. A grain of this preparation was given three times daily; and, without any other remedies, the disease dis- appeared in less than ten days. A case is related which yielded speedily under the use of this article, given in doses of three grains, mornings and evenings.|| Cuprum ammoniacum has also been used with success in chorea. Willan cured a case in a very short time with this article.1T The nitrate of silver has succeeded in removing this affection. I have used this article with success in a case that was excited by ter- ror; but in no other instance has it appeared to be beneficial in my hands, although I have employed it in eight or nine cases at least. Dr. Franklyn cured a case of chorea by the conjoined employment of this article and cold affusions, (Lond. Med. and Phys. Jour. No. LXVIII.;) and Dr. Powell used it with marked advantage in this affection. (Transact. Lond. College of Phys. vol. iv.) The rust of iron will sometimes succeed better than any other remedy of this kind in the removal of this affection. The little patient, whom I have already mentioned, was cured by this article. * " Nuper confirmatam et numeris omnibus absolutam choream St. Viti solo floram zinci usu, tuto, cito et cucunde curavi." Institut. vol. iii. p. 242. f Medic, and Surg. Observat. p. 153. X Duncan's Annals. § Compendium of Medical Practice. Part i. chap. x. || Memoirs of the Med. Society of Lond. 1773, vol. x. If Lond. Med. Journ. vol. iii. p. 11. p. 187. 88 CHOREA. I had employed a course of purgatives, the nitrate of silver, flowers of zinc, and vesication along the spine and on the back of the neck, without any apparent benefit. By the advice of Dr. Parrish, the rust of iron was given; in less than three days a very decisive impression was already made on the disease, and in about three weeks all the convulsive motions were removed. I have since used this article in two instances with success. One of these, a little girl, was cured by it about two years ago. Within the last six weeks, she has again been seized with the disease, and in this attack I have not been able to obtain any advantage from the iron. It should be given in large doses. Dr. Elliotson administered this article in very large doses—from a drachm to half an ounce three times daily. He relates eight cases, all of which were cured by this remedy. (Med. Chirurg. Transact, vol. xiii.) Chenopodium ambrosioides has been highly extolled for its powers in this disease. It was first recommended by Plenk, and has since been used very successfully by Mick, Ecker, and others.* It is given in powder from one scruple to a drachm, two or three times daily.t Camphor.—No small number of cases have been published illus- trative of the good effects of this article in chorea. Pitt used it suc- cessfully in combination with valerian; and Wilson (Med. Comment. Edinb. vol. ii.) reports a case which yielded under the employment of camphor and assafcetida. Richter says that this article is particu- larly useful in cases attended with seminal irritation, or in such as are produced by inordinate venereal indulgence. A variety of other remedies are said to have been used with ad- vantage in this affection. Werlhof cured the disease with the animal oil of Dippel.% Cardamine pratensis is recommended by Michaelis and Naegel; Stoll recommends the extract of belladonna, and Dr. Kerrison succeeded in curing an obstinate case with it.§ Stramonium has been successfully employed in this affection by Krevsi°- Hufe- land, Odhelius, and Sidren.|| Fowler's arsenical solution proved very beneficial in the hands of * Pinel's Nosography—Translated into German by F. V. Ecker. f I have used this plant in several cases of chronic hysteric affections with marked benefit. I usually employ it in the form of infusion—an ounce of the herb to a pint of boiling water—in doses of a wine-glassful four or five times daily. It is particularly useful in cases attended with a feeling of numbness in the extremities, and with much gastric disturbance from flatulency. The chenopodium ambrosioides is one of the most common weeds in the neigh- borhood of this city. It grows in the streets and along the fences in almost every part of the suburbs. X Observ. de Febrib. sect. ii. § London Medical Repos. No. XXXIV. art. ii. || Ausfuhrliche Arzneimittellehre. Von Dr. Geo. Aug. Richter. B. ii. p. CONVULSIVE AFFECTIONS OF INFANTS. 89 Dr. Newnham.* Dr. Raven has published four cases in which the tincture of colchicum was used with great benefitt In one instance of a violent grade in a girl aged about seventeen, he gave 40 drops of this tincture every four hours. On the third day after commenc- ing with this remedy the disease was already nearly subdued; and by continuing its use in gradually augmented doses, perfect health was restored to the patient. A very remarkable case is related by Dr. K. Wood, in the seventh volume of the Medico-Chirurg. Trans- actions, which was cured by beating a drum during the paroxysms Dr. Young has reported some cases of this disease which yielded speedily to the use of the root of actea racemosa (cimicifuga race- mosa.) He gave a teaspoonful of the powdered root, three times daily. "This remedy, he says, appeared to arrest the progress of the disease almost at once. After using it only two days, one of the pa- tients was visibly benefited, and was entirely cured in five days."J Electricity has also been recommended for the cure of chorea. De Haen states that he has known great benefit to result from the application of this agent; and Fothergill has published some remarks illustrative of its good effects in this disease.§ Galvanism, also, has been recommended; and Richter asserts that music has sometimes produced astonishingly tranquillising effects in this disease. Sect. VI.—Convulsive Affections of Infants. At no period of life are convulsions so apt to occur as during the age of infancy. With a nervous system peculiarly excitable, infants are subject to so many sources of permanent and transient irritation, that a very large portion of them suffer more or less from convulsive affections; and these constitute an alarming proportion in the cata- logue of fatal infantile maladies. According to the statement by the late Dr. Clark of Dublin, it appears that of 17,650 children born in the Dublin lying-in-hospital, one-sixth part died during the first year; and of those who died, nineteen out of twenty perished by convul- sions. This proportion of mortality from convulsions, however, very greatly exceeds that which a similar estimate drawn from pri- vate practice would yield. Still the frequency and fatality of this affection, under its various forms, is by no means inconsiderable in every rank of society, and under every variety of climate and exter- nal circumstances. Both the anatomical and physiological pecu- liarities of the infantile system, are indeed such as to account for the especial aptitude to convulsive maladies during this tender period of life. The mind and body of an infant, not yet inured to the impres- sions of internal and external causes, possess the most lively suscep- * London Med. Repository, No. XLII. | Lond. Med. and Phys. Jour, xxxvi. Sept. and Oct. 1816. X American Jour, of Med. Scien. vol. xii. p. 57. § Philosophical Transactions, for the year 1779. 8* 90 CONVULSIVE AFEECTIONS OF INFANTS. tibility to the various perturbating and exciting influences to which it is unceasingly subjected. "The muscles, during infancy, are pale, soft and fragile; their contractions quick, frequent and feeble; and the external surface of the body is endowed with a very high degree of sensibility. The circulation of the blood is very rapid, and the capillary system is peculiarly active. The lymphatic system exerts a more powerful influence upon the general economy of the infant, than upon the adult. The nerves are large, in proportion to the size of the body, and resemble medullary pulps. Both the cerebral and ganglionic nerves are much more strongly developed in relation to the body, than at any other period of life. The brain is large, and the nerves which proceed from it are of a very considerable size. The sensations of a child are quick and transient; slight impressions give rise to powerful effects; and when reaction takes place, it is strong and sudden, and coincides with the general mobility of the infantile system."* Mr. North observes that the children of parents who marry either very early, or at an advanced age, are more liable to convulsive af- fections than the children of those who marry in the prime of life. I have met with very striking instances of aptitude to convulsions in several families, which accord entirely with this observation. It has, also, been said that convulsions are much more common in cities, and particularly in the higher and more luxurious classes of society, than among the laborious and less pampered inhabitants of the coun- try. Of this, there can scarcely exist a doubt. The fresh and pure air of the country has an especial tendency to invigorate the infantile system, and to diminish nervous irritability, and thus to render the ordinary causes of convulsions less apt to excite such affections. It is, perhaps, mainly from the want of a pure and wholesome air in hospitals, that convulsive diseases are so much more common in these institutions than elsewhere. That the predisposition to convulsive affections is often hereditary, is amply demonstrated by observation. We occasionally meet with families, in which the occurrence of re- peated paroxysms of convulsions is almost a matter of course in all the children, as they successively pass through the process of pri- mary dentition; and, on the other hand, in very many families, blessed with a numerous offspring, such affections never occur, al- though the ordinary exciting causes may be conspicuously present. The children of mothers endowed with a very susceptible physical and moral constitution—with a quick and active imagination, great sensitiveness and mobility of temper, are in general most apt to suffer convulsive affections. Observations have also been made in relation to the configuration and size of the head, as an indication of the natural aptitude to affections of this kind. It has been said, for instance, that children who have very large heads are more liable to convulsions than those who are less liberally furnished in this way. This obser- vation, however, is I believe, wholly without any foundation. * North. On the convulsive affections of children, p. 11. CONVULSIVE AFFECTIONS OF INFANTS. 91 Exciting Causes.—The exciting causes of convulsions are ex- tremely various. In general, whatever is capable of causing strong sanguineous determinations to the brain, or of producing nervous irritation of the sensorium commune, may give rise to convulsive affections in children. The vascular turgescence of the brain, which in adults causes coma, or apoplexy, is apt, during the infantile period, to produce general convulsions. Even a moderate degree of sanguineous engorgement of the brain, is frequently productive of convulsions, in children predisposed to the affection. This is often illustrated by the occurrence of strong convulsions in fevers of strong vascular reaction, and particularly in the cold, and some- times hot stages of intermittents. In very young children, the pa- roxysms of an ague are very often ushered in by convulsions. 1 have known instances, in which paroxysms of convulsions occurred periodically for four or five days, before the nature of the malady was understood. In some instances, however, the disease arises from cerebral or nervous irritation, without any extraordinary sanguineous determi- nation to the head; and these are, in general, the most serious and unmanageable cases. This cerebral irritation is usually purely sym- pathetic, depending on a primary local irritation seated either in the alimentary canal, or in some other part, more especially in the gums from dentition. It must be observed, nevertheless, that both intes- tinal irritation and dentition are very frequently attended with an increased determination of blood to the brain; and the latter espe- cially, is but very rarely unaccompanied by this additional source of cerebral disturbance. When an attack of convulsions is preceded and attended with a flushed and turgid countenance, dilated pupils, a full and active, or a contracted, frequent and tense pulse, with strong beating of the ar- teries of the neck and temples, and a warm and dry skin, we have conclusive evidence that the cerebral irritation which causes the con- vulsions is mainly, if not wholly, produced by vascular turgescence in the brain. In such cases, the child generally remains in a lethar- gic state, for a longer or a shorter time after the subsidence of the convulsions. When, on the contrary, the countenance is pale and the pupils contracted, the skin cool or of the natural temperatnre, the pulse small, frequent, quick and irregular or feeble, we may infer that the attack is not dependent on sanguineous irritation of the brain, but the result of nervous irritation, transferred to the common sensorium, most probably from a primary nervous irritation, located in the intestinal canal. Among the most common exciting causes of this affection are: Worms, and various other irritating substances lodged in the alimen- tary canal, such as acid indigestible articles of food; over distension of the stomach, acrid intestinal secretions, &c. Repelled cutaneous eruptions, and suppressed discharges from ulcers or excoriations, particularly when seated behind the ears. General plethora, with a predisposition to irregular sanguineous determinations to the brain. 92 CONVULSIVE AFFECTIONS OF INFANTS. Dentition—Irritation from the latter cause is incomparably the most frequent source of convulsive affections during infancy. Con- vulsions not unfrequently occur in the acute exanthematous affec- tions, either just before the eruption is about making its appearance, or in consequence of the sudden recession of the exanthemc, before the period of its regular declension. Convulsions may also be ex- cited by a direct or mechanical injury of the brain. I have known several instances, where a fall on the head, so as to cause considera- ble concussion of the brain, almost immediately gave rise to general convulsions, without any permanent or fatal lesion of the brain. Even severe local injuries of parts situated remote from the ence- phalon, will sometimes excite an attack of convulsions. In some cases, a slow and insidious vascular irritation will go on in the brain, with scarcely any decided symptoms of disease, until either an effusion of serum upon the surface or into the ventricles of the brain, or some other cerebral lesion, is effected. In cases of this kind, a paroxysm of convulsions is sometimes the first unequivocal intimation of the child's indisposition; and what was previously con- sidered as mere fretfulness and general irritability of temper, of no serious import, now suddenly assumes the character of an almost hopeless form of cerebral disease. Cases of this kind, however, are almost invariably connected with more or less paralysis, and fre- quently with strabismus, and must be regarded rather as insidious instances of hydrocephalus or of cerebral inflammation, than as con- vulsions of the ordinary form, of which I am now speaking. The Prognosis of infantile convulsive affections must depend mainly on the nature of the exciting cause, and the violence and du- ration of the attack. Cases arising from a primary irritation located in the alimentary canal, or from the irritation of dentition, are, caete- ris paribus, always less dangerous than instances depending on a primary irritation or lesion of the brain, or its spinal prolongation. Even purely sympathetic irritative convulsions, arising from intes- tinal or dental irritation, may terminate fatally, by the shock and structural lesion which the brain may receive from the violent deter- mination of blood which in some instances takes place tq the vessels of the encephalon. This is more particularly apt to be the case in children of a corpulent and very plethoric habit, and where the con- vulsive attacks are of a protracted duration. In ordinary habits, there is but little to be apprehended from convulsions during infancy when the attacks are slight and of short duration; and this observa- tion applies especially to those instances which, instead of leaving the infant in a dull and lethargic condition, are almost " immediately succeeded by the natural cheerfulness of the child." (North.) When death occurs suddenly during a paroxysm of convulsions, we almost always perceive manifest signs of strong sanguineous congestion in the vessels of the head—such as a darkish and turgid aspect of the face, fulness of the veins of the neck and head, heavy and almost stertorous breathing; and in such instances, the little patient dies " in a state nearly allied to apoplexy in the adult." The reviewer CONVULSIVE AFFECTIONS OF INFANTS. 93 of Dr. North's excellent treatise on this affection, asserts that he has made more than thirty dissections of children who had died of con- vulsions, and that he invariably found the vessels of the encephalon strongly engorged with blood, attended with more or less serum in the ventricles of the brain; and, in several cases, "considerable ex- travasation of blood from a ruptured vessel" was detected.* When paralysis and squinting occur the most serious cerebral lesion may be inferred, and the prognosis is, of course, of the most unfavorable kind. Convulsions that come on suddenly, without any premonitory symptoms, are, in general, much more apt to terminate favorably, than those cases which supervene after a considerable period of slight indisposition—such as great fretfulness, starting from sleep, grinding the teeth, occasional flushes on one or both cheeks, a variable appetite, deranged state of the bowels, &c. Before I go on to speak of the treatment of the convulsive affec- tions of children, it will be necessary to give an account of a very singular form of spasmodic or convulsive disease, occurring in chil- dren during the period of lactation. This affection, was, I believe, first distinctly noticed by Dr. John Clark of Dublin, in his Com- mentaries. About sixteen years ago, an interesting paper was pub- lished by Dr. Kellie on this subject;! and at a subsequent period, Dr. James Johnson published some observations on the disease, of a very interesting character.^ The most satisfactory account of this remarkable form of convulsive disease, that has as yet been given to the public is to be found in the treatise of Dr. North, already quoted in several places. Dr. James Johnson denominated this affection carpo-pedal spasm; others have designated it as a form of cerebral spasmodic croup; and Dr. North has treated of it under the head, A spasmodic affection of the ch.st and larynx in young children, accompanied by general or partial convulsions. The following are the phenomena and general course of this affection, as detailed by Dr. North, and in the interesting paper on this subject published by Dr. Kellie. The disease generally occurs between the third and seventh month of age. It usually makes its approaches in a very gradual manner. At first the symptoms are often so slight, as scarcely to attract the attention of the persons about the infant. Among the earliest symp- toms of the approach of the disease is a very peculiar hurried breath- ing, accompanied " by that kind of noise which an increased secre- tion of mucus in the air passages would produce," occurring at the moment the child wakes from sleep. Frequently the child awakens, as in a fright, and is immediately affected with this agitated respira- tion, and rattling in the trachea. " If the little patient has previously enjoyed a good state of health, the characteristic rotundity of fea- * Medico-Chirurgical Review, July, 1826, p. 157. j- Edinburgh Med. Journal, vol. xii. X Med. Chir. Journal, vol. iii. 1817. 94 CONVULSIVE AFFECTIONS OF INFANTS. ture observable in infants, quickly undergoes a remarkable change; the countenance becomes anxious, the sides of the nose are drawn in, the face is pallid and emaciated, the child frowns almost con- stantly, and when put to the breast, it sucks greedily for a mo- ment, but suddenly ceases to do so, throwing back the head with violence." The bowels always become constipated in the progress of the disease. These symptoms may recur, with more or less fre- quency, for a very considerable time, before any remarkable change takes place, indicative of a further development of the affection. " A convulsive motion of the hand is usually the next morbid sign which excites attention. The child's thumbs will be found constantly and firmly pressed upon the palm of the hand; the wrist and ankle-joints are bent rigidly inwards; the head is often thrown backwards, by which the anterior muscles of the neck are kept painfully upon the stretch. The inconvenience at the moment of waking is not now a mere acceleration of breathing. This symptom still continues in an aggravated degree—but the noise accompanying the respiration has gradually assumed a very different character from that which at first marked it. Each inspiration is now attended by a loud crouping noise, which may be heard in an adjoining apartment; the chest and larynx appear to be painfully constricted; the heart palpitates vio- lently; the child sobs, but never cries in its natural manner during these paroxysms of suffering. So great is the difficulty of breathing, that it sometimes appears to be almost totally suspended for a few seconds. The countenance is then pale, as in syncope. Sometimes, though rarely, the face is dark, and the vessels of the head and neck turgid, as in apoplexy. As the disease advances, the little patient experiences more or less frequent attacks of general convulsions, during which the features are much distorted; and the whole body is occasionally implicated in the convulsive movements. In a child, in whom the convulsions were very frequent and severe, the state of opisthotonos was so complete, that for many days the head and heels were the only parts which touched the bed; and if, with difficulty, this apparently painful position was altered by the mother, it was quickly resumed. In the majority of cases, no sustained febrile action is to be detected, nor is there usually any indication of particular de- termination of blood to the head."* Sometimes, the locked state of the thumbs, rigidly bent position of the hand and foot, and stri- dulus or croupy respiration, will continue several weeks with scarcely any intermission, though irregular intervals of remission and exacerbation are always more or less conspicuously noticed. " The child sometimes appears lively for a short period, and the counte- nance may be animated by a momentary gleam of cheerfulness; but it almost invariably awakens from its slumbers, however tranquil they may sometimes appear, with a convulsive paroxysm similar to that described above." After the termination of a paroxysm, the * North loc. citat. p. 259. CONVULSIVE AFFECTIONS OF INFANTS. 95 child appears to be greatly exhausted) and with scarcely the power of voluntary motion for some time. Dr. Kellie's description of this affection is somewhat different from the one just given from Dr. North's work; but in the main and characteristic phenomena, they coincide sufficiently to enable any one to refer it to one and the same form of infantile disease. "On the anconal aspect of the metacarpus of the hand," says Dr. Kellie, "and on the rotular aspect of the meta- tarsus of the foot, a remarkable tumor occurs, having a considerable degree of roundness and elevation, resembling that sort of swelling which might arise on the same parts from a blow or contusion. It seems to arise suddenly, and when first observed it has somewhat of a mottled livid and purplish color, resembling the chilled hand of a full and healthy child after exposure to a cold and frosty atmos- phere. It has no inflammatory heat, and does not appear to be mor- bidly sensible, or to give any pain to the child when handled ; nor does it pit on pressure, but rather gives the sensation of firmness and resistance. When an attempt is made to move it sideways, under the skin, it conveys the notion of a disease peculiar to infants, known by the name of skin-bound. These tumours terminate abruptly at the carpus and tarsus, so that in lusty children it seems, in these places, as if confined by a cord or bandage. They sometimes con- tinue for two or three weeks; occasionally,'they disappear in a few days; and in other instances, they disappear and re-appear at short in- tervals. The tumor sometimes becomes leucophlegmatic, loose, with considerable oedema spreading upwards on the legs. This however never occurs unless the swelling continues for several weeks without abatement; but its more sudden disappearance w^hout undergoing these changes, or without passing into a state of leucophlegmasia, is by far more common. This swelling on the tops of the hands and feet is connected in a great proportion of cases with a spastic con- traction oj the flexor muscles of the thumbs in the upper, and the toes in the lower extremities. The thumb becomes rigidly con- tracted, and permanently bent downwards and laid flat upon the palm of the hand; and in like manner, the toes are bent down to the plantar aspect of the foot. Along with the thumb, the carpus is also in some cases drawn inwards by a spastic contraction of its flexors."* In Dr. James Johnson's caseyi" the child, (nineteen months old) was seized three or four times in the hour, " with spasmodic affec- tions of the respiratory muscles, consisting of repeated attempts to fill the chest, during which, she threw herself back, as in opisthoto- nos, and appeared as though she would be suffocated. These fits would last ten or twelve minutes, after which, the child was some- what easier, but always fretful and peevish. The backs of the hands and insteps were swollen and hard; the thumbs rigidly contracted, * Dr. Kellie, loc. citat. | Med. Chir. Jour. May, 1817, pp. 448, 449. 96 CONVULSIVE AFFECTIONS OF INFANTS. and locked across the palms of the hands; the toes were bent down towards the soles of the feet; and both wrists and ankles were firmly bent by the contraction of the flexor muscles. The bowels were torpid; the stools clayed or slimy and offensive; and the child was extremely irritable, both by day and by night." During the pre- ceding summer, I met with an instance of this affection, in a child about nine months old, in other respects of a remarkably vigorous and robust state of health. The symptoms of this case coincided so closely with those mentioned in Dr. Johnson's case, that his descrip- tion applies in every point to its phenomena and course. It does not appear that this singular affection is attended with much danger, when timely aid is afforded with proper remedial means. Dr. North had seen but one fatal instance of this malady; and Dr. Johnson states, that in his own practice no instance of death has occurred from it. The case which came under my own observation, terminated favorably, after the process of primary dentition was completed. It should nevertheless be regarded as a disease of an unfavorable tendency; for it cannot be doubted that the cerebral irritation which gives rise to its characteristic pheno- mena, may, under certain states of predisposition, and in co-operation with other causes, tending to encephalic disease, readily pass into a state of vascular irritation, or sub-inflammatory action in the brain or its meninges; and thus ultimately give' rise to fatal effusion, or lesion in the brain, or its spinal prolongation. In the only dissection which is reported by Dr. North, the traces of cerebral disorder were sufficiently conspicuous. The vessels of the brain were very turgid; a small portion of blood was effused under the dura mater in several parts; a small quantity of serum was found in the ventricles; and the whole mass of the cerebrum was unusually firm, while the cerebellum was softer than common. The thorax was not examined. Dr. North ascribes the inordinate determination to the head, and the evidences of encephalic disorder presented on dissection, in this case, to an accidental and overwhelm- ing " rush of blood to the head, caused by a very passionate fit of crying," just before the occurrence of the last and fatal paroxysm. He thinks the characteristic phenomena of the disease are entirely independent of cerebral derangement, and that " in the majority of cases, there is no evidence of affection of the brain," and that we have no right to assume that certain individual symptoms—such as the crouping noise or bent thumb, must necessarily be followed by affection of the brain. From a general view of the phenomena of the malady, it appears to me, nevertheless, highly probable, that the disease is ab initio and essentially connected with nervous irritation of the sensorium, propagated at last in very violent cases to the spinal cord. The frown- ing aspect of the countenance—the starting from sleep—the peevish and fretful temper—-the occasional flushing of one cheek mentioned by Kellie, the costiveness and hepatic torpor, &c. all seem to indi- CONVULSIVE AFFECTIONS OF INFANTS. 97 cate a state of nervous irritation or erethism of the brain; and the opisthotonic spasms, which are wont to supervene in aggravated cases, point very directly to irritation of the spinal cord. Whatever may be thought, as to the proximate cause of this affec- tion, all writers on this subject agree in ascribing its origin to dental irritation. It seems to be much more apt to occur in children of a robust and full habit of body, than in such as are of an opposite con- stitution. So far as I have been able to ascertain, the disease has never been observed to occur except during the actual progress of primary dentition; and where it does not terminate fatally, at an earlier period, it always subsides soon after the completion of this process. Treatment.—The chief indications to be attended lo in the treat- ment of the affections under consideration, are; to obviate the influ- ence of the remote irritating cause; to allay the nervous or cerebral irritation upon which the convulsive phenomena immediately de- pend; and to protect the brain from too powerful a determination of blood to, and congestion of its vessels. Where there is reason to believe, from the swollen and irritated state of the gums, that dental irritation is the exciting or accessary cause of the convulsive altack, the gums should be divided down to the advancing tooth. This measure is particularly important in the " carpo-pedal" form of convulsions, mentioned above; as it appears, invariably, to be a consequence of irritation from this source. If, on the other hand, it should appear that gastro-intestinal irritation is the exciting cause of the disease, whether from crude or indigestible ingesta, acrid secretions, or worms, immediate steps should be taken to remove the offending cause. If the child has received any unu- sual food, of difficult digestion, into the stomach, a few hours before the occurrence of the convulsions, it will be proper to administer a full dose of ipecacuanha, with the view of exciting free vomiting. Before resorting to this remedy, however, it is necessary, to apply the means presently to be mentioned calculated to derive the circu- lation from the head, and to protect the brain from the effects of strong vascular engorgement. I have lately seen an instance of vio- lent convulsions, which continued until spontaneous vomiting brought off a large quantity of raisins, with which the child had been suffered to gorge its stomach. To remove the irritating matters that may be lodged in the bowels, purgative enemata, and if the child can be in- duced to swallow, infusion of senna and spigelia may be advanta- geously resorted to. In all instances, indeed, purgative injections are appropriate, on account of their revulsive tendency; and what- ever other measures are adopted, these, if the necessary means are at hand should not be neglected. Blood-letting, though not always applicable, is in some instances a very important auxiliary in the management of these affections. A principal object in the treatment of convulsions, is to protect the brain from fatal oppression; and for this purpose bleeding is one of Vol. II—9 98 CONVULSIVE AFFECTIONS OF INFANTS. our most efficient means. Where the signs of strong domination to the head are manifest—and especially in robust and pletnonc chidren, blood should be promptly abstracted. On ^e contrary however, it will be prudent to abstain from this evacuation in patients of a weak and related habit, and where the ordinary evidences of vascular engorgement are absent. With regard to local.Weeding, by leeches To the head, my own experience accords entirely with the following observations of Dr. North. " I have never seen * ell- marked symptoms of determination to the head in children removed by leeches, however freely they were applied Their application never fails to annoy the little patient considerably, and their etiec is not to be relied on." If it be deemed necessary to draw blood directly from the vessels of the head, this writer recommends bleeding from the jugular vein, or by cupping upon the temples or behind the ears. In cases where the little patient sinks into a state of coma, with flushed countenance, throbbing of the carotids, &c. after an at- tack of convulsion, local depletion, in any of these latter modes, is sometimes indispensable to the safety of the patient's life." Some practitioners are in the habit of giving large and repeated doses of calomel, in the convulsions of infants, under an idea that there is something peculiarly beneficial in the operation of this article in affections of this kind. Dr. North objects strongly to this practice, as tending in no small degree to injure the constitutions of children. That calomel is too heedlessly and indiscriminately given in the af- fections of children, particularly in the United States, I have not the smallest doubt. I am quite certain, that I have seen instances where this practice was the cause of great and irreparable constitutional injury. Nevertheless, it has appeared to me, that one or two active doses of this article, so as to cause free alvine evacuations, is capable of procuring more advantage, in general, in the convulsions of in- fants, than any of the other usual means for evacuating the alimentary canal. Revulsive applications, with the view of equalising the nervous excitement, and deriving the circulation from the encephalon, are always proper, and often promptly efficient in moderating or arrest- ing the convulsions. Warm pediluvium, the water being as warm as can be borne without injuring the skin, is one of the most bene- ficial of this class of remedies. This measure is particularly apt to afford relief in convulsions excited' by the irritation of dentition. The good effects of very warm applications to the feet are much en- hanced by cold applications to the head. While the feet and legs are immersed in warm water, a piece of flannel, wet with cold water, should be applied over the head and temples. These measures are especially important in cases attended with symptoms of sanguineous congestion in the head, and cannot be omitted without losing one of our most efficient remedies in such affections. Not unfrequently, these applications are alone sufficient to put a speedy termination to sympathetic convulsions. Where the determination to the head is CONVULSIVE AFFECTIONS OF INFANTS. 99 very great and persistent, it will be proper to apply pounded ice in a bladder to the scalp, while applications of warm water or sinapisms are made to the feet. Some writers recommend putting the patient into a warm bath, while the cold applications are made to the head; but I suspect, that, at most, warm semicupum will in general exert a better revulsive effect, than immersion of the whole body. Dr. North observes, that for many years he has "directed the practice of immersing the child's lower extremities in a warm bath; while cold water is poured, in a gentle stream, on the head of the cervical spine." While these applications are being made, "the countenance and pulse should be attentively watched. When paleness and col- lapse of the face supervene, and the pulse declines or intermits, the cold applications should be suspended, and the head and trunk co- vered with a dry cloth; but as soon as signs of reaction return, the process is to be resumed even to the third or fourth time, till its good effects shall be decisive and manifest in the suppression of all con- vulsive motions." (North.) The operation of blisters is in general too slow to admit of useful applications in the ordinary cases of infantile convulsions. Never- theless, where there is reason to apprehend a repetition of the at- tacks, small blisters laid behind the ears, or on the back of the neck, are in general decidedly beneficial. Vesication on this part is parti- cularly calculated to afford advantage in those cases which supervene on the drying up of superficial and discharging ulcerations behind the ears. Some benefit may also be expected from the application of blisters to the inferior extremities, as counter-irritants. Dr. North, whose authority upon this subject deserves much respect, says "that in many instances where there was evident determination to the head, without any general excitement, he has obtained the best effects from blisters to the calves of the legs, or between the shoul- ders." The application of blisters to the head, in any of the inflam- matory or congestive affections of the brain, is very rarely attended with advantage; and in many cases appears rather to augment than relieve the evil. In hydrocephalus, I have never known even the slightest temporary advantage from vesication of the scalp. It is, nevertheless, not improbable, that in sympathetic convulsions, some benefit might accrue from counter-irritation on the scalp; though my experience furnishes me with no facts in confirmation of the useful- ness of this practice. Rubefacient frictions along the course of the spine, is a practice I resort to in most instances of protracted convulsions, and in some cases manifest benefit appeared to me to result from it. When the convulsions assume a tetanic character—the body remaining for some time rigidly bent backward, leeching, and sinapisms over the spinal region would seem to be more especially indicated. Formerly, physicians were much in the habit of exhibiting anti- spasmodics in infantile convulsions—such as assafcetida, camphor, valerian, musk, and ol. succine. In children of a very nervous or 100 HYSTERIA. irritable habit, some benefit may occasionally be derived, during the fit, from assafoetida, musk, or the oil of amber, provided no signs of determination to the head be present. Upon the whole, however, these are, under the most favorable circumstances, of very equivo- cal propriety; and they are decidedly improper, where the arterial reaction is considerable, and the vessels of the head engorged. Opium is a remedy that may either do very serious mischief, or no small degree of good, according to the particular states of the system, and the character of the attending circumstances of the case. In instan- ces attended with cerebral erethism, or encephalic vascular conges- tion, nothing perhaps would be more likely to do harm than opium, more especially in robust and full habits. In general, it may be said, that wherever local or general depletion is indicated, opiates are to be avoided. On the contrary, however, where convulsions arise sympathetically, in consequence of some remote and fixed irritation; as in the alimentary canal, and the habit of the patient is irritable, relaxed and feeble, opium, judiciously administered, may afford de- cided benefit. It is indeed, anceps remedium, but the practitioner, who has learned to discriminate between the circumstances that in- dicate or contra-indicate the propriety of its use, will often find it a most valuable auxiliary. Tn general, it is altogether inadmissible in convulsions arising from the irritation of dentition; and in cases de- pending on causes seated within the head, it is, if possible, still more inappropriate. When the primary irritation is located in the alimen- tary canal, we may, under the other favorable circumstances just mentioned, employ small doses of Dover's powder, repeated accord- ing to the exigencies of the case, with manifest advantage. Opiate embrocations over the chest and spinal region, will also, in such cases, afford benefit. These are particularly useful, where from great ner- vous irritability there is a strong tendency to convulsive attacks, un- accompanied with general, vascular irritation. When convulsions arise from repelled chronic cutaneous affections, we must endeavor to prevent the recurrence, by the use of the warm bath, frequently dry frictions, and sulphur given internally. Setons and issues may also aid us in such cases. The treatment proper in the carpo-pedal form of convulsions, embraces the employment of general and local bleeding; laxatives; small doses of calomel, to correct the functions of the liver; cold applications to the head; rubefacient and anodyne embrocations along the track of the spine; warm bath and pediluvium; a strict attention to the state of the gums; and the avoidance of every thing calculated to cause unusual excitement of the system. Sect. VII.—Hysteria. In relation to the diversity and variableness of its phenomena hysteria is truly a "protean d.sease." It is essentially a dynamic affection of the nervous system, manifesting itself by morbid phe- HYSTERIA. 101 nomena in every sensitive and irritable part of the system, in the voluntary and involuntary muscular systems, in the sensorial organs, the brain, the intellectual faculties, the digestive apparatus, the va- rious glandular viscera, in short, it presents in its multifarious symp- toms every morbid sympathy, perhaps, of which the animal system is susceptible. Hysteria may be divided into three modifications, namely, 1. chronic or habitual hysteria; 2. paroxysmal or convulsive hys- teria; and 3. hysteric insensibility or stupor, without spasms of the voluntary muscles. 1. Chronic or habitual hysteria occurs in weak, delicate, and irri- table habits, particularly in such as are affected with profuse leucor- rhoea, or suffer frequent menorrhagic discharges. Females affected with this form of the disease are usually called nervous. They are almost always complaining of some unpleasant or painful sensations; their temper is variable, often fretful, sometimes animated, talkative, and anon peevish and gloomy; they pass often rapidly from laughing to crying, from gaiety to melancholy, from despondency to hope, and vice versa, from the most trifling causes. They often complain of various distressing sensations in the abdomen, head or chest. Flatulency, a rumbling noise in the bowels, severe colic pains, a sense of weight and bearing down in the region of the uterus, pain in the neck of the bladder, dysury, a feeling of emptiness, or of fulness and tension in the pit of the stomach, variable appetite, slow diges- tion, eructations, occasional spells of great anxiety and alarm, pal- pitation, weakness, and syncope, or,a sense of sinking in the prae- cordia, ringing in the ears, confusion of mind, transient pains in various parts of the body, and the sensation of a ball rising in the throat to the top of the sternum, causing oppressed and hurried re- spiration, and a feeling of impending suffocation, (globus hystericus) are among the most common symptoms of this modification of the disease. A peculiar numbness, or feeling as if insects were creeping on the top of the head, is sometimes experienced; and a violent cir- cumscribed pain, often not above an inch in circumference, is a fre- quent affection in this form of the disease. Many females affected with chronic hysteria frequently experience a troublesome pain con- fined to a small space just below the left breast; and others suffer much inconvenience from a deep seated circumscribed pain in the left iliac region. Patients laboring under this form of constitutional hysteria sel- dom become affected with convulsions. The ordinary exciting causes of the hysteric paroxysm are much more apt to produce in them syncope, insensibility, or temporary mental derangement, or spasmodic and very painful affections of the alimentary canal, dyspnoea, and globus hystericus, than distinct convulsions. 2. The hysteric paroxysm usually comes on suddenly. Some- times the fit consists in violent and convulsive laughing, alternating with crying and screaming; or attended with mental alienation; 9* 103 HYSTERIA. rapid and incoherent talking; singing; suffocative spasms of the throat; a wild and furious expression of the countenance; raving; gnashing the teeth; tearing out the hair; beating the breast with the hands; biting, &c. Occasionally these symptoms subside without terminating in convulsions. More commonly, however, convul- sions, of terrific violence, speedily supervene. The spasms usually partake more of the tonic or tetanic character, than of the clonic or strictly convulsive form. The body is rigidly bent backwards, or variously and most powerfully contorted; the breast projected for- wards, and the head drawn backwards; the face swollen; the tongue protruded, or the jaws firmly closed; the eyes rolling, prominent and red; the teeth gnashed; the fists clenched; the arms spasmodi- cally thrown about, and the abdominal muscles violently contracted; in short, the whole muscular system is thrown into such violent spasms, that scarcely any attempt of the by-standers is sufficient to restrain the contortions, or prevent the patient frOm being thrown out of bed. When the paroxysm ceases, the patient is left in an exhausted, and stupid or somnolent condition, which in the course of an hour or two passes off, without leaving any other affections than a feeling of general soreness, and a slight pain or uneasiness in the head and pit of the stomach. This form of hysteria does not often occur in very weak and delicate individuals, habitually labor- ing under the former variety of hysteric symptoms. It is more commonly met with in sanguineous, plethoric and robust females, of strong passions; and occurs usually, as the immediate consequence of some disagreeable mental emption, or the sudden suppression of the catamenial discharge. In plethoric and irritable habits the hysteric attack occasionally seizes chiefly on the heart and arteries, giving rise to what the older pathologists called turgescentia nervosa* The face becomes flushed and turgid; the heart palpitates violently; the pulse beats tumultu- ously; the carotids throb; the patient complains of headache, becomes slightly delirious, and often experiences transient pains in the side, with hurried and anxious respiration. In some instances, the paroxysm assumes the phenomena of vio- lent asthma, with a highly excited state of the vascular system. Sometimes the disease assumes the form of severe cholera, with ex- treme gastric pain, and continued retching or vomiting. 3. In some instances, the patient, without any previous spasmodic affections, sinks into a state of complete insensibility. She lies on her back, with the extremities extended and relaxed, the eyes closed, the teeth firmly locked, and the breathing slow and intermitting, but without being laborious or audible; the pulse is generally regu- lar, slow, and small; the countenance natural or pallid; the extremi- ties cool; and the sensorial functions and power of swallowing appear to be entirely suspended. Occasionally a deep and long inspiration * Richter, loc. cit. vol. vii. p. 445. HYSTERIA. 103 is made; and the patient is apt, when some degree of sensibility re- turns, to tear the clothes from her bosom, or to press upon it with both her hands. Sometimes young females will continue in this state for many hours. I have known it to last a whole day; at others the paroxysm is transient. It generally passes off rather suddenly. The patient awakes, as it were from a deep sleep, suddenly raises herself into a sitting posture, looks about with an air of surprise, and speedily recovers the entire possession of her mental and corporeal powers. During this state of hysteric stupor, the urine is almost always retained, or perhaps suppressed, and soon after its subsidence a large quantity of a pale or watery appearance is commonly dis- charged. This modification of the hysteric paroxysm is most apt to occur in young unmarried females, from sudden suppression of the menses, or a consequence of violent mental emotions—and perhaps still more commonly from taking heavy and indigestible food during the cata- menial period. Pathology.—Hysteria, though not exclusively, is chiefly confined to females. It never occurs during childhood, and its appearance in the form of convulsions or distinct paroxysms in old age, is al- most equally uncommon. The range of its sway is almost entirely confined to the period which intervenes between the commence- ment and the complete cessation of the uterine functions. It is par- ticularly apt to occur, in its less violent forms, at the latter critical epoch of female life; and paroxysmal or convulsive hysteria occurs often shortly before and after the first appearance of the catamenia. There is, therefore, something peculiar in the female organisa- tion, which renders them so especially the subjects of this remark- able affection; something, we may presume, distinct frum mere delicacy of structure and nervous irritability; for although men of nervous temperaments and weak and irritable habits may occasion- ally suffer some of the lighter symptoms of hysteria, they very rarely, if ever, so far as 1 know, become affected with the true hys- teric paroxysm. Let us advert then to the circumstance, that the susceptibility for this disease commences only with the development of the proper uterine or sexual functions, and again diminishes, and finally ceases, with the entire cessation of these functions—that, in short, the period of life during which the uterus maintains its influ- ence or sympathies in the female system, is that period also to which the occurrence of hysteria is almost exclusively confined, and we are led to the conclusion, that, in some way or other, the female ge- nerative organs have an intimate concern in the production of this affection. From these and olher analogous circumstances, it has been inferred that the proximate cause of hysteria is located in the uterus—a doc- trine which is indeed expressly implied in the name given to this affection. Hippocrates, Zacutus Lusitanus, Fr. Hoffman,* Rave, * Med. Rationel. Systema. torn. iv. p. 161. 410 HYSTERIA. Salmuth, and more recently Villermay, entertained this view of the pathology of hysteria; and Richter observes, that the generative system is " very frequently'," the point whence the morbid sympa- thies, which give rise to the hysteric phenomena, radiate; and that in such cases, the disease may, in certain respects, be regarded as proceeding from the sexual organs.* The general opinion at present, however, is that the brain, and not the uterus, is the essential seat of hysteria; and there can be no doubt indeed, that the convulsive form at least, as well as many other morbid phenomena manifested by the disease, are directly dependent on cerebral irritation. It appears, nevertheless, highly probable also, that many symptoms belonging to this affection, are the immediate result of an irritation located in the ganglionic system of nerves, ex- clusive, perhaps, of any direct dependency on cerebral reaction. Hysteria is emphatically a nervous affection. Its fundamental con- dition would appear to consist in an extremely sensitive and excitable state of the whole nervous system, and a consequent inordinate acti- vity of the various organic sympathies. We may presume, that if in a system thus constituted, an irritation occurs in any part of the body, it will be rapidly transferred, either to the organs which main- tain the closest sympathetic relation, with the part primarily irritated, and give rise in them to local pain, or spasm, or uneasiness; or to the brain causing disturbance of the intellectual or sensorial functions, and being thence reflected upon the muscles and other parts, excit- ing spasms, pain, and convulsions. Mr. Tate, in a small work on hysteria lately published, endea- vors to prove that the proximate irritation on which the pheno- mena of hysteria depend, is located in the spinal marrow. He asserts, that in the majority of cases of this disease, whether of a paroxysmal, or chronic character, considerable tenderness will be found to exist in some part of the spinal column, and, in some cases, the soreness to pressure is very great. The application of a tartar emetic plaster, over the part of the spine which is morbidly tender, very rarely fails, he says, to remove the disease, however violent it may be, or long it may have continued.t Causes.—The predisposition to hysteria depends sometimes on a peculiar constitutional habit, and in some instances, is manifestly hereditary. Girls of a delicate and relaxed habit of body, light hair, blue eyes, a fair skin, and sanguineous habit, with precocious intel- lect, animated dispositions, lively fancy, and early sexual develop- ment, are in general most liable to hysteric affections in after-life. Very generally, however, the predisposition to hysteria is acquired from the influence of causes that tend to produce plethora, nervous irritability, and general relaxation. This affection is, comparatively * Specielle Therapie, Bd. vii. p. 451. f A Treatise on Hysteria, &c. &c. By George Tate, Surgeon, &c. London, 1831. HYSTERIA. 105 speaking, not often met with in individuals inured to an active or laborious course of life, or accustomed to a plain and regular mode of living. Like gout, it is much more commonly encountered in the mansions of the rich and luxurious, than in the hovels of the poor and laborious. Indolence, sedentary habits, a pampered and luxurious mode of living, the too early and overstrained exercise of the mind, the habitual excitement of the imagination, and of the moral sympathies, by the perusal of high-wrought descriptions of affecting incidents, or of circumstances calculated to awaken and keep alive agitating emotions, are among the most common and in- fluential causes of the nervous or hysteric predisposition. The de- pressing passions also have a powerful tendency to predispose to, as well as to excite, hysteric affections. The exciting causes of hysteria are exceedingly various. They may, however, be arranged under the following heads:* 1. Those which act immediately upon the sensorium com- mune.—Violent anger, terror, grief, jealousy, remorse, envy, dis- appointed ambition, prostrated hope, hatred, loss of reputation, un- fortunate love, mortified pride, opposed desires, in short, whatever strongly agitates or affects the mind, may excite hysteric symptoms. Under this head we must also place the production of the disease by the sight of persons laboring under the hysteric paroxysm. Osiander relates some very remarkable instances of this kind;t and cases excited in this way are mentioned by Tissot,:}: Whytt, Row- ley^ Reil, and others. 2. Disagreeable impressions on the organs of sense, depending generally upon idiosyncrasy.—Richter states, that acute and melt- ing tones, particularly those produced by the Harmonica, have often suddenly excited hysteric affections. Disagreeable odors, also, sometimes produce this effect; and the same consequence has been known to result from certain impressions received through the sense of touch. 3. Irritating substances lodged within the alimentary canal. In persons predisposed to hysteria, indigestible and irritating articles of food are particularly apt to excite hysteric affections. This is one of the most abundant sources of those habitual hysterical com- plaints so frequently met with in females of nervous temperaments and weak digestive powers. Intestinal irritation from wind, acrid secretions, or worms, may also give rise to this affection. 4. Suppressed Evacuations.—The sudden suppression of the catamenial discharge during its flow, often gives rise to extremely violent paroxysms of hysteria. The remote cause in instances of this kind, is, usually, cold—particularly the application of cold to * Richter, 1. cit. Bd. vii. p. 456. X Entwickelungs Krankheiten, vol. i. X On the Diseases of the Nervous System, vol. ii. § On the Diseases of Females. 106 HYSTERIA. the feet while the menses are flowing, or just about making their appearance. Authors mention, also, suppressed perspiration, and haemorrhoidal discharge, among the exciting causes of this disease; and repelled chronic cutaneous eruptions are said, occasionally, to give rise to hysteric affections. 5. Excessive Evacuations.—Inordinate sanguineous or serous discharges may, perhaps, more frequently, act as predisposng, than exciting causes of hysteria. Be this as it may, it is certain, that fe- males who are affected with profuse leucorrhcea, or frequent monor- rhagia, are peculiarly liable to hysteric complaints. Excessive haemor- rhoidal evacuations, chronic diarrhoea, profuse lochia, and nursing infants too long at the breast, appear to be particularly favorable to the occurrence of various nervous affections. 6. Causes that tend to augment the sensibility and to pro- duce a habitual erethism of the sexual organs have, without doubt, a powerful influence in the production of hysteria.* The frequent excitation of voluptuous feelings by improper reading, con- versation, pictures, or the workings of an unchastened and active imagination, &c, are, I apprehend, not unfrequently deeply concerned in the causation of this affection. Where the sexual propensity is early developed, and supported by influences of this kind, and its gratification firmly resisted by moral restraints, or unsatisfied from less praiseworthy motives, hysteric paroxysms are particularly apt to occur. Hence, perhaps, the occasional removal of the hysteric diathesis in young females by marriage. Diagnosis.—Many eminent pathologists have regarded hysteria and hypochondriasis as essentially the same affection.t The general opinion at present, however, is that they are distinct diseases; and this is unquestionably the correct view of the case. The following are the prominent distinguishing characters of these affections: 1. Hysteria occurs chiefly in individuals of nervous, irritable, and plethoric habits, of great mental and corporeal excitability, quick perception, rapid transitions of disposition and temper. Hypochon- driasis, on the other hand, very generally attacks persons of slug- gish, melancholic temperaments, unirritable fibre, addicted to deep and fixed reflection, musing, and revery. 2. Hypochondriasis is not so variable in its phenomena, and more protracted in its course, with less manifest remissions and exacerba- tions than hysteria. 3. Hysteria generally comes on and goes off suddenly, and is at- tended with an increased excitability of the nervous system, and with various painful and spasmodic affections. Hypochondriasis almost always approaches slowly, without spasm or distinct pain, and gradually increases in violence, and again goes off in the same gradual manner. * Richter, loc. cit. Bd. vii. p. 460. f Stahl, Sydenham, Whytt, Tissot, Van Swieten, Selle, K. Sprengel, Henke, and Zimmerman, were of this opinion. HYSTERIA. 107 4. In hypochondriasis, the primary irritation is much more dis- tinctly seated in the abdominal viscera; the digestive and hepatic functions are more prominently and permanently affected than in hysteria. 5. In hypochondriasis the mind is, as it were, paralysed—fixed with steadfastness upon some engrossing subject. In hysteria the intellectual powers are versatile; often active, and sometimes wildly confused. Hysterical patients experience more corporeal sufferings; hypochondriacs more of mental distress. The former are more oc- cupied with present complaints; the latter look into futurity with distressing and gloomy forebodings of distant evil. The hypochon- driac feels himself an insulated, deserted and doomed being—loses his sympathies for the world—even his natural propensities and passions are absorbed by the ruling idea. The hysteric patient, on the contrary, is often agitated by various emotions and feelings; he loves, hates, cries, laughs, hopes, fears, is garrulous or taciturn, in rapid succession, and often apparently without any adequate causes. Treatment.— Treatment proper in convulsive or paroxysmal hysteria.—The principal indications in the treatment of hysteric convulsions, are:—1. To obviate inordinate sanguineous congestion in the head, by depletory and revulsive applications; 2, to allay the morbid excitement in the nervous system, by anodyne and antispas- modic remedies; and 3, to remove, as much as may be in our power, the local irritating causes, upon which the irregular determinations and morbid actions, both of the nervous and sanguiferous systems, depend. It nas already been observed, that strong sanguiferous determi- nation to the head perhaps always occurs in the hysteric paroxysm. The suffused and turgid face, projecting and blood-shot eyes, disten- sion of the jugulars, and throbbing of the carotid and temporal arte- ries, so generally noticed during a fit of hysteric convulsions, are sufficient evidences of a highly congested state of the encephalon. If, in addition to the signs of inordinate sanguineous determination to the head just mentioned, the pulse be active, full or tense, or the general habit of the patient manifestly plethoric, bleeding to an ex- tent sufficient to make an evident impression on the pulse should be immediately practised. This is not only a proper precautionary measure for obviating any serious consequences that may result from the strong vascular turgescence within the head, but it is also deci- dedly beneficial as a preparatory step to the employment of other remedies.* This evacuation is especially useful in cases that occur in young and sanguineous females, from the sudden suppression of the catamenial discharge. In instances of this kind, an efficient blood-letting rarely fails to moderate the symptoms very speedily, and occasionally, to induce a complete intermission of the spasmodic actions. With the view of equalising the circulation and nervous * Dr. Dewees, Treatise on the Diseases of Females, p. 486. 108 HYSTERIA. excitement, sinapisms to the inferior extremities, or, if practicable, warm pediluvium, may also be very beneficially applied. In prescribing internal remedies in the hysteric paroxysm it is of much consequence to pay particular attention to the nature of the exciting cause. When the paroxysm is the immediate consequence of gastric irritation from indigestible or irritating articles of food an emetic should be immediately administered, and vomiting excited as speedily as possible. I have frequently administered the sulphate of zinc in such cases, with the happiest effect. The usual ant.spas- modics will do little or no good in instances arising from causes of this kind; and it is therefore particularly necessary, on being called to such cases to inquire into the nature of the ingesta or diet taken previous to the occurrence of the paroxysm. In some instances de- pending on gastric irritation, the convulsions alternate with violent retching, attended usually with excruciating pains in the stomach. WThen this happens, vomiting should be encouraged by copious draughts of tepid water, or by moderate doses of ipecacuanha. As soon°as the offending contents of the stomach are entirely thrown off, a full dose of laudanum should be administered, provided no symp- toms of strong cephalic congestion be present. When the hysteric paroxysm is excited by mental emotions, nar- cotic and antispasmodic remedies are appropriate means. Laudanum, sasafcetida, musk, sulphuric ether, and castor, may be employed for this purpose. Laudanum is particularly valuable in hysteric affec- tions resulting from moral causes. It may be given by itself, or, perhaps, more advantageously, in union with ether or assafoetida, ac- cording to the following formula.* It is sometimes impossible to introduce any medicines into the stomach during the hysteric paroxysm. When this is the case, anti- spasmodic and anodyne enemata ought to be resorted to. From twenty to thirty grains of assafoetida, dissolved in six or eight ounces of water, with the addition of a teaspoonful of laudanum, may be thrown into the rectum. In those violent paroxysms of hysteria which sometimes occur in consequence of the menses becoming suddenly arrested during their flow, from the application of cold to the feet, bleeding, sinapisms to the ankles, warm pediluvium, and particularly turpentine enemata, with the internal use of assafoetida, are particularly applicable. In an extremely violent case of this kind, in a young and unmarried woman, 1 lately administered about half an ounce of the tincture of secale cornutum, with prompt and very decided benefit.. In ten minutes after this article was swallowed, the convulsive symptoms * R.—Tinct. opii gss. / ^ther sulphu. gii.—M. S. From 40 to 80 drops, and repeated ac cording to its effects on the system. R.—Tinct. opii ^ii. ----assafcetid. %\.—M. S. A dessert spoonful every half hour until the symptoms are moderated. HYSTERIA. 109 were entirely allayed. In very obstinate and protracted instances of this character, I have known great advantage to result from tur- pentine injections.* My usual practice has been to repeat the terebinthinate injections until the bowels are well evacuated; and, when this is effected, to throw about two drachms of turpentine, mixed with a drachm of laudanum and a small portion of milk, into the rectum. When the hysteric paroxysm precedes the eruption of the menses, camphor, or camphor with opium, is, according to the experience of Dr. Dewees, the most efficient remedy. He recommends the fol- lowing mixture for this purpose!—a mixture which I have myself employed with much advantage in such cases. Here also warm pe- diluvium, rubefacient frictions to the inner part of the thighs, warm bricks wrapped in dry flannel and applied to the pelvis, turpentine enemata, and cold applications to the head, are particularly indicated. In that variety of parox3Tsmal hysteria in which the patient lies in a state of torpor and insensibility, distinct from syncope, 1 know of no remedy so effectual for dispelling the attack as an emetic. If a full dose of ipecacuanha, or of the sulphate of zinc, can be intro- duced into the stomach and vomiting excited, complete recovery will generally speedily ensue. I have known patients, after having lain for several hours in a state of insensibility, awaken as from a sleep, sit up and converse rationally almost immediately after vomiting was excited by an emetic. In cases of this kind, prompt relief may also sometimes be obtained from a large sinapism to the epigastrium. In a case which I lately attended, where vomiting could not be ex- cited, although several full doses of ipecacuanha and sulphate of zinc were introduced into the stomach, I directed a strong sinapism to be applied over the whole epigastrium. In less than twenty minutes she suddenly raised herself, looked about with an air of surprise, and immediately began to vomit, which had the effect of soon removing every symptom of the complaint. Antispasmodic enemata too may be very beneficially employed in such cases—and for this purpose nothing perhaps is so effectual as an aqueous solution of assafoetida. Opium and the more diffusive stimulants do not appear to answer well in instances of this kind. Much benefit may, however, be oc- casionally obtained by stimulating the olfactory nerves with ammo- nia, or the fumes of a burned feather. * R.—01. terebinth, giss. Vitelli ovi. Solut. gum. arab. ^viii.—M. f R.—G. camph. 3ii. Spir. vin. rect. q. s. f. pulv. adde, Pulv. G. arab. giii. Tinct. thebaic, acetat. gtt. Lx. Sacch. albi giii. Aq. fontanae ^vi.—M. Dose a tablespoonful every hour or two. Vol. II.—10 110 HYSTERIA. Besides the remedies already mentioned, a variety of other means may be employed with occasional success in the hysteric paroxysm. The injection of very cold water into the rectum will sometimes promptly allay the hvsteric paroxysm. Riverius speaks particularly in favor of the injection of cold water and vinegar; and Darwin used ice-water with marked success. Great benefit may also, at times, be obtained from injections of a decoction of ipecacuanha, in the proportion of two drachms of the root to eight ounces of'water. Dr. Dewees considers the so common practice of exciting the olfactory nerves by stimulating volatiles, as of very doubtful pro- priety. In plethoric habits, and where there is much sanguineous determination to the brain, the impropriety of this practice appears indeed very obvious. Richter observes, that applications of this kind are equally apt to prove injurious in cases attended with great general nervous excitability. There exist, moreover, in many in- dividuals subject to hysteric affections, very extraordinary idiosyn- crasies in relation to particular odors. Some patients will be very disagreeably or injuriously affected by certain articles of this kind, yet greatly tranquillised or beneficially excited by others. Richter mentions the case of a lady who was always readily roused from hysteric stupor or syncope, by the smell of old and rank cheese. I know an hysteric female in this city, who is invariably very dis- agreeably affected by the smell of hartshorn, but the fumes of burn- ing feathers rarely fail to produce beneficial effects. In some in- stances, the smell of strong vinegar does more good than the more volatile and pungent articles usually employed for this purpose. (Richter.) The smell of garlic bruised and moistened with vinegar, occasionally produces a very prompt and beneficial effect. We may sometimes suddenly arrest the lighter hysteric paroxysms by excit- ing some sudden emotion, as of anger, in the mind of the patient. What I have hitherto said refers chiefly to convulsive paroxysms of hysteria. The most unmanageable and troublesome cases of this disease, however, are those chronic instances of hysteria usually denominated nervous affections, and which, though seldom marked by violent paroxysms, are nevertheless attended with frequent, and generally distressing nervous symptoms. As palliatives, the anti- spasmodics and narcotics already mentioned are very much employed in this modification of the disease. In ,general, assafoetida gives more perfect and prompt relief than any other article of this kind. Some patients, however, derive much more benefit from other anti- spasmodics. Indeed, there exists the utmost diversity with regard to the degree of relief obtained by different individuals from reme- dies of this kind. A mixture of sulphuric ether and laudanum* constitutes, with most patients, an excellent antispasmodic. Opium is, in truth, a most soothing remedy in chronic nervous affections. It allays the inordinate excitability of the nervous system; subdues * R.—Sulph. a;ther, §ss. Tinct. opii 3ii—M. Take 30 drops every two hours till relieved. HYSTERIA. Ill for a time all unpleasant sensations and morbid sympathies; and diffuses a delightful feeling of tranquillity throughout the whole or- ganisation. Could these effects be enjoyed without the risk of con- tracting a habit for taking this oblivious drug, opium would indeed be to patients of this kind the magnum donum dei. Let no ner- vous person, however, resort frequently to this medicine. It will come at first like an angel, with its balmy powers, to dispel pain, lowness of spirits, and mental disquietude of every kind; it will bring hilarity and pleasantness of feeling when its aid is first invoked; but it will not fail ultimately to insinuate itself into every fibre, and to cause indescribable wretchedness and suffering to the unfortunate victim. In many individuals, the ordinary preparations of opium, particularly laudanum, produce very disagreeable effects. Where such an idiosyncrasy exists, and the indications are favorable to the employment of this narcotic, the acetated tincture of opium may, in general, be used without any unpleasant consequences whatever. Some patients, who cannot take laudanum without very distressing effects, will feel no inconvenience from it if it be given with eight or ten grains of the carbonate of potash. Castor, with some individuals, is peculiarly beneficial as a pallia- tive. I have frequently known this article to procure much relief after the more active antispasmodics had been ineffectually used. It seems to be particularly calculated to do good when the disease is attended with much uneasiness and flatulent pains in the lower part of the abdomen. Some persons, on the contrary, cannot take this medicine without unpleasant consequences. I have usually employed the castor in combination with other articles of similar powers, ac- cording to the following formula.* In cases attended with much debility of the digestive organs, valerian often produces very excellent effects. From its gently tonic powers, it is indeed peculiarly suited to such cases. The ethereal tincture is an excellent preparation for this purpose.! An aqueous infusion also, with the addition of 10 or 15 drops of the liquor ammon. succinata to each dose, or of four or five grains of super carbonate of soda, generally answers very well. The root of the pathos foztida (skunk cabbage,) will occasion- ally afford much relief in chronic hysteric affections. I have very * R.—Tinct. castor, ^ss. ----aloes compos, ^ii. ----opii 3i.—M. S. Take from 30 to 40 drops every hour until relieved. R.—Tinct. castor, ^ss. ----valerian aether %i. Liq. ammon. succinat. ^ii.—M. S. Twenty drops every hour or two. | R.—Rad. valerian 3ji. .Ether sulphur, ^viii.—M. Digest for three days. Dose from 30 to 40 drops. 112 HYSTERIA. often prescribed this article with more than mere temporary advan- tage. A wine-glassful of the infusion (one ounce of the root to a pint of water) may be taken every four or five hours. In some instances of chronic hysteria, emetics have been known to act very beneficially. Dr. Dean, of Harrisburg, observes, "in some cases where the patients had labored under this disease for ten years, and during that time had, by the advice and direction of respectable physicians, exhausted, with at most, but temporary be- nefit, the whole class of remedies which are usually prescribed, I have, by the continued exhibition of vomits, either entirely removed the complaint, or so far interrupted the habits of the diseased action in the stomach, that antispasmodic and tonic medicines would, in general, complete the cure."* I have, in a few instances, resorted to this practice with considerable advantage. Ipecacuanha is the proper article for vomiting in this affection. In the management of chronic hysteria, it is particularly important to confine the patient to a light, unirritating, and digestible diet. No permanent relief can be procured where this rule is not rigidly ad- hered to. It is equally important to enjoin regular, but not fatiguing exercise, by walking or gestation in the open air; and all unpleasant mental excitement, or disagreeable sensorial impressions, should be as much avoided as possible. Particular and continued attention must, moreover, be paid to the state of the bowels. If they are torpid, it will be necessary to order some mild aperient, so as to procure regular alvine evacuations. For this purpose, I know of no medicine so beneficial in cases of this kind, as the following pills, t In the remediate management of this form of hysteria, it is espe- cially necessary to attend to the exciting causes of the disease. Nei- ther proper regimen, nor the use of anodynes, antispasmodics, or tonics, will procure more than very incomplete and temporary ad- vantage, so long as a fixed local irritation exists somewhere in the system. The primary object, therefore, should be, to ascertain, if possible, whether there is any source of irritation present. If no obvious exciting cause of this kind can be detected, which is indeed but very rarely the case, and the disease appears to depend mainly on a morbid irritable condition of the nervous system, in connection with general debility, advantage may be expected from the use of tonics, in conjunction with a mild, digestible, and nourishing diet; regular exercise in the open air, and agreeable society. The ferru- * Medical Recorder, vol. iv. p. 259. f R—Massas pill, hydrarg. 9ii. G. aloes gr. xx. Tart, antimon. gr. ii. Pulv. capsici. Qii. Mucilag. g. arab. q. S—M. Divide into 40 pills. Take two every other night. 3 HYSTERIA. 113 ginous preparations will, in general, answer better in cases of this kind than the usual vegetable tonics. Iron is a peculiarly valuable tonic, in instances, where, along with an irritable and vascular system, the general habit is relaxed, enfeebled, and sluggish, and the diges- tive powers habitually feeble. The preparation I have found most beneficial in such cases is the prussiate of iron.* When given in full and regular doses, it scarcely ever fails to moderate the frequency of the pulse, whilst its fulness is increased. This article, in fact, pos- sesses the power of at once diminishing the morbid irritability of the system, and of invigorating its powers. I have been much in the habit of employing it in diseases attended with great irritability and weakness, and frequently with the most decided advantage. It would seem that the prussic acid which it contains is sufficiently separated from its base h)' the vital actions, to exert its peculiar in- fluence on the system. The cold infusion of wild cherry bark also is an excellent tonic in chronic hysteric complaints. In cases of this kind, much benefit may be obtained from the use of the shower- bath, in conjunction with the measures just indicated. The water should at first be tepid and impregnated with salt, and the tempera- ture afterwards gradually reduced, in proportion as the energies of the system are invigorated. Where, however, there is a fixed local irritation present, tonics are in general not only useless, but frequently injurious. Should the irritation exist in the alimentary canal, from a torpid and loaded state of the bowels, a course of mild purgatives must be instituted before recourse can, with propriety, be had to tonics. In instances con- nected with menstrual irregularities, efforts should be made to ob- viate this source of general irritation. The most common uterine disorder accompanying and supporting chronic hysteria, is profuse leucorrhoea and prolapsus uteri. I have within the present year succeeded in relieving two patients, who had for many years been almost continually afflicted with distressing nervous symptoms and debility, by the use of astringent injections into the vagina, the in- troduction of pessaries, and the internal use of tonics. Both these patients labored under profuse leucorrhoea, apparently entirely in consequence of very great prolapsus uteri. Chronic hysteria is also frequently connected with habitual me- norrhagic discharges. This is particularly apt to be the case about the period of the final cessation of the menses. In instances of this kind much advantage may sometimes be derived from minute doses of aloes, in conjunction with the use of from thirty to forty drops of the tincture of cinnamon three or four times daily. In some instances chronic hysteria depends on phlogosis of the * R.—Prussiat. ferri 3i. G. Aloes socc. gr. xv. Conserv. rosar. q. s.—M. Divide into 30 pills. Take one every four hours. 10* 114 PUERPERAL CONVULSIONS. mucous membrane of the alimentary canal. I attended a lady last summer who had been almost continually affected with various hys- teric symptoms for several years. She had used much medicine, but with little or no advantage. I found her epigastrium somewhat tense, and very tender to the touch. Leeches were directed over this region, and afterwards frictions, with tartar emetic ointment— and the lightest farinaceous diet enjoined. By the use of these ap- plications, without any other remediate means, her health was com- pletely restored. Occasionally habitual nervous symptoms are excited and main- tained by intestinal irritation from an accumulation of feculent and other irritating substances. When the bowels are torpid, the abdomen tumid and hard, the alvine discharges small and unnatural, the breath foetid; the appetite variable, and the patient complains of an itching in the nose, a course of laxatives—or what is perhaps better, the daily use of purgative enemata, with a mild diet, an occasional small dose of blue pill, and small portions of infusion of any of the tonic vege- table bitters, constitutes an appropriate course of treatment. When the disease is attended with a morbid exaltation of the sexual propensities—a circumstance which we sometimes detect by the actions and conversation of the patient—or of which we are in- formed by the candid and very proper avowal of the sufferer— camphor, in union with hyoscyamus—regular exercise, sleeping on a hard mattress, earjy rising, the cold or tepid shower-bath, and tra- velling, will rarely fail to afford particular benefit. The cold bath is always a powerful auxiliary in the treatment of hysteric affections. Where the debility is great, tepid water ought at first to be used for bathing, and the temperature gradually diminished, if we find the system sufficiently energetic to react after coming from the bath. In general, much more advantage will be derived from the shower-bath than from other modes of applying the water; and we may enhance the beneficial effects of the bath by adding a considerable portion of salt to it. Sea-bathing, with exercise by walking, or gestation, rarely fails to improve the health of nervous patients. Chalybeate mineral waters, in conjunction with agreeable society, and free motion in the open air, is also a most excellent re- mediate means in cases of this kind. Sect. VIII.—Puerperal Convulsions. Eclampsia Gravidarum et Parturientium. The term puerperal, given to this form of convulsive disease, is not a very appropriate one; for the puerperal state is by no means necessarily connected either as a concomitant occurrence, or as the cause of this frightful affection. The condition of pregnancy seems however, in some way or other, very essentially concerned in its causation. Dr. Dewees thinks that this disease may occur in preg- PUERPERAL CONVULSIONS. 115 nant women from causes unconnected with gestation. This may be true; but the state of pregnancy would, nevertheless, seem to have an especial agency in modifying or aggravating convulsions, from whatever immediate exciting cause they may arise. What, we may ask, gives to this variety of convulsive disease its peculiarly dan- gerous and fatal character? It can only be attributed to certain cir- cumstances connected with advanced pregnancy, or with the process of parturition. It is indeed highly probable, that the disease under consideration is essentially an epileptic affection, aggravated and supported by the influence of the gravid uterus. Epilepsy is, mani- festly, always attended with strong vascular turgescence in the brain, and the same condition is as obviously present in puerperal convul- sions. Epilepsy is not, however, a very dangerous affection; where- as eclampsia gravidarum is always peculiarly hazardous. Whence then this striking difference of severity between these two affections? May it not depend chiefly on the tendency of the distended uterus in the latter period of gestation, to favor the determination of blood to the head, and to keep up the vascular turgescence in the brain? If by the peculiar position, or great distension of the uterus, the large arteries in the lower part of the abdomen are in some degree compressed, the blood will, one may presume, be more abundantly determined to the vessels of the head; and if the vascular turgescence in the brain be very strong, a paroxysm of convulsions may be the result. If, then, a fit of convulsions is thus excited or brought on by causes not immediately connected with pregnancy, the paroxysm will be aggravated and supported by the continued effects of the enlarged uterus in determining the blood to the head. In epilepsy attacking females in the early months of pregnancy, or in the unimpregnated state, there is but little immediate danger to be apprehended; for the vascular turgescence in the brain is not supported by a permanent cause of sanguineous determination to the head. When the disease, however, is excited by pressure of the uterus upon the large arteries in the lower portion of the abdomen, or at the entrance of the pelvis, the cause which in the first place produces the cerebral congestion, and consequently the convulsions, continues and maintains, or still further increases the vascular tur- gescence within the head, and can hardly fail to give rise to fatal effusion, if the general mass of the blood be not promptly and greatly diminished by venesection, or the foetus be not speedily expelled from the uterus to enable this organ to contract. The premonitory symptoms, the character of the remedies calculated to do good, and the phenomena of the disease itself, all indicate in the most unequi- vocal manner, that is is preceded and accompanied by strong san- guineous congestion in the head; and the exclusive confinement of the disease in its characteristic form to the latter period of gestation, when the uterus has attained its greatest volume, as well as the oc- casional complete subsidence of the convulsions when delivery is speedily effected, afford very plausible evidence that the cerebral 116 PUERPERAL CONVULSIONS. congestion upon which the paroxysm probably immediately de- pends, is either the direct consequence of, or strongly promoted by an impediment offered to the arterial circulation in the abdomen from pressure by the distended uterus. The attack of puerperal convulsions is invariably preceded by premonitory symptoms indicative of strong determination to the brain. In some instances, they are experienced for many days pre- vious to the occurrence of the paroxysm; in others, they occur only a few hours before the supervention of the attack. They consist in a sense of fulness, weight, tension, severe and deep-seated pain in the head, vertigo, ringing in the ears, temporary blindness, weak- ness of the inferior extremities, a fulness of the vessels of the head, and occasionally a severe dull pain in the stomach. After these symptoms have continued for a longer or shorter period, the patient is suddenly seized with convulsions. The mus- cles of the face are in a state of rapid convulsive action, and the whole body is frightfully agitated, as in severe cases of epilepsy. In some instances, the convulsive actions are stronger on one side than the other. During the paroxysm, the face is flushed, livid, and turgid with blood; the tongue is thrust out between the teeth; the carotids beat violently, and the jugulars and veins of the head are greatly distended; the respiration is at first hurried, with a sputter- ing noise of the lips, and towards the conclusion of the fit, a copious discharge of frothy saliva issues from the mouth. The pulse is at first full, strong, and tense, becoming afterwards smaller, rapid, and eventually almost imperceptible. (Dewees.) The subsidence of the paroxysm is always gradual; "the force and frequency of the convulsions abate; the pulse becomes more distinct and less frequent; the breathing is less hurried, and less op- pressive; the face loses part of its lividity; the muscles are agitated only at intervals, and their action resembles the commotion excited by passing a brisk electric shock through them, and eventually sink into repose. The patient, however, remains for the most part insen- sible or comatose, with stertorous breathing or loud snoring; she cannot be roused by any exertion for some time, and if she recover, for a moment, her scattered senses, she is without the slightest recol- lection of what passed. This truce is almost always of short dura- tion; convulsion follows convulsion, without our being able to deter- mine the period or the cause of their return." Dr. Dewees has divided this affection into three varieties—namely, the epileptic, the apoplectic, and the hysteric. It does not appear clear, however, upon what grounds he has founded the second variety; for he points out no material circumstances by which it is distinguished from the epileptic variety. What he calls the apo- plectic variety of the disease, is evidently only a higher grade of the epileptic variety, and differs from it merely in the greater degree of vascular turgescence in the brain, and the increased liability to fatal extravasation or effusion. Puerperal convulsions, as 1 have PUERPERAL CONVULSIONS. 117 already observed, appear to be essentially epileptic—that is, imme- diately dependent on strong sanguineous congestion in the encepha- lon, from whatever cause this may arise. When the determination to the head is very great, the symptoms will assume more or less of an apoplectic character, or fatal extravasation may be the conse- quence. The division of the disease into the epileptic and hysteric varie- ties, however, is founded on correct pathological principles, and is especially important in a practical point of view. It would indeed be more proper, perhaps, to consider them as distinct forms of con- vulsions—the one essentially hysteric, the other epileptic. Although hysteria is.by no means a common affection after the term of quick- ening in pregnancy, hysteric convulsions may, nevertheless, occur from the ordinary exciting causes of this affection during utero-ges- tation, in individuals of a nervous temperament Or an hysterical habit. The hysteric variety of this disease is often excited by mental emotions, and may be distinguished from the epileptic form, by the premonitory symptoms, which are generally distinctly hysterical- such as violent palpitation of the heart, a feeling of faintness, globus hystericus, a pale instead of a suffused countenance, &c; and by the phenomena of the paroxysm, which, though indicative of violent nervous irritation, do not manifest any very violent degree of vas- cular turgescence in the head. The face is not much flushed, and, in some instances, remains even of a pallid hue. The larger muscles are agitated with extreme violence; and those on the posterior part of the body are generally thrown into a state of violent tonic con- traction, causing a rigid recurvation of the body—the head and lower extremities being drawn backwards, whilst the breast, abdo- men, and hips, are thrown forwards into an arch, as in tetanus. " There is no frothing at the mouth; and the patient, after the fit, can for the most part be roused by attention, or will frequently become " coherent as soon as she recovers from the fatigue or exhaustion oc- casioned by the violence of her struggles, and though she may lie apparently stupid, she will, nevertheless, sometimes talk or indis- tinctly mutter. After the convulsion has passed over, she will often open her eyes and vacantly look about; and then, as if suddenly seized by a sense of shame, will sink lower in the bed, and attempt to hide her head under the clothes."* Treatment.—From what has already been said concerning the pathology of this affection, it is manifest that in the epileptic form of the disease, the principal indication is to lessen as speedily as possible the sanguineous engorgement of the vessels of the brain. The treatment, in short, differs in no essential point from that which is proper in apoplexy. Blood should be promptly and copiously ab- stracted. This measure may be regarded as absolutely indispensable to success in the management of this affection. In a case which I Dewees. 118 PUERPERAL CONVULSIONS. lately saw in consultation with Dr. Dunn, nearly forty ounces of blood were at once abstracted. This evacuation, together with sina- pisms to the feet and purgative enemata, succeeded in removing the disease, and the patient was, in about a week afterwards, delivered of a healthy child without any further unfavorable occurrences. In conjunction with copious abstractions of blood with a lancet, local bleeding by cupping from the temples or shaven scalp, may be of material service. Much benefit may also be derived from cold ap- plications to the head, while sinapisms are applied to the inferior extremities. The rectum should be evacuated by laxative enemata; and as soon as the patient is able to swallow, an active cathartic ought to be administered.* These constitute almost the only useful or proper remediate means in the treatment of this form of convul- sive disease. When the disease occurs near the termination of the period of gestation, labor is almost always brought on; and it should be a rule to deliver as speedily as can be done with propriety; for the expulsion of the foetus often puts a termination to the recurrence of the paroxysms. Such a favorable result is, however, not always obtained from the evacuation of the uterus. When the onset of the disease has been violent, and the cerebral congestion is strong and continuous, the paroxysms will recur again and again after the de- livery of the child is effected; and such instances rarely terminate otherwise than in death. If the os uteri is somewhat dilated and dilatable without much effort, it is best, nevertheless, to deliver at once by turning and bringing down the feet. I have, in two instan- ces, delivered in this way with the happiest effect-on the disease. In another case, however, a patient of Dr. M'Clellan, the result was not favorable. The delivery was easily accomplished, and the pa- tient appeared to do well when I left her. She was induced, how- ever, by her friends, to take a little whiskey, " to strengthen her heart," (she was an Irish woman;) and the consequence was a return of the paroxysms, which soon terminated her life. When the os uteri is rigid, no advantage can be obtained by forcibly dilating it and delivering by the feet. In such cases, it is better to wait until the head is forced down in the cavity of the pelvis, and to deliver with the forceps as soon as it can be accomplished. In the hysteric variety of the disease, bleeding, though not so ab- solutely indispensable as in the former variety, can, nevertheless, not be prudently dispensed with. In general, from sixteen to twenty ounces of blood taken from the arm will suffice in cases of this kind. Where, however, the momentum of the circulation is strong, and the symptoms indicate much engorgement of the vessels of the head, the bleeding must be continued without any regard to quantity until the action of the pulse is decidedly moderated. The rectum * R—Calomel gr. x. P. jalap gr. x. —aloes gr. v.—M. To be taken all at once. TETANUS. 119 should also be immediately emptied by purgative enemata, and sina- pisms may be applied to the wrists and feet. If, from the constitu- tional habit of the patient, the nature of the exciting cause, and the premonitory and actual symptoms of the case, there is no reason to doubt of its hysterical character, recourse should be had, after the foregoing means have been used, to opiates and antispasmodics. A full dose of laudanum with an assafoetida enema, will, in general, an- swer better for this purpose than any other remedies of this kind. The case, in short, should be treated as a poroxysm of hysteric con- vulsions. Instances of this kind very rarely terminate fatally. T)r. Dewees has never known an instance of death from this variety of the disease. It is equally rare that parturient pains are excited by this affection. When it occurs in the early periods of pregnancy, however, it may give rise to abortion—an instance of which occurred to me a few years ago. Sect. IX.— Tetanus. Tetanus consists in violent tonic spasms of the voluntary muscles, with the powers of sensation and thought unimpaired. There exists, therefore, a radical difference between this disease and the affections which are properly called convulsive; for in the latter forms of spas- modic disease, more or less disorder of the sensorial and intellectual powers, almost always exists, and the spasmodic affection is charac- terised by sudden contractions and relaxations of the voluntary mus- cles, alternating in quick succession, giving rise to violent concussive motions of the body and extremities. Tetanus is divided, by nosologists, into different varieties, accord- ing to the particular set of muscles chiefly affected. When the affec- tion is confined to the muscles of the jaws and throat it is called trismus, or locked-jaw. Sometimes the extensor muscles of the trunk and inferior extremities are principally implicated, causing a rigid recurvation of the body, so as to bend it violently backward into the form of an arch—and this variety is denominated opisthoto- nos. The term emprothotonos is applied to the disease when the body is curved forwards; and pleurothotonos designates its lateral incurvation. These distinctions possess no practical importance— the disease being essentially the same in all of them. There is an- other distinction, however, founded upon etiological circumstances, which it is of more consequence, both in a prognostic and therapeutic point of view, to bear in mind:—namely, the division of the disease into idiopathic and traumatic tetanus. The former term is applied to those cases which arise from the operation of general causes; such as cold or narcotic poisons; the latter designates those instances which occur in consequence of some mechanical injury; such as wounds, bruises, burns, and other organic lesions. Tetanus almost always approaches gradually—so that several days often elapse between the first manifestations of its invasion, and its 120 TETANUS. state of complete development. At first, slight spasmodic sensations are usually felt in the muscles of the larynx; in consequence of which the voice undergoes some change, and deglutition sometimes becomes slightly affected. About the same time an uneasy sensation is occa- sionally felt in the praecordial region, and soon afterwards a feeling of stiffness occurs in the muscles of the neck, and about the shoulders. The muscles of the jaws now begin to stiffen. At first this rigidity is not so great as to prevent the patient from opening his mouth to a considerable extent. The contraction, however, increases with more or less rapidity, until the teetn of the upper and lower jaws are im- moveably pressed agai nst each other. When the disease has advanced to this stage, sudden and painful retractions about the scorbiculus cordis occur at intervals, accompanied by a simultaneous retraction of the head and an aggravation of the symptoms already mentioned. Deglutition, even during the intermissions of these paroxysms, is now performed with pain and difficulty, and is apt to excite a return of the spasms. As the disease advances, the pain and retraction at the epigastrium return every ten or fifteen minutes, in exceedingly vio- lent paroxysms, and are always immediately followed by a powerful spasmodic retraction of the head, and a rigid contraction of almost every muscle of the body. The muscles of the chest and throat are violently and painfully contracted; the arms and legs forcibly ex- tended; the shoulders thrust forwards; the abdominal muscles firmly retracted against the viscera; and the whole frame thrown into a most painful and unyielding state of tonic spasm. These paroxysms last usually but a few minutes—the muscles of the trunk and ex- tremities resuming for a while, a comparatively relaxed state; but those of the jaws remain firmly contracted during the remissions. In the latter period of the disease, the spasms remit but slightly and transiently: the patient is in almost a continued rack of torture; the muscular contractions are general and extremely violent; the coun- tenance becomes frightfully distorted; copious sweats break out; the pulse is quick and irregular; the respiration hurried and laborious; the voice grating and unnatural; the eyes dim and watery, and the jaws immovably locked. Towards the fatal termination of the dis- ease slight delirium generally occurs. At this period a severe spasm often terminates the scene. The usual mode of termination in falal cases is by apoplexy. In some instances, all the muscles become completely relaxed a short time before death takes place. The patient seems to have emerged from this terrible malady. Every part of the body is in the ordi- nary state of relaxation. Suddenly, however, extreme prostration of strength ensues. He becomes insensible and comatose; the coun- tenance assumes acadaverousexpression, and death speedily follows.* It is worthy of notice, that the muscle's which are supplied with ganglionic nerves, as well as those which derive their nerves imme- * Richter, Specielle Therapie, Bd. viii. p. 368. TETANUS. 121 diately from the brain, do not become affected until towards the fatal termination of the disease. The muscles of the fingers and the tongue are seldom affected until the disease has acquired its ut- most degree of violence. The mind is very rarely disordered in tetanus. I have seen in- stances in which the intellectual powers remained entire up to the last moment of the disease. The appetite and the digestive func- tions, also, are generally but little affected. During the paroxysms, the pulse is contracted, hurried, and irregular, and respiration is af- fected in like manner. In the remissions, both the pulse and respi- ration usually do not differ much from their natural conditions. The duration of tetanus is various, although it commonly termi- nates before the fifth or sixth day, and not unfrequently as early as the third day. In some instances, however, it continues much longer and occasionally it assumes a chronic character. (Richter.) When the disease is about terminating favorably, the remissions become more complete and protracted, during which, patients frequently ex- perience a sense of formication in the extremities. It always passes off very gradually, and in general the pectoral and abdominal mus- cles are the last to regain their healthy condition. An increased irritability of the nervous system and general weakness continue several months after recovering from an attack of tetanus. Accord- ing to the statements of some writers, tetanus sometimes passes into other forms of disease. Stark states that it has been known to ter- minate in remitting and intermitting fevers.* Instances have also been recorded, in which paralytic affections remained after the sub- sidence of the disease. (Richter.) Causes.—Tetanus is most apt to occur in young, and robust indi- viduals of irritable habits of body. It is rarely met with in persons of very advanced age; new-born infants, however, are peculiarly liable to its attacks. High atmospheric temperature appears to exert a powerful influence in predisposing the system to "tetanus. It in- creases the general irritability, and by exciting inordinately the perspiratory function, renders the system more susceptible of the injurious influence of sudden applications of cold. It is on this ac- count, that idiopathic tetanus is so much more common in hot than in the temperate and cold latitudes. In intertropical countries, it occurs most frequently along the sea-coast and in elevated situations. The cool sea-breeze during the night, after the heat of the day, seems in such localities to be the ordinary exciting cause of idiopathic tetanus. Schmucker states that tetanus occurred very frequently in the Prussian army from slight wounds in the mountainous districts of Bohemia, where in summer the days are extremely warm and the nights uncomfortably cool. The exciting causes, as has been already intimated, are of two kinds, namely:—such as produce local or structural lesion; and such * De tetano ejusque specibus praecipuis, causis et ratio curandi, p. 169. Vol. II.—11 122 TETANUS. as affect the system by a general influence. Of the former kind are wounds or mechanical injuries; and of these, contused, lacerated, and punctured wounds, are most apt to give rise to this affection. Tetanus is particularly apt to follow wounds in which a nerve is partly divided or lacerated without being completely divided. The insertion of an artificial tooth, (Plenk,) including a nerve in a liga- ture passed round an artery; amputation; the extirpation of tumors; compound and comminuted fractures; gun-shot wounds; cutting corns on the feet too closely;* the sudden access or introduction of cold air into wounds, particularly of gun-shot wounds when the sloughs are about being thrown off, (Larrey;) in short, every kind of incised, punctured, lacerated, or contused wounds, however trivial, may, under favorable circumstances, give rise to this affection. I once met with a very remarkable instance which appeared to have been excited by the irritation of a dead foetus in utero.t Tul- pius mentions a case of tetanus from suppurative ulceration of the bladder in consequence of calculous irritation. J Richter has known it occasioned by the removal of an encysted tumor from the cheek; and De Haen mentions an instance which was excited by the appli- cation of lunar caustic to a similar tumor.§ A case is mentioned by Bajon,|| which was caused by the application of an escharolic to an ulcer on the leg. Instances of tetanus produced by gangrenous wounds are mentioned by Mursinna,1T Hopfengaertner, and White. * I have seen a fatal case produced in this way. f This case occurred about eight years ago. A poor woman, in the ninth month of pregnancy, who resided at Bush-Hill, came to my office for medical advice. She walked into town, and appeared to be healthy. She complained, however, of an inability to open her jaws, and I found that she could not sepa- rate the teeth more than about an eighth of an inch. She could assign no cause for this affection. I ordered her to be bled, and to apply a blister on the back of the neck. Next day I was requested to visit her. I found her much more indisposed than on the previous day, and the jaws were now firmly locked, with slight spasmodic contractions of the muscles of the throat. I bled her profusely, gave her another cathartic, and applied caustic potash over the track of the tem- poral muscles, and along the course of the cervical vertebra. On the following morning, I found her affected with distinct and general tetanic paroxysms, which gradually became more and more violent and frequent. In the afternoon, I dis- covered, during the intermissions of the spasms, that labor had commenced. On examination, I found the os uteri considerably dilated, and the head of the fetus in the cavity of the pelvis. I immediately sent off for a forceps, and in the course of about half an hour after, delivered her of a dead and partially putrid fetus. The tetanus, nevertheless, continued, and terminated in death on the following morning. I observed that the parturient contractions of the womb, and the tetanic spasms, recurred in regular alternation. X Observ. Med. Amst. 1672. L. iii. cap. ii. § Ratio Medend. Pars. vi. cap. iv. § ix. || Jour, de Med. T. xxx. p. 419. If Jour. f. Chirurgie, 1820. B. i. st. iii. TETANUS. 123 The most dangerous wounds, however, in this respect, are punc- tures of tendinous, aponeurotic, and very nervous parts—as the palms of the hands, soles of the feet, and under the nails of the fingers and toes. Traumatic tetanus frequently does not come on until the wound which gives rise to it has cicatrised. Most com- monly the disease supervenes about the eighth or ninth day, and this is especially the case when it arises from gun-shot wounds. Sir J. M-Grigor asserts that if tetanus does not occur within twenty- two days after the injury has been received, the patient may be regarded as free from danger on this account.* Among the general causes of this affection, cold, suddenly suc- ceeding high atmospheric temperature, is decidedly the most power- ful. Sleeping in the open and cool night air, is a very common exciting cause of tetanus in hot climates. The influence of cold appears to be particularly favorable to the occurrence of this dis- ease from wounds or mechanical injuries. I have already referred to the observations of Schmucker and Larrey on this point, and Mursinna has noticed this circumstance particularly. When the dis- ease occurs from this cause, it generally comes on about the third or fourth day of the exposure. The very frequent or endemic occur- rence of tetanus in Southern climates—at Barbadoes, Java, St. Do- mingo, Cayenne, and generally in the Antilles, as described by Hillary, Pouppee, Desportes, Bajon, Moseley, Blane, Clark, and others, must be ascribed to the combined, or rather alternate influ- ence of high atmospheric temperature, and of cold and damp night air. Tetanus may also be produced by drinking cold water while the body is in a state of free perspiration from fatiguing exercise in warm weather. Rush, Mtirsinna,t and Stuitz,J mention instances occasioned in this way. Tetanic spasms sometimes occur in the latter stage of severe forms of fever. Pathology.—From seeing those muscles particularly affected which derive their nerves from the spinal marrow—whilst those which are supplied with ganglionic nerves are, in a great measure, exempt from spasm; as well as from the undisturbed state of the sensorial and intellectual functions, tetanus was, at an early period of our science, referred to the spinal marrow as its primary and essential location.§ * Medico-Chirurg. Transact. Vol. iv. p. 449. f Jour. f. Chirurgie, B. i. st. iii. p. 406. X Medic. Annalen. 1802, p. 756. § Galen was of this opinion; and Willis, Femelius,(a) Burserius,(i) Hoff- man, and more recently Frank, Marcus, d'Outrepont,(c) Walther, Schaal,(d) (a) De Medicina Universa.—Pathol, vi. ch. iii. p. 417. (b) Iustitutiones Med. Pract. vol. iii. p. 201. (c) Salzburg. Medicinische Clrirurgische Zeituug. No. XXXIV. 1818. (d) Dissertat. de Tetano. Berol. 1820. 124 TETANUS. This view of the pathology of tetanus is founded chiefly on the phenomena usually detected in the spine on post mortem examina- tion; and on the artificial production of tetanic symptoms by certain mechanical injuries of the spinal marrow. Dr. John Frank was the first who directed the attention of physicians particularly to the morbid appearances of the spinal marrow in those who die of tetanus. In one instance he found the spinal matter soft and considerably altered in structure, with effusion of serum between its coats, and an engorged state of the blood-vessels. In another case, strong traces of previous inflammation were detected throughout the whole extent of one side of the spinal prolongation.* Dr. Reid afterwards published a paper, (loc. cit.) from which it would appear that the principal seat of the inflammation is in the membranes of the spinal cord. In an extremely violent case, he found a whitish soft sub- stance deposited between the arachnoid membrane and the pia mater. In less violent cases, serous effusions were found between the mem- branes. Similar observations have been published by d'Outrepont, Walther, Saunders, Abercrombie, Broussais, Monot, Jobert,t and other pathologists. This pathology of tetanus is moreover supported by the fact, that tetanic spasms may be artificially produced in ani- mals by thrusting a slender wire along the spinal canal, so as to irri- tate the marrow without materially compressing it. This experi- ment has been frequently performed by Dr. Walther of Berlin, with the most striking results; and similar consequences were witnessed from this operation by Le Galois, Philip, Brodie, and other physi- ologists. The fact, therefore, that strong marks of inflammation in the spinal prolongation of the encephalon are very common post mortem phenomena in tetanus, appears to be sufficiently established. It may, nevertheless, be doubted whether these morbid conditions of the spinal cord be the proximate and essential cause of the tetanic spasms, or only secondary, and one of the ultimate consequences of the disease. If, on the one hand, this view of the nature of the dis- ease be favored by the occasional successful employment of topical bleediqg, blistering, irritating and cauterising applications along the course of the spine; it is, on the other hand, as strongly discounte- nanced by the equally frequent beneficial effects of alcoholic liquors, Le Galois, Brera, Thompson, Abercrombie, Harles, Rachetti, Esquirol, Cope- land, Carter, Philip, Brodie, 0'Bierne,(a) Reid,(o) Saunders, and others, have expressed similar views. * The side of the spinal matter which was thus affected corresponded with the hand injured, that gave rise to the disease. X Monot and Jobert's report of some cases that occurred in the Hospital St. Louis, and St. Antoine. Medico-Chirurg. Rev. January, 1827. (a) Dublin Hospital Reports, vol. iii. (*) Transact, of an Associat. &c. of the King and Queen's College of Physicians in Ireland, vol. viii. TETANUS. 125 and other powerful internal stimulants. It is highly probable, not- withstanding, that there exists, as an essential link in the chain of causation, strong irritation in the spinal marrow and its membranes, which, in most instances, give rise to vascular turgescence, and in the progress of the malady, to inflammation and consequent effusion or disorganisation. Inflammation and its consequences are, I pre- sume, not essential to the production of the disease, but a consequence only of the spinal irritation upon which the spasmodic affection de- pends.* Mr. Swan, a few years ago, published an essay on this disease^ in which several cases are related, tending to show that tetanus depends on irritation and inflammation of the ganglia.t In the cases which he reports, the ganglia of the great sympathetic, manifested unequi- vocal marks of irritation and disease. The semilunar ganglion was, in most instances, strongly injected, and all the other ganglia of this nerve were more or less inflamed. Prognosis.—The prognosis in this disease is always highly unfa- vorable.f Traumatic tetanus is particularly fatal in its tendency. Cases that depend on general causes are usually much more under the control of remediate management. That variety of tetanus which occurs in new-born infants (trismus nascentium,) termi- nates, almost universally, in death. Parry asserts, that if the pulse becomes very frequent on the first day of the disease, if it rises above one hundred and twenty beats in a minute, the case may be regarded as inevitably mortal. When, on the contrary, it does not go beyond one hundred or one hundred and ten beats by the fourth or fifth day, reasonable hopes of recovery may be entertained. "When the disease comes on gradually, and the muscles of the jaws are alone affected during the first three or four days; when the abdo- men is not preternaturally hard, and the bowels obstinately costive; * Dr. M. Funk, a German physician, has lately published an account of seve- ral dissections of persons who had died of tetanus. In the first case, the dura mater was reddened in the cervical portion of the spinal cord; about the first dorsal vertebrae, and below it, the canal was filled with extravasated blood, which had also extended a short distance along the nerves. In the lumbar re- gion the extravasation was greatest, and the dura mater was here considerably thickened. The surface of the cord itself was rose-red, the origin of the nerves swelled, and the cauda equina much reddened. In another case, a large quantity of bloody serum was found between the dura mater and arachnoid, and the ves- sels were very much injected, with some extravasation throughout the whole course of the spine. In a third, fourth, and fifth case, equally strong marks of spinal inflammation were detected.(a) | An Essay on Tetanus, founded on Cases and Experiments. London, 1825. X Aretaeus very justly designates tetanus as, inhumana calamitas, injucundus aspectus, triste intuenti spectaculum, et malum insanabile. (a) Glasgow Medical Journal. 11* 126 TETANUS. when the skin is moist and moderately warm; and above all, when the patient enjoys sleep, we may entertain strong hopes of an even- tual recovery. An increased flow of saliva, where mercury has not been used, is always to be regarded as favorable; and the less the general expression of the countenance is changed, the better. On the other hand, where the attack is violent and sudden; when the muscles of the neck, back, and abdomen, are rigidly contracted; when the patient complains of a shooting pain from the sternum towards the spine; when the belly feels hard, and the least pressure thereon produces spasmodic twitchings or contractions of the muscles of the neck, jaws, &c, or when the same effect is brought about by the presentation of any substance, solid or fluid, near the mouth, we may have much reason to fear a fatal termination."* Treatment.—When a wound or injury has been received, from which tetanus may be apprehended, efforts should be made to pre- vent its occurrence, by a proper management of the local injury. Experience has fully established the fact, that the best means for preventing the disease is the production of free suppuration in the injured part. When this process can be fully established in wounds, even of the most unfavorable character, the occurrence of the dis- ease will almost certainly be prevented. It has been frequently ob- served, that the less inflammation there is in the injured part, the greater will be the liability to tetanus. This circumstance has sug- gested the propriety of exciting inflammation in the wounded part, by means of irritating applications. For this purpose we may apply spirits of turpentine, lunar caustic, caustic ley, cantharides, or, ac- cording to Larrey, the actual cautery, followed by warm stimulating poultices; or the part may be incised or scarified, and afterwards further irritated by some application of this kind. When nerves or tendons are but partially divided by the injury, the division should be completed by free incision. General remedies have also been recommended, with the view of preventing the disease. Larrey in- sists strongly on the importance of preventing the access of cold and damp air to wounds, particularly gun-shot wounds, as a prophylactic measure. Dr. Thomas states, that in the British army, opium is mixed with the dressings as a preventive of this affection. Dr. Pot- ter of Baltimore states, that he has found no application so useful, in this respect, as warm emollient cataplasms.t Dr. ClarkJ advises a slight mercurial ptyalism after unfavorable wounds, more especially in hot climates. An equable and comfortable temperature, with a simple diet and rest, are important auxiliaries in preventing the dis- ease after wounds. A very great variety of remedies and modes of treatment have been proposed, and occasionally employed with success in this fright- * Dr. Morrison.—Vide Johnson on Tropical Climates, vcl. ii. X Note to Gregory's Practice, vol. ii. p. 141. X On the Diseases of the West Indies. TETANUS. 127 ful malady. The practitioner who consults the records of medicine for light on the remediate management of tetanus, will probably find himself very much perplexed. He will find the doctrine of its de- pendence on spinal and ganglionic inflammation strongly counte- nanced by examples of post mortem phenomena; and yet he will read, on the one hand, the laconic, but sweeping denunciation against the most powerful antiphlogistic—"bleeding is to be condemned;"* whilst, on the other hand, he will find stimulants and tonics repro- bated, and prompt and copious depletion pointed out as the sheet- anchor of our hopes. He will find Broussais and others, ridiculing the idea of treating tetanus with stimulants and antispasmodics;! and then, turning to Morrison and a great number of other respect- able authorities, he will learn that these are the very remedies which, in their hands, proved most successful. These facts may be irrecon- cilable, according to our imperfect views of the pathology of this affection, but they are notwithstanding facts, and there is therefore something in the nature of the disease, which, in spite of theory, renders both exciting and depletory measures, at times, decidedly beneficial. To me indeed these apparently contradictory statements appear to admit of a plausible though hypothetical explanation. Te- tanus is manifestly an irritative disease. In the traumatic variety, it would seem to be the result of a peculiar irritation, passing from the extremities of wounded nerves to their origin, giving rise to morbid action in that part of the nervous centre which more im- mediately presides over the powers of the voluntary muscles. Hence, opium and whatever is capable either of blunting the irritability, or causing a strong counter-excitement in the nervous system, may overcome morbid excitement and ultimately subdue the disease. As, however, all violent local irritation tends to produce congestion, and finally more or less inflammation in the part, this may at times be an early consequence. Here, general and local depletion will be proper; and, if promptly and efficiently practised, in conjunction with other suitable remedies, before effusion and disorganisation have taken place, may prove successful. Nay, even direct depletion, and the liberal use of opium, are not incompatible, for, while we dimin- ish the momentum of the circulation on the one hand, we lessen, on the other, the morbid irritation upon which the disease and the in- flammation depend. No small number of cases may be cited in which copious blood- letting was decidedly beneficial. Mr. Barr bled a young man affected with traumatic tetanus, to the extent of fifty ounces at once, pleno- rivo. In half an hour the patient's jaws relaxed in some degree, and three fluid drachms of laudanum were exhibited. The spasms continued, though in less violent and frequent paroxysms. He was afterwards bled to the amount of thirty-two ounces on the third day, * Elements of the Theory and Practice of Physic, vol. ii. f Journal de Med. Phys. Fev. 1827^ 128 TETANUS. and sixteen on the fourth. Exceedingly large doses of calomel and opium were also regularly given. On the fifth day, the disease yielded completely.* M. Lisfranc has reported a successful case, in which eight bleedings were practised from the arm, and in the course of nineteen days, six hundred and eighty leeches applied along the vertebral column.t M. Burmester treated a case of traumatic te- tanus successfully by copious blood-letting, opium, mercury, and the warm bath.J We may also refer to the case reported by Dr. Alex- ander, which yielded to copious and repeated venesection, leeches to the abdomen, mercury, and active purging.§ M. Le Pelletier, chief surgeon of the hospital at Mans, in an able memoir on this dis- ease, observes: "It is neurilematic inflammation that we mustattack in the treatment of tetanus, and the only means sufficiently powerful to subdue it in its bud is venesection, not practised with reserve, but with the utmost degree of promptness and freedom.|| Local bleed- in«- by leeches or cups along the track of the spine, is decidedly in- dicated in this affection." When we reflect, says Dr. Johnson, that the brain and spinal marrow must be the immediate seat of the irri- tation or inflammation which gives rise lo the phenomena of tetanus, we can hardly look with confidence to any remedy which has not a strong tendency to remove this irritation or inflammation. What is more likely to effect this indication than powerful and repeated de- pletion from the head and spine, but especially from the latter?TT Purgatives, also, are important auxiliaries in the treatment of this affection. Dr. Hamilton recommends their use as a principal curative means; but he does not adduce any very decisive or direct evidence from his own experience, in support of the propriety of relying chiefly on their employment. He gives indeed some state- ments from his own practice of" the good effects of active purgation in what " appeared" to him cases of incipient tetanus, but it may be reasonably doubted whether these instances were really tetanic. Unquestionably, cathartics deserve to be regarded as highly useful remedies in this disease, but we may with propriety, I think, demur, when we are advised to rely on them as principal curative means. In all instances, perhaps, it will be proper to exhibit active cathartics, not only with the view of removing the ordinary sources of intes- tinal irritation, but also as revulsive and depletory measures. From fifteen to twenty grains of calomel, followed in the course of four or five hours with a dose of castor oil and spirits of turpentine, (an ounce of the former to two drachms of the latter) may be given in the commencement of the disease, and repeated according to the * Edinburg Med. and Surg. Journ. No. XVII. X Rev. Medicale, torn. ii. for 1829, p. 342. X Med. Chirurg. Transact, vol. xi. art. xiv. § Edinb. Med. and Surg. Jour. Oct'r. 1825. j| Revue Medicale, torn, iv. ann. 1827, p. 346. \ Medico-Chirurg. Rev. July, 1827, p. 176. TETANUS. 129 circumstances of the case. In that variety of the disease, which occurs in new-born infants, purgatives have been generally consi- dered as indispensable. There is no remedy whose good effects in this disease is so fre- quently mentioned as opium. One of the latest writers who speaks particularly in favor of relying chiefly on this narcotic, is Dr. Mor- rison. During eight years of practice at Demerara, where tetanus is of frequent occurrence, he employed it in a number of cases, and he declares, that in more that a dozen instances, the cure could be fairly attributed to this remedy. Its good effects are, however, not to be procured from small doses. It must be given in very large and repeated portions.* Dr. Morrison generally commenced with one hundred drops of laudanum, and increased each succeeding dose by thirt)'- drops every two hours, until either sleep or stertorous breath- ing came on, when it was discontinued. The quantity of opium, which has been advantageously given in some instances, is indeed enormous. In Dr. Barr's case, referred to above, " a drachm of solid opium was given at once," on the third day of the disease, and after eighty-two ounces of blood had been abstracted. "In twenty minutes the patient began to doze a little, but not to sleep. In about an hour he fell asleep, shortly after which the breathing became slow and very laborious. In two hours he was roused, when he felt nausea, which was succeeded by full vomiting, which produced much relief. One slight spasm only afterwards occurred." The bowels should always be well evacuated by active cathartics and injections, previous to resorting to the opium. In traumatic tetanus, at least, copious venesection and leeching along the spine, would appear to be an im- portant preliminary or concomitant measure with the employment of opium. In most of the cases that have been reported in illustra- tion of the good effects of copious bleeding, opium was freely ad- ministered.! The method of Stftitz, which in some parts of Europe has gained much celebrity, consists in the alternate use of opium and large doses of carbonate of potash, together with warm alkaline baths.f Bouchet, surgeon of the Hotel Dieu at Lyons, gave one drachm of opium with three of the carbonate of potash in 24 hours with complete success in traumatic tetanus. In a recent number of Hufeland's Journal,§ an instance of traumatic tetanus is related, in * A Treatise on Tetanus with cases. Lond. 1815. f Dr. Odeir of Geneva, says, " the best means for ascertaining whether the disease is tetanus, in doubtful cases, is to exhibit opium in gradually increasing doses. If the disease is tetanus, it will require an exceedingly large dose be- fore its narcotic effects are manifested. But in cases that simulate tetanus, as is sometimes the case with hysteria, this narcotic evinces its powers much more readily and energetically."—Manuel de Medicine Practique, p. 189. X Stuitz ueber den Wundstarr Krampf Hufeland's Jornal, Bd. xviii. st. iv. p. 5. § October, 1827. 130 TETANUS. which this mode of treatment, with a copious blood-letting in the commencement, was used with the happiest effect. The method, however, no doubt, derives its powers, chiefly if not wholly, from the opium and warm-bathing. Applied externally, the acetate of morphium has been employed with marked success, in this affection. Dr. Jos. Cerioli, of Cremona, has related a case of traumatic tetanus, which, " after copious blood-letting, and the use of large doses of morphine internally, together with the warm bath, and stimulating frictions, along the spine, without any advantage, yielded, very soon, to the external application of morphine. About ten days after the commencement of the disease, the cuticle was removed from the back of the neck, by means of an epispastic. Some acetate of mor- phium was then applied to the part, and repeated in about six hours." The effect produced by this application, was extremely remarkable; in a few hours the clonic spasms were weaker, the motion of the jaw more free, the contraction of the lineaments of the face became relaxed, the pains of the neck and back had diminished sensibly, the sufferer enjoyed a tranquil sleep, with slight occasional interruption. By the continued application of this narcotic, the patient was, finally, entirely relieved of the complaint, without any other remedy.* Mercury, also, has been a good deal employed, and according to respectable authorities, with decided advantage in tetanus. Dr. Wal- ther, in a memoir on the use of mercury in this affection, declares that from successful experience, he is led to regard this remedy as among the most valuable means we possess for the cure of tetanus. In the Medical Essays and Observations of a Society in Edinburgh, published a century ago, Dr. Donald Monro states, that a gentleman in Jamaica, had cured twelve cases of tetanus in succession " by plac- ing his patients in a very warm room, and then rubbing in large quantities of mercurial ointment over the limbs and body until ptyalism was raised. This with large doses of opium, was the only means used. Dr. A. Monro of Edinburgh tried the same plan in a case of traumatic tetanus, and with complete success."t Larrey, however, states, that mercurial frictions during the French cam- paigns in Egypt, almost uniformly did harm. Dr. Rush cured a case in the Pennsylvania Hospital by copious salivation, assisted by bark and wine. It would appear from the observations that have been published on this point, that ptyalism is much more apt to do good in idiopathic, than in traumatic tetanus. Dr. Morrison states, that he met " with many examples of the beneficial effects of mercury in this disease, and as it does not interfere with other remedies, the free administration of mercury, he says, ought never to be omitted." Wine and other alcoholic liquors, though apparently directly contra-indicated, have been much used, and successfully too, in te- * London Med. and Phys. Jour, from the Aunali Universali di Med. May, 1829. f Med. Chir. Rev. vol. x. p. 304. TETANUS. 131 tanus. In conjunction with bark, mercury, and irritating applications to the wound, wine was a favorite remedy in this affection with Dr. Rush. " Wine," he says, " should be given in quarts and even gallons daily." Dr. Currie cured a case in the Liverpool infirmary; the patient having drunk, in a short time, " nearly a quarter cask of Madeira wine," and Dr. Hosack has published observations illustra- tive of the beneficial effects of this stimulant in tetanus.* In the London Medical and Physical Journal for March, 1825, Dr. Nicholls has reported a case of incipient traumatic tetanus, which was suc- cessfully treated by the administration of wine, laudanum, bark, and steel, with ammonia and nourishing diet. Various other stimulants have been employed in tetanus. The spirits of turpentine, in particular, has of late years attracted con- siderable attention as a remedy in this disease. Dr. Hutchinson gave it in a case of idiopathic tetanus, in an epileptic subject, with complete success.t A similar case is related by Dr. William Tamis, which yielded to the internal administration of this article.J Dr. Mott, of New York, has given an account of a case of traumatic te- tanus, which was cured by the spirits of turpentine after the disease had resisted the influence of the cold and warm bath, tobacco, opium, bark, wine, and blisters to the spine. A teaspoonful of the turpen- tine was.given every fifteen minutes for two hours, when the spasms intermitted. It was afterwards repeated at longer intervals, until one hundred and twenty-three teaspoonfuls were taken. § Tobacco was recommended for the cure of this disease, by Dr. Edmund Gardener as early as the beginning of the eighteenth cen- tury. It has lately been a good deal employed, and no inconsiderable number of instances have been published illustrative of its good ef- fects. Dr. O'Beirne's case, related in the third volume of the Dublin Hospital Reports, is an interesting example of the occasional bene- ficial influence of tobacco in tetanus. Tobacco enemata (a scruple of tobacco to a pint of boiling water) were employed at longer or shorter intervals, for fifteen days in succession, and the disease was thereby completely overcome. Dr. Anderson, who practised at Trinidad, has reported three cases of traumatic and idiopathic tetanus, which yielded under the employment of the tobacco.j| He directed thejaws, throat, and chest to be fomented for half an hour at a time by a strong decoction of fresh tobacco leaves. After the fomentations, cataplasms of tobacco were applied to the jaw and throat. The warm bath, into which some tobacco was thrown, was also used every three hours, and a tobacco enema administered every twelve hours. The trismus did not yield until the third day, when thejaws * New York Medical Reposit. vol iii. p. 22. f Lond. Med. and Phys. Jour. No. CCLXXXVIII. X Ibid, for May, 1823. § New York Med. and Phys. Jour. vol. ii. p. 388. || Transact, of the Med. Chir. Society of Edinburgh, vol. i. and vol. ii. 132 TETANUS. became a little relaxed, and under the same treatment the patients gradually recovered. Lefoulon, also employed this powerful narcotic with success in tetanus;* and Dr. Norcom cured a case by the simultaneous employment of opium internally and tobacco clysters.t The prussic acid would appear to possess very considerable re- mediate powers in this affection. Dr. Trezevant, of Columbia, South Carolina, has given the history of a case, which strongly illus- trates the beneficial tendency of this potent remedy in tetanus.f It appeared, also, highly useful in a case treated successfully by Pro- fessor Pattison, in which it was freely used, in conjunction with the application of caustics along the spine. Various other internal re- medies have been given with more or less benefit in tetanus. Dr. Brown exhibited the tincture of cantharides in large doses with success; and Dr. Elliotson has published some observations, which go to show that considerable advantage may occasionally be derived from very large doses (^ss.) of the subcarbonate of iron.§ The external employment of cold water, either by affusion or the plunging bath, is one of the oldest remedies employed in tetanus. || Dr. Wright was the first, in modern times, who directed the attention of the profession, particularly to the employment of cold affusions in this affection.l His observations were soon followed by those of Cochran,** and Currie, who fully confirmed the favorable accounts he had given of its effects. Dr. Rush also obtained decided advan- tages from cold affusions in this disease. The only fortunate case I have ever witnessed, was treated by mercury, opium, and very fre- quent cold affusions. The warm bath, also, had been frequently employed in the treatment of tetanus. Richter observes, that the warm bath seldom fails to procure at least temporary mitigation of the symptoms. Dr. Morrison speaks favorably of the effects of warm bathing in tetanus; but the exertion, he says, which the pa- tient must undergo, to get in and out of the bath, sometimes does more harm than can be counterbalanced by this measure. " Patients (he observes) are so alive to all external impressions, that the least ex- ertion is often sufficient to excite violent spasms. On this account, the patient should be kept as quiet as possible, and very few ques- tions asked, and every thing tending to excite mental exertion avoid- ed." It must be observed, moreover, that according to the expe- rience of some practitioners, much mischief has resulted from the use of the warm bath in tetanus, independent of the exertion which * Harles' Neue Jour. d. Med. Chir. Leter, B. vi. No. II. X Philadelphia Journal of Med. and Phys. Sciences. X Medical Recorder, vol. v. October, 1825. § Med. Chir. Trans, vol. xv. part i. || Hippocrates, lib. iv. sect. v. aph. 2, et lib. v. sect. ii. aph. 21. Avincena: lib. iii. cap. 7. If Lond. Med. Observ. and Inquir. vol. vi. ** Med. and Philosoph. Comment, vol. iii. TETANUS. 133 it requires. Dr. Hillary states, that he has known instantaneous death to follow warm bathing in this disease. This, however, may be affirmed of perhaps every important remedy that has been admin- istered in tetanus. From what has been said above, concerning the pathology of te- tanus, no remedies appear to be more clearly indicated than external irritating applications along the track of the spine. This is, indeed, an old practice. Celsus lays particular stress on the assiduous em- ployment of frictions and rubefacients over the vertebral column;* and if these are insufficient, he advises the application of cups; or, finally, the actual cautery over the vertebrae of the neck. Dr. William Carter, among modern writers, is, I believe, the first who employed blisters along the whole course of the spine in this affection. He has published a case which was successfully treated by blistering in this manner, with the occasional use of an active cathartic! Several other cases are extant, illustrative of the good effects of this practice. A much more powerful and prompt means of this kind is the caustic potash. Dr. Hartshorne, of this city, was, I believe, the first who applied this caustic over the spine for the cure of this af- fection. He has reported a case which yielded completely under the employment of this application, together with the internal use of opium, ether, brandy, and extract of stramonium, in large doses. In this case the good effects of the caustic were unequivocal. The internal remedies, just mentioned, had been employed for several days without any advantage. The caustic was at last applied over the cervical vertebra, and in about two hours afterwards a diminution of all the tetanic symptoms had already taken place.J A case, equally satisfactory, in relation to this practice, is related by Dr. T. Thomas, of Easton, Maryland. After wine, mercurial frictions, and opium, had been ineffectually employed, the caustic potash was applied over the course of the cervical vertebrae. ''The effect," says Dr. T. " was really delightful; the new action excited by the caustic destroyed completely the morbid action of the system; the spasms ceased, and in one hour the patient appeared free from disease."§ Many other cases have since been published, demonstrating the beneficial effects of this practice.|| I have already referred to the * Fricatio cum omnibus vertebris, hominum utilis sit, turn iis prascipue, quas in collo sunt. Ergo die nocteque, interpositis tamen quibusdam temporibus, hoc remedio utendum est: dum intermittitur imponendum malagma aliquod ex calefacientibus. Si vero etiam vehementius dolor crevit, admovendffi, cervicibus cucurbituriae sunt, sic ut cutis incidatur. Eadem aut ferramentis aut sinapi adurenda. Celsus, de Medicina. Lib. iv. cap. iii. X Med. Transact, of the Lond. College of Physicians, &c. vol. ii. p. 34. X Eclectic Repertory, vol. vii. p. 245. § Ibid. || Dr. Worthington, (Medical Recorder, vol. iii. p. 527.) Dr. Joel Lewis, (Ibid. p. 176.) Professor Potter, of Baltimore. Vol. II.—12 134 HYDROPHOBIA. recommendation of the actual cautery to the region of the cervical vertebras, in this disease, by Celsus. In modern times, Mursinna has resorted to this measure, with almost instantaneous mitigation of the symptoms. Dr. M'Clellan also employed it in one instance with unequivocal benefit. The application of moxas, along the spine, might, no doubt, be used with advantage. From all that has been said concerning the treatment of tetanus, it appears manifest, therefore, that copious bleeding, leeching, and cupping, along the spinal region, mercury, large doses of opium, tobacco enemata, active purgatives, the free use of wine, and caustic applications over the cervical and dorsal vertebras, constitute the most important curative means in this affection. Sect. X.—Hydrophobia. Hydrophobia is one of the most ancient diseases.* The first dis- tinct account, however, which was given of this terrific malady, is to be found in the writings of Ccelius Arelianus.t Celsus speaks of it as a disease well known before his time. In the human species, hydrophobia has never, so far as is known, arisen from general causes. In man it is always the result of a spe- cific virus or contagion derived from an animal laboring under the disease. The hydrophobic virus appears to be exclusively attached to the saliva: and hence almost the only mode in which it is propa- gated is by wounds inflicted with the teeth of a rabid animal. With- 'out doubt, however, the disease may be communicated by bringing the contagious virus in contact with an excoriated or wounded sur- face in any manner. This has indeed been verified by direct expe- riment. Magendie and Brechet inoculated two dogs with the saliva of a rabid man. One of these dogs became rabid, and bit two others, which also became mad. Instances have moreover been recorded of the propagation of hydrophobia by the accidental contact of the morbid saliva with wounds, or excoriations on the lips, hands, or other exposed parts of the body.J In the dog, fox, and wolf, and in the domestic cat, and perhaps • * Among the ancient Egyptians, rabies canina appears to have been known, and ascribed to a disease of the spleen. Horapollo (Hieroglyphica, I. 39.) says, g-V\ma h, ImiSh toujo to (Zov fiivov israga ra. trt^a. eXck^o'tsjcv tyii. eite (Je) S-avaToj avrZ, tin fxavta, ir^ims-ot, iwo toZ - • IS T3 CD s O T3 e has assumed a chronic state, it will be proper to divide it by an incision. In sloughing ulcers, without indurated bases, we may often de- rive much benefit from stimulating applications. Carmichael par- ticularly recommends Venice turpentine, or balsam copaiva, mixed with one or two parts of olive oil. I have known very prompt ad- vantage derived in sloughing ulcers of this kind, from the applica- tion of poultices made of crumbs of bread and a strong decoction of oak bark. A lotion of one part of the tincture of myrrh to seven parts of camphorated mixture, may also be very beneficially applied where the sloughs are extensive. (Carmichael.) A pure air is all-important in the management of this variety of venereal sores. The true syphilitic chancre.—When early resorted to, the exci- sion or destruction of the chancre with caustic, will frequently arrest the further progress of the local affection, and prevent the occurrence of the secondary constitutional symptoms. This practice is, how- ever, not always free from unpleasant consequences; for although the sore may be thus speedily healed, buboes will occasionally ap- pear; and the virus is sometimes confined under the eschar produced by the caustic, and corrodes the parts underneath, so as to form a deep ulcer. In irritable and depraved constitutions, too, the irri- tation produced by the caustic is apt to give rise to very injurious consequences. Swediaur asserts, that he has seen " the most dread- ful symptoms produced by this application." Although mercury is unquestionably our only means for counteracting the formation of secondary affections, it does not appear to possess any especial con- trolling power over the primary local affection. Nevertheless, as it is of much importance to protect the system against the occurrence of a general syphilitic taint, it will be proper to put the patient, at once under the use of a gentle mercurial influence, in conjunction with proper local applications to the chancre, unless the primary sore be irritable, and the general system inflammatory, or of a manifestly depraved or scorbutic habit. When these contra-indicating condi- tions to the employment of this remedy exist, measures must be t 516 SYPHILIS. previously taken to remove the irritable and phlogistic state of the system by pure air, diaphoretics, opium, and laxatives. Most of the recent writers recommend the mildest local applications—simple ablution to keep the parts clean, and dressing the chancre with dry lint, or the most soothing ointments; and in the majority of instances, these will be found better than the irritating applications formerly so much employed. Swediaur, however, is a strenuous advocate for the employment of the red oxide of mercury mixed with lard, as a local remedy for syphilitic chancre. He also speaks very favor- ably of the effects of "finely powdered corrosive sublimate, mixed with a little saliva, and rubbed for five or six minutes, once or twice a day, on the ulcers. These remedies, (he asserts,) are generally highly useful, notwithstanding the assertion of modern writers." To sum up all, he says, " I am of opinion that mercury topically applied, is never injurious in syphilitic ulcers; but on the contrary, that it is extremely serviceable, and almost sufficient to effect a cure, when the ulcers are local, and arise from a primary disease; lastly, that it is always necessary when the progress of the disease is rapid and alarming." I have repeatedly resorted to applications of this kind with very satisfactory results, although, in general, I have ab- stained from*them until the system was put under a moderate mer- curial influence. My usual mode of proceeding, is to destroy the chancre with lunar caustic, when 1 am consulted during the first five or six days after its appearance; but when the chancre has already made considerable progress, 1 at first, simply keep the parts clean by frequent ablution, and direct it to be dressed with simple cerate; as soon, however, as the system is moderately impregnated with mercury, I destroy the callous edges of the chancre with caustic; and direct the sore to be dressed with red precipitate ointment; or to be touched frequently, during the day, with a solution of the sul- phate of copper (four grains to an ounce of water;) or finally, to be washed repeatedly with the black mercurial lotion. The mercurial impression should be kept up for six or eight weeks; but it is of the utmost importance that the patient should avoid a damp and cold atmosphere, and that he should be particularly cautious to keep up an equable action of the skin by warm clothing. He should use a mild and unirritating diet, and abstain, wholly, from the use of sti- mulating drinks. During damp and variable weather, there is great risk of receiving injury from cold, while the system is under the mercurial influence; and to avoid this accident, the patient should, if possible, remain within doors. The treatment proper for the removal of the constitutional venereal symptoms, has been particularly a field of much conten- tion—all turning upon the point, how far mercurial remedies may be necessary or injurious in the management of these affections. It is now, however, very generally admitted, that in what are termed the pseudo-syphilitic symptoms, the employment of this potent remedy may, often, be very properly dispensed with—that it is cal- SYPHILIS. 517 culated under certain circumstances to do much injury, and that in no instance is it necessary to carry its employment to the great extent which was formerly so indiscriminately and generally prac- tised. Nevertheless, we may upon good grounds, I think, refuse to join in the hue and cry set up against the employment of mercury in venereal cases—for there is much reason to believe, that many of the baneful consequences which have occurred from its administra- tion, have proceeded rather from its abuse, than its use, or from accidental influences contravening its salutary influence. The most violent declaimers against mercury, are those who have practised in hot climates—and in military and other hospitals, and generally among patients whose previous modes of living, were such, as to de- prave the general constitutional habit—all of which circumstances are certainly very well calculated to interfere with the salutary ope- ration of this remedy, and to convert it, often, into a decidedly dele- terious agent. It must be admitted, that the various forms of constitutional vene- real affections, may in general be ultimately removed by a long course of the usual diaphoretic ptisans, proper regimen, and other simple measures, calculated to improve the general health of the system. This is more especially practicable, so long as the second- ary symptoms are confined to the skin and throat: but even in this stage of the progress of such affections, the moderate and gentle use of mercury will almost always greatly expedite the cure, and in some instances will be found indispensable to the entire eradication of the malady. Although very generally a mild mercurial influ- ence, regularly sustained, will be sufficient to procure all the benefits that may be derived from this remedy, yet instances do sometimes occur, which after a long course of gentle mercurial action, without any permanent advantage, will readily yield to a full salivation. About four years ago, 1 met with a striking illustration of this fact The patient had for three years labored under secondary venereal symptoms, which were the consequence of a phagedenic primary ulcer. He had undergone three moderate, but ldng continued mer- curial courses, with only very temporary benefit, and during the eight months immediately before I saw him, he daily took the sarsa- parilla decoction and syrup—of the latter of which he had already taken above forty bottles. His nose and internal fauces were much ulcerated, and various painful swellings on the ulnae, tibiae, and cra- nium, had reduced him to a most distressing condition. 1 put him immediately upon the use of large and repeated doses of calomel, and confined him to his bed? In five days very profuse ptyalism was induced, which was kept up for two weeks, and then left to subside gradually, under the use of sarsaparilla infusion. In six weeks he was entirely cured, and he has since enjoyed, apparently, a perfect state of health. The papular form of venereal eruption, will very generally dis- appear under the use of antimonials and sarsaparilla, with a mild Vol. II.—44 51S SYPHILIS. and unirritating regimen, aperients, the warm bath, and the avoid- ance of a variable, damp, and cold atmosphere. Nevertheless, where this eruption continues obstinately, and the patient's strength de- clines, recourse should be had to mercurial remedies, which will rarely fail, in a short time, to manifest a most beneficial effect. The tubercular eruptions which usually appear on the eyebrows, fore-arms, back, and hairy scalp, and which at last becomes converted into irregular crusts, leaving ragged, ill-looking ulcers, of a glassy, shining, and level surface when they separate, are in general much improved by a mild mercurial course, employed after the general phlogistic symptoms, which usually usher in the eruption, have been reduced by venesection, antimonials, aperients, diluent drinks, &c. Carmichael recommends the free use of the decoction of sar- saparilla and antimonials in this variety of the disease; and where the secondary ulcers are extensive and irritable, with phagedenic edges, the use of free doses of cicuta, in conjunction with the com- pound decoction of sarsaparilla, is often highly beneficial. The in- ternal use of the nitrous acid too, is sometimes very efficacious, where the tubercles spread in foul and irregular ulcers; and it may be very conveniently given in union with the sarsaparilla. Although Mr. Carmichael advocates the non-mercurial mode of treating this and some other varieties of secondary venereal affections, he " does not wish to be understood as wishing to exclude the use of mercury al- together, for the cure of this most formidable of venereal complaints." It is against the abuse, not the use of this remedy he contends. The fact appears to be, that where from idiosyncrasy, or a peculiar, irritable, and scorbutic condition of the system, the operation of this remedy is not diverted from its ordinary salutary effects, it may in general be employed with as much advantage in this as in any of the other forms of secondary venereal affections. Mr. Bacot asserts it as his conviction, that the tubercular variety of eruptions, with its consequent ulcerations, is in general " strikingly benefited by the mild employment of mercury." Without, however, extending these observations as to the parti- cular circumstances under which the employment of mercury may be proper or improper, it will be sufficient to observe, in a general way, that in all instances where the cutaneous and other secondary symptoms do not yield in a reasonable course of time to the use of sarsaparilla, the compound decoctions of the woods, antimonials, rest, an equable temperature, and simple and unirritating diet, re- course should unquestionably be had to a more or less active course of mercury. Where the constitutional symptoms are attended with much general irritation or febrile excitement, the use of mercury ought to be delayed until the general phlogistic and irritable habit of the body has been moderated by the use of the measures just in- dicated. It should also be particularly borne in mind, that where the ulcerations in the throat are attended with high inflammation and swelling, mercury cannot in general be safely administered until SYPHILIS. 519 this local inflammatory condition has been moderated by general an- tiphlogistics, emollient gargles, the inhalation of aqueous vapor, perfect rest, low diet, and nauseating antimonials. In instances attended with an irritable habit of body, much advan- tage will usually result from the employment of opium or hyoscya- mus in conjunction with mercurials. This combination is more especially necessary in cases attended with much pain in the extremi- ties or bones, and where the mercury seems to augment the gene- ral irritation. So far as my own limited experience has enabled me to judge, I am well satisfied that the regular employment of full doses of Dover's powder will in general very materially enhance the good effects of mercury, under almost every variety and circum- stance of the disease. One of the most important observances in the employment of this remedy, is the rigid avoidance of a cold, damp, and variable atmos- phere. If the patient can be induced to remain in his room, which should, however, be kept perfectly clean and well ventilated, and at a uniform temperature, the beneficial influence of the mercury will be much more certainly obtained than when he walks about in the open air, unless the weather be warm and dry. The diet too should be of the lightest and least irritating kind, and every sort of stimulat- ing drink must be especially interdicted. It has already been stated, that in the commencement of the con- stitutional symptoms, it often becomes necessary to employ measures for the reduction of the general phlogistic habit, before mercurial remedies can be with propriety resorted to. It may also be observed, that even in inveterate cases, the use of aperients, the warm bath, and especially the compound decoction of sarsaparilla, continued for three or four weeks, are often decidedly useful preliminary measures to the employment of mercury. With regard to the extent to which the mercurial action is to be carried, no precise rules can be laid down for the management of secondary venereal affections. It is admitted, nevertheless, that it seldom becomes necessary to induce full ptyalism—a moderate and equable action, maintained for a considerable length of time, being commonly sufficient to procure all the advantages that can be derived from this remedy. To this, however, exceptions will occur; and where the disease does not yield under the combined influence of an alterative course of this medicine, and the usual diaphoretic or depurative ptisans, we ought certainly to push the mercury to the full extent of its influence, where no symptoms or circum- stances exist which seem to contra-indicate its vigorous employment Some difference of opinion prevails as to the preparation of mer- cury most eligible for the treatment of venereal affections. In re- cent cases, the blue pill, with or without ipecacuanha, is generally, preferred. In chronic syphilitic affections of every form, I have scarcely ever employed any other mercurial than the corrosive sub- 520 SYPHILIS. limate, in doses of from one-eighth to one-sixth of a grain, with two grains of the extract of cicuta, three times daily. Professor Zondi has, within a few years, published a new mode of using mercury in chronic venereal complaints, which I have known employed in two instances with extraordinary success, lie makes one hundred and twenty pills out of twelve grains of corro- sive sublimate, and directs them to be taken in the following way: On the first day one is taken; on the second none; on the third two; on the fourth none; on the fifth three pills; and so on, increasing the dose by one pill every other day, and omitting them on the in-r tervening days, until they are all taken, by which time the cure is completed. During the treatment, infusion of senna is to be taken, so as to keep up a regular action of the bowels, and the patient is restricted to half the ordinary quantity of his food, and is permitted to leave his house only during very fine weather. About two years ago I saw this plan of treatment put in practice with complete success. The patient was affected with venereal nodes and caries, with ulcers on different parts of his body, and had been long wholly unfit for any kind of employment. I had him under treatment for six months; in three of which he used the compound decoction of sarsaparilla, and the last three months he was under an alterative course of mercury, without deriving any particular benefit from all I prescribed. He was then admitted into the Pennsylvania Hospi- tal, and underwent two full mercurial courses, but he came away without being in the least relieved. My friend, Dr. Mcering, had expressed to me a wish for a proper subject to put Zondi's mode of treatment to a fair trial. I took him to this patient: he prescribed the corrosive sublimate in the above way, and in five weeks the patient was relieved of ail his symptoms; and he is now perfectly healthy, and has made several long voyages since he underwent the treatment. The Proto-Ioduret of Mercury has, recently, been strongly re- commended as a remedy in syphilitic affections. M. Biett pre- scribes it according to the formula given below.* Sarsaparilla and guaiacum in the form of a ptisan, are without doubt, highly valuable remedies in the treatment of venereal affec- tions; and in conjunction with antimonials, a simple diet, warm bathing, and aperients, will often remove the milder forms of the * R.—Proto-ioduret of mercury ^i. Powder of marsh mallows 3L—M. Divide into 72 pills.—Or, R.—Proto-ioduret of mercury 9ii. Thridace Jss. Extract of guaiac 5ji.—M. Divide into 48 pills. He commences with one pill a day, for the first three days, and gradually increases the number to three or four a day, never more than one, however, at a dose. He orders at the same time, some alterative infusions. SYPHILIS. 521 disease without the aid of mercury. Although I should not be dis- posed to depend solely on these means, yet the sarsaparilla infu- sions, in common use, can hardly be omitted with propriety, in con- junction with mercurials, in the cure of such affections. A great variety of formulae have been proposed for preparing these ptisans; but the following are acknowledged to be among the most effectual.* An excellent mode of administering mercury, is, to give it in solu- tion in a ptisan of this kind. As a local application to the chronic and foul ulcers which occur in some instances on different parts of the body, as well as to those which are seated in the fauces, the black or yellow mercurial washes, or a weak solution of blue vitiiol, will in general answer a very good purpose. Although mercury is unquestionably the most important remedy we possess, for the cure of syphilis and certain syphiloid affections, there are several other articles highly worthy of attention as means for removing diseases of this kind. Among these, gold appears to be the most valuable. I have employed the muriate of gold in ten * R.—Rad. sarsaparil. §ii. Flor: borag. officin. Petal, ros. gall. Fol. sennae. Sem. anis. aa %n. Sacch. communis. Mel. despumat. aa Ifcii.—Boil in a sufficient quantity of water to ex- tract the virtues of the sarsaparilla. Strain, and add the sugar and honey; then boil it down to the consistence of a syrup. To each pound of the syrup may be added one grain of corrosive sublimate. The dose is from one to two ounces twice or thrice daily. This is the Sirop de Cuissinier. R.—Rad. sarsaparilla. Lign. guaiac. offic. aa ifei. Fol. senn. G. arab. aa §i. Rad. zingiberis ^ss- Aq. fontana? Ibx.—Boil the two first ingredients in water for one hour; strain, and add to the residuum the same quantity of water as before, then boil it for two hours, and towards the end of the boiling add the other ingredi- ents: strain, and to both decoctions add— Sacch. communis. Mel. opt. aa. tbiii.—Boil the whole to the consistence of a syrup. The dose is gii. twice or thrice daily. This is the rob antisyphilitic of Laffecteur. I have used the following syrup with peculiar advantage: R._Rad. sarsaparillae 3iii. Fol. chimaphyllae umbel. S"ii. Sulphuret. antimonii, enclosed in a linen cloth, gi. Au. bullient. Ibiii.—Boil it down to three half pints; then add— Mel despumat. gviii.—Dose, a wine-glassful four times daily. 44* 522 SYPHILIS. or twelve cases of constitutional syphilis, and in several instances, with complete success. One case of long standing, and extremely severe, which had resisted the repeated employment of mercury, and sarsaparilla, was entirely cured by the use of this preparation in union with the extract of cicuta. I have usually commenced with one-tenth of a grain three times daily, and gradually increased it to one-sixth of a grain. It should be given in the form of a pill, and the patient must be directed to avoid taking acids into his stomach The best mode of using it is in union with the extract of conium or of hyoscyamus. Without the addition of some article of this kind, it often gives rise to very unpleasant sensations in the stomach. For a more particular account of the remedial powers of this article, the reader is referred to my work on the Materia Medica. The acetate of copper (verdigris) has been highly extolled by some German physicians, as a remedy in syphilitic affections. M. Schlegel has published a number of cases illustrative of its good ef- fects in diseases of this kind. He asserts, that by the following com- bination, he has almost uniformly succeeded in removing even the most inveterate syphilitic affections.* This article was formerly muchemployed in scrofulous and other varieties of ulcerative diseases, and I have myself given small doses of it in affections of this kind with the happiest effect. It may be given in doses of from one- eighth to one-sixth of a grain three times daily; and when united with full doses of the extract of cicuta, it is capable of doing much good in obstinate scrofulous and venereal ulcerations.! The carbonate of ammonia, too, has had zealous advocates as a remedy in syphilitic affections. In conjunction with full doses of opium, it is capable of procuring much benefit in cases attended with a debilitated and irritable state of the system. In a case 1 attended about a year ago, twenty grains of the carbonate of ammonia with a grain and a half of opium were given three times daily with the happiest effect. The patient was much debilitated, and in a pecu- liarly irritable condition, with a large, foul, and sanious ulcer on the sternum. Under the use of this combination the ulcer healed, and the general health of the patient was greatly improved. For the cure of venereal nodes, when not attended with much febrile irritation, we possess no remedy more frequently successful than arsenic. I have repeatedly prescribed from ten to twelve drops of Fowler's solution, twice or thrice in a day, with entire success. This potent article is also a valuable medicine in the arthritic or rheumatic pains which are apt to succeed syphilis and ill managed * R.—^Jrugo aeris gr. ii. Solve in aceti concent. 9ii. Camphorae gr. iv. Opii gr. ii. Micae panis q. s. ut fiant pilul. No. 40.—Take from 5 to 10 three times daily. f See Eberle's Mat. Med. vol. i. p. 304, 3d edition. BUBOES. 523 mercurial courses. From one-tenth to an eighth of a grain of arsenic, with two grains of the extract of aconitum, should be given three times daily. For the same purpose, I have also used the sulphate of zinc with excellent effect. Two grains of this article united with half a grain of opium, may be given three times daily. In several very severe and obstinate cases, this combination procured great and permanent relief. Buboes. Buboes are often extremely troublesome affections; and in irrita- ble and scorbutic habits, or from an abuse of mercury and improper exposure, often give rise to the most destructive and unmanageable ulcerations. Buboes may arise either from mere sympathetic irrita- tion, or from absorption of the venereal virus. The former variety of buboes is not uncommon in virulent gonorrhoea; and they arise, often, from the superficial ulcerations and patchy excoriations which occur on the internal surface of the prepuce and glans penis. Sym- pathetic buboes often disappear as soon as the primary local irritation upon which they depend is removed. Sometimes, however, they become indolent, and remain stationary for a long time. In in- stances of this kind, mercurial frictions, blistering, or simple emollient poultices, will either dispose them to disperse or to proceed to sup- puration, after which they readily heal. I have lately used frictions with the hydriodate ointment, in a case of indolent sympathetic bubo, with marked benefit Profe*or Alban G. Smith, has been in the habit of employing an ointment composed of one ounce of strong mercurial ointment, in- timately mixed with two or three drachms of the extract of bella- donna. A small portion (about half a drachm) is to be rubbed on the tumor two or three times daily. He assures me, that of all the means he has ever employed for the dispersion of buboes and other glandular engorgements, this ointment, has most frequently answer- ed his intentions. I have, in several instances of enlargement and induration of the mammae, used this remedy with the most satisfac- tory results. Swediaur divides buboes into the tonic and atonic; a distinction which is frequently verified in practice. The former are attended with symptoms of active inflammation in the tumor, and with an evident phlogistic state of the general system. The pulse is full, hard, and quick, and the local pain violent and constant. The atonic bubo is accompanied with the reverse conditions—the symptoms in- dicating general debility. So long as the inflammation is not very high, or signs of com- mencing suppuration have not yet made their appearance, efforts should be made to disperse the tumor as speedily as possible. It is a common opinion, that the dispersion of a bubo without bringing it to suppuration, is apt to be followed by dangerous consequences, under the idea that the venereal poison may be retained in the sys- 524 BUBOES. tern, and give rise to subsequent unpleasant affections. For this ap- prehension, however, there is not the least foundation. Many practitioners are in the habit of depending chiefly on mercu- rial frictions upon the tumor or on the inner surface of the thighs, for the purpose of discussing buboes; but this practice is very rarely followed with success, unless active antiphlogistic means, both local and general, be employed at the same time. The most efficient means for reducing inflamed buboes, where the general habit is phlo- gistic, are: local and general bleeding, saline purgatives, nauseating doses of tart antimony, a very simple and unirritating diet, perfect rest, together with cold astringent lotions—particularly lead-water to the tumor, and mercurial frictions on the inner surface of the thighs. When the general irritation or phlogistic excitement is not considerable, venesection may be dispensed with; but in instances attended with a bright red erysipelatous appearance of the skin over the tumor, in robust and plethoric habits, scarcely any thing will avert suppuration, except very eflicient general blood-letting. When these measures do not arrest the progress of the bubo, and its tendency to suppuration is uncontrollable, means should be used to promote the suppurative process, and for this purpose, I know of nothing better than emollient poultices. Professor Dupuytren strongly recommends an ointment, composed of twenty-four parts of strong mercurial ointment mixed with six parts of muriate of ammonia. This is to be applied by frictions over the region of the engorgement. I have used this ointment with much success in indolent buboes, and in glandular indurations about the neck. • In atonic buboes, advancing slowly, and remaining for weeks in nearly a stationary condition, without manifesting a tendency either to suppuration or to resolution, the application of blisters to the tumor will often succeed in dispersing it, or at all events expedite its termi- nation in suppuration. Both Mr. Carmichael and Mr. Bacot recommend blisters, as, in general, decidedly the best applications to indolent buboes. The former observes, that, " in such cases, (hard and indolent buboes,) the greatest advantage may be derived from the repeated applications of blisters to the indurated bubo, which soon either causes the dispersion or suppuration of the tumor;" and Mr. Bacot says it is a practice which he has pursued for nearly fifteen years, with the most satisfactory results. (Loc. cit. p. 24.) When buboes of this kind occur in persons of a languid and feeble state of the body, much benefit will sometimes be derived from a generous diet, and the use of tonics and wine. When we fail to disperse the tumor, and it has been brought to suppurate, the matter should not be suffered to ulcerate an opening through the integu- ments. A free incision, with a common abscess lancet, should be made into the cavity and the matter evacuated. When the buboes advance to suppuration, while their integuments are firm, and but little discolored, Mr. Bacot advises the passing a small seton through BUBOES. 525 the base of the tumor. Mr. Swediaur and some other writers, however, think it much better to suffer suppurated buboes to open spontaneously by ulceration; for the artificial opening, he says, "is often made too early, before the abscess is fully maturated." This, however, is an argument rather against the improper, than the judi- cious use of the lancet; for it is not improbable that an incision made before the tumor is fully suppurated, may give rise to unpleasant consequences. It is undoubtedly proper to delay making an incision until the abscess appears to be matured, but after this has been brought about, it is difficult to conceive any advantage from suffer- ing the matter to remain some days longer confined. When the abscess is laid open, it will generally heal under the use of gently stimulating ointments and emollient poultices; but in some instances the ulcerative process continues: or the abscess acquires an indolent and unfavorable character, which prevents it from healing. In syphilitic bubo, mercury is indispensable; but where there is a scrofulous or a scorbutic habit, and in instances where the general system is enfeebled and irritable, the worst conse- quences will sometimes follow the active employment of mercurials. When a bubo assumes a more unfavorable aspect under the use of mercury, it should be immediately discontinued, and opium with sarsaparilla decoction freely used; and in feeble habits, recourse must be had to cinchona, the mineral acids—particularly the nitrous acid and opium, with a generous diet and pure air. When the opened abscess remains stationary, soft, and flabby, discharging a copious thin ichorous fluid, we may inject a weak solution of sulphate of copper, or of the yellow mercurial lotions (corrosive sublimate gr. x., limewater 3viii.) into the cavity, and apply stimulating cata- plasms—such as a common poultice with a few drachms of cinchona mixed with it; or pieces of linen moistened with the tincture of galbanum over the sore. The internal use of opium or cicuta in full doses, will also be particularly serviceable in cases of this kind. The regular use of the latter narcotic is especially valuable in cases attended with symptoms of scrofula. When the bubo opens while a portion of it remains indurated, Mr. Swediaur recommends repeated cathartics, and the application of irritating remedies, such as the mercurial ointment, weak solu- tions of corrosive sublimate, &c. The solution of sulphate of copper, or the black mercurial wash, will often answer well in such nocpe Sometimes the ulcers formed by suppurated buboes become sur- rounded with projecting, indolent, and undermined edges; "and if these edges are not removed by art, the ulcer will remain for months, and perhaps years, without healing." In such cases, says Carmichael, " caustic, however powerful, is so slow in its operation unon the extensive and undermined edges of the buboes, that 1 always make use of the scalpel for their removal; and this treatment has caused many of them to heal in five or six weeks, which would have resisted any other mode of practice as many months, b ull 526 AMEN0RRHQ5A. courses of mercury always increase their tendency to burrow, and to extend their circumference." In foul and sanious ulcers of this kind, without the elevated and indurated edges just mentioned, much benefit will sometimes result from charcoal or carrot poultices; and where the surface is spongy and indolent, the application of nitric acid by strips of linen moist- ened with it, often produces a very excellent effect. Minute portions of the muriate of mercury, in conjunction with full doses of the extract of cicuta, very generally contribute mate- rially towards the successful management of ulcerated buboes. When the system is irritable, opium in large doses, or the extract of cicuta, or hyoscyamus, should be regularly given without the mercurial. Sect. III.—Amenorrhoea. This is one of the most common forms of menstrual disease, which, though sometimes borne without any material inconvenience, seldom fails ultimately to derange the general health, and unless remedied, often leads to the most distressing and dangerous consequences. The exciting causes of amenorrhoea are exceedingly various. Every thing which is capable of deranging the general health, has a tendency to excite irregularities or suppression of the catamenial discharge. Organic and inflammatory visceral affections—more es- pecially pulmonary consumption—chronic hepatitis, and gastro-in- testinal phlogosis or irritation, are rarely unaccompanied by men- strual irregularities, and often by a total and obstinate suppression of this evacuation. Mental emotions, particularly protracted grief and despondency, and sudden terror or violent anger, have a powerful tendency to arrest the catamenial discharge. Metastasis of rheuma- tism—of erysipelas—and of chronic cutaneous affections; habitual haemorrhoidal discharges, as well as other varieties of haemorrhage, leucorrhoea, and deficient and unwholesome nourishment, may also give rise to this affection. But by far the most common cause of amenorrhoea is cold, operating on the system either during the inter- val of the menstrual period, or immediately before the menses are about to appear, or finally during the actual flow of the evacuation. When the exciting cause acts during the interval of the catamenial periods, the menses will either not make their appearance at the next period, or they will, perhaps, begin to flow sparingly for a few hours, and then cease. In general, no material inconvenience is felt from the absence of the evacuation, and in some instances it returns spon- taneously at the succeeding period. Occasionally, however, consi- derable uneasiness in the pelvic region, pain in the loins, irregular determinations of blood to the head or chest, and in nervous subjects, various hysterical symptoms, are the immediate consequences of the suppression. But although the system frequently bears the suppres- sion of this evacuation without any materially unfavorable conse- quences during the first six or eight weeks, more or less derange- ment of the general health invariably ensues, if the menses fail to AMENORRHOEA. 527 make their appearance after the second or third period. The usual symptoms which ultimately arise from this affection are: languor and debility; a pale and sickly expression of the countenance; swell- ings of the ankles; various nervous affections such as paroxysms of palpitation of the heart, and dyspnoea; flatulent and spasmodic paina in the bowels; loss of appetite; and in relaxed and leucophlegmatic habits, leucorrhoea. In subjects predisposed to phthisis pulmonalis, or some other local or general disease, protracted suppression of the catamenial evacuation is always particularly dangerous,from its strong tendency to develop such affections. When the menses are suddenly suppressed, whilst they are flow- ing; or when the remote cause of the obstruction is applied imme- diately before the impending appearance of the evacuation, the con- sequences are much more violent and sudden. In such cases, the most alarming symptoms sometimes almost immediately follow the suppression of the discharge. In some cases, paroxysms of violent spasmodic pains occur in the bowels and stomach, attended occasion- ally with severe retching. In other instances, strong determinations of blood take place to the brain, giving rise to raving delirium, hys- teric mania, convulsions, or a temporary loss of sensation and volun- tary motion. Sometimes extremely alarming palpitations of the heart, with great difficulty of breathing, occur, and in some cases the irritation passes at once upon the sanguineous system, occasioning high febrile reaction, and local inflammatory affections. Treatment.—When one or more of the violent affections just men- tioned succeed the sudden suppression of the menses, the first object must be to allay the alarming and painful symptoms, without any immediate attention to the restoration of the evacuation. The at- tempt, indeed, to reinstate the catamenial secretion, at the period when it becomes arrested, is almost always abortive: yet the reme- dies which may be proper to palliate or remove the present symp- toms, will occasionally have the effect of bringing back the suppressed evacuation. In young and plethoric subjects, or where strong determinations of blood take place to the head or lungs, efficient venesection should be promptly resorted to. We can, indeed, seldom allay the violent spasmodic and painful symptoms very materially by this measure alone; but in the habits just mentioned, it constitutes an essential preliminary to the successful employment of other remedies— par- ticularly opium and ether, which in most instances afford more speedy relief than any other remedies we possess. Active cathartics and purgative enemata, sinapisms to the inferior extremities, warm pediluvium, and antispasmodics, are the principal means to be relied on. In weak and nervous females, it will not be necessary, and often improper, to bleed. In cases of this kind, warm pediluvium, with a few full doses of laudanum and camphor, will in general speedily allay the alarming and painful symptoms which often accompany this accident Dr. Dewees states, that he has found nothing to an- swer so well where the pain in the stomach or lower part of the 528 AMENORRHCEA. abdomen is severe, "as an injection composed of a gill of thin starch, a teaspoonful of laudanum, and thirty grains of finely pow- dered camphor; and if it be complicated with hysteria, the addition of three teaspoonfuls of the tincture of assafoetida, instead of the camphor, may be useful." I have in several alarming instances known very complete relief obtained from the injection of laudanum into the bowels; but where the stomach will retain the medicine, it will act more promptly when administered by the mouth. Little or no benefit, however, will result from an ordinary dose of this narcotic in cases of this kind. From two to three grains of opium, with ten or fifteen grains of camphor, should be given at once. It should be particularly recollected, that where the tendency to cepha- lic congestion is strong, or in full, young, and vigorous subjects, an efficient abstraction of blood must be premised to the use of these remedies. In one case of suddenly suppressed menses, attended with wild raving and paroxysms of extreme pain in the stomach, half an ounce of the tincture of secale cornutum completely allayed all the symptoms in less than fifteen minutes. A vast variety of remedies have been recommended for the pur- pose of restoring the suppressed catamenial evacuation; but we may safely affirm, that the amount of injury which has been done by the indiscriminate and unseasonable exhibition of medicines of this kind, (emmenagogues) is incomparably greater than that of all the ad- vantages which have as yet resulted from their employment. I do not wish to be understood as condemning, unqualifiedly, the use of such remedies; for under judicious management, they are not only often decidedly useful, but in some cases, indispensable to success. The practice, however, of resorting to active emmenagogues in the beginning of the treatment, without an especial regard to the general state of the system, and the peculiar circumstances of the case, under an idea that they possess a direct or specific power of restoring this secretion, has been, and no doubt will continue to be, the source of various and irremediable mischief. Amenorrhoea in young subjects is at first almost invariably accom- panied by a manifest phlogistic habit of body. In instances of this kind, moderate abstractions of blood, aided by a simple and unirri- tating diet, laxatives, and regular exercise in the open air, are all- important remediate measures. Where the disease has developed local inflammations, or sustains irregular determinations to internal organs, especial means should be used, in conjunction with the gene- ral remedies just mentioned, to counteract the local affection, before any direct attempt is made to excite the uterine vessels. Blisters, rubefacients, the warm bath, antimonials, &c. may all be beneficially employed under circumstances of this kind. In France, the application of leeches to the pudendum is a very common practice, and there can be no question as to the propriety and favorable tendency of this practice. M. Chomel recommends the application of four or five leeches daily, for five or six clays in succession, at the expected menstrual period. Some days previous AMENORRHOEA. 529 to the employment of the leeches, he orders dry cupping on the up- per and inner part of the thighs, and warm vapor baths to the lower part of the body.* When the suppression occurs in relaxed and debilitated females, with a small, feeble, and languid pulse, the first object should be to invigorate the general system, and to improve the digestive and alvine functions. Iron;t mild tonic bitters; a simple, but nourishing diet, exercise by gestation, and gentle aloetic aperients;! are especially indicated in such cases. I have derived much advantage in amenor- rhoea, attended with languor and debility, from the black sulphuret of iron, in union with small portions of ipecacuanha. Five grains of the former, with one of the latter, may be given three times daily. It is proper to observe, however, that even in cases attended with much languor and weakness, mild aperients are sometimes important remedies, preliminary to the employment of tonics; for it is not uncommon to find the bowels exceedingly loaded in such cases, and there can be but little advantage derived from invigorating measures, so long as this condition of the intestinal canal continues. Sometimes cases that come on slowly, and apparently without any direct exciting cause, will be found, on close examination, to be connected with chronic irritation, or phlogosis of the mucous membrane of the bowels, from a remora of fecal matter in the bowels, or from the habitual use of a superabundance of coarse, irritating, or indigestible aliment. I have recently seen a remark- able instance of this kind. The patient, a laboring woman, about twenty-five years of age, had suffered a long time under amenor- rhoea, and the usual attending nervous symptoms. When I first saw her, she was debilitated, and considerably emaciated, but stated that her appetite was very craving. As she ascribed all her complaints to the absence of the menstrual discharge, she had taken a great deal of medicine, obtained from one of our public charitable institu- tions, for the purpose of " bringing on her courses." On examina- tion, I found her abdomen tumid and hard, the tongue like a piece * Rev. Med. January, 1828. f R.—Ferri. phosphat. gi. Pulv. zingiberis gii. ----aloes soccot. gr. v.—M. Divide into ten equal parts. S. Take one twice or thrice daily.—Or, R.—Extract, gentian. 31. Sulphas, ferri. gr. iv. G. aloes, socc. gr. v—M. Divide into twenty pills. S. Take one every morning, noon, and evening. X R.—Pulv. rhaei. 9iv. G. aloes Qi. Pulv. capsici. i. Muc. g. arab. q. s.—M. Divide into twenty pills. Take two at night on going to bed. Vol. II.—45 530 AMENORRHOEA. of raw flesh along the edges and point, and the appetite voracious— in short, with all the symptoms of high irritation of the mucous membrane of the stomach and bowels. I ordered her a few doses of castor oil, and put her on the exclusive use of rye-mush and milk for her diet, with which she faithfully complied. In four weeks the tension and fulness of the abdomen had subsided, and the tongue presented a much better appearance. The diet was continued, with the addition of a little weak animal broth at noon, and I prescribed an emulsion of balsam copaiva, in small doses, to be repeated thrice daily. This she continued for four weeks, at the end of which time she thought herself quite well, although the menses had not yet returned. She was now put on the use of the following pills,* which in two weeks restored the long suppressed catamenia. By thus pursuing a general treatment adapted to the particular circumstances of the case, we may often restore the menstrual eva- cuation; and should we even fail in effecting this purpose, we shall, nevertheless, gain some advantage, by placing the system in a condi- tion favorable to the operation of the remedies more directly calcu- lated to act upon the uterine system.t Dr. Dewees speaks in the highest terms of praise of the tincture of guaiacum as an emmenagogue. " I have for more than eight and thirty years," he says, " almost daily used this medicine in suppressed catamenia; and more especially in chose of long standing, without its having failed in any case proper for its use—that is, where the suppression was not the consequence of disease of the uterus or of pregnancy." This is, indeed, great praise; for Dr. Dewees must have treated perhaps several thousand cases of this affection during the long period he mentions. That Dr. Dewees has been eminently successful with the employment of this remedy is unquestionable; yet it may be mentioned as a singular circum- stance, that although I have employed it in no small number of cases of this affection, and, as I thought, in a vigorous and persevering manner, I have never known it to procure the least apparent benefit, except in one case only. It must be observed, too, that although the doctor's mode of employing this remedy has been for many years well known to the practitioners of this city, 1 have, as yet, * R.—Sulphat. ferri. gr. v. G. myrrh. G. aloes aa gr. x.—M. Divide into twenty pills. S. Take one every morning, noon, and evening. f These remedies appear to promote the menstrual evacuation, solely by their tendency to determine the blood to the pelvic viscera, or more particularly to the uterus; and it is hence obvious, that where symptoms of high irritation or chronic inflammation of the uterine system are present, all medicines of this kind are highly improper. When, for instance, a puruloid leucorrhoeal discharge attends, with other signs of vaginal irritation, purgatives, low diet, rest, emollient injections into the vagina, and, perhaps, local bleeding, are indispensable preli- minary measures. AMENORRHOEA. 531 met with none who has been even moderately successful with it Dr. Dewees himself notices this fact " I have learned," he ob- serves, " that some of my brother practitioners have not been equally successful with it—but I think I can readily account for their fail- ure; first, from their not placing the system in a proper situa- tion for its use; and secondly, by not properly persevering in the remedy." The medicine in which I have hitherto most confided as an em- menagogue, after the system was duly prepared by general treatment, is aloes, in small doses, in combination with the extract of savin and ipecacuanha, according to the following formula.* I have, indeed, often failed with this medicine; but, upon the whole, I have more frequently succeeded with its employment than with any other article or combination. The tincture of melampodium, too, has occasionally succeeded well in my hands; and within the last few years, 1 have employed the spirits of turpentine with success in several cases. Where hysterical symptoms attend, peculiar advan- tage may sometimes be obtained from the following pills.t The tincture of cantharides, too, has been highly recommended as a re- medy in this affection. Dr. Joseph Klapp, of this city, has pub- lished an account of his experience with this article, from which it would appear, that under judicious management, it will often ope- rate very beneficially.J It should be given in gradually increased doses, beginning with twenty or twent-five drops three times daily, until a slight degree of strangury is produced, when it must be omitted, and resumed when the urinary affection has subsided. This article is certainly worthy of particular attention as an emmena- gogue, after proper evacuations have been made. I have but seldom prescribed it; but in one of the few instances in which I employed it, the menses were very speedily restored after it was carried to the extent of causing slight strangury. This remedy is especially adapted to cases that are attended with leucorrhoea—but in such instances, it is particularly important to reduce the local inflamma- tory action of the vagina, by proper local and general remedies, previous to the employment of the cantharides. There is, indeed, scarcely an end to the number of articles and combinations that have been boasted as remedies for exciting the menstrual secretion; * R.—G. aloes socc. gr. xv. Extract, sabin. 9ii. Pulv. ipecac. 9i. Mucilag. g. arab. q. s.—M. Divide into forty pills. Take two pills three times daily. X R__G. aloes ^ii. — assafcetid. Jjii. — myrrh, ^ss. Sulph. ferri. 3ss.—M. Divide into three grain pills. Take two twice daily. X Med. Recorder, vol. i. 532 DYSMENORRHEA. but so far as my experience enables me to judge, they are all much more apt to fail than to succeed in restoring the suppressed catame- nial function. Dr. Lavagna, within the last five or six years, has published an interesting statement of the good effects of injections of the aqua ammonia, diluted with water, into the vagina, as a remedy for the suppression of the menses. Dr. Hosack, also, has reported a case often years' duration, which yielded to the employ- ment of the ammonia in this way. Ten or twelve drops of the aqua ammonias purae, mixed with an ounce of milk or water, is to be thrown into the vagina by means of a syringe, four or five times daily. If this does not produce a very perceptible sensation in the part, a few drops more of the ammonia must be added to the subsequent injections; but if the irritation be excessive, the quan- tity must be diminished. Dr. Hosack diluted a drachm of the am- monia with a pint of rain water, of which a syringe full was thrown into the vagina three times daily. The cure was accomplished in five weeks.* I have heard of but one instance of the employment of this remedy in this city; and in this case it failed in doing good. The testimony, however, that has been published in its favor, is respectable, and well worthy of attention. Dr. Loudon has published an account of two long standing cases of amenorrhoea, which yielded to the repeated application of leeches to the mammae. Two leeches were applied to the lower part of the breast, every other day for one month. About the end of the third week, the breasts swelled enormously, and in five or six days more, the menses began to flow. Sect. IV.—Dysmenorrhoea.—Painful and Imperfect Menstru- ation. Dysmenorrhoea is a common, and generally an extremely harass- ing affection. It may occur at every period during the menstru- ating stage of life; but it appears to be the most common between the twentieth and thirtieth years of age, and in subjects of an irri- table and sanguineous temperament. In many instances, severe pains are experienced in the back, loins, and lower part of the abdo- men, for five or six hours previous to the appearance of the men- struous evacuation. This, however, soon ceases, and an immediate aggravation of the torturing pain follows. Sometimes the catame- nia begin to flow moderately, with little or no previous pains; but in an hour or two they become suddenly arrested, at the same time that violent pains come on in the hips, hypogastrium, loins, back, and thighs, with a distressing sensation of forcing or bearing down in the pelvis. Occasionally, a very slight menstrual discharge continues uninterruptedly for three or four days, accom- panied throughout with extremely severe pains in the pelvis and lower portion of the abdomen; and in some rare instances, the * New York Med. and Phys. Jour. DYSMENORRHEA. 533 catamenial evacuation, although attended with great suffering, is sufficiently copious and prolonged in its course, and may even exceed the regular duration and quantity of an ordinary healthy menstruation. (Jahn, Burns.) In by far the greater number of cases, however, the evacuation, as has just been stated, begins to flow moderately, and after an hour or two ceases again, under great sufferings. Some patients are much harassed by severe head- ach or nausea, and paroxysms of violent retching and vomiting, during the first few hours of the complaint. These pains continue for a period, varying from two or three hours to several days, terminating commonly in the discharge of a pseudo-membranous substance from the vagina, similar in appear- ance to the decidua. Females laboring under painful menstruation generally experience two distinct kinds of pain; namely: the inter- mitting expulsive pains resembling those of labor or abortion; and the constant menstrual pains in the back, pelvis, loins, and thighs, which occur often in regular menstruation, shortly before the ap- pearance of the evacuation. Dr. Dewees observes, that there are two distinct states of this affection, which in a prognostic point of view are worthy of atten- tion. Thus, in some cases the mammae sympathise strongly with the uterus—becoming tumid, and often very painful and tender to the touch; whilst in other cases the breasts remain wholly free from any affections of this kind. The former variety of cases, says Dr. Dewees, are much more manageable than the latter—an observation which I believe to be well founded, however inexplicable it may be. Some writers seem to think that the formation of a pseudo-mem- braneous substance upon the internal surface of the uterus is always present in this affection, and constitutes in all instances, the imme- diate cause of the difficult and painful menstruation. This, however, does not appear to be founded on correct observation. I have known females to suffer very painful and incomplete menstruation for two, three or four periods in succession, and afterwards menstruate regu- larly without any particular difficulty, where no membraneous matter whatever was at any time discharged. It must moreover be ob- served, that painful menstruation is not universally attended with a scanty flow of the catamenial fluid. I have met with several in- stances where, in point of quantity and duration, there was nothing irregular in the menstruation, but where, notwithstanding, extreme suffering attended each menstrual period. This, we may reasonably presume, could not take place, if the internal surface of the womb were coated with false membraneous matter. It may indeed be supposed, that the bloody secretion in such cases is furnished by the vessels of the mouth of the womb, or even by those of the vagina; but this assumption is extremely improbable. It cannot be denied, that iii very many cases, such membraneous concretions are present, and exercise a direct agency in the production of the difficulties which occur in this affection. It is nevertheless certain, that these 45* 534 DYSMENORRHOEA. masses of concreted lymph are themselves the product of a morbid action of the secreting vessels of the uterus; and there can scarcely exist a doubt, that this diseased vascular action may of itself produce the difficulty and pain in question, independent of the formation of pseudo-membraneous matter. 1 cannot accord with Dr. Dewees, in his notions concerning the etiology of this affection, or rather " of the membraneous productions so often yielded in dysmenorrhoea." " Before I attempt an explanation of the formation of this mem- brane," he says, " I must direct the attention to a very remarkable circumstance in the character of the menstrual blood, namely, its not possessing the property of coagulation. From this it appears, that the blood, or part of it, has suffered some change by the action of the uterine vessels; and that this change has been imposed upon the coagulating lymph by the process of secretion. Now, it is not difficult to suppose that the uterus, like every other organ, may have its functions impaired; in consequence of which the texture of the coagulating lymph, instead of being subdued, as it is wont to be when the uterine secretory action is perfect, remains nearly the same as when it entered this viscus; except that it may be attenuated, as in some inflammatory diseases; and it will, from this imperfect elabo- ration, be thrown into the cavity of the uterus, without being dis- possessed of the power of separation and of coagulation. It is poured into the uterus in a very gradual manner; and from this circum- stance may tarry there sufficiently long to separate into its constitu- ent parts; the colored part, or red globules, from their greater weight, will leave the imperfectly subdued lymph, and fall to the bottom of the uterus, and sooner or later be discharged; while the coagulating lymph, either in part or altogether, will be left to spread itself over the internal surface of the uterus; and there quickly as- sume, as is usual with it when in contact with living parts, the ap- pearance of a membrane."* These sentiments appear to me not only contrary to well estab- lished pathological principles, but most unquestionably, also, to the phenomena of dysmenorrhoea. That the menstrual action of the uterus is morbid or deranged, is, indeed, sufficiently obvious; but so far from this derangement consisting in an impaired or enfeebled action of the uterine vessels, every phenomenon clearly indicates that the vessels of the uterus are in a state of increased excitement, amounting perhaps in many cases to a sub-inflammatory action. The sense of fulness, tension, and pain in the pelvis, loins, and back; the accelerated, quick, and tense pulse; the hot and feverish skin, are strong manifestations of inordinate excitement and sanguineous congestion in the uterine system. Lymph is never thrown out in such a state as to form membra- neous matter, except from inflamed, or at least highly irritated sur- faces. The formation of such concretions is, indeed, one of the most * A Treatise on the Diseases of Females, second edition, p. 91. DYSMENORRHOEA. . 535 certain evidences of previous inflammatory action in a part. Most assuredly Dr. Dewees will not contend that the decidua, which strongly resembles the membraneous masses thrown off in dysmen- orrhoea, is formed by an impaired action of the uterine vessels, and in the manner stated in the above quotation. It may be observed too, that if incrustations of lymph arise from the gradual separation of blood retaining its coagulability, in consequence of impaired or deficient action of the uterine vessels, we should, no doubt, frequently meet with these pseudo-membraneous formations in the slow and protracted uterine menorrhagiae, which are apt to occur about the period of the final cessation of the menses—but which, so far as I know, has never been observed. From an attentive estimate of the phenomena of this affection, as well as from analogy and certain established principles in pathology, we may, I think, conclude, that in dysmenorrhoea generally, whether attended with the formation of membraneous structures, or devoid of such concretions, the uterus is in a state of much sanguineous congestion, attended with an irri- table and highly irritated condition of its vessels. The discharge at first flows moderately for a short time; but the action of the vessels appears soon to transcend the grade of menstrual secretion, and, in- stead of the catamenial fluid, lymph is often secreted by the irritated vessels, which concretes on the internal surface into the form of a membraneous substance. This opinion of the pathology of dysmenor- rhoea is much strengthened by the fact, that all medicines that have a tendency to excite the uterine vessels, as the usual emmenagogues, are uniformly pernicious. Would this be the case if the disease were the result of an impaired action of these vessels? From much close attention to this disease, for the last six or seven years, I have been led to believe that it is very frequently depend- ent on a rheumatic affection of the uterus. In a case which I attended some time ago, the connection of rheumatism and this af- fection was strikingly illustrated. The patient, of an irritable and sanguineous habit, was very subject to rheumatic pains in the left, and sometimes in the right ankle joint, which often continued for several weeks. For more than five years, she observed that when- ever she felt the pain in the joint at the menstrual period, she men- struated with little or no difficulty; but when the period returned while the ankle was free from pain, she invariably suffered excru- ciatingly during the very sparing and transient flow of the menses. Dr.&Mackintosh thinks, that in no inconsiderable number of in- stances, dysmenorrhoea depends on a nearly impervious state of the os uteri.. He states, that he has in his museum, many preparations of the uterus, which were taken from females who had died of dif- ferent diseases, particularly phthisis, " and whose histories proved that they had labored under dysmenorrhoea from the very begin- ning of their menstrual lives." In these preparations, the orifices of the womb are, many of them, so small "as to be just capable of receiving a bristle; others allow a common sized silver probe to enter, and a few are a little larger still." We can readily conceive. 536 DYSMENORRHOEA. that such a condition of the mouth of the uterus, would be apt to give rise to the symptoms of dysmenorrhoea. The menstrual dis- charge not finding a ready exit, must cause more or less distension of the uterus, and thereby excite contractions, and painful bearing- down sensations in the womb. " The continuance and frequent re- currence of this uterine irritation, will sooner or later give rise to inflammation in the lining membrane of the uterus, which will ac- count for the formation of the decidua," which is, in many instances, discharged. Impressed with these opinions, Dr. M. resolved to at- tempt the cure of this affection by mechanical dilatation of the orifice of the womb, as soon as he should meet with a patient who would submit to the operation. "I could not," he says, " propose such a measure to a modest woman, without being able to give an assurance almost amounting to a certainty that it would cure her." Chance, however, threw a suitable case in his way; this was a young woman, who at each menstrual period, suffered very severe pains, &c. in the back and region of the womb, with scarcely any perceptible cata- menial discharge. The uterus was much lower down than natural; no orifice could be felt, but only a small dimple where the opening ought to have been. He could not introduce even the smallest silver probe. An artificial opening was made; and some time after he commenced dilating this orifice, by daily increasing the size of the instrument. On the next menstrual period she menstruated regu- larly, and has done so since, without pain or difficulty. " I have since," says Dr. M., " dilated the os uteri in six cases of dysmenor- rhoea, and I may mention generally, that the success of the practice has been most satisfactory." Treatment.—The treatment of dysmenorrhoea is divided into palliative and radical; the former to allay the extreme suffering during the presence of the affection; and the latter, to prevent its recurrence, by means employed during the interval of the attacks. I have already observed, that all emmenagogue remedies, or such as are calculated to determine the circulation to the pelvic organs, are always highly improper. Dr. Dewees considers camphor in large doses as decidedly the best palliative remedy we possess in this painful affection. He recommends the administration of ten grains of this article every hour, until the pains are in great degree allayed; and when the stomach will not bear it, he advises its use in the form of an enema. I have used this remedy with much benefit in some cases; but I have almost invariably prescribed it in union with Do- ver's powder, in the proportion of six or eight grains of the former to four grains of the latter, every hour. If we can early induce a general perspiration, the painful symptoms almost always speedily deeline. To promote this intention, it will be proper to confine the patient to bed, and to direct the use of warm, diaphoretic diluents— particularly elder blossom, or eupatorium perforatum tea. Opium, given in full doses, with small portions of ipecacuanha, so as to ex- cite nausea, but not vomiting, is, perhaps, upon the whole, the best palliative, where the patient is capable of taking this narcotic with- DYSMENORRHOEA. 537 out the disagreeable effects which, in some habits, it is apt to pro- duce. It may be advantageously given in combination with cam- phor, in the proportion of a grain of the former to eight of the latter, every hour, until the symptoms are mitigated. Dr. Dewees mentions a case, which was cured by the use of secale cornutum; but this case does not appear to me to merit the title of dysmenor- rhoea. It would seem to have been an instance of menorrhagia, accompanied by frequent severe pains occasioned by the contrac- tions of the womb to expel the coagula. The warm-bath will occasionally afford considerable relief in dysmenorrhoea, more es- pecially when it is used in conjunction with camphor or opium. Bleeding is often decidedly indicated, and although it does not appear to be capable of exerting any direct influence over the symp- toms, it is an important auxiliary, or preliminary measure, where the pulse indicates its use, to the employment of the means already mentioned. In instituting a course of treatment for the radical cure of dys- mennorhoea, particular attention must, in the first place, be paid to the general state of the system. In plethoric and phlogistic habits, a mild vegetable diet must be enjoined, and it is especially import- ant to attend to the state of the digestive and-internal functions. When there are signs of a loaded and torpid state* of the bowels, it will be highly important to adopt a course of mild aperient treat- ment, before recourse is had to remedies more immediately di- rected to the uterine system. An occasional dose of blue pill in the evening, with a gentle purgative on the following morning, should be used, until the bowels are put in a healthy condition. Jahn as- serts, that the occasional employment of an ipecacuanha emetic will sometimes afford very considerable advantages in this affection. When the diathesis is manifestly phlogistic, and the pulse tense or active during the intervals of the attacks, small abstractions of blood, and even antimonials, in conjunction with a vegetable diet and ape- rients, are obviously proper. When the disease is accompanied with a rheumatic or arthritic diathesis, the warm bath, gentle dia- phoretics, particularly decoctions of lignum guaiacum, and small doses of the flowers of sulphur, will often be found especially useful. Among the various remedies that have been recommended as par- ticularly calculated to prevent the recurrence of the affection, the tincture of guaiacum is at present most generally relied on by the practitioners of this city. Dr. Dewees, who introduced this article to the notice of the profession as a remedy in dysmenorrhoea, regards it as incomparably the most efficient means we possess for counteracting this affection. It should be given in as large doses as the stomach will bear, and its use persisted in for three or four months, and even longer, if its good effects are not previously ob- tained. Dr. D. observes, that it is not uncommon to find the first return of the menstrual period, after commencing the use of this remedy, attended with unusually severe symptoms; and he consid- ers this as a favorable symptom. I have employed it eccasionally, 538 LEUCORRHOeA. but with very indifferent success. The remedy with which I have most frequently succeeded in effecting a cure, is the extract of stramonium. It is now about six years since I first resorted to this article for the cure of this affection, and I have on record a con- siderable number of cases that yielded to its powers. My mode of employing it is to give the one-eighth of a grain of the extract (Clut- terbuck's preparation) three times daily, commencing about four days before the expected return of the attack. I am persuaded, from what I have witnessed of its powers in this vvay, that we pos- sess no other article which can, at all, be compared to it as a remedy in this affection. Immediately previous to commencing with its use, the bowels should be freely opened by a purgative, and the patient ought to abstain from all kinds of stimulating food and drink. The decoction of polygala senega has been recommended as a means for curing this affection. Dr. Chapman has expressed his confidence in its powers; but it does not appear that his experience on this head has been sufficiently confirmed by others, to have gained it any reputation in this respect. Formerly I employed it freely in five or six cases, but in no instance with success. I have known an instance where a salivation, accidentally caused by a mercurial purge, removed the complaint effectually. What would the tincture of colchicum do in cases of this kind? If my notions concerning the rheumatic nature of this affection be correct, it would seem reasonable to expect advantage from this remedy. Sect. V.—Leucorrhoea.—Fluor Albus. This affection consists in a morbid secretion and discharge of a mucus, or muco-purulent fluid, from the vagina; and is, perhaps, the most common disease to which females are subject It may occur at every period of life, from infancy to old age, but its appearance between puberty and the final cessation of the menses is by far the most common. The causes of leucorrhoea are very various. In general, what- ever is capable of relaxing the system, as a luxurious, indolent, and sedentary manner of living; habitual exposure to a humid atmos- phere, and want of pure air and wholesome nourishment, are espe- cially calculated to predispose to the occurrence of this disease. Females of a relaxed, leucophlegmatic, and nervous habit of body, are particularly liable to leucorrhoeal discharges, whereas those of a rigid fibre, and a robust and muscular structure, are, comparatively, rarely affected with this disease. Every thing which is capable of causing irritation in the mucous membrane of the vagina, and of establishing a preternatural determination of blood to the genital organs, may excite leucorrhoea. But the tendency of causes of this kind to give rise to the disease, depends nevertheless in a great degree on the previous constitutional predisposition to this affection; for in many healthy, robust, and active females, scarcely any vagi- nal irritation, from accidental causes, will produce more than a tern- LEUCORRHOEA. 539 porary increase of the mucous secretion. In individuals, on the contrary, of an opposite habit of body—particularly when favored by luxurious living and indolence, the slightest additional irritation of the mucous membrane of the vagina will be apt to excite a more or less permanent morbid secretion from this membrane. The fol- lowing are the most common and powerful exciting causes of this disease. 1. Excessive venereal indulgence. Prostitutes, even though previously unaffected with gonorrhoea, are rarely free from morbid vaginal secretions of a leucorrhoeal character. 2. Difficult parturition, or the irritation caused by the employment of obste- trical instruments. 3. Frequent and profuse menorrhagia is frequently followed by leucorrhoea, being usually sustained by the same causes or circumstances that gave rise to the hemorrhagic dis- charge. 4. Prolapsus uteri is almost invariably attended with more or less leucorrhoeal discharge, in consequence of the continued vaginal irritation by the dislocated uterus. 5. Ascarides, by keep- ing up a constant irritation in the rectum and neighboring parts, or bypassing into the vagina, are no unfrequent exciting cause of leucorrhoea in young girls and children. 6. The abuse of em- menagogues, particularly when unseasonably employed for bring- ing on what is often injuriously supposed and treated as tardy men- struation about the age of puberty, often gives rise to obstinate leu- corrhoea. 7. A loaded and torpid state of the bowels, is a common cause of this complaint in young females. 8. Tight lacing or dress- ing about the waist, by pressing the viscera down upon the uterus, and causing prolapsus, or a descent of this organ from its natural position into the vagina, as well as by impeding the free circulation of the blood in the portal vessels, is a fertile source of leucorrhoea among young and fashionable females. I will venture to say, that of late years, since the preposterous custom of pressing the waist into as narrow a space as cords and steel springs can bring it, has been so general, there are more instances of prolapsus and leucor- rhoea among young females than at any other former period, when the abdomen was a little better accommodated with room. 9. The depressing mental emotions, by debilitating the general system, and favoring a sluggish circulation in the portal system of vessels, may give rise to the disease. 10. Metastasis of Rheumatism, &c. is, I conceive, much more frequently concerned in the production of this affection than is generally supposed. It is by no means un- common, to find females, affected with leucorrhoea, to complain of more or less pain in the joints, and 1 have satisfied myself that the vaginal disease is not unfrequently a purely rheumatic affection. 11. Self-pollution is by many of the German writers regarded as one of the most frequent sources of this disagreeable affection in young females. 12. Atmospheric influences, particularly vicissi- tudes of temperature, and a warm and humid atmosphere. It is said that in Holland, where the air is always loaded with much moisture, leucorrhoea is a very common affection. 13. Suppressed haemorrhoids; diseases of the uterus; tumors pressing upon the 540 LEUCORRHOEA. vagina; mechanical injuries; the intemperate use of spirituous liquors, &c. may all give rise to the disease. Some females are invariably affected with more or less profuse leucorrhoeal discharge for five or six days immediately after the completion of each menstrual evacuation; and others experience the disease only some days previous to each appearance of the menses, remaining in a great measure, or wholly free from it, during the re- mainder of the menstrual intervals. Symptoms.—In some instances, the discharge has the appearance, of the common vaginal mucus. In others it is white, resembling pulverised starch mixed with a mucilaginous fluid. Sometimes it presents the appearance of pus, possessing an acrid and corroding quality. These differences in the appearance of the discharge, indi- cate the relative degrees of violence of the affection. In point of quantity also, great diversity occurs in different cases. In some instances it is so moderate as hardly to occasion any incon- venience, whilst in other cases the evacuation is extremely copious. When the discharge is very profuse, and of an acrid quality, the external parts of the genital organs become red, swollen, and painful, and this state of irritation usually extends into the vagina, and even to the mouth of the uterus, rendering the whole passage, and espe- cially the os tincae, very tender to the touch. When the disease is suffered to continue, it seldom fails at last to make an injurious impression upon the whole system. The coun- tenance at length becomes pallid and sickly; the eyes dull, languid, and surrounded by a bluish or lead-colored circle; the eyelids tumid; the mind dejected, discontented, and fretful; the whole system debilitated and sluggish; the extremities cold; the pulse small and feeble, or small, frequent, and somewhat corded; the diges- tive functions deranged, attended with acid eructations, gastralgia, pains in the back, loins, and lower extremities; colic pains in the lower part of the abdomen, constipation or diarrhoea, and pain in voiding the urine. By degrees the discharge usually becomes more and more copious and purulent; the relaxation and languor of the muscular system increase, whilst the pulse becomes more frequent and irritated. At length, in aggravated cases, the slightest bodily exertions give rise to hurried respiration and palpitation of the heart; and in instances of great severity, the powers of digestion at last become exceedingly weak; nausea and vomiting frequently come on, and finally hectic and rapid emaciations arise. Fortunately, however, cases of this violent character are by no means common; the great majority of instances being much less severe, though sufficiently annoying and debilitating, to become a source of much uneasiness and anxiety. Women who are habitually affected with leucorrhoea, very rarely become pregnant; and where the leucorrhoeal discharge is profuse, it may be doubted whether conception can at all take place. In most instances of severe leucorrhoea, the menses are entirely suppressed; and in all cases they are more or less irregular, both in time and LEUCORRHOEA. 541 quantity. Sometimes they occur at irregular intervals in the form of menorrhagia, but more frequently they appear very sparingly for a day or two, succeeded by an increased flow of the leucorrhoeal discharge. Much discussion has taken place on the question, whether leucor- rhoea is a disease of relaxation or debility, or connected essentially with an irritated or inflammatory excitement in the affected parts. It appears to me, however, that it cannot be properly said to be either a disease of debility and relaxation, or one of irritation or subinfkimmation, in an exclusive sense. That the mucous membrane of the vagina and mouth of the uterus is in a state of irritation and even sub-inflammation in this affection, is indeed not to be questioned; but it must be recollected that irritation or inflammation is by no means incompatible with debility in the same structure. And let it be borne in mind too, that all the efficient remedies for arresting the discharge, are such, as are directly calculated to increase the tone of the vessels which give rise to the morbid secretion. Can- tharides and astringent injections, are the means most generally relied on in this city, for the cure of this affection. Without doubt, inflammation of an active kind, is often developed in the course of the malady, and requires reduction before the tonic or stimulant remedies, just mentioned, can be used with propriety; but that such inflammation is merely accidental, and by no means essential to the disease, is manifest, from the continuance of the discharge, after every symptom of an active inflammatory character has been sub- dued. In relation to the general system at least, the terms debility and relaxation, may most assuredly be correctly applied to this disease in a great majority of cases. The languor, general weakness, and relaxation, as well as the feeble and sluggish pulse, so frequently noticed in profuse leucorrhoea; are sufficient evidence of the correct- ness of this observation. 1 am by no means disposed to advocate the old doctrine, that the discharge is owing to a mere relaxation or passive state of the ves- sels from which it occurs. The increased flow of mucus is un- questionably the result of a morbid action of these vessels; and the immediate cause of this morbid action, consists in that peculiar de- ranged condition of the vital properties, designated by the term ir- ritation. Nevertheless, this irritation does not imply an increased power of action; on the contrary, it is very evident, that the vital energies or powers of action of the irritated vessels, are, in the in- stance in question, decidedly impaired. In most cases, the mucous membrane of the vagina is, in the commencement of the disease, merely in a state of irritation. In its progress, however, chronic inflammation is apt to occur from the constant action of the acrid secretions or from the accidental supervention of new exciting causes, both of a general and local character. Treatment.—The cure of leucorrhoea is almost always attended with oreat difficulty; and protracted and severe cases often continue, Vol. II.—46 542 LEUCORRHOEA. in spite of the most judicious and persevering course of remedial management. Although, properly speaking, a local disease, leucor- rhoea seldom fails ultimately to derange other organs, and to esta- blish by degrees a general state of ill-health. This, however,, occurs only in protracted and severe cases, or in very delicate and irrita- ble habits. In some instances the general health is impaired before the leucorrhoeal discharge commences. Whether primary or con- sequent, however, the general state of health ought always to be es- pecially attended to, as an important preliminary step in the remedial management of this affection. General or constitutional indisposi- tion is always a most serious obstacle to the restoration of particular functions, or the cure of local maladies. In the treatment of the present disease, this circumstance must be especially attended to. When the pulse is active, and the general habit phlogistic, it will be proper to commence the treatment with antiphlogistic measures; and bleeding, simple and unirritating diet, purgatives and antimoni- als, should be resorted to in cases of this kind. It will rarely be necessary, however, to practise more than one or two moderate blood-lettings, even under the most obvious indications of its use- fulness. Purgatives and low diet, will in general be quite adequate to reduce the phlogistic irritation of the system. In cases attended with indications of a loaded state of the bowels, repeated purgatives are especially demanded; and we frequently find obvious signs of functional disorder of the liver, in severe and prolonged instances of the disease, requiring a cautious employment of alterative doses of blue pill and laxatives. In prescribing more directly for the removal of the disease, par- ticular attention must be paid to the actual condition of the mucous membrane of the vagina, as it is indicated by the appearances of the leucorrhoeal discharge. When the discharge consists of a thick, transparent, ropy mucus, the vaginal mucous tissue is at the lowest grade of leucorrhoeal irri- tation. The pulse, in this grade of the disease, rarely indicates the necessity of blood-letting, unless accidental causes have increased the momentum of the circulation. In al! instances, however, whether the circulation be active or languid, it will be proper in the com- mencement to evacuate the bowels by one or two purgatives. Where the bowels are tumid, hard, and torpid, which is not unfrequently the case in instances manifestly of general languor and sluggishness of the system, laxatives should be repeated until the bowels are brought to a natural condition. When the leucorrhoeal discharge is white and opaque, or purulent, the local applications must, in the first place, be such as are calcu- lated to moderate the vaginal irritation. For this purpose, it will be useful to direct the patient to inject warm water into the vagina three or four times daily, until the tenderness and irritation of the parts are in a great degree removed; and we may in general derive considerable advantage in this respect, from the injection of a weak solution of sugar of lead after each injection of warm water. By pur- LEUCORRHOEA. 543 suing this management, in conjunction with a simple vegetable diet, laxatives, rest, and, if indicated, blood-letting, the local and general irritation will usually yield sufficiently, in six or seven days, to ena- ble us to resort with propriety to the means more directly calculated to remove the irritation upon which the morbid discharge depends. Before I proceed to mention the efficient remedies of this kind, it is proper to observe, that especial regard should be had, both in the preparatory and final management of the disease, not only to the actual grade of vaginal irritation, but also to the exciting causes of the malady. To this latter object, I am inclined to think, there is seldom sufficient attention paid; and yet, it must be obvious, much, and in many instances, almost every thing, depends on the adaptation of the remedies to the peculiar circumstances which gave rise to, and, perhaps, still sustain, the disease. Among the internal remedies generally most relied on, for the cure of leucorrhoea, the tincture of cantharides holds the first rank. This article was, I believe, first recommended as a remedy in this disease by the late Dr. Robertson, of Edinburgh; and in this country, Dr. Dewees has for many years employed it with much success. When properly and perseveringly used, after suitable preparatory measures, it will not unfrequently completely remove the disease. I cannot, indeed, assert, that 1 have been often successful with its employment; but in a few very severe and protracted cases, 1 have used it with entire success. It may be commenced with in doses of from twenty to thirty drops three times daily, and graclually in- creased until it causes a slight degree of strangury. When this symptom occurs, it must be omitted until the ardor unnas disappears, when it should be resumed; but in smaller doses than those which were last given, and again increased until the neck of the bladder becomes affected. In some instances it will be necessary to continue its employment in this manner, omitting and resuming it according to its effects on the urinary passages, for three, four or even six months, before the disease will be permanently subdued The balsam copaiva also is a valuable remedy in this affection. I have more frequently succeeded with the use of this article than with cantharides; but to most patients it is an exceedingly offensive medicine, and in many instances its effects on the stomach are such as to render its use wholly inadmissible. To procure any material advantage from it, it should be given in large doses, and continued for thref or four weeks. Where it can be thus freely administered, t will rarely fail to make a very decided impression on the disease and in conjunction with proper local means, often put aperrna^ ston to the discharge. From forty to sixty drops should be g.ven hree times daUy, Sid when the stomach will bear it, the dose may ^S^coZlidwHy beyond this quantity. I have always found it most conveniently and readily taken in a portion of warm milk; or we may give it, rubbed up with gum arabic, white]sugar-andI water, in theTon*of an emulsion! When it acts too freely on the bowels, a few drops of laudanum should be added to each dose. The tine- 544 LEUCORRHOEA. ture of cubebs has likewise been recommended in this affection; but it is in all respects much inferior to the balsam copaiva. In cases entirely free from inflammatory irritation in the affected parts, and where the general habit is not phlogistic, the spirits of turpentine may be used with material advantage in some instances. I have lately succeeded in curing a case of this kind with the use of this remedy and astringent injections; but in the majority of instances, it is much too irritating to admit of being employed with propriety. Where the general habit is languid and relaxed, some advantage may occasionally be obtained from the internal use of tonic and astringent remedies. The infusion or extract of the root of rhalany, has been particularly recommended by some European writers; and in a few instances in which I prescribed it, considerable benefit ap- peared to result from its use. Dr. Dewees states, that he has " effected cures in some obstinate cases by the use of alum and nitre—five grains of alum and ten of nitre given three times daily." I have for eighteen years past been in the habit of prescribing alum in com- bination with ipecacuanha in this disease, and have often known it to produce the happiest effect. I usually administer it in doses of ten grains, with four grains of ipecacuanha—at first twice, and after six or seven days, three times daily. This will, in most instances, excite considerable nausea, and occasionally vomiting; but after a few days of employment it ceases to produce this effect; and it has even appeared to me, that the emesis which it usually excites, enhances its beneficial operation. As soon as the discharge becomes thin and more abundant, and the local inflammatory excitement has been moderated by the general measures already indicated, recourse should be had to astringent in- jections, in conjunction with the use of the tincture of cantharides, or the terebinthinate remedies, or alum powders just mentioned. The sulphate of zinc forms an excellent astringent injection in most instances of the disease. At first a drachm to a quart of water will be sufficiently strong to inject with; but its strength should after- wards be gradually increased to two, three, or even four drachms, with the same proportion of water. The sulphate of copper also may be very advantageously used for this purpose. Twenty-five or thirty grains to eight ounces of water, will form an injection of proper strength. I have occasionally found a solution of alum, in a decoc- tion of oak bark, as recommended by some of the older writers on this subject, to procure more benefit than any other injection. A drachm to a pint of water may be used for this purpose. Various other injections have been recommended—such as a strong decoction of oak bark; pulverised kino, mixed with water; decoction of nut- galls, &c. I have of late years, repeatedly used the diluted sulphuric acid; and in most cases with decided benefit. Three drops of the oil of vitriol to an ounce of water, will, in general, be sufficiently strong; if it produces no sensation of warmth, or slight uneasiness in the vagina, its strength should be increased. Dr. Jewel places great reliance on the use of the nitrate of silver, in this affection. He is LEUCORRHOEA. 545 of opinion that a very common cause of leucorrhoea is a subacute or chronic inflammation of the cervix uteri, and he asserts that we have no remedy equal to the nitrate of silver in subduing this inflamma- tion and its consequences. His mode of employing the nitrate of silver, is either to conceal the caustic in a silver tube, and apply it to the mouth of the uterus, or to apply a solution in the proportion of three grains to an ounce of water, by means of a bit of sponge tied neatly and firmly to a piece of whalebone. In some cases, which he reports, he applied the nitrate in the form of injection. For this purpose he used at first twelve grains of this substance to six ounces of water. Dr. Marshall Hall observes that the best mode of employ- ing astringent applications to the vagina in this disease, " is to direct the patient to make a scroll of linen of a form and bulk nearly suffi- cient to fill the vagina:" this scroll is then fully imbued with a strong solution of the sulphate of zinc, and inserted into the vagina after washing it out with cold water. This tampon or scroll may be renewed every three hours.* Some advantage may occasionally be derived from the application of a blister over the sacrum. In leucorrhoea depending on prolapsus of the uterus, no treatment can succeed in arresting the discharge until the womb is replaced to its proper position; and this can be done only by the use of a pessa- ry. It is to be particularly noted, however, that the introduction of a pessary is altogether out of the question, until the irritation and tenderness of the vagina and womb have been subdued by the local and general antiphlogistic means mentioned above. When the disease is attended with a rheumatic diathesis, or with rheumatic affections, the tincture of guaiacum, and probably colchi- cum, may be very appropriately employed. Richter recommends camphor and hyoscyamus where the disease has supervened on the disappearance of a chronic cutaneous disease, or some habitual serous evacuation. Iodine also has lately been recommended as a useful remedy in this affection. I have prescribed it in two cases, and its use was persisted in for six weeks, without, however, doing any perceptible good. * An Essay on Disorders of the Digestive Organs, &c. &c. p. 169. 46* APPENDIX. CHOLERA ASPHYXIA—SPASMODIC CHOLERA. Cholera asphyxia made its first appearance in August 1817, at Jessore, a town about sixty miles distant from Calcutta, in Hindos- tan. Thence, it extended its ravages along the principal rivers and greal roads, with a pretty uniform progress, until it had crossed the Indian peninsula, and broke out at Bombay, about one year after its commencement at Jessore. Having reached this point, the disease appeared, for a few years, to have attained the utmost western limit of its sway. In June, 1821, however, it made its appearance at Muscat in Arabia, and advancing in a northwestern direction through Persia, it reached Astracan, at the mouth of the Volga, in Septem- ber, 1823, and, nearly at the same time, broke out at Tripoli, on the eastern coast of the Mediterranean. In 1830, it again made its ap- pearance at Astracan; and thence extending itself rapidly through- out Russia, Poland, and Germany, it reached the eastern coast of the Baltic in the summer of 1831. Soon afterwards, the disease appeared in Sunderland, in England; and in the following spring it commenced its ravages in our own country. Symptoms.—In many instances the approach of this disease is attended with giddiness, a slight degree of languor, and mental de- pression—a feeling of uneasiness and distension in the abdomen, and almost constant churning noise of flatus in the bowels. Slight cramps, affecting the fingers and toes, particularly during the night, frequently occur—and many complain of a peculiar numbness, and feeling of inability to move the limbs. These symptoms, are, gene- rally, followed by moderate diarrhoea, the discharges being, usually, natural, and seldom attended with much griping. The duration of thia stage is very various. In some instances, the diarrhoea con- tinues for several days, before the characteristic symptoms of the disease supervene; in other cases, its duration is but a few hours; and, occasionally, the first intimation of the attack is a sudden ex- tremely copious evacuation, the patient feeling as if the whole con- tents of the intestines were passing off at once. Sometimes, though seldom, the disease commences by nausea and vomiting alone, with- out any diarrhoea. The first alarming symptoms are, commonly, a sudden feeling of faintness, giddiness, ringing in the ears, dimness of sight, uneasiness cholera asphyxia. 547 " amounting sometimes to great anxiety, or feelings of horror." The bowels begin to rumble; a burning pain is usually felt at the pit of the stomach, and violent purging and vomiting ensue, fol- lowed by a feeling of great prostration. " If the attack occurs in the day, the patient sits down affrighted at his own situation, or if in bed, awakes, and lies for a moment astonished at the novelty of his feelings: there is a new influence that appears to pervade the whole body, a sensation as if of fluttering on the pit of his sto- mach, and as a sense of weight or constriction round the waist. This is followed by a prickling sensation in the arms and legs, ex- tending sometimes to the fingers and toes; the hands and feet be- come cold, and bedewed with a copious clammy moisture, the pulse is usually oppressed and slow, sometimes quick and weak; and there is often pain in the forehead."* When, in this state, the patient raises himself in bed, or attempts to move, he immediately either feels sick, or is purged. The appearance of the fluid discharged by the stomach and bowels, resembles that of barley water, or of a so- lution of soap in hard water, " consisting of a clear fluid, with more or less of a white flocculent matter floating in it. After the first choleric evacuation, cramps usually supervene. The flexors of the fingers and toes are first affected with spasm; the gastrocnemii and muscles of the thigh are next attacked ; and in some cases, the whole mus- cular covering of the abdomen and trunk is affected. The face soon acquires a deadly pale hue,- attended with an expression of great anxiety and distress. The pain or burning sensation in the epigastrium increases; the hands exhibit a shrunken appearance, as if they had been long immersed in water; the skin, generally, is cold, damp, and sodden, and the eyes are sunk, and surrounded by a dark ring. At this period of the disease, there is often much rest- lessness and jactitation; in some instances, however, the patient lies quiet, and desires not to be disturbed. The whole surface of the body has, by this time, acquired a marble-like coldness, and a more or less livid or bluish hue. This lividity of the skin is particularly conspicuous on the hands, feet, face, and chest. The breath and tongue, also, are cold, and the whole surface is covered with a pro- fuse3, clammy sweat. The thirst is, generally, extremely urgent; the pulse at the wrist and arms is imperceptible, and the respiration is commonly slow, somewhat oppressed, and irregular. In old per- sons, a peculiar fetor, usually emanates from the body. During the whole course of the disease, the secretion of urine, and of bile, of tears and of saliva, is wholly suppressed. Notwithstanding the ex- treme coldness of the surface, there is often so great a sensibility to the impression of heat, that the application of external warmth gives great annoyance to the patient Although the circulatory and secretory functions are almost wholly suspended, « yet the sensorial * Observations on the Pestilential Cholera, as it appeared at Sunderland, &c. By W. Ainsworth, Esq.,—page 53. 548 cholera asphyxia. powers continue unaffected, nearly, if not entirely, to the last. The patient is sensible of all that passes around him; he answers with distinctness and accuracy any question that may be put to him, though it may be in mononsyllables only; while his hands are cold and bloodless, he yet retains the sense of touch, and even feels with increased sensibility, sometimes complaining of a painful impression of heat from the application of bodies of moderate temperature. He also, occasionally, retains considerable muscular strength; and the respiration sometimes goes on with ease and regularity, till within a few minutes of death. The whole exhibits an impressive picture of the death of one set of organs, while life still maintains its seat in others.* The preceding symptoms belong to what is, with propriety, called the second stage of the disease. When this, (the cold or blue,) stage does not prove fatal, it is invariably followed by more or less of arterial reaction, constituting the third stage of the malady. The liver and kidneys now resume their functions, though, doubtless, in a morbid or imperfect manner. When the febrile reaction is mode- rate, the patient, usually, soon convalesces. More frequently, how- ever, delirium and coma speedily ensue, and the patient dies in a state of apoplectic stupor. Sometimes local visceral inflammations are developed with the arterial reaction; and according to the ob- servation of some writers on this subject, the stage of reaction occasionally assumes the character of a malignant fever, of a con- gestive or typhoid form, in which " the tongue becomes more loaded, is redder at the tip and edges, and dryer; there is headache, the urine is highly colored; there is soreness upon pressure on the liver, stomach, and belly, the eyes are suffused and drowsy, the gums and lips are covered with a black sordes; the patient is pale, squalid, and powerless; the pulse low and languid.; and these symp- toms are commonly terminated in delirium and death."—(Ains- worth.) The second or cold stage sometimes terminates in coma, with no other manifestation of increased arterial action than a slight throb- bing of the carotids, and warmth of the chest. From this comatose stupor the patient can at first, generally, be roused for a moment; but in a short time, the coma becomes perfect, and death ensues, in perhaps a few hours. Occasionally the comatose state is preceded by sudden furious delirium; the patient raves wildly, " but the strug- gle is usually short, and soon subsides into total insensibility."— (Haslewood.) The preceding description may serve to give a general view of the course and phenomena of this frightful malady; but it is proper to observe, that in relation to the violence or frequency of the purg- ing and vomiting, great diversity occurs in different cases. In some * Cholera, as it has recently appeared in the Towns of Newcastle, &c. By T. M. Greenhow—page 4. cholera asphyxia. 549 instances, not more than two or three alvine evacuations take place; and cases'have been witnessed in which no discharge whatever occurred from the bowels. I have myself seen a case, in which but a single alvine choleric discharge took place, although the pa- tient speedily sunk into a fatal collapse. The evacuations some- times occur without effort or uneasiness; at others they are thrown out with great force. Although the calls are often 'very sudden and irresistible, the evacuations are very seldom attended with griping or tenesmus. In the advanced stages of the disease the purging usually ceases, " but in "some cases a watery fluid issues from the rec- tum whenever the patient moves his body, or changes his position." In some cases the vomiting is frequent and vehement; in other instances it occurs but seldom, and occasionally this evacuation is entirely absent. Dr. Kennedy states, that in certain epidemics of this disease, "scarcely an individual case has manifested this symp- tom. Sometimes very large quantities of serous fluid are ejected with great force; at others, the contents of the stomach are brought up, without any effort, by an action apparently of the oesophagus, somewhat similar to that which occurs in rumination. The animal functions also, are disordered in very different degrees. In some cases the patients have been able to " walk, and to perform many of their usual avocations," even after the circulation of the blood was so much arrested as to render the pulse imperceptible, at the wrist In the majority of cases, however, the animal functions are early impaired, and in some instances great prostration of strength occurs as the disease is developed. Spasm has been regarded as an essential phenomenon of this ma- lady. Observation, however, does not confirm this opinion; for cases have been noticed.in which all the other symptoms character- istic of this malady were present, without any spasmodic affection of the muscles of voluntary motion. The spasms are generally much more violent in robust and athletic habits, than in such as are of feeble and relaxed habit of body. " In the low and most dan- gerous form of cholera, spasm is generally wanting, or is present in a very slight degree." (Kennedy.) The spasms in this disease are of a mixed nature, partaking more of the tonic than the clonic character, " the relaxations being less prompt and frequent than in epilepsy or convulsion, and seldom durable as in tetanus." In some instances spasmodic twitchings of the muscles have been noticed a considerable time after death. The blood undergoes a remarkable change in this disease. The profuse aqueous discharges by the stomach and bowels, as well as by the skin, soon deprive this fluid of nearly the whole of its serous portion, in consequence of which it acquires a much darker color and thicker consistence than natural. When a vein is opened in the stage of collapse, only a few drops of thickened black blood issue from the orifice, or at most, it trickles down the arm like a stream of treacle. " By pressure and friction, perhaps, it begins to flow 550 CHOLERA asphypia. more freely, and if it continues, the color gradually improves. When this is the case a singular appearance is occasionally ob- served:—the stream consists of two distinct and separate portions, running side by side, the one still dark and tenacious, the other bright, of thinner consistence, and running with greater velocity." (Haslewood.) The blood taken from a cholera patient, coagulates speedily, into a loose gelatinous looking substance, of a very dark color, without separating any serum. From the foregoing description, it is manifest that the series of phenomena which characterise this malady, divide themselves into three distinct stages—viz. 1, the stage of irritation; 2, the stage of collapse; and 3, the stage of reaction. The first stage, however, is not always recognised, nor is it attended with any phenomena that can be regarded as peculiar to cholera, or as affording satisfac- tory diagnostic indications of its presence. It exhibits a more or less obvious state of morbid excitement of the nervous system, and disorder of the gastric and intestinal functions, " which may arise from various causes, and pass away without being followed by the diagnostic symptoms of cholera." The characteristic or diagnostic symptoms of cholera do not exhibit themselves until the disease has advanced to its second stage; and it is only in this fully developed state of the disease, that it can be certainly recognised. The phe- nomena which characterise this stage of the malady, are: 1, fre- quent discharges from the stomach and bowels of a serous or watery fluid, resembling rice or barley water; 2, complete suppression of the biliary and urinary secretions; 3, profuse cold and clammy sweat; 4, a failure and almost total suspension of the action of the heart and arteries; 5, complete failure of the animal heat, as evinced by the icy coldness of the surface, and the cold tongue and breath; 6, a livid or bluish hue of the skin, with a corrugated state of the hands and feet; 7, a thick and black state of the blood; 8, spasms or cramps of the muscles, commencing in the extremities and pro- ceeding to the trunk; 9, an early and extraordinary alteration of the expression of the countenance; 10, and finally, with all these violent symptoms, an almost undisturbed state of the mental faculties and sensorial powers. It is manifest from this assemblage of symptoms, that the diag- nosis of cholera, when fully developed, can very rarely be attended with any material difficulty. The disease with which spasmodic cholera would seem most liable to be confounded, is the ordinary cholera—the cholera biliosa. " Where the evacuations are tinged of a yellow or greenish hue, where the matter vomited is bitter to the taste, while the skin remains warm and the pulse good, the dis- ease may, with confidence, be regarded as ordinary bilious cholera; but where, after the first emptying of the primae viae, the evacuations are of a watery consistence, colorless, turbid, or white—s-when no urine is voided, when the surface becomes cold, the features collaps- ed, the spirits depressed, and the pulse flags, the case may almost CHOLERA ASPHYXIA. 551 certainly be regarded as cholera asphyxia." (Kennedy.) In the more advanced period of the disease, the total cessation of the pulse in the extremities—the icy-cold and clammy skin, the shrivelled, cor- rugated and bluish appearance of the hands and feet, and the general depression, can leave no doubt as to the nature of the malady. Post-mortem appearances—The external appearances of sub- jects who have sunk under this disease do not differ materially from those which the body presents during the latter period of the stage of collapse. The surface exhibits a livid, purple or blue color: the skin of the hands and feet is corrugated; " the eyes are deeply sunk- en, and have a dark ring around the orbits; the flexor muscles are rigidly contracted, the tendons standing out prominent on the ex- tremities: the hands are firmly clenched, requiring an effort to open them. The uvula, tonsils, and pharynx are covered with granula- tions, as is likewise the base of the tongue. These granulations vary in size from that of a pepper-corn, to that of a pea, and are probably the mucous follicles altered by inflammation. They con- tain a yellowish pus, of more than ordinary consistence. The oeso- phagus is corrugated; the mucous membrane of the stomach is often thickened, and of a delicate pink or brownish yellow color, with spots of redness as if from recent inflammation. These red spots have often little rounded vesicles of the shape and size of half a pea projecting from the centre, containing a small quantity of liquid pus. These vesicles are often numerous, particularly in the small intestines. They are probably mucous follicles altered by inflam- matory action. The stomach and intestines are generally filled with a turbid liquid like rice water, with little flocculi of a white mem- braneous substance floating in it. The glands of Pyer are enlarged in cases where the disease has been protracted into the typhoid state. The glands of Brunner are often in these cases rendered visible, as large as pepper-corns, and have black points at their centre. The valvulae conviventes of the duodenum are flaccid, thickened, and swollen, covered with the little vesicles just men- tioned, and occasionally they are ulcerated. The peritoneum is dry, and has a shining opaline lustre. The bile ducts are often thick- ened and are generally open; the liver is considerably gorged with blood; the spleen generally small and flaccid; the heart contains black blood in all its cavities, and is soft and easily torn; the blood is imperfectly coagulated, resembling thick molasses. The pulmo- nary veins contain clots of yellow coagulated lymph, tremulous like jelly." The trachea contains frothy mucus of a reddish or brown color. The mucous membrane of the larynx is often red and congested. The lungs are seldom engorged with blood, and almost always crepitate well; the veins of the kidneys are turgid with dark un- cotfgulated blood; the bladder is usually firmly contracted into a small mass, beneath the pubes. The sinuses of'the brain are always much engorged with very thick black blood. The brain itself is, 552 CHOLERA ASPHYXIA. generally, firm, tough and dry, and in cases where the disease was of long duration, or where death took place in the stage of reaction, it has always been found highly congested, with more or less opacity of the arachnoid membrane.* Dr. C. T. Jackson states, that he has often found the semilunar ganglion enlarged, and of a deep red color, and sometimes softer than natural. " The state of this ganglion, however," he observes, " varied so much that I can give no precise account of its morbid anatomy in this malady. It is obvious that the changes of color in this ganglion might have been the effects of the change in the color of the blood." Concerning the essential pathological character of this extraordi- nary malady, very little is known that can be deemed satisfactory. It seems, indeed, very probable that the cause of the disease, what- ever may be its nature, acts primarily on the nerves of the mucous membrane of the alimentary canal. In a great majority of cases, the approach of the disease is gradual, exhibiting a train of initial symptoms, clearly indicating a morbidly irritable condition of the stomach and intestines. The impaired digestion, the diarrhoea, or constant tendency to diarrhoea, the rumbling noise of flatus in the bowels, the pain or uneasy feeling in the pit of the stomach, the headache, the quick and sharp pulse, these symptoms, so generally noticed, where the premonitory stage is recognised, show very con- clusively, that the first obvious morbid effects of the cause of cholera is derangement of the gastric and intestinal functions. This pri- mary irritable and deranged state of the alimentary canal is more or less speedily followed by a rapid sinking and apparently total loss of the vital energy of the nerves subservient to the functions of organic life. The functions of the liver and kidneys are wholly suspended; the lungs cease to exert their appropriate vital influence on the blood and inspired air; the vital actions, by which animal heat is developed, are almost wholly arrested—in short, the whole machinery of organic life is lending, rapidly, to a state of total in- action, as if from palsy; whilst the organs subservient to the animal functions—the intellectual, the sensorial, and locomotive powers are in general but slightly affected. The very thick and dark state of the blood, depends on the rapid and almost total loss of its serum, by the relaxed exhalents of the alimentary canal and skin, and partly also, on the retention of the recrementitious carbona- ceous matter, in consequence of the suspension of the pulmonary and hepatic functions. Dr. Jackson of Philadelphia rejects the opinion, that the feebleness or suspension of the organic functions—the weakened state of the heart, and the functional torpor of the liver, lungs, kidneys, &c. depend on a loss of power in the ganglionic system of nerves. "The facts of the disease," he says, " give no countenance to this supposition. The insufficiency of this expla- * Dr. C. T. Jackson,—Medical Magazine, No. 4, 1831. See Amer. Jour. of the Med. Sciences, vol. xi. p. 266. CHOLERA ASPHYXIA. 553 nation is palpable, and we must resort to the more direct, obvious, and quite adequate cause, found in the exhaustion and alteration of the circulating fluids by the excessive evacuations from the stomach, bowels and skin." The blood, he says, is speedily deprived of nearly the whole of its serous and saline portion. " It is then no longer sufficient in quantity to fill up the vascular and angeal appa- ratus. Shrinking and shrivelling, first of the remoter tissues, capil- laries and vessels, ensue; the blood no longer filling the calibre of the arteries, the pulse disappears, and the heart, losing its accustomed stimulation, acts with diminished energy." In consequence of this condition of the blood and the heart, he thinks the lungs, the liver, and the kidneys, cease to perform their functions. This explanation is indeed sufficiently " direct and obvious," but I doubt much, whether it will be deemed " quite adequate." If the diminished quantity and changed state of the blood were the sole cause of the functional torpor of the excretory organs and heart, how is it, that the voluntary muscles, the organs of sense, and the brain continue to act with no remarkable reduction of power, even after the pulse is extinct in the extremities? Can it be presumed, that the morbid condition of the blood would thus prostrate the powers of the heart, lungs, liver and kidneys, and yet, at the same time, permit the brain and muscular system to act with nearly their ordinary vigor? It should be observed, too, that in some instances, the attack of the disease is so sudden and vehement, that the pulse ceases in the extremities, at the very commencement of the attack, and before the discharges from the stomach, bowels, and skin can have drained the blood vessels of their serum. It is certainly a very remarkable circumstance, that the organs supplied with cerebral or spinal nerves, should be, comparatively, so little affected, whilst those supplied by the ganglionic or sympathetic system of nerves, are so deeply im- plicated in the malady. Cause.—Whatever may be the nature of the remote or specific cause of cholera, it is manifest that all individuals are not equally susceptible of its deleterious influence. The natural or constitutional predisposition to disease consists, probably, in a naturally delicate and irritable state of the mucous membrane of the alimentary canal— a condition " which may have shown itself, on a former occasion, in a peculiar liability to disorders of the stomach and bowels, from slight causes, or by habitual tendency to diarrhoea and dyspepsia." An excitable and easily subdued nervous system may also be regarded as constituting an aptitude to the influence of the cause of cholera. In individuals of this habit, the depressing effects of fear and terror must be peculiarly apt to give force to the cause of this disease. Among the accidental causes of increased predisposition to cholera, the following are regarded as the most detrimental. Poverty and its too frequent concomitants, filth and mental depression, together with deficient and crude .aliment, have in all countries, and in all ages co-operated most powerfully with epidemic causes in multi- Vol. II.—47 554 CHOLERA ASPHYXIA. plying their victims. The broken down in constitution—the ha- bitually intemperate, and the dissolute, have every where been the first and most certain sufferers. Exposure to a cold and humid atmosphere, particularly at night; excessive fatigue of the body; inordinate mental excitement—the abuse of spirituous liquors—and crude, indigestible, and irritating articles of food, are particularly calculated to favor the development of cholera, in persons exposed to the influence of its cause. The articles of diet which have been found most injurious in this respect, are, salt pork, warm pastry, spawn of fish, hard-boiled eggs, smoked meats and fish, melons and cucumbers, lettuce, radishes, cheese, sausages, raisins and nuts. Every thing, in short, which has a tendency to irritate the stomach, or which requires strong digestive powers, ought to be carefully avoided during the approach or prevalence of this epidemic. Ex- cess in eating, whatever may be the nature of the diet, may give efficiency to the remote cause of the disease. Protection from the cool and damp night air, and from atmospheric inclemencies and vi- cissitudes, by good lodging and warm comfortable clothing—clean- liness, fresh air, the avoidance of excess in diet and drink—a cheer- ful, confident, and equable state of mind—the absence of inordinate personal fear, with a simple, nutritious, and digestible diet—these advantages will go far towards protecting the system from the dele- terious influence of the epidemic cause, v What is the nature of that deleterious principle which gives rise to cholera? Upon this subject all inquiries have hitherto resulted in little else than vague conjecture. Some ascribe this malady to an aerial poison,Agenerated by the decomposition of vegetable and animal matter. This opinion is met with the objections, that the disease has prevailed at all seasons, in winter as well as in summer, and in localities where the materials for such miasmata were, to all appearances, too sparingly present for the production of an epidemic. Others have supposed the choleric cause consists of a poisonous air or effluvium, engendered deep beneath the surface of the earth, by a slow process of decomposition or chemical change in some mine- ral strata, or by central volcanic action. There is certainly some- thing very analagous between the effects of the choleric cause, and those which result from mineral poisons, particularly arsenic. The slow progress of the disease for the period of more than seventeen years, in a broad zone over the surface of the earth, often in oppo- sition to the regular currents of the wind, seems to accord well with what one might suppose would be the progress of an epidemic if it depended on a subterranean cause of this kind. There are some who are disposed to believe, that the cause de- pends upon some occult modification in the constitution of the atmos- phere itself./ But this opinion is met by the objection, that, if such were its origin, it could hardly have advanced in a direction con- trary to the prevailing current of the aii^or winds—a circumstance which has frequently been observed. A few writers contend, that CHOLERA ASPHYXIA. 555 the disease depends on a deficiency of the electric fluid in the atmos- phere, whereby the animal system is deprived of its most subtle and pervading stimulus, and the organic affections debilitated. The disease has, also, been ascribed to the influence upon the human system, of some change in the magnetic condition of the earth; and Hahneman, with a few other writers, has adopted the Linnean doc- trine, of animalcular origin. It is maintained by the advocates of this hypothesis, that cholera arises from an infinite number of ani- malculae, too small to be perceived by the most powerful micro- scope, which, floating in the atmosphere, enter into the lungs, and ali- mentary canal, and thence make their way into the current of the circulation. This opinion is ingeniously and zealously defended by Dr. Neal, in a late work, written expressly to illustrate this view of the subject. It is unnecessary, here, to enter into a discussion upon the various points involved in these opinions. It may be sufficient to observe that they are all, as yet, wholly conjectural; and that, the experi- ence and observation of the profession, though intently directed to this object, have, hitherto, failed in establishing any thing on the subject which can be regarded as possessing any considerable degree of probability. Does the human body laboring under cholera, engender a poison, which, when brought to acton a healthy individual, will give rise to the same distemper; in other words, is the disease communicated from the sick to the healthy in the manner of a contagion? This is an important question. The fatality, and calamitous consequences of epidemics, are always greatly augmented, by the conviction among the people that the reigning disease is contagious. Besides the unhappy effects on the minds of the people, the vexatious, and often ruinous sanitary restrictions and quarantines, to which the existence, or supposed existence, of contagion usually leads, are in themselves evils of very great magnitude, and never fail to augment both public and private distress.—Where the evidence of contagion is so slight, therefore, that the most careful and judicious observers are led to entertain strong doubts of its existence, it is manifestly the duty of those whose station gives them an influence over public opinion, to discourage the belief in the prevalence of contagion. If the authority of those who have witnessed epidemic cholera is to be taken as evidence on this point, the foundation for the opinion of its contagious character is but very slight It is stated that in India, ninetv-nfne out of one hundred physicians believe that cholera is not contagious; and in every country and district that has been invaded by this disease, a great majority of the most experienced and enlight- ened of the profession entertain the same conviction. In many popu- lous cities and districts, as at Moscow, Orenburg, and Paris, the ma- jority of medical men, as well as of citizens, did not doubt the conta- gious character of the disease while they contemplated it at a distance; but after it had made its appearance amongst them, and they were 556 CHOLERA ASPHYXIA. furnished with an opportunity of observing for themselves, the belief in its contagiousness was almost universally abandoned. The quarantine regulations and sanitary restrictions which were enforced with the utmost vigilance and rigor at London, Paris, Hamburg, and other places, when the disease first broke out, were, on further experience and inquiry, so greatly relaxed as to demonstrate, in the clearest manner, the change of sentiment which took place under the light of experience, in relation to this point. There is not, I am persuaded, a single unequivocal instance on record, of the direct communication of this malady from the sick to the healthy. It is true that many apparent examples of this kind, have been adduced, but these have always been attended with circumstances of doubt and uncertainty; whilst on the other hand, innumerable instances have been noticed, wholly inconsistent with the supposition of con- tagion. Were some one of the unequivocally contagious diseases— were small-pox, for instance, now, for the first time to appear amongst us, can it be imagined, that after an almost universal pre- valence, during a period of more than seventeen years, the conta- gious character of the disease would not have been incontestibly established? In the report of the extraordinary committee of health, at Moscow, it is stated "that at the opening of bodies of persons who had died of cholera, to the minute inspection of which four or five hours a day, for nearly a month, were devoted, neither those who attended at the operations, nor any of the assisting physicians, nor any attendants, caught the infection, although with the exception of the first day scarcely any precautions were used." In the cholera hospital of this city, (Cincinnati,) in which, during a period of nearly five weeks, there were constantly from fifteen to twenty cholera patients, not a single case of the disease occurred among the attending physicians, nurses, and other attendants, although some of these remained in the wards, day and night, during the whole pe- riod, and frequently slept on beds, in which cholera patients had lain and died. Dr. Walker, speaking of the disease as it prevailed at Moscow, says, that "persons had put on the clothes of patients who were very ill, or had died of cholera—had lain in their beds, and even along side of dead bodies—had bathed in the same water where very bad cholera patients had been bathed just before, and that, notwithstanding not one of these individuals was attacked with the disease." Without pursuing this subject any further, it may, I think, be safely asserted, that the cause of cholera was, originally, and still continues, to be generated by circumstances foreign to the human body; and that it is propagated by being diffused throughout the atmosphere. Treatment.—In the treatment of cholera, much depends on a proper attention to the different stages of the disease; for the reme- dies and mode of management best adapted to one stage, would be wholly inefficient, or even injurious, at another period of the com- plaint. " A misapplication of the remedial measures," says Dr. CHOLERA ASPHYXIA. 557 Kennedy, "has been the source of extraordinary confusion and con- tradictory testimony. Several remedies, on which the strongest de- pendence is to be placed, in the management of cholera, have fallen repeatedly into temporary disgrace,from their having been prescribed in stages of the disease, when their use was altogether improper." The premonitory period.—When the patient complains of irregu- lar appetite, disordered digestion, a sense of fulness, or uncomfort- able feeling in the epigastrium, unusual heat in the abdomen, noise and commotion in the bowels, diarrhoea, or a peculiar feeling as if diarrhoea would on the slightest effort come on;—when these symptoms are present, the indications of cure are: 1. To cor- rect the intestinal and hepatic secretions, and allay the vascular and nervous irritation of the alimentary canal. 2. To regulate the diet, so as to adapt it to the irritable state of the stomach and the disordered condition of the digestive functions. To accom- plish these purposes a simple, unirritating, and digestible diet must be enjoined, such as: stale wheat bread, water and soda crackers, rice, homminy, grits, barley or oatmeal gruel, chicken or mutton broth, beef tea, black tea, or weak coffee with cream; and for com- mon drink, toast-water, barley or rice water, or weak cold camomile tea. Ten or twelve grains of calomel with one grain of opium should be immediately administered, and afterwards one of the following pills, every two, three, four or six hours, according to the urgency of the symptoms. R—Submuriat hydrarg. d'i.; g. opii. gr. ii.; pulv. camph. gr. v.—M. Divide into five pills. The patient should not be permitted to walk about or even to sit up. If the extremities are cool and the surface pale and shrunk, the patient should bathe his feet in warm water impregnated with salt, then lie down in bed well covered " with warm applications to the feet, as bottles of warm water, warm bricks, irons, or bags of heated oats, or sand, &c."* When at this early period the patient complains of nausea, 1 have found nothing so effectual in giving relief as small doses of a solu- tion of camphor in sulphuric ether. From six to ten drops every twenty or thirty minutes of a solution of thirty grains of camphor in an ounce of the ether, will seldom fail to allay the nausea and vomiting at this stage of the complaint This solution with the ad- dition of small doses of laudanum is particularly beneficial where the incipient stages are attended with symptoms of a decidedly nervous character. Dr. Samuel Jackson states, that in cases of this kind, he has frequently used the following prescription, with the most satisfactory results: R—Tinct lavend. compos.; tinct cam- phorae, aa 3iv.; liq. Hoff. anod. tinct. opii. aa^ij. M. ft. mist. From ten to twenty drops of the above are to be administered at appro- priate intervals. By the preceding mode of management, the pre- monitory or incipient symptoms of the disease, have, in a large majority of instances, been speedily and effectually subdued, and * Dr. Samuel Jackson. Amer. Jour, of Med. Sciences, vol. xi. p. 324. 47* 558 CHOLERA ASPHYXIA. the full development of the disease prevented. After the irritable state of the stomach and bowels has been allayed, a mild purgative should be ordered. For this purpose, powdered rhubarb, or the compound extract of colocynth, or fresh castor oil, will answer very well. The operation of the purgative, should be followed by an anodyne. During convalescence from these symptons, and, indeed, for a considerable period after their disappearance, the patient ought to use a mild, digestible and nutritious diet, and especially to avoid overdistending the stomach with food or drinks. Many relapses have occurred in consequence of some error in this respect If, notwithstanding these remedial measures, the disease assumes a more serious character, that is, if the evacuations begin to assume, or have assumed, the appearance of rice-water, and the patient ex- periences cramps in the extremities, then the primary objects are, to allay the cramps, vomiting, and purging, and to support the action of the heart and capillary circulation. From eight to ten grains of calomel, in union with half a grain of opium, should be given every hour. Many respectable authorities recommend much larger doses of calomel, whilst others, of equal respectability, employ it but sparingly. That calomel is a valuable remedy in this disease admits, I think, of no doubt; but my own experience has fully con- vinced me, that all the benefits which this remedy can afford, may be obtained from the doses I have just mentioned.* To allay the nau- sea and vomiting, the aetherial solution of camphor, already men- tioned, is an excellent remedy. From ten to twenty drops should be given, every half hour or hour, according to the urgency of the symptoms. Dr. Jackson recommends the following mixture for this purpose, and I have no doubt of its usefulness. R—Bi-carbon. po- tassae 3iv.; acetat opii. gtt. xv.; aquae camphorae 3iv.—M. ft. solut. Half an ounce, mixed with an equal quantity of lemon juice, should be taken, in the act of effervescing, every half hour. A sinapism should be laid over the abdomen; and dry heat assiduously applied to the extremities. The employment of the warm bath has been strongly recommended by some writers; but the relaxing and debilitating effects of the bath, together with the agitation and fatigue of the body almost necessarily attending its use, have often done very se- rious injury. In the " India Reports of Cholera," many instances are mentioned, " where the warm bath, in the second stage of cholera, manifestly hastened the death of the patients." These objections do not apply to the use of the alcoholic vapor bath. This applica- tion may be made, without disturbance or fatigue to the patient; and * By some of my western brethren the dose of calomel I have stated above, will be deemed very inadequate. The quantities of this article, which have been administered in cholera, by some highly respectable western physicians, are, indeed, truly enormous. I have it from unquestionable authority, that in not a few instances, one pound and a half, at least, has been given to the patient, in the course of forty-eight hours. CHOLERA ASPHYXIA. 559 I have known it to be resorted to, in the early periods of the disease, with very decided advantage. There is no remedial measure that has been more urgently advocated by some, and more strongly re- probated by others, than sanguineous depletion. To draw blood from the body, in a disease so strongly and so certainly tending to total prostration of the vital powers, does, indeed, at first sight appear very unpromising. Ample experience, however, has satisfactorily established the fact that, in the early periods of the disease, before collapse of the vital energies has taken place, and in subjects not enfeebled by age, or previous ill-health, blood-letting is sometimes attended with the most favorable results. Many of the most re- spectable physicians of India, speak in strong terms of praise, of the effects of general bleeding in cholera. Dr. Taylor, in his report to the president of the Bombay medical board, says, that, " when the principal symptoms are great oppression at the breast, laborious breathing, and a feeling of suffocation, or when the patient was af- fected with general tremors, giddiness, or locked jaw, bleeding was the only remedy which afforded effectual relief. But while blood- letting, in the early stage of the disease, and under certain circum- stances, almost uniformly produced the most decided salutary effects, it was, in general, unavailing in the latter stages, when the limbs were cold, the pulse not to be felt, and the eyes fixed and sunken." Indeed, when once the disease has advanced to the state of collapse, it is almost impossible to procure the discharge of blood, which mere- ly trickles forth in drops, and often fails entirely to issue from the orifice. Dr. Kennedy, in his excellent treatise on this disease, de- clares, that " every patient from whom blood could be freely obtain- ed, was almost sure of recovery;" and this declaration is supported by the majority of his medical brethren in India. In our own coun- try, many physicians of the" highest respectability have recorded their testimony in favor of general blood-letting, in this malady. Dr. Hopkinson of Philadelphia, a young physician, rising rapidly to eminence and distinction in his profession, says, " to overcome or remove the universal venous congestion in cholera, there is no sub- stitute for venesection. The blood must be drawn from a vein. It will not do to open an artery; this exhausts the patient, but does not relieve the venous congestion. If the pulse is not perceptible, or if it be very feeble, it is better to begin by applying cups over the abdomen, and if then the pulse rise, we may open a vein in the arm or in the foot, and watching the pulse, let the blood flow until reaction, or the improved condition of the patient indicates the attainment of our object" These precepts accord fully with my own sentiments on this subject. Local depletion by cupping or leeching, is, by some, regarded as, in general, decidedly preferable to blood-letting from a vein; and doubtless in many cases, it is capable of affording all the advantages that can be derived from depletion, with less risk of hastening pros- tration, than would attend the opening of a vein. In the early pe- 560 CHOLERA ASPHYXIA. riod of the disease, when the pulse is yet moderately full and active, almost immediate relief sometimes follows the application of leeches or cups to the epigastric and iliac regions. Dr. Samuel Jackson says: " it is surprising to witness how prompt, often, is the allevia- tion and abatement of the symptoms, following the application of from thirty to sixty leeches to the epigastric or iliac regions. In no instance did I find it necessary, in the patients 1 treated, in the first stages, to repeat the local depletion. One application was suffi- cient to procure a favorable result In several instances, general depletion made but little impression, while prompt relief ensued upon local depletion." It was not until near the termination of the last epidemic cholera in this city, that I ventured on sanguineous depletion in its remedial management; and the few cases in which I at last adopted this practice, gave me cause to regret, very much, that I had not sooner resorted to this important remedy in the treatment of this malady. As a general rule, local bleeding, by cupping or leeching is, without doubt, preferable to venesection; but when the pulse is moderately full and active, and the patient not of a feeble and nervous habit, blood may be freely drawn from a vein, with little or no risk of in- jury, and generally with decided advantage. But besides the general abstraction of blood, and consequent relief of the internal venous con- gestion, which the application of leeches or cups to the epigastrium affords, in common with venesection, it has the additional advan- tage of acting more directly on the abdominal organs, and by its derivative and sedative effects, of obviating the congested and irrit- able condition of the stomach and bowels. To allay the thirst, which is generally extremely harassing, the patient must be allowed to drink weak iced lemonade, iced gum water, barley water slightly acidulated and sweetened, artificial seltzer with or without lemon syrup, and iced water in small quanti- ties. When the thirst is attended with a sense of heat or burning in the stomach, much relief may often be obtained by swallowing small pieces of ice. " In many instances," says Dr. Jackson, " ice itself was given in very small pieces," and the effect, he states, was most grateful, and manifestly salutary. If the disease advances, and the temperature of the body and action of the heart begin to sink—if the pulse becomes small and feeble, and the hands and feet assume a corrugated and livid appearance, unceasing efforts must be made to sustain the activity of the capillary circulation, and the warmth of the body. Frictions with flannel moistened with a strong infusion of capsicum, or some other irritating liniment, or dry frictions with a flesh brush, together with sinapisms to the abdomen and extremities, are best adapted to answer this intention. It will also be proper to administer stimulants internally; 8uch as small portions of brandy and water, ammonia, turpentine, ether, &c. To check the excessive serous discharges from the stomach and CHOLERA ASPHYXIA. 561 bowels some practitioners have advised the internal employment of the sugar of lead; and from what I have seen of its effects in this dis- ease, I am inclined to think, that much advantage may, often, be deriv- ed from it, in this respect. Two grains of the acet. plumb, in union with a grain of camphor, may be given every half hour, until the watery discharges cease; or from twenty to thirty grains, dissolved in a small quantity of water, may be injected into the rectum. I have employed this article, in both these ways, in three or four cases; and, as it appeared to me, with a very manifest effect in diminishing the quantity and frequency of the serous evacuations. When the disease has advanced to the third stage, or the state of collapse, the treatment already mentioned must be continued; and to restore the fluids drained from the blood vessels, by the excessive discharges through the stomach, bowels, and skin, the patient should drink freely of some agreeable beverage, such as barley water, rice water, water mixed with a small portion of brandy; soda water, seltzer water, or weak chicken, mutton, or beef tea. As soon as the evacuations have ceased or are suppressed, the opium which was directed with the calomel, should be omitted, or given only in very small portions. When freely given in this stage of the disease, opi- um may do serious injury, either by blunting the sensibility of the system, already too torpid, or by promoting a dangerous determina- tion to the brain, should reaction take place. To persons who have been intemperate, or who have been addicted to the use of spirituous drinks, stimulants must be pretty freely allowed, in this stage of the disease. The carbonate of ammonia, is an excellent stimulant for this purpose, and generally agrees better with the stomach than any other remedy of this kind. Much has been said in favor of mustard emetics, in the collapse, or " blue" stage of cholera. Dr. Gibson, of Sunderland, declares that he has employed this remedy with the happiest effect in the advanced stages of the disease; and Greenhow says, " in the cold, blue or pulseless stage of the intense type of the disease, I believe it to be a very valuable remedy in relieving the irritation of the stom- ach, and exciting reaction." In this city, the mustard emetic was employed both in this and in an earlier period of the disease, by- several of my medical brethren, and, I have understood, often with decided advantage. My own experience, however, has not fur- nished me with any evidence of the usefulness of this practice in the stage of collapse; but I have derived very manifest advantage froni this emetic at an early period of the disease.* The tendency of forcible vomiting to excite the action of the heart and arteries and to impel the blood from the central vessels to the circumference, is in- deed well known; and it does not appear improbable, therefore, that * The mustard emetic is thus prepared. Dissolve a teaspoonful of com- mon salt in a gill of warm water, then mix with it a tablespoonful of finely powdered mustard. This is to be taken at one draught. 562 CHOLERA ASPHYXIA. any article which is capable of producing a sudden and vehement vomitive exertion, should occasionally give a salutary impulse to the circulation in this malady. Dr. Stevens, conceiving that the proximate cause of cholera, con- sists in a deficiency of the saline elements of the blood, administered the non-purgative salts; and the result, he informs us, was highly encouraging. In the account which he gives of his experience with this remedy, he states, that in some cases, where the pulse had already ceased in the extremities, the administration of the car- bonate of soda, was speedily followed by a return of the pulse, and an increased temperature of the body. This treatment has been adopted by many other physicians, both in this country and in Europe, and several statements have been published strongly in favor of its usefulness. Mr. Wakefield, an English physician, of great respec- tability, declares that he employed this remedy, in the cholera, as it occurred in the prison at Cold Bath Fields, with extraordinary success. Fifteen fully developed cases of cholera, were " put under the saline treatment, and all of them recovered. When the patients were first admitted, the following powder was immediately given, either in a half a tumbler of tepid water, or occasionally, in a little thin, clear beef-tea. R.—Supercarbonate of soda 3ss; muriate of soda J}i; chlorate of potass grs. vii. This was repeated every hour, and continued until the patients were recovering from the state of eollapse; after which, it was diminished in frequency, in proportion as the reaction increased."* When the stomach is very irritable, the tartrate of soda, in a state of effervescence, is said to be the most agreeable and effective form of administering the alkali. Mr. Wakefield advises, that, in addition to the use of the powder just mentioned, enemata should be administered, every two or three hours, composed of a large tablespoonful of muriate of soda, dis- solved in warm water. Mr. Whitmore states, that of eleven cases of cholera, which occurred "amongst a small colony of Italians, the first three were treated by bleeding, brandy and opium, and they all died. The other eight cases were put under the saline treatment, as recommended by Mr. Wakefield, and all but one, speedily and com- pletely recovered. In accordance with the sentiments of Dr. Ste- vens, saline fluids have, also, been injected into the veins in the cold or " blue" stage of this malady. Dr. Thomas Latta, of Leith, resorted to this practice, in a considerable number of cases; and he assures us, that, "in every case, even the most desperate cholera symptoms were removed." The quantity of saline fluid injected, amounted in some few instances, to one hundred and twenty ounces; and, it would appear, that, unless the quantity introduced into the veins, is very considerable, (from eighty to one hundred and twenty or thirty ounces,) no reliance can be placed on the permanency of its beneficial effects. In New York, and Philadelphia, this remedy * London Med. Gazette. Amer. Jour, of Med. Scienc. vol. x. p. 51. 1. CHOLERA ASPHYXIA. 563 was repeatedly tried, and a few cases have been mentioned in which it proved successful. Both this, and the preceding mode of em- ploying alkalies in this malady, have entirely failed, in the hands of many judicious practitioners, and however successful this mode of treatment may have been, in the practice of some, its claims to particular attention are still very doubtful. I have seen the carbonate and tartrate of soda freely administered, in six or seven cases, in the cholera hospital of this city, without, in a single instance, observing any decided beneficial effects from its influenoe. Dr. Charles Lee, of the Greenwich Hospital, New York, relied wholly on the employment of external applications, for exciting reaction in the stage of collapse. " At first," he says, " we relied on powerful internal stimulants and external revulsives; but our suc- cess was small, no permanent reaction could be produced. At length I concluded that there was no absorption from the mucous mem- brane; that from the violent action it had undergone, its functions were lost, and brought into the same condition as that of the skin. The only thing then left, was to undertake to introduce medicines into the circulation, mechanically through the skin. The indica- tions were, to restore the circulation, relieve spasm, promote the action of the absorbents, and unlock the secretions. To effect these objects, I prepared the following mixture. R.—Strong mercurial ointment, fti; powdered camphor ftss; powdered Cayenne pepper giv. Mix well together, and have the patient rubbed all over for half an hour at a time, and repeat the operation, accordingly, till the mouth is affected. The success of this plan was perfectly aston- ishing. Without administering a particle of medicine internally, reaction is sure to follow, in from one to three hours, even in the most perfect collapse." This plan of treatment appears to be well adapted to fulfil the principal indications in cholera; but it is ex- tremely doubtful whether this, or any other remedy, can avail aught in the state of " perfect collapse." When the disease has proceeded to this extent, all remedial efforts are probably wholly unavailing; and if recovery from perfect collapse, do take place, it must be the result, rather of a spontaneous effort of the vital energies, than of any remedial impulse. The application of irritating applications over the tract of the spine, is said to have produced very excellent effects in the spasmo- dic and more advanced periods of the disease. Sinapisms, tartar emetic ointment, and turpentine, have been employed for this pur- pose. In a case which occurred in the practice of the late Dr. Staughton, the application of cups over the spine, just as the patient was passing into a state of collapse, was speedily followed by de- cided melioration of the symptoms. Would not the application of moxa to the epigastrium and spine prove beneficial in this disease? M. Petit of the Hotel-Dieu, in Paris, thinks, that the principal indi- cation to fulfil, in the treatment of cholera, " is to keep up a con- stant impression upon the spinal marrow." With this view, he 564 CHOLERA ASPHYXIA. applies " over the whole tract of the spine, a strip of flannel, wet with a liniment composed of an ounce of the spirits of turpentine, and a drachm of aqua ammonia, and passes slowly over it a very hot flat- iron." This almost immediately produces vesication; and is, we are told, generally speedily followed by a return of the warmth of the skin, renewed activity of the circulation, and cessation of the vomiting and cramps. In addition to this application, frictions of the extremities, with a decoction of mustard, to which some aqua am- monia is added, must be diligently made. If reaction takes place, there is generally much danger of exces- sive determination of blood to the head; and many cases have ter- minated fatally, from sudden oppression of the brain, producing vio- lent delirium or coma, or even convulsions, in the stage of reaction. During the first five or six hours after reaction commences, the case ought to be carefully watched, and the febrile action moderated, if it tends to become violent, by blood-letting. Very often, indeed, de- lirium or deep coma ensues, with but a moderate degree of arterial reaction, as indicated by the pulse. In cases of this kind, sinapisms, or warm applications should be made to the feet, while ice, or flannel wet with iced-water, is constantly applied to the head, having pre- viously applied leeches or cups to the temples. During convalescence from cholera, the diet should be mild, di- gestible, and nourishing—and the patient ought to be particularly cautioned against indulging too freely in eating. Above all, he should avoid crude vegetables, and rich pastry. Dr. Kennedy states that a copious draught of cold water, during convalescence from this disease, has frequently brought on a relapse. Fatigue of body and mind, too, ought to be avoided, more especially in persons of a weak and delicate habit of body. INDEX. KT The Numerals refer to the Volume—the Figures to the Page. PAGE. A. Amaurosis, ii. - - - 198 Symptoms, ii. - . - 200 Diagnosis, ii. - . • 201 Prognosis, ii. - . . 202 Causes, ii. - . . ib. Treatment, ii. - . . 203 Amenorrhoea, ii. ... 525 Causes, ii. . . ib. Treatment, ii. - - - 527 Anasarca, ii. - - - 434 Angina Pectoris, ii. - - 268 Pathology, ii. - - - 269 Treatment, ii. - - - 273 Aorta, aneurism of, ii. . - 260 Apoplexy, ii. - - .10 Perfect or strong, ii. 11 Hydrocephalica, ii. - 12 Diagnosis, ii. - . - 13 Prognosis, ii. - - - ib. Causes—predisposing, ii. - 16 exciting, ii. . -17 Pathology, ii. - - - 20 Treatment, ii. - - . 24 Arachnitis, i. 287 Symptoms, i. - - - 289 Diagnosis, i. - - - 292 Pathology, i. - - - 294 Causes, i. . . . ib. Treatment, i. - - - 296 Ascites, ii. - - - - 431 Asphyxia, ii. 233 from drowning, ii. - ib. Treatment, ii. - 237 from irrespirable gases, ii. 240 Treatment, ii. from electricity, ii. Treatment, ii. from cold, ii. Treatment, ii. Asthma, ii. Symptoms, ii. - Prognosis, ii. - Causes, ii. Pathology, ii. - Treatment, ii. - Atmospheric heat, its relations with the animal system, i. - - 49 Vol. II.—43 241 242 243 ib. 244 207 ib. 214 208 211 214 PAGE. B. Bilious pleurisy, i. - - . 308 rheumatism, i. . 390 fever, i. - - . 128 colic, ii. - - - 318 Bladder, inflammation of, acute, i. - 372 chronic, i. 375 Brain, inflammation of, i. - - 283 Bronchitis, acute, i. - 336 Diagnosis, i. - - . 337 Post mortem appearances, i. - 338 Prognosis, i. - - . ib. Treatment, i. - . . 339 Bronchitis, chronic, i. - . 342 Diagnosis, i. - - - 344 Post mortem appearances, i. - 345 Causes, i. ib. Treatment, i. - - - 346 Bronchocele, ii. - - . 468 Diagnosis, ii. ... 470 Etiology, ii. ... 471 Treatment, ii. - - - 476 Bubo, ii. - - - . 522 C. Catalepsy, ii. 70 Diagnosis, ii. - . - 72 Causes, ii. . . 73 Prognosis, ii. - - - 75 Treatment, ii. - - - ib. Catarrhal consumption, i. - - 342 ophthalmia, i. - 421 Causes of fever in general i. - 39 Their general character and sources, i. - -42 Cerebritis, or softening of the brain, i. 300 Symptoms, i. - - . 301 Treatment, i. - . - 303 Chancre, ii. - . - 503 Syphilitic, ii. - . - 505 Pseudo-syphilitic, ii. - - 507 Chicken-pox, i. . - - 464 Chlorosis, ii. ... 485 Symptoms, ii. - - - ib. Causes, ii. . - - 487 Treatment, ii. - - - ib. Cholera Asphyxia, spasmodic, ii. - 546 Phenomena, ii. - - 550 566 INDEX. PAGE. PAGE. Cholera, diagnosis, ii. • 550 Cystitis, causes, i. - - 373 Post mortem appearances, ii. - 551 Treatment, i. - - ib. Pathology, ii. - - 552 Cystitis, chronic, i. • 375 Causes, ii. - 553 Symptoms, i. - - ib. Not contagious, ii. - 555 Treatment, i. - ■ 376 Treatment, ii. - - 556 Cynanche tonsillaris, i. - 209 Cholera, of adults, ii. . 301 Symptoms, i. - - ib. of infants, ii. - 304 Causes, i. ■ 210 Treatment, ii. - - 307 Treatment, i. - - ib. Treatment of cholera infantum, ii. 310 Chorea, ii, - - 77 D. Causes, ii. - 81 Pathology, ii. - . 82 Delirium tremens, ii. - 172 Prognosis, ii. - . 83 Symptoms, ii. - - ib. Treatment, ii. - - ib. Pathology, ii. - - 174 Clap, ii. - - 490 Prognosis, ii. - - 175 Cold, its effects on the animal system, i. 44 Treatment, ii. - - 176 Colica pictonum, ii. - - 323 Dementia, ii. - 163 Pathology, ii. - - 325 Diabetes insipidus, ii. - 387 Causes, ii. . 324 Symptoms, ii. - - 389 Treatment, ii. - - 326 Causes, ii. - ib. Colic, flatulent, ii. - - 315 Treatment, ii. - - 391 Treatment, ii. - . 316 Diabetes mellitus, ii. - 373 bilious, ii. - 318 Symptoms, ii. - - 374 Treatment, ii. - - 320 Causes, ii. - 377 Constipation, ii. - 335 Pathology, ii. - - ib. Causes, ii. . »6. Post mortem appearances, ii. - 379 Remedies, ii. - - 336 Prognosis, ii. - - 380 Consumption, pulmonary, i. - 352 Treatment, ii. - ib. bronchial, i. - - 342 Diagnosis, general, i. ■ 77 catarrhal, i. - - ib. Order of inquiry, i. - 79 'Contajrion, i. . . - C4 by the countenance, i. ■ 84 fixed, solid, i. . ib. attitude and motions, i. 89 volatile, effluvium, i - ib. nervous system, i. - 94 Modes of disinfecting, i. - 68 alimentary canal, i. - 96 Continued fever, i. - . 154 blood vessels, i. - 97 Convulsions, of children, ii. - 89 respiratory organs, i ib. puerperal, ii. - - 114 cuticular surface, i. ■ 100 Carpo-pedal, ii. - 93 lymphatic system, i. 101 Treatment, ii. - - 97 secretions, i. - . ib. Cow-pox, i. - - 451 Diarrhoea, ii. ■ 291 Its origin, i. . 452 Causes, ii. . 293 Appearances, i. - 453 Prognosis, ii. - . 299 Prophylactic powers, i. - 457 Post mortem appearances, ii. . 292 Causes of deterioration, i. - ib. Treatment, ii. - ■ 296 Effects upon diseases, i. . ib. Dropsy, ii. - . 425 Croup, i. - - 323 of the abdomen, ii. - . 431 Symptoms, i. - - ib. of the brain, i. . 287 Causes, i. - 324 of the chest, ii. 432 Prognosis, i. - 328 of the cellular membrane, ii. 434 Diagnosis, i. - 329 Treatment, ii. 435 Treatment, i. - - ib. Drowning, suffocation from, ii. 233 Cynanche laryngea, f. - 320 Dysentery, (mucous enteritis,) i. . ib. Symptoms, i. . - ib. Symptoms, i, - ib. Treatment, i. - . 321 Causes, i. . . 235 Cynanche trache'alis, i. - 323 Pathology, i. 236 Pathology, i. - • 324 Prognosis, i. . 238 Diagnosis, i. - 329 Treatment, i. . ib. Treatment, i, - - ib. Dysmenorrhoea, ii. - 532 Cystitis, i. - . 372 Symptoms, ii. . ib. Symptoms, i. - - ib. Pathology, ii. . 533 Suppuration, i. - 373 Treatment, ii. - 536 INDEX. 567 Dysury, ii. . Causes, ii. Treatment, ii. E. Eczema, i. - Simplex, i. Rubrum, i. - Impetiginodes, i. Chronic, i. - Causes, i. - Diagnosis, i. Treatment, i. - Enteritis, acute peritoneal, i. Symptoms, i. - Diagnosis, i. - Post mortem appearances, i. Causes, L Prognosis, i. - Treatment, i. - Enteritis, chronic, i. Causes, i. - - Post mortem appearances, i. Treatment, i. - Enteritis, mucous, i. Causes, i. Prognosis, i. Treatment, i. - Enuresis, ii. Epilepsy, ii. Causes, ii. Pathology, ii. - Diagnosis, ii. - Prognosis, ii. - Treatment, ii. - Epistaxis, i. Causes, i. Prognosis, i. - Treatment, i. - Erysipelas, i. phlegmonodes, i, neanatorum, i. - gangrenosum, i. cedematodes, i. - biliosum, i. Causes, i. - - Pathology, i. - Treatment, i. - Erythema, i. - - Causes, i. Diagnosis, i. - Treatment, i. - Exanthemata, i. minor, i. F. Fever, general pathology, i. Broussais's doctrine, i! general etiology, i. - general course and type, i. various stages, i. definition of type, i. Fever, intermitting, i. PAGE. 418 ib. ib. 536 536 536 ib. 537 ib. ib. 538 225 ib. 226 227 227 228 ib. 248 249 ib. 250 233 235 238 - 420 . 47 . 51 . 54 . ib. . 55 . 56 . 556 . ib. - 557 . ib. - 498 . 500 . 502 - ib. . 501 . ib. . 505 . 504 . 506 . 540 . 541 . ib. . 542 . 436 . 512 Fever, stages of, i. - inflammatory variety, i. congestive, i. gastric, i. malignant, i. anomalous intermittents, i. - Prognosis, i. - Causes, i. - - - Treatment, i. - of inflammatory, i. of congestive, i. of gastric, i. of malignant, i. Fever, synocha, i. - synochus, i. - - typhous, i. - Fever, remitting, i. - Symptoms, i. - gastric remittents, i! hepatic remittents, i. Causes, i. Prognosis, i. - Treatment, i. - Fever, Yellow, i. - Symptoms, i. - Etiology and origin, i. Post mortem appearances, i. - Black vomit, what, i. - Treatment, i. - Fever, inflammatory, i. Symptoms, i. - Causes, i. Treatment, i. - Fever, common continued synochus, different forms of, i, Causes, i. Diagnosis, i. - Prognosis, i. - Treatment, i. - Fever, typhus, i. - Symptoms, i. - Causes and origin, i. - Prognosis, i. Treatment, i. - Fever, scarlet, i. - varieties of, i. sequela, i. Diagnosis, i. Treatment, i. - Fluor Albus, ii. Causes, ii. Symptoms, ii. - Treatment, ii. - 13 15 39 70 ib. 72 103 G. Gastralgia, ii. nature of, ii. Treatment, ii. Gastritis, acute, i. - Diagnosis, i. Causes, i. Prognosis, i. PAGE. 103 105 106 ib. ib. 107 109 110 112 116 ib. ib. ib. 155 156 157 128 ib. 132 ib. 135 134 135 146 ib. 149 148 ib. 151 158 ib. . 160 . 168 i. 163 . ib. . ib. . 167 - 168 . ib. . 179 . ib. . 183 - 188 - ib. . 478 . ib. . 483 - ib. . 487 . 538 . t&. . 539 - 541 184 196 ib. 214 215 216 ib. 568 INDEX. PAGE. Post mortem appearances, i. - 216 Treatment, i. - . . ib. Gastritis, chronic, i. . - 218 Symptoms, i. - . . ib. Diagnosis, i. - . - 220 Causes, i. . . ib. Post mortem appearances, i. - 222 Treatment, i. - - - 223 Glossitis, i. - - .207 Treatment, i. - . . 208 Goitre, ii. - - . . 468 where found, ii. - . 469 Causes, ii. . . 472 Treatment, ii. . . 476 Gonorrhceal rheumatism, ii. . 391 Gonorrhoea, ii. - . . 490 Symptoms, ii. - - 491 in women, ii. . 493 Secondary symptoms, ii. . ib. Excoriations, ii. . . 492 Treatment, - . . 495 Gout, regular, i. - . . 407 irregular chronic, i. - 409 Diagnosis, i. - - - 412 Causes, i. - . . ib. proximate, i. - - 414 Treatment, i. - - - 415 H. Haematemesis, i. - . . 559 Causes, i. 506 Prognosis, i. . - ib. Treatment, i. - - - 561 Hematuria, i. 562 Causes, i. 563 Treatment, i. - . . ib. Haemoptysis, i. . . 565 Predisposition, i. 566 Causes, i. 567 Prognosis, i. . . ib. Treatment, i. - . . ib. Haemorrhages, i. . . 549 Pathology, i. - . . 550 Effects on the system, i. . 550 Causes, i. 553 Prognosis, i. . . 554 Treatment, i. - - - 555 Haemorrhoids, ii. - - . 348 Molimina and consequences, ii. 349 Local affections, ii. - - 351 Causes, ii. . . 352 Treatment of local affections, ii. 354 Treatment of haemorrhage, ii. 356 Treatment of tumors, ii. . 358 Heart, chronic diseases of, ii. - 249 hypertrophy of, ii. . . 257 dilatation of, ii. . . 258 sympathetic disturbance of, ii. 265 Treatment, ii. - . . 261 Heat, atmospheric, i. . .49 Hemiplegia, ii. . . 32 Treatment, ii. - .39 PAGE. Hepatitis, acute, i. - 265 Terminations, i. 266 Causes, i. 270 Diagnosis, i. - - 268 Treatment, i. - - 271 Hepatitis, chronic, i. 275 Post mortem appearances, i. - 276 Treatment, i. . . 277 Herpes phlyctenodes, i. . . 513 Diagnosis, i. . 514 zona zoster, i,. . -514 Treatment, i. - . 516 circinatus, i . - 517 Treatment, i. . ib. labialis, i. - 518 preputialis, i. ib. Treatment, i. . 519 Hydrocephalus acutus, i. . 287 Symptoms, i. . 289 Diagnosis, i. . . 292 Pathology, i. . . 293 Post mortem appearances, i. - ib. Causes, i. . ib. Treatment, i. . 296 Hydrophobia, ii. . . 134 Symptoms, ii. . . 139 Post mortem appearances, ii. - 141 Treatment, ii. . . 143 Hydrops, ii. . 425 General symptoms, ii. - 430 Hydrothorax, ii. . . 432 Hysteria, convulsive, ii. . . 100 chronic, ii. . -101 Hysteric torpor, ii. . . 102 Pathology, ii. . -103 Causes, ii. . . 104 Diagnosis, ii. - . . 106 Treatment, ii. . . 107 Hysteritis, acute, i. . . 377 Treatment, i. . 380 Hysteritis, chronic, i. - . 382 Phenomena, i. . 383 Treatment, i. - . ib. I. Icterus, ii. ... 361 Causes, ii, . . 364 Pathology, ii. . . ib. Prognosis, ii. . . 367 Treatment, ii. . . 368 Idio-miasmata, i. - - 57 Effects on the human system, i. 58 Effects in conjunction with koino-miasmata, i. . - 63 Idiotism, ii. . - 164 Ileus, ii. . . 330 Pathology, ii. . . 332 Treatment, . . 333 Indigestion, ii. . . 275 Causes, ii. . . 276 Symptoms, ii. . . 280 Treatment, ii. . . 283 INDEX. 569 PAGE. Inflammation in general, i. - - 200 Phenomena, i. - 200 Pathology, i. - - - 20^ Terminations, i. - - 203 Inflammation of the brain, i. 282 &, 300 of the meninges, i. - 286 of the stomach, acute, i. 214 of the stomach, chro- nic, i. - of the peritoneum, acute, i. of the peritoneum, chronic, i. - of the bowels, perito- neal, i. of the bowels, acute, mucous, i. of the bowels, chronic mucous, i. of the liver, acute, i. chronic, i. of the spleen, acute, i. chronic, i. of the kidneys, acute, i. 367 of the bladder, acute, i. 372 of the bladder, chro- nic, i. of the trachea, i. of the bronchia, mu- cous, i. of the bronchia, chro- nic, i. of the pleura, acute, i. of the lungs, i. of the larynx, i. of the tonsils, i. of the tongue, i. of the eyes, i. catarrhal, i of the eyes, rheuma tic, i. of the eyes, gonor rhoeal, i. of the eyes, purulent, i. 425 of the eyes, scrofo- lous, i. - of the iris, i. of the parotid gland, i. of the pericardium, i. of the womb, acute, i. chronic, i. Intermitting fever, i. Intestinal worms, ii. Causes which favor their pro- duction, ii. Their origin, ii. Tricocephalus dispar, ii. Ascaris vermicularis, ii. Ascaris lumbricoides, ii. Taenia lata, ii. Taenia solium, ii. Symptoms, ii. 218 252 260 225 233 248 265 275 280 280 375 323 336 342 304 304 320 209 207 421 421 424 426 429 434 212 384 377 382 103 337 339 337 340 ib. ib. ib. 341 ib. PAGE. Treatment of ascarides, ii. - 343 of lumbrici, ii. - 342 of taenia, ii. - 344 Alston's method, ii. - - ib. Desault's method, ii. - - ib. Herrenschwand's method, ii. - ib. Hufeland's method, ii. - 345 Nouffer's method, ii. - ib. Sch mucker's method, ii. - 346 Bremser's method, ii. - ib. Iritis, i. - - - .434 Treatment, i. - - - 435 Ischuria renalis, ii. - - 402 Causes, ii. - - 404 Prognosis, ii. - - - 405 Treatment, ii. - - ib. Jaundice, ii. ... 361 Causes, ii. - - - 364 Pathology, ii. - - - ib. Treatment, ii. - - - 368 K. Koino miasmata, i. - How generated, i. - Physical characters, i. Effects on the animal system, i. Union of koino and idio-mias- mata, i. - Laryngitis, i. Symptoms, i. - - Prognosis, i. - - Treatment, i. Leucorrhoea, ii. - Causes, ii. - Symptoms, ii. Pathology, ii. Treatment, ii. Lichen, simplex, i. Agtius, i. - - Causes, i. Diagnosis, i. Treatment, i. Lithiasis, ii. - Urinary deposites, ii. pulverulent deposites, ii. crystallised do. ii. solid concretions, ii. Lithic acid diathesis, ii. Amorphous lithic sediments, ii. Yellow deposites, ii. Red or lateritious sediments, ii. Pink sediments, ii. Causes of the lithic acid sedi- ments, ii. - Causes of crystallised depo- sites, ii. Phosphatic diathesis, ii. Treatment, ii. 48* 50 51 54 59 64 320 320 321 321 538 ib. 539 540 541 532 533 534 534 535 392 ib. ib. ib. ib. 394 ib. ib. ib. ib. ib. 395 397 398 570 INDEX. PAGE. Treatment of lithic acid diathe. sis, ii. - - 398 of phosphatic dia- thesis, ii. - 400 Liver, inflammation of, acute, i. - 265 chronic i. - 275 M. Malaria, (marsh) i. - 50 Mania, ii. ... 159 Mania-a-potu, ii. - - 172 Cause, ii. - - ib. Symptoms, ii. - - ib. Treatment, ii. - - 176 Measles, i. ... 467 inflammatory, i. . 470 congestive i. . . 471 typhous or malignant, i. 471 gastric, i . . 472 Sequelae, i. . . 472 Diagnosis, i. . . . 473 Prognosis, i. . . 474 Treatment, i. . . . 474 Menorrhagia, i. . . 571 chronic, i. . . 572 Effects on the system, i. . 572 Causes, i. 573 Treatment, i. . . 573 Mental derangement, ii, . . 148 Causes, ii. . . 149 Prognosis, ii, . , 155 Post mortem appearances, ii. . 158 Treatment, ii. . ,168 Miasmata, idio, i. . . .57 Miasmata koino, i. . ,50 Infection, what, i. . . ib. Physical character, i. , 54 Morbific influence, i. . 59 Union of koino and idio-mias. mata, i. . .63 Miliary fever, i. . . 530 Causes, i. 531 Nature, i. . . 530 Treatment, i. . . 532 Modified small pox, i. . . 458 Monomania, ii. . . 161 Morbilli, (measles) i. . . 467 Mumps, (parotitis) i. . . 212 N. Nephritis, i. 367 Diagnosis, i. . . 368 Causes, i. 369 Treatment, i. . . 370 Nervous affections, chronic, ii. . 7 Nettle-rash, (urticaria) i. . . 526 Treatment, i. . . . 529 Neuralgia, ii. 180 Symptoms, ii. . , 181 Causes, ii. . . .186 Pathology, ii. . , ib. Treatment, ii. . . 189 O. Ophthalmia, i. , 421 catarrhal, i. , 421 Treatment, i. p 421 rheumatic, i. , 424 Treatment, i. 424 gonorrhceal, i. , 426 purulent, i. . , 425 Treatment, i. . 427 scrofulous, i. . 422 Treatment, i. . 431 syphilitic, i. - 434 P. Painter's colic, ii. . 323 Palsy, ii. - - 30 Pathology ii. - 36 Hemiplegia, ii. - 32 Paraplegia, ii. - 34 Partial paralysis, ii. - 35 of the face, ii 38 of the wrists, ii. 39 Causes, ii. - 35 Treatment, ii. - 39 Parotitis, i. - - - 212 Character, i. ■ 213 Treatment, i. - 213 Peritonitis, acute, i. - 252 Symptoms, i. - 252 Causes, i. - 254 Terminations, i. - 254 Post-mortem appear- ances, i. . 255 Treatment, i. . 255 chronic, i. . 260 Causes, i. _ 261 Post mortem appear- ances, i. . 262 Terminations, i. . 262 Treatment, i. . 263 Pemphigus, acute, i. - 519 chronic, (pompholix) i. 522 Causes, i. - - 524 Diagnosis, i. - - 524 Prognosis, i. . 524 Treatment, i. - . 525 Pericarditis, i. - _ 384 Petipneumonia, i. _ 307 Peripneumonia notha, i. . 336 Diagnosis, i. - . 337 Post mortem appearances, i. . 338 Treatment, i. . 339 Phlegmasia dolens, i. . 576 Pathology. . 577 Treatment, i. - . 579 Phrenitis, (phrensy,) i. - 283 Character, i. . 283 Causes, i. - - 284 Prognosis, i. - . 284 Pathology, i. - . 284 Treatment, i. - _ 285 Phthisis pulmonalis, i. - 352 INDEX. 571 Phthisis tubercular, i. Nature, i. Prognosis, i. . Treatment, i. tracheal, i. Symptoms, i. Causes, i. Prognosis, i. Treatment, i. imposthumous, i. . melanotic, i. cancerous, i. granular, i. pleuritic, i. bronchial, i. Diagnosis, i. Treatment, i. Piles, (haemorrhoids,) ii. Pneumonia, (pleurisy,) acute i. Causes, i. Post mortem appearances, i. Prognosis, i. Treatment, i. Pneumonia, (lungs,) i. Symptoms, i. . > Terminations, i. Post mortem appearances, i. Engorgement, i. Red hepatization, i. Gray hepatization, i. . Gangrene, i. Diagnosis, i. Prognosis, i. Treatment, i. Pneumonia biliosa, i. Treatment, i. Pneumo-thorax, ii. Symptoms, ii. Diagnosis, ii, Treatment, ii. Puerperal convulsions, ii. Phenomena, ii. Varieties, ii. Treatment, ii. . Purulent ophthalmia, i. gonorrhoeal, i. Egyptian, i. infantile, i. Purpurea, i. • simple, i. hsemorrhagia, i. • Pathology, i. Treatment, i. Q. Quinsy, (tonsilitis,) i. Causes, i. Treatment, i. R. Remitting fever, i. Retention of urine, u. Causes, ii. PAGE. 356 from paralysis of the bladder, ii. 357 inflammation, ii. 360 spasm of urethra, ii. . 361 mechanical obstruction, ii. 352 lenal retention of urine, ii. ib. Treatment, ii. 353 Rheumatic ophthalmia, i. . 360 Rheumatism, acute, i. 365 bilious, i. 354 Prognosis, i. ib. Causes, i. 355 Metastasis, i. ib. Diagnosis, i. 353 Treatment, i. 342 Rheumatism, chronic, i. . 344 Causes, i. . . , 346 Treatment, i. 348 Rheumatism, gonorrhceal, i. 304 Ringworm, (herpes circmatus,) i. . . 305 Remedies, i. . . 306 Roseola, i. . . . . ib. Diagnosis, . 314 Prognosis, i. . . 307 Treatment, i. . . ib. Rubeola. (See Measles.) i. . . 308 Symptoms, i. . . 309 Modifications, i. . ib. Diagnosis, i. . . ib. Prognosis, i. . . 310 Treatment, i. . . ib. . 311 S. . 313 Scarlatina, i. . 314 simplex, i. . 308 anginosa, i. . 314 maligna, i. . 244 Sequela, i. . 245 Diagnosis, i. . ib. Prognosis, i. . • . 247 Treatment, general, i. . . 114 local, i. . 115 Scorbutus, (scurvy,) ii. . 116 Post mortem phenomena, ii, . 117 Symptoms and general progress . 425 Causes, ii. . 426 Prognosis, ii. . . ib Treatment, ii. . . ib Scrofula, ii. . 543 Causes, ii. '. . 544 Treatment, ii. . . ib Scurvy, ii. . ; . 54£ Scrofulous ophthalmia, i. . 54" Shingles, i. Small pox,i. . 20< . 21( . ib . Small-pox, confluent, i. ' Small-pox modified, i. Phenomena, i. " Softening of the brain, i. Splenitis, i. . 12 3 terminations, i. . 40 5 Treatment, i. . . 40 7 St. Anthony's fire, i. • PAGE. 407 408 410 411 412 ib. 424 390 ib. 391 392 393 394 395 401 401 403 391 517 ib. 542 , 543 ib. lb. 467 . 469 . 468 . 473 . 474 . ib. . 478 . ib. . 479 . 481 . 483 . ib. . 484 . 487 . 495 . 479 . 481 ,ii.479 . 481 . 482 . ib. . 452 . 454 . 458 . 479 . 429 . 514 . 437 . 441 . 464 . ib. . 300 . 280 . ib. . 282 . 498 572 INDEX. PAGE. PAGE. Stomach, acute inflammation, i. . 214 Urticaria, subcutanea, i. . 528 Chronic, i. . 218 Causes, i, . ib. Strangury, ii. . 418 Prognosis, i. . 529 Strumous, iritis, i. . 434 Treatment, i. . . ib. Suspended animation, ii. . 233 Urine, incontinence of, ii. . 420 Suffocation from drowning, ii. . ib. Uterus, inflammation of, i. . . 377 from irrespirable gases, ii . 240 chronic, i. . . 382 Syphilitic iritis, i. . 434 Syphilis, ii. . 501 V. origin, ii. . ib. Variola, i. . . 437 primary ulcers, ii. . 503 distinct, i. . 438 venerola vulgaris, ii. . 507 confluent, i. . 441 venerola superficialis, ii. . 508 crystalline, i. . 443 phagedenic ulcer, ii. . 509 suppuration, i. . 439 syphilitic chancre, ii. . 505 consequences, i. . 443 indurated sloughing ulcer, ii. 509 Post mortem appearances, i. . 444 constitutional syphilis, ii. 506 Treatment, i. . . 447 treatment of primary ulcers, ii. 510 Vaccina, i. . 451 treatment of constitutional phenomena and progress, i. 453 disease, ii. . 516 origin, i. . . 452 Diagnosis, i. . 455 T. Varioloid affections, i. . 458 Tetanus, ii. 119 Varicella, i. . 464 Idiopathic, ii. . ib. Character, i. . ib. Traumatic, ii. ib. Symptoms, i. . . 465 Causes, ii. . 121 Vitus's, St. dance, (Chorea,) ii. . 77 Pathology, ii. . 123 Prognosis, ii. 125 W. Treatment, ii. 126 Whooping cough, ii. . 220 Tic douloureux, (neuralgia,) ii. 180 Phenomena, ii. . ib. Tongue, inflammation of, i. 207 Pathology, ii. . . 226 Tonsils, inflammation of, i. 209 Treatment, ii. . . 227 Tuberculous consumption, i. 356 Worms, intestinal, ii. . 337 Typhus, i. 179 U. Y. Urticaria, i. 526 Yellow fever, i. . , . 146 febrilis, i. ib. evanida, i. 527 Z. tuberosa, i. 528 Zona, i. . 514 GLOSSARY. *#* As it is probable that this book may be purchased for family reference, the Publisher has added a Glossary of the technical terms used in the Work. J. G A. ABDOMEN, the belly, or paunch. Abscess, a collection of matter. Adipose, fat. Anasarcous, dropsical. Anginose affections, inflammatory affections of the throat. Anormal, irregular, unnatural. Anthelmintic, having the power of destroying worms. Antiphlogistics, medicines that reduce fever and inflammation. Antispasmodics, medicines that allay spasms or cramps. Aperients, medicines that gently open the bowels. Aphthae, small superficial ulcers in the mouth. Apyrexia, the period of intermission in agues. Ardor urinac, a scalding of urine. Arthritis, rheumatic pains of the joints. Asphyxia, apparent death, suspended animation. Asthenia, diminished vital energy. Axungia, hog's lard. B. Belladonna, deadly night shade. Blennorrhoea, a morbid secretion of mucus. Bronchia, the air tubes in the lungs. Bronchotomy, an incision into the wind pipe. Bulimia, insatiable craving for food. C. Cachexia, a general weak, relaxed, and disordered state, without fever. Canthus, angle of the eye. Capillary vessels—Capillaries, the very minute vessels, between the arteries and veins. 574 GLOSSARY. Cardia, the upper orifice of the stomach. Cardiac region, the pit of the stomach. Carotids, the arteries that convey the blood to the head. Catamenia, the monthly discharge of females. Cataplasm, a poultice. Catheter, a hollow tube for drawing off the urine. Cephalalgia, headach. Cephalic, relating to the head. Cerebral, relating to the brain. Cerebrum, the brain. Cervical vertebrae, the joints of the spine, in the neck. Cervix uteri, neck of the uterus. Chyle, the milky fluid produced by digestion. Chyme, the food after it has undergone the progress of digestion in the stomach, and has passed into the bowels. Colliquative stools, profuse watery discharges from the bowels. Colly Hum, an eye wash. Coma, profound lethargic stupor, or sleep. Comatose, morbidly sleepy. Congestion, the accumulation of blood in a part. Constipation, costiveness. Crassamentum, the red globules of the blood, collected in a mass with the coagulable lymph. D. Dejections, alvine, evacuations by the bowels. Diliquium, fainting. Demulcents, soothing, mucilaginous fluids, as flaxseed tea. Dentition, teething. Derivatives, remediate applications, that draw the blood from an affected part Desquamation, scaling off, or separation of the skin in small scales. Diagnosis, the distinguishing marks of particular diseases. Diaphoresis, gentle perspiration. Diaphragm, the muscular partition between the chest and abdomen. Diathesis, any particular disposition or habitude of the body. Dietetic, relating to the regulation of the diet. Diluents, bland drinks. Diuresis, increased discharge of urine. Diuretics, medicines that increase the flow of urine. Duodenum, the first twelve inches of the small intestines. Dyspnoea, oppressed breathing. Dysuria, difficulty and pain in passing urine. E. Ejections, discharges from the stomach by vomiting. Electuary, a compound medicine, made into the consistence of honey. GLOSSARY. 575 Emesis, vomiting. Emetic, a medicine that causes vomiting. Emulsion, a milk-like fluid, formed by mixing oily or resinous sub- stances, by means of mucilage, with water. Encephalic, relating to the cavity of the skull. Encephalon, the brain with its membranes. Endemic, a disease peculiar, or especially prevalent, in certain local- ities or districts. Enema, a clyster, an injection; enemata, injections. Engorgement, an accumulation and stagnation of fluids in a part. Enuresis, involuntary discharge of urine. Epidermis, the outer skin. Epispastics, substances that blister the skin, as Spanish flies. Epistaxis, bleeding from the nose. Errhines, substances used to produce sneezing. Erysipelas, St. Anthony's fire. Erythema, a slight inflammation of the skin. Eschar, the dead substance produced by applying caustic, &c. Etiology, relating to the causes and origin of diseases. Exacerbation, the period of increase of a fever. Exanthemata, acute eruptive diseases. Excitability, the capacity of being excited by stimuli. Excitement, the action caused by stimuli. Exfoliate, to cast, or scale off, as the skin, or a piece of dead bone. Expectorants, medicines that promote spitting. Exsanguinous, bloodless, with but little blood. F. Farinaceous, made of meal. Fascia, a tendinous expansion. Fauces, the posterior part of the mouth, or top of the throat. Febrific, that which causes fever. Febrifuge, a medicine that has the power of arresting the progress of an intermitting fever; as bark. Febrile, feverish. Fistula, a deep tube-like ulcer. Foramen, an opening, or hole. Fraenum, bridle. Function, the action or office performed by an organ Furfuraceous, branny; consisting of thin light scales. G. Ganglion, a small knot or roundish enlargement of a nerve or tendon. Gansrene, mortification. Gastralgia, pains in the stomach without fever. Gastric, relating to the stomach. Gastritis, inflammation of the stomach. 576 GLOSSARY. Gastro-enteritis, inflammation of the stomach and bowels. Gestation, riding in a carriage, or any locomotion without bodily exertion. Gustatory, relating to the taste. Guttatim, by drop?. H. Haematemesis, vomiting of blood. Haematuria, voiding bloody urine. Haemoptysis, bleeding from the lung?. Haemorrhage, bleeding from any part of the body. Haemorrhoids, piles. Haustus, a draught of liquid medicine. Hectic, a slow habitual fever, with sweats snd emaciation. Hemicrania, pain on one side, of the head. Hemiplegia, palsy on one side. Hepatisation, change of structure so as to resemble the substance of the liver. Hernia, a rupture. Herpetic, having the character of a tetter. Humoral, relating to the fluids, particularly the blood. Hydragogue, a purge that produces watery stools. Hydrocephalus, dropsy in the head. Hydropic, dropsical. Hypercatharsis, excessive purging. I. Iatraleptic, the application of remedies externally. Icterode, yellow, jaundice-like. Icterus, jaundice. Idiopathic, original affection of a part. Idiosyncrasy, any peculiar habit. Ileum, the lower part of the small intestines. Iliac regions, the flanks, the lateral and lower parts of the abdomen. Impetigo, a species of ringworm. Integuments, the skin. Irritability, the capacity of being excited into action. Ischuria, difficulty or stoppage of urine. L. Lactation, the act of suckling. Lasdentia, medicines, or other agents that cause injury. Lateritious, like brick-dust, brick-colored. Leucophlegmatic, a pale, relaxed, debilitated, and torpid state of the body. Leucorrhoea, the whites. Liniment, a very thin ointment GLOSSARY. 577 Lithiasis, a disposition to discharge gravelly matter with the urine. Lithontriptic, a remedy used for dissolving stones in the kidneys or bladder. Lumbago, rheumatism in the loins. Lymphatics, vessels that carry white fluids. M. Malaria, pestiferous exhalations from marshes and putrifying sub- stances. Meninges, the coverings of the brain. Meningitis, inflammation of the coverings of the brain. Metastasis, a translation of a disease from one part to another. Miasm, the same as malaria. Morbific, capable of causing diseases. N. Narcotic, medicines, that blunt the sensibility of the nerves. Nephritic, affections of the kidneys. Neuralgia, painful affections of a nerve. Normal, natural, healthy. Nosology, a systematic arrangement, explanation and definition of diseases. 0. (Edema, swelling from a dropsical collection in the cellular mem- brane. (Esophagus, the gullet. Olfactory, relating to the sense of smelling. Ophthalmia, inflammation of the eyes. Opiate, a medicine whose prominent ingredient is opium. Organic affection, a disease in which more or less of the substance of a part is changed or disordered. Orthopnoea, great difficulty in breathing. Ossified, changed into a bony structure. Os uteri, mouth of the womb. P. Paracentesis, making an opening into the cavity of the abdomen or chest to give exit to fluids; tapping. Paralysis, palsy. Parenchyma, the proper substance of organs. Pathognomonic, characteristic symptoms. Pathology, doctrine of the causes and nature of diseases. Lately, this term has been, not very properly, applied to the diseased appear- ances discovered on dissection. Pectoral, relating to the breast. Pectoriloquism, a peculiar sound in the lungs when the patient speaks, heard through the sides of the chest by the stethoscope. Vol. II.—49 578 GLOSSARY. Percussion, striking the breast with the extremities of the fingers to ascertain the kind of sound produced. Pericardium, the membranous sack surrounding the heart. Peristaltic motion, the vermicular motion by which the bowels push forwards their contents. Pharmaceutic, relating to the compounding &c. of medicines. Pharynx, the top of the gullet. Phlegmasia, inflammation. Phlegmonous, inflammatory. Phlogosis, superficial inflammation. Phymosis, contraction of the foreskin, so as to prevent it being drawn back. Plethora, fulness of blood. Pleuritic, of the character of pleurisy, attended with pain in the side of the chest. Post mortem, after death. Prolapsus, a falling down. Prostate gland, a gland situated at the neck of the bladder. Ptyalism, salivation. Pulmonary, relating to the lungs. Puruloid, resembling pus or matter. Pus, the yellowish thick fluid or matter formed by inflammation. Pylorus, the lower orifice of the stomach. Pyrexia, fever. Pyrosis, water-brash, or the heart-burn. Q. Quartan, a periodical disease returning every 72 hours. Quotidian, daily; an ague that returns daily. ' R. Rachialgia, colic, with costiveness and vomiting. Rachitis, rickets. Ramollissement, softening. Rete mucosum, the mucous-like expansion immediately under the skin, and in which coloring matter, that constitutes the color of the surface, is deposited. Rhagades, chaps in the skin, deep fissures in the skin. Rubefacients, external applications that inflame the skin. S. Sanguiferous, conveying the blood. Sanguineous, bloody, relating to the blood. Scirrhus, a hard, degenerated, tumefaction of a gland. Sebaceous, suet-like matter. Secretion, the separation of a fluid or substance from the blood, by the action of a living organ. Secretory, vessels, or organs, that separate a peculiar fluid or sub- stance from the blood. GLOSSARY. 579 Sedatives, medicines that diminish the actions of the system. Semicupium, warm bath, the body being immersed only up to the middle. Sensorium, the brain, the centre of feeling. Serous, watery. Strumous, scrofulous. Subsultus tendinum, a convulsive, sudden twitching of the sinews. Symptomatic, the consequence of some other affection. Syncope, fainting. ' Synochal, fever of a highly inflammatory character. Synochus, fever of a sub-inflammatory character. T. Tarsus, the edge of the eyelid. Tenesmus, an ineffectual and painful urging to go to stool. Therapeutic, relating to the employment of remedies. Thoracic, belonging to the chest. Thorax, the chest. Torwina, griping pain. Tubercles, small, hard tumors, resembling cheese in their internal structure. Type, the peculiar form assumed by a fever as to the period inter- vening between its paroxysms or exacerbations. Typhoid, resembling typhus fever. U. Ureters, the tubes which convey the urine from the kidneys to tne bladder. Urethra, the canal of the penis, through which the urine is dis- charged. Utero-gestation, the term of pregnancy. Uterus, the womb. V. Vaccina, cow-pox. Vesication, blistering. THE END. \ NLM032068254