-».V*t*Vi A TREATISE \'- / PHILADELPHIA: GRIGG, ELLIOT & CO., 14 NORTH FOURTH STREET. 1849. Wl3 EJ/f-t Entered according to the Act of Congress, in the year 1845, 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. PHILADELPHIA : T. K. AND P. G. COLLINS, PRINTERS. TO GEORGE M'CLELLAN, M.D., FORMERLY PROFESSOR OF SURGERY IN THE JEFFERSON MEDICAL COLLEGE, ETC. ETC. THIS WORK IS INSCRIBED, AS AN ACKNOWLEDGMENT OF THE HIGH REGARD ENTERTAINED FOR THE POWERS OF HIS MIND, AND THE GENEROUS SENTIMENTS OF HIS HEART, BY HIS OBLIGED FRIEND, THE AUTHOR. PREFACE. In the composition of this work, an effort has been made to exhibit a distinct view of the essential phenomena and princi- ples pertaining to the various subjects which it embraces, with an especial endeavor to avoid the extremes of unsatisfactory brevity on the one hand, and of fatiguing prolixity of detail and discussion on the other. With the exception, therefore, of a few instances in the introductory portion of the work, the author has indulged but little in controversial discussion and general specu- lation. His object has been, to give a digest of facts and estab- lished principles, rather than of opinions and points of disputation. He has not, however, failed to give an exposition of those patho- logical and therapeutic principles, which appeared to him fairly deducible from the particular phenomena brought under consi- deration ; and whenever his own experience and reflections have led him to differ from others, he has freely, though he trusts with becoming deference, stated his sentiments. It will be perceived, that no general doctrine or system of pathology is exclusively or especially favored in the following pages. Medicine, as it is now generally cultivated, is strictly eclectic. The judicious and unprejudiced physician will neither condemn nor adopt unreservedly any of the leading doctrines advanced in modern times. He will see something to admire and embrace in the systems of Brown, of Cullen, of Darwin, of Broussais—and even of the fanciful Hahnemann; although when offered to his acceptance as doctrines of universal application, he may very reasonably refuse his assent. It will be seen, also, and perhaps by some regarded as a defect, that no formal classification has been adopted in the arrangement of the work. Nevertheless, the order that has been observed in the succession of the various subjects, is probably as natural as that obtained by any of the modes of systematic arrangement vi PREFACE. usually pursued in works of this kind. It is now generally, and very justly believed, that the artificial, classific, ordinal and specific distinctions of nosology have an unfavorable influence on the progress of comprehensive and philosophical views in pathology. The primary elements of disease, like those of matter, are probably but few in number. A few elementary modes of morbid action (if the expression may be used), modified in their general results or phenomena, by different grades of intensity, modes of combination and the structures implicated, constitute the fundamental morbid conditions of which the phe- nomena by which diseases are described are merely the external manifestations. It is here that the unfavorable tendency of nosological distinctions mainly exists. Instead of leading the student to contemplate the morbid symptoms as the mere external expressions or signs of disease, modified by various accidental circumstances, and especially by the structures chiefly affected, the artificial divisions of nosology are apt to lead him to regard the groups of symptoms, usually associated, as so many distinct essences, possessing fixed and specific peculiarities of character. To these objections, the arrangements founded on the particular structure primarily implicated in the disease, are not liable. It must be admitted, however, that correct and philosophical as such a classification may appear to be in theory, the attempt to reduce it to practice is attended with many very serious difficul- ties. Nevertheless, should another edition of this treatise be called for, it is the intention of the author to arrange its materials upon this plan of classification. It is not improbable that various errors may have escaped the author's attention in the course of the work; but he has no apo- logies to offer for any defects it may be found to possess; and he sends it into the world in the hope that, with whatever ble- mishes and deficiencies it may be chargeable, it will be found a useful compilation of facts and principles in pathology and practice. EDITOR'S PREFACE TO THE SIXTH EDITION. Since the death of the learned author of this work, a Sixth Edi- tion has been called for by the repeated demands of practitioners as well as students of medicine. Notwithstanding the publication of other excellent and popular works on the same subject, the credit of Dr. Eberle's Practice has been unimpaired. A larger number of copies have probably been printed and sold than of any other medical book which has been composed in this country. By well informed practitioners, this statement cannot be consi- dered as an undeserved compliment to the memory of Dr. Eberle. In sound medical learning, in judicious criticism, and discrimi- nating tact, our author scarcely had his superior. As he paid me the compliment of an unsolicited dedication, after we had ceased to be colleagues in one of the medical schools of this city, it would appear to become my duty to volunteer my services in promoting the publication of this edition, by such notes and improvements as the progress of Medical Science during the last five years may have suggested. GEO. M'CLELLAN. Philadelphia, 1845. CONTENTS. PRELIMINARY OBSERVATIONS ON THE PATHOLOGY AND ETIOLOGY OF FEVER. CHAPTER I. Page Of the Pathology of Fever in General,......17 CHAPTER II. Of the Causes of Fever. Sect. I. Of Predisposition, and Predisposing Causes, ... -36 Sect. II. Of the Sources of Morbific Causes, and their General Character, - 38 Sect. III. Atmospheric Temperature, and its relations with the Animal System, 40 Sect. IV. Of Miasmata,...........44 Of the relations of Miasmata to the Animal System, &c .... 50 Sect. V. Of Contagion,...........55 CHAPTER III. Of the General Course, Type, and Stages of Fever, .... 58 CHAPTER IV. On General Diagnosis, ..-----... 64 OF THE ACUTE DISEASES OF THE SANGUIFEROUS SYSTEM. I.—GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS INDEPENDENT OF LOCAL INFLAMMATION. CHAPTER V. Of Intermitting Feves,..........83 X CONTENTS, CHAPTER VI. Page Remitting Fever,...........10* CHAPTER VII. Yellow Fever, - -.........114 CHAPTER VIII. Continued Fever,...........120 Sect. I. The Synochal Grade of Idiopathic Fever, or Simple Inflammatory Fever,............123 Sect. II. The Synochus Grade of Idiopathic Fever,.....126 Sect. III. Typhus,............137 II.—GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS, CONNECTED WITH OR DEPENDENT ON LOCAL INFLAMMATION. CHAPTER IX. Of Inflammation in General, ...... • 153 CHAPTER X. Of the Phlegmasia of the Alimentary Canal, and its Accessory Organs. Sect. I. Of Glossitis,...........158 Sect. II. Of Tonsilitis,...........159 Sect. III. Of Parotitis,........... 151 Sect. IV. Of Acute Gastritis,..........163 Sect. V. Of Chronic Gastritis, -........166 Sect. VI. Of Acute Enteritis,..........2~j 1. Acute Peritoneal Enteritis,.......171 2. Acute Mucous Enteritis,........176 Dysentery,..........l77 Sect. VII. Of Chronic Enteritis,.....-... 187 Sect. VIII. Of Acute Peritonitis,.......- - 190 Sect. IX. Of Chronic Peritonitis,......---196 Sect. X. Of Acute Hepatitis,..........200 Sect. XL Of Chronic Hepatitis,.........207 Sect. XII. Of Splenitis,...........210 CHAPTER XI. Of the Phlegmasia of the Nervous System. Sect. I. Phrenitis,............213 Sect. II. Arachnitis,...........2i6 Sect. III. Cerebritis—(Ramollissement du Cerveau,).....225 CONTENTS. xi CHAPTER XII. Of the Phlegmasia of the Respiratory Organs. Page Sect. 1. Pneumonia,...........228 Pleuritis,............ H. Peripneumonia,..........230 Pneumonia Biliosa,..........231 Sect. II. Cynanche Laryngea. _--...... 239 Sect. III. Cynanche Trachealis,.........242 Sect. IV. Acute Bronchitis,..........252 Sect. V. Chronic Bronchitis,..........256 Sect. VI. Phthisis Pulmonalis,.........263 CHAPTER XIII. Of the Phlegmasia of the Urinary and Genital Organs. Sect. I. Nephritis,............274 Sect. II. Cystitis,............277 Sect. III. Chronic Cystitis,..........279 Sect. IV. Hysteritis,...........281 Sect. V. Chronic Hysteritis,..........284 CHAPTER XIV. Of the Phlegmasia of the Sanguiferous System. Pericarditis, (Arteritis,—Phlebitis, &c)......286 CHAPTER XV. Of the Phlegmasia of the Fibrous and Muscular Structures. Sect. I. Acute Rheumatism,..........290 Sect. II. Chronic Rheumatism,.........298 Sect. III. Gout,............303 CHAPTER XVI. Of the Inflammatory Affections of the Eyes. 1. Catarrhal Ophthalmia,.........313 2. Rheumatic Ophthalmia,........315 3. Purulent Ophthalmia,.........ib. 4. Scrofulous Ophthalmia,........319 5. Syphilitic and Strumous Iritis,.......322 CHAPTER XVII. Of the Cutaneous Phlegmasia. Exanthemata,...........324 Sect. I. Variola,............*&■ xii CONTENTS. Page Sect. II. Vaccina, -----.....- 334 Sect. III. Modified Small-pox,.........34° 1. Varioloid Affections,.........ib. 2. Varicella,...........343 Sect. IV. Rubeola, Morbilli, .........346 Sect. V. Scarlatina,...........354 Sect. VI. Erysipelas, --.......... 370 CHAPTER XVIII. Minor Exanthemata. Sect. I. Herpes, -........... 380 1. Herpes Phlyctenodes,.........ib. 2. Herpes Zoster,..........381 3. Herpes Circinnatus,.........383 4. Herpes Labialis, --........ 384 5. Herpes Praeputialis,.........ib. Sect. II. Pemphigus,...........385 Sect. III. Urticaria,...........390 Sect. IV. Miliaria,...........392 Sect. V. Lichen,............394 Sect. VI. Eczema,...........397 Sect. VII. Erythema,...........400 Sect. VIII. Roseola,...........401 Sect. IX. Purpura,...........402 CHAPTER XIX. Vascular Irritations with a flow of Blood. Hemorrhages,...........406 1. Epistaxis, - - - . - . . . . _ . 412 2. Haematemesis,..........423 3. Hematuria,...........426 4. Haemoptysis,..........428 5. Menorrhagia,........._ 422 CHAPTER XX. Phlegmasia of the Lymphatic System. Phlegmasia Dolens,......... 42f CONTENTS. x[[[ CHRONIC DISEASES. CHAPTER I. Of Chronic Nervous Diseases. Page General Observations,..........431 Sect. I. Apoplexy,...........433 Sect? II. Paralysis, --......._. 447 1. Hemiplegia, ..„.......44g 2. Paraplegia, ..........450 3. Paralysis Partialis,.........451 Sect. III. Epilepsy,...........461 Sect. IV. Catalepsy,...........477 Sect. V. Chorea,.....;.......482 Sect. VI. Convulsive Affections of Infants,.......491 Sect. VII. Hysteria, -- ........499 Sect. VIII. Puerperal Convulsions,........510 Sect. IX. Tetanus,...........513 Sect. X. Hydrophobia,...........524 CHAPTER II. Chronic Nervous Affections, in which Intellectual and Moral Faculties are Disordered. Sect. I. Mental Derangement, -.._.....534 1. Mania,...........542 2. Monomania,..........543 3. Dementia,...........545 4. Idiotism,...........ib. Sect. II. Delirium Tremens,..........551 CHAPTER III. Local Chronic Nervous Affections. Sect. I. Neuralgia,...........557 Sect. II. Amaurosis,...........570 CHAPTER IV. Chronic Affections of the Respiratory Organs. Sect. I. Asthma,............577 Sect. II. Whooping-Cough,..........586 Sect. III. Asphyxia,...........596 Sect. IV. Pneumothorax,..........604 xiv CONTENTS. CHAPTER V. Chronic Diseases of the Heart. Page Sect. I. Of the Diseases of the Heart,........607 1. Hypertrophy of the Heart,.....- - - 6*3 2. Dilatation of the Ventricles,........614 3. Aneurism of the Aorta,........615 Sympathetic Affections of the Heart,.......619 Sect. II. Angina Pectoris,..........621 CHAPTER VI. • Chronic Diseases of the Alimentary Canal. Sect. I. Indigestion,.........." 626 Sect. II. Diarrhoea,........... 638 Sect. III. Cholera,............645 Cholera Infantum,..........647 Sect. IV. Colic,.....".......655 1. Flatulent Colic,..........ib. 2. Bilious Colic,..........657 3. Colica Pictonum,..........660 Sect. V. Ileus,............666 Sect. VI. Constipation,...........669 Sect. VII. Intestinal Worms,..........671 Sect. VIII. Hemorrhoids,..........679 Sect. IX. Jaundice,...........687 CHAPTER VII. Chronic Diseases of the Urinary Organs. Sect. I. Diabetes Mellitus,..........696 Sect. II. Diabetes Insipidus,.........- 706 Sect. III. Lithiasis,...........710 1. Lithic Acid Diathesis,.........711 2. Phosphatic Diathesis,.........713 Sect. IV. Ischuria Renalis,..........717 Sect. V. Retention of Urine,..........720 Sect. VI. Dysury,............728 Sect. VII. Enuresis,...........730 CHAPTER VIII. Chronic Diseases of the Serous Exhalant Vessels. Hydrops,............734 1. Ascites,...........738 2. Hydrothorax,..........739 3. Anasarca, .......... 740 CONTENTS. XV CHAPTER IX. Chronic Affections of the Lymphatic System. Page Sect. I. Scrofula,.............753 Sect. II. Bronchocele,...........764 CHAPTER X. Chronic Disorders of the Assimilative Functions. Sect. I. Scorbutus............. 772 Sect. II. Chlorosis,...........776 CHAPTER XI. Chronic Diseases of the Sexual Organs. Sect. I. Gonorrhoea,...........780 Sect. II. Syphilis,............788 Buboes,............803 Sect. III. Amenorrhea,..........805 Sect. IV. Dysmenorrhea,......--.-810 Sect. V. Leucorrhea,..........- 814 APPENDIX. Cholera Asphyxia—Spasmodic Cholera,.......£21 Index,..............835 Glossary, - - ......... "^ t A TREATISE ON THE PRACTICE OF MEDICINE. PRELIMINARY OBSERVATIONS ON THE PATHOLOGY AND ETIOLOGY OF FEVER. CHAPTER I. ON THE PATHOLOGY OF FEVER IN GENERAL. The history of practical medicine consists of little else than a review of the doctrines which have successively risen and sunk again, concerning the nature and treatment of fever. Whatever other objects of interest or importance within the dominion of medical science may have attracted the attention of physicians, fever has at all times been viewed as presenting the most extensive and inviting field for observation and the exercise of ingenuity. It is in this department that observation and research have been most industrious in accumulating mate- rials, and that hypothesis has luxuriated in her wildest exuberance. When, indeed, it is considered that the destroying angel has made his most desolating visitations under the form of febrile epidemics, and that in the long list of human maladies, fever occurs in perhaps nine cases out of ten, the paramount importance of this subject is strongly forced upon our convictions.* From a retrospective glance over the history of our science, we are forced to acknowledge that there is, perhaps, no subject which is more eminently calcu- lated to humble the pride of human reason than this one. In relation to this subject, pathology has been in a continued state of revolution and instability. The human mind has been engaged with it for near three thousand years. Theories have risen and sunk again in a continued and rapid series of succession; each has had its hour " to strut upon the stage," and its votaries to yield it faith; * "If we except," says Van Swieten, " those who perish by a violent death, and such as are extinguished by mere old age, and which are indeed few, almost all the rest die either of fever, or of diseases accompanied with fever. We read in Pliny with what fear and trembling the Romans endeavored to have this universal disease—fever, appeased by their supplications in the temple of Fanum; and hence, perhaps, it is, that fevers are called diseases by Hesiod, and that Horace calls all diseases simply fevers, when they rushed out of the box of Pandora— » ' Post ignem aetherea domo Subductum, Macies, et nova febrium Terris incubuit cohors.'" Van Swieten's Com., vol. v. p. 1. 2 18 GENERAL PATHOLOGY OF FEVER. but the stream of time has hitherto overturned all these unsubstantial, though often highly wrought fabrics. Has the mind then made no real advancement in relation to the pathology of fever? Are we now no nearer correct and rational views concerning this import- ant subject than were our forefathers? Has genius always wandered in idle quest, antl brought back no substantial trophies from#the regions of pathological speculation on this point? Far from it. Like the asymptotes of the parabola, the human mind is continually verging towards truth, although it may never reach it in relation to the essential nature of fever. There has probably never been a theory or doctrine promulgated on this subject, which did not clear away some old rubbish, or bring to fuller view some of the relations of the phenomena it presumed to elucidate. The dreams of speculation have vanished; but the facts and correct principles which were necessarily mingled with them, remain as so much valuable treasure saved out of the wrecks of former systems. The mass of solid materials which has been thus gradually accumulated, has now in a great measure displaced those vague and hypothetical foundations upon which former doctrines in relation to this subject were constructed. Hypothesis is no longer tolerated in science. Philosophy does not acknowledge her as a legitimate ser- vant. The cyclus of her empire has gone by; and the genius of rational induc- tion is now the only power under whose direction the votary of science presses forward to conquest in the field of knowledge. Like many other things which are at once obvious to the senses, and concern- ing the existence of which almost every one can decide, fever does not admit of a strictly correct and unobjectionable definition ; since there is not a single symp- tom which is invariably present, and which can be regarded as absolutely essen- tial to its existence. Boerhaave collected together, from a great number of authors, all the symp- toms which had been observed in fevers. He then struck from this list all those symptoms which did not appear in all, but only in certain modifications of fever —retaining such only as, by the common consent of authors and his own obser- vations, were found to be present in every instance of fever. The result was, that only three symptoms were left standing—namely, a quick and frequent pulse, preternatural heat of the surface of the body, and a sense of cold or chilliness in the commencement. But he might have gone farther, and struck from his list these symptoms also; for it is quite certain that cases of fever do occur in which there is neither preternatural quickness and frequency of the pulse, nor an increased temperature of the surface of the body; nor is a sense of chilliness, tliough perhaps the most constant of all the febrile symptoms, universally present in the initial stage of fever.* Notwithstanding the great difficulty, or rather impossibility, of giving a strictly unexceptionable scientific definition of fever, yet the train of phenomena which this state of disease presents under all its modifications—varying more or less in their concomitance and succession—offers, upon the whole, a character suffi- ciently distinct and definite for easy and certain recognition. Pathologists have divided fevers—according to the mode of their development —into idiopathic and symptomatic, and the propriety or impropriety of this divi- sion constitutes, at the present day, one of the most important and warmlv con- tested subjects in pathology. By the former class, are understood those 'fevers that are developed and sustained by causes which produce a general morbid state of the system, independent of local inflammation or fixed irritation. Those * [In malignant epidemics patients often die in the forming stage of disease before febrile reaction is mamfested Nevertheless the case is pronounced nTbe o'ne of thTpe^g fever! Congestive fevers are described by many authors in which there was never any development of external heat or ex.-itement of the pulse. It is questionable, however, whether hiTno TJTrlT T -aPP Tr^ the ^^V If 6Very COndUi°" that P"^ or accom, anTes a Ln o?noi o^-M t " ^ ^^ th6re ^ ^^ te U° °C" f" *e eXten" GENERAL PATHOLOGY OF FEVER. 19 who admit the existence of such fevers, suppose that the remote febrific cause produces a deleterious impression on the sentient extremities of the part upon which it acts, which, deranging function after function, according to the catena- tion of the organic sympathies, finally results in a state of general disease, cha- racterized by the ordinary phenomena of fever: or, as they presume, (he remote cause may gradually change the healthy character of the circulating blood, which, acting as a morbific irritant on the heart and arteries, gives rise to febrile reaction. Many eminent pathologists, on the contrary, contend that such fevers can have no existence ; and that all febrile excitement is purely symptomatic, and of course essentially and wholly dependent on a pre-established local irritation or inflam- mation. According to these views, the direct influence of the remote cause of fever is limited to the production of the primary local inflammation or irritation, the subsequent pyrexial phenomena being the result solely of this primary local affection ; in other words, the secondary and sympathetic excitement of the pre-established focus of irritation. At the head of those who advocate the exclu- sive symptomatic nature of fever is Broussais, who, whatever may be thought of his peculiar doctrines in relation to this subject, has manifested a professional zeal, and an activity and acuteness of intellect which have justly placed him high among the " greater lights" of our profession. Not satisfied, however, with the adop- tion and defence of the general doctrine of the universality of symptomatic fever, Broussais contends that the inflammation or irritation whence the febrile sympa- thies radiate as from a focus, is almost universally located in the mucous mem- brane of the alimentary canal; and hence gastro-enteritis is with him the Jons et origo of febrile phenomena. That fever is a very common result of local inflammation, is unquestionable. So intimate are the sympathetic relations between all the various parts of the animal body, that no structure or organ can be strongly irritated without causing a sympathetic irritation in other organs or structures. If the primary irritation involve the sanguiferous capillaries, the irritation will be communicated by sym- patic to the general vascular system, and fever will be the result; but if the local irritation be purely nervous, it will be diffused, and as it were locked up in the general nervous system, and give rise to convulsions, or some other form of general nervous affection. Without doubt, too, inflammation of the mucous mem- brane of the alimentary canal is much more common in febrile diseases than was formerly, and by many, is still supposed. It is even probable that in many instances of fever, such an inflammation constitutes the primary and essential cause of the febrile phenomena. This is, perhaps, most apt to be the case in those instances of fever which result from the combined agencies of impure and indigestible diet and atmospheric vicissitudes. But although we may admit the correctness of these observations, yet to refer all fevers, remitting, intermitting, and continued, to gastro-enteritis, is as remote from truth as it is detrimental in its influence on practice. The advocates of the physiological doctrine, as it is called, endeavor to sup- port their sentiments in relation to this subject, by the phenomena detected on post-mortem examination, and by arguments founded on physiological principles. It is affirmed that marks of inflammation almost universally occur in the mucous membrane of the alimentary canal, in subjects that die of febrile affections. The capillary vessels, to a greater or less extent, of this membrane, it is said, are found injected ; and in many instances other and less equivocal traces of previous inflammation are discovered. Admitting that such manifestations of inflamma- tion are as universal as they are asserted to be, is there not much reason to be- lieve that, very frequently at least, the inflammation supervened during the course of the disease, as a consequence of the fever, rather than that the inflammation was pre-established, and became the immediate exciting cause of the febrile phe- nomena ? We frequently see inflammations supervene in parts exposed to obser- vation many days after general fever has been fully established. Indeed, when it is considered that in all febrile affections, the secretions which are poured-into 20 GENERAL PATHOLOGY OF FEVER. the intestinal tube are unnatural and vitiated—that the process of digestion is suspended, or much impaired, and consequently, that fermentation and decom- position of the contents of the stomach and bowels are especially favored—is there any cause to wonder that we should so often meet with traces of inflamma- tion in the digestive organs in those who die of febrile affections ? The Brous- saian mode of treating fevers, although especially meant to obviate such inflam- mations, appears to me, in one respect, well calculated to favor their occurrence. The almost total proscription of purgatives from the list of our remedial means for the treatment of fever, so far from lessening the tendency to gastro-enteritis, tends, I conceive, in general, to an opposite result. In a recent work by Bouil- laud, there are upwards of sixty cases of fever reported, in not a single instance of which was there a purgative medicine administered by the mouth. In all of these cases, however, marks of inflammation, and, in the majority, ulcerations were detected in some portion of the mucous membrane of the bowels. That this should have been observed, will not appear strange, when it is considered that in all the cases, most of which continued from three to four weeks, all the acrid and vitiated contents of the intestines were suffered to remain, undisturbed, to act on their delicate lining membrane. To one not thoroughly imbued with Broussaism, it does appear strange that any one should withhold a laxative, under the apprehension of its causing in- jurious irritation, and yet suffer, without any such fears, the most irritating sub- stances to lie quietly in the bowels. It is true, laxative lavements were repeatedly resorted to in these cases, but that these did not disturb or remove the acrid materials which were enclosed in the bowels, is abundantly manifest from what Mr. Bouillaud himself has stated. After having gravely told us that in all the cases he describes, the traces of mucous inflammation in the bowels were tres prononce, he states that " in general the stomach and small intestines were filled with a yellowish or greenish bile, and that the residue of the alimentary sub- stances, which were found in the small and large intestines, invariably exhaled an intolerably fetid smelt, and frequently exhibited the consistence of mustard. This residue, mixed with various fluids secreted in the intestines, appeared to have undergone a complete process of putrefactive decomposition, as was evi- dent from the extreme offensiveness of the smell, and the fetid gas which dis- tended the boivehy* Can it be reasonably supposed that the transient and moderate irritation of a purgative in these cases would have been more injurious than the constant im- pressions of the acrid and irritating substances which were so long left in imme- diate contact with the bowels? It is thus, it can hardly be doubted, that many instances of gastro-enteritis, so abundant in the practice and dissections of the Broussaian school, are developed. Were laxatives employed with due modera- tion, it is probable that the so much dreaded gastro-enterite would, in some instances at least, perhaps in many, be prevented, and the world deprived of a large proportion of those triumphant demonstrations which are continually brought out in formidable array in support of the physiological doctrine. As a further offset to the evidence adduced from post-mortem examination, it must be observed, that so far as the mere redness or injected state of the mucous membrane is concerned, we can draw no certain inference as to the previous ex- istence of inflammation in this structure. That these phenomena are frequently the result of changes effected in articulo mortis, or post-mortem, is fully demon- strated by the observations of Mr. Yellowly and of Mr. Seeds.t * Traite Clinique et Experimental des Fievres. Par J. Bonillaud Pari* 1S26 + "^ ™«« have happened to every one,': says the lormer of these writers'"accustomed to he exam.nation of dead bod.es, to see appearances of vascular injection in the vlnouicoa of he stomach buch appearances have very frequently been referred to inflammation bm they have probably been but little studied. I have several times been present at tne^xammaJon of bodies, wl ere the vascularity of the villous coat of the stomach was so con iderable a even to give rise to suspaons that the appearance had been produced by something^ delete !oUS. 1 was GENERAL PATHOLOGY OF FEVER. 21 Broussais and his followers are, indeed, fully sensible of the observation of Celsus : Neque quicquam esse stultius quam quale quid vivo homine est, tale cxistimare esse moriente imo jam mortuo ; for where they fail in detecting a red and injected state of the mucous membrane of the bowels, they account for its absence by ascribing it to a post-mortem change; thus availing themselves of this fact when it affords an argument in their favor; whilst they manifest an unwillingness to allow any importance to it when it is adduced against their doctrine. It cannot, indeed, be presumed that the injected state of the mucous membrane S)f the intestinal tube, so often discovered in those who die from fevers, is always, or even generally, to be ascribed to a mere post-mortem change; but that such changes do sometimes, nay, often occur, and that they have been assumed as evidences of previous inflammation, there can exist but little doubt. The first obvious effect of the remote febrific causes, consists almost universally in a diminution of the nervous energy, and consequently of the action of the heart and arteries. This is manifested by the weak and contracted pulse, the general languor and lassitude, the diminished temperature and the sense of chilliness which usher in all febrile affections. These initial phenomena of fever are especially conspicuous in intermittents, remittents, and in catarrhal affections. There is nothing in the character of these symptoms which can justify the in- ference that they are dependent on inflammation. " Inflammation," says Dr. Armstrong, " cannot exist in the cold stage of fevers, all the phenomena of which are directly opposed to inflammation." The course and phenomena of inter- mitting fevers present us, indeed, with insurmountable objections to the "physi- therefore induced to embrace frequent opportunities of viewing the state of the inner surface of the stomach, and I so often found in it the appearances alluded to, as to induce me to imagine, that the opinion which is commonly entertained of their being marks of disease, is not well founded. In persons suddenly destroyed, when apparently in perfect health, he found the mucous membrane of the stomach highly injected." Mr. Seeds, too, found that in animals bled to death, the membranous structures frequently exhibit a state of injection which might, at first sight, be readily mistaken for inflammation. It is well known that the arterial tubes possess a power of contracting to a considerable ex- tent, by what Bichat calls the contractility of texture, and that this power is not limited to the period of life, but continues some time after death. It is equally ascertained that the capillaries are endowed during life with a peculiar degree of sensibility which causes them to resist the entrance of such fluids as they are not destined to convey in the performance of their natural functions. This peculiar sensibility, by virtue of which the serous capillaries refuse, or contract against the intromission of red blood, would seem to depend on the regular influx of the nerv- ous influence. That this is the case, appears highly probable, if hot certain, from the different* results arising from the forcible injection of fluids into the arteries of living and dead animals. "Push into the aorta of a living animal, by means of a syringe, different fine fluids, and you will never see them fill the capillary system, or issue by the exhalents;" when, however, the same experiment is performed on an animal soon after death, the fluid will be found to pass readily into the serous capillaries, and pass out by the exhalents, excretory ducts, &c. (Bichaf). Mr. Buniva's experiments, quoted by Bichat, with injections upon dead and living animals, illustrate this fact in a very striking manner. He fixed the pipe of a syringe into an artery of a living animal; on endeavoring to force the fluid into the vessel he found very great resistance, the piston passing down very slowly, and only with the application of much force. On causing the animal to be suddenly killed, by dividing the spinal marrow just below the occiput, the fluid passed rapidly out of the syringe into the artery, although but little force was applied. While the capillaries retained their full portion of vitality, they resisted the introduction of the fluid; but as soon as they had lost their sensibility, in the death of the animal, they yielded like passive tubes to the fluid forced upon them by the vis a tergo. The application of these facts to the post- mortem production of a red and injected state of the membranous structures, especially the more vascular ones, is easily to be understood. So long as the serous capillaries retain their vitality, they resist the entrance of red blood into them. As soon, however, as their vital properties cease to exist, they lose the power of resisting the intromission of red blood—becoming, in fact, mere passive and yielding tubes. But as the arteries continue to contract on their contents, some hours after the extinction of life, they must necessarily force the blood forward into the relaxed and unresisting capillary system, into which it will therefore be driven, as into a sponge, and give to the more vascular structures the red and injected state so often found on post-mortem examination, where no previous inflammation whatever existed 22 GENERAL PATHOLOGY OF FEVER. i ological doctrine" The periodicity of these fevers is strongly opposed to the idea of their immediate dependence on the gastro-enteritis. It is, indeed, true, that affections of an inflammatory character have been known to recur in a strictly periodical manner; but such cases must be viewed as anomalies, and altogether contrary to the almost universal course and character of phlegmasial diseases. An inflammation which observes a perfect periodicity in its attacks, must be sui generis. If intermitting fever depend on inflammation of the mucous membrane of the alimentary canal, then must this inflammation be periodical, and therefore essentially distinct from the inflammation which produces remitting fever; for in this malady it must be continuous. These two forms of fever are, however, produced by the same remote cause ; and we are therefore forced to admit, by the assumption of this doctrine, that the same remote cause is capable of produc- ing two kinds of inflammation essentially distinct from each other. The cha- racter of the remedies, too, which have been found most effectual in arresting intermitting fever, is directly opposed to the idea that gastro-enteritis constitutes its proximate cause. Who can believe that quinine, arsenic, black pepper, and other remedies of a similar character, are peculiarly calculated to cure inflamma- tion of the mucous membrane of the alimentary canal ? Indeed, these very articles appear to be particularly dreaded by the disciples of this doctrine, on account of their tendency to create gastro-enteritic irritation, and yet all experience goes to prove that they are decidedly the most prompt and valuable means for the cure of intermitting fever. M. Broussais's theory of the mode in which the remote causes of febrile affec- tions produce gastro-enteritis is gratuitous, and but little calculated to satisfy the understanding. " Every irritation," he says, " which is capable of producing a perception in the brain, passes back by the nerves to be repeated in the mucous membranes.'''' Thus, if a person be inoculated with small-pox virus, the irritation of the primary pustule, or of the inoculated point, is conveyed to the brain, whence it is reflected by the nerves upon the mucous membranes of the ali- mentary canal, where it establishes an inflammation. This intestinal inflamma- tion constitutes the essential cause of eruptive fever, and the eruption itself is only a metastatic disorder of the cutaneous system. The assumption, then, " that every irritation which is capable of producing a perception in the brain, is reflected by this organ to be repeated in the mucous membranes of the aliment- ary canal," forms the main principle in the Broussaian doctrine of the etiology of fever. That the mucous membranes of the intestinal tube possess a very wide sphere of sympathetic relations, is a fact indeed as undeniable as it is important in a pathological point of view. But that this structure constitutes a subordinate sensorium commune, to which all morbific impressions are especially conveyed, after having been perceived by the brain, is a position which all the zeal and in- genuity of its advocates have as yet failed, and I apprehend will ever fail, to place upon that firm basis which it ought to have to serve as a foundation of our patho- logical faith. I do not mean to object to the general fact, that all impressions capable of ulti- mately exciting fever, are in the first place communicated to the sensorium com- mune, and thence reflected throughout the system, and sometimes upon some particular organ or structure ; but this reflected impression does not, it may be justly maintained, necessarily establish a focus of irritation, nor always, or even generally, fall especially upon the intestinal mucous membrane. If the impressions of morbific causes are always transferred to the mucous membrane of the alimentary canal, the impressions of all agents, remedial as well as others, must of course be referred to the same structure. This, however does not accord with the results of observation. When mercury is rubbed on the skin, the salivary glands, the gums, and the mucous membrane of the mouth, receive the chief impressions excited by this agent. Will it be contended that a gastro-enteritis must be established before salivation can be produced? If opium be applied to any part of the body, the impressions are concentrated in the nervous GENERAL PATHOLOGY OF FEVER. 23 centre. When cantharides are applied to the surface, the irritation is conveyed to the neck of the bladder, and not to the mucous membrane of the bowels, and yet fever may be the result. From these and many other similar facts that might be adduced, it is manifest that the supposed law of the animal economy, by which, as is alleged, all febrific impressions are reflected from the brain and repeated in the mucous membranes of the bowels, is gratuitous, or to say the least, highly improbable. The fallacy of those doctrines which confine the primary inflammation to some one structure exclusively, is strikingly illustrated by the circumstance, that differ- ent writers have fixed on different structures, as the parts primarily affected in fevers. Thus Clutterbuck maintains, with Broussais, that fever is always a purely symptomatic affection depending on local inflammation pre-established by the febrific cause. He asserts that this primary inflammation is invariably located in the brain and its membranes, and adduces the phenomena discovered on post- mortem examination, in testimony of the correctness of his doctrine. Broussais, on the other hand, asserts that the primary inflammation is not in the brain, but in the mucous membrane of the bowels, and appeals with equal confidence to the appearances exhibited on dissection for confirmation of his doctrine. This discrepancy is in itself sufficient to show the weak foundation on which these two doctrines rest; for if the evidence afforded by autopsic inspection in relation to this subject were not extremely ambiguous, it would, one may suppose, be impossible to draw from it conclusions so very discrepant, and yet so nearly equal in point of plausibility. The advocates of the gastro-enteritic pathology of fever place no inconsiderable reliance for support to their doctrine on, what they are pleased to assert, their superior success in their remedial management of fevers. Leeches, and an almost total abstinence from food, with cooling, acidulated, mucilaginous drinks, constitute nearly the whole of their remedial applications; and they claim for this mode of treatment a greater success than that which they allow to others who pursue a more active course of treatment in fevers. It does not appear, however, that the golden age of medical success, so confidently promised by Broussais, on the introduction of his doctrine, has as yet arrived;* for the state- ments which have been published in France, in reference to the comparative mortality under the Broussaian, and the other modes of treatment, give no sup- port to the claims of superior success set up for the former. We might, however, admit the excellence of the Broussaian mode of treating fevers, without yielding our assent to the correctness of the doctrine that the gastro-enteritis is primary where it does exist. There exists but little doubt in my mind, that in continued and remitting fevers, active purgation is not unfrequently carried to an injurious extent; for, although we may, and, as I conceive, ought, to reject the opinion that such fevers depend essentially on the gastro-enteritis, yet we cannot doubt, that a very considerable degree of irritation, amounting in many instances to in- flammation, does often supervene during the progress of the disease, as an epi- phenomenon, and unconnected with the origination of the fever. In cases where such a condition of the mucous membrane of the intestinal canal occurs, during the course of the disease, the soothing treatment recommended by Broussais, is no doubt more salutary than the vigorous purgative plan so commonly pursued in this country and in England. Unquestionably, intestinal irritation and inflam- mation perform an important part in febrile diseases. These conditions may * In 1821, Broussais asserted "that the tables of mortality declare in favor of the new doctrine, and that its influence upon population would be more favorable than that of the introduction of vacci- nation." Uniortunately, however, this happy influence of the nouvelk doctrine remains yet to be realized ;"j" and the advocates of the doctrine may console themselves lor the tardiness of this influence, with the certain prospect of not being very soon deprived of the opportunity of pub- lishing their ordinary quantum of post-mortem examinations. V t Refutation de la Doctrine de M. L. Doct. Broussais, par L Castel. 24 GENERAL PATHOLOGY OF FEVER. arise as consequences of the general febrile reaction, as well as from harsh and repeated purgation, and the use of other irritating remedial agents. But it is equally probable that gastro-enteritis is often excited by acrid and vitiated secre- tions, and other offensive materials retained in the bowels in consequence of withholding suitable laxatives, in the commencement and during the progress of the malady. Broussais has done much good, by awakening the attention of the profession to these pathological conditions; and thus furnishes another proof of the fact, that new doctrines, though fundamentally erroneous, seldom fail to do some good, by directing the views of physicians to important circumstances, which were previously overlooked, or too much neglected. In leaving this subject, I deem it right to observe, that however widely we may differ from Broussais in relation to the pathology of fever, all must admit that he has just and high claims to the respect and gratitude of the profession for the light which he has thrown on the nature, symptoms and treatment of mucous intestinal inflammation, as well as on the physiological and morbid sympathies of the animal system. Broussais is unquestionably one of the most enlightened and ingenious patho- logists of the present day. His is now the only general doctrine which espe- cially occupies the attention of the profession. Like all the preceding great doc- trines in medicine, it is destined, perhaps, to culminate for a while in the firma- ment of our science, and to attract its host of worshipers; but, assuredly, sooner or later it must sink again, and add another to the long list of once highly-favored, but now exploded and neglected doctrines. That the Broussaian system contains much that is valuable, it would be unjust to deny; but to these concessions in its favor, there are, unless the majority of competent judges greatly err, offsets of no small moment. In relation to this doctrine, as indeed to every one else, it behooves us to embrace the useful and reject the false; in short, to adopt the good advice of Lucretius,* "-------------doctrinam acri Judicio perpende; et si tibi vera videtur Dede manus—aut si falsa est, accingere contra." Having now given a summary of the principal objections which may be urged successfully, I conceive, against the " new physiological doctrine," I proceed to an exposition of the following propositions, as embracing the leading, and it is believed, tenable points of doctrine, in relation to the mode of origin and charac- ter of febrile diseases. 1. Fever is a general disease—the sanguiferous system being essentially and predominantly disordered. 2. The morbid vascular excitement of fever is located, essentially, in the * [Clutterbuck's opinion, published in 1807, gave origin to the doctrine that fever is not a primary affection, but essentially a local inflammation, the seat of which is in the brain. Frank of Vienna, attributed fever to an inflammation of the arterial system; and some of the Italian physicians extended the same idea to the inner coat of the vena porta. The advocates of the non essential doctrine of fever, however, have chiefly proceeded on the foundation of Broussais. As often as they have been able to detect any trace of morbid alteration of structure in the intestinal canal, after the termination of a fever, they have attributed the general disorder to a local cause. It had long been known that the glands of Peyer and Brunner, in the mucous coat of the small intestines, were liable to inflammation and even ulceration. But it was reserved for the celebrated Louis, of the Hotel Dieu, in Paris, to discover that such a condition of these small glandular follicles, especially the conglomerate ones, was the true cause of one of the most frequent forms of fever. The progress of pathological anatomy has unquestionably developed new and important facts; but we may doubt whether it has not of late given a wrong direction to medical inquiry. Effects and concomitant phenomena are perpetually mistaken for causes. It would not surprise us if some writer should come out with the doctrine that cutaneous erup- tions and scabs, and that buboes and carbuncles, are the true causes of the small pox and plague.—Mc] GENERAL PATHOLOGY OF FEVER. 25 capillary system of blood-vessels—consisting in irritation, and not in mere in- creased or decreased action. 3. This irritated excitement may be the result of morbific causes acting direct- ly on the internal surface of the sanguiferous system ; or, of irritating impressions conveyed sympathetically to this system, from a primary focus of irritation. 4. The first link in the chain of morbid actions, which occur in the develop- ment of fever, always commences in the nerves. 5. The remote or exciting causes of fever rarely produce local inflammation, anterior to the development of the general febrile reaction. Their action is con- fined to the production of morbid impressions on the nerves, which passing inwards to the brain, usually cause a temporary depression of its energies, and consequent disturbance in the equilibrium of the nervous and vascular excitements ; at the same time that the morbid impressions reflected by the brain throughout the system, contribute to the functional disturbance and irritation of certain inter- nal organs or structures. 6. Although local inflammation is not essential to the production and support of fever, yet, in many instances of idiopathic or general fever, more or less in- flammation supervenes, after the febrile reaction is established ; and occasionally the development of the febrile excitement and local inflammation is effected simultaneously. 7. Inequilibrium of excitement, and local determinations of blood, constitute an important characteristic of fever ; for, although strictly a general malady, there are always some organs or structures in a state of increased morbid excitement,^ whilst, at the same time, others are in an enfeebled, languid or torpid condition. In stating that fever is a general malady, it is not presumed that every struc- ture of the organization is in a state of actual disease ; but as the nervous and vascular systems are so intimately concerned both in the composition and func- tions of every part of the body, it may well be inferred, that where these two systems are in a morbid condition, as they manifestly are in fever, every other irritable and sensible structure must suffer more or less functional derangement. Nevertheless, it cannot be questioned that the essential morbid excitement, which constitutes fever, is located in the sanguiferous system. The disordered action of the heart and arteries—the increased temperature of the body—the altered state of the secretions—the morbid appearances on dissection—and, in most instances, the changed state of the blood, afford sufficient evidence of the para- mount disorder of the blood-vessels in febrile affections. The morbid vascular action of fever is an irritated and not a mere increased action of the heart, arteries and capillaries. There exists a wide difference between irritation and mere excitation. The former is the result of stimuli acting either directly or indirectly upon an organ or structure, whose vital properties are in a deranged or morbid condition ; and is therefore always essentially connected with a disordered state of the nerves of the part affected. This result is not simply a greater or less degree of the natural or healthy excitement, but an action or excite- ment essentially morbid or distinct from healthy action. Mere excitation, or in- creased action, on the other hand, is the result of stimuli acting on an organ or system whose vital properties remain in a healthy or underanged condition. A few ounces of alcohol, for instance, will cause a high degree of arterial action in an individual not accustomed to this stimulus; and the same effect will be produced by any sudden and violent bodily exertion, as running, rapid walking, &c. Here, then, there is increased action of the heart and arteries, with an augmented state of the animal temperature ; but this does not constitute fever. The vital properties remain in their normal condition, and the organs thus inordinately excited, return to their natural and healthy grade of action, as soon as the exciting cause ceases to act. As, however, all excessive action tends to weaken, and finally to derange the vital properties of the over-excited parts, so, when such stimuli are very pro- tracted in their influence, they may, at last, disorder these properties and give rise to fever. Without such a derangement or morbid condition of the sensibility 26 GENERAL PATHOLOGY OF FEVER. and irritability of the heart, arteries and capillaries, no fever can occur; for so long as the vital properties are in their natural state, all irritants or stimuli can produce only a greater or less degree of normal excitement, and the secretions will be diminished or increased, but not depraved. As soon, however, as these properties have departed from their healthy condition, every stimulus, whether natural or morbific, must necessarily excite morbid actions. Hence, it may be concluded that every cause which produces fever, in whatever way its influence may be conveyed to the sanguiferous system, must necessarily derange its vital properties, either directly or indirectly, before that general irritated vascular action which constitutes fever, can be established. It is evident, therefore, that although the characteristic phenomena of fever depend on morbid action of the heart, arteries and capillary vessels, the nerves also are essentially and primarily disordered in febrile diseases; for irritation, as has just been observed, necessarily implies a morbid or deranged condition of the vital properties, and it cannot be doubted that, so far, at least, as the capil- lary system is concerned, these properties are derived immediately from the nerves. From a careful analysis of the phenomena of fever, it would appear that, although the sanguiferous system, generally, is prominently disordered in fever, yet the essential febrile excitement is especially located in the capillary system of blood-vessels. Fever cannot exist without capillary irritation or derangement of the secretory and excretory functions. So long as the capillary functions remain free from morbid excitement, or the principal secretions continue to be performed in a healthy manner, no increased action of the heart and arteries can constitute fever, but only an over-excited state of these organs, which will subside when the exciting cause is removed. A person who is thrown into a violent gust of passion, experiences vehement action of the heart and arteries ; but unless the capillary vessels are brought into a state of morbid excitement, or irritation, it will not be fever, but simple super-excitation.* On the other hand, manifest disorder in the action of the heart and arteries, does not appear to be essential to the existence of fever. Fevers of the most malignant and fatal character— attended with unequivocal manifestations of capillary disorder, such as hemor- rhage, petechia? and inflammation, not unfrequently occur, in which no obvious deviation from the natural action of the heart and arteries can be detected. Dr. Smith, in his very valuable treatise on fever, observes, that the order in which the morbid actions which constitute fever, occur, "is, first, derangement in the nervous and sensorial functions; this is the invariable .antecedent: secondly, de- rangement in the circulating function ; this is the invariable sequent: and thirdly, derangement in the secreting and excreting functions : this is the last result in the succession of morbid changes. Derangement in the functions of secretion and excretion never comes first in the series: derangement in the nervous and sensorial functions never comes last in the series.: derangement in the function of the circulation never comes either first or last in the series, but always the second in succession." That derangement of the nervous system constitutes the initial link in the chain of morbid actions which occur in the development of fever, cannot be doubted. The mental and muscular languor—the general malaise and uncomfortable sensa- tions—the pains in the loins and extremities—the morbid sensibility to low tem- perature— the dejection and irritableness of temper, and the confusion and weakness of the intellectual powers, which so universally usher in febrile dis- eases, afford unequivocal evidence of pervading derangement in the nervous system. In relation to the subsequent order of the morbid changes which supervene in * Some of the sentiments stated in this chapter, do not differ materially from those given by Dr. Southwood Smith, in his interesting work on fever. The views here given, whether correct or incorrect, I have taught in my public lectures ibr seven years past. GENERAL PATHOLOGY OF FEVER. 27 fhe development of fever, however, we cannot adopt the sentiments expressed by Dr. Smith. The assertion that the heart and arteries are universally and neces- sarily deranged, next in order to the primary disorder of the nervous system, and before the capillary or secretory extremities of the blood-vessels are brought into a state of morbid excitement, appears. I think, contrary both to correct physiolo- gical principles, and to the results of observation. It is well known that the extreme vessels, the secreting capillaries, are incomparably more closely con- nected with, and dependent for their functions on, the nervous system, than the heart and larger blood-vessels. It is scarcely necessary to refer to the experi- ments of Wilson Philip and other modern physiologists in support of this obser- vation. From this physiological principle alone, then, we would be led to infer, that the extreme vessels—those which are immediately, or at least very intimately, concerned in the process of secretion and calorification—would be the first to suffer derangement of function from general morbid excitement of the nervous system. That capillary derangement is, in fact, the immediate sequent of the primary functional disturbance of the nervous system in the evolution of fever, appears to me sufficiently demonstrated by the phenomena presented in the forming stage of the disease. Who does not know that torpor of the cutaneous exhalents is one of the most common initial symptoms of fever? This function is frequently prominently deranged, before any manifestations of the morbid action of the heart and arteries can be detected. When kiono-miasmata acts slowly upon the system, we often find, along with the above-named symptoms indicative of disordered nervous excitement, decided evidence of functional de-^ rangement of the liver, as well as of the perspiratory vessels. The utter ground- lessness of Dr. Smith's sentiments on this point, may, indeed, be predicated on the simple circumstance, that it has led him, necessarily, to deny, that pneumo- nia, hepatitis—in short, all the affections embraced under the general term phleg- masia, are fevers! Believing, as lie does, that the order of morbid changes, from the nerves to the heart and arteries, and finally, to the secretory capillaries, is universal, and as invariable as the laws of nature, he is, of course, obliged to deny the name of fever to the general sympathetic phenomena which occur in consequence of local inflammation—for in these symptomatic fevers the succes- sive morbid changes occur, he says, in a different order. " Febrile diseases," he observes, " are commonly divided into idiopathic and symptomatic—a division which is liable to the fundamental objection, that the diseases included under the second head are not fevers, but inflammations. There are no fevers but idio- pathic fevers.'''' And the reason why the general symptoms of the phlegmasia do not constitute fever is, he says, because *' in pneumonia, in enteritis, in hepa- titis, &c, the spinal cord and the brain are never the organs in which the first indications of disease appear; the earliest indications of disease that can be dis- covered, having their seat in the affected organ itself, and it being only after the disease has made some progress, that the other organs (the heart and arteries, and the brain) and functions are involved." Ingeniously as Dr. Smith has argued upon this subject, very few, it may be presumed, will agree with him in denying that the general morbid actions arising from local inflammation, are truly and essentially febrile. In truth, however, the alleged diversity in the order of the morbid changes of idiopathic and symptomatic fevers, has no existence. Local inflammation, like every other exciting cause of fever that does not act directly on the heart and arteries, can affect the general system only through the medium of the nerves; and hence, we almost invariably find the same train of symptoms accompanying the rise of fever from inflammation, as is known to usher in idiopathic fever. What do we observe when fever comes on from a wound ? The patient, at first, experiences some degree of febrile languor—accom- panied with a sense of slight chilliness, malaise; and derangement of the exha- lent functions of the skin. These symptoms, though often so slight and transient as to be scarcely perceptible, invariably precede the occurrence of the febrile reaction of the heart and arteries ; and hence the order of sequence in the morbid 28 GENERAL PATHOLOGY OF FEVER. actions, which take place in the development of symptomatic fever, does not differ from that which obtains in idiopathic fever. The nerves always receive the first shock and morbid change. This speedily gives rise to more or less con- spicuously deranged action of the secretory capillaries—and finally the heart and arteries are morbidly excited. While Dr. Smith, more confidently than prudently, asserts that " there can be no fever but idiopathic fevers," Broussais and his disciples assert, that " the ex- istence of idiopathic fever is impossible." Such are the contradictory extremes to which theory is apt to lead the understanding! That fever may occur both with and without local inflammation, may be disputed by theorists, but cannot be doubted by those who observe diseases with unbiased judgments, in the light of common sense. It must, indeed, be admitted, that local irritation or local morbid action invari- ably occurs, as the initial morbid condition, whence the series of consecutive deranged actions in the evolution of fever have their origin. This admission does not imply a concession in favor of the Broussaian doctrine, since it is predicated, in part, on the demonstrable position that the local morbid excitement is not unfrequently located in a greater or less extent of the lining membrane of the blood-vessels themselves, and produced by irritating agents admitted into the cir- culation from without, or by retained recrementitious elements acting directly on the internal surface of the sanguiferous system.* It appears to me that there is no pathological fact which is more susceptible of satisfactory illustration, than that fever frequently arises from morbific causes acting immediately on the sanguifer- ous system, and establishing a primary irritation in a greater or less extent of its internal lining membrane. Without denying the all-pervading influence of that principle of the living system, called sympathy—or still more comprehensively, without denying that all the phenomena of life, whether of health or disease, are but so many mani- festations of the action of the living solids, it is a truth equally undeniable, that the blood may and does frequently serve as the medium through which deleterious agents act immediately on the heart and arteries, and thus give rise to febrile phenomena. " The venous system," says Bichat, " may be regarded as a general reservoir, into which are poured all the materials which are to be thrown out of the body, and all those which are to enter it. In this last respect, this system of vessels performs an essential part in the production and support of diseases. The deleterious substances may be introduced into the blood-vessels with chyle, and produce ravages in the system in circulating with the fluids. There can be no doubt, moreover, that, besides the principles which convert the venous into arterial blood, there often passes through the lungs into the circulation, deleterious miasmata, which produce diseases, as my experiments on asphyxia have proved. The intestines, the lungs, and the skin are the three avenues through which the morbific agents may gain admission into the circulation."t That foreign substances are readily taken up by the absorbents and veins, and conveyed into the circulation in an unassimilated state, is now no longer a sub- ject of doubt or dispute. It appears to me highly probable, that miasmatic agents act upon the animal system, in part at least,"by being admitted through the lungs, into the current of the circulation. Some contend that these aerial morbific causes act primarily on the stomach. It is asserted, that the miasma, becoming entangled in the saliva, and swallowed with this fluid into the stomach, establishes a primary morbid impression in its delicate mucous membrane. It is alleged, in confirmation of this opinion, that the stomach, possessing a very extensive circle of sympathetic relations, and being highly sensitive to impres- sions, is peculiarly calculated to become the primary focus of morbid excitement * M. Bouillaud, whose work I have already mentioned, advocates this view of the etiology of certain varieties of fever. t Anatom. Gener., vol. i. p. 284. GENERAL PATHOLOGY OF FEVER. 29 from external morbific causes. It is affirmed, moreover, that the initial symp- toms of fever point out the primary influence of the febrific cause on the stomach. The depressed or abolished appetite, the nausea and vomiting, and the peculiar sense of uneasiness in the epigastrium, are considered as affording strong evi- dence of the correctness of this opinion. It is asserted, finally, that the lungs are endowed with an inferior degree of sensibility, and that their sympathetic relations are by no means very extensive, and that, therefore, they are but im- perfectly adapted for receiving and propagating morbid impressions from external causes. In reply to these arguments, it must be observed, that it does not seem pro- bable that a sufficient quantity of miasmata could gain admission into the stomach to produce disease. As to the evidence drawn from the character of the premo- nitory symptoms, it cannot afford any available support to this doctrine. A severe wound, or contusion, will give rise to nausea, vomiting, and immediate loss of appetite. Such phenomena only show that the stomach readily sym- pathizes with impressions made on every part of the body, when of sufficient degree of intensity. With regard to the alleged insensibility of the lungs, or their limited sphere of sympathy, we might admit its justness without being reduced to the necessity of adopting the opinion that miasmata act primarily on the stomach. It is not presumed that aerial morbific agents act simply on the nervous extremities of the respiratory passages, and thus give rise to a chain of sympathetic morbid actions. It is contended, that agents of this kind pass through the lungs into the current of the circulation, or effect certain morbid alterations of the blood, in consequence of which, the lining membrane of the heart, arteries, and capillary system is irritated, and the vascular system thrown into a state of febrile excitement. That agents of this kind are absorbed into the circulation, and act upon the system through the medium of the blood, may be inferred from a number of familiar facts in relation to the inhalation of odoriferous effluvia. The inhalation of the fumes of turpentine, of garlic, and of various other sub- stances of a similar character, is speedily followed by the manifestation of these odors in the urine. How are we to account for the extraordinary effects which arise from the inhalation of nitrous oxide, and of the vapor of sulphuric ether? It does not seem probable that these effects are produced by the mere action of these causes on the pulmonary nerves ; for when these substances are taken into the stomach, the nerves of which are so highly sensitive, no such consequences ensue. These facts go to show, that substances capable of affecting the animal eco- nomy, will, when admitted into the lungs in a gaseous form, promptly and powerfully exert their peculiar influence upon the system. There are no good grounds, therefore, for denying that miasmata and contagious effluvia may pro- duce their deleterious effects through the same avenue. The bronchial tubes and cells expose a very extensive surface to the impressions or absorption of such agents; a circumstance which, it may be presumed, is well calculated to favor their morbific influence on the system. The experiments of Magendie, in relation to the effects of putrid effluvia on the animal system, may also be cited in favor of this opinion. On exposing animals to the inhalation of putrid effluvia, some suffered no injury, whilst others rapidly emaciated, and died at different intervals within twenty days. When, however, the putrid substances, from which the effluvia experimented with emanated, were introduced into the stomach, no obvious inconveniences were experienced by the animals.* To these facts we may add, that small-pox virus, when swallowed into the stomach, will not, or, at all events, extremely seldom, infect the system; whereas every one knows how readily the disease is communicated by inhaling the effluvia which emanate from the bodies of those who labor under the malady. It appears very evident, therefore, that aeriform febrific agents act upon the * Journal de Physio!ogie, 1823. 30 GENERAL PATHOLOGY OF FEVER. system through the medium of the respiratory organs; and the facts just men- tioned render it highly probable that they enter into the current of the circulation, and act immediately on the internal surface of the heart, arteries and capillaries, perhaps more commonly on some portion of the latter set of vessels. It is not presumed, however, that agents of this kind always, or perhaps at any time, act exclusively through the medium of the blood, in the way just stated. Any part of the organization which exposes a sensitive surface to the impres- sions of such causes, may, no doubt, enable them to operate injuriously on the general system. All that is here contended for is, that morbific agents of every kind, but especially gaseous substances, do often pass into the circulation, and that being thus mixed and carried along with the blood throughout the system, they act directly on the nervous extremities of the internal membrane of the vascular system, and thus excite febrile reaction, without the previous establish- ment and agency of local inflammation.* Besides the source of direct vascular irritation already referred to, there is another one, perhaps still more common and extensive in its influence ; namely, retained recrementitious matter, in consequence of accidental glandular torpor or inactivity. When an excretory organ is impeded in its functions, and ceases to effect a due elimination of the recrementitious matter which it is destined to cast off', the effete elements must necessarily remain in the blood, unless some other organ vicariously supplies the function of the torpid emunctory. A source of vascular irritation will thus be created ; for it cannot be presumed that recremen- titious matter, even in its elementary state, can long remain rommingled with the blood, in inordinate quantity, without giving rise to more or less of morbid excite- ment. "Thus, if from certain causes elements entering into the composition of bile, abound in the blood, a source of disorder or of irritation is present in the blood. This irritating cause must act upon those parts which are sensible to its impressions, and to which it is incessantly and immediately applied. Derange- ment of the whole vascular system becomes the consequence of such irritation offered to the nerves ramified upon the heart and blood-vessels, but more espe- cially in the organ destined to combine and to secrete under new forms, the materials now so abundantly presented to it."t Thus, too, if the cutaneous ex- halation be arrested in consequence of the sudden influence of cold, a large por- tion of the recrementitious perspirable matter will be retained in the circulation. If this be not removed out of the system, by the vicarious action of some other organ, the blood will become surcharged with substances which the welfare of the economy requires to be cast off, and which must necessarily impart to it a mor- bific or irritating quality. This circumstance, together with the internal conges- tions which usually attend torpor of the cutaneous exhalents, becomes a direct source of irritation to the heart and arteries, and consequently of febrile ex- citement. With all the evidence which we possess, therefore, that the blood frequentlv be- comes charged with substances of an irritating or deleterious character, there can, surely, exist no reasonable doubt, that fever is sometimes the result of direct and primary irritation of the heart and arteries; for it will not be denied, that agents which are capable of causing morbid impressions on the nerves of the skin, the alimentary canal, or of any other organ, will be equally capable of producing irri- tation in the heart and arteries, when brought in immediate contact with their internal surface; and no one, certainly, will maintain, that irritating impressions made upon the whole or a part of the internal surface of the vascular system, will not be as likely to excite that morbid vascular action which constitutes fever * Dr. James Johnson, the very able editor of the Medico Chirurgical Review observes__"It has always been our opinion that febrific causes made their first impressions on the nervous system; but this, we think, does not disprove that absorption first takes place__still less that absorption is not necessary at all/'—Med. Chir. Uev. t London Medical Repository, No. 102, p. 5U9. GENERAL PATHOLOGY OF FEVER. 31 as when the irritation is conveyed to this system sympathetically, from some re- mote local inflammation.* Evident, therefore, as it unquestionably is, that fever may, and often does, arise from morbific impressions made primarily on the vascular system, it is never- theless equally manifest, that it is, perhaps, still more frequently the result of a purely sympathetic irritation, proceeding from local irritation or inflammation pre-established by the febrific cause. This latter mode of febrile origin is, ac- cording to some modern pathologists, the only possible way in which fevers can arise; as if morbific impressions made directly upon the blood-vessels, could be less apt to derange their functions than when communicated to them sympa- thetically through the medium of the nerves. It is probable, however, that the primary morbid condition whence the sympathetic febrile actions emanate, con- sists much more frequently in mere irritation of functional derangement than in actual inflammation. I presume that those febrific causes which do not make their impressions directly on the lining membrane of the heart, arteries, or capil- laries, by being admitted into the circulation, cause, in the first place, irritation and consequent functional derangement in one or more important organs or struc- tures of the system. In consequence of this local irritation or deranged action, the equilibrium of excitement and of the circulation becomes disturbed, the vital properties deranged, and the sanguiferous system is finally brought into a state of febrile reaction. Fever, as has already been observed, always, perhaps, commences by a local irritation, or morbid excitement. Even when the disease results from causes that act immediately on the internal surface of the vascular system, the irritation, or primary morbid excitement, is probably confined, at first, to a comparatively small portion of this system. Every agent, whether morbific or medicinal, ap- pears to have a tendency, in its ulterior operation, to affect particular organs or structures in preference to others. On whatever part of the system the primary impression is made, the excitement produced is chiefly conveyed to some par- ticular organ or part, according to the peculiar character of the primary impres- sion. Ergot, whether received into the stomach, or injected into the rectum, produces an excitement in the nerves of the part to which it is applied, which is especially conveyed to the gravid uterus, and, so far as can be perceived, to no other part. The infusion of jalap, introduced into the circulation, will act upon the alimentary canal, and produce purging; cantharides, whether taken into the stomach or applied to the surface, is apt to inflame the neck of the bladder; and in short, the influence of almost every agent appears to possess a kind of elective affinity for some particular organ or structure of the organization. That this should be the case, might, indeed, be inferred from physiological principles, in- dependent of the evidence of experience. That each organ and structure of the animal system is endowed with a peculiar modification of the vital properties, may be regarded as an established fact in physiology. In this principle we may perceive the reason why different agents manifest peculiar tendencies to act on different parts of the system. Without doubt, when an impression is made on the system, it will be most felt by that structure whose specific or peculiar vital properties are most in relation with it. When an impression is made on the nervous extremities of any part of the body, the excitement produced is * [Although Cullen allowed that the fluids underwent morbid changes in fevers, he main- tained that they were the consequences, not the cause of disease Of late an attempt has been made to revive the humoral pathology, by a more accurate chemical examination of tire bluod, and by experiments of injecting morbid and irritating matters into the circulation. The facts which have been ascertained certainly show that a morbid state of the biood may perform an important part in developing some of the phenomena of fever. But they do not warrant the conclusion of some of the European investigators, nor of Dr. Stevens, of the West Indies, that fever is entirely dependent upon such a cause. The saline treatment of Dr. Stevens has not as yet got into credit with the profession; nor has the practice of medicine been at all modified by the recent advance of humoral pathology.—Mo.] 32 GENERAL PATHOLOGY OF FEVER. conveyed by the nerves to the brain, and from this organ it is reflected or radiated throughout the whole nervous system. That this is the ordinary course of nervous excitement from impressions made on the sentient extremities, will scarcely be disputed by any one who has carefully attended to the functions of the brain and its appendages. It is impossible to give a rational explanation of many sympathetic phenomena, unless we trace the course of nervous excitement from its origin to the brain, and thence to the part which manifests the sympa- thetic action. If, then, each organ and structure of the animal system be en- dowed with its peculiar modification of excitability,* we may justly presume that some parts of the organization will be insensible, whilst others will be more or less sensible to particular impressions, and consequently there will be some parts in which a new excitement will be produced by the impressions reflected by the sensorium commune, whilst in other organs and structures no immediate effect will be produced. Thus, if tartar emetic be kept in contact with the ex- ternal region of the stomach, the impression which it causes will be conveyed to the brain, which, in its turn, will reflect the impression throughout the whole nervous system; but as the stomach alone is endowed with a mode of feeling capable of receiving this peculiar impression to a prominent degree, it will be in this organ that its effects will be most conspicuous.! Let us suppose, then, that a febrific agent acts primarily upon the nerves of the stomach or of the skin, or of any other part of the body. The impression produced, will be conveyed to the sensorium commune, whence it will be re- flected throughout the whole nervous system. But as the various organs and structures of the system are endowed, each with its own peculiar modification of the vital properties, some may be insensible, whilst others, perhaps, are pecu- liarly susceptible of receiving and responding to the reflected morbific impression; and these, it may be reasonably presumed, will be irritated and functionally de- ranged, before the other organs or structures become affected. From the part thus primarily irritated, the morbid excitement passes from organ to organ, or tissue to tissue, according to their various sympathetic relations with each other, and with the part primarily affected, until the whole system becomes morbidly excited. It is extremely improbable that the morbid excitement or impression caused by a febrific agent, can ever bring every part of the system, simultaneously, or pari passu, into a state of morbid action. The direct influence of the remote or exciting causes of fever, do not, probably, extend beyond the simple impression which they make on the sentient extremities. Every subsequent morbid change in the development of fever, must depend wholly on the relative affinities of the various structures with each other, and with the character of the primary im- pression; and, from what has been said above, it can scarcely be doubted, that the primary impression or nervous derangement, resulting directly from the action of the morbific cause, always terminates in the production of prominent morbid excitement in some particular organ or structure preliminary to the actual deve- lopment of the general febrile vascular reaction. * The word excitability is here used to express the power of being excited into action, and includes both sensibility and contractility. f The author of a Review of the first edition of this work, doubts the correctness of this assertion. It must be admitted, that tartar emetic, when applied to the external surface, very rarely produces either nausea or vomiting. I have, nevertheless, met with one^ remarkable instance of this kind. At three different periods a solution of this article was applied to the epigastrium, and at each time he experienced very distressing and protracted nausea. The general fact, however, which it is intended to illustrate by the above observation, cannot be disputed. It is well known, as has been observed in the preceding page, that to whatever part remedial substances are applied, they manifest the same tendency to act on particular organs or structures, as if they were taken into the stomach. I have known tobacco applied to the feet to give rise to nausea and vomiting, and every physician must have observed similar facts. [I have repeatedly observed this fact; tartar emetic plasters occasionally produce severe vomiting in irritable patients.—Mc] GENERAL PATHOLOGY OF FEVER. 33 That the primary morbific impressions are, however, almost universally di- rected upon the mucous membrane of the alimentary canal, as is asserted by Broussais, appears to be as far from truth, as that all fevers are purely symp- tomatic. Almost every organ or structure of the system may, without doubt, be the first to suffer functional derangement or irritation from external morbific im- pressions. The lungs, the liver, the brain, or the skin, &c, sometimes receive the reflected impressions, and become the primary focus whence the febrile actions emanate. Observation, moreover, discountenances the opinion that the primary local derangement thus produced, amounts often to the grade of inflam- mation. Deranged or irritated excitement of an organ or structure may be ade- quate to set on foot a train of morbid changes which will ultimately terminate in febrile reaction. A draught of cold water, while the body is in a state of free perspiration, may, in its ultimate consequences, establish fever. In this case the impressions of the cold water on the nerves of the stomach, are transmitted through the medium of the sensorium commune, to the cutaneous exhalents and capilla- ries. A state of torpor and functional derangement of these vessels, together with the deranged sensibility of the cutaneous nerves, immediately ensues, and the patient experiences a sense of chilliness, with more or less constriction of the extreme vessels. These, then, are the first sympathetic phenomena arising from the influence of the remote or exciting cause; and from these morbid changes, others proceed in regular sequence until the fever is fully developed. Thus, from the torpor of the exhalents and diminished circulation in the external capillaries, three pathological conditions necessarily arise, which tend especially to excite febrile reaction. In the first place, a large portion of recrementitious perspirable matter will be retained in the circulation ; secondly, the retreat of the blood from the extreme vessels will cause it to accumulate in the heart and large internal vessels; and thirdly, the action of the liver* and other internal organs, will be more deranged in consequence of their direct sympathetic relations with the cutaneous exhalents. But although the organs which sustain the primary irritation—and from which the morbid febrile changes are diffused throughout the system, as from a centre, are not, perhaps, at first in a state of actual inflammation, yet, as they are already morbidly irritable and irritated, they will be especially apt to pass into a state of complete inflammation soon after the febrile reaction is established, and an increased momentum given to the blood. It may be observed, too, that when a morbific cause acts directly on the stomach, as in the example just assumed, the fever will be apt to become early complicated with conspicuous irritation or inflammation of the mucous membrane of this organ ; in consequence of having sustained the direct injurious impressions of the remote cause, and consequently, being, from the very onset of the disease, in a morbid condition. It must be remembered that inflammation consists not only in congestion of the inflamed capillaries, but also in an altered or morbid condition of their vital properties: and hence, when an organ is already in a state of morbid excitement or irritation, inflammation will very readily ensue, when, by a general increased momentum of the circulation, the blood is urged into the debilitated and morbid" capillaries. It is on this account that we so often find inflammation supervening in the stomach and intestinal canal in fevers. The mucous membrane of these organs being so much exposed to the action of irritating causes, is far more fre- quently the seat of irritation than any other structure of the system, and it is almost invariably in a more or less deranged condition in all general diseases. This being the case, it is evident that this structure must be especially liable to secondary inflammation in febrile affections; and this, in fact, is fully con- firmed by experience. Inequilibrium of the circulation and excitement is one of the most important * Vide Johnson on the Diseases of Tropical Climates. Of the correctness of his sentiments concerning the influence of what he calls the cutaneo-hepatic sympathy, I entertain no doubt. 3 34 GENERAL PATHOLOGY OF FEVER. characteristics of fever. Although fever is emphatically a general malady, and a morbidly excited condition, it must not be supposed that every sensible and irritable structure, though functionally deranged, is in a state of increased excite- ment. While the heart and arteries are energetic, and morbidly active, the mus- cular system is usually languid and enfeebled. An increased activity of the intestinal capillaries and exhalents may be attended with diminished activity of ihe capillaries and exhalents of the external surface. Inordinate action of the kidneys is often accompanied with torpor of the liver, and always with torpor of the cutaneous exhalents. Sometimes the capillary system is inordinately active, whilst the heart and arteries manifest but little or no increase of excitement; and occasionally the brain and nerves are in a state of great activity, with very feeble reaction of the heart and arteries. The same observations apply to the distribu- tion of the blood. Whilst it is morbidly deficient in some organs, it will be excessively abundant in others; whilst the capillaries of one structure or organ are engorged and inflamed, those of other parts will be devoid of the regular portion of the circulating fluid. These facts have a most important bearing on practice; for they point directly to the fundamental principle of treatment— namely, to excite and invigorate those organs that are torpid, at the same time that we depress and debilitate those that are morbidly active. It has been supposed that febrile excitement, or the essential morbid action of fever, is always the same; and that the various modifications which this form of disease is known to assume, depend wholly upon the local irritation or inflam- mation which may occur, or rather the organ or structure which may be its seat. To a certain extent, this opinion appears to be well founded. It is very evident, for instance, that in proportion as the brain and nerves become affected, so will the fever acquire a low or typhoid grade in its general character. Of two indi- viduals seized with fever from the influence of atmospheric vicissitude, one will, perhaps, be affected with a low or typhoid form of fever, whilst, in the other, the fever will assume a high grade of inflammatory or synochal reaction. In the fprmer, prominent symptoms of severe nervous disorder will attend; and if the disease be violent, decided manifestations of cerebral inflammation will probably occur. In the latter case, little or no prominent signs of cerebral disturbance or irritation will ensue; but instead of this, symptoms of local inflammation in the fibrous or serous structures, or in one or more of the abdominal organs, will pro- bably be observed. That the occurrence of irritation or inflammation of the brain should impart a low and typhoid character to fever, and thus give to it a peculiar aspect, is by no means difficult to comprehend ; for it is manifest, that when the fountain of the vit,al energies, the brain, is prominently deranged, all the powers of life, how- ever excited, must languish and sink. This subject will, however, be more par- ticularly, discussed under the head of continued fever, being referred to at present merely for the purpose of directing the reader's attention to the general fact, that fevers, arising from the same cause, and essentially identical, receive import- ant modifications from the seat and grade of the local affections which may super- vene. The mode in which the occurrence of local inflammation may be favoured during the progress of fever, has already been mentioned. Besides the peculiar influence of the remote causes, in deranging particular organs or structures, in preference to others, and thus laying the foundation for local inflammation, there are, however, other circumstances which are, perhaps, still more commonly con- cerned in favouring the supervention of inflammation, and inviting it to particular organs. The human system is rarely found in so perfect a state of health, that some of its various organs or structures are not more or less debilitated or disturbed. The multifarious influences that are continually operating on the animal economy, do not suffer the vital machine to go on without some, though often imperceptible, derangement in one or more of its various organs. Add to this, the congenital debility of some structures, and the constitutional prepotency GENERAL PATHOLOGY OF FEVER. 35 of others, and we have a sufficient number of latent causes, (varying in different individuals, and in relation to some, in the same individuals at different periods,) to determine the occurrence of local inflammation, when the nervous and vascu- lar systems are thrown into a state of tumultuous excitement. Much variation occurs in different cases, as to the period after the commence- ment of the febrile changes, when local inflammations of this kind supervene. If any organ or structure happen to be especially predisposed to inflammatory excitement, or when the exciting cause is of such a nature as to act with great force upon some organ or structure, inflammation may commence with the onset of the febrile vascular reaction. More commonly, however, the local inflamma- tion does not supervene until several days after the commencement of the fever; and in many instances, not until the latter period of the disease. The occurrence of local inflammation in general fevers, of course always greatly increases the obstinacy and danger of the disease; and this is pre-eminently the case, when such inflammations supervene in fevers of typhoid character. Prone, as febrile affections unquestionably are, to give rise to secondary in- flammations, many instances occur which remain entirely free from inflammation throughout the whole course of the malady, although irregular determinations and inequilibrium of excitement appear to be inseparably connected with this form of general disease. It has been observed above, that fevers, essentially identical in the nature of the general febrile excitement, often assume prominent modifications, apparently radically diverse from each other, in consequence, solely, of the different organs or structures which happen to sustain the principal force of the malady. From this unquestionable fact some pathologists have inferred that there can be funda- mental and specific diversities of fever, presuming that the general febrile excite- ment is always essentially the same; and that all the diversities which occur in the course and phenomena of this mode of disease, are invariably the result of the diverse local affections that may accompany the malady. It appears to me, however, that the occurrence of original and specific diversities in the nature of febrile excitement, is susceptible of very plausible, and, to me at least, sufficiently satisfactory illustration. It is impossible to conceive why the capillary system of blood-vessels, in which doubtless all the essential febrile actions reside, should not be as susceptible of radical diversities of excitement as the nervous system itself. Upon this point we may be allowed to refer to the exanthematous affec- tions ; for, whatever Broussais and his followers may say to the contrary, some of these diseases are, at least in the first stage, simply febrile, without local in- flammation. In the general phenomena of the fever of distinct small-pox, during the first day of its course, there is nothing that is different from an ordinary synochus, and yet no one can for a moment seriously doubt, that the essential morbid excitement of the extreme vessels in this affection, is specifically distinct from that of all other febrile diseases. It is true that this disease is produced by a specific cause; but the morbific impressions made by malaria, are probably as distinct from those of cold, as the impressions of small-pox virus are from those of either of them. No one has ever observed yellow fever or the plague to arise from atmospheric vicissitudes ; and malaria by itself has, I presume, never been known to give rise to inflammatory rheumatism, or to simple catar- rhal fever. If, then, in relation to the exanthemata, general febrile excitement is unquestionably susceptible of radical and specific peculiarities, the possibility of such fundamental diversities in the nature of the morbid excitement of fever, independent of accidental local affections, must be admitted even in the general fevers usually denominated idiopathic. It is probable that koino-miasmata, idio-miasmata, and cold, or atmospheric vicissitudes, produce each its peculiar mode of morbid excitement; for, although the general and obvious febrile actions, and even the accompanying local affections which they respectively produce, may not be perceptibly diverse, yet, it maybe presumed, the fundamental morbid condition or excitement of the nervous and capillary systems, upon which the 36 CAUSES OF FEVER. febrile phenomena depend, is, in each variety of fever, radically distinct, or sui generis. So far, however, as the fevers occasioned by one or the other of these remote causes, differ in form and general character from each other—as, for in- stance, the various forms of miasmal fevers—it can scarcely be doubted, that the most common source of these diversities consists in the accidental local affections which occur, or the character of the structure most prominently deranged, or the greater or less intensity of the operation of the remote cause. CHAPTER II. OF THE CAUSES OF FEVER. The causes of fever are generally divided by pathologists into two varieties, the predisposing and the exciting. The former are all those external and in- ternal causes which tend to lessen the power of vital resistance to the influence of morbific agents. The latter are those causes which excite actual disease by the deleterious or irritating impressions which they make on the animal system. There exists, however, no absolute difference in the nature or character of these two varieties of morbific causes. The same agent, or circumstance, may mani- fest its influence on the animal economy, either as a predisposing or an exciting cause of fever, according to the degree of intensity with which it acts, or the previous condition of the system. Sect. I.—Of Predisposition, and Predisposing Causes. When, either from a general condition of the organization, or some local, func- tional or organic defect, the animal economy is especially susceptible of the influence of morbific causes, a predisposition to disease is said to exist; and this predisposing condition may be either natural, or accidental, or hereditary. As the human system is continually under the influence of causes which have a tendency to interrupt and terminate its actions, life would be but ephemeral in its duration, and harassed by constant disease, if the animal organization were not endowed with the inherent power of resisting, to a degree, the influence of injurious causes. It is by the aid of this vital resistance, that man is enabled to live through a long series of years, amidst a multiplicity of causes, which con- spire unceasingly to his destruction. In relation to the degree in which this power of resisting injurious influences is possessed by different individuals, there exists great diversity: and hence the various degrees of constitutional or natural predisposition to fever, which obtain among different individuals. Thus, the prick of a needle will, in one individual, cause great pain and constitutional irri- tion; in another, syncope; in a third, convulsions or tetanus; and in a fourth, scarcely any perceptible consequences at all.* There exists, therefore, a natural or constitutional predisposition to disease in some individuals, wholly independ- ent of accidental causes or mere casual debility; and this constitutional aptitude to disease depends, probably, on the peculiar organization of the animal system. Under the head of natural, or constitutional predispositions, must be ranked those specific predispositions which render the system susceptible of certain specific diseases, and which are wholly lost by the actual occurrence of these maladies. These specific predispositions are especially incomprehensible and * Sur le differens Degrees de Resistance vitale dans les Maladies, &c. Par M. L. Martinet, M.D.—Revue Medicale, Oct. 1824. CAUSES OF FEVER. 37 mysterious. Neither temperament, nor constitutional vigor, nor debility, nor any circumstance connected with the health of the individual, appears to have any relation with, or influence upon them. With regard to accidental, or acquired predisposition, observation has not left us so entirely in the dark. According to the late Dr. Rush, general or local debility, accompanied by an increased excitability, constitutes the state of predis- position to fever. Without doubt, general debility, with increased excitability, must render the system more liable to the action of irritating or exciting causes; yet it does not appear that this condition of the system can, with propriety, be considered as constituting the essential state of the organization which predisposes to fever. It is well known that the most robust and healthy individuals are gene- rally the first and most certain victims of febrile epidemics. The vigorous and healthy are often prostrated under the devastating dominion of pestilence, and even under the less ruthless sway of the milder paludal fevers, whilst the feeble and the valetudinarian pass along untouched. It may, moreover, be observed, that in the feebleness of convalescence from bilious, typhus, and other forms of fever, fresh attacks, or relapses, are by no means so common as one would expect, if mere debility constituted febrile predisposition. When we wish to obviate fever, after a surgical operation, we reduce the system by a low diet, purgation, and perhaps blood-letting.* In a general way, every cause, capable of deranging the health of the animal economy, may, when acting with moderate force, produce such a change in one or more organs, as will predispose the system to fever, requiring only some further exciting cause to evolve actual febrile disease. Predisposition, produced by the influence of accidental causes, consists, probably, always in more or less functional derangement of one, or, at most, a few structures or organs, or in a disturbance of the healthy balance of excitement and the circulation. I have already stated some reasons which render it highly probable that the impression of every morbific cause, on whatever part of the system primarily made, is, in the first place, reflected upon some particular organ, according to the nature of the impression, and the organic sensibility of the various parts of the system. If this be correct, it is manifest, that if the morbific impression, thus reflected upon an organ or structure, be too weak to establish a sufficient degree of irrita- tion to excite general derangement, or febrile reaction, the result will be only a slight degree of insulated functional derangement, or irritation, which, though not manifested by any feelings or appearances of ill health, is still an incipient link of disease, and wants only some additional morbific influences to enable it to put in motion the latent train of morbid sympathies. How greatly mere functional derangement of an important organ aids the cause of fever in developing diseases, is often conspicuously illustrated by the influence of digestive derangement in the production of fever. Let but this citadel of the animal system languish, and the enemies of human health will speedily attack the outposts, and make an easy conquest of the whole. Hence, of all the precautions which those who visit insalubrious climates may be required to adopt, the avoidance of everything which is calculated to derange the digestive functions, is perhaps the most important. By a well-known law of the animal economy, every agent, however delete- rious, gradually diminishes, and finally almost destroys the susceptibility of the system to its influence, by long-continued or very repeated action. Hence, every agent will, cseteris paribus, manifest its operation with a promptitude and in- tensity, proportionate to the degree of previous immunity from its influence. It is this circumstance which causes the difference of predisposition to endemial fevers, between the acclimated natives of insalubrious regions, and strangers ar- riving from northern latitudes. This variety of predisposition depends in no de- gree on a want of constitutional vigor or general health. The robust and healthy * Richter's Specielle Therapie, vol. i. p. 36. 38 CAUSES OF FEVER. are, in general, as much, if not more, under its influence, than the weak and in- firm. By a gradual or protracted exposure to morbific agents, the animal economy loses, insensibly, its natural susceptibility to their influence. When such a change is effected by the combined operation of climate and endemial morbific agents, the system is said to be acclimated or seasoned, and the individual, thus seasoned, enjoys a comparative immunity from the diseases of the climate. Besides the foregoing source of predisposition to disease, from causes peculiar to hot climates, there is another and perhaps not less powerful one—namely, atmospheric heat. High atmospheric temperature is, strictly speaking, rather a predisposing than a morbific agent in relation to its influence on the human sys- tem.* In this respect it exercises a very powerful influence in the production of diseases. Long-continued exposure to an elevated degree of solar heat, tends, very considerably, to increase the general irritability of the system, and to lessen the power of vital resistance. Hence, the frequency of tetanus in hot climates, from injuries, or from the influence of the cool and damp night air; and hence, too, the greater liability to this and other irritative affections, during the hot sea- sons of our own climate, than in the cold months. Atmospheric heat tends, moreover, to predispose to fever, and other affections, by the profuse and con- tinued perspiration it causes, as well as the redundant secretion of bile it is apt to excite. By these over-excited actions of two important organs, the general system is exhausted, whilst the organs themselves are rendered more susceptible to the injurious impressions of one of the common and powerful exciting causes of disease—namely, cold. In relation to those predispositions to disease which are transmitted from pa- rent to offspring, it may be sufficient to observe, in this place, that they depend, no doubt, on a peculiar physical condition or intimate state of the organization, which, we may presume, is as apt to be imparted by the parent to the offspring, as the contour of the countenance, or of the general structure of the body. Sect. II.—Of the Sources of Morbific Causes, and their General Character. When we take a general survey of the source of all the possible clauses of dis- ease, we find that in relation to their origin, they range themselves under the following four general heads, viz :t I. Recrementitious substances, which, in health, are separated and thrown out of the system, but being retained in the circulation, or reabsorbed, become a source of irritation to the sanguiferous system, and, therefore of irritative diseases. These morbific causes are always secondary, be- ing themselves the consequences of an anterior injurious cause or im- pression. Thus the retention of the perspirable matter can occur only in consequence of the influence of some previous cause, adequate to disturb or arrest the action of the cutaneous exhalents. The recrementitious fluids, which appear to be most injurious to the animal economy, when retained in the circulation, even in their elementary forms, are the per- spirable matter, the bile, and the urine; and of these the first is, perhaps, the most frequently concerned in the production of disease. The influ- ence of causes of this kind in the development of disease, is, probably, much more extensive than is generally admitted in etiological inquiries. In all that extensive class of febrile affections which arise from the influ- ence of cold, retained perspirable matter performs, probably, a principal part in the development of the irritative vascular excitement. Checked perspiration, or, more correctly speaking, inactivity of the cutaneous exhalents, constitutes the initial link in, perhaps, three-fourths of our febrile dis- * Dr. James Johnson on Tropical Climates, &c. \ Richter*s Specielle Therapie, vol. i. CAUSES OF FEVER. 39 eases. Let it not be imagined, that, as the recrementitious substances which are retained in the circulation are in a simple or elementary state, they cannot pos- sess powers sufficiently irritating or active to excite morbid vascular action. In whatever form these substances may exist in the blood, they are still recremen- titious, and it is not to be presumed, that materials of this character could be long retained without an injurious influence on the animal economy. Accidental tor- por of one emunctory is often vicariously supplied, by increased activity of another, and disease thus prevented. Thus if, after the cutaneous exhalents have been rendered torpid by a sudden influence of cold, the flow of urine becomes unusually copious, disease will rarely ensue. Indeed, the all-wise and benevo- lent Creator has provided against the injurious consequences which must otherwise have resulted from the constant changes to which the function of the skin is necessarily exposed, by placing in the interior an organ whose functions may, in a great degree, supply any accidental deficiency in the action of the former. II. Irritating substances generated within the body, but wholly independent of any organic actions. These causes of disease are usually generated in the prima? viae, and consist of worms, acids, mucus, and various other irritating substances, resulting from the fermentative or putrefactive pro- cesses. Worms have been, and by some are still considered as innocent inmates of the human body. This, however, is most certainly an erroneous sentiment. Without doubt, a few, or even a considerable number of worms lodged in the alimentary canal, may not be able to disturb the general system, when in a state of good health and constitutional vigor; but when the body is debilitated and irritable, as it commonly is during the period of dentition, the presence of worms in the intes- tinal tube will frequently give rise to the most alarming affections. Worms tend, moreover, to sustain and protract fevers produced by other exciting causes ; an inattention to which frequently renders the progress of ordinary diseases pecu- liarly perplexing and unmanageable. It is not uncommon to meet with cases of slight febrile disease in children, from cold, which continue in spite of appro- priate remedial efforts, gradually assuming the form of slow remitting fever, with a foul tongue, and gastric disturbances, and at last suddenly assume a favorable aspect, on the expulsion of a few large lumbrici. The agency of causes of this kind in the production of fever, was, however, formerly considered much more extensive than it appears, in reality, to be. Ver- minous epidemic fevers are described by some of the older writers, and saburral fevers were supposed, as it would appear, very common. Without ascribing so great an importance to these causes, as originators of fever, it is nevertheless unquestionable that they do at times give rise to febrile affections, independent of all other morbific irritants. Their febrific tendency is, however, much more fre- quently manifested in the support, or additional violence which they give to fevers arising from other causes, than in originating febrile affections by their own im- mediate influence. III. Morbific agents, generated out of the animal body, consisting either of deleterious substances floating in the air, or of the sensible proper- ties of the atmosphere, or finally mechanical causes—namely : mias- mata, noxious gases, heat, cold, electricity, humidity, and mechanical injuries, &c. IV. The fourth and last class of morbific agents comprehends those which are generated by morbid organic actions of the living system, constituting the various contagions. The principal causes, embraced under the last two heads, are so extensive in their influence on the human system, and so interesting and important, both in a medical and scientific point of view, that a separate and full exposition of their respective modes of origin, and physical, as well as morbific characters, will not be deemed inappropriate in a work of this kind. 40 CAUSES OF FEVER. Sect. III.—Atmospheric Temperature, and its relations with the Animal System. A certain quantity of heat is indispensable to life, throughout the whole range of organized beings. Every animated being possesses an inherent power to generate heat, and to resist, to a certain extent, the physical law of the distribu- tion of heat; and, consequently, to maintain its peculiar or specific temperature, when placed in a medium either many degrees below or above its own tempera- ture. The constant and rapid reproduction of heat by the vital powers, keeps up the natural temperature of the animal body although surrounded by a medium which abstracts its heat with great rapidity. Such, indeed, is the evolution of heat by the human body, that an atmosphere of the temperature of 98° is gene- rally oppressive and unpleasant by the feeling of warmth which it causes, although at this temperature of the air, no heat can be communicated by the surrounding atmosphere to the body. The temperature most grateful and invigorating to the human system, ranges from about 60° to 65°. "This temperature of the air appears to abstract the heat of the body in about the same proportion in which it is generated in the healthy state of the system ; and this degree of the tempera- ture is, therefore, the most congenial, for it neither exhausts the vital powers, nor gives rise to unpleasant sensations." There exists, however, considerable diversity in the human constitution, in relation to the power of supporting the extremes of temperature. This depends not only on the original vigor of the system, but also, greatly, on the influence of habit and modes of living. A person endowed with a vigorous constitution, and with habitual good health, will bear a degree of cold without any unpleasant feel- ings, which, to one of a feeble and exhausted system, will be a source of painful sensations and indisposition. Habit, in relation to previous exposure, has a powerful influence in varying the effects of temperature on the animal system. The same temperature will cause feelings of severe cold or great warmth, accord- ing as the body has been previously exposed to a high or low temperature. Whenever the surrounding medium abstracts the heat of the body more rapidly than it is generated by the regular actions of the animal economy, the sensation of cold will be produced: and the intensity of this sensation will always be pro- portionate to the rapidity with which the heat is abstracted, and the feebleness of the heat-generating power of the system. I. Physiological effects of cold.—When the temperature to which the human system is exposed, is so low as to give rise to the sensation of cold, its imme- diate effects are : 1. Diminution of the action of the cutaneous exhalents, and of the external capillary blood-vessels, giving rise to a pale, shrunken, and dry state of the skin ; 2. Diminished action of the heart and arteries—manifested by smallness, weakness, and slowness of the pulse. In relation to the effects of low temperature on the frequency of the pulse, however, there exists some discre- pancy of opinion among physiologists. From the experiments of Drs. Stock, Spooner and M'Donnel, it would seem, that although the strength and size of the pulse are diminished by cold, yet its frequency is considerably increased. Against these experiments we may oppose those performed by Currie, Rush and Klapp;* and in my own experiments I have invariably found the pulse dimi- nished, both in frequency and in volume, when cold was applied to any parti- * That Dr. Stock and the other experimenters observed what they record upon this point, cannot be doubted. We can readily admit that when the body is suddenly plunged into cold water, the mode adopted by them, the pulse will at first be accelerated. It must be observed that when the body is suddenly immersed in cold water, the blood is violently driven in upon the heart and larger vessels, and the respiration is performed in a hurried and imperfect man- ner, in consequence of which, the heart is excited into a temporary exertion to .overcome the load which oppresses it, and the pulse consequently at first accelerated. CAUSES OF FEVER. 41 cular portion of the body.* 3. Diminished sensibility of the external parts, passing by degrees throughout the whole system. Hence the benumbed state of hands, fingers, and other external parts, the torpor of the sensorial functions, and the sluggishness and feebleness of muscular action which occur from the pro- tracted influence of severe cold; and in this way, too, an almost irresistible incli- nation to sleep occurs when the cold is very intense. Artificial somnolency has been produced in certain animals by exposing them to a very low degree of tem- perature. 4. When moderately applied, cold increases the powers of the diges- tive organs. Hence the aphorism of Hippocrates, Hieme ventres calidorus sunt. The appetite increases, and the process of digestion is performed more rapidly in moderately cold and dry than in warm weather. We are informed by Xenophon, that the Greek soldiers, on their return from Asia, were exceedingly harassed by the most severe sensations of hunger, while passing the snow- covered mountains of Armenia, although they were allowed their ordinary rations of food. When cold becomes very intense and protracted, however, the diges- tive as well as all the other organs of the system become enfeebled and inactive. 5. The sudden application of cold causes a hurried, irregular and imperfect action of the respiratory apparatus ; and when intense, it checks or impedes the efforts to dilate the chest, and these effects increase, pari passu, with the increased influence of the cold, until at length respiration is performed so imperfectly as to prevent the due decarbonization of the blood, and the whole organization sinks into a state of torpor and insensibility. 6. Moderate cold is favorable to nutri- tion. "Man and all animals are fatter in winter than in summer ; and in the north than in the south." When, however, the cold is applied in an intense grade and prolonged in its influence, the process of nutrition is disturbed and inter- rupted. 7. The pulmonary exhalation, and the secretion of urine are increased by cold, and supply, in a degree, the checked exhalation by the skin from the same cause. S'ringuntur tubuli pellis, coguntur et intus Tott variis pellenda viis excreto, fyc. 8. Cold, when prolonged in its influence, diminishes the venereal propensity, (Montesquieu, Esp. des Loix, b. 14, c. 2,) but it does not appear to repress the function of generation ; for although the venereal appetite be less constant and urgent in cold than in warm climates, yet the power of procreation would seem to be even greater in the former than in the latter. "In Sweden it is not uncom- mon to see women have twenty or thirty children ; and in Russia marriages are followed by a numerous progeny."t 9. Cold retards the development of the sexual organs, and the period of pubescence, more especially in the female sex. In northern latitudes the catamenia rarely commence before the sixteenth or seven- teenth year, whereas in the ardent climates of the intertropical countries, the menstrual evacuation is apt to make its appearance as early as the twelfth, and not unfrequently as early as the tenth year of age. Cold is, therefore, a sedative agent; for, although, when moderately and tran- siently applied, it is generally followed by phenomena attributable to a stimulating influence, yet these are not, strictly speaking, the immediate consequences of the low temperature, but rather of the reaction of the vital energies, after the tem- porary reduction of their activity by the cold. When an agreeable glow, and * The pulse of the inhabitants of northern climates is habitually slower than the ordinary standard of frequency in the middle latitudes. Amongst the Greenlanders, it is by no means uncommon to find the pulse as slow as 40 and 45 in a minute.—Beaupre on the Effects and Properties of Cold, p. 50. f Beaupre on the Effects of Cold, &c, p. 18. "In the coldest regions, approaching the poles, excessive cold retards the generative flame, and, we may say, extinguishes the lamp of physical love. Beyond the 65th degree of latitude, population continues to decrease, and ends at Spitz- bergen and Nova-Zembla. Lapland and Iceland females are said to menstruate but little; they are apathetic in love, and know but little of the bitter feelings of jealousy, or the vehemence of sexual attachment." 42 CAUSES OF FEVER. augmentation of the general vigor are experienced after leaving a cold bath, they arise, probably, not from the direct stimulus of the cold, but from its having de- pressed the excitement of the surface, and increased the susceptibility to the action of stimuli; in consequence of which the ordinary influence of the atmosphere, the warmth of the clothing, and even the stimulus of the blood, as well as exer- cise, and other usual exciting influences, will cause an increased degree of excite- ment, more especially in the cutaneous capillary system. That the phenomena of increased activity and vigor, which sometimes ensue, are solely the conse- quence of a reaction in the system, after the cold has temporarily diminished the excitement, and thereby increased the susceptibility to subsequent excitation, is fully demonstrated by the fact, that unless the system be endowed with a con- siderable degree of energy and activity, no such favorable effects will follow the application of cold. If cold produced these effects by its stimulating powers, it would, one may reasonably believe, produce them when the system is in a state of feebleness ; because mere weakness can never annul the operation of a stimu- lus, provided the excitability be not exhausted. That cold must necessarily di- minish the actions of the system, is evident from its being, in fact, nothing else than a comparatively diminished grade of temperature. For if heat be a stimu- lus, it is manifest that this stimulus must be lessened in its powers, just in the ratio in which its intensity is decreased. Thus, if 80° produce a certain degree of excitation, 60° {cseleris paribus) must produce a less degree and 40° still less, and so on. Correctly speaking, every agent capable of affecting the animal economy, is a stimulus; but when we speak of cold and its effects, it is to be always understood in a relative sense; for when it is said that cold is a sedative, it can mean nothing else than that it is less stimulating than a higher degree of temperature. It is to be observed, however, that although cold unquestionably tends to diminish the actions of the system, yet, when applied suddenly, it often mani- fests a very conspicuous exciting agency on the nervous or sensitive system. Thus, a few drops of cold water sprinkled on the face of a person in a state of syncope, or approaching to this state, will generally produce immediate excitation and return of consciousness. In asphyxia from carbonic acid, or electricity, too, cold water dashed on the face and breast, often causes immediate respiration and other manifestations of returning life. In cases of this kind, the sudden sensation which the cold produces, acts, probably, as the exciting cause. II. Cold as a morbific agent.—Cold is, perhaps, the most common and fre- quent of all the remote causes of diseases in the temperate latitudes. Its injurious tendency appears to be much enhanced by being conjoined with humidity ; for, a very dry and cold air is far less capable of abstracting the animal temperature than low temperature united with humidity. But the most important circum- stances which render the impressions of low temperature prejudicial to the ani- mal economy, relate to the previous condition of the system itself, with regard to the cutaneous transpiration, and antecedent exposure to high temperature. The morbific influence of cold is always efficient in proportion as the body has been previously exposed to an elevated temperature; and, more especially, in proportion as the perspiration is more or less copious. The most powerful of all the predisposing conditions of the animal system to the injurious effects of cold, is a state of free perspiration, from fatiguing and exhausting exercise or labor, under the influence of high solar heat. In this state of the body, and scarcely in any other, the sudden application of cold to a large extent of the sur- face, or to the stomach, in the form of ice or cold water, will often suddenly pro- duce the most alarming, and even fatal, consequences.* When the animal temperature is not rapidly carried off by free perspiration, and the system not debilitated by fatigue, cold can never give rise to such sudden, violent, and dan- gerous consequences. The effects here alluded to, as resulting from the impres- * Rush's Medical Inquiries. Currie's Medical Reports. CAUSES OF FEVER. 43 sions of cold, while the body is in a state of free perspiration, from fatiguing exercise and atmospheric heat, appear to be of a nervous or spasmodic character, consisting generally in sudden prostration and effacement of the vital energies of the system. As a febrific cause, cold plavs a very important part in the produc- tion of disease. It is not, however, merely as cold, or low temperature, that it is most influential as a febrific cause; vicissitudes of temperature, sudden changes from warm to cold, or from cold to warm weather, are the sources whence febrile disease is so abundantly derived: and these changes are always injurious in proportion to the suddenness of the transition, and the greatness of the change. A very gradual change of atmospheric temperature rarely produces disease, except in such as are peculiarly predisposed to influences of this kind. The mode in which cold produces fever has already been explained. Its first effects on the system are torpor of the cutaneous exhalents, and a retreat of the blood from the surface to the internal organs. The recrementitious perspirable matter is thereby retained, and the blood rendered more irritating, or at least, surcharged with offensive substances. In consequence of these morbid conditions, the heart is excited into increased action, by which the blood is again propelled into the ex- ternal capillary system, without, however, overcoming the torpor of the exhalents. If any portion of the capillary vessels be predisposed, by previous debility, to morbid excitement, high vascular irritation will be apt to occur in this part, and probably to the extent of actual inflammation. Should the mucous membrane of the respiratory passages be predisposed to irritation, catarrhal or pneumonic affections will be the consequence. If the alimentary canal be in a state of acci- dental or habitual irritation, dysentery or enteritis will probably occur. In short, whatever part of the system may be in a condition peculiarly predisposed to dis- ease, inflammation or high vascular irritation will most likely be developed in it, by the increased momentum of the circulation, and the immediate local impres- sions of the recrementitious elements retained in the circulation.* When the degree of cold is excessive, or very prolonged in its action on the animal system, it gradually abstracts the animal temperature to a degree incom- patible with vital action, and asphyxia, gangrene, or death ensues. The tend- ency which very low temperature has to produce these effects, is greatly con- trolled by the degree of constitutional energy, as well as the degree of corporeal exercise, of those who are exposed to its prolonged influence. A person of a vigorous and healthy habit of body, will readily bear a degree of cold without particular injury, which would soon destroy an individual of a weak and infirm state of the system. In all instances where cold is applied in a degree capable of gradually reducing and finally arresting the vital actions, an indomitable inclina- tion to sleep supervenes just before the fatal torpor comes on. When this op- pressive somnolency ensues, all feelings of pain or suffering cease—and if it be not resisted, death is inevitable. Heat.—High atmospheric temperature acts much more frequently as a predis- posing than an exciting cause of disease. " Solar heat," says Dr. James John- son, " produces only the predisposition, while terrestrial exhalations and cold call into action the principal diseases of hot climates. The mode in which solar heat contributes to the production of disease, appears to be either by augmenting the general irritability of the system, or more generally, by exciting inordinate func- tional action of the skin and the liver, and thereby rendering them more suscepti- ble of the paralyzing impressions of cold. Between the skin and the liver there exists a close and powerful sympathy, in consequence of which, whatever excites the functions of the former, produces, perhaps, an equal increase of the functions of the latter organ."t Hence, high atmospheric heat very generally produces an increased secretion of bile, by its influence upon the liver through the medium of the skin, whose functions it is so peculiarly adapted to augment. It is manifest * Dr. James Johnson, passim. t James Johnson, On the Influence of Tropical Climates, <$r& 44 MIASMATA. that an inordinate activity of these two functions from the influence of heat, must render them extremely obnoxious to torpor or inactivity from the sudden appli- cation of cold ; and it is equally obvious, that a sudden torpor of these two im- portant emunctories cannot occur without an immediate injurious consequence upon the whole system. Solar heat is, moreover, extensively concerned as^ an indirect cause of febrile affections, by favoring the production of marsh mias- mata. By its expansive and exciting influence, it sometimes gives rise to sudden and dangerous local determinations, particularly to the head, causing apoplexy, and that state of cerebral oppression called a stroke of the sun. Sect. IV.—Of Miasmata. The term miasmata is here used as designating a highly important class of febrific agents of a gaseous form, which act on the animal system through the medium of the atmosphere. This class of agents consists of two orders, name- ly:— 1. Infection, comprehending those febrific effluvia which are generated by the decomposition of vegetable and animal matter; and—2. Aeriform contagions, generated by the animal system in a state of disease. 1. Infection, or that variety of febrific agents which is produced by decompo- sition out of the animal system, consists of two genera, namely:—1. Those which result from the humid decomposition of vegetable and animal substances contained in the public filth of cities, in marshes, and in other soils and situations furnishing these materials. This genus is usually designated by the term marsh miasm; but from the common or public source of these morbific effluvia, it has been proposed, and by some adopted, with much propriety, I conceive, to dis- tinguish them by the compound term koino-miasmata. 2. Those febrific effluvia which are generated by the decomposition of the natural exhalations and excre- tions of the human body, accumulated and confined in crowded and ill-ventilated habitations. These deleterious effluvia, originating from the decomposition of matter derived from the human body, have, with equal propriety, been designated by the term idio-miasmata, expressive of the personal or private character of their source.* Before treating of these febrific agents, in an etiological point of view, it will be proper to describe, more circumstantially, the manner and cir- cumstances in which they are generated, as well as their physical characters, so far as these can be known. I. Koino-miasmata, usually designated by the terms marsh-miasmata, or malaria. This morbific agent was not unknown to the ancient Greek physi- cians. They personified it under the emblem of a many-headed monster, whose devastating influence was so severely exercised over the luxuriant fields of Ar- golis, that it was made one of the labors of the potent son of Alcmenus to rid the * These distinctive terms were originally proposed and adopted by the late Dr. Edward Miller, of New York, in the year 1804. He observed that there were two species of miasmata ; the one consisting of febrific exhalations from marshes and other soils, and the other of effluvia generated by the decomposition of personal and domestic filth. "In order to distinguish these two varieties of miasmatic agents, and, at the same time, duly to fix in the mind the impression of the origin and production of them, it is judged expedient to designate each by terms which will, invariably, express the process of nature in their formation. As the Greek language has been generally resorted to in the framing of scientific nomenclature, I shall employ the adjective KOINOZ, common or public, to denote one species of miasma, and IAI02, personal or private, to de- note the other. The application of these terms will be readily understood. That portion of the air charged with miasmata exhaled by solar heat, from the surface of swampy ground, or from masses of filth overspreading the open area of cities, according to this distinction, is denominated Atmosphera koinomiasmatica. And that other small portion of air, contaminated by miasmata, emitted from, and surrounding the body, clothes, bedding, and furniture, of persons immersed in the filth of their own excretions, and of those associated in the same family with them, accumu- lated, long retained, and acted upon by animal heat, is denominated Atmosphera idio miasmatica." —Attempt to deduce a Nomenclature, fyc. Med. Repository. New York, 1804. MIASMATA. 45 country of this dreaded source of pestilence. Hercules, accordingly, drained the extensive Lernean marshes, and thus dried up this abundant source of pesti- ferous emanations. Heat and moisture are indispensable to the generation of koino-miasmata; without these, no decomposition can take place, and without decomposition no deleterious agents can be generated from dead vegetable and animal substances. In latitudes where the atmospheric temperature seldom rises above 60°, the dis- eases which arise from this agent occur but very rarely, and, perhaps, never in an epidemic manner. The Lithuanian marshes of Russia do not render the surrounding districts insalubrious. It would seem, indeed, from a long series of observations, that koino-miasmata are seldom evolved to a degree sufficiently copious or active to create extensive disease, so long as the temperature of the air does not rise above 80° of Fahrenheit. It is, however, not necessary that moisture should be present in great abundance for the production of miasmata. Indeed, grounds completely covered with water, send forth but very little of this deleterious effluvium, however favorable the temperature and other circumstances may be. Hence, copious and continued rains, by inundating marshy soils, render such localities comparatively salubrious, (Dalzille, Ferguson.) Ferguson was led to infer, from his observations on this point, that miasmata were extricated wholly independently of the humid decay or decomposition of vegetable and animal matter, and apparently without the agency of humidity. He asserts that this aeriform poison is never extricated, in any considerable quantity, until the moisture of the soil is so far dissipated as to leave the ground in the last stage of the drying process. This, however, is decidedly contradicted by almost uni- versal experience. In proof of his opinion, among other observations, he says: " In the months of June and July our army marched through the singularly dry, rocky, and elevated country on the confines of Portugal, the weather having been previously so hot, for several weeks, as to dry up the mountain streams. In some of the hilly ravines, that had lately been water-courses, several regiments took up their bivouac, for the sake of being near the stagnant pools of water that were still left among the rocks. Many men were seized with intermitting fever." From this, and similar facts, he thinks himself warranted to conclude, that the humid decay of vegetable and animal matter has no immediate agency in the production of miasmata, and that moisture, particularly, is not essential. But "half dried ravines and stagnant pools of water" are surely no evidence of a want of humidity, and present, one should think, precisely the conditions most favorable to the emission of miasmata from vegetable and animal decomposition. It may be observed, that in every instance adduced by Dr. Ferguson, in proof that the extrication of miasmata does not depend on the humid decay of vege- table and animal matter,the soil from which the miasmata were emitted had been previously thoroughly saturated with water, during the rainy season, and moisture must, therefore, have existed in sufficient abundance, a short distance under the surface of the soil, however parched the latter may have been. Under such cir- cumstances, miasmata might be abundantly sent forth, without any obvious hu- midity and vegetable decomposition, on the surface; for the vegetable and animal remains, collected during the rainy season, must have been gradually decomposed during the drying process, and left, in part, at least, mingled with the portions of the soil on the surface. In this state, then, the slow evaporation of the humidity under the surface, in passing up into the air, would dissolve the putrid but dry particles of animal and vegetable remains, and convey them in the form of an effluvium into the circumambient atmosphere. That a considerable degree of humidity is especially favorable, and even es- sential, to the evolution of miasmata, is evident from the circumstance that marshes, stagnant pools, and the oozy shores of rivers, have, in all ages, and in all coun- tries, been found the most insalubrious portions of the earth during the hot sea- sons. As to the variety of soil most favorable to the production of miasmata, we 46 MIASMATA. possess no very definite or certain information. It has been asserted, that an argillaceous soil is most favorable for the extrication of this effluvium ; but its tendency in this way appears to depend solely on its greater compactness, in consequence of which, it retains humidity much longer than other soils, and thus favors the formation of marshes, and of standing pools of water. It is not, however, from marshy or low and humid soils alone, that this morbific effluvium is disengaged; for "there is scarcely a spot of this earth's surface to be found that is not covered or imbued with both vegetable and animal remains in a state of decomposition, and ready to afford pabulum for the sun's rays, with or without humidity, to extricate malaria."* Wherever vegetable matter meets with sufficient heat and moisture to cause it to enter into humid decomposition, there miasmata will be evolved, and in our own climate there are very few, if any situa- tions, that do not at times furnish all these conditions to a greater or less extent. A mixture offresh and salt water in marshes, appears to enhance the copious- ness and virulence of miasmata to a very obvious degree. It is a singular fact, that the water of the sea is much more apt to enter into putrefactive decom- position than fresh water; and this, no doubt depends on the great quantity of organic matter which it contains. M. Monfalcon mentions some interesting ex- amples illustrative of this fact.t The extensive pool of Valdec, in the south of France, is quite saline. Not more than a few rods from it is a large pool of fresh water called Engrenier. When the waters of these two pools rise, and run into each other, as they occasionally do, much sickness soon occurs throughout the adjoining parts. In the vicinity of Lukes, on the south of the Ligurian Apen- nines, there is a large marshy plain accessible to the high tides of the ocean. The neighboring districts were almost uninhabitable from the pestilential effluvia which emanated from this marsh, until the waters of the sea were separated from the sweet water of the marsh by means of sluices and hydraulic works, when it be- came healthy, and the population increased rapidly. Of the nature of koino-miasmata, we possess, as yet, no certain knowledge. Examined chemically, the air of the most pestiferous marshes is foifnd to differ in nothing from the purest and most salubrious air. According to the experi- ments of Professor Julia, of Lyons, it would appear that 1. The deleterious influence of koino-miasmata depends on particles of putrid animal or vegetable matter dissolved and suspended in aqueous vapor. 2. The air of marshes does not differ from atmospheric air in any of the prin- ciples which chemical analysis can detect. 3. None of the gases disengaged from bodies in a state of putrefaction, ex- hibit themselves in a sensible quantity. 4. The disorders caused by koino-miasmata are not in any degree dependent on the predominance of azote, of carbureted hydrogen, of ammonia, of nitrous oxide, &c, in the air. That koino-miasmata consist in particles of putrid vegetable and animal matter, dissolved in aqueous vapor, receives considerable support from the experiments of Gaspard and Magendie on the effects of putrid exhalations on animals, and which have already been cited in a former part of this volume. Magendie found, that on exposing different animals to the exhalations of putrid animal matter, affections were produced analogous to those which are known to occur in man from the influence of pestilential miasmata. It is not improbable, therefore, that such putrid materials, suspended in vapor, constitute the deleterious principle of miasmata of this kind; and it may be reasonably presumed, that the different modifications of disease produced by this agent, in different localities, depend in a great degree on the different degrees of concentration, as well as on the parti- cular character and proportion of the substances from whose decomposition the putrid miasmal particles are derived. It can hardly be doubted that the relative * Dr. James Johnson, Med. Chir. Rev. ■j" Histoire Medicale des Marais. Paris, 1828. MIASMATA. 47 proportions of animal and vegetable matter which may enter into miasmal exha- lations, will determine the violence of their influence, and modify its results on the system. Plausible as these sentiments may be, it should not be forgotten that they are founded on no certain data, and that we may, after all, as yet be remote from the truth in relation to this subject. Whatever may be our views concerning the essential nature of koino-miasma, observation has made us acquainted with certain of its physical properties, as well as with its general effects on the human system, and which is perhaps all that it imports us, in a practical relation, especially to know. Koino-miasmata possess a greater specific gravity than atmospheric air (De Lisle). They cannot, consequently, ascend into the air without being attached to and carried up by lighter bodies: and these vehicles consist, without doubt, of aqueous vapors. Hence, persons sleeping in elevated chambers, are much less apt to contract miasmal diseases than such as are lodged on the ground floor (Hunter on the Diseases of Jamaica, Blane, Lempriere,* De Lisle). And hence, too, the greater salubrity of hills, and very elevated parts, than the adjoining low grounds. The ancient Romans appear to have been fully aware of this fact, and they availed themselves of it by almost uniformly selecting very elevated posi- tions, or hills, for the sites of their towns. It is true, that some very remarkable exceptions have occurred to this fact. Bancroft mentions the great mortality which has repeatedly been observed on the top of Montefortune, at St. Lucie: and on the Hospital and Richmond hills, at Grenada, while the surrounding low situations were comparatively salubrious. Dr. O'Hallaran, in his account of the yellow fever of the south and east coasts of Spain, mentions similar examples of the great prevalence of miasmal diseases on very elevated situations, whilst the surrounding marshy grounds were but little infested with this deleterious efflu- vium. He refers particularly to Monjui, a hill 700 feet high, overlooking Barce- lona, the air of which, he says, is so deleterious, that it was found necessary to relieve the stationary guard every eight or ten days; and he adds that the inju- rious influence of the exhalations arising from the swamps below manifested itself more conspicuously upon the summit of the hill than in the subjacent parts. Dr. Blane, who mentions similar facts, explains them by supposing that the va- pors formed on the low and swampy grounds ascend, and, with the miasmata which they hold in solution, pass over the lower situations, and impinge and settle on the neighboring hills. It is, indeed, by no means uncommon to see fogs, which rise out of the low grounds, ascend and hover over the tops of the neigh- boring mountains, and it may well be presumed that these fogs will convey along with them a large portion of the miasmata which may be extricated from the same grounds whence the aqueous vapors rise. Koino-miasmata are abundantly precipitated to the surface of the earth during the night, and more especially during the first hours after the setting, and shortly before the rising of the sun. Hence, in part, the greater liability of contracting miasmatic diseases from exposure between the setting and the rising of the sun than after the sun is considerably above the horizon (De Lisle, Bancroft, Sir James Fellows, Johnson). The most dangerous point in the twenty-four hours of the day is " that which accompanies the setting and that which immediately precedes the rising of the sun, and the least critical time is when the sun is at its highest point above the horizon" (De Lisle). In these facts we have strong evidence of the correctness of an observation already made—namely, that the miasma is united with and suspended in the air by aqueous vapor, which, falling in the form of dew, carries down along with it the deleterious miasmatic particles. Koino-miasma may be arrested in its progress or passage from its source to * Drs. Blane and Lempriere, in their Report to the Secretary of War concerning the Walche- ren fi-ver, observe: "On no account should ground floors be used to sleep on: the more lofty the building.-. th« better, for the tenants of the upper stories not only enjoy the best health, but, when taken ill, have the disease in the mildest form.''—Bancroft on Marsh Exhalations. 48 MIASMATA. other parts, by whatever is capable of impeding and intercepting the progress of aqueous vapor. Thus the interposition of a dense forest, of a high wall or fence, of a chain of elevated hills, in short, of any mechanical obstacle of this kind, has been known to protect the inhabitants of villages, of camps, of convents, and of single habitations, from the pestiferous influence of neighboring marshes. De Lisle relates several very remarkable facts illustrative of this observation (Mon- falcon, Bancroft). A convent situated on Mount Argental, near the village of St. Stephano, was, for a long time, remarkable for its salubrity, until the trees by which it was surrounded were cut down, when it became extremely sickly. From the same circumstance, miasmata are sometimes confined by obstacles of this kind, and so accumulated in particular localities, as to acquire a high degree of concentration and power. Marshes surrounded with dense forests, in warm climates, have often given unequivocal illustration of this fact. The same effect, in causing a stagnation and accumulation of miasmata, has been observed in most situations environed by high hills. In some of the valleys in the mountainous regions of South America, malaria are thus accumulated to a degree which gives them the utmost virulency, while the surrounding elevated parts are entirely free from miasmal diseases. This is remarkably the case of Acapulco, which, as Dr. Macculloch* observes, may be regarded as a striking instance " of the imprison- ment of malaria by hills." It is in this way, too, says this writer, that we " may explain the peculiar virulence of jungles and pine swamps, and even of woods everywhere." Considerable diversity of opinion has been expressed as to the distance to which miasmata may be diffused from their source in a state of sufficient con- centration, to produce fever. In a quiescent state of the atmosphere, the sphere of activity is probably much more limited than has been generally supposed. Bancroft thinks that they are rarely carried beyond a quarter of a mile, even by unobstructed currents of air, in a state sufficiently active to produce fever; and he adduces several observations which seem to confirm this opinion. Unques- tionably, however, currents of air passing over marshes often convey the mias- mata which arise from them to a very considerable distance, sometimes several miles, in a state of concentration fully adequate to the production of their usual deleterious effects on the human system. " In Italy," says Dr. Macculloch, " the poisonous exhalations of the lake Agnano reach as far as the convent of Camaldoli, situated on a high hill, at the distance of three miles, proving that thus far, at least, malaria can be conveyed by the winds." The account of the thirty Roman noblemen, mentioned by Lancisci, is an interesting and striking illustra- tion of this fact. They were sailing near the mouth of the Tiber on a party of pleasure. Suddenly the wind shifted, and blew over the putrid marshes. Twentv- nine out of the thirty were soon seized with intermitting fever. The effects, often truly frightful, of the harmattan, after becoming loaded with the pestilen- tial effluvia of the swamps of Benin, afford also a strong illustration of this fact. From this circumstance it not unfrequently happens that those who reside on the leeward margin of marshes, or sluggish streams, are extremely harassed by mi- asmal diseases—while those who sojourn on the windward side remain almost entirely exempt from these affections. Dr. Macculloch relates an instance from his own observation which strikingly illustrates this fact. "An army was en- camped in a very pestiferous plain, yet the health of the men did not suffer, be- cause, being near the shore, the sea-breezes predominating at that season, swept back the malaria into the interior country. From some cause the encampment was transferred to another point, without recollecting that the change of the regular winds was approaching. They did commence, sweeping in a new direc- tion across the plain, and, within a few days, many thousand men were disabled or destroyed." During the autumns of 1820,'21, '23, and '24, there was scarcely a family be- * An Essay on the Production and Propagation of Malaria &c. MIASMATA. 49 tween the eastern shore of the Schuylkill and the city of Philadelphia, that did not suffer from intermitting and remitting fevers ; whilst among the inhabitants of the western shore, and of the high grounds a short distance back, there was, comparatively, but little sickness. The cause of this difference manifestly con- sisted in the course of the wind, which, during the periods here mentioned, as indeed is generally the case, blew almost continually from the west, northwest, or southwest, and thus swept the miasma, which was generated along the oozy borders of the Schuylkill, in an eastern direction. Violent storms, and copious showers of rain, tend powerfully to free the at- mosphere from koino-miasmata. The former violently disperses them, and the latter sweeps or washes them down to the surface of the earth. Nothing is more common than to find miasmatic epidemics to remit immediately after copious floods of rain or violent storms (Rush, Bancroft, Monfalcon). A humid air is a much better vehicle for the transportation of miasmatic exha- lations than a dry one. The particles of the miasmatic poison attach themselves to the humidity of the air, and are thereby carried along by currents of wind. It is to be remarked, however, that, although atmospheric humidity appears to favor the dissemination and action of miasmata, yet observation would seem to show that when these effluvia pass over a surface of water, they become ab- sorbed, or in some way lost. This circumstance may, in part, account for the short distance assigned by Bancroft to the dissemination of miasmata from their source; for in all the examples which he adduces in support of this opinion, the miasmata were conveyed over bodies of water. II. Idio-miasmata.—This variety of miasmata is generated by the decomposi- tion of the matter of perspiration, and the other excretions of the animal body; and hence it most frequently occurs in the confined and crowded hovels of the poor, in crowded jails, ships, hospitals, and wherever many individuals are con- fined in apartments not duly ventilated. From an inability to procure separate dwellings, the poor are generally obliged to take up with small apartments, into which two or three families are often crowded ; and in order to save fuel, and indeed frequently from the total want of fuel, every access of the external cold air is carefully cut off. Add to this the filth and want of proper Changes of clothing, almost inseparable from extreme poverty, and you have a combination of circumstances peculiarly calculated to generate a miasma, by the putrefactive decomposition of the animal exhalations with which the air and every article of clothing in such apartments must be saturated. It is chiefly during the cold season of winter that this variety of miasmata is generated. When the weather is warm, the air of crowded and filthy apartments is constantly renewed by the doors and windows being kept open, and the accumulation and stagnation of the animal exhalations thereby prevented. Dr. Smith observes, that this miasm is especially apt to be generated in the apartments of the sick, particularly " of those who are laboring under the typhus state of fever."* It may be observed, however, that the exhalations which emanate from the body in a state of disease, and which possess the power of producing the same disease as that under whose influence they are evolved, cannot, with strict propriety, be ranked with the present class of miasmal poisons. They belong to the contagions. I would restrict the term idio-miasma to those morbific effluvia which are generated by the decomposition of the animal secretions, whether formed in a state of health or disease, and to the ordinary exhalations from the body, when accumulated in such a manner as to deteriorate the atmosphere of confined rooms, if these be really capable in themselves, and without decomposition, of exciting fevers. Idio-miasmata are always quite limited in the sphere of their influence. Be- yond the room or habitation in which they are generated their operation can- not extend; unless, indeed, they are absorbed or adhere to articles of clothing, and are conveyed abroad in a state of sufficient activity to act on the human ' Elements of the Etiology and Philosophy of Epidemics, p. 52, 4 50 MIASMATA. system. Whenever fever is found to spread from a source of idio-miasmata, it is in consequence, doubtless, of the generation of a new contagious miasm by the disease, which is produced in the first instance by the idio-miasmatic poison. I am well aware that this opinion involves what has been declared a manifest in- consistency—namely, the origination of a contagious disease by a common or general exciting cause. All such objections, founded merely on speculative inferences, may be met by facts, which must stand good, however irreconcilable they may appear to be with the dogmas of philosophy, or with admitted princi- ples. It is a fact, for instance, that typhus may be originated by the miasm resulting from the decomposition of the secretions or exhalations of even healthy individuals, crowded and confined a long time in narrow and unventilated apart- ments. And that, although not necessarily a contagious malady, typhus may, under peculiar circumstances, generate a specific virus which is capable of ex- citing the same disease in others, is a fact supported by a mass of testimony which cannot be reasonably rejected. "There are a few physicians," says one of the most eminent medical writers of the present day,* " who believe that epi- demic or endemic fevers arise from specific contagion, though facts daily teach us that typhus, yellow fever, dysentery, &c, occasionally, and under particular circumstances, give out a something (call it what you please), which produces a similar disease in the healthy stander-by, who happens to come within its range. If we may venture to prognosticate, we would anticipate that this will be, as it assuredly now is, the more general opinion among practitioners." From the circumstance of this variety of miasmatic poison " becoming innox- ious when diffused in the atmosphere, even a few feet beyond the apartments in which it is generated," none of the forms of disease, which it is capable of pro- ducing, are apt to occur epidemically. Typhus, nevertheless, has been known to occur in a manner well entitled to the name of epidemic. The late widely-spread epidemic of Ireland was surely strongly characterized in its progress and extent of diffusion by every feature which can give to diseases the character of an epidemic. Though engendered and nursed in the lap of wretchedness and poverty, it did not, in its desolating sway, fall exclusively upon those who were suffering under the distressing privations of penury. Its fatal visitations were abundantly made to the ample and airy habitations of plenty and comfort, and almost— ------Eequo pulsat pede pauperum tabernas Regumque turres. The question here occurs: " If idio-miasma becomes innoxious by being diffused in the atmosphere even a few feet beyond the apartments in which it is engendered," how can typhus, which is manifestly originated by this effluvium, become epidemic, or be produced in large and well-ventilated dwellings remote from the usual sources of this miasm? Is it by the idio-miasma attaching itself to the clothes of individuals, or to other substances by which it may be con- veyed from one to another place? If this be admitted, then idio-miasma must possess the character of a contagion. Is it not more probable, that in the majority of instances of this kind, the disease is propagated by a specific virus, generated by a morbid secretion, and conveyed as other contagions of an aeri- form character are conveyed? It does not seem probable that idio-miasmata can be disseminated by fomites. If it can be so disseminated, it must possess all the characteristics of a veritable contagion. Of the relations of Miasmata to the Animal System, fyc. Having given an account of the physical character and conditions under which the two infectious effluvia, koino and idio-miasmata, are evolved, I proceed to the consideration of their relations, as morbific agents, with the human system, as well as with each other. Upon this subject I stand largely indebted to the * Dr. James Johnson, Med. Chir. Rev., vol. vii. (1825), p. 65. MIASMATA. 51 ingenious and truly philosophical work of Professor Smith, of New York; for, although I have long since entertained similar views in relation to the combined agency of these miasmal poisons in the production of fevers, yet the enlarged, systematic, and precise views taken of this subject by Dr. Smith, have afforded me some new and interesting insights into this part of the etiology of fevers. The class of fevers arising from koino-miasmata are very distinct in their ge- neral character, and we may presume, in their essential natures, from those which are the result of idio-miasmata. The former give rise to intermittent, remittent and bilious fevers; and the latter miasm is the source of typhus, and the low nervous fevers of former writers. The deleterious power of koino-miasmata is manifested not only by the vio- lent and fatal fevers which they are known to produce so abundantly, but also by the more slow inroads they make on the physical and moral condition of those unfortunate beings who are habitually exposed to their influence. The indigenous inhabitants of marshy districts, in warm climates, present an aspect of suffering and wretchedness from this cause which is well calculated to draw forth the commiseration of those who are more fortunately located. Continually exposed to the deleterious influence of these baneful exhalations, man, in such situations, exhibits a state of feebleness and early decrepitude, strongly indicative of a broken-down constitution, and deep, irremediable chronic disease. So deep and pervading, indeed, are the effects of malaria on the human system, that it never fails to debase, in a remarkable manner, both the physical and moral con- stitution of a people, who, through successive generations, reside in situations abundant in perennial sources of miasmata. Not only do the stature and sym- metry of the body suffer conspicuous deterioration, but the mind becomes torpid, feeble, pusillanimous, and the moral sentiments debased. But while such chronic and constitutional effects are wrought by the habitual endurance of koino-miasma, the system loses its susceptibility of being excited into those violent commotions of febrile action which this agent is so apt to pro- duce in individuals less accustomed to its impressions. The natives of marshy districts are comparatively much more rarely affected with the higher grades of miasmal fevers than those who are only occasionally brought within the sphere of its influence. In the former, the agency of this poison proceeds as it were by a slow and concealed combustion, whilst in those who are not accustomed to its influence, its effects burst out in a raging and rapidly consuming flame. There can be but little doubt that koino-miasma varies in its powers, and often very considerably, according to various circumstances in point of locality, and the relative proportions of the animal and vegetable matter which supply the materials for its composition. Dr. James Johnson, whose authority I am always disposed to respect, has expressed his belief in the occurrence of such diversities in the peculiar morbific powers of this agent. "The fever of Batavia," he observes, "differs from the fever of Walcheren—the fever of Antigua, from the fevers of the Ganges—and all these differ materially from the plague of the Levant." That certain countries and localities have an especial tendency "to generate one mode or variety of fever, while, in other situations, some other variety as exclusively prevails," is an observation founded on abundant testimony of unquestionable authority. In Germany, intermittents almost universally as- sume the tertian type; in Italy, the quotidian type greatly predominates; and in Hungary, paludal fevers are peculiarly apt to be attended with petechia?. "The fevers of the Pontine marshes are noted for the shortness of their intermissions; whilst Holland is not less remarkable for the variety of the types than the slow progress of the fevers. In Spain, as in Africa, the West Indies, and the southern parts of the United States, the black vomit and the yellowness of the skin are similarly characteristic symptoms."* Even in localities situated within a short distance from each other, the most remarkable difference occurs in the character • An Essay on Malaria, &c , by John Macculloch, M. D. 52 MIASMATA. of the fevers which they engender. Thus, "the fevers of Walcheren," says Dr. Macculloch, "differ materially from those of Bresken on the opposite shore of the Scheldt; and in France those of Rochefort differ as completely from those of the Lyonnais." It cannot be presumed that the relative proportions of animal and vegetable matter should be the same in different localities, and equally improbable is it that the same kinds of these materials should be present in the different situations where miasmata are generated. There must be great diversity in both these respects, and a corresponding diversity in the essential morbific qualities of the miasmata evolved from them. I have already mentioned the experiments of Magendie in relation to the effects of putrid animal substances on the animal system. From these, it appears, that "different kinds of flesh, when in a putrid state, produce different effects on the animal economy,"* and it is, therefore, reasonable to conclude that miasmata will differ in their powers according to the greater or less proportion and kinds of the animal and vegetable matters con- cerned in their production. The influence of koino-miasmata on the human system, like that of other general causes of disease, is much under the control of the physiological state of the animal economy, of idiosyncrasy, of temperament, predisposition, and of accidental external causes. Thus of a number of individuals exposed for a cer- tain time to the same miasm, some may become affected with intermittent fever, others with mild remittent fever, some with malignant bilious fever, some with bilious colic, some with dysentery, and others, perhaps, will escape the disease entirely. The influence of high atmospheric temperature in predisposing the system to the deleterious impressions of miasmata is, probably, very considerable. Long continued exposure to solar heat appears to have an especial tendency to affect the biliary organs, and to render the system generally irritable. These condi- tions, it may be presumed, are peculiarly favorable to the morbific influence of malaria; and it is not improbable that they sometimes contribute, in a consider- able degree, to render the miasmatic fevers of intertropical or hot climates so peculiarly violent and dangerous. Dr. Macculloch dwells much on "errors of diet" as a predisposing cause of the miasmal fevers. It would appear, that the free use of animal food, in tropical climates, is peculiarly calculated to favor the morbific influence of miasmata; and this is said to be especially the case when the animal food is taken " in the middle of the day, or frequently in one day." On examining Niebuhr's narrative, says Dr. Macculloch, "it is most apparent that the deaths of his companions were the consequences of gross feeding." "On this question," says the same writer, "there can perhaps be no better evi- dence than the opinions and practices of the intertropical nations themselves, among the mass of whom this subject seems well understood; while in many countries it is a caution actually often given to Europeans by the natives, though most generally neglected by them. It is, probably, from long experience, in some measure, of its advantages, as well as from more obvious causes, that a vegetable diet is so general throughout the aborigines of the torrid climates, while it is doubtless from principle, also, that among the people of Africa, to the north- ward, at least, the sole or the principal meal is supper." The class of diseases produced by koino-miasmata, if we take into view their various modifications, is by no means limited in its range. The most simple form of disease arising from this cause is the intermittent fever. In proportion as this febrific effluvium increases in potency, so does it produce fevers of a higher and more violent grade. The range of activity of this miasma extends from the simple tertian of the temperate latitudes to the malignant and fatal plague of the East, or the scarcely less fatal bilious fever of Batavia. Besides general fevers—assuming an endless diversity of character in different * Journal de Physiologie,. Janvier, 1823. MIASMATA. 53 seasons and climates, koino-miasmata produce, also, various other affections, both local and general. Dysentery, cholera, and diarrhoea, are enumerated among the maladies produced by malaria. It may be doubted, however, whether miasma, by itself, without the co-operation of other causes, has any particular tendency to excite those affections. I apprehend, that in many instances occurring in ma- larious districts, as elsewhere, atmospheric vicissitudes, or cold, exerts no small degree of influence in determining the disease upon the alimentary canal. Dur- ing the autumn of 1814, one-fourth, perhaps, of the men of four regiments en- camped near Baltimore, were affected with intermitting and remitting fever in the month of September. The weather was remarkably warm, equable and dry. The months of October and November, however, were rainy, extremely variable in temperature, and the majority of the men, who were previously lodged in covered rope-walks and houses, were now encamped in tents. A week after the rainy and cold weather set in, dysentery and diarrhoea began to appear abund- antly, and in the course of three weeks more, there were but very few cases of intermitting or remitting fever, but more than eight hundred cases of dysentery. Nevertheless, the capability of miasmata of producing these forms of intestinal disease by its own unaided powers, is not to be questioned, although it is, I think, equally evident, that the co-operation of sudden changes of atmospheric tempera- ture, or cold, is especially calculated to enhance the tendency of the miasmata to occasion these diseases. From these remarks, cholera ought to be excepted, for the cholera of India, at least, is most undoubtedly the product of a miasmatic agent. Dr. Macculloch mentions tic douloureux as a common consequence of the in- fluence of miasmata—more especially in Italy; and the occurrence of periodical hemicrania, from this cause, is by no means unfrequent even in our own climates. In truth, there is scarcely a malady that may not be produced or simulated by the operation of malaria on the human system. The period which intervenes between the reception of koino-miasma and the first manifestation of its influence on the human body, is extremely various. Of many persons exposed to it at the same time, some may be immediately af- fected, others in a few days, some not until several weeks have passed, whilst others may remain free from its effects a still longer time. As the powers of koino-miasmata most probably vary considerably in different countries and localities, it may be inferred, as has already been observed, that the fevers which they produce are impressed with a corresponding diversity in their character; and observation would seem to confirm this inference. Dr. Smith thinks, that whatever external or general diversities may occur in fevers produced by this miasma, " their pathology or essential nature is everywhere the same." This is highly probable; for the diversities in question would seem to depend more on the mere grade of violence, local affections, and general course of these fevers, than on any radical difference in their essential pathological conditions. Upon this point, however, it becomes us to speak with diffidence, as this ques- tion cannot be solved by mere closet inferences and reasonings, but by close ob- servation and careful experience, in relation to these fevers as they occur in vari- ous countries, climates, and localities. How far a mixture, or the combined agency of koino and idio-miasmata, may operate in producing novel or anomalous varieties of fever, it is impossible to say; but that such a combination does sometimes occur, and give rise to fevers of a peculiar or mixed character, will scarcely be doubted by any one who has given due attention to this interesting subject. Professor Smith, to whose work I have already so frequently referred, has given this subject a comprehensive and minute consideration, and to whom, indeed, the credit is due for introducing this interesting point of etiology to the notice of the profession. " Let us suppose," says Dr. Smith, " the circumstances in which typhus originates, to occur in sum- mer, such as the crowding of individuals into small apartments, badly ventilated, and rendered offensive by personal and domestic filth. These causes would 54 MIASMATA. obviously produce typhus in its ordinary form. But suppose there exist, at the same time, those exhalations which occasion plague and yellow fever, or inter- mittent and remittent fevers. Under such circumstances, we should not expect to see any one of those diseases fully and distinctly formed, but a disease of a novel or modified character." There exists no doubt in my mind of the correctness of Dr. Smith's observation, that the late Bancker Street fever in New York, as well as the peculiar fever which prevailed among the blacks in this city, a few years ago, was engendered by the united influence of these two miasmal poisons. I once had a striking illustration of the anomalous and fatal character which the united action of koino and idio-miasmata is apt to impart to fever. During the fall of 1814, while attending in the capacity of regimental surgeon, in the en- campment at Baltimore, ten men affected with mild remitting fever were lodged in a room of confined dimensions, and as the weather was cold, the room was kept pretty warm by fire, and the doors and windows as little opened as was ad- missible. The adjoining room was exceedingly crowded with invalids, and but little attention paid to cleanliness and ventilation. In a short time several cases of fatal typhus occurred in this room. Soon after this, the patients who were affected with intermitting fever in the next room, manifested new and more alarming symptoms ; blood began to ooze from their gums ; extreme tenderness of the epigastrium occurred ; the intellect was but little disturbed; the eyes were dull, watery, and staring; the temperature of the skin and the pulse nearly na- tural; the animal powers so little prostrated, that one of the men died a few mi- nutes after he had been sitting up with his back leaned against the wall of the room. They were all immediately removed to the Baltimore Hospital, and all except one died in a few days. There can be no doubt that this peculiar modi- fication of febrile disease was the result of the impressions of idio-miasmata (engendered in the house), made on systems already under the morbific influence of koino-miasmata.* * A considerable effort has of late been made to destroy the doctrine of miasma. Dr. Willis, in his treatise on the Pathology of Fever, totally denies the existence of miasma, and inscribes all its imaginary influences to moist warm air. He advances many arguments in favor of this idea, and quotes the observation of Fourcault, that a healthy animal will soon die if its body be covered with an impervious glaze. " Becquerel and Breschet, repeating the experiment of Fourcault, discovered that the extinction of life under such circumstances was accompanied by a signal fall of temperature; the animal whose body was endued with an impervious glaze, began to lose heat on the instant, and the loss never ceased till life had fled." The function of the skin is intimately connected with vital manifestations—and Dr. Willis conceives that this explains why such serious consequences should follow its derangements. "In a hot dry atmo- sphere animals perish from the effects of excitement; in a warm, moist air of a temperature no higher than that of their own bodies, they die as they do when covered with an impervious glaze—the conditions requisite to the access of oxidized plasma, and the removal of deoxidized plasma are wanting, and life ceases as a matter of course." The reviewers, who show the greatest deference to the views of Dr. Willis, attribute much importance to the fact that the dew point in warm and moist situations is very little below the temperature of the atmosphere; and also to the new observation of Fourcault, that albuminous urine is produced by covering an animal with glaze. Notwithstanding the ingenuity of these ideas, and the importance of these facts, it will be found very difficult to overcome the weight of evidence brought forward in the preceding chapter to prove the existence of miasma from the influence of winds, situation, atmospheric vicissitudes, &c. This theory of Dr. Willis is, moreover, very deficient in the way of accounting for the varie- ties of such fevers as are usually attributed to the different forms of marsh effluvia. How can a single cause like "warm and moist air," produce a quotidian in one place, a tertian in another a bilious remittent in others—with all the various epidemic and endemic complications of them that are so constantly remarked by authors and practitioners? How can a mere exposure to such a condition of the air produce a predisposition to fever which is frequently not developed until the lapse of many weeks'? There is no validity in the argument that miasm does not exist, because we cannot analyze it by chemical reagents. We do not doubt the existence of the contagious cause of small pox, although no chemistry can appreciate it.__(Mc.) CONTAGION. 55 Sect. V.—Of Contagion. By a contagion is understood a deleterious agent secreted by the animal body in a state of disease, which, when brought to act on a healthy individual, will produce a disease specifically similar to the one from which it derives its origin. Contagions occur under two distinct forms, and may, therefore, be divided into two varieties: viz., 1. Those which consist of a palpable matter or virus; and, 2. Those which consist of an imperceptible effluvium. The chronic contagious maladies are propagated exclusively by a palpable virus, and consequently always by actual contact. Those acute contagious diseases which are not attended by a specific local affection, or an exantheme, are, on the other hand, exclusively propagated by a morbific contagious effluvium, and by consequence, solely through the medium of the atmosphere. Those acute diseases, which are essen- tially connected with a specific local affection, or an exantheme, are communi- cated both by a palpable virus, and by an imperceptible effluvium, and conse- quently both by actual contact and through the medium of the atmosphere. We perceive, therefore, that of the extremes of a purely local, and a purely general malady, there is, on the one hand, communication of the disease solely by a palpable matter, and, on the other, by effluvia only; and that where the local and the general affections meet in the same disease, as essential concomitants, (in the exanthemata,) there the two modes of propagation also obtain.* It must be observed, however, that though in a practical point of view we may properly adopt these distinctions between contagions communicated by contact and through the medium of the atmosphere, yet, in reality, an actual contact must, necessarily, always occur between the contagion and the individual, before it can possibly produce disease, whether the contagion be a palpable matter, or an imperceptible miasm. The only material difference consists in the mode in which this contact is effected. One of the most remarkable peculiarities of contagious diseases, is their in- herent and undeviating tendency to preserve their essential individuality, under whatever circumstances of age, sex, constitution, temperament, modes of living, climate, and place, they may occur. Thus, the small-pox of the present day differs in no essential circumstance from the same disease as it was observed and described by Rhazes more than eight centuries ago; and the itch has changed in nothing since the time of Galen. Any certain contagion can, so far as we know, produce only one disease; and if the system has become insusceptible of such disease, its peculiar cause is no longer a morbific agent in relation to that system. The laws of the acute contagious diseases differ entirely from those which govern the rise, progress and declension of the chronic contagious affections. The former observe the utmost regularity in all these respects. The rise, ad- vancement and decline, in short, the whole series of essential phenomena, are governed by laws as steadfast as those which regulate the motions of the planets. The latter class of diseases, on the contrary, are extremely irregular in their course, having no definite period of duration, nor established order and duration of the successive phenomena of their course. The power which the acute contagious diseases have of destroying the sus- ceptibility of the human system to the subsequent influence of their specific causes, constitutes one of the most remarkable and mysterious characteristics of this class of maladies. In this respect, they differ as far from the chronic affec- tions of this kind, as they do from the febrile diseases produced by general or * This arrangement is adopted from Dr. Hosack's very lucid classification of contagions and their peculiar diseases. There is no writer of the present day whose views upon the character and arrangement of this class of maladies deserve higher respect and attention tlian those which have been promulgated by Dr. Hosack. 56 CONTAGION. non-contagious causes. In consequence of this law of acute contagious diseases, no malady of this kind can ever relapse during the period of convalescence. Considerable diversity of sentiment has been expressed in relation to the dis- tance to which contagious miasmata may be dispersed from their source, in a state of sufficient activity to generate disease. That their sphere of activity is very limited, however, has been abundantly demonstrated both by direct expe; riment and observation. The experiments of Dr. O. Ryan, professor of physic in the college of Lyons, prove that the contagious miasm of small-pox does not extend more than a few feet beyond its source.* The most malignant contagions are rendered inert and harmless by being diffused in the atmosphere, and even by diffusion in the air of a well-ventilated apartment. Ventilation diminishes the activity of contagious effluvia simply by diffusing the miasm in a large por- tion of atmospheric air, in consequence of which those who become exposed to it, receive it in weak and inefficient doses. Contagions are perpetuated and conveyed to great distances from their source, by being absorbed by, and attached to, various substances, such as clothing, fur- niture, bedding, &c, with which they are often transported even across the ocean. Animal substances, such as wool, hair, and articles manufactured from them are said to retain contagious matter with the greatest tenacity. The more the sub- stances which have become saturated with contagion are kept from the access of the open air, the more virulent and active will be its powers when it is brought to act upon the human system. Thus articles of clothing, after having been im- pregnated with contagious virus, will retain the power of infecting much longer, and in much greater intensity, if they are kept confined in close rooms, or locked up in chests or closets, than when they are freely exposed to the open air. It is by articles of this kind, locked up in trunks, that the small-pox, and other con- tagious maladies, have been conveyed to distant parts of the world in ships, although no person on board may have been sick with the disease during the voyage. The articles which are thus imbued with contagious virus, are called fomites. It was the opinion of Cullen, that contagions are more powerful when they are thus lodged in fomites, than when they arise immediately from the human body, or when in a separate state. The same opinion is expressed by Dr. Lind. The influence which peculiar atmospheric constitutions have on the activity of contagions, and on their tendency to dissemination, is a subject as interesting as it is inscrutable. The most careless observation is sufficient to convince any one, that there exists in the varying constitutional, or perhaps accidental condi- tions of the atmosphere, a powerful modifying principle in relation to the powers of contagious agents. At times, it would seem impossible for a contagious dis- ease to extend the sphere of its ravages; for, although sporadic cases may occur here and there, yet no neglect in relation to proper seclusion will enable the dis- ease to assume an epidemic or endemic character. During other periods, on the contrary, the accidental importation of fomites, or the occurrence of a case of contagious disease, acts like a spark of fire thrown among combustible materials, and speedily spreads disease extensively among the people. The same power- ful atmospheric influence shows itself in the diversity of character, in relation to the grade of violence, malignity, and general diathesis, which the same malady is observed to assume at different periods of its prevalence. That these things depend on some modifying agency of the atmosphere, there can exist but little doubt. What this condition of the atmosphere consists in, it seems impossible to ascertain; it is probable, however, that it has no immediate connection with either the temperature or the hygrometrical state of the air; for with the excep- tion of typhus, which is manifestly favored by cold weather, the contagious diseases of every kind prevail equally during the heat of the summer and the cold of the jvinter. The mode in which contagions are either favored or re- * Rees's Cyclopaedia; art. Contagion, CONTAGION. 57 tarded in their progress, by atmospheric constitutions, consists, probably, not in any influence which they may exert immediately on the powers of the contagion, but rather, perhaps, in their tendency to modify the human constitution, so as at one time to render it peculiarly susceptible of the influence of the contagion, and at another to diminish, or for a time to annul, the natural predisposition to its operation. Of the primary source of contagion we know but very little. It is probable, that each contagious disease was at first developed, independent of contagion, by the accidental concurrence of various circumstances, which, in the infinite series of such contingencies, may not again occur for many centuries. That a disease may be originated by the concurrence of general causes, without the agency of a contagion, and which may afterwards communicate itself to others, by a specific virus of its own elaboration, we have a familiar example both in typhus fever and in itch. There is reason to believe, indeed, that various contagions have been thus produced, which have long since passed away from the face of the earth ;* and it is not an idle conjecture to say, that new contagions may hereafter arise, which, after having exhausted their power on mankind, may again disap- pear forever, or until a similar concurrence of causes, which at first evolved the contagion, again occurs. It is an interesting fact, that contagious diseases sometimes originate in the lower orders of animals, and are afterwards communicated to the human species. Hydrophobia and the vaccine disease are familiar examples of this kind. Pro- fessor Remur has published some observations which go to show that other dis- eases, such as the virulent coryza of horses, the plica of long-haired animals, and the gangrenous inflammation of the spleen, which occurs in cows, may be com- municated by immediate contact to man. The following rules have been recommended for preventing the spread of con- tagious maladies to those who are obliged to approach patients laboring under diseases of this kind (Haygarth). 1. " The chamber in which the patient lies must be kept clean and freely ven- tilated. No bed curtains must be allowed to be drawn around the pa- tient." 2. " Dirty clothes, utensils, &c, should be often changed, and immediately immersed in cold water; and washed clean when taken out." 3. " The discharges from the patient must be instantly removed ; and the floor around the patient should be rubbed clean once a day with a wet cloth." 4. " Avoid the current of the patient's breath, as well as the effluvia which ascend from his body, and from the evacuations." 5. " Visitors ought not to go into the patient's chamber with an empty sto- mach ; and, in doubtful circumstances, on coming out they should blow from the nose and spit from the mouth any contagious poison which may adhere to these passages." Although it is quite certain that contagions will adhere to and imbue various substances, especially clothing, so as afterwards to reproduce the same disease, at a distance from their source, and often a long time after they had been gene- rated ; yet it seems to be well ascertained, that such substances (clothing) can rarely be so greatly imbued with contagion by a slight and transient exposure to the poison, as to be capable, afterwards, of producing disease in the healthy. The clothes of transient visitors, for instance, will scarcely ever imbibe sufficient contagion to communicate the disease to others. Dr. Clark affirms, " that in eighteen years of medical practice, he never communicated the contagion of * The sudor Anglicanus, so accurately described by Caius, appears to have been a highly con- tagious disease. It visited England five times in the period of seven years, and swept off a vast number of victims by its fatal violence. In many instances, those who were affected with it died within an hour, and few who sank under its malignity suffered longer than four or five hours. It has not been known to occur for several centuries past, its contagion having long since become wholly extinct. 58 GENERAL COURSE, ETC., OF FEVER. small-pox or of scarlet fever to any one, although he had frequently, on the same day, visited many patients sick with these diseases, and in their most malignant forms." Mere ventilation is inadequate to destroy the contagion deposited in fomites. To effect this important object, a great variety of means, such as exposing them to various vapors and fumes, have been devised. Without enumerating the different disinfecting agents which have been successively brought forward and again re- jected, it will be sufficient to mention those which experience has shown to pos- sess active powers in this respect, and which are now relied on as unquestionable disinfecting agents. The nitrous acid vapors have been much employed for disinfecting ships and houses in which contagion has been found to exist. Such was the evidence brought forward of the efficacy of the nitrous acid fumes in purifying infected places and fomites, that the British Parliament voted a national donation of five thousand pounds to Dr. Carmichael Smith for the discovery. This vapor is readily obtained by mixing with powdered nitre, in a cup, a little of sulphuric acid, and applying gentle heat with a lamp. At present, however, chlorine, and the chlorides of lime and soda, are regarded as decidedly the best disinfecting agents we possess. M. Labarraque's disin- fecting soda liquid is a compound of soda and chlorine, and its efficacy in de- stroying infectious matter has been conclusively demonstrated. " It is now much used in removing the offensive odor arising from drains, sewers, or all kinds of animal matter in a state of putrefaction. Bodies disinterred for the purpose of judicial inquiry, or parts of the body advanced in putrefaction, may by its means be rendered fit for examination; and it is employed in surgical practice for de- stroying the fetor of malignant ulcers. Clothes worn by persons during pestilen- tial diseases, are disinfected by being washed with this compound. It is also used in fumigating the chambers of the sick, for the disengagement of the chlo- rine is so gradual, that it does not prove injurious or annoying to the patient. In all these instances chlorine appears actually to decompose the noxious exhala- tions by uniting with the elements of which they consist, and especially with hydrogen." " Pure chloride of soda is easily prepared by transmitting to saturation a cur- rent of chlorine gas into a cold and rather dilute solution of caustic soda. In pre- paring the disinfecting liquid of Labarraque, it is necessary to be exact in the proportion of the ingredients employed. The quantity used by Mr. Faraday, founded on the directions of Labarraque, are as follows : Dissolve 2800 grains of crystalized carbonate of soda in T28 pint of water, and through the solution contained in a Wolf's apparatus, transmit the chlorine evolved from a mixture of 967 grains of sea-salt and 750 grains of peroxide of manganese when acted on by 967 grains of sulphuric acid diluted with 750 grains of water."* CHAPTER III. OF THE GENERAL COURSE, TYPE, AND STAGES OF FEVER. The series of phenomena which intervene between the commencement of a fever, and its termination in convalescence, constitutes what is technically called its course. The course of a fever is either intermitting, remitting, or continued, according as its phenomena intermit, or remit, or are continuous. The series of phenomena which constitute the course of a fever, may be di- * Turner's Elements of Chemistry. GENERAL COURSE, ETC., OF FEVER. 59 vided into six periods or stages: viz., (he forming, the cold, the hot, the critical, the declining, and the convalescing periods. It should be observed, however, that these stages are not always distinctly marked, in violent and continuous forms of fever, although very few fevers occur in which the primary stage of oppression, the stage of excitement, and the period of declension, may not be distinctly observed. The febrile paroxysm of an inter- mitting fever offers the most distinct exemplification of the successive changes or stages which occur in the course of a fever. 1. The forming stage—the stadium prodromorum includes the period which intervenes between the first impressions of the febrific cause, and the actual com- mencement of the febrile phenomena. This period is characterized by a variety of feelings or sensations, which, though manifesting a deviation from the healthy condition of the system, do not constitute any definite state of disease. These constitute the premonitory symptoms. Their duration is very various ; and in some instances, though very rarely, they are entirely absent—the disease making its attack at once, without any previous manifestations of its approach. This is most apt to occur in fevers of very vigorous reaction, and in such as are of a malignant character. The longer or shorter duration of the premonitory stage depends, however, probably as much on the different powers of vital resistance as on the difference in the degree of concentration or activity of the remote febri- fic cause. The whole train of premonitory symptoms may be regarded as the result of the struggle between the vital powers and the febrific cause. If the cause be feeble, and the vital resistance great, its first impressions may give rise to some unusual or unpleasant sensations, until the system finally triumphs over its influence, and disease be obviated. When the relative powers of the cause and the vital resistance are more nearly balanced, the struggle between them may be prolonged, until the latter yield and disease be developed; and where the system resists feebly, whilst the febrific cause acts with energy, the contest will probably be short, and the fever occur suddenly, with violent symptoms. There exists, nevertheless, in almost every febrific cause, a natural tendency to produce some peculiar premonitory symptoms, although the general and most conspicu- ous of these phenomena are pretty nearly the same in almost every form of febrile disease. In general, those fevers which are apt to run through a protracted course, have a much longer train of premonitory symptoms than such as are violent and of short duration. Thus, the premonitory period is almost uniformly much more protracted in typhus and typhoid than in the synochal fevers. The following are among the most common symptoms of this initial period of febrile affections: loss of appetite ; disturbed sleep; yawning, stretching, lassi- tude; wandering pains in the limbs and back ; an unpleasant sensation in the sto- mach ; a harsh and dry skin; irregularity of the bowels ; a general feeling of mal- aise; nausea; eructations; interruptions of the ordinary habits and appetites; fretfulness ; discontent; slight headache ; slight creeping sensations of cold ; the drying up of old sores; tremors of the extremities ; changed expression of the countenance; giddiness; and perhaps some other slight deviations from a state of perfect health, or the ordinary habits and feelings of the individual. If we examine the symptoms of this stage in the usual order in which they occur, we will perceive that the nervous system is the first that suffers ; this is manifested by the lassitude, languor and slight transient pains, which usher in this stage. Next, the digestive organs are brought into a state of slight suffering; and finally the skin. The heart and arteries appear to be the last organs which are brought into morbid action in the development of fever. 2. The cold stage.—Nearly all fevers commence with more or less sensation of chilliness. The feeling of cold is not always attended with an actual subduc- tion of sensible temperature. In some instances the skin of the patient feels warm to the touch, whilst he is shivering under the severest sensations of cold. It is manifest, therefore, that in such cases, the feeling of cold depends in reality on an altered or morbid condition of the sensibility of the skin, in consequence 60 GENERAL COURSE, ETC., OF FEVER. of which its power of perceiving (if I may use the expression) the ordinary degree of animal temperature is diminished. In most instances of febrile chills, however, there occurs an actual reduction of the temperature of the surface, espe- cially of the hands and feet. Not unfrequently these parts feel quite cold to the touch of a healthy person, whilst the surface of the trunk and the forehead are of the natural temperature, and sometimes apparently even higher; although the sensation of chilliness experienced by the patient will be diffused throughout his whole system. The chills are attended with a pale, contracted, and dry state of the surface; the volume of the body is diminished ; the respiration confined, irregular, anxious, and oppressed, attended frequently with a short dry cough; the head feels confused ; the tongue is dry, attended sometimes with great thirst; the pulse extremely small, frequent, and feeble; nausea often occurs, and some- times vomiting. The sense of chilliness is usually diffused over the whole body; though in some instances, it is partial, and occasionally, limited to a small part of the body. In general, the more violent the chills are, the more vigorous will be the subsequent arterial reaction. As the cold stage gradually subsides, the arterial reaction regularly rises, until chilliness has wholly gone off, and the disease has entered into the 3. Third, or hot stage.—This stage is characterized by what may be termed the essential phenomena of fever : viz., augmented heat, and a return of the natural fullness and color of the surface ; flushed countenance; a full, quick, fre- quent and vigorous, or a small, tense, quick and frequent pulse ; throbbing pain in the head; eyes prominent and sensible to the light; a dry and hot skin; urine scanty and high-colored; continued wakefulness, &c. These symptoms, with more or less intensity, continue for a longer or shorter period, until the acme of the febrile condition has arrived at the period when 4. Crisis supervenes. By crisis is understood, in the most general accepta- tion of the term, that period in the course of a fever at which it has arrived at its highest point, and a determination either to a fatal or favorable issue takes place ; and by which, therefore, the fate of the patient is determined. The period dur- ing which this decision occurs, is necessarily always short; and is almost univer- sally attended with some evacuation. The most common critical evacuation of a simple febrile paroxysm consists of a very greatly increased flow of perspiration, and hence the subsequent period during which this evacuation is continued, is called the sweating stage, but which 1 would call 5. The stage of declension—stadium decrementi morbi.—This stage may be considered as commencing immediately after the favorable crisis has taken place. In the rapid, continued fevers, and in a single paroxysm of an intermittent, one crisis only occurs ; but in by far the greater number of protracted, and especially in remitting fevers, the crises continue to recur through the whole period of de- clension at every tertian exacerbation, until the disease is finally subdued. The duration of this stage is extremely various. In general, the period of declension will be pretty nearly in proportion to the period occupied in the progress of the fever at its acme. The space of time which is occupied by one paroxysm of a fever and its suc- ceeding intermission, or which intervenes between the regular periodical exacer- bations of fever not paroxysmal, is called the revolution of a fever. The revo- lutions of fevers are various in point of duration; some fevers completing theirs in twenty-four hours, others in forty-eight, whilst others require seventy-two, and some even ninety-six hours. The form which a fever assumes, in this respect, is called its type; so that a fever which occupies twenty-four hours from the commencement of one paroxysm to another, is said to be of the quotidian type; whilst one which revolves every forty-eight hours, is of the tertian type ; and when this period is extended to seventy-two hours, the fever is of the quartan type; and a period of ninety-six hours constitutes the quintan type. The quo- tidian, the tertian and the quartan types constitute the three principal and pri- mary types of fevers ; all of which are, however, subject to modifications which GENERAL COURSE, ETC., OF FEVER. 61 may readily mislead the careless observer, so as to confound them, or mistake one for the other, especially the quotidian and the tertian. It has been observed, that in fevers of the quotidian type, the paroxysms generally come on in the morning—a circumstance, whicb has been almost invariably verified in my own experience, and which is, indeed, so constant, that Cullen was induced to notice it in his definition of a quotidian. Tertians com- monly come on towards noon; but they are much less regular, in this respect, than fevers of the preceding type. Two simple tertians sometimes go on cotem- poraneously in the same patient; so that, instead of the paroxysms recurring only every other day, they occur daily, as in a quotidian. These cases are called double tertians, and are distinguished from quotidians by the paroxysms of the alternate days being similar in relation to the precise time of their occurrence, grade of violence, duration, and other circumstances. Thus the paroxysms on the odd days will perhaps recur at nine o'clock in the forenoon, whilst those which happen on the even days will come on at two or three o'clock in the afternoon, so that, although each day has its paroxysms, the fever cannot be properly considered as a quotidian, but the cotemporaneous progress of two simple tertians, the one having commenced a day sooner than the other. Fevers, however, rarely assume the double tertian type from their commencement. They usually begin and con- tinue for some time in the simple tertian type—the duplication occurring afterwards; and when the type thus becomes doubled, the new or accessory paroxysms are generally considerably milder than those of the original or simple tertian. It is asserted, that a double tertian seldom terminates without first assuming the single tertian type—the accessory or weaker paroxysm disappearing first.* There are other varieties of double tertians, mentioned by the older writers, such as the tertiana duplicata, in which two paroxysms occur every second day, and none on the intervening one ; the hsemitritseus of the ancients, in which a paroxysm occurs daily, the intermissions or remissions between the first and second, the third and fourth, being much more prolonged than those which occur between the second and third, the fourth and fifth, &c. Authors also mention a triple tertian—tertiana triplex. The quartan type, also, has been known to assume similar modifications. Double and triple quartans are mentioned in the books ; as well as other anoma- lous varieties of this affection. Before I proceed to the consideration of the particular forms of fever, it will be proper to say something concerning crisis or critical days—a subject which, though but little regarded at the present day, appears to me entirely worthy of attention. It may, I think, be assumed as a safe principle, that doctrines or sen- timents concerning facts which are objects of mere observation and experience, cannot be wholly erroneous or illusory, after having obtained the entire confi- dence, through a series of more than twenty centuries, of a vast number of as accurate and devoted observers of nature as have ever adorned our profession. Without professing a belief in the correctness of the doctrine of crisis as it was taught by the ancients, and by many of the moderns, we may yet admit, on good grounds, it is conceived, that there exists a natural tendency in the operations of the animal economy, whether in a state of health or disease, to certain periodi- cal fluctuations, which, under particular circumstances, manifest themselves in a way sufficiently conspicuous to exhibit an obvious revolution in the increase and declension of the morbid actions of the animal system. It was early observed, that there are certain regular periods in the course of many febrile affections, at which prominent changes are wont to occur, preceded generally by a manifest aggravation of the symptoms, and followed or attended by certain evacuations. These evacuations, from their being almost always followed by an obvious abate- ment in the symptoms, were called critical, and were thought to consist of noxious or febrific matters, thus thrust out of the system by the sanative powers • Richter's Specielle Therapie, vol. i. 62 GENERAL COURSE, ETC., OF FEVER. of nature. Fever was supposed to be nothing else than an effort of nature to prepare and cast out of the system the morbific materials which disturbed the regular actions of the animal economy, and that the amendment which ensued was the immediate consequence of such eliminations of morbific matter. At the present day it is, however, more correctly maintained that these critical discharges are the effects, and not the causes of the amelioration which occurs about the periods at which they take place ; and that they are to be viewed rather as the first manifestations of a favorable change in the condition of the system than as the immediate causes of such a change. That this is the correct view in relation to the nature of such discharges, there can, indeed, exist no doubt; but this view of the subject does not deprive it of its importance, and directs our attention rather to the periodical exacerbations and inherent tendencies in these maladies to ter- minate their course at one period in preference to another, than merely to the evacuations which are apt to supervene at such times. In no forms of fever, perhaps, are these tendencies to terminate at a certain fixed period more fre- quently manifested than in intermittents. There appears, in these fevers, a tend- ency to a septenary revolution, which I have often seen verified in the most unequivocal manner. If an ague of the quotidian type be suffered to run on until it terminates spontaneously, the termination will almost universally occur, if it occur at all, either after the seventh, fourteenth, or twenty-first parox- ysms ; and I have repeatedly found, that febrifuge remedies, exhibited immedi- ately after these septenary periods, will arrest it with more certainty, and with much less liability to relapse, than when employed during any of the intervening intermissions. From the same inherent tendency, the relapses which are so common in this disease will, in a vast majority of instances, occur about the sep- tenary periods from the time of the last paroxysm, and most commonly about the eighth or fourteenth, and sometimes for several periods about the twentieth day. (Jackson,* Sprengle.t) Observation has shown, that the crises of fevers happen almost uniformly on the odd days, reckoning from the commencement of the malady. According to the observations of Hippocrates, the crises occur in conformity to the tertian type, until the fifth crisis, or the eleventh day of the fever, after which they ob- serve the quartan type, occurring only every fourth day. It must be observed, however, that these evacuations do not occur exclusively on the days just indi- cated, for they are sometimes, though rarely, found to happen on the intervening days. Galen supposed that when the crisis falls on any other than a critical day, the fever has been diverted from its natural tendency by the accidental oc- currence of irritation in some part of the system. Galen divided the critical days into the perfect, the secondary, and the intercurrent. The perfect are those which happen on the seventh, fourteenth, twenty-first, and twenty-eighth days. The secondary, or less perfect, occur on the intermediate day between each perfect or septenary crisis—namely, the fourth, eleventh, eighteenth, twenty-fifth, &c, days. If, for example, it was observed that a slight deposit in the urine, or a moderate flow of sweat took place on the eleventh day, it was regarded as an indication of a more perfect crisis on the fourteenth day. The intercurrent crises occur on the remaining odd days—that is, on the fifth, ninth, thirteenth, &c. Such are the principal points in the doctrine of crisis, as it was taught by the ancients, and more especially by Hippocrates, and his comment- ator Galen. No one, at the present day, however, pretends to have observed the many minute distinctions and phenomena which are embraced in the ancient doctrine on this subject; indeed, there are very few who regard it as at all worth any attention ; and the profession seem long since to have thrown it into the common mass of error and misconception which has been formed out of the wrecks of former systems and doctrines. However antiquated it may appear, at the present advanced stage of our science, to profess some faith in the general • On the Diseases of Jamaica, f Handbuch der Pathologie, Band ii. p. 171. GENERAL COURSE, ETC , OF FEVER. 63 correctness of this doctrine, I cannot, at the risk even of being set down as a cherisher of obsolete and exploded sentiments, divest myself of the conviction, that among much that is erroneous and absurd in this doctrine, there are im- portant and fundamental truths which ought not to be carelessly rejected. In order to understand the nature of crisis, every fever must be considered aa having a. tendency to some one of the principal types mentioned above. A simple tertian intermittent may be regarded as the elementary type of fever. In fevers of this type, an exacerbation or paroxysm, and a crisis, will occur on every odd day; and if we consider a continued fever as made up of tertian paroxysms prolonged and running into each other, or as possessing a natural, though countervailed tendency to the elementary or tertian type, there will, in like manner, occur more or less considerable tertian exacerbations, with their accom- panying discharges. From what has already been said concerning the manifest septenary movements of intermittents, the tendency of continued fevers to ter- minate on the fourteenth or twenty-first days, which can scarcely be denied, would seem to be in conformity with an original law of the animal economy under a state of febrile excitement. The evacuations which usually accompany the crisis of fever are,—1, hemor- rhages ; 2, a flow of sweat; 3, an increase or changed character of urine; and 4, diarrhoea. Critical hemorrhages are generally attended with an increased action of the heart and arteries, and often with a manifest determination to, and conges- tion in, the part from which the discharge occurs. They must be regarded as mere manifestations of a previous change in the system, and hence this critical kind of evacuation cannot be substituted by an artificial abstraction of blood; since, although blood may be abstracted, the peculiar action of the solids, which constitutes the actual crisis or change to a favorable tendency, cannot be thus produced. Crisis by hemorrhage, is generally confined to inflammatory fever; or, more correctly speaking, to fevers attended with an increased activity and action of the heart and arteries. Critical hemorrhages most commonly pro- ceed from the nose, and, according to the observations of many of the older writers, are frequently preceded by the dicrotus pulse, in which two distinct wave-like beats occur during each diastole of the artery. Immediately before the irruption of the blood the carotids beat strongly, the face becomes flushed, sparks appear be- fore the eyes, the eyes are red and suffused with tears; and, in some instances, frequent sneezing and a thin watery discharge from the nostrils occur just before the hemorrhage appears. Critical sanguineous discharges have also been known to occur from the uterus, the rectum, and sometimes, though very rarely, from the stomach, and even from external parts. Crisis by an increased flow of perspiration is by no means uncommon. Ca- tarrhal and rheumatic fevers are more apt to terminate by this mode of crisis than any other forms of febrile affection. This discharge is not, however, to be re- garded as indicative of a favorable change in the malady, unless it be generally diffused over the whole surface, and especially, unless it be attended with a tur- bid state of the urine, or a copious sediment in this latter evacuation. The surface should, moreover, be soft, and of a natural temperature—that is, not cold and clammy. Crisis by urine, independent of perspiration, is a very uncommon mode of ter- mination in febrile complaints. A critical urine derives its favorable character not so much from the mere quantity of the evacuation, as from its appearances and the materials with which it is impregnated or mixed. For inspection, the urine whiqh is evacuated at the termination of a paroxysm, or in the morning, ought to be chosen. In a truly critical urine there may be seen at first a cloud float- ing in the upper part of the vessel, then a globular body of mucus about the middle, and a sediment at the bottom.* So universal is the concurrence of a critical * Vogel, Richter, Hufeland. I have frequently noticed these appearances in the urine, eva- cuated after a paroxysm of intermitting fever; and I am well satisfied that it is a cotnmon oc- currence in the urine discharged soon after fevers have commenced to decline. 64 GENERAL DIAGNOSIS. urine, and a general moisture of the skin, that these two evacuations may be con- sidered as essentially connected. A critical discharge from the bowels is less common than those I have already mentioned. It occurs most frequently in bilious fevers, and in such febrile affec- tions as are attended with some visceral disease within the abdomen.^ These discharges do not, however, occur as the others do, in the acme or exacerbations of the fever, but during the periods of remission. They are generally very co- pious. The signs of an approaching crisis by diarrhoea are a peculiar trembling of the under lip; stammering speech; a full and wave-like pulse; pain and rumbling noise in the bowels; discharge of wind; a moist tongue; itching in the nose ; paucity of urine, &c. (Richter.) CHAPTER IV. ON GENERAL DIAGNOSIS. Nothing so much distinguishes the experienced and truly well-qualified phy- sician from the mere hap-hazard recipe-doctor and routinist, as the ability to estimate correctly the import of symptoms; to trace their various relations with each other, and to determine from them the seat, nature, and extent of maladies. The number of those who are remarkable for accuracy in diagnosis, is always very small; for eminent proficiency in this respect can be obtained only by persever- ing observation and study, aided by a minute and comprehensive acquaintance with physiology and pathology. Diagnosis embraces a much wider range of inquiry than that which is pre- sented by the actual phenomena of diseases. It is not alone from morbid symptoms that the intimate character and tendency of diseases can always be satisfactorily determined. Age, sex, moral and physical temperament, climate, occupation, habit of living, corporeal conformation, previous diseases, hereditary predisposition, and the character of the predisposing and exciting causes, often afford important aid in the formation of a correct diagnosis. In chronic diseases, especially, the light which may be obtained from circumstances of this kind, is frequently of the utmost importance in this respect. The manner in which patients are examined, also, has a direct and important bearing on diagnosis. A confused, desultory, or immethodical mode of investi- gating the symptoms of diseases, and the various circumstances which may have contributed to determine their character, seldom leads to a clear and precise diag- nosis. Indeed, the manner in which a physician examines his patients affords no inconsiderable criterion for judging of his practical qualifications. Method, regularity, and deliberation, in this respect, are almost always associated with skill in diagnosis, and consequently in the treatment of diseases. The first objects which strike the attention of the physician, on approaching a patient, are his countenance, attitude, motions and voice. It is natural, there- fore, to commence the examination with these symptoms. In many instances these external conditions of the patient afford very important information as to the nature and seat of maladies; and in no case, perhaps, can they be entirely neglected without losing very useful suggestions in relation to the diagnosis. The countenance should be deliberately and closely examined, and its devia- tions from the healthy aspect and expression noticed. Many diseases are at- tended with expressions of countenance so peculiar and striking, that they may be at once recognized by the observant and experienced physician. The attitude, motions, and external condition of the patient's body, must, also, be particularly GENERAL DIAGNOSIS. 65 noticed. The degree of emaciation—the color and condition of the skin, and the general physical habit and conformation, should be observed. The various regions of the body should be carefully examined, more especially in diseases of a chronic and obscure character. In some general maladies, such as^scurvy, syphilis^ scrofula, &c, the ecchymoses, glandular indurations, eruptions, blotches, exostoses, nodes, &c, afford important diagnostic evidence. Old cicatrices, too, merit particular attention; particularly when seated along the neck and in the groins. The former almost always indicate a scrofulous diathesis, whilst the latter afford good grounds for suspecting the existence of a syphilitic taint. The existing disease, for which the physician is called to prescribe, may have a very intimate connection with one or the other of these maladies or constitutional taints; and as patients are apt to neglect giving proper information on this sub- ject, or even seek to conceal the fact of their having been affected with such a disease, these old marks or cicatrices are sometimes of essential service, to a full and satisfactory investigation of the case under examination. Having attended to these external circumstances, the examination of the case must be pursued, by interrogating the patient. The manner in which the examination is conducted, is of great importance. A careless, irregular and hurried, or a peevish, fretful and impatient manner of examining, seldom fails to lessen the good will and confidence of the patient for his medical attendant; whilst a mild, deliberate, earnest and interested deportment, not only gains the patient's confidence and respect, but contributes very materially to a full deve- lopment and correct understanding of the nature of the malady. The questions should always be proposed in terms perfectly intelligible to the patient; and when there is reason to doubt whether the interrogatory has been correctly apprehended, it should be repeated in different terms. The employment of a pompous and technical phraseology is more apt to excite the contempt and dis- trust of intelligent patients, than to draw forth correct and satisfactory responses. It is of considerable consequence, also, to follow a determined and regular order in the questions put to the patient. Without a proper attention to order or method in this respect, important questions are apt to be forgotten, and some which have already been proposed and answered, uselessly repeated. Although the interrogatories should be sufficiently numerous and varied to obtain a full view of the symptoms and feelings of the patient, and of the circumstances which may have contributed to the development and modification of the disease, yet trivial and irrelevant questions should be avoided. The following order of inquiry appears to me the most natural and advan- tageous. 1. Ascertain the age, occupation and place of residence of the patient. In many instances, indeed, these circumstances, more especially the last, can have no useful bearing on the diagnosis; but this is by no means always the case; for, in some cases, very important diagnostic and practical suggestions may be obtained from a careful consideration of these facts. 2. Inquire next, at what time the disease commenced; whether it came on gradually or suddenly; whether the existing symptoms differ from those which attended the disease at an earlier period; whether the progress of the complaint is continuous or parox- ysmal, constant or occasional, uniform or attended with exacerbations and re- missions ; whether, in the course of the disease, new symptoms have supervened, and former ones disappeared, and whether the permanent symptoms have in- creased much in violence since the commencement of the complaint. Correct information in relation to these circumstances is often indispensable to a satis- factory diagnosis. "In many instances, indeed, the succession and general progress of the symptoms afford more useful data for the formation of a correct diagnosis, than a consideration of the symptoms existing at the time of examina- tion. Unfortunately, the majority of patients are incapable of giving a proper account of the early symptoms and progress of their maladies; and the physician is thus frequently deprived of the light which a correct and circumstantial expo- sition of the preceding symptoms and course of the case might afford." 3. The 5 66 GENERAL DIAGNOSIS. patient should now be asked whether he experiences any pain, and if so, in what part of the body. He should be directed to place his hands on the region in which the pain is felt; for patients are apt to express themselves very vaguely and incorrectly in relation to the part in which the pain is seated. Thus, we are often told that pain is felt in the stomach, yet when the region is pointed out with the hand, it is, perhaps, found to be seated in the lower part of the abdomen, or within the chest. Inquiry must also be made whether the pain be acute or darting; dull and aching; stinging or burning, or throbbing;—whether it be deep seated or superficial, continuous or intermitting, wandering or fixed, transient or protracted; and, if intermitting or paroxysmal, whether its occurrence be periodi- cal or at irregular and uncertain intervals. Pressure should be made on the part in which the pain is located, and its effects carefully noticed; and it is particu- larly important to ascertain whether there is soreness or tenderness to pressure in certain organs or regions of the body, more especially in the various regions of the abdomen; although the patient may not complain of any pain in these parts, when undisturbed by pressure. It will also be proper to ascertain whether the affected parts are swollen, discolored, or in any other way changed from their normal or healthy appearance and conformation. 4. The state of the sanguiferous system should next be inquired into. The pulse must be attentively and de- liberately examined; and in doing this, attention must be paid to the circumstance, that the pulse of an infant, during the first three or four weeks after birth, beats between 120 and 130 strokes in a minute; and that its natural frequency under- goes a gradual reduction as age advances, until about the age of puberty, when it arrives at the standard of a healthy adult pulse, namely, from about 72 to 80 pulsations in a minute. It should be observed, too, that climate, the time of day, corporeal exertion, position of the body, and mental emotions or exercise, exert, often, a very material influence on the state of the pulse. In the morning, whe- ther in health or disease, the pulse is generally considerably slower and softer than after dinner or towards evening. In feeble and nervous individuals, we often find the pulse much more frequent when they are standing up, than when in a recumbent position. In this case, the muscular exertion required to main- tain the erect posture operates on the circulation in the same way as exercise, and therefore accelerates the action of the heart and arteries. Nothing, however, is so apt to give rise to a wrong estimate of the state of the pulse, as that mental excitement and flurry which feeble and irritable patients are apt to experience on the entrance of the physician into the sick chamber. I have frequently found a difference of more than twenty pulsations in a minute, between an examination made immediately after entering the room, and a second one, some ten or fifteen minutes afterwards. It is therefore an important rule, to delay examining the pulse, until the agitation of the patient's mind has subsided. By introducing the examination with some encouraging and cheering remarks, and proceeding in the order already mentioned, there can seldom be any risk of mistake, from this source, as to the actual state of the pulse. In examining the pulse, the patient's arm should be held in a horizontal and semiflexed position. Two or three fingers must be applied to the artery, and the pressure gradually varied in force, in order to form a correct estimate of the degree of tension, vigor, hardness or compressibility of the pulse. Thirty or forty pulsations, at least, ought to be felt before the fingers are taken off. It is not uncommon in certain obscure cere- bral affections, to find an intermission in the pulsations, at intervals of from ten to thirty and even a greater number of beats. A transient examination may not only fail to detect such intermissions, but is in general, quite insufficient for obtaining a satisfactory view of the precise character of the pulse. All conversa- tion should be forbidden, both on the part of the patient and the attendants. In certain affections, and when the system is under the influence of certain remedial agents, (as digitalis,) it will be proper to examine the pulse in different positions of the patient's body; namely, in the recumbent, sitting and standing postures. This is particularly useful in certain organic affections of the heart. There is, GENERAL DIAGNOSIS. 67 perhaps, no department of symptomatology in which a high degree of proficiency is so seldom met with among physicians, as that which relates to the morbid manifestations of the pulse. Many seem to think that the only modifications of the pulse which are worthy of particular attention, relate to its frequency, full- ness, hardness, tension and regularity. There are various other states of the pulse, however, which, though not easily described, communicate to the expe- rienced and diligent observer definite and important views concerning the patho- logical conditions'with which they are associated. The ancients, and even some of the moderns, undoubtedly carried their refinements and pretensions, in relation to this subject, to an absurd extent. It is not improbable, however, that among much useless rubbish, which in the progress of our science, has been swept away con- cerning the organic pulses, as they were called, some valuable facts and principles were included, which might be advantageously revived. Be this as it may, a faithful and continued attention to the morbid states of the pulse, with diligent and well directed efforts to obtain definite conceptions of its various modifications, and to associate them with their respective pathological conditions, will, in gene- ral, result in the acquirement of a precision and readiness of discrimination, and accuracy of diagnostic application, which few who have not made the pulse a particular object of study and observation can well conceive or credit. 5. Having ascertained the condition of the pulse, the attention should be particularly directed to the organ or part in which the primary or essential malady appears to be seated. Inquiry must next be directed to those structures or organs which are known to hold the most intimate sympathetic relations with the part or organs principally affected. Thus, if the patient complains of much pain, or of other unpleasant sensations in the head, after having obtained a circumstantial account of the cephalic symptoms, the examination should be directed to the state of the alimentary canal. Again, if there is a fixed pain in the lumbar region, the im- portant question whether the pain be located in the kidneys, or in some neigh- bouring structure, may, in general, be readily settled, by attending to the condition of those organs with which the kidneys sympathize most strongly; namely, the stomach, the ureters, and the testes. If there is a retraction of the testes, pains shooting down along the ureters, with nausea and vomiting, the fact of its being a renal affection may be regarded as sufficiently ascertained. In the investigation of diseases, it should be recollected that the prominent and most annoying symptoms are by no means always located in the part where the primary and actual malady is seated. A slight inflammatory affection at the origin of a spinal nerve, not unfrequently manifests itself by severe and protracted pain in some remote part of the body ; as in the chest, the abdomen, or the infe- rior extremities. When, therefore, a fixed pain is unattended with any other manifestations of disease in the part; when there is neither inflammation, nor soreness nor tenderness to pressure, we may presume that the primary affection, upon which the disease depends, is located in some other part of the body ; and on proper inquiry, it will perhaps be found to be seated at the spinal origin of these nerves, which are distributed to the structure in which the pain is felt. To ascertain whether this be the case, firm pressure must be made on each of the spinous processes of the vertebral column. If, in passing successively from one spinous process to another, the patient flinches and complains of pain in one or more vertebrae, it may be inferred that the source of the painful affection is pro- bably seated at the root of the nerves which pass out from that part of the spine. Many diseases, which appear to be of a general character, consisting seemingly in mere functional derangement, are nevertheless intimately connected with ob- scure and frequently very serious local affections. The diagnosis, in such cases, is generally extremely difficult. In some instances, a probable opinion as to the existence, seat and character of such obscure and local affections, can be formed only by taking into view the effects of certain remedies and the nature of the exciting causes, in connection with the actual symptoms and general progress of the malady. Inflammation of some portion of the mucous membrane of the 68 GENERAL DIAGNOSIS. alimentary canal, often attends general diseases with manifestations so slight and inconspicuous as sometimes to escape the notice of even attentive observers. In relation to the diagnosis on this point, especial attention must be paid, in the examination of the symptoms, to the appearance of the tongue ; the condition of the alvine evacuations; the effects of irritating ingesta; the effects of firm pres- sure on different parts of the abdomen, with regard to the sensations which it excites ; the state of the skin ; and if the malady is of a chronic character, the temper and condition of the mental faculties. It should be particularly noticed, whether the surface of the tongue be red, and of a granular or smooth appear- ance—whether irritating and solid ingesta give rise to pain and distress in the stomach, or tormina in the bowels ; whether pressure on any part of the abdo- men gives rise to a pain or a feeling of soreness ; whether the skin in connection with these symptoms be dry, harsh, and contracted, and whether the temper is morose, gloomy, taciturn and irritable. The particular appellation of these phe- nomena will be fully illustrated in a subsequent part of this chapter. I proceed now to the consideration of the particular diagnostic signs as pre- sented by the countenance, the attitude, the nervous system, the alimentary canal, the blood-vessels, the respiratory organs, the cuticular surface, the lymphatic system, and the secretions. 1. The countenance is variously and often strikingly changed by diseases, and affords, in many instances, highly important diagnostic indications. Hippocrates strongly recommends the study and examination of the countenance in disease. His attention, however, was directed principally to the prognostic signs mani- fested by the countenance, and the observations which he has left us, on this subject, are among his most valuable contributions to our science. In relation to diagnosis, however, we find but few observations in his writings, concerning the morbid expressions of the countenance. This point has been more particularly attended to in latter times ; and although there is still much room for profitable inquiry, yet the facts and principles which have already been established, are sufficiently numerous and interesting to show the importance of attending to the countenance, as a source of valuable diagnostic information. M. Jadelot, physician to the Hopital des Enfans Trouvees, has published some interesting observations on the physiognomical expression of certain forms of disease in children. According to his observations, there are three principal physiognomical traits, which, in children, are often very conspicuous—each indicating a peculiar morbid condition of the system. The first consists of a distinct pale or lead-colored streak, with an appearance of depression, commencing at the greater angle of the eye, and terminating a little below the projection formed by the cheek bone. This he calls the ocuio-zygo- matic trait. This trait indicates disorder of the " cerebro-nervous system." It is strongly marked in all those maladies whose primary and principal seat is in the brain or on the nerves. It is likewise present whenever the nervous system, more especially the brain, participates actively in affections which are in the first place located in other structures or organs ; but in cases of this kind, some other facial trait usually co-exists, which indicates the character of the complication. Thus, for instance, when intestinal irritation from worms or other causes, finally occasions hydrocephalus, epilepsy, &c, the oculo-zygomatic trait will be added to the previous physiognomical expression indicative of the intestinal disorder. The second trait begins at the upper part of the alas nasi, and embraces, in a semicircle more or less complete, the outer line of the orbicularis oris. It is not uncommon to observe, towards the middle of the cheek and forming a tangent with this trait, another one which in certain faces constitutes the dimple of the cheek. These two traits, says M. Jadelot, are referable to similar affections. The first he calls nasal, the second genal. This trait, and its accessory, indicate disorder, particularly chronic irritation or inflammation of the alimentary canal, and of the abdominal viscera. It is observed in diarrhoea, indigestion, verminous irritation, &c. GENERAL DIAGNOSIS. 69 The third trait begins at the angle of the lips, and is lost on the margin of the chin. This is called the labial trait. It seldom forms a deep line, being modi- fied by the changes which the neighboring parts undergo. The other traits are more or less deeply marked according as the diseases to which they belong are more or less severe or protracted in their course. This trait attends diseases of the heart and of the respiratory organs, and may almost always be observed in cynanchae, carditis, hydro-pericardium, organic affections of the heart, pneu- monia, &c. M. Salle observes, that at the onset of all severe diseases, the inspection of the child's countenance may serve as a useful guide to the physician in discovering the organ principally affected. "The presence or absence of the oculo-zygo- matic trait, in the initial stage of the disease, will inform him whether the cerebro- nervous system be primarily affected, or whether its supervention be merely the result of sympathy." He asserts that at a single glance he has often been ena- bled to pronounce with confidence the existence of abdominal disease, by observ- ing the presence of the nasal trait. It is said to be particularly conspicuous in dysentery and chronic diarrhoea. I have, for several years past, attended very carefully to these observations of M. Jadelot, and am entirely persuaded that they are correct, and of essential service in the diagnosis of certain diseases of children. In addition to these physiognomical expressions, the singular change of coun- tenance which, according to Dr. Wolff,* occurs in children laboring under chronic or sub-acute peritonitis, deserves to be mentioned. This writer asserts that in the hydropic stage of this affection, "the skin at the root of the nose immediately between the eyes," acquires a swollen or bloated appearance, by which the general expression of the countenance is strikingly altered. " The parents of my patients," he says, " frequently noticed a change in the expression of the countenance, without being able to say in what it consisted; but a;S soon as I directed their attention to the tumefaction of the skin at the spot mentioned, they agreed with me that the change in the appearance of the child's coun- tenance arose from it, and were surprised that they had not discovered it them- selves." This singular trait, he asserts, is one of the most constant and certain diagnostic signs of the disease, after serous effusion in the abdomen has com- menced. Sprengle observes, that chronic disease of the spleen is, almost invariably, at- tended with a remarkable bluish tinge of the tunica albuginea. I have verified this observation in several instances.—During my term of attendance last winter at the Commercial Hospital of this place, a patient was brought into the house, laboring under some chronic malady. At the first glance of his countenance, I noticed the singular blue tinge of the albuginea. I pointed it out to the students in attendance, and stated the diagnostic inference which, according to the ob- servations of Sprengle, this appearance justified—namely, that the patient was laboring under some chronic affection of the spleen. This man has since died, and on post-mortem examination, the spleen was found very much enlarged, and otherwise disordered in its structure. Pain, whether from spasm or inflammation, always causes a peculiar con- traction of the muscles of the countenance. The physiognomical expression of pain is, indeed, so characteristic, that the most inexperienced will readily inter- pret it correctly. An attentive and experienced observer may even perceive, in the peculiar contraction of the features, in what class of organs, or in what organ, the cause of the pain is seated. Thus, when the diaphragm is inflamed, the pain, from the situation in which it is felt, might be supposed to be seated in the stomach, the liver, or the spleen ; but the peculiar grinning expression of the countenance (risus sardonicus), which attends injuries, or inflammation of the diaphragm, indicates at once the true seat of the disease. * Hufeland's and Osan's Jour der Practischen, Heilkunde, May, 1829. , 70 GENERAL DIAGNOSIS. Pain depending on inflammation of the mucous membrane of the alimentary canal, generally gives an expression of gloom, irascibility and discontent to the countenance; and this is more especially the case when the stomach and duo- denum are affected. When the lungs are the seat of painful sensation, there is an expression of great anxiety depicted in the countenance, attended with an unusual expansion of the nostrils during each inspiration. Even when there is no acute pain, in affections of the lungs, this peculiar anxious expression of the countenance and expansion of the alae nasi generally occur, in consequence of the congested condition of these organs impeding the respiratory functions. Dr. Marshall Hall observes, that the more acute the pain is, in inflammation of the thorax, the more contracted, in general, will be the features. When the pain is very severe, the alae nasi are acute and elevated, and the nostrils are strongly contracted and expanded, by the alternate acts of respiration. In addition to this, there is sometimes a vivid flush on the cheeks, terminating abruptly, and bounded by a very pale streak towards the nose. In great difficulty of breath- ing, from a congested state of the lungs, the countenance is not only marked by an expression of anxiety, but becomes, also, more or less suffused with a dark or livid hue, accompanied with turgidity or fullness. Whenever, therefore, this livid appearance, and turgidity of the vessels of the face occur, in diseases of the lungs, we may be assured that there exists either great sanguineous con- gestion in these organs, or an effusion of fluid into them. This is still more certainly the case, if, with these physiognomical signs, the surface of the body is rather below the natural temperature. The countenance peculiar to tubercular phthisis is so striking that even the most careless observers, in general, readily recognize it. The delicate paleness of the face, the circumscribed flush on the cheeks in the afternoon, the pearly whiteness of the tunica albuginea, the quivering motion of the lips and chin in speaking, are well known as the invariable and ill-boding attendants of pul- monary consumption. In " inflammation of the abdominal viscera," says Dr. Hall, "attended with severe pain, the muscles of the face are in a state of continued contraction; the features are unnaturally acute, the forehead is wrinkled, and the brows knit. The nostrils are acute and drawn up; the wrinkles, which pass from them ob- liquely downwards, are deeply marked, the upper lip is drawn upwards, and the under one frequently downwards, so as to expose the teeth. The state of the features is aggravated on any increase of the pain from change of position or external pressure. When the abdominal pain arises from spasm, the muscles of the face are exceedingly contracted and distorted during the paroxysms of pain; but in the intervals of the paroxysms, the countenance assumes a calm and placid aspect." In organic affections of the heart, the countenance generally acquires a very peculiar expression. In cases of this kind, the prolabia are more or less vivid, the face puffy or oedematous, and of a peculiar dingy hue, or suffused with a livid flush. This circumstance is worthy of notice, in relation to the diagnosis between organic affections of the heart and hydrothorax. In the latter affection, the countenance almost always exhibits a pale, or pale livid aspect, instead of the vivid flush so common in cardiac diseases. (Hall.) In the soporose affections, also, the countenance is variously and characteristic- ally affected, and affords important diagnostic indications. In the apoplectic attack, the face is generally flushed, or livid, and the blood-vessels of the head and neck turgid. The muscles of the face are frequently paralytic on one side, so as to destroy the natural symmetry of the features, the mouth is drawn to- wards the unaffected side, whilst the eyebrows, nostril, angle of the mouth, and cheek of the paralyzed side sink down. The flush and fullness of the face do not, however, continue throughout the whole course of the disease; towards the fatal termination of the attack, the countenance usually becomes pale, and some- what contracted. In syncope, the countenance is pale, shrunk, and covered with GENERAL DIAGNOSIS. 71 a cold perspiration, presenting a death-like appearance; and in that state of in- sensibility which sometimes occurs in hysteria, the countenance is nearly natural, both in color and expression. In the two latter affections there is no unusual sanguineous congestion in the head. The blood is accumulated in the lungs and heart, and hence, when recovering from the state of insensibility, patients gene- rally experience a sense of great weight and pressure in the chest, more especially in the region of the heart. Chlorosis is always attended with a very peculiar and characteristic appear- ance of the countenance. " The incipient stage is denoted by paleness of the complexion—an exsanguious state of the prolabia, a slight appearance of tumidity of the face, or fullness of the eyelids." In some instances, a tinge of green or of yellow is observable in the pallor of the countenance, and the eyelids are of a dark lead-colored hue. " In the confirmed stage of the disease, the face is still more pallid; the prolabia acquire a slight lilac hue, and the integuments, in general, a puffy and tumid appearance. In the more chronic form of this malady, the countenance exhibits an appearance of sallowness, of squalid or dingy paleness, with a ring of darkness occupying the eyelids, extending a little towards the temples and cheeks; and. in some instances, a similar dark streak surrounds the mouth." Dr. Hall observes, that this sallowness or icterode ap- pearance of the countenance must not be confounded with the different shades of icterus, or bilious tinge. In icterus or jaundice, that is, when the discoloration depends on the deposition of bilious matter, the tunica albuginea of the eyes is invariably more deeply tinged with yellow, than any other portion of the surface; whereas, in the more icterode, or sallow appearance of the complexion, observed in chlorosis, and in some other chronic affections, the eyes do not exhibit any distinct tinge of yellow. When, therefore, the countenance of a patient presents a yellowish hue, without a similar tinge of the albuginea, we may conclude, that it does not depend on the presence of bilious matter in the circulation, or on biliary derangement. In chronic irritation of the bowels, from worms, or other irritating substances lodged in the alimentary canal, a remarkable pale tumefaction of the upper lip frequently occurs, in connection with the nasal and genal traits, mentioned above. This swollen state of the lips is generally but transient in verminous affections. It usually comes on at night, during sleep, and seldom continues more than two or three days. A somewhat similar swollen state of the upper lip often occurs in children affected with scrofula; more especially when the disease is principally seated in the mesenteric glands. In cases of this kind, however, the tumefaction is much more permanent; there is also more lividity of the prolabia and the cheeks, and the peculiar traits mentioned by Jadelot, (the nasal and genal,) are not present. In inflammation of the arachnoid membrane, the expression of the counte- nance is generally strikingly characteristic. Besides a general expression of surprise, confusion, and discontent which it is impossible to describe, but which cannot easily be mistaken when once seen and contemplated, the most promi- nent morbid expressions of the countenance are those furnished by the eye. According to the observations of Martinet and Duchatelet, the pupils are either much dilated or contracted; the conjunctiva presenis a greater or less degree of redness; and when the inflammation has made considerable progress, and is about terminating in effusion, or structural lesion of the brain, there are squinting, and constant rolling of the eyes, or they are turned upwards so as to conceal the cornea. In nearly all instances, the upper eyelids become paralyzed, so that the patient, in endeavoring to look at any object, is unable to raise the lids by their proper muscles, and is, therefore, obliged to draw them upwards, together with the integuments of the forehead, by the contraction of the occipito-frontalis mus- cle.* Martinet observes, that these latter symptoms, namely, the turning up of * Recherches sur l'Inflammation de 1'Arachnoid, Cerebrale et Spinale. Par Duchatelet et L. Martinet, Paris, 18-1. 72 GENERAL DIAGNOSIS. the eyes and paralysis of the upper eyelids, are the most constant symptoms manifested by the countenance in this disease. Whytt and Camper also declare that they are among the most certain diagnostic signs of this dangerous malady. Sprengle (Handbuch der Semiotik) says, that the appearance of the tunica albuginea affords an excellent diagnostic sign between scarlatina and measles. In the former, he asserts, the albuginea exhibits a uniform red tinge, with little or no suffusion of tears; in the latter malady, the redness is not general or uni- form, the injected capillaries of the conjunctiva leaving intermediate spaces of a natural or white color. (Ziegler's Beobachtungen, p. 24.) The countenance in common synochus, or general inflammatory fever, usually exhibits a very different aspect from that which occurs in fevers depending on acute local inflammation seated in the thorax or abdomen. In the former, the face is more or less tumid and flushed, the conjunctiva of the eyes is injected or red, and " the nostrils are rapidly and conspicuously dilated and contracted by the hurried respiration." In acute symptomatic fever, on the contrary, the countenance is generally somewhat pale and contracted, and there is no hurried movement of the nostrils, nor redness of the eyes, if the inflammation be not seated in the head. In the acute bronchitis of infants the face is invariably re- markably pale: whereas, in infantile remittent and common synochus fever, from cold, it is almost constantly suffused with a flush. It must be observed, however, that in the advanced stage of pneumonic inflammations, whether in infants or adults, when the minute bronchial ramifications have become loaded with mucus, or serous effusion has taken place into the pulmonary tissue, the countenance acquires a more or less distinct livid hue—a phenomenon always indicative of great danger. On the other hand, the countenance, which is flushed in the early stage of synochal or remitting fever, becomes pale and somewhat shrunk towards the termination of the disease. I pass on in the next place, to notice those diagnostic circumstances which relate to the attitude and motions of the patient. The morbid variations of atti- tude are best understood, by contrasting them with the healthy postures of the body during sleep. " It may be presumed, that, both in health and in disease, that posture is assumed which affords the most repose to the system in general, and most relief in the performance of its various functions. In healthy and undis- turbed sleep the usual posture is that of one side ; the head and shoulders are generally somewhat raised, and, together with the thorax, bent gently forwards ; the thighs and legs*are in a slate of easy flexion. The position is apt to be changed from time to time, the person lying on one or the other side alternately. The posture of the body during sleep, here described, is such as affords the most ease and repose to the different viscera, and most facility and disencumbrance in the performance of their functions, and such as allows of the greatest muscular relaxation compatible with these more essential points." The supine position (decubitus dorsalis) when attended with twitching of the tendons, or tremor of the extremities, always indicates great muscular debility. When in the progress of a continued fever, we find the patient to assume this pos- ture with the inferior extremities extended, we may presume from this symptom alone, that the disease is assuming a sinking or typhus character. This is still more decidedly the case, when in connection with this position the patient gra- dually slides down towards the foot of the bed. It requires much less muscular exertion to maintain the supine posture than any other that can be assumed. In a very debilitated condition of the system, there is not enough of muscular power to preserve the body in the lateral posture. If the patient be placed on one side, he soon turns on his back, and is utterly unable by his own exertions to resume the lateral position. Celsus observes, that when a person affected with fever lies on one side, with the legs slightly retracted, he may be regarded as not in a very dangerous condition. In relation to the degree of muscular energy manifested by patients, there exists a marked difference between idiopathic and symptomatic fevers. In common GENERAL DIAGNOSIS. 73 acute fevers of an idiopathic character, the patient soon feels very weak, and cannot support himself in the erect posture, without great and exhausting efforts, and a feeling of faintness. This is rarely the case in symptomatic fever. In fevers of this kind, the sense of prostration is seldom great, nor do we observe the muscular tremor, vertigo and faintness on assuming the erect position. In diseases of the chest, the position assumed by the patient is often highly characteristic. In hydrothorax, the patient usually lies with the head and shoul- ders considerably elevated, by additional pillows. When out of bed, he is often observed to sit up, with the arms placed along the side, and the hands fixed and pressing forcibly on the chair or sofa on which he sits ; in other cases he leans a little backwards, still supported by the arms and hands, which are placed behind his back. " This kind of posture is often constant, or immediately resumed, if any accident occasions it to be changed ; it gives rise to an ele- vation of the shoulders, from which the body is supported, or as it were sus- pended." The attitude of course varies with the degree and progress of the hydropic effusion in the chest. In order that the patient may continue to enjoy some rest while lying down, the head and shoulders must be more and more raised, until, at last, he is sometimes incapable of remaining in bed, and is obliged to sit up " with the legs hanging down." When hydrothorax is asso- ciated with organic disease of the heart, or of the lungs, the necessity of remaining in the erect posture is, in general, particularly urgent. These circumstances admit of a ready explanation. The effused fluid in the chest produces distress and difficulty of breathing in proportion as it presses upon and impedes the free action of the lungs. In a recumbent position, with the head and shoulders low, it is obvious that the fluid must envelop and encumber a much larger portion of the lungs than when the patient is sitting up or lying with the shoulders ele- vated ; for in this posture the fluid sinks down to the bottom of the thorax and leaves a considerable part of the lungs free from its embarrassing pressure. Hy- dropic accumulation in the chest may be distinguished from mere organic disease of the heart or of the lungs, attended with symptoms resembling those of hydro- thorax, by making firm pressure on the abdomen and attending to the effects. If there is thoracic effusion, the patient will experience general agitation, cough, and a sense of suffocation when pressure is thus made on the abdomen. This arises from the abdominal viscera being pressed up against the diaphragm, by which the fluid in the chest is raised, so as to embarrass the lungs and cause the phenomena just mentioned. In organic affections of the heart, without thoracic effusion, no effects result from abdominal pressure. In affections of this kind, as well as in hydrothorax, the patient is unable to remain easy in a recumbent posture with the head low, more especially in very severe cases. But in addition to this circumstance, the effects which arise from corporeal exertion in organic affections of the heart, are much more violent and distressing than in hydrotho- rax. Almost every muscular effort or unusual exercise produces, to an extreme degree, dyspncea, anxiety, and agitation. Ascending stairs, or a hill, seldom fails to bring on a paroxysm of the most alarming palpitation, and suffocative breathing. Although similar effects result from the operation of these causes in hydrothorax, yet they are much less violent and alarming than in cardiac dis- eases. When in hydrothorax, the dropsical effusion exists only on one side of the chest, the patient invariably lies on the affected side. Inflammation in the abdomen, with acute pain, is in general attended with a characteristic position of the body, and which distinguishes affections of this kind, very pointedly, from spasmodic pains of the stomach and bowels. In acute abdominal inflammation the patient assumes a certain position, and care- fully avoids active muscular exertion and change of posture. In spasmodic pains in the abdomen, or colic, on the contrary, the patient usually " writhes to and fro," and constantly changes his posture. In abdominal inflammation the patient lies on the back, with the knees drawn up, and the head and shoulders raised by additional pillows, so as to relax the abdominal muscles and obviate as 74 GENERAL DIAGNOSIS. much as possible pressure on the inflamed viscus. Great care, moreover, is taken to prevent any pressure from the hands or bedclothes on the abdomen, and all the necessary motions of the body are performed with peculiar caution and slowness. In spasmodic or colic pains, so far from avoiding pressure on the abdomen, the patient often lies on the belly, or presses forcibly on the bowels with his hands. After the paroxysm of pain in colic is over, the patient resumes an easy position; but in the absence of an aggravation of inflammatory pain, the same cautious posture and manner are still retained as before. (Hall.) When the inflammation is seated in one of the kidneys, the patient when in bed, inclines his body a little forwards and towards the side affected. By this position the muscles of the loins on the affected side will be somewhat relaxed and the pressure on the inflamed kidney diminished. When, in the advanced stages of typhous or typhoid fevers, attended with delirium, the patient is ob- served to keep his inferior extremities constantly drawn up, while recumbent on the back, retention of the urine may be suspected. I have known patients affected with typhoid fever, and in such a condition as not to be able to give an account of their sensations, in whom protracted retention of the urine was de- tected solely by noticing this retraction of the legs, or constant raised position of the knees. In most instances of inflammation of the liver, the patient cannot lie on the left side without great aggravation of his sufferings. This symptom is, indeed, not always present in hepatitis, and when taken by itself, cannot be regarded as of any particular diagnostic importance. When it occurs, however, in connec- tion with other symptoms indicative of hepatic inflammation, it may be con- sidered as no inconsiderable evidence of the existence of this affection. If in a case of hepatitis, the patient is observed to lie easiest on the left side, we may infer that the inflammation is principally seated on the concave surface of the liver. Next in order are the diagnostic signs manifested by the tongue, gums, cavity of the mouth, fauces, and teeth. In examining the tongue, particular attention should be paid to its color, form, surface, and mode of protrusion. In the simple forms of fever, unattended with inflammatory irritation of the mucous membrane of the stomach, the tongue is,slightly coated with a white fur. This state of the tongue is rarely attended with dryness, and does not, in general, indicate a very great degree of gastric derangement. When in the progress of a disease the tongue changes from a white and somewhat loaded state, to a clean and deep red appearance, we may infer with confidence, that inflammation has supervened in the mucous membrane of the stomach. A clean and red appearance of the tongue, attended either with a rough or a smooth surface, is always to be regarded as conclusive evidence of an inflamed or highly irritated condition of the mucous membrane of the alimentary canal. In dysentery, we generally find the point and margin of the tongue of a deep red appearance, whilst the centre is loaded with a streak of brown and dry fur. This is particularly apt to be the case in the chronic form of the disease. In chronic gastritis and enteritis, the tongue almost invariably exhibits a dark red appearance. In some instances, this red- ness is attended with a rough or granulated surface, and in others it presents a smooth or glossy appearance; sometimes the whole surface of the tongue ex- hibits this red and rough or glossy appearance. This is generally the case when the inflammation is seated in the stomach. In many instances, however, these appearances are confined to the tip and margins of the tongue, more especially when the inflammatory irritation is located in the mucous membrane of the colon. In fevers depending on acute inflammation, not seated in the mucous mem- brane of the alimentary canal, the tongue seldom exhibits any prominent devia- tions from its natural state. Thus in fevers from wounds, from regular gout, and from external phlegmonous inflammation, the tongue generally varies from its healthy condition only by being covered with a thick white fur, and by unnatural GENERAL DIAGNOSIS. 75 dryness. (Hall.) In the commencement of typhus fever, the tongue is coated with a white fur, as in common synochus fever; but the white tongue of typhus differs from that of simple acute fever, in being covered with a thick layer of transparent, tenacious slime, which in the progress of the disease becomes dry, brown, and finally nearly black. The appearance of the tongue affords a good distinguishing sign between tubercular phthisis pulmonalis, and hectic fever with cough from hepatic or gastric disease. In genuine pulmonary consumption the tongue very generally retains nearly its natural appearance; whereas in affections of the stomach and liver simulating phthisis pulmonalis, the tongue is always more or less coated with a brown fur, accompanied usually with a depraved taste. In the early stage of chlorosis, the tongue presents a pale and tumid appearance, with enlarged and prominent papillae. As the disease advances the tongue be- comes more and more pallid, clean and smooth, and finally acquires a peculiar flabby and semi-transparent appearance. The gums and prolabia are very pale and exsanguious, and generally somewhat swollen. Hall gives the following de- scription of the morbid appearances of the tongue in dyspepsia. "In acute dyspepsia, the tongue is in general loaded, the mouth clammy, the taste bitter or nauseous, the breath fetid, whilst the surface of the face is generally oily. In some severe cases the coat on the tongue is very thick, and eventually peals off, leaving its surface smooth, red and tender, attended with an oedematous appear- ance of its substance. In very protracted and severe cases of dyspepsia the tongue is apt to become clean, with universal enlargement of the papillae over the surface as in the beginning of chlorosis; or its surface is formed into lobules resembling in form those of the base of the cerebellum. In cases attended with chronic inflammation of the mucous membrane of the stomach, the surface of the tongue becomes red, smooth and glazed." The appearance of the tongue in chlorosis does not differ materially from that which it presents in chronic dys- pepsia, except that in the former disease it is pale instead of red, and indicates, in addition to gastric derangement, a defect in the process of sanguification. (Hall.) A contracted and pointed tongue is a very common attendant on inflammatory affections of the brain and its meninges. This state of the tongue is often to be observed in very severe cases of typhus; and when it does occur we almost in- variably find it associated with other indications of cerebral inflammation—such as red and prominent eyes, constant delirium, flushed cheeks, &c. In fevers attended with stupor or general torpor, depending on congestion, the tongue, in- stead of being contracted and pointed, presents a dilated and flabby appearance. This relaxed and dilated state of the tongue is seldom accompanied by delirium ; but instead of this, there is usually a general diminution of sensibility and irri- tability, as well as of muscular power and the temperature of the surface. Dr. Miner mentions this appearance of the tongue as one of the most constant symp- toms of typhus syncopalis. A tongue covered with yellow or yellowish-brown fur, attended with a bitter taste, indicates prominent derangement of the biliary organs. A tremulous tongue is, in general, one of the first symptoms of the passage of the synochus fever into a typhous or low state. In the early stage of scarlatina, a number of florid papillae protrude through the white coat on the surface of the tongue; and Bateman states that this ap- pearance will always enable us to distinguish it from measles. In chronic hepatitis, the gums have a peculiar firm, smooth, or glossy appearance, whereas in chronic dyspepsia, they usually present a soft or spongy condition. The next class of symptoms to be considered are those manifested by the nervous system. The most common, and generally the earliest symptom of deranged function of the brain, is disturbed sleep. In the diseases of children an unusual drowsiness, especially when attended with a disordered state of the alimentary canal and febrile irritation, is often one of the first symptoms to awaken 76 GENERAL DIAGNOSIS. alarm and suspicion of probable disease within the head. Under whatever cir- cumstances profound morbid sleep or coma may occur, it always denotes cerebral oppression from congestion or effusion, or some other cause capable of com- pressing this organ. When, therefore, in the course of diseases attended with symptoms of cerebral irritation or inflammation, somnolency supervenes, we may conclude that great congestion, or effusion, or disorganization of the cerebral structure, has taken place. Wakefulness is indicative of great cerebral irritation or exhaustion. It is par- ticularly apt to occur from sympathetic excitement of the brain, depending on intestinal irritation and exhaustion from loss of blood. When morbid wake- fulness depends on these causes, it is almost invariably attended with great rest- lessness or jactitation, a distressing feeling of anxiety in the region of the heart, and a pale and contracted countenance. Sudden starting during sleep is generally connected with intestinal irritation from indigestion or worms. (Hall.) Children whose bowels are loaded with sordes or worms are particularly apt to start in sleep, " and this symptom is one of the most certain diagnostic signs of such a condition of the alimentary canal." Similar hurried wakenings occur in organic affections of the heart, and in hydropericardium, and frequently, also, in hydro- thorax ; but in these complaints, the starts from sleep are almost always attended with a distressing sense of suffocation, or impending dissolution, great agitation and alarm. Acuteness of hearing and sight occurs in the incipient stage of cerebral inflam- mation; but they are equally, and often more strikingly presented in sympathetic irritation of the brain from intestinal irritation, accompanied with exhaustion. (Hall.) As a general observation, however, it may be said that when the senses of sight and hearing are morbidly acute, or when there is intolerance of light and sound, the brain is in a state of irritation, whether sympathetic or idiopathic. Obtuseness of hearing is a common symptom in the advanced stages of typhoid fevers, and indicates a considerable degree of sanguineous engorgement, but not inflammation of the brain. Strabismus, and seeing objects double, always denote very considerable cerebral disturbance. These symptoms arise from sanguineous or serous effusion into, or upon the surface of the brain, and from disorganization of a portion of the structure. Torpor or defect in the sense of touch, if general or confined to one side of the body, indicates an oppressed state of the brain, and may be both the precursor or consequence of apoplexy. When torpor of feeling is confined to one extremity, or only to a part of an extremity, we may infer that the nervous communication between the affected part and the sensorium commune has been partially interrupted, by compression of the principal nerve leading to the part, or that the nervous extremities of the part have become diseased and incapable of transmitting the nervous power. Morbid sensations are among the most common phenomena of diseases. In many affections, indeed, there are peculiar and characteristic modifications of sensibility, which it is of importance to notice in a diagnostic point of view. In strumous disease of the mesentery, an unusual sensibility to cold constitutes a peculiar and very early symptom. " In this disease, the patient is greatly sensible to cold and to the least draught of air, and in cold weather especially, constantly draws near or hangs over the fire, until the hands and legs assume a brown color from the influence of the heat." Pain may depend on inflammation, on spasm, or on nervous irritation. Each of these kinds of pain has a peculiar character by which it may in general be readily distinguished. The pain of inflammation is attended with great tender- ness or soreness of the affected part—is increased by pressure—generally con- tinuous, and always attended with more or less of febrile irritation. Spasmodic pain, on the contrary, is intermitting—is neither throbbing nor burning, like that of inflammation, nor is it attended with redness, swelling, augmented heat, or febrile excitement. Pressure, which always increases the pain of inflammation, GENERAL DIAGNOSIS. 77 generally mitigates spasmodic pains. Neuralgic pain differs from inflammatory and spasmodic pain, by occurring in transient and extremely violent paroxysms. It darts with the rapidity of lightning along the ramifications of the affected nerve. It is not attended by swelling or increased heat, unless some degree of inflammation be associated with it; and the slightest agitation or touch is apt to renew its excruciating paroxysms. It is a fact demonstrated by daily observation, that the character of inflamma- tory pain is peculiarly modified by the nature of the structure in which the in- flammation resides. This circumstance necessarily arises from the physiological fact, that each structure of the animal system is endowed with a peculiar modifi- cation of the vital properties. From this variety in the general character of in- flammatory pain, according to the structure in which it resides, we frequently obtain important diagnostic indications. In the mucous membranes, inflam- mation is attended with a burning or stinging pain, and is seldom very vio- lent: in the serous membranes the pain is lancinating, and generally extremely acute; in the fibrous tissues, it is dull, aching and gnawing; in the nerves, rapid, darting, remitting and excruciatingly severe; and in the parenchymatous and cel- lular structures, it is dull, throbbing and heavy. Thus the pain experienced from inflammation of the pleura, is acute, piercing, and generally extremely severe; whilst that from inflammation of the substance of the lungs, is dull, pressing, and generally inconsiderable in violence. The pain attending inflam- mation of the mucous membrane of the stomach is of a burning, gnawing, or stinging character; that of the liver is acute, throbbing, and generally accompa- nied with a sense of fullness and tension in the right hypochondrium and epi- gastrium. The character of the pain may, moreover, assist us in determining in what portion of this organ the inflammation is principally seated. When the substance of the liver is the principal or exclusive seat of the inflammation, the pain is seldom very acute or violent—being obtuse, heavy, and heating. When the convex surface of this organ is affected, the pain is usually extremely severe, darts upwards towards the left or right shoulder, and is always much increased by external pressure, deep inspiration, cough, and motion. In cases where the concave surface is the seat of the inflammation, the pain is, in general, dull, ac- companied with much anxiety in the epigastrium, nausea, and often vomiting. Cases of this kind frequently resemble gastritis; but may be distinguished from this affection by the pain, distress, and vomiting not being increased by taking warm liquids into the stomach. In many instances the painful sensation is referred to a different and often remote part from that in which the primary irritation or affection is seated. Irri- tation in the neck of the bladder frequently gives rise to pain in the glans penis; inflammation of the liver often causes pain in the left, and sometimes right shoul- der; and severe and protracted pain in the knee and legs, is generally among the first painful sensations attending hip disease. In many cases, indeed, pain in the knee is felt for a considerable time before any unpleasant sensations are ex- perienced or complained of in the hip; and I have not unfrequently known va- rious applications made to the knees of children for the relief of pain in that part, which was subsequently found to be merely symptomatic of scrofulous disease of the hip. Inattention to these and similar facts has often led to very useless and painful applications, and placed the physician under the mortifying, and, in- deed, justifiable imputation of ignorance or culpable carelessness. The next class of symptoms to be considered, are those manifested by the morbid conditions of the alimentary canal. From the nature and appearance of the alvine evacuations, we may often derive important diagnostic information. The functional derangements of the liver are, in general, readily distinguished by the character of these evacuations. Ash, or clay-colored feces indicate either deficient secretion of bile, or obstruction to its regular flow into the intestines. This condition of the biliary organs is almost always attended with increased irritability of the stomach. When the alvine discharges are liquid, and of a bright green color, as is frequently the case in infants, the existence of much acid in **78 GENERAL DIAGNOSIS. the bowels may be confidently inferred. Bile, as it comes from the liver, never possesses such a color. It is only by being mixed with acid in the intestines, that it acquires this appearance. However dark and vitiated the bile may be before it is discharged into the bowels, it will always communicate a yellow color to water. It becomes green in the intestines by the action of the acid it meets there. According to the observations of Dr. Cheyne, the appearances of the stools afford a good diagnostic sign between infantile remittent fever and hydrocephalus. In the former disease, the alvine discharges are, generally, dark brown or mud-like, and extremely fetid. In hydrocephalus, the stools are usually gelatinous, dark green, sometimes black, like tar, and of a peculiar sickly smell. Watery and reddish stools containing small flakes of mucus, resembling the washings of flesh, always indicate a high degree of inflammatory irritation of the mucous mem- brane of the small intestines. The diagnosis of disease is also much aided by an attention to the morbid con- ditions of the respiratory organs. In general, the greater the velocity and mo- mentum of the blood, the more rapid is the respiration. In acute diseases, attended with a frequent and full pulse, breathing is always accelerated. In affections of the head, attended with sanguineous congestion in the brain, respi- ration is generally more or less irregular, unequal and suspicious. When the congestion, and consequent cerebral compression, are so great as to produce par- tial insensibility, the breathing becomes slow, irregular and stertorous. Whatever obstructs the functions of the brain, or interrupts the nervous communication between it and the respiratory apparatus, impedes or destroys the function of respiration : and the slowness and irregularity of the respiratory acts will be in proportion to the degree in which the functions of the brain are oppressed. In pneumonia, breathing is sometimes performed by the action of the diaphragm alone, without any perceptible elevation and depression of the ribs of the affected side. In abdominal inflammation, with acute pain, on the contrary, respiration is performed almost exclusively by the action of intercostal muscles, the alternate rising and falling of the abdomen, so conspicuous in thoracic inflammation, being almost entirely absent. " This peculiarity of breathing," says Dr. Hall, " may be distinctly observed by looking on the chest and drawing the bed-clothes tight over the abdomen : the respiration has sometimes the appearance of heaving of the chest; every movement of the diaphragm is cautiously avoided on account of the motion which its action communicates to the abdominal viscera. The diaphragm and abdomen begin to move, as the pain diminishes, whether from mitigation of the disease, from sinking, or from gangrene." 4- In inflammation of the substance of the lungs, or of the mucous membrane of the ultimate bronchial tubes, respiration is performed with great difficulty, and in violent cases with distressing anxiety and labor. " The shoulders are elevated, and the lower part of the sternum is drawn back, during each act of inspiration, whilst the abdomen is at the same time suddenly protruded, and the upper part of the chest raised." In the diseases of children, the manner in which respira- tion is performed often throws important light on the character of the disease. When, with more or less cough, the inspirations are short and catching, more especially when the countenance, at each inspiration, exhibits an expression of pain or suffering, the existence of pectoral inflammation may be confidently in- ferred. If the countenance is pale, and the breathing wheezing and laborious, the inflammation is probably seated in the mucous membrane of the bronchia. Laborious and anxious breathing on muscular exertion or strong mental excite- ment, particularly from walking up hill, or ascending stairs, is strongly indicative of organic disease of the heart. The dyspnoea of hydrothorax differs from that of organic cardiac disease, in being more liable to recur in violent paroxysms from the causes just mentioned in the latter than in the former affection. In hydrothorax, too, the dyspnoea, thus excited, comes on gradually, whilst in organic disease of the heart the paroxysm of suffocative breathing recurs with sudden violence. Asthma is attended with a peculiar mode of dyspnoea. The act GENERAL DIAGNOSIS. 79-" of inspiration consists of a quick and imperfect dilatation of the thorax, but ex- piration is much more protracted, labored and wheezing. " When the disease is violent, every muscle subservient to this function is brought into strong exertion, with the exception of the intercostals, which, although excited to strong efforts, are incapable of that degree of action which is necessary for the due expansion of the chest. What, however, particularly characterizes the dyspnoea of asthma, is the wheezing during expiration." When the breathing is hurried, panting, sighing, and the lungs are but partially filled during inspiration, there is probably much debility accompanied by or depending on nervous intestinal irritation. This state of the system and of the respiratory organs is generally attended with great restlessness, jactitation, and inability to sleep. Having described some of the more remarkable diagnostic phenomena, in relation to respiration, it remains for me to consider the diagnostic indications derived from the character and attending circumstances of coughing. With regard to the phenomena of cough, therefore, we may notice the follow- ing general diagnostic circumstances :—Patients affected with inflammation of the pleura, lungs, or peritoneum, always repress the cough as much as possible, in order to obviate the great increase of pain which free coughing invariably pro- duces in these affections. When, therefore, the patient is observed to make great efforts to stifle or suppress the acts of coughing, the existence of local inflamma- tion may be confidently inferred. The seat of the inflammation will be pointed out by the other accompanying symptoms. The cough attending acute inflam- mation of the mucous membrane of the bronchia has a much duller sound, and is attended with much more mucous rattling in the chest than that which results from acute inflammation of the pleura. This remark applies particularly to the early period of these affections; for in the advanced stage of the latter malady, the cough is generally as dull and rattling as in bronchitis. Cough depending on gastric or intestinal irritation, is generally attended with a peculiar hollow sound : this kind of cough is frequently met with in children laboring under verminous irritation. The character of the cough will, in general, afford consider- able aid in distinguishing phthisis laryngea from phthisis pulmonalis; or that form of consumption which arises from ulceration in the larynx, from true pul- monary consumption. In the former the cough comes on in violent and spasmo- dic paroxysms, particularly in the morning on rising from bed; whilst in the latter form of the disease, the cough is usually much less sudden and violent in its attacks, and is, besides, destitute of the spasmodic or convulsive character of the former. In the laryngeal variety of the disease, the cough has a deep hollow sound, not unlike that which is produced by verminous irritation of the bowels, whereas, in pulmonary phthisis, it always has a " flattened and lacerating sound." In the former of these maladies, violent fits of coughing are excited by the patients passing from a warm into a cold air, by inhaling smoke or the dust raised by sweeping, or any irritating fumes, and the same effect is frequently produced by swallowing food. In pulmonary phthisis, coughing is very rarely excited by these causes, and when they do produce this effect, the cough is usually slight and of very short duration. The character and appearance of the matter expectorated afford important diagnostic indications. In peripneumonia, the tenacity of the matter expec- torated is so great, that we may reverse the vessel which contains it, and retain it in this position for some time, without detaching it from its sides. Laennec regards this kind of sputa as pathognomonic of this affection, " since it is the only symptom which is found exclusively in this form of pulmonic inflammation." These sputa are somewhat diaphanous and of slightly yellow or greenish color. In acute bronchitis the expectoration is much less tenacious in its consistence, and is generally quite transparent, resembling the white of eggs. When the fluid expectorated has a dark appearance, like dissolved blood, and possesses a very fetid smell, we may infer that some portion of the diseased lung is in a 80 GENERAL DIAGNOSIS. gangrenous condition. In chronic bronchitis, particularly in those cases which result from pertussis, the matter expectorated often presents a white cream-like appearance, bearing considerable resemblance to the whitish friable matter which is sometimes brought up in small quantities in the latter stage of tubercular phthisis. This white matter, in the latier disease, consists of the softened sub- stance composing the tubercles. Mucous membranes, under a high degree of irritation, often secrete a fluid which bears a strong resemblance to genuine pus ; but which, in its composition and properties, is, nevertheless, strictly a mucus. Various tests have been recommended for distinguishing puruloid secretions of this character from genuine pus, and a correct decision on this point is of much importance in forming a satisfactory diagnosis ; for when the matter expectorated is found to be pus, there can be no doubt that the structure from which it pro- ceeds is in a state of active inflammation or ulceration. If, on the contrary, it be found to possess the character of mucus, we may infer that neither an active state of inflammation nor ulceration exists in the diseased organ, but only a high degree of irritation, or sub-inflammatory excitement. The specific gravity of pus is considerably greater than that of mucus; ,the former sinks in water, the latter floats on the surface. This is the usual test, but cannot always be relied on ; for although we may safely pronounce the matter expectorated to be pus when it sinks quickly to the bottom of the vessel, yet we cannot, with entire assurance, infer that it is mucus when it remains floating on or near the top of the water; for a considerable portion of pus is often so intimately mixed with bronchial mucus, as to give it a nearly uniform appearance, and cause the sputa to swim on the surface. The following tests have been proposed, and I think are entitled to confidence.—The muriate of ammonia coagulates pus ; but on mucus no such effect is produced by it. Heat coagulates mucus, but not pus. Water added to the solutions of pus in sulphuric acid, and in a solution of caustic potash separately, produces in each a copious precipitate. Mucus treated in the same way does not exhibit the same effect. Dr. Young mentions the following test: A small portion of pus put between two glasses, will, when held near the eye, and looked through at a distant candle, exhibit an iridescent spectrum, of which the candle is the centre. Mucus does not present this phe- nomenon. The morbid conditions of the external surface of the body should always be carefully observed. In examining diseases, particular attention should be paid to the temperature, the color, the state of dryness or moisture, the fullness or con- striction, and the roughness or smoothness of the skin. The existence of oedema, or of emaciation, moreover, is an important diagnostic circumstance. A yellowish or icteric hue of the skin, and especially of the tunica albuginea, is a well-known indication of derangement of the biliary organs. In the various forms of disease produced by marsh miasmata, this symptom is rarely absent. This appearance of the skin, says Mr. Hall, must not be confounded with the sallow hue which occurs in chlorosis, cancer, and some other organic affections. " Sallowness is not necessarily accompanied by a yellow hue of the albuo-inea; but the icteric appearance of the skin is always associated with a similar tinge of the eyes. When, therefore, the albuginea is free from this yellowish hue, we may infer that the biliary organs are not particularly disordered, however sallow the general surface may be. When a decided icteric or jaundiced hue of the skin is associated with constant and obstinate torpor of the cutaneous ex- halents, or dryness of the surface, we may infer that the biliary derangement, upon which these phenomena depend, consists of chronic inflammation and in- duration of the liver ; and this diagnosis may be regarded as still more certain, if, at the same time, the gums have a peculiar and unnatural firmness. A purple or bluish color of the skin, when not the immediate consequence of cold, indi- cates deficient decarbonization of blood in the lungs. This appearance occurs, in a striking manner, in the Asiatic cholera. When this livid hue is confined to some particular part of the body, it denotes great venous congestion in the part. GENERAL DIAGNOSIS. 81 Thus a livid color of the face indicates great engorgement of the blood-vessels of the head, and is almost universally connected with, or rather dependent on, obstructed circulation through the lungs, and attended with an imperfect per- formance of the respiratory functions. A pale semi-transparent appearance of the surface, particularly of the prolabia and face, occurs after profuse hemorrhage, or from whatever greatly exhausts the system or produces the process of sanguification. This appearance of the skin is always accompanied with great languor and debility, and depends, gene- rally, on a morbid excess of the serous portion of the blood. This state of the system is almost invariably attended with more or less of anasarcous effusion. A pale and cachectic appearance of the face, attended with a leaden hue of the prolabia and a puffy swelling under the eyes, is frequently noticed in organic affections of the heart. A cold state of the surface of the body, attended with a sensation of heat in the internal parts, indicates great sanguineous congestions of the viscera. The heat is sometimes very unequally distributed throughout the various parts of the body, and it may be laid down as a general rule, that in whatever part the heat is preternaturally elevated, there is an unusual determina- tion of blood to that part. Thus in hydrocephalus, the head is almost always considerably warmer than in any other part of the body ; and in dysentery and peritonitis the abdomen is preternaturally hot to the touch, whilst the extremities in the latter stage of the disease are unusually cool. (Hall.) In organic affec- tions of the heart, the hands, nose and cheeks are very apt to become preter- naturally cold, whilst the heat within the rectum and under the tongue is gene- rally considerably higher than natural. (Fare.) A pungent, stinging heat of the surface, or the calor mordax, as it is technically called, indicates a high grade of malignity or a tendency to putrescency in fevers. This pungent heat differs very distinctly from the burning heat which occurs in synochal or inflam- matory fever. By laying the hand on the skin of a patient laboring under inflammatory fever, the sensation of heat is at first very great, but on suffering the hand to remain for a short time, the sensation of heat gradually diminishes, until it seems to the touch but little, if in any degree, above the natural tem- perature of the body. In typhus gravior, on the contrary, the heat (calor mordax) becomes more and more pungent and severe, and the biting or acrid sensation of heat remains in the hand, even after it is removed from the patient's body. The appearances and character of the urine also often afford valuable diagnos- tic indications. In inflammatory affections it is generally very red and small in quantity ; in nervous diseases, more especially in hysterical affections, this secre- tion is usually copious and limpid, or but slightly colored. In diseases of the biliary organs, the urine is almost invariably conspicuously tinged with bile. To distinguish urine colored with bilious matter from the highly-colored urine of inflammatory fevers, a small strip of white linen or paper should be immersed in it. If the urine contains bile, the linen or paper will receive a very distinct yellow stain, which will remain when dried. If it be free from bilious matter no such tinge will be communicated. Much has of late years been said concerning the connection between a serous or coagulable condition of the urine (in hydropic affections), and a phlogistic or inflammatory state of the system. Drs. Blackall, Wells, and Ayre have investigated this subject with minute attention. It has been satisfactorily ascertained by these and other pathologists, that in those cases of dropsy which are attended with an obvious phlogistic diathesis, and especially such as arise from the influence of general causes, the urine, with scarcely an exception, contains a large quantity of coagulable serum. The quantity of serum mixed with the urine may, therefore, be regarded as a pretty correct index of the degree of general inflammatory excitement attending the disease. Serous urine may be regarded as a sort of pyrexometer in hydropic affections, which, thougli not' universally to be relied on, is yet sufficiently constant to entitle it to the 6 82 GENERAL DIAGNOSIS. attention of the practitioner. I am satisfied, from considerable attention to this subject, that in almost every instance where there is coagulable serum in the urine of dropsical patients, the general condition of the system will be found manifestly phlogistic. The mode of testing the urine, for this purpose, is to expose a portion of it in a spoon to the heat of a lamp. When, in hydropic affections, the urine is high-colored, and on cooling becomes muddy, or deposits a red or reddish sediment, we may infer with great probability that the liver is in a state of organic disease. (Cruikshank.) 83 » OF THE ACUTE DISEASES OF THE SANGUIFEROUS SYSTEM. I.—GENERAL IRRITATIVE DISEASES OF THE BLOOD-VESSELS INDEPENDENT OF LOCAL INFLAMMATION. CHAPTER V. OF INTERMITTING FEVER. Intermitting fevers occur under the three primary types mentioned in a pre- ceding chapter, and occasionally under the various complications which these types are liable to assume. According to the type which they assume, therefore, they are divided into quotidians, tertians, quartans, quintans, fyc. The fit or paroxysm of an intermitting fever consists of three distinct periods, all of which are characterized by a series of peculiar phenomena, each succeed- ing period being the immediate consequence of the one which precedes it. The symptoms which characterize the forming state of an intermittent parox- ysm, do not differ from those which usually precede the development of the other forms of fever. A sense of great lassitude, frequently yawning and stretch- ing, a feeling of uncomfortable weariness of the whole body, and slight aching pains in the loins and extremities, constitute the first manifestations of the ap- proach of an intermittent fever. Cold stage.—After the foregoing symptoms have continued for an indefinite time, the patient begins to experience slight and transient sensations of cold along the back; attended often with an irresistible disposition to yawn and change the position of the extremities ; the fingers and feet lose their natural temperature, and feel slightly benumbed; the patient becomes restless, and soon tired of the same position; his ideas pass with unusual rapidity through his mind; he is incapable of fixing his attention upon any particular object, and generally mani- fests an unusual irritability of mind, or ill temper, or a taciturn moroseness. The sensation of chilliness, with more or less rapidity, extends itself from the extre- mities over the whole body; the skin becomes universally pale, contracted, and rough ; the pulse loses its activity and size, becoming small, contracted, frequent, and firm.^ When the sense of chilliness has passed from the extremities to the body, a slight trembling of the muscles begins, generally, at first, in the jaws, and extending thence quickly over the whole frame. This trembling is sometimes so severe as to agitate the patient as if he were in a paroxysm of convulsions, and sometimes exhausts him so much as to leave him scarcely able to move his limbs after their subsidence. These tremors are technically called rigors. During the chills the sensibility of the surface is benumbed, and the whole body becomes diminished in volume, so that rings which were previously tight drop from the fingers. The feeling of cold is not confined to the surface, but appears in violent 84 INTERMITTING FEVER. cases to penetrate even to the bones, and to pervade the whole system, " and is accompanied with an indescribable sense of universal pain and fatigue."* The breathing also is hurried, anxious, and oppressed, and frequently attended with a short, dry cough, deep sighing, and a sense of weight and tightness in the chest. Along with these symptoms there occur usually much dejection and confusion of the mind, and in some instances, a slight degree of delirium. In very debilitated persons a violent fit of rigors often induces a complete state of stupor or coma, more especially when feebleness of body is attended with general plethora. In many instances, frequent and distressing vomiting occurs, particularly about the period of its subsidence, and the ejections are generally bilious, though occasion- ally ropy, transparent, and insipid. The thirst is always urgent in this stage, and the mouth and fauces are dry and clammy.-• The urine is clear, colorless, with- out sediment, and often copious. Generally, the chills are universally diffused over the body ; but in some cases they occur partially, remaining confined to one or more parts of the body; and instances have been recorded in which a single extremity only was affected with the chills. In some cases of intermit- ting fever, the cold stage is attended with but a very slight sensation of chilliness creeping along the back and over the extremities; and I have known this stage to commence with violent vomiting, and to terminate speedily in stupor and par- tial insensibility. The duration of the cold stage is very various, ranging from a few minutes to four or five hours. Sooner or later, however, the chills begin to abate; transient flushes of heat pass over the face and body; the chilliness now recedes rapidly, and the heat encroaches pari passu, until it has obtained an entire ascendency. At this time the nausea and vomiting are usually most severe—both of which often continue until the hot stage is completely developed. The hot stage is characterized by a full and flushed countenance ; an intensely hot and dry state of the surface of the body; great thirst and dryness of the mouth ; great acuteness of the sensorial powers; a full, strong, and frequent pulse; a more free and regular respiration than in the preceding stage, though still more oppressed and hurried than natural; great pain in the forehead; pain in the back and extremities ; sometimes slight delirium just before the commence- ment of the succeeding stage; a scanty and deep-colored urine without sediment. This stage is as various in its duration in different cases, as the preceding one. It continues, however, almost always much longer than the cold stage. The temperature of the skin is always very considerably augmented. Fordyce ob- served it as high as 105° of Fahrenheit. This stage terminates in the last, or, The sweating stage.—When the perspiration begins to appear, an obvious abatement of all the febrile symptoms occurs. The sweat appears at first about the head and breast, and thence gradually extends over the whole surface of the body. On the appearance of this evacuation, the pulse loses its hardness and frequency, but still retains its fullness. The breathing at the same time becomes free and natural; the febrile heat subsides rapidly; and the urine, though still very high-colored, deposits a lateritious or pale red sediment. This gradual melioration of the febrile symptoms continues under the free flow of the perspi- ration, until the paroxysm terminates in a state of perfect convalescence or apyrexia. The apyrexia, or intermission, though entirely free from febrile phenomena, cannot, however, be regarded as a state of health; for, during this interval, the patient usually feels some degree of languor; becomes easily fatigued; complains often of a want of appetite, and an indisposition to bodily or mental exertion. He possesses, moreover, an unusual degree of sensibility to the impressions of cold air; and his countenance exhibits a pale and sickly aspect. In some, though comparatively few instances, the appetite is good, and the patient experiences no feelings of indisposition whatever during the intermission. The more conspicu- ous the symptoms of imperfect health are, during the intermissions, the more * Macculloch on Intermittent and Remittent Fever, &c. INTERMITTING FEVER. 85 difficult, in general, will it be to prevent its recurrence; or, the more readily will it relapse after it has been suspended. Intermittents of every type are subject to certain prominent modifications in relation to their general character, which, as they have important practical bear- ings, deserve particular attention. We meet with intermittents, for instance, which are attended with unequivocal manifestations of an inflammatory charac- ter; others occur in which symptoms of great internal venous congestions are equally conspicuous; a third variety of intermittents will exhibit strong symp- toms of biliary and gastric irritation; and a fourth variety will be characterized by phenomena indicative of a more or less malignant character. According to these circumstances, intermittents may be divided into the four following varieties, viz: 1, the inflammatory; 2, the congestive; 3, the gastric; and 4, the malig- nant intermittents. 1. Inflammatory intermittents occur most frequently during winter and in spring. Quotidians are more apt to assume this character than tertians; and tertians more apt than quartans (Richter). In young, robust, and plethoric sub- jects, vernal quotidians are especially prone to manifest inflammatory symptoms. Intermittents of this character generally begin with strong rigors. In the hot stage, the temperature of the surface is very intense, and the pulse is peculiarly strong, hard, and full. The most characteristic marks of inflammatory intermit- tents occur, however, during the intermission. However profuse the perspiration in the last stage, the apyrexia does not become complete. The pulse remains quick, somewhat tense and accelerated; the thirst is still considerable, and the skin dry and warmer than natural; the whole system is irritable; the temper is fretful or discontented; slight headache is experienced; and transient pains are often felt in the extremities and the back. In many instances a short and dry cough occurs, with some oppression in the chest, or other pectoral affections. Richter observes, that inflammatory intermittents are very rarely attended with symptoms of gastric disturbance from vitiated secretions, bile, &c. The inter- missions in agues of this kind are usually short. (Richter.) 2. Congestive intermittents occur seldom. They happen generally in persons of exhausted and debilitated habits; and in such as are of an irritable and nervous temperament, connected with habitual or accidental debility. They are charac- terized by a very protracted cold stage, deep-seated pain in the head, vertigo, fainting, a sense of weight or oppression in the breast, coma, a small and weak pulse; the hot stage coming on very slowly, and developing itself very imper- fectly, so that instead of hot skin, flushed countenance, and a full and vigorous pulse, the system continues to be oppressed, the skin scarcely warm, the counte- nance pale and contracted, the breathing confined and anxious, and the pulse frequent, small and tense, with an internal sensation of heat. 3. Gastric intermittents are characterized by prominent symptoms of gastric and intestinal irritation, redundancy of biliary secretion, and other saburral mat- ters lodged in the alimentary canal. The ordinary intermittents of the temperate climates, occurring in Autumn, are usually of this kind. Intermittents of this modification are attended with a foul and bitter tongue; much nausea and bilious vomiting; great pain in the forehead; diarrhoea; an icteric hue of the skin and albuginea; urine loaded with bilious matter; thirst for acid drinks, and sensation of weight or fullness in the right hypochondrium. Intermittents of this kind are apt to produce visceral disorders, more especially indurations of the spleen and liver, and finally, a cachectic condition of the system which is often extremely difficult to remove. (Richter.) 4. Malignant intermittents are of frequent occurrence in hot climates, and are always of the most dangerous character. They are characterized by a very copious and fetid perspiration in the third stage, together with colliquative hemor- rhages from various parts of the body, sometimes petechia, and other marks of malignity. They run their course with great rapidity, death usually taking place in the third paroxysm. (Alibert.) 86 INTERMITTING FEVER. Irregular and anomalous intermittents. Intermittents do not, however, al- ways pursue the regular course that has just been described. In some instances, anomalies of a remarkable character occur, both in relation to the phenomena and the succession of the stages of the disease. I have known a case in which the first two paroxysms occurred in a perfectly regular manner; but after employ- ing arsenic, unsuccessfully, during the second and third intermissions, the parox- ysms returned without a cold stage, the patient experiencing, instead of it, a peculiar feeling of numbness on the top of the head, with great dullness of hear- ing, for about forty or fifty minutes before the supervention of the hot stage. There are instances on record, of the inversion of the natural order of the cold, hot, and sweating stages; several distinct instances of which occurred under my observation in the fall of 1828. Cases have been noticed in which the perspira- tion, in the third stage, was substituted by diarrhoea; and Cleghorn states, that he saw tertians, which terminated by an increased flow of urine, with scarcely any sweat. In infants, the paroxysms of intermitting fever are sometimes ushered in by convulsions; but the convulsions are most apt to occur at the commencement of the hot stage. Indeed, the cold stage of very young children is seldom marked by distinct rigors. A pale and shrunken countenance, with an obvious reduction of the temperature of the surface, yawning, and stretching, usually manifest the presence of this stage in infants. There are certain affections, not of unfrequent occurrence, which, from their strict periodicity, as well as from their apparent origination from the same causes that give rise to intermittents, are termed masked agues, febres intermittentes larvatse. Thus, neuralgia, in various parts of the body, sciatica, rheumatism of the eye, haemicrania, toothache, cramp in the stomach, dysentery, cholera, hic- cough, mania, and acute pains in other parts of the body,* have been known to recur in a manner strictly periodical, and to have yielded readily to the same remedies which are found to arrest the course of an ague. These affections, when thus perfectly periodical, generally manifest their alliance to intermitting fever, by being almost always preceded by a very slight sensation of chilliness, and by being attended with a moist skin and a turbid urine at the termination of the paroxysm. (Richter.) Intermittents are sometimes complicated with other affections, such as dysen- tery, cholera, jaundice, and visceral inflammations. The vernal intermittents are most apt to become complicated with inflammatory affections; and those which occur in Autumn are most frequently combined with disorders of the alimentary canal and nervous system. Paralysis and apoplexy, according to the observations of Dr. Macculloch, are by no means uncommon occurrences in intermitting fever; and they occur, sometimes, as direct consequences of the influence of the mias- mata, without any distinct febrile phenomena. Many of the affections which supervene in intermittents appear to result from the inroads of the fever itself on the constitution: but the majority of these ma- ladies, whether occurring as concomitants, sequelae, or substitutes of the fever, are, without doubt, direct consequences of the deleterious influence of the remote cause. Dropsy, jaundice, scirrhus, &c, are, probably, usually the result of the general febrile disease. Unquestionably, too, aneurismal enlargements of the heart and large vascular trunks, must be regarded as the consequence of the vio- lent congestion of the blood which occurs in the internal organs during the cold stage. In the same way, apoplexy sometimes occurs in the commencement of intermitting fever; for the blood recoils so powerfully from the external to the internal vessels, in the cold stage of the disease, that those who are, in other respects, predisposed to determinations to the head, are liable to suffer apoplectic oppression of the brain from this cause. Dr. Macculloch warmly opposes the * Macculloch on Intermittent and Remittent Fever, &c. See, also, Joum. Generale de Med., No. 291, foot note. Also, Gazette de Sante, No. 17. INTERMITTING FEVER. 87 opinion, that in apoplexies of this kind there is any particular congestion of blood in the brain. The cases which I have myself seen, however, do not permit me to doubt that they were essentially connected with cerebral pressure from inordi- nate vascular turgescence. It is not unlikely, however, that those apoplectic symptoms which occur as the immediate consequence of the powerful influence of miasmata on the brain, independent of chills, or torpor of the vessels of the surface, are in no way dependent on cerebral compression from sanguineous congestion. Paralysis, neuralgia, mania, &c, as well as the above-named affections of the alimentary canal, are, however, almost invariably direct malarious affections; occurring with or without any manifest febrile phenomena ; and frequently ex- hibiting their affinity to intermitting fever, by their paroxysmal and strictly peri- odical character. For a full exposition of the nature, phenomena, and manage- ment of these miasmal diseases, the reader is referred to Dr. Macculloch s Treatise on Intermitting and Remitting Fever. But if intermitting fever has a tendency to produce other affections, it has been found also to remove various diseases of a chronic and obstinate character. Celsus observes, that intermitting fever is often remedial of itself; (lib. ii., cap. 8, p. 70.) The tendency of quartans to cure epilepsy, is mentioned by Hippocrates, (Epidem. 1;) and we are told that the celebrated mathematician De la Hire was permanently relieved of an habitual and most violent palpitation of the heart, by an attack of ague of the quartan type. (Academ. des Sciences, Van. 1718; Hist., p. 110). Fordyce states, that rheumatism, cutaneous erup- tions, hysteria and indigestion, have been effectually removed by attacks of inter- mitting fever; and Vogel asserts, that he has known asthma and hypochondriasis cured by this disease. Almost all writers, however, attribute much more sana- tive power in this respect to quartans than to either of the other two types. Intermittents, when suffered to pursue their course without being controlled or embarrassed by external influences, appear to have a natural tendency to termi- nate spontaneously, after a certain number of paroxysms have been passed through. Quotidians, for instance, if they are simple and regular, will tend to terminate their course on the seventh day, and tertians on the fourteenth. Quartans will generally run on to the sixth week. Of the natural tendency of the two former types to terminate at about the periods just indicated, I have the strongest con- viction from my own observations. The disease may not generally terminate spontaneously at these periods, but its tendency to do so will be such, that if assisted by a proper febrifuge, it will not only more certainly be arrested, but a relapse will scarcely ever occur, unless the remote cause continues to act on the system. Every one who has had considerable experience in the treatment of inter- mittents, must have been struck with the great frequency of relapses, even where the patient has been removed out of the sphere of the influence of the remote cause. From what I have observed in relation to this subject, I will venture to say, that if the usual febrifuges were withheld until after the seventh paroxysm, such an occurrence would, under all circumstances, be comparatively very rare. I have already adverted to the tendency of intermitting fevers to relapse at stated intervals ; and although I cannot undertake to reconcile the apparent opposition in these statements, namely, that fevers of this kind tend naturally to terminate and also to relapse at the septenary periods, yet of the truth of the observation I entertain the strongest conviction. Prognosis.—The intermittents of temperate climates are among the least dangerous of febrile affections. In hot latitudes, however, they often assume a highly malignant and fatal character. Death from a simple and mild intermittent does, nevertheless, sometimes occur; and when this happens, it is nearly always in the cold stage, and with symptoms of apoplexy. I have met with two fatal instances of this kind. The violent internal congestions which occur during the cold stage, are well calculated to produce cerebral oppression and apoplexy, particularly in persons who are naturally predisposed to this malady. In general 88 INTERMITTING FEVER. much less danger is to be apprehended from this disease in the young, robust and vigorous, than in persons of feeble, nervous, and depraved habits of body. In individuals of the latter habit, there is sometimes not sufficient vital energy to react and develop the hot stage, and they occasionally sink into a state of lethargy or fatal apoplexy. The more irregular an intermittent is, in relation to its type and particular phenomena, the more difficult in general it is to effect a permanent cure. Postponing agues are more favorable than such as anticipate their parox- ysms. The latter tend to the continued form. A scabby and humid eruption about the mouth and nostrils is a favorable sign. When habitual discharges, whether natural or morbid, reappear after having been suppressed by the ague, perfect convalescence generally soon follows. The state of the digestive func- tions has an important bearing on the prognosis of intermittents. So long as digestion is performed with considerable activity, and there are no decided marks of gastric irritation, very little difficulty in general will be experienced in remov- ing the disease. But when these functions are prominently deranged, and there are manifestations of much debility of the stomach, we may calculate on meet- ing with considerable difficulty in our efforts to prevent the return of the parox- ysms; for even should a temporary stop be put to the progress of the disease, the liability to relapse in this state of the digestive apparatus, is such as to render the best-directed treatment often abortive. Delirium seldom occurs in intermittents, and when it does happen, it must be viewed as unfavorable; and even more so than mere coma. In malignant inter- mittents, delirium is common; indeed, it may be regarded as almost peculiar to the worst varieties of this disease. Difficult and oppressed breathing, attended with hiccough and frequent deep sighing, is a bad sign. Sydenham observes, that a tumid and hard abdomen, with swelling of the tonsils, is in general indi- cative of a fatal termination. One of the most unfavorable signs is a profuse and prolonged colliquative and offensive diarrhoea. Bloody urine also is very unfavorable. The latter symptoms are almost exclusively confined to the violent intermittents of hot climates. When, during the intermission, the patient re- mains very much debilitated and oppressed, and the feet and legs are oedematous, considerable danger may be justly apprehended. Tertians are, in general, more readily removed than quotidians, and quotidians than quartans. Intermittents not unfrequently change into the remittent form ; and this conversion is, of course, always an unfavorable occurrence. When such a change is about to happen, the paroxysms of the intermittents are progressively prolonged until they run into each other. Simple tertians always reduplicate their type before they assume the continued or remittent form. The conversion of the intermittents into the remittent form is particularly favored by whatever is capable of causing or augmenting the general phlogistic condition of the system, and especially by the accidental supervention of some internal inflammation. . The unseasonable employment of tonics and stimulants is frequently productive of such changes in the form of the fever. Causes.— The only general cause of intermitting fever is koino-miasmata. Intermittents are the simplest, and in general the least dangerous of all the febrile diseases produced by this variety of miasmata. In the vicinity of marshes, we may often trace the various grades of miasmatic fevers from the most violent and fatal to the simplest and mildest varieties, as we progressively remove from the focus of the deleterious exhalations towards the circumference of its influence. On the borders of the soil whence the miasmata emanate, if very copiously en- gendered, continued and highly fatal cases of bilious fever will prevail; at a greater or less distance from this point, mild remittents will predominate ; and at a still more remote situation, intermittents will be most common. From the same cir- cumstances, the first diseases which occur in miasmatic districts are generally intermitting fevers; as the season advances, remittents occur, and finally prevail with great violence; as the cold weather approaches, and the extrication of mias- INTERMITTING FEVER. 89 mata begins to diminish, intermittents again become more common, and the re- mitting fevers gradually disappear. The tendency of koino-miasmata to produce intermittents. is much enhanced by sudden changes of atmospheric temperature. Intermittents are never more prevalent than when the days are very warm, and the evenings and mornings cool and damp. In some instances, several weeks elapse between the reception or impressions of the miasm and the occurrence of the fever. I have repeatedly known persons to be attacked with intermitting fever in this city several weeks after they had been exposed to koino-miasmata in the country.* Persons who have been exposed to miasmata should carefully avoid everything capable of debilitating the system, and particularly the digestive organs, for at least two weeks after exposure. Although koino-miasmata may be regarded as incomparably the most frequent cause of intermitting fever, yet various other causes may, under favorable circum- stances, give rise to this form of fever. Richter observes, that the worms and other causes of intestinal irritation have been known to produce intermitting fever. He mentions, also, suppressed catamenia and hemorrhoidal discharge, as well as the drying up of old ulcers, as occasional causes of intermitting fever. I have seen one instance, in a delicate child, where a distinctly formed ague was mani- festly produced «by intestinal irritation from too free an indulgence in irritating articles of food. An interesting case is related by Mr. Earle,t in which a regular intermittent was produced by the irritation of a small piece of dead bone in an old wound, and which was at once arrested on removing the irritating substance. It would seem that either the generation of miasmata, or their power of producing intermitting and remitting fevers, is greatly controlled by certain occult conditions, wholly unconnected with any appreciable circumstances, with regard to atmo- spheric temperature, or any of the other known requisites for the production of this poison. In certain districts of the temperate latitudes, malarious fevers will sometimes disappear, or become extremely rare for a number of successive years ; and then gradually become more and more common, until, in the course of a few seasons, they assume the prevalence of an epidemic; and yet no material differ- ence will be obvious between these periods of exemptions from and prevalence of disease, in relation to what are deemed the necessary concomitants for the production of miasmata. Proximate cause.—In relation to the proximate cause of this form of fever and of its periodicity, we may at once confess our entire ignorance ; for all that has hitherto been advanced in relation to these mysterious subjects amounts to nothing more, at best, than some ingenious conjectures and hypothetical specula- tions, with a great deal of crude and absurd reasoning and idle suppositions. As to the sentiments of Broussais, which place the proximate cause of this and all other fevers in an inflammation of the mucous membrane of the alimentary canal, it can neither be profitable nor interesting to repeat again what I have already advanced in refutation of its correctness. Treatment.—The treatment of intermittents must be considered under two distinct heads; namely, that which is proper during the paroxysm, and that * Upon this point Dr. Macculloch differs so far as I know from every other writer who has attended to this subject. He maintains that the interval between the application of the mias- mata, and the first manifestations of its morbific effects on the system, seldom, if ever, extends beyond twenty-four hours. "I know not," he says, "if physicians have fairly observed that the supervention of intermitting fever may be later than twenty-four hours from the exposure to the cause;-' and he asserts that the attack of intermitting, as well as remitting fever, "sometimes instantaneously follows the application of the poison." That the febrific powers of miasmata may be manifested very soon after they are applied, cannot be questioned, but the assertion that the period between the reception of the poison, and its obvious effects, does not probably extend beyond twenty four hours, is undoubtedly contradicted by almost daily experience in our own climates. f Medico-Chir. Review, January, 1827. 90 INTERMITTING FEVER. which is to be employed during the intermissions, and upon which the radical cure of the disease depends. In the ordinary regular intermittents of the temperate latitudes, remedial interference during the paroxysm of the disease is extremely uncommon, and is indeed very generally altogether unnecessary. Nevertheless, where the febrile excitement becomes very violent in the hot stage; or where the system is so enfeebled that dangerous congestions and oppression occur during the cold stage, medicinal aid is not only proper, but sometimes absolutely essential to the safety of the patient. During the cold stage of an intermittent, the patient ought to be kept moderately warm; and as the thirst is generally very urgent, bland and warm drinks should be freely allowed. In general, however, stimulating drinks, and the application of much artificial heat, with the view of moderating the distress- ing sense of cold, are improper; since they very rarely lessen the feeling of chil- liness, and tend often considerably to increase the violence of the succeeding hot stage. These observations apply to the regular disease, occurring in individuals of sufficient vital energy to develop the hot stage, without any artificial support. When the patient is feeble, nervous or exhausted, it will, generally, be beneficial to aid the vital powers during the cold stage, both by external and internal ex- citing agents, more especially, by the application of external heat. Without such aid, the cold stage will probably be greatly prolonged, and th# system so op- pressed by internal congestions as to prevent the regular development of the subsequent stages. Various means have been adopted for the purpose of curtailing the cold stage; and of these, emetics and opium appear to be the most efficient. An emetic ad- ministered at the beginning of this stage, will frequently put a speedy termination to its progress; and a full dose of opium, taken a short time before the expected occurrence of the chills, will generally have the same good effect. This latter remedy was particularly recommended by Dr. Trotter; and other eminent phy- sicians have given their testimony in its favor. In debilitated and relaxed habits the exhibition of a grain or two of this narcotic, just before the accession of the chills, will generally prove decidedly beneficial. I have frequently resorted to it in cases of this kind, with obvious advantage. In persons of a full and vigorous habit of body, it will rarely do any good, and may readily do mischief by in- creasing the violence of the reaction and of the determination to the brain, in the hot stage. Compression with the tourniquet, also, was some years ago strongly recommended to the profession, for arresting the cold stage of intermittents, by Dr. Kellie.* I have known it to be employed in four cases, and although the effects of it were by no means equal to those which Dr. Kellie ascribes to it, there was, nevertheless, a manifest impression made on the violence and progress of the chills. Dr. Kellie asserts, that by obstructing the circulation in an upper and in a lower extremity, by means of a tourniquet, we may, in general, stop the cold stage in three minutes ; and that if the compression be made immediately previous to the accession of the cold stage, it will be entirely prevented. The limited experience which I have had in relation to this practice, does not confirm this very favorable account of its effects; although some, and occasionally per- haps considerable advantage may, no doubt, be obtained from it. I should ap- prehend, however, that in vigorous and plethoric subjects, considerable danger must attend this practice, from the tendency which it must have to favor vascular turgescence of the brain; and thereby dangerous oppression or apoplexy. Within the last two years, Dr. Mackintosh has published some highly inte- resting observations on the utility of blood-letting in the cold stage of agues, which, though contrary to the sentiments universally entertained concerning the character of this stage of febrile development, and the known tendency of blood- letting, are nevertheless too strongly confirmed, by well attested facts, to justify us in rejecting* them, without further experience. " There are few things," says * Medical Commentaries for the years 1794-97, by Dr. Duncan, of Edinburgh. INTERMITTING FEVER. 91 a late writer, " more repugnant to the imagination of a medical man than that of venesection in the cold stage of intermittents. Books and lectures all inculcate a diametrically opposite practice. We see the face and the surface of the body pale and cold; the pulse feeble and quick ; the teeth chattering; the whole body shivering; and the suffering patient huddling himself up in all the clothes he can find to keep the spark of life from being extinguished ! The very idea of ab- stracting the vital fluid, which seems almost entirely to have vanished, is horrible. But yet, when we come to reflect that the blood has only shifted its- place from the circumference to the centre, and that the internal vessels and organs must now be gorged with this fluid, and as it were in a state of suffocation, there is nothing very incongruous in the attempt to relieve the suffering organs by ab- stracting a portion of blood from the general circulation." Moreover, when we advert to the circumstance that blood-letting has been strongly recommended and successfully employed to remove the internal congestions which occur in typhus fevers, where there is generally an actual deficiency or impairment of the vital energies, it does not appear so very extraordinary, that the same means should be adequate to restore the equilibrium of the circulation, or to remove the internal congestion in an ague, where the vital powers are not impaired, but only op- pressed. Dr. Mackintosh states, " that he has seen men in the most severe sufferings from'the chills, relieved after the abstraction of six, eight, and ten ounces of blood; and he has known three ounces to suffice. The relief, which is the most perfect relief that can be conceived, is so sudden, when a good orifice is made, that it has surprised and delighted every one who has seen this practice." Dr. M. had this practice tried on himself in 1810; and, although bark and other remedies had entirely failed, he found that before twelve ounces of blood had been drawn, "the rigors ceased with all their unpleasant accompaniments," and neither the hot nor the sweating stage ensued. " A pleasant sense of heat succeeded the painful one of cold; and instead of weakness, he was sensible of an acquisition of strength. He afterwards bled many other patients in the cold stage of this malady, and uniformly with the same favorable results. This prac- tice was put in operation in the Royal Ordnance Hospital, of Edinburgh, in the presence of many medical gentlemen, and, must, therefore, be regarded as amply attested."* In a single instance 1 have drawn blood, in the cold stage of this disease; and in this case, it moderated the violence of the chills and curtailed their duration in a manifest degree. I have not since had a favorable opportunity of repeating this practice, but from the result of this case, and the strong testi- mony of Dr. Mackintosh, I feel inclined to give it a further trial, whenever an opportunity of doing so shall present itself. It cannot be presumed, however, that this practice is equally well adapted to all cases. Dr. Zabriskie, of New York, states that he found it, in general, decidedly beneficial in persons " of a plethoric, full habit, with strong pulse, and not enfeebled by intemperance or by the fever." In patients enfeebled by intemperance, or the long continuance of the fever, with a small and weak pulse, bleeding in the cold stage sometimes gives rise to alarming symptoms.! In the hot stage, it sometimes becomes necessary to moderate the violence of the febrile excitement, especially when delirium or alarming local determinations take place. Blood-letting is of course the most direct and efficient means for this purpose, and where the indications for antiphlogistic measures are strong, it ought to be promptly employed. In agues of a decidedly phlogistic diathesis, blood-letting during the hot stage will often contribute considerably to the suc- cessful employment of the bark in the intermission. I have sometimes known the bark promptly efficient in arresting the disease, after a copious blood-letting during the paroxysm, where it had previously failed. In cases attended with a very hot and dry skin, and a full and vigorous pulse, cool, bland and acidulated * Ed. Med. and Surg. Journ., April, 1827 ; and Medico-Chir. Rev., July, 1827, p. 186. t Am. Journ. of Med. Scicn., vol. xiii. p. 80. 92 INTERMITTING FEVER. drinks are both grateful and salutary. A draught of cold water while the skin remains dry, will often speedily subduct the febrile heat and predispose to per- spiration. It may also be proper, in instances of very high general febrile excitement, to exhibit some of the refrigerant diaphoretics—such as nitre—anti- mony—the saline effervescing mixture.* As soon, however, as the skin begins to be moist, cold drinks must be withheld. During the last or sweating stage, we may allow tepid drinks of a bland character freely. • When the stomach is extremely irritable—giving rise to frequent and violent vomiting, in the cold or hot stage, tepid diluents should be given, until there is reason to think that the bile is discharged. Opium is, perhaps, our best remedy for checking excessive vomiting in this disease. This article does not often aggravate the violence of the reaction, when given in the hot stage, as might be apprehended. Indeed, Dr. Lind zealously advocates the propriety of exhibiting a full dose of opium, soon after the hot stage is developed, as a general practice. He asserts that it takes off the burning heat of the fever, hastens the accession of the sweating stage, and often produces a soft and refreshing sleep, from which the patient awakes free from all complaints, and in full perspiration. He thinks, moreover, that the use of opium in the hot stage tends to obviate dropsy and jaundice. I have given opium in the hot stage to check vomiting, and have always found it to answer this purpose very promptly and completely, without any unpleasant consequences. I cannot, however, think that opium is a proper remedy in the hot stage of ague, unless it be in broken-down constitutions, or in such as are feeble and exhausted by previous injurious influences—or unless it be employed to remove some accidental affection of a distressing or dangerous character. In cases where the reaction of the heart and arteries is incomplete, and where much internal congestion continues to exist through this stage, opium is, without doubt, a valuable remedy. To put a stop to excessive vomiting in this, as well as in other diseases not attended with phlogosis of the mucous membrane of the stomach, I know of no medicine which is more promptly and certainly effectual than a solution of camphor in sulphuric ether, in the propor- tion of two scruples of the former to an ounce of the latter; of which twenty or thirty drops may be given with about ten grains of calcined magnesia every half hour until the vomiting is arrested. I have rarely found the second dose neces- sary. Whatever advantage may result from remedial treatment during the paroxysm, universal opinion concurs in regarding the intermission as the proper period for the safe and certain radical treatment of intermitting fevers. In prescribing for the radical cure of intermittents, it is of no small consequence to^attend to the particular character of the disease in relation to the four modifications or varieties mentioned above; for each of these requires some peculiar modifications of treatment. 1. The inflammatory variety, as has already been stated, is marked by symp- toms during the intermission, which indicate an irritated and phlogistic condition of the system, incompatible with the salutary influence of the bark and the other febrifuge remedies of this kind. In this modification of the disease a strictly antiphlogistic treatment must precede the employment of the tonics usually re- sorted to. The patient must be put on an antiphlogistic regimen; one or two cathartics composed of calomel and jalap—or calomel succeeded in a few hours by an ounce of Epsom or Glauber's salts, will be proper; and where the inflam- matory diathesis is very conspicuous, blood-letting, nitre, antimonials, &c, are often indispensable. In cases of this character, blood-letting will, in general, prove most efficient in reducing the phlogistic habit, when it is practiced pretty J The following mixture is an excellent remedy for this purpose : }£.—Spirit, mindereri ^iv. Spirit, nitr. dulc. gii. Vin. antimon. gi. Syrup limonis, 5j i.—M. Take a tablespoonful every hour. INTERMITTING FEVER. 93 copiously during the hot stage. In cases of vernal intermittents, in which the bark or quinine had failed in consequence of the general irritated and phlogistic condition of the system, I have succeeded perfectly with these febrifuges, after the patient had taken one of the following powders,* every two hours during an intermission, and a small bleeding in the hot stage of the succeeding paroxysm. In the congestive and malignant varieties of ague, it will seldom be proper to "lose much time in preparing the system for febrifuge tonics. In such cases, the powers of the system must be economized, and tonics early and liberally resorted to. In the gastric modification, which is most commonly met with in the tem- perate latitudes, there exist obvious indications of gastric impurities and disor- der—such as nausea ; bilious vomiting and purging ; foul tongue ; loss of appe- tite ; pains in the stomach and bowels; bitter or depraved taste, &c. In inter- mittents of this character, it will be peculiarly proper to attend to the state of the alimentary canal, before the bark or tonic remedies are resorted to. Mild mer- curial purgatives are generally decidedly beneficial. In some instances, it may be necessary to repeat them several times before the bowels are brought to a proper state for the employment of febrifuges. Emetics, too, will often contri- bute much to the success of the bark or quinine. In intermittents of a well- formed inflammatory character, there are seldom any unequivocal manifestations of gastric impurities, and hence these evacuations are much less useful or import- ant in them than in the variety I have termed gastric. Among the various articles which have been recommended for the cure of intermittents, the Peruvian bark, with its preparations, is unquestionably by far the most important. Within the last ten years, the sulphate of quinine has, in a great measure, taken place of the bark in substance, and in many respects, this preparation possesses important advantages over the crude material. It has indeed been said, that the bark itself will sometimes remove the disease where the quinine has failed ; but the converse may be said with equal correctness ; for I have in several instances succeeded with the latter, after the former had been used in large doses without success. Mr. Valpes, of Naples, in a recent com- munication to the French Royal Academy of Medicine, states, as the result of his inquiries, that the sulphate of quinine is preferable to the cinchona, in intermit- ting fevers, whilst the latter is preferable in the fevers formerly denominated putrid,] and which are produced by idio-miasmata.J From my own experience, I have not been led to think that there exists any essential difference in the febri- fuge virtues of these two remedies; but as the quinine is much less nauseous, and can be given in sufficient doses in a very small bulk, I should, from these advantages, always prefer it to the bark in substance, unless some idiosyncrasy exist against its influence, which can be ascertained only by experience. Much difference of opinion has been expressed, both in relation to the period of the disease, and the particular time of the intermission at which the bark may be most effectually administered in this form of fever. It has been contended, that it will generally be much better to suffer several paroxysms to take place, before any attempt is made to arrest their recurrence. Recamier has re- cently advocated this practice, as both the most effectual and the safest to the future health of the individual. I do not at all doubt the correctness of this mode * B--—Pulv. nitrat. potassse giss., pulv. doveri. grs. vj., calom. grs. vj. M.—In chart. No. vj. dividend. + Revue Medicale, Mai, 1828, p. 306. I In March, 1825, the number of lunatics brought to the Maison d'Aversa in the kingdom of Naples, was so great that it was found necessary to lodge them in a convent, which was not properly prepared to receive them. The most filthy of these unfortunate beings were put into a small dormitory, which was in a state of extreme filthiness. A fever soon broke out among them, which was at first regarded as a petechial fever, and was treated by antiphlogistics. The disease made a rapid progress, and became unusually fatal. The sulphate of quinine was finally employed, but this appeared rather to aggravate the symptoms than to afford any advantage. At last, the bark in substance was given, and immediately resulted in the happiest effects.—Revue Medicale, Mai, 1828, p. 306. 94 INTERMITTING FEVER. of management. Unquestionably, a great majority of our ordinary agues may be immediately arrested, and with perfect safety, by giving the bark, during the first or second intermission; but in this case relapses are much more common than where the disease has been suffered to run on to the fifth or seventh paroxysm. 1 have found agues arrested after the first or second paroxysm, relapse again and again, until they were suffered to run on to the fifth or seventh day, when a few . doses of quinine put a permanent stop to their progress. It has long been my practice, when I have met with relapsing agues, to suffer them to run on through five or seven paroxysms, before any attempt was made to arrest them, and I have invariably found this plan permanently successful. In cases which require preparation, especially in inflammatory intermittents, delay is, of course, essen- tial, before the bark can be employed with propriety. I would not, however, lay it down as a general rule, that the disease should be suffered to run on through five or seven paroxysms ; for where the apyrexia is very complete, and the patient experiences no feelings of illness during the intermissions, the bark may almost always be given with complete success, as soon as the bowels are evacu- ated by a suitable cathartic* In instances of an opposite character, or such as have shown a tendency to return after a week or two, it will be very difficult to put a final stop to the paroxysms, if the febrifuge be employed during the first or second intermission. A case came under my notice, during the preceding au- tumn, which had already relapsed four times, and always punctually on the seventh day. After each relapse, the patient took quinine in full doses, which always arrested the disease for the short period mentioned. When he applied to me, I advised him to suffer his disease to go on for some time, without any other medicine than a mild purge every other day. He did so ; and on the ninth day, the disease left him spontaneously and permanently. The foregoing observations apply, of course, to the regular intermittents of the temperate latitudes; for in that rapid and fatal variety, which is termed malignant, no time should be lost by preparatory measures, but immediate recourse had to large and frequent doses of the bark, as soon as a favorable intermission occurs. The same rule applies to the disease occurring in very feeble, nervous, and exhausted subjects; for unless it be speedily removed, the system may sink under the repeated shocks of the paroxysms. With regard to the particular period of the intermission at which the bark may be most successfully given to arrest the succeeding paroxysm, a diversity of sentiments have been expressed by writers. Some have advised its employment in large doses immediately after the sweating stage has passed off; whilst others recommend it to be given largely, "as near to the time of the expected paroxysm as the condition of the patient's stomach will allow." (Cullen.) There are others, again, who think it best to exhibit the bark in divided and frequent doses throughout the whole period of the intermission. (Fordyce.) A few years ago, Dr. Ridgway published some cases which go to show that one large dose of cinchona given as near as possible to the commencement of the approaching paroxysm, will as cer- tainly avert the paroxysm as when given in repeated doses throughout the inter- mission.t Since Dr. Ridgway's publication, Dr. Brown, of Boston, has published a small work, in which he adduces testimony of a similar purport.^ According to Dr. Brown's experience, two or three grains of the quinine taken just as the first symp- toms of the approaching paroxysm are experienced, will, when followed up at intervals with a second, third, and sometimes a fourth dose, almost invariably put a stop to the disease. When given just as the cold stage commences, " its influence over the rising symptoms becomes manifest in a few minutes ; the pulse becomes more full and distinct; the respiration more easy; the skin acquires its natural temperature; and, in eleven minutes in his own case, not one unpleasant symp- * R.—Pulv. jalap . . . Calomel, aa. grs. x.—M. London Medical and Physical Journal for April, 1825. A Treatise on Repelling the Paroxysm of Intermitting Fevers. Boston, 1836. I INTERMITTING FEVER. 95 torn remained." This state, however, generally continues but a short time, and it becomes necessary to repeat the dose, sometimes three and even four times before the paroxysm is subdued. Dr. Ridgway gave an ounce of the bark at once, as soon as the premonitory symptoms of the paroxysm were felt, and always found it to prevent the attack. There can be no doubt that the disease may be speedily arrested in this way ; but it may be reasonably questioned, whe- ther it possesses any real advantage over the plan of exhibiting this febrifuge in efficient doses during the latter period of the intermission. I have generally prescribed the quinine in two grain doses every hour, commencing about six hours before the beginning of the approaching paroxysm; and I have had no cause to be dissatisfied with the consequences. Indeed, I have reason to appre- hend that a large dose of quinine given during the chills, is calculated to produce very disagreeable effects. In two instances, one a delicate married lady, and the other a lad about twelve years old, a most singular and raving species of maniacal affection ensued; apparently from taking large doses of this medicine after the chills had commenced. In both instances this alarming mental disturbance con- tinued for several hours. I maybe wrong in ascribing it to the cause here assigned, but the circumstances strongly favored the suspicion. Whatever views we may adopt, with regard to the time at which it may be best to begin with the bark or quinine, there can be no doubt concerning the propriety of giving large doses,* in such a manner as to make a decisive im- pression on the system in the latter period of the intermission. I am well satis- fied that two or three large doses—three grains of the quinine, given two or three hours before the paroxysm, will do more towards averting it than a larger quantity exhibited in small doses throughout the whole interval of the apyrexia. In relation to the propriety of employing emetics and cathartics as preparatory measures for the use of the bark, authors express contradictory opinions. Un- questionably, where the signs of gastric impurities are conspicuous, and there exists no urgent necessity from the nature of the case, to arrest the disease promptly, it will be proper to evacuate the alimentary canal previous to the em- ployment of the bark. These evacuations will also be useful in cases where the inflammatory habit is so strong as to prevent a complete apyrexia. Neverthe- less, in the ordinary cases of the disease, where there are no signs of a loaded state of the bowels, and the apyrexia is very complete, the bark may be success- fully employed without either previous purgation or emesis. Upon the whole, however, I should, in all instances of this disease not attended by malignity or great prostration, prefer one or two mild cathartics, before the bark is taken, for the reasons already mentioned. The Peruvian bark has been frequently accused of having a tendency to pro- duce visceral indurations and other unpleasant consequences; such as rheuma- tism, dropsy, &c. This accusation is, however, wholly unfounded. No doubt, indeed, can exist that these and other injurious consequences may be produced by the injudicious employment of this remedy. When given, for instance, in agues, attended with strong marks of an inflammatory condition of the system, without proper antiphlogistic preparatory measures, we can readily conceive that the bark would favor the natural tendency of such cases to terminate in these disorders. In this respect, however, the bark does not differ from other tonic and stimulating remedies ; for it is not by anything peculiar in the bark that these effects are produced, but simply by the power it possesses, in common with the majority of febrifuge remedies, of favoring the phlogistic diathesis, and the pro- gress of obscure inflammations. The bark is now generally given by itself. Formerly it was customary to give it in conjunction with various other remedial articles which were thought to * If the bark in substance be employed, not less than two drachms ought to be administered at each dose. Such doses taken at intervals of an hour, or an hour and a half, within the last five hours of the intermission, will, perhaps, do all that can be effected by bark in this disease. 96 INTERMITTING FEVER. augment its febrifuge powers. It is extremely doubtful, however, whether any combinations can materially improve its virtues; and unless some particular circumstance be present which may render the use of other remedies proper, or unless the bark by itself produce unpleasant or injurious effects on the alimentary canal, it will probably be best to employ it singly. When it causes much con- stipation, it may be usefully given as follows: R.—Pulv. cinchon. condam. ^j. rhei ^ss. muriat. ammonia gj.—Misce. In chart. No. iv. dividendae. One to be taken every hour or two. When the bark purges, it should be given with small portions of Dover's powder, or opium. The former, especially, acts beneficially in such instances, five grains of which may be given at each dose. Alkaline remedies become necessary in cases where there are signs of much acid in the stomach. The subcarbonate of potash is an excellent adjuvant to the bark in cases of this kind. From ten to twenty grains of the alkali may be given with each dose of the bark ; and to prevent this from acting on the bowels, which it is apt to do, it is generally necessary to make a triple compound—viz., bark, subcarbonate of potash, and opium, or what is better, confectio opii. When the stomach is irritable, the bark will generally be speedily rejected. In this case we may sometimes cause it to be retained by uniting it with some aromatic substance, such as serpentaria, or cloves, or nutmeg, or the calamus aromaticus. The serpentaria is, perhaps, the best aromatic adjuvant to bark, where the stomach is too weak to retain it singly. I have, however, always found small doses of opium to answer better than any other remedy for this purpose. The addition of powdered black pepper answers extremely well in cases where the vomiting arises simply from gastric debility. Where, however, this occurrence depends on a highly irritated con- dition of the mucous membrane, neither this nor any other aromatic can be proper. In this condition, indeed, the bark itself cannot be employed until the gastric irritation is subdued by leeches, blisters, or cupping over the epigastrium. The employment of the quinine is much less apt to produce the inconveni- ences just mentioned than the bark in substance; but even this preparation will sometimes produce violent purging or vomiting—several very violent instances of which I have encountered in my practice. Formerly it was customary to employ the decoction, or the tincture, or what is better, both in union with each other, where the bark in substance could not be conveniently administered, or where the stomach rejected it. Since the introduction of the quinine into prac- tice, however, this mode of exhibiting the cinchona has been but little employed; nor does it appear probable that any circumstances can occur which may not be as well met with this very convenient and concentrated preparation, as with either the decoction or the tincture of the bark. The most convenient and elegant formula for exhibiting the quinine, is, perhaps, the following: R.—Sulphatis quinae grs. xvj, Elixr. vitriol gtt. xvj. Syrup, limonis §j.—M. Dose, a teaspoonful every hour or two for an adult. As this mixture, though a very neat and concentrated one, is sometimes much objected to on account of its bitterness, especially by children, 1 have generally prescribed it according to the following formula, by which almost all the bitter- ness is wholly removed: R.—Sulphat. quinoe grs. vj. Elixr. vitriol gtt. x. Pub. extract, glycyrrh Jiss. Aq. fontanae Sjij —M. Dose, a teaspoonful for a child between two and five years of age. In cases of ague, which, from long continuance, or from some previous malady, are attended with visceral indurations or enlargements, the quinine or bark must be given, either after a gentle mercurial course, or in conjunction with mercurial INTERMITTING FEVER. 97 remedies. The blue mass will in general answer best for this purpose, as it is mild, and less apt to pass off by the bowels than calomel. In many instances of this kind, the bark will, in fact, fail entirely in putting a stop to the continuance of the disease ; and I have known it to do manifest mischief even when given in conjunction with mercury. In such cases, mercury is the appropriate remedy; and, under careful management, will rarely fail to arrest the disease. From three to five grains of the blue mass, taken thrice daily, until the gums become slightly affected, will generally suffice to remove the complaint. —Amer. Jour. Med. Sciences, ACUTE PERITONITIS. 195 will usually bring on copious purging. I have used, with much advantage, a mixture of cremor tartar and powdered jalap in this affection. This will seldom fail to produce very abundant watery discharges from the bowels. There are few articles which excite so copious a discharge from the intestinal exhalents as cremor tartar; and when given in union with jalap, its operation is generally prompt and active. From twelve to fifteen grains of the jalap to forty grains of cremor tartar, may be given every hour until the bowels are freely moved. Dr. Pring strongly recommends the use of calomel in puerperal peritonitis, in ten grain doses, every six or eight hours. " Copious stools," he says, " quickly followed a sudden salivation, and a favorable convalescence was afterwards main- tained by purgatives of the weaker sort." The application of a blister to the abdomen will often do considerable good, where, after decisive blood-letting and purging, some tenderness on pressure re- mains on the inflamed parts. Leeching, if practicable, should, however, always be premised to vesication ; but neither of these local means can be resorted to with a prospect of much benefit, until the acute character of the disease has been subdued by prompt and copious general depletion. The blistered surface should be dressed with some application capable of keeping up a free discharge; and for this purpose, the mercurial ointment is, perhaps, the most useful in the affection. Mercurial frictions have, indeed, of late, been particularly recom- mended in the treatment of this disease. M. Velpeau has reported four cases (Rev. Medicale, Jan. 1837), in which two drachms of mercurial ointment, ap- plied by frictions to the abdomen every two hours until the mouth became sore, appeared to do much good. M. Laennec also cured several cases of subacute peri- tonitis by mercurial frictions. As soon as the mouth became sore, the symptoms began to decline. (Rev. Medicate, Mai, 1824.) I have met with one case in which the supervention of the mercurial action appeared to exert a strong influ- ence in arresting the further progress of the disease. This was a very acute case. Copious venesection was practiced, and large doses of calomel adminis- tered with castor oil as purgatives ; on the third day, the mouth was found to be sore and the breath fetid ; convalescence speedily ensued. Among the internal remedies beneficial in this disease, opium with calomel deserves to be particularly mentioned. After the violence of the local and gene- ral symptoms has been broken down by energetic venesection, leeching and purging, we may, in general, resort to this combination with great advantage. I can speak with much confidence of the usefulness of this remedy, having, for the last ten years, employed it in this disease with unequivocal benefit in a consider- able number of instances. In puerperal peritonitis especially, opium either alone or in combination with calomel, is often peculiarly serviceable. " In puerperal fever," says Dr. Armstrong, "in which the peritoneum chiefly sustains the in- tensity of the inflammation, opium may be given with considerable advantage, particularly when the local pain and constitutional irritation are excessive ; though in that stage of excitement, it must not for a moment be forgotten, that bleeding and purging are the principal measures. When the stage of collapse approaches, opium may, perhaps, be accounted the primary measure, since the allaying of irritation is then the principal object. Whenever opium is administered in any species of abdominal inflammation, the dose should be large; for a small dose often stimulates, whereas a large one is a direct sedative." This narcotic may be very usefully administered in this affection at the same time.that cathartics are employed : for opium in large doses, whilst it allays the pain and general irritation, often manifestly promotes the operation of purgatives in peritoneal in- flammation. I have usually prescribed this article in combination with calomel, in the proportion of two grains of the former to three of the latter every three or four hours. Antimony and nitre are seldom admissible in this disease, on account of the great gastric irritability which usually prevails. Digitalis has been recommended as a useful article in this affection. When the pulse remains irritated and sharp, 196 CHRONIC PERITONITIS. after the disease has been in a great degree subdued, digitalis in small, but fre- quent doses, may be advantageously used. One grain should be given every two or three hours, until the frequency and tension of the pulse are sufficiently mo- derated. Most practitioners employ this remedy in much larger doses than the one just mentioned; but 1 have generally found the action of the pulse more speedily moderated when given frequently and in small portions, than in larger ones at longer intervals. When a state of collapse ensues after the inflammation has been overcome by the means already mentioned—an event which occasionally occurs in puerperal peritonitis—it must be counteracted by the employment of stimulants. Wine, the carbonate of ammonia, opium and camphor, and Dover's powder with qui- nine, are the best articles for this purpose. " There is a period in some cases of abdominal inflammation where the disease is just subdued, but where there is a kind of balance between recovery and gangrene. The pain will vanish; the pulse become weak ; the vital powers appear to sink, and a coldness overspread the body. The symptoms are too often indicative of mortification ; but every experienced practitioner must have occasionally witnessed cases of recovery even from this alarming stale. Here we must give wine ; for, if gangrene have com- menced, no harm can ensue from the remedy ; and if it have not commenced, the wine may happen to give a salutary stimulus to the nervous and vascular sys- tems, when stagnation of the vital fluids is on the point of taking place, and where further evacuations would be instant death." (Johnson.) The nourishment throughout the whole course of the disease should be of the mildest and weakest kind. A little thin barley or rice-water may serve at once for food and drink. The greatest care must also be taken to guard the patient against taking cold during the period of convalescence; as a renewal of the dis- ease, in a subacute form, is extremely apt to occur from this and other exciting causes. Sect. IX.—Of Chronic Peritonitis. The approach of chronic inflammation of the peritoneum, when not the sequel of the acute form of the disease, is so gradual and insidious, that it seldom be- comes the object of medical attention until incurable structural changes have taken place, or effusion into the cavity of the abdomen. It is only by attending to the passage of the acute into the chronic form, that we are enabled to give an account of the early symptoms of the latter. When the peritoneum becomes affected with the chronic inflammation, more or less uneasiness and tenderness are experienced in the abdomen, and when pressure is made externally, or the patient coughs, sneezes, or performs any sudden motion by which a concussion of the body is produced, a feeling of soreness is felt about the umbilical region. In many instances, there is slight pain in some part of the abdomen, which may be either continuous or occasional. In no instance, however, is the abdominal pain severe, for serous membranes, in a state of chronic inflammation, never give rise to acute pain ; and many cases are recorded in which this structure was found completely disorganized from chronic inflammation, without the patient having complained of any pain whatever. The abdomen generally becomes fuller, and in some instances elastic, or more or less tympanitic. Frequently, a sense of tightness and pricking soreness is felt across the lower part of the abdomen, after fatigue from bodily exertion. "There is no tension of the skin of the ab- domen as in the acute species; on the contrary, the skin and abdominal muscles often sit loosely upon the peritoneum, which gives a sensation to the touch, as of a tight bandage underneath, over which the skin and muscles may be felt, as it were, to slide. The patient always complains more of tightness than of pain ; and as the tightness is much increased by any congestion in the bowels, the relief CHRONIC PERITONITIS. 197 which he experiences from evacuating their contents leads him to attribute his sensations to an habitual costiveness."* On feeling the external surface of the abdomen, we sometimes find deep-seated spots of induration which are more or less tender to the touch. (Abercrombie.) In some instances, the patient experiences a sensation as if a ball were rolling about the abdomen. Broussais ascribes this sensation to the adhesion between the different convolutions of the intestines into a round and movable mass. Such adhesions between the coils of the intestines may be suspected, says Armstrong, "by a lobulated or irregular feel of the bowels under the hand when passed over the abdominal integuments." The bowels in this affection are generally torpid. The pulse is often not perceptibly affected ; except in the advanced periods of the disease, and towards evening in the early stage, when it usually becomes jerky or somewhat accelerated, quick, and contracted. The appetite is generally sufficiently strong, nor is the function of digestion particularly disordered, but in some instances vomiting occasionally occurs. The face and whole surface of the body are generally pale, with an expression of ill health and languor in the coun- tenance. Slight febrile exacerbations towards evening, with more or less op- pressed respiration and cough when the patient lies horizontally on the back, and the appearance of oedema of the feet with paucity of urine, are pretty certain indications that effusion is taking place in the abdomen. The affection is not unfrequently connected with disease of the lungs. Chronic peritoneal inflammation varies greatly with regard to its duration. It sometimes terminates in fatal disorganization and effusion within a few months; and cases occur which continue in a very slow and insidious way for many months, and even for several years, before the system is worn down by the gene- ral irritation it ultimately causes. Whether protracted or short in its course, this affection of the peritoneum always terminates in more or less effusion, or suppu- rative secretion in the cavity of the abdomen. In truth, ascites is, in the majority of cases, dependent on a low degree of inflammatory irritation of the perito- neum. Causes.—Chronic is frequently a sequel to acute peritonitis. It sometimes occurs as the consequence of acute mucous inflammation of the intestinal canal— the inflammation passing from the former membrane to the peritoneal covering of the bowels. This is, indeed, no uncommon occurrence. I have met with two instances of subacute peritonitis, which came on in consequence of dysen- tery; and one other remarkable case which supervened on acute mucous inflam- mation of the bowels, brought on by irritating ingesta. Dr. Hodge of this city has given an account of a well-marked case of this kind, which was evidently produced by dysenteric inflammation.! Long-continued torpor and congestion of the portal system from hepatic torpor or protracted constipation, are probably sometimes the cause of this affection. It may also be the consequence of acute or chronic inflammation of the solid viscera of the abdomen—particularly of the spleen and liver. Blows or injuries inflicted on the abdomen ; difficult parturi- tion ; suppression of perspiration, and of hemorrhoidal discharge; metastasis of erysipelas; cold, &c, will sometimes give rise to this affection. Post-mortem appearances.—More or less fluid is invariably found effused into the cavity of the abdomen in those who die of this affection. This fluid is com- monly of a whitish or whey-like color; sometimes it is limpid and yellow; and occasionally it is found of a reddish appearance, with small flocculi of false membranes floating in it. Occasionally, though rarely, the extravasated fluid is mixed with a considerable portion of blood; and instances occur in which it appears to consist of pure blood. (Scoutteten.) 1 have met with a case of this latter kind. The intestines are often glued together in different parts by the in- tervention of false membranous matter; sometimes sacs are formed by these * Pemberton on the Viscera. X American Journal of Medical Sciences, &c, April, 1829. 198 CHRONIC PERITONITIS. membraniform exudations, and the intestines, containing purulent matter or other fluids of various appearances. Occasionally the intestines are found agglutinated into one mass, " and partly covered with thickened and adherent omentum." (Broussais.) Thickening of the peritoneum is a very common post-mortem phenomenon in this affection. In some instances, this membrane, though thickened and other- wise disorganized, is but little injected or red ; in other cases, it is found reddish and highly injected. Very frequently the surface of the peritoneum is covered with innumerable small white granulations of a tubercular character.* Bayle states, that in a subject he examined, where these tubercular depositions were very abundant, he could easily scrape them off with a scalpel; and where this was done, the peritoneum underneath appeared perfectly sound. In some in- stances, the peritoneum is considerably thickened by granular depositions between its two layers. (Gasc,| Broussais, Abercrombie,^ Pemberton.) The mesenteric glands are usually enlarged and indurated. Treatment.— Chronic peritonitis might, perhaps, be generally removed, if it could be subjected to remedial treatment during its incipient or early period. Such, however, are the obscurity and uncertainty of its early phenomena, that it rarely becomes an object of medical attention until it has proceeded to an extent which renders the most judicious treatment almost invariably abortive. Brous- sais, indeed, for a considerable time regarded this affection as wholly beyond the reach of remedial management. Subsequent experience, however, convinced him that if proper remedies are applied during the first twenty or thirty days of the disease, it may sometimes be effectually subdued, and he thinks it possible that it may yield even at a much later period of its course. This writer accounts for the great difficulty of curing this form of peritoneal inflammation, by referring it to the impossibility of producing the absorption of the tubercular matter which is so constantly deposited between the layers of the peritoneum, and which, therefore, keeps up a continued irritation in this membrane. Externalirritating and depleting applications to the abdomen, constitute our most efficient means for combating this affection. Leeching is decidedly indicated, and often, no doubt, contributes considerably to the removal of the disease, where disorganization or effusion has not yet occurred. After local depletion, a large blister should be applied over the abdomen, and kept discharging by dressing it with mercurial ointment. From several instances which have lately come under my notice, I am inclined to regard pustulation, by means of tartar emetic ointment, more effi- cacious than blistering. We may also use stimulating frictions, followed by emollient applications to the abdomen, with a prospect of advantage; more espe- cially where the general system is in too irritable a state to admit the more irri- tating applications just mentioned. The application of moxa to the abdomen has never, I believe, been recommended in the treatment of this affection. From its known powerful influence in subduing deep-seated inflammations, it is not improbable that considerable and prompt benefit might be derived from this ap- plication in the present affection. The warm bath has also been recommended as a useful auxiliary in the treatment of this disease. Within the last few years, frictions with mercurial ointment have been used with success in this affection, by Velpeau and Laennec; and from the accounts which they have published, this remedy would seem to be entitled to very great consideration. The latter writer has reported seven cases of chronic and subacute peritonitis which yielded to mercurial frictions. Two drachms of the ointment should be rubbed in every * "It is always difficult, and frequently impossible," says Dr. Armstrong, "to predict that tubercles exist on the serous membrane of the abdomen. But when the skin assumes a delicate hue__when the conjunctiva is blanched—when the expression of the face is more softened and pensive than natural, and especially when the patient has any cough, a presumption of their existence might be excited." ! Dictionnaire des Sciences Medicales, vol. xl. X Edinburgh Medical and Surgical Journal, No. lxiii. CHRONIC PERITONITIS. 199 two hours, until the gums become slightly affected. Since the publication of the first edition of this work, I have witnessed the good effects of this practice in a well-marked case of this variety of peritonitis. The disease had continued several months before I prescribed for the patient. The abdomen was enlarged, very tense, and extremely tender to the touch. A course of mercurial frictions over the abdomen, together with one of the following pills* at night, had the effect of gradually subduing the disease, and restoring the patient's health. Diuretics also are strongly recommended in the treatment of this disease, but they can be regarded only as auxiliary to the more direct and efficient applica- tions already mentioned. Broussais advises the use of diuretic articles in the way of frictions on the abdomen. The tincture of cantharides, or of squills, may answer for this purpose. If any advantage is to be derived from this class of remedies, however, it will probably be better to exhibit them by the mouth, whilst other more efficacious applications are made to the abdomen. Dr. James Johnson recommends the following combination as a particularly powerful and useful diuretic, in the present, as well as in other affections: R.—Acidi tartarici Qi. Sodae carboni grs. xxiv. Infus. digitalis fl. ^ss. Spir. aetheris nitrici fl. ^i. Tinct. scillae Yt^iv. Aq. menthae ^ij.—M. ft. This dose to be taken twice or thrice daily. Mild laxatives must from time to time be used, so as to obviate costiveness and consequent irritation from this source. Castor oil, or the acetate of potash, and cremor tartar, will commonly answer well for this purpose. Although active purgatives are not among the means generally recommended in this disease, I have in a few instances known decided benefit to result from the employment of the following mixture: R.—Crem. tartar ^iss. Pulv. scillae Ji. Pulv. sulphat. potass. £ij. Tart, antimonii grs. ij.—M. ft. S. Take £ss. three or four times daily. This combination produces copious watery discharges from the bowels, and stimulates the kidneys to increased action. To allay the general irritation which is apt to occur in this disease, we may give small doses of Dover's powder, or full doses of extract of hyoscyamus, or of conium maculatum. From the diaphoretic tendency of the first of these articles, it deserves, I think, a preference in this affection. It is of great import- ance in the management of this disease, to restrict the patient to the weakest and mildest articles of nourishment. Dr. Johnson observes, in reference to the possibility of procuring the absorption of the tubercular matter deposited in the peritoneum in this disease: " There can be little doubt that the absorbents might be made to act upon many extraneous and morbid growths in the human body, by rigid abstinence alone, if patients had fortitude to persevere in the measure. For our own part, we should place more confidence in this than in any other remedy ; and practitioners should at all times bear in mind, that without strict abstemiousness there is little hope of a cure in chronic peritonitis."—(Med.- Chir. Rev., Sept. 1820.) May we not expect some advantage from iodine, in the form pf frictions on the abdomen, in this affection ? It appears to me worthy of trial. * R.—Massse. hydrarg. grs. xxx. G. aloes grs. x. Tart, antimonii gr. i.-—M. Divide into ten pills. 200 ACUTE HEPATITIS. Sect. X.—Of Acute Hepatitis. Although not a very frequent disease in the temperate and colder latitudes, hepatitis is one of the most common maladies engendered by the influence of an intertropical or hot climate. The acute form of this disease often makes its attack suddenly, and with great vehemence, particularly in those parts where it prevails endemically, as along the sandy coast of Coromandel and the marshy districts of Bengal. When the invasion occurs thus suddenly and violently, the patient is seized, without scarcely any previous symptoms of indisposition, with pain in the right hypochondrium, accompanied with a sensation of tightness across the abdomen, difficult respiration, and an inability to continue in the recumbent position, the patient feeling easiest when in a sitting posture with the body inclined forwards. This mode of attack is frequently observed in the intertropical regions. In the temperate latitudes it usually comes on in a more gradual and less impetuous manner. The patient complains of a feeling of tightness in the right hypochondrium'and epigastric region, with slight incipient febrile symptoms, for a considerable time before the true character of the dis- ease becomes obvious. The pain attending acute inflammation of the liver is apt to extend itself from parts remote from this organ, more especially to the breast and to the clavicle and shoulder of the right, and sometimes the left side. In some instances these sympathetic pains are even more severe than those experienced in the liver itself. Mr. Annesley observes that when the internal structure of the liver is the seat of the inflammation, the pain is generally heavy and aching ; but when the surfaces or the ligaments become affected, it is usually acute, tensive, and pungent. Pressure on the right hypochondrium always greatly aggravates the pain in that part, and a similar effect is almost invariably produced by an attempt to lie on the left side ; although in some instances the reverse obtains, the patient feeling most ease when recumbent on the left side. A dry and troublesome cough, with more or less difficulty of breathing, are common attendants on this disease. When these symptoms are connected with pain in the thorax, the disease may be readily mistaken for pneumonia. Nausea and bilious vomiting frequently occur in acute hepatitis, and, in general, the severer these symptoms are, the less cough and difficulty of respiration will be experienced by the patient. In many instances there is a distressing " feeling of anxiety at the epigastrium and praecordia, accompanied with frequent deep sigh- ing, particularly when pressure is made simultaneously on the right hypochon- drium and under the right shoulder-blade." A more or less jaundiced hue of the white of the eyes and skin about the breast, face, and neck, is one of the most constant phenomena of this disease. (Louis.)* The urine, also, is invariably highly imbued with bile, exhibiting a deep yellowish-brown color. The thirst is usually very urgent, and the skin hot and dry. The pulse is generally full, active and firm ; but in some instances it is small, tense and quick: and this is said to be the case when the concave surface of the liver is the seat of the inflammation, and the peritoneal surface of the stomach or colon partici- pates in the inflammation. The tongue is coated with a white or thick yellowish fur, and the taste is often bitter; or, " it is smooth and glossy, marked by fissures, and lobulated." (Annesley.) In general, the bowels are costive; yet, in hot climates, diarrhoea often attends from the beginning of the malady. (Chisholm.) Cases of this kind generally commence like dysentery. The patient is seized with violent griping, followed soon by small watery or slimy discharges from the bowels, accompanied with * Mr. Annesley states, that jaundice is not a frequent concomitant of hepatitis in India, unless the ducts or gall-bladder become involved in the disease, or when it supervenes upon biliary calculi or other obstructions of the ducts. ACUTE HEPATITIS. 201 soreness at the pit of the stomach, or of the right side. If pressure is made on the right hypochondrium, the patient shrinks from the touch; yet the pain in this part is seldom violent. " The degree of violence of the bowel affection," says Dr. Johnson, " will very generally indicate the degree of rapidity and dan- ger of the hepatic inflammation. A scalding sensation in making urine almost always occurs ; and the brain often sympathizes strongly with the liver in this affection, giving rise to more or less mental disturbance." Acute hepatitis rarely continues beyond the sixth or seventh day, without tending either to resolution or suppuration. When the latter has taken place, the pain becomes moderated; the patient experiences a sense of weight and throbbing in the region of the liver, with irregular rigors; more or less profuse night sweats; a sense of sinking, with anxiety and oppression in the praecordia ; a clammy skin ; and a sense of formication. In some cases, " nearly the whole of the right lobe becomes one enormous abscess." Sometimes adhesions take place between the parts surrounding the hepatic abscess and the internal surface of the abdomen ; and when this occurs, and the abscess points outwards, the pus may be discharged by puncture or incision, and the patient often cured. When the abscess is about pointing externally, the general fullness, distension and pain in the region of the liver and epigastrium, which occur before the suppurative process commences, are at first somewhat increased ; but as the suppuration goes on, and the matter proceeds outwardly, a soft and more or less circumscribed tumor makes its appearance, whilst the general fullness and tenderness in the right hypochondrium, in a great measure subside. " When the abscess advances beneath the false ribs, or near the epigastric region, it is generally sufficiently perceptible; but when it points higher up, or more posteriorly, so as to come beneath the ribs, then the bulging out of the hypochondrium is merely marked with fullness of the intercostal spaces, and pain and soreness limited almost en- tirely to one spot. In a great majority of hepatic abscesses, the direction is to the exterior and superior surface of the liver, and hence the communication so frequent with the diaphragm and lungs when they fail in pointing more externally." (Annesley.) Sometimes the liver forms adhesions with the colon, or some other portion of the intestinal canal, and the abscess bursting into it, the pus is dis- charged by stool. Dr. Saunders thinks it probable, that the matter formed in the substance of the liver, may sometimes pass into the bowels through the biliary ducts. When adhesions form between the liver and diaphragm, the abscess may burst into the cavity of the thorax, or into the pulmonary cells, in which latter case it is often brought up copiously by expectoration. Dr. Wilson* observes, that there is perhaps no instance of recovery after this accident; an observation, however, which has been abundantly contradicted by the experience of others. I have seen an instance in which an enormous quantity of thin reddish pus was discharged from an hepatic abscess through the lungs, followed by a perfect re- covery of the patient's health. Annesley mentions cases of this kind ;! and Schmidtmannj; relates two instances of a similar character and successful termi- nation^ Purulent expectoration sometimes attends hepatitis, from the inflam- mation extending to the mucous membrane of the bronchial tubes, or to the sub- stance of the lungs, without any direct communication between the abscess in the liver and the cavity of the thorax. Cases occur, in which the hepatic ab- scess bursts in the cavity of the abdomen ; these are almost necessarily fatal. It has been doubted whether an abscess containing laudable pus can be formed in the parenchymatous structure of the liver. Louis states, that by far the greater * On Febrile Diseases. ! Loco chat. Sum ma Observationum Medicarum, vol. ii. Louis asserts, that abscesses in the liver are incurable: for in all his examinations he never found a single instance of cicatrization in the liver. Dr. Johnson remarks, upon this assertion, " that those who have practiced in India know that abscesses of the liver will heal occasionally, whether they are opened externally, or make their way into the intestines."—Med.-Chir. Rev., January, 1827. 202 ACUTE HEPATITIS. number of abscesses which occur in the proper substance of the liver, do not con- tain genuine pus, but a fluid less homogeneous, containing small flakes of blood of a darkish gray color, or like the washings of flesh. In 430 dissections, he found but five instances of purulent abscess in the substance of the liver, and not one in its coverings. When genuine pus is formed in hepatitis, the abscess probably occurs in the cellular membrane, between the peritoneal covering and the glandular structure of the liver.* Gangrene also, though very rarely, occurs in hepatic inflammation. (Bichat.) Annesley, however, seems to doubt whether this mode of termination ever takes place in hepatitis. He states that he never met with an instance of this kind, although his opportunities for observation were very ample. In some instances, the disease terminates in a softening of the structure of the liver. Annesley sometimes found the surface of this viscus "marked with red, brown, brick-colored, greenish-brown, and even with almost black spots and streaks, while the internal structure was inflamed, congested with blood, much tumefied, and softer than natural." Abercrombie found the parenchyma of the liver soft, broken down, and nearly of a black color.! It is supposed by Dr. Saunders,:): that in the acute variety of this disease, the capillaries of the hepatic artery are exclusively implicated in the inflammation; and that in the chronic form the inflammation exists in the extreme branches of the vena portae. The same opinion is expressed by Professor Puchelt;§ and Winslow ascribes both varieties to an inflamed state of the vena portae. There is certainly no good reason why the capillaries of the vena porta? may not become the seat of inflammation; and when we take into consideration the peculiarity of the hepatic circulation, the opinion of Dr. Saunders is not without considerable plausibility. Diagnosis.—Pain in the right clavicle and shoulder has generally been re- garded as one of the most characteristic phenomena of hepatitis. This symptom, however, is much less common than is generally supposed. M. Louis[| doubts whether it is really indicative of hepatic inflammation, and thinks it arises usually from some affection of the lungs or pleura. Upon this subject Mr. Annesley observes: "The pain sometimes complained of at the top of the right shoulder, and so improperly stated as being one of the chief signs of hepatitis, is, when present, certainly characteristic of the disease in the right lobe; but unfortunately this symptom is only occasionally present; and the inexperienced practitioner, who has been taught to look to this as a distinctive mark of the disease, infers, when it is not observed, that the liver is sound."^f Hepatitis may be distinguished from pneumonic inflammation, by the following diagnostic circumstances. In pleuritis, the cough and oppression in the chest are much severer than in hepatitis. In the latter affection, the patient rests easiest when lying on the affected side; in the former, the reverse obtains. In hepatitis, pressure on the right hypochondrium greatly aggravates the pain, whilst pressure on the intercostal spaces produces little or no increase of suffering; in pleuritis, the former does not, but the latter does increase the pain. When the substance of the lungs is inflamed, the difficulty of breathing and the pain are aggravated by lying on the sound side, as in hepatitis; but in the former affec- tion, respiration is performed chiefly by the action of the abdominal muscles and the diaphragm ; whereas, in the latter, (hepatitis,) breathing is effected almost entirely by the action of the intercostal muscles—the chest being sensibly dilated and collapsed by the act of respiration, whilst the abdominal muscles are quies- * Memoir on Abscesses of the Liver. By M. Louis.—Repertoire Med., No. ii., 1826. ! Pathological and Practical Researches, &c. &c. Edinburgh, 1S28. On the Liver. Ueber das Venen System, &c. Leipsic, 1815. || Repertoire Med., No. ii. 1826. IT Researches into the Causes, Nature and Treatment of the Diseases of India, &c. By James Annesley, Esq. ACUTE HEPATITIS. 203 cent. The pneumonic symptoms are always most conspicuous when the convex surface of the liver is inflamed. The diagnosis between hepatitis and inflammation of the stomach is rarely attended with any difficulty. The latter affection is almost invariably attended with a very contracted and weak pulse, whilst in the former it is generally mo- derately full and hard. In gastritis, great muscular prostration usually attends from the commencement of the disease, and everything taken into the stomach is commonly almost immediately rejected ; in hepatitis, the strength is at first not much impaired, and although frequent vomiting may occur, it is not so readily excited by ingesta as in gastritis. In the former, pressure on the right hypo- chondrium—in the latter, pressure of the epigastric region, causes most pain. From the pain produced by the passage of biliary concretions through the gall- ducts, or by spasm of these passages, hepatitis is distinguished by the absence of fever in the former, the pulse rarely rising above 90 beats in a minute, and the heat of the skin being but little or not at all raised above the healthy standard. In spasm, or irritation by biliary concretions of the gall-ducts, the pain often intermits for a time; in hepatitis, it is continuous. In the former affection, the easiest posture is when the body is bent forward on the pelvis; in hepatitis, the patient leans a little to the right side, with the knees slightly drawn up. When the inflammation is confined to the peritoneal covering of the liver, there are always more pain and fever than when the glandular structure of this organ is the seat of the disease. (Abercrombie.) Causes.—Dr. Saunders and others describe the frequent occurrence of hepa- titis in hot climates, to the prevalence of a peculiar miasm in these regions. There can, indeed, exist but little doubt, that koinomiasmata often contribute materially to the production of this disease; but their agency is probably rather predisposing than exciting, in relation to this affection. Miasmata unquestion- ably possess an especial power to derange the biliary functions ; and it may be reasonably presumed, that where, from the general prevalence of this cause, in conjunction with high atmospheric heat, the liver is in an habitual state of mor- bid excitation or functional derangement; every adventitious exciting cause— such as the sudden influence of a cool and damp night air ; errors in diet, and consequent gastric derangement; the intemperate use of spirituous liquors, &c, would be peculiarly apt to develop inflammation in the biliary organs. Dr. James Johnson has advanced some novel and very plausible sentiments in rela- tion to the etiology of this disease. He observes, that " between the extreme vessels of the vena portarum in the liver, and those on the surface of the body —in other words, between the biliary secretion and the perspiration, there exists one of the strongest sympathies in the human frame ; and that, whatever in- creases or decreases the action of the cutaneous exhalents, increases or decreases also the secretion of bile in the liver. Knowing, therefore, as we do, how uniformly high atmospheric temperature excites excessive perspiration, we can- not be at a loss to account for the frequency of hepatitis in hot climates. The excessive and continued perspiration occasions a loss of tone in the extreme ves- sels of the surface; and this loss of tone in the capillaries of the skin, is accom- panied by a corresponding loss of tone in the secretory vessels of the liver. As, however, the perspiratory vessels, from their excessive and long-continued action, become debilitated and extremely sensible to the slightest degree of cold, so when the temperature of the atmosphere is suddenly reduced, as is generally the case in hot climates during the night, when the dew falls, the extreme vessels of the surface are instantly struck torpid, which, in consequence of the sympathy just mentioned, is immediately followed by a similar torpor of the secretory ves- sels of the liver. The perspiration and biliary secretion being, therefore, thus simultaneously arrested, and the passage of the blood through the liver obstruct- ed, a commotion is raised, which, as there already exists a congestion in the portal circle, falls mainly upon that system, and gives rise to inflammation." That there exists a strong sympathy between the liver and the skin, is strikingly 204 ACUTE HEPATITIS. illustrated by the fact, that in chronic hepatic inflammation, or in torpor, or scir- rhus of this organ, the skin is always dry and harsh—it being nearly impossible in these affections to excite a perceptible general exhalation from the surface. It appears to me, nevertheless, that the influence of malaria is too much over- looked in this sympathetic doctrine. High and continued atmospheric heat is so universally attended with the extrication of miasmata, that it would seem ex- tremely difficult to say how much of the previous hepatic excitation, and conse- quent atony, is to be ascribed to the one or the other of these causes. That a very considerable share of the effect in question is to be placed to the account of malaria, seems to be demonstrated by the fact, that bilious and hepatic affec- tions are far from being common on board of ships cruising in tropical seas, and where the materials for miasmatic exhalations are absent; although the influence of atmospheric heat is constant and great. Besides the exciting causes just mentioned, there are many others of a less general character, capable of giving rise to this affection. Violent and fatiguing exercise ; contusions of the right hypochondrium; metastasis of gout* and rheu- matism ; wounds and injuries of the cranium;! atmospheric vicissitudes; a draught of cold water while the body is in a state of free perspiration ; irritation from biliary concretions in the gall-ducts; suppression of haemorrhoids ; violent rage ; terror ;| and mental despondency,§ &c, may all give rise to acute inflam- mation of the liver. Hepatitis may be excited in children by the irritation of dentition.H Treatment.—In this disease, as in other inflammatory affections, the abstrac- tion of blood is a primary remedy. There are two reasons for resorting to de- cisive blood-letting in the commencement of this affection—namely, the necessity of promptly lessening the general momentum of the circulation, as well as the ( congestion in the liver and portal vessels; and the importance of subduing the general phlogistic condition as early as practicable, in order to favor the effects of mercurial remedies, upon the prompt influence of which much of our reli- ance must be placed. (Johnson.) As soon as blood has been drawn to an ex- tent sufficient to make a manifest impression on the system, an active mercurial cathartic must be administered. From fifteen to twenty grains of calomel, fol- lowed in about two hours by a full dose of castor oil, or of infusion of senna and manna, constitute an appropriate and efficient purgative in this disease. It is often necessary to repeat the bleeding several times in the course of the first few days, before the arterial reaction becomes permanently moderated ; and this is particularly apt to be the case in the disease as it occurs in temperate latitudes. In warm climates, a frequent repetition of venesection is not often necessary or even proper—one or two efficient bleedings in the commencement of the disease being in general sufficient to bring down the febrile reaction. The application of leeches to the epigastric and hypochondriac regions, will often contribute very materially to the reduction of the hepatic inflammation ; but one or two efficient bleedings from the arm should be premised to the local abstraction of blood. It may be necessary to reapply the leeches where, after * Quantis implicetur, says Schmidtmann, perieulis hepatitis ex podagra retropulsa subnata lugubri illustris Augusti Gottl. Richter, pnpccptoris mei summe colendi interim probatur; qui quippe ex podagra hepar petente et inflammante, annum agens septuagesimum, post paucos ab invasione dies occubuit.—Observ. Medicar., torn. ii. p. 231. X Louis doubts this:—The rise, however, of hepatic inflammation and abscesses from this cause is well established by the testimony of many observers. See the Memoirs of M. Bertrandi and M. Andouille, in the Memoires de 1'Acad. Roy. de Chirurg., torn. iii. p. 439. X Schmidtmann mentions an instance of hepatitis caused by terror: "Jam memoravi me de- prehendisse, hepatitidem terrore esse exciiatem."—Summa Obs. Med., vol. ii. p. 197. Hippo* crates speaks of terror as an exciting cause of this affection : De internis adfectionibus. Sect. iii. cap. i. § A very striking and interesting case of this kind is related in the Annuaire Medico-Chirur- gicale for 1822. U Hufeland's Journal der Pract. Heilkunde, vol. xviii. p. 62. ACUTE HEPATITIS. 205 the adoption of the measures just indicated, the pulse still retains some activity and the local symptoms are not considerably relieved. The bowels should be kept in a loose state throughout the whole course of the disease ; and calomel must always constitute a principal ingredient in the purgatives employed. From eight to twelve grains of this preparation may be given at first, every six hours, and followed by the exhibition of a small dose of Epsom or Glauber's salts ; or of castor oil, or infusion of senna and manna, if after ten or twelve hours the calomel do not procure free evacuations. After the general arterial reaction has been moderated by direct and local depletion, and the bowels well evacuated, our principal dependence should be placed on the speedy induction of modern ptyalism, in conjunction with blisters applied over the region of the liver and moderate purgation. The practice of giving opium with calomel in this affection, particularly after the violence of the phlo- gistic excitement has been broken down by venesection, was long ago recom- mended as decidedly beneficial by Dr. Robert Hamilton ; and it has since his time received the warm sanction of many of the most eminent practitioners. " I know from pretty ample experience," says Dr. Johnson, " that in conjunction with antimonial powder, opium forms a most admirable auxiliary to mercury in acute hepatitis ; not only soothing many uneasy sensations of the patient, but deter- mining to the surface and promoting a diaphoresis, which is of infinite service in this as in most Other affections."* Dr. Armstrong also expresses his confidence in the usefulness of this narcotic in hepatitis ; and in my own practice I have had unequivocal evidence of its beneficial effects in tfiis malady. From three to four grains of calomel, with a grain of opium, may be given every four or five hours, and continued until the gums are obviously affected. The addition of two or three grains of the pulvis antimonialis to each dose of the calomel and opium, will do good not only by its diaphoretic powers, but also, as it would seem, by its tendency to favor the induction of the mercurial influence ; and our main object must be to bring the system under this influence as early as possible. Whilst these articles are given, it will generally be necessary to exhibit an occasional dose of castor oil, or one of the saline purgatives. In the more vio- lent and rapid cases of this disease in hot climates, it is often very difficult to obtain the timely operation of mercury on the system merely from its internal exhibition. When there is reason to apprehend difficulty in this respect, mer- curial frictions should be used in addition to the internal employment of calomel. One or two drachms of the ung. hydrarg. may be rubbed in on the arms or thighs three or four times daily, where ptyalism appears to be tardy in its appearance. Dr. Johnson states, " that the absorption of mercury into the sys- tem, and the consequent early induction of general mercurial action, are accele- rated by causing the patient to swallow a considerable quantity of warm dilut- ing drink, as thin water gruel, every night at bedtime." The application of blisters large enough to extend over the whole right hypo- chondriac and epigastric regions, is a highly useful measure, after bleeding has been efficiently practised. They almost always give considerable relief to the local pain, and by creating a permanent determination to the external surface immediately over the inflamed liver, they tend in no small degree to subdue the local affection. As auxiliaries to bleeding, purgatives, and calomel, antimonials will, in general, be useful where the stomach is not too irritable. The pulvis antimo- nialis, in doses of about three grains, may be given either in combination with calomel and opium, or in union with nitre, or the sulphate of potash, every three or four hours; and to promote the diaphoretic operation of these remedies, as well as the specific effects of the mercury, the warm or tepid bath will fre- quently be found very useful. * The Influence of Tropical Climates, &c, vol. i. 206 ACUTE HEPATITIS. When the inflammation has terminated in suppuration (an event which is an- nounced by the occurrence of rigors, a sense of sinking and anxiety in the prae- cordia, night-sweats, and occasionally formication of the skin, with a fullness and feeling of weight about the margin of the ribs, and a dull throbbing pain in the liver), the further employment of mercury, with a view to its general influence, is improper. "If the local symptoms and the state of the pulse and of the system seem to require it, the application of a few leeches in the vicinity of the tumefaction will be generally serviceable; and afterwards poultices should be assiduously employed with a view of promoting the external pointing of the abscess." (Annesley.) The bowels also should be regularly though gently evacuated, after the formation of abscess has taken place, which may be best done by five or six grains of calomel, followed in a few hours by a small portion of one of the neutral purgative salts. When the abscess does not point exter- nally, nothing more can be done than " to palliate symptoms as they rise, and wait for the event." In instances where the abscess does point outwardly, and the fluctuation of the matter can be distinctly felt, an opening should be made into it, and exit given to its contents. " But this operation ought not, however, to be undertaken precipitately, and before the purulent formation has made its way sufficiently near to the external surface of the organ, or before the part at which it points has formed adhesions to the opposite part of the abdominal parietes. The practitioner should also be fully convinced, from the state of the tumor in the hepatic region, and from the history of the case, that abscess actually exists, and that the tumor does not proceed from an excessive accumu- lation of bile in the gall-bladder. When the pain and general fullness are di- minished, and replaced by a distinct tumor, without acute pain, soft and fluc- tuating at its apex, or with a soft elasticity and slight lividity or redness of the surface, and a somewhat hardened and elevated base, the operation may be undertaken with every expectation of success." The operation of paracentesis thoracis has been successfully performed in cases where the abscess had burst into the cavity of the thorax. An interesting case of this kind is related by Mr. Huggins, in the London Med. Repos. for July, 1827. After suppuration has taken place, and the matter found a favorable exit, there is, perhaps, no remedy which will afford so much advantage as the nitro-mu- riatic acid. It may be employed both internally and externally as a foot-bath, in the manner recommended by Dr. Scott. Equal parts of the nitric and muri- atic acids are the proportion in which they are usually employed. From a half to a whole drachm of this mixture, diluted in a sufficient quantity of water, may be taken daily; and in order to prevent the acid from coming in contact with and injuring the teeth, it should be sucked through a small glass tube, or a quill; or the feet and legs may be immersed from thirty to forty minutes every evening in a warm bath, of the strength, at first, of half an ounce of the acid mixture to a gallon of water, and afterwards gradually increased in strength to the amount of six or eight drachms to the gallon. In two instances of hepatic suppuration from acute inflammation, the patients recovered completely under the protracted use of this bath. Considerable advantage may also be obtained, in suppuration of the liver, from small doses of the muriate of mercury in union with the extract of cicuta, in the proportion of one-tenth of a grain of the former, to two grains of the latter, three times daily. Mr. Annesley has derived advantage from the nitric acid in combination with laudanum, hyoscyamus, or conium, particularly when the abscess has opened into the lungs. When in cases of this kind, the system becomes much exhausted, and the night-sweats are copious, or where the digestive powers fail, recourse ought to be had to some of the tonic bitters, in conjunction with nitric acid and the extract of conium. CHRONIC HEPATITIS. 207 Sect. XI.—Chronic Hepatitis. Chronic inflammation of the liver, when not the consequence of an acute attack of the disease, begins, generally, with symptoms of functional disorder of the digestive and biliary organs; and dyspepsia frequently seems to be the only affection present. The patient complains of irregular appetite, and impaired powers of digestion; acidity; flatulence; slight colic pains; occasional nausea and vomiting; and a sense of fullness in the region of the stomach. In many instances, a slight dull pain and weight are felt in the right hypochondrium, ac- companied, in some cases, with a dragging pain in the right shoulder. Most commonly, however, no distinct pain is experienced in the region of the liver, except when firm pressure is made on this part. In such instances, a sense of uneasiness and tightness is usually felt in the right hypochondrium; and if ex- amination be made, a manifest tumefaction is often discovered in this part. The white of the eyes, and skin of the face, neck and breast, become tinged with a yellowish hue, and the countenance acquires a contracted and sickly aspect. The bowels are always very irregular, costiveness being most common, alternat- ing, in some instances, with diarrhoea, the discharges being frequent, scanty, dark-colored, offensive, slimy, greenish, or watery and muddy. The urine is generally highly tinged with bilious matter, and creates a sense of scalding in the neck of the bladder on being voided.* The tongue is for the most part white, and rather dry ; the taste bitter or disagreeable: and in the advanced periods of the disease, the gums often have a peculiar and unnatural firmness. One of the most constant and characteristic symptoms of chronic hepatitis, is a dry, harsh, and constricted state of the skin. (Johnson.) So torpid are the cutaneous ex- halents in this affection, that every effort to produce a general moisture, or even softness of the skin, is generally abortive. A short dry cough, with slight diffi- culty in breathing, is a frequent attendant on this disease. In the chronic, as in the acute form of this disease, the patient can seldom rest as easy on the left as on the right side. As the disease advances, emaciation becomes more and more conspicuous; slight febrile exacerbations come on towards evening, attended with a burning heat in the palms of the hands and soles of the feet; the nights are restless; and when the inflammation terminates in suppuration, hectic and rapid emaciation consume the vital powers. When the convex surface of the liver is the principal seat of the inflammation, the pain will be referred to the thorax ; but when the concave surface is the part chiefly affected, the patient generally refers the pain to the stomach or bowels. Chronic inflammation of the liver often occurs as a consequence of the acute variety of the disease; but it more frequently arises from the slow operation of the same causes which excite acute hepatitis. From the great frequency of chronic affections of the liver in warm and miasmatic situations, there can exist but little doubt, that the slow and continued operation of marsh miasmata is a principal cause of this affection. That this miasm has a particular tendency to produce biliary derangement, seems evident from the sallow and jaundiced ap- pearance of those who reside in marshy districts. The liver being in a state of almost constant excitation in situations of this kind, and finally disordered in its functions, is especially predisposed to congestion and slow inflammation, on the supervention of any other cause capable of deranging the cutaneous or digestive functions. Post-mortem appearances.—Chronic inflammation may terminate variously. No recent traces of inflammation are detected in the liver on post-mortem ex- amination. The viscus usually exhibits an ash or clay color, and is generally * Mr. Rose and Dr. Henry assert, that urea and hthic acid are not found in the urine of persons laboring under hepatitis. 208 CHRONIC HEPATITIS. somewhat changed from its healthy, or natural shape. Dr. Saunders observes, that the lower margin of the left lobe, which in the healthy liver is thin, is com- monly found rounded and gibbous in chronic hepatitis. In some instances the liver is of a much more firm and solid consistence than natural, although its weight is often specifically lighter than the healthy organ. In some cases, particularly in hot climates, the liver suffers much greater organic destruction than mere change of consistence and color. Dr. Lind found the liver, in persons who had died of this disease, so eaten through as to resemble a honeycomb. Suppuration is a common termination of chronic hepatic inflammation in India. " Notunfre- quently, very minute abscesses are scattered through the substance of the liver, both with and without the appearance of a distinct cyst, the matter collected being of a firm or cheesy consistence, and yellowish-white color. (Annesley.) Sometimes, however, one large abscess is found in the structure of the liver. Tubercles of various sizes and appearances, are occasionally found imbedded on the surface, and interspersed through the substance of the liver. These morbid depositions vary in consistence " from a gristly or cartilaginous state, to one of semi-fluidity;" the firmer ones when divided often presenting either a concentric or radiated texture. In the most chronic cases, the substance of the liver some- limes acquires almost a cartilaginous consistence. Annesley states, that in those who had been addicted to the use of spirituous liquors, the substance of the liver besides small tubercles, exhibited " a cheesy consistence and texture of a deep nankeen-like color." Occasionally the liver is firm, and much diminished in size, and its internal structure has sometimes exhibited a par-boiled, scabrous, dry and spongy appearance.* Treatment.—General depletion is very rarely indicated in this variety of he- patic inflammation. In cases of a subacute character, more especially when they occur as a consequence of an acute attack of the disease, it will sometimes be useful to abstract small portions of blood; but even in instances of this kind it will be better to deplete by leeches applied to the epigastrium. " In the chronic hepatitis of India," says Annesley," there are few cases where repeated though moderate leeching will not be advantageous." After each leeching, an emollient poultice should be applied over the right hypochondrium, and a mercurial aperient administered at night. When the phlogistic action of the liver has been reduced, (where such reduction may be indicated by the local pain, and action of the heart and arteries,) by moderate depletory and aperient measures, recourse should be had to a more regular administration of mercurial remedies. In the employment of mercury in this affection, however, it must be managed so as not to produce active ptyalism. Full salivation seldom proves beneficial, and may do injury in this form of the disease. A moderate, uniform and prolonged mercurial influ- ence will generally procure all the advantage that this remedy is capable of afford- ing. From three to four grains of blue pill, in combination with a grain of the extract of conium, or of hyoscyamus, should be given three times daily, until the gums become slightly affected.! The medicine is then to be discontinued until the soreness of the gums is going off, when it is to be resumed, and given once or twice daily, so as to keep up a uniform impression on the system without producing ptyalism. During this mercurial course, mild laxatives should from time to time be given, so as to keep up a regular action of the bowels. For this purpose, small doses of Glauber's or Epsom salts, or of powdered rhubarb, may * Researches into the Causes and Treatment of the Diseases of Warm Climates. By James Annesley, Esq., p. 470. ! I have been in the habjt of uniting small portions of ipecacuanha to the blue pill and conium in this and other chronic complaints. Thus: R.—Massae hydrarg £i. Extract, conii maculat. ^ss. Pulv ipecac. gi.—M. Divide into thirty pills. S. Take two every morning,noon and evening. CHRONIC HEPATITIS. 209 be given every second or third day, according to the state of the bowels. Mr. Annesley recommends the following aperient pill in this affection: R.—Hydr. submuriatis Qi. Extract, colocynth. comp. ^ij. Antim. tart. gr. i. Pulv. ipecac, grs. iv. Sapon. Castil. grs. x. 01. carui q. s.—M. ft. pilul. xviij. S. Two of these pills may be taken every night on going to bed. In most cases one pill will be sufficient. To preserve the tone of the stomach, as well as the regular action of the bowels, it will be useful to prescribe a weak infusion of some of the tonic bitters —as gentian, colomba and quassia. A tablespoonful of an infusion of this kind, with ten or twelve drops of nitric acid, may be taken morning, noon and evening. Dr. Johnson recommends the following formula as an excellent tonic in this affection: R.—Decoct, taraxac. ^iv. Carbonat. soda? gi. Extract, taraxac. gij. Tinct. gentian ^ij.—Misce. S. Take two or three tablespoonfuls twice daily. "The more the taraxacum is employed," he says, "the more certain proofs will it afford of its utility." The aperient and diuretic qualities of this root are unquestionable.* In speaking only of a moderate mercurial action, I refer particularly to this affection as it is usually met with in the temperate latitudes. In the intertropical regions, chronic hepatitis is generally much more rapid in its progress, and is much more apt to terminate in abscess than in the colder climates. In conse- quence of this it is often necessary to employ the mercury more freely, and to carry it to the extent of producing salivation. Chisholm and Johnson recom- mend the production of moderate ptyalism, and there can be no question of the general propriety of this practice in hot climates. The nitro-muriatic acid bath was some years ago strongly recommended to the profession, as a remedy in this variety of hepatitis, by Dr. Scott, and it has since received the approbation of many other practitioners, whose opportunities for testing its virtues in this way were very ample. " As a general rule," says Dr. Scott, " it may be observed, that whenever the mercurial preparations are indicated, the nitro-muriatic acid will be found useful—with this difference, that in cases where mercury is highly injurious, from delicacy or peculiarity of con- stitution, or from other causes, the nitro-muriatic acid may be employed with safety and advantage." Dr. Johnson, who speaks very favorably of this remedy in chronic hepatitis, gives the following directions for using it. " Into a glass vessel capable of holding a pint or more of fluid, put eight ounces of water: and then pour in four ounces of nitric, and the same quantity of muriatic acid. One ounce of this mixture to a gallon of water will form a bath of a medium strength, The feet and legs of the patient are to be immersed in this bath at the temperature of about 96°, and kept there twenty minutes, or half an hour, just before going to bed. This should be done every night, and the same bath will remain good for five or six nights." If no prickling or itching sensation is felt in the feet and legs after they have been immersed for twenty or thirty minutes, more of the acid must be added to the bath. The nitro-muriatic solution may also be used with benefit in the form of a wash. Two or three drachms of the above mixture should be added to a pint of warm water, and the body and thighs sponged with it, night and morning, for fifteen or twenty minutes at a time. Mr. Annesley states, that " he found great advantage from employing this solution in the form of a poultice in torpor of the liver, and in chronic affections of the organ attended with enlargement, and a deficient and morbid state of the biliary secretion." * Med.-Chir. Rev., Jan. 1829. 14 210 SPLENITIS. Mr. Annesley speaks in the most favorable terms of this remedy in chronic affections of the liver. Where the structure of this organ is enlarged, and the biliary and intestinal secretions disordered, he declares this mixed acid one of the most valuable remedies we possess." I have frequently used it in affections of this kind, and generally with marked advantage. - • , • The internal use of the nitrous acid also has been found very beneficial in this affection. From two to four drachms diluted in a large portion of some mucilaginous fluid, may be taken in the course of twenty-four hours. It seldom fails to induce more or less ptyalism, when its employment is continued for some time; but it often acts beneficially without the production of salivation. It may be given simultaneously with mercury. (Annesley.) Sir James M'Grigor, indeed, thinks that peculiar advantages result from the conjoined use of these remedies. Blisters are beneficial in chronic hepatitis ; but I have generally seen more advantage derived from pustulation of the right hypochondrium by frictions with tartar emetic ointment. The white precipitate ointment forms a most excellent counter-irritating application in this affection. Two drachms of white precipitate, rubbed up with an ounce of lard, and applied two or three times daily by frictions to the region of the liver, will seldom fail to bring out a copious crop of large suppurating pustules, more permanent than those which are produced by tartar emetic, and much less painful and irritating. A seton in the right hypochondrium has been found very useful in the more chronic instances of this affection. The diet should be light, unirritating and digestible; and the patient must especially avoid a cold and damp atmosphere ; or the influence of sudden changes of atmospheric temperature. In general, persons who are affected with this dis- ease are peculiarly sensitive to low temperature; and it is a matter of considera- ble consequence to the successful issue of our remedial efforts, to place such patients in a temperature perfectly agreeable to their sensations and uniform in its grade. Sect. XII.— Of Splenitis. The physiological relations of the spleen are as yet but very imperfectly under- stood ; nor have the diseases to which it is subject been " either carefully studied or clearly revealed." " Our ignorance of its use during health has rendered us less alive to its conditions in disease; and the obscurity of its functions when natural, has made their study when disordered less" interesting in its object, and less successful in its issue." It does not appear that this viscus is often the seat of active or acute inflammation,* although chronic inflammation is probably much more common than is generally suspected.! When acutely inflamed, the patient commonly feels a heavy pain under the false ribs of the left side, which is con- siderably increased by external pressure. The left hypochondrium is said to become fuller than natural, and in some instances, considerable pain is felt under the right scapula. The skin and eyes become slightly jaundiced, and the urine highly tinged with bilious matter. A burning and oppressive sensation in the stomach, with nausea and vertigo, particularly when the patient raises himself in bed, and other dyspeptic symptoms, frequently attend the affection.^ In chronic splenitis, slight uneasy and occasionally painful sensations are from time to time experienced by the patient; and there is difficulty in lying on the left side, accompanied with dyspeptic symptoms, a cachectic aspect of the coun- * [I have never seen more than one case of acute splenitis; and that was a decisive one. The tenderness of the tumefied organ was peculiar and excessive, and the constitutional disturbance was very severe. For three days the symptoms were alarming; but active deple- tion, general and topical, followed by active mercurial cathartics, finally gave relief—Mc] X Richter thinks that chronic splenitis is even more common than chronic hepatitis.—Die Specielle Therapie, band. i. s. 576. X Marcus, vide Annalen der Medizin, band. vii. s. 327. SPLENITIS. 211 tenance, and a gloomy, morose, desponding, or variable and fretful temper. Persons affected with chronic inflammation of the spleen are said to be prone to attacks of vomiting of blood—(Marcus, Richter,)—more especially when the in- flammation has terminated in induration of this viscus. The blood, perhaps, passes into the stomach through the vasa brevia. From the foregoing symptoms, it is manifest that the diagnosis between this affection and hepatitis must always be attended with considerable "uncertainty. The pain in the left side, and the vertigo when the head is raised, or on sitting up, are the only symptoms mentioned that are not as common in the latter as in the former affection. Inflammation of the spleen may terminate in suppuration, softening of its structure, (ramollissement,) hypertrophy and induration. Suppuration, however, occurs but very rarely in this affection. M. Jaquin- elle relates an instance in which a large abscess in the spleen had burst into the colon; and Wardrop found nearly the whole structure of this viscus converted into an abscess containing a purulent fluid. Dr. Tweedie, physician to the Lon- don Fever Hospital, has related a case of inflammation of the spleen which ter- minated in suppuration ; and Dr. Raikem, of Volterra, has given an account of a similar ease. In Dr. Tweedie's case two abscesses were formed in the spleen, one in the centre, and another a4 the point of its adhesion to the diaphragm, the peritoneal covering and fibres of which it had destroyed. In Dr. Raikem's case, the interior of the spleen was hollowed out into one great abscess."* Softening of the structure of this organ is a very common occurrence, parti- cularly " after some forms of general disease." In fatal cases of typhus, ramol- lissement of the spleen is almost always present.! This softening consists of "a broken down semifluid pulp, resembling black currant jelly." (Abercrombie.) Enlargement of the spleen is particularly apt to occur in remittents and inter- mittents. It is probable, however, that this condition is rarely the consequence of inflammation—being the result, generally, of great and protracted sanguineous congestion of this organ. During the cold stage of intermittents, the spleen al- ways becomes greatly engorged with blood, and when this disease continues a long time, enlargement, induration, and sometimes a complete disorganization of this organ take place. Dr. Vetch states, that in the only three cases of intermit- ting fever which he has known to terminate fatally during the cold stage, the spleen was found so much distended with blood, and its structure so much altered, that it resembled a mass of dark uncoagulated blood, which was broken down by slight pressure of the finger. This state of the spleen is attended with great increase of its vascularity; whilst little or no morbid change usually occurs in its proper substance. Dr. Abercrombie observes, that " one of the most singular facts in the pathology of the spleen, is the very rapid manner in which enlarge- ment of it takes place ; and the equally rapid manner in which it subsides.";]; In some instances, tubercles and hydatids are found in the spleen ; and authors mention a pale induration of this organ as an occasional phenomenon. (Diemer- .* Edin. Med. and Surg. Jour., April 1830. X Dr. Vetch, physician to the Charterhouse, mentions the following symptoms as generally accompanying enlargement of the spleen. There is littleor no pain complained of by the pa- tient; " the appetite is usually good, yet the powers of assimilation are obviously deficient; the patient loses flesh ;(a) is incapable of any muscular exertion; his features have a dark, bilious, or mahogany hue, but the conjunctiva preserves a white and healthy appearance; perspira- tion is in time wholly suspended, and the skin acquires the appearance and feel of satin; the lips are pale, and there is generally much wasting of the gums; the urine is limpid, and secreted very rapidly, but contains little or no urea. The patient's mind is desponding and morose; and there is coldness of the lower extremities."—Med. and Phys. Journ., Ib24. $ Med.-Chir. Rev., January 1829. (a) [Infants aTe sometimes affected with permanently enlarged and very indurated spleens, which produce extreme anemia without any remarkable degree of emaciation. Dr. Elliotsoii thinks such cases proceed fiom the parents having been exposed to marsh miasma. I have seen them where no such cause could be suspected. Chalybeates and iodine are the only remedies; but my success has been poor enough with them.—Mc ] 212 INFLAMMATION OF THE BRAIN. broeck.) Dr. Abercrombie mentions, also, infiltration of a gelatinous fluid, and deposition of adipose matter into the substance of the spleen. Treatment.—Acute inflammation of the spleen is to be encountered with the usual antiphlogistic remedies proper in visceral inflammations. Decisive blood- letting, purgatives, and counter-irritating applications to the region of the spleen, constitute the principal means for combating this affection. The warm bath, after the active state of the disease has been in some degree reduced, is said to be a useful auxiliary. In the chronic form of the disease, leeching and pustulation of the left hypo- chondrium by frictions with tartar emetic ointment; the warm bath; mercurial laxatives; a seton in the left side; alterative doses of blue pill with extract of hyoscyamus; diaphoretics; and the protracted use of minute doses of tartar emetic, are the remedies upon which our chief dependence is to be placed. In enlargement and induration of the spleen, particularly when they occur as the sequela? of intermitting fever, I have found no remedy more useful than large doses of the muriate of ammonia. The formula given in the chapter on inter- mitting fever may be employed with a pretty certain prospect of success in cases of this kind. Small doses of tartar emetic, also, are decidedly beneficial in en- largement of the spleen. One grain dissolved in two quarts of some bland fluid or water, may be taken in place of the common drink, and continued for eight or ten days. Alterative doses of blue pill with ipecacuanha, in the proportion of two grains of the former to one of the latter, will frequently succeed in removing this state of the spleen. The bowels must be regularly moved by some mild aperient; and the diet should be mild, digestible, and nourishing. The warm bath, and frictions with dry flannel or the flesh brush, will assist in the removal of this affection. Iodine has recently been employed for the reduction of enlargement and in- duration of the spleen; and it would appear to possess very active powers against this affection. It may be used either internally in the form of tincture; in doses of from eight to ten drops three times daily; or in frictions with the hydriodate ointment, over the region of the spleen.* CHAPTER XI. OF THE PHLEGMASIA OF THE NERVOUS SYSTEM. The pathology of encephalic inflammation is attended with much difficulty on account of the variety of structures which compose the encephalon, and the con- sequent diversity which occurs in the symptoms and terminations of its inflam- matory affections. Within the cranium there are no less than three distinct structures, namely, the fibrous, the serous, and the cerebral, and there is reason to presume, that the phenomena of cephalitis will be considerably modified, ac- cording as one or the other of these structures is the principal seat of the inflam- mation. It is not probable, however, that any one of the structures within the cranium can suffer inflammation, without involving, in some degree, the others; and all attempts, therefore, to assign to each structure its peculiar symptoms under inflammation, must necessarily be attended with considerable uncertainty. Nevertheless, there are certain modifications of the phenomena of cephalitis, which observation has taught us to refer to particular structures, and which may, * [The most decisive effects in enlargement of the spleen have been produced in my hands by occasional doses of Clutterbuck's extract of elaterium, in combination with a small pro- portion of calomel.—Ma] INFLAMMATION OF THE BRAIN. 213 therefore, be taken as a basis for the division of encephalic inflammation into certain varieties, sufficiently distinct to demand separate consideration. Agreeably to these circumstances, cephalitis presents us with the following varieties, viz: Meningitis and cerebritis.—Meningitis must be again divided into inflamma- tion of the pia mater, with more or less inflammatory action in the rest of the membranes and the brain; and arachnitis. The first of these subdivisions con- stitutes the affection commonly called phrensy (phrenitis;) and the last is known under the inappropriate name of hydrocephalus. Sect. I.—Phrenitis (Phrensy). Phrenitis generally begins with pain and a sense of fullness in the head, attended, in most instances, from the commencement, with considerable nausea and vomiting. As the pain and febrile reaction increase, the eyes become red and sparkling; the face flushed; and the patient often experiences a peculiar sensation of uneasiness along the course of the spine. Delirium is commonly an early attendant on the disease, and in most instances, soon acquires a degree of violence resembling the most furious and ungovernable mania. In this aggra- vated state of the disease, the face becomes turgid; the eyes wild and furious; the carotids beat strongly; vision is imperfect and deceptive; and the whole system is in a continued state of restlessness or agitation. During the early part of the disease, the sense of hearing is generally painfully acute, but in its advanced periods, complete deafness often occurs. At first, the pulse, along with its firm- ness and activity, has considerable volume; but in the progress it becomes small and tense, and not unfrequently intermitting. Respiration, though hurried and anxious at first, becomes slow, deep, and somewhat laborious in the latter stage of violent instances of the disease; and in many cases deglutition is performed with much difficulty. The liver often sympathizes strongly with the brain in this disease, giving rise to a copious secretion of bile, jaundice, and other manifestations of hepatic de- rangement. Dr. Wilson observes, "that there is often a remarkable tendency to the worst species of hemorrhages from the bowels, towards the termination of fatal cases; an observation which was confirmed by a remarkable instance which came under my own notice. On the day preceding the fatal termination of this case, an exceedingly copious discharge of dissolved blood took place from the bowels, and on the following morning the hemorrhage occurred also from the mouth and gums. Causes.—Phrenitis is not often an idiopathic affection. It occurs most com- monly during the progress of general fevers, particularly synocha, and the aggra- vated instances of typhus. The ordinary exciting causes of this variety of encephalic inflammation are, violent passions; insolation ; the sudden influence of cold while the body is in a state of free perspiration ; drunkenness ; sup- pression of habitual sanguineous discharges; and particularly metastasis of gout, erysipelas, and parotitis, and the extension of other external inflammations about the head to the brain, an occurrence sometimes met with in small-pox. I have known the disease to supervene in consequence of a large phlegmonous swelling under the left ear; and another instance, from a similar inflammation on the back of the neck. Prognosis.—Hemorrhages, in the advanced period of-the disease, particularly from the bowels, may be regarded as almost a certainly fatal sign. Bleeding from the nose, however, at an early period, seldom fails to mitigate the violence of the disease, and should always be promoted as a most favorable occurrence. Coma supervening on violent delirium, is indicative of great danger ; for after the occurrence of this symptom, little or no hopes of recovery can be enter- tained. 214 INFLAMMATION OF THE BRAIN. Phrenitis is always attended with considerable danger; and the unfavorable- ness of the prognosis must of course be proportionate to the violence of the symptoms, and the obstinacy with which they resist remedial treatment. Mor- gagni observes, that when phrenitis supervenes on peripneumony, the worst consequences are to be apprehended; and the same observation is made by Schmidtmann.* Pathology.—It is stated above, that in the disease just described, the inflam- mation is principally located in the pia and dura mater; and this appears to be entirely confirmed by the phenomena which are presented on post-mortem ex- amination. I am aware, that Bichat asserts that the dura mater is scarcely sus- ceptible of inflammation ;! but this assertion is contradicted by others, and with justice. Shaw, in his Manual of Anatomy, states, that after phrenitis, the traces of inflammation are always very conspicuous on the surface of the dura mater, " which is generally as much blood-shot as the conjunctiva in ophthalmia, with layers of lymph occasionally on the inner surface." The observations of Mor- gagni, also, go to establish the same fact; for, in nearly all the dissections which he relates of subjects who had died of this disease, the pia and dura mater showed the strongest signs of previous inflammation. The substance of the brain itself does not often exhibit unequivocal traces of inflammation in those who die of phrenitis ; but in nearly all instances, flakes of coagulable lymph, and often pus mixed with serum, are found between the membranes, and in some cases the dura mater has been found eroded to a considerable extent. (Morgagni.) Indeed, inflammation of the cerebral substance alone is very rarely attended with the violent delirium and pain which distinguish the affection under consideration; nor is delirium a very constant and prominent phenomenon of arachnoid inflammation, though frequently connected with very severe and lan- cinating pains in the head. It cannot, indeed, be doubted, that the brain becomes more or less involved in the inflammation which constitutes this disease, but the principal seat of the inflammation would seem to be placed in the pia and dura mater. Morgagni states, that he has found the membranes alone affected, al- though, in the majority of cases, traces of inflammation were also discovered in the cerebral structure. Treatment.—There is no inflammatory affection which more urgently de- mands a vigorous antiphlogistic treatment than the present one. Blood-letting, promptly and efficiently used, is a sine qua non in the remedial management of this affection, as indeed it is in all the modifications of cephalitis. Many of the oiher phlegmasial diseases may often be treated successfully without sanguineous depletion. Pneumonia is treated by somej with opium and calomel; and by others,§ with tatar emetic, with little or no abstraction of blood. But phrenitis is, perhaps, never treated with success without efficient blood-letting, nor is it likely that any other remedial measures would be of adequate avail, without the aid of this most prompt and efficient of all our antiphlogistic means. Blood should be drawn from a large orifice, and suffered to flow until unequivocal signs of its effect on the action of the heart and arteries are manifested. Carried to the extent of inducing an approach to syncope, bleeding will generally speedily subdue the furious delirium and intense pain in the head. In all inflammatory affections of the head, particular advantage may perhaps be obtained by taking the blood from one of the jugulars or the temporal arteries. Although bleeding is always most serviceable when adequately performed in the onset of inflamma- tory affections, yet in the present disease it may be advantageously resorted to throughout the whole course of the malady, if the pulse remains tense and quick.|| Topical bleeding by leeches or cups, is less beneficial in this than in * Summa Observationem Medicarum, vol. i. Berlin, 1819. ! Pathological Anatomy, translated by I. Togno, M.D., p. 58. Schmidtmann, Vogel. Rasori, and the advocates of the contra-stimulant doctrine. || [After the first blood-letting the pulse should be carefully watched, and at every subse- INFLAMMATION OF THE BRAIN. 215 the less violent forms of encephalic inflammation in its early stage.* After the momentum of the circulation has been diminished by general bleeding, leeches or cups, applied to the temples and about the head, will in general procure con- siderable advantage. The application of cold water or ice to the head is a valu- able auxiliary in the treatment of this disease. The hair should be cut short, or shaved off, and bladders partly filled with cold water, into which a lump of ice is put, should be kept constantly applied to the top of the head. Purgatives of the active kind will assist materially in reducing encephalic inflammation. In all affections of the head, whether congestive or inflammatory, there is usually considerable torpor of the intestinal canal, and it is generally necessary to prescribe large doses of some active purgative to procure an adequate evacua- tion of the bowels. As the liver usually sympathizes strongly with the brain in its inflammatory affections, calomel forms an appropriate constituent in the pur- gatives proper in this disease. From ten to twelve grains of this article, fol- lowed after the lapse of three or four hours with infusion of senna, or a full dose of Epsom or Glauber's salts, will in general answer well as a purgative in this affection. Care must be taken in the use of calomel, lest ptyalism be in- duced, an occurrence which could hardly fail proving injurious. The bowels should not be suffered to remain inactive for more than five or six hours at a time, and this should be attended to, not only during the active course of the dis- ease, but throughout the period of convalescence. Cathartics do good in this affection, both as revulsive and evacuant means. By exciting the intestinal ex- halents, and thus directing the circulation more particularly to them, purgatives tend, in no inconsiderable degree, to diminish the flow of blood to the head, as well as the general momentum of the circulation, by their indirect depletory effects, and the removal of irritating matters from the intestinal canal. Many writers recommend the application of blisters to the head, after the vio- lence of the febrile excitement had been in some degree subdued by the deple- tory measures. In the early periods of the disease they are useless, and per- haps injurious, but when the violence of the inflammation is moderated, and the disease, as it were, lingering on the confines of convalescence, advantage may, perhaps, be derived from vesicatories applied to the shaven scalp. It has ap- peared to me, however, that more benefit is derived in the inflammatory affec- tions of the brain, from blistering the back of the neck, than from vesicatories laid on the top of the head. When applied on the neck we may at the same time continue the use of cold applications to the scalp, a union of applications particularly appropriate to this disease. The patient's head should be kept in an elevated position, in order to lessen the impetus of the circulation in the affected parts. In all inflammations, con- siderable benefit accrues from placing the inflamed part, if feasible, in a raised position, as we thereby favor the return of blood from the inflamed structure by the veins, and impede, in some degree, the access of the blood by the arteries, in consequence of the additional resistance offered by the gravity of the blood to the propulsive efforts of the heart. Among the internal antiphlogistic means, nitre, in combination with antimony, quent reaction the bandage should be removed, and more blood drawn from the same orifice. I have in this way repeated the evacuation several times on die first day with the most decisive effect.—Ma] * Mr. Chauflhrd states that he has often seen an inflammatory affection of the head aggra- vated by leeches to the temples or behind the ears, and relieved at once by drawing blood from the feet and ankles. He mentions several cases of ophthalmia, unchecked and uncured by local bleedings from the neighborhood of the eyes, speedily disappear by the application of leeches to the lower extremities. The good effects are much enhanced by the warm hip or foot baths; cold applications at the same time kept constantly applied to the head.—Med.-Chir. Rev., 1S32, p. 188. Dr. Johnson observes that " revulsive bleeding" may be used with exceeding good effects, especially in those cases of cerebral disease dependent on obstruction of any accustomed dis- charge. 216 INFLAMMATION OF THE BRAIN. or digitalis, may be accounted the most useful. From ten to twelve grains of the nitrate of potash, with half a grain of digitalis, may be given every two hours. Digitalis is particularly well suited to the management of this, as well as of other inflammatory affections, after the violence of the disease has been broken down by the remedies already mentioned, and when it continues its course in a reduced or subacute form. Given in small and frequent doses, it will, under these circumstances, often make a very decided and salutary impres- sion upon the action of the heart and arteries. From a quarter to half a grain of the powdered leaves may be given every two hours, until it either causes a reduction of the frequency and activity of the pulse, or produces nausea or other symptoms of gastric disturbance. During the whole course of the disease, the chamber of the patient should be kept dark, silent, and cool, and everything avoided which has a tendency lo dis- turb or excite the system. No nourishment whatever, with the exception of toast-water and lemonade, or similar beverages, must be allowed, so long as there are pain in the head, and general febrile irritation. Sect. II.—Arachnitis. Hydrocephalus acutus ; acute dropsy in the brain; apoplexia hydrocephalica —(Cullen.) Encephalitis—(Porter.) Phrenicula—(Rush.) Hydrencephalus —(Smith.) Cephalitis profunda—(Good.) Arachnitis is a much more common form of encephalic inflammation than the preceding one.* It has of late years been extensively investigated by Martinet and Duchatelet, of Paris, and by Dr. Abercrombie of Edinburgh, whose patho- logical researches in relation to this subject are highly interesting and valuable. I treat of hydrocephalus and arachnitis under the same head, for it is now placed beyond all doubt, that the malady known and described under the name of hy- drocephalus, consists essentially of arachnoid inflammation. The term hydro- cephalus is, indeed, altogether inappropriate to the disease; for, instead of direct- ing the mind to the primary and essential affection, it has reference only to one of its ordinary consequences—namely, serous effusion on the surface and within the cavities of the brain. Dr. Rush was one of the first who taught correct views concerning the pathology of this disease. " Having for many years," he says, " been unsuccessful in all cases but two of internal dropsy of the brain which came under my care, I began to entertain doubts of the common theory of this disease, and to suspect that effusion of water should be considered only as the effect of a primary inflammation in the brain." He regarded this disease as a subacute grade of cerebral inflammation, or an inflammation less violent than that which gives rise to the symptoms of phrenitis, and therefore distin- guished it by the name of phrenicula.X The impropriety of designating this disease by the name of dropsy, is often strikingly exemplified by the post-mor- tem phenomena; for, in some instances, very little or no serum is effused into the ventricles, or upon the surface of the brain, although the symptoms were unequivocally those which are acknowledged to characterize hydrocephalus.— (Abercrombie.)J * Dr Coindet states, that in France, 20,000 deaths occur of this disease annually, while Dr. Alison informs us, that 40 out of 120 patients die of this affection in the New-Town Dispensary ; and according to the late Dr. Davis, of London, 8 out of 45 deaths in the Universal Dispen- sary were produced by hydrocephalus.—Med.-Chir. Rev., March 1828, p. 385. f Dr. Porter contends that hydrocephalus is not phrenitis, (though he admits that meningitis may be superadded,) but an inflammatory condition of the posterior arteries of the encephalon, and of the base of the brain.—Med.-Chir. Journ., July 1819. X [In the majority of all the cases in which I have made post-mortem examinations for acute hydrocephalus in children, I have been disappointed in regard to the anticipated effusion. In- flammation of the enveloping and penetrating portion of the membranes has always predomi- nated, and often the cerebral injection has terminated in bloody extravasation.—Ma] INFLAMMATION OF THE BRAIN. 217 It is, nevertheless, probable that effusion within the cavity of the cranium does sometimes occur without inflammatory action of the vessels of the encephalon, from mere congestion of the cerebral blood-vessels. This is, perhaps, the case in some of the instances which are ushered in by convulsions, or a state of som- nolency and stupor, without any manifest previous febrile irritation. Be this as it may, arachnoid inflammation constitutes unequivocally the essential pathological condition of what is generally known under the denomination of hydrocephalus. Arachnitis occurs most commonly during childhood; and the period of den- tition is the age during which the greatest aptitude exists to the disease. That there should be a particular proneness to this malady during the process of den- tition is easily to be understood. Whilst this process is going on, there is almost always more or less local irritation in the immediate vicinity of the brain, ■con- nected with a general irritable and phlogistic condition of the system—circum- stances which, co-operating with the natural predominance of the cerebral circu- lation in infancy, are well calculated to invite to inflammatory affeetions of the head during this period of life. Symptoms.—Arachnitis may be divided into three stages. The first stage may be called the irritative period ; for, in the commencement of the disease, the symptoms are those of an irritated, rather than an inflamed condition of the brain. The approach of the disease is frequently very gradual, more especially during early childhood. In many instances, the brain manifests a very irritable condition for several weeks previous to the full development of the disease. The patient is wakeful' irritable in temper; evincing a repugnance to strong light, on account of the sensible state of the retina; the pupils are contracted ; the dispo- sition fretful and variable; small children cry frequently, without any apparent cause, and, when sleeping, often start or awake suddenly, with violent screaming, " and an expression of terror in the countenance." Nurslings, when awake often " start at the slightest noise, and shriek suddenly as if pricked with a pin."* This state of cerebral irritability sometimes exists and continues for a lime without passing into the inflammatory state; the child gradually returning to its ordinary condition of health. When, in this state, some additional exciting circumstances supervene—such as cold, dentition, or intestinal irritation from improper food, or other irritating substances lodged in the bowels, this irritative condition of the brain is increased, and sooner or later converted into inflammation. A new train of phenomena now ensues, which characterizes the inflammatory, or second stage of the disease. The patient complains of transient pains in the head, al- ternating often with similar pains in the abdomen. The restlessness and irrita- bility of temper increase; the pulse is irritated, quick, tense and active; the physiognomy expressive of discontent and suffering; one or both cheeks marked with a circumscribed flush; the eyebrows knit and frowning; and the eyelids generally half closed, on account of the sensible state of the retina. The bowels are commonly torpid, and sometimes relaxed, the stools presenting an unnatural appearance. As the disease goes on, the cephalic pains become more and more severe, suffering occasional remissions, and sometimes subsiding entirely for a few minutes. These pains are felt chiefly in the forehead, shooting backwards towards the temples. Children manifest their sufferings from the headache, by frequently applying the hands to the forehead. At this period of the disease, the stomach is usually very irritable—the retching and vomiting becoming often very troublesome, particularly when the patient is raised to a sitting posture. I have met with many instances in which no disposition to vomit was manifested whilst the patient remained in a recumbent position; but the moment the head was raised from the pillow, sickness and vomiting ensued. Indeed, children affected with this disease always bear the erect position with great uneasiness. * Dr. W. Nicholl's Transact, of the Association of Fellows and Licentiates of the King and Queen's College, Dublin, vol. iii. Practical Remarks on Disordered states of the Cerebral Struc- tures occurring in Infants. By W. Nicholl. M. D., London, 1821. 218 INFLAMMATION OF THE BRAIN. " In the early part of the disease, the little patient cannot sleep with the head low ; he lies in the bed with outstretched arms, which have a tremulous motion; are often directed towards the head, and firmly clasped upon it; he is constantly turning and tossing from one side of the bed to the other, and very frequently groans much, as if under the influence of pain." (Monro.) The sickness of the stomach sometimes alternates with the cephalic pains. (Quin, Fothergill.) One of the most common and characteristic symptoms of this complaint is fre- quent and deep sighing; though this is seldom much noticed until the disease is fully developed, and is generally most remarkable about the period when the inflammation is about terminating in effusion. During the latter part of the in- flammatory stage, transient delirium usually occurs : but the delirium of arachnitis is never violent or furious, but of the tranquil kind, and rarely so great that the patient may not be roused from it, so as to give distinct answers. (Martinet.) The skin in this stage is generally above the natural temperature, and dry ; the tongue, for the most part, remains clean, or covered only with a thin white fur, with pale red edges. In cases, however, which depend on gastric irritation, it is apt to be covered with thick brown fur, becoming dry and rough towards the termination of the disease. After an indefinite period, these inflammatory symp- toms are succeeded by a new train of phenomena, marking the third stage or the period of cerebral oppression. The delirium is now more continuous; the coun- tenance exhibits an aspect of surprise and stupor; the pupils are dilated or much contracted; the conjunctiva is suffused and reddish ; the eyes turned up under the upper lids during sleep ; constant somnolency supervenes, the patient being wholly inattentive to surrounding objects, and when roused, speedily relapses into the same somnolent state. The mind is torpid, and apparently incapable of any attention. The drowsiness increases more and more, until a complete state of coma ensues. In some instances, the coma comes oh suddenly in con- junction with paralysis of one side of one extremity; but it more commonly approaches in the gradual manner just described. Indeed, instances occur, in which no febrile excitement is developed, the first manifestations of the disease being an unusual drowsiness or torpor. In this latter case, arachnoid inflammation exists, no doubt, without showing itself by its usual symptoms ; for it is well as- certained that inflammation may go on in the brain, even to the extent of termi- nating in extensive and fatal disorganization, without causing either pain or any other general symptoms characteristic of inflammation. Soon after the somnolent stage supervenes, paralytic affections generally occur. A tremulous motion of one arm, with the hand firmly contracted inwards, is usually one of the first manifestations of paralysis in infants ; and, by degrees, the power of using the arm and leg of one side becomes entirely lost; one or both upper eyelids usually becoming paralyzed at the same time, so that the patient, in endeavoring to look at anything, is unable to raise the lids by their proper muscles, and is, therefore, obliged to draw them up with the integuments of the forehead, by the contraction of the occipilo-frontalis muscle.* Previous to the occurrence of paralysis, stra- bismus almost always occurs, and in many instances, there is double vision. In general, a sudden amendment in nearly all the symptoms takes place soon after the inflammation has terminated in effusion ; and parents and friends, nay, even physicians, may be deceived into the hope that the disease is about assuming an unexpected favorable change. This flattering calm is, however, seldom of long continuance, and almost universally ultimately fallacious ; for, sooner or later, convulsions suddenly supervene, or the patient relapses into a state of fatal coma and stupor. Convulsions rarely, if ever, remain wholly absent towards the fatal termination of this disease. During the somnolent stage, the pulse is generally slow and full, and often irregular; but in the convulsive or paralytic period, it becomes frequent, small and irregular. In the latter stage of the disease, * Recherches sur l'lnflammation de l'Arachnoide. Cerebrale et Spinale. Par Parent Ducha- telet et L. Martinet. Paris, 1821. INFLAMMATION OF THE BRAIN. 219 both hearing and seeing are often totally lost, yet general sensibility, or the sense of touch, usually remains to the last moments. I have seen infants, perfectly deprived of the sense of seeing, and apparently of hearing, readily lay hold of the nipple and suck as soon as it was brought in contact with the lips, although in a continued state of stupor or sleep. The paralvsis which occurs in the latter stage is always of the hemiplegic kind. In most cases, small children keep one arm in continued motion. (Cheyne.) Martinet and Duchatelet state, that patients suffering under this disease exhale a very disagreeable odor, which they com- pare to the smell of mice. Arachnitis does not, however, always come on in the gradual manner and with the regular train of symptoms just described. Sometimes the disease commences and proceeds in a manner very similar to the infantile remittent; and at others it is ushered in by convulsions, without any perceptible antecedent febrile irritation. In this latter case, however, there is, perhaps, always some evidence of ill health, previous to the supervention of the convulsion, such as fretfulness, variable ap- petite, irregular state of the bowels, tumid abdomen, foul breath, swelled upper lip, starting, and grinding the teeth, during sleep, and other symptoms indicative of intestinal irritation. I have known the disease to commence and proceed to the last stage with scarcely any other symptom than slight febrile irritation, with little or no pain in the head, but a constant and nearly ineffectual desire to pass urine. In one instance there was not above a gill of urine discharged in twenty- four hours during the first five days of the malady, and no other particular mor- bid condition was perceptibly present. In this case the urine was not retained, for the introduction of the catheter brought off none. Dr. Monro observes, " that there are cases in which the little patient has a desire every hour to pass water;" and states that he " attended a child affected by this disorder, who passed for some days very little urine." The liver generally sympathizes strongly with the brain in its inflammatory affections. During the former stage of the present com- plaint there is usually a deficiency of bile; but in its advanced periods, the bile is not only more copious, but vitiated in its quality—the stools acquiring from its admixture with the ordinary secretions and contents of the bowels, a dark glairy, or deep green appearance, resembling, as Dr. Cheyne observes, "chopped spi- nage." Diagnosis.—The characteristic symptoms of the first stage are: irritability of temper; irregularity of the bowels; variable appetite; starting in sleep; tran- sient flushes of the face; an irritated, quick pulse, an occasional frowning ex- pression of the countenance; wakefulness; and grinding the teeth. In the second stage: more or less continued pain in the head; torpor of the bowels; nausea and vomiting, particularly on assuming the erect posture ; irregular febrile exacer- bations ; a peculiarly distressed expression of the countenance; sudden starting from sleep; transient acute pain in the abdomen; a circumscribed flush on one cheek ; intolerance of light and sound ; hot and dry skin, with frequent, tense, and generally active pulse. In the last stage : constant somnolency ; torpor of the intellectual functions; strabismus; paralysis of one or both upper eyelids; more or less hemiplegia, coma, and convulsions. From infantile remittent, arachnitis differs in the great irregularity, both in relation to duration and time of recur- rence of the remissions and exacerbations of the second stage. The appearance of the stools, too, will often assist us in the diagnosis between these two affec- tions. In infantile remittent, the alvine discharges are fetid and of a dirty brown color; in arachnitis, they frequently have a glairy and dark green appearance. (Cheyne.) Dr. Coindet states that a micaceous deposition like crystals of bo- racic acid in the urine, is almost peculiar to hydrocephalus in its second stage. M. Gintrae (Journal Generate de Medecine, 1825) gives the following, among a number of other diagnostic symptoms, between idiopathic arachnitis or cerebral fever, and infantile remittent, or fever from intestinal irritation. In idiopathic cerebral fever, the abdomen becomes flattened ; in infantile remittent, or fever from intestinal irritation, from worms, &c, the abdomen is almost always tumid 220 INFLAMMATION OF THE BRAIN. and hard. In the former affection, costiveness almost invariably attends, and when alvine evacuations do occur, ihey are generally green, slimy, or gelatinous: in the latter disease, there is frequently more or less diarrhoea, the motions being brown, mucous and fetid. In idiopathic cerebral fever, the secretion of saliva is diminished: in fever from verminous irritation, it is generally increased. (Brera.) In cerebral fever, the tip and edges of the tongue are usually red: in fever from intestinal irritation by worms, the root and middle of the tongue are covered with a thick fur. In idiopathic cerebral disorder, the pain in the head is often ex- tremely severe and continuous; in verminous fever, the pain is less severe, being obtuse and vague, the child seldom complaining of it as particularly distressing. In the former affection, the patient often directs his hand to the head; while in the latter, " it is usually to the nose that the fingers are directed, in consequence of the itching there." In verminous fever, we often perceive a movement of de- glutition during sleep, and hiccough, with occasional slight convulsive movements of the thumb and index finger. In the idiopathic cerebral disease, the nostrils are dry; in fever from verminous irritation, they are usually moist. In the former there is often a circumscribed flush on one or both cheeks: in the latter, the face is commonly pale and leaden. In cerebral disease, the temperature of the head is above that of the abdomen : in intestinal irritation, the reverse obtains. In the former, the urine is small in quantity, red, and sedimentous: in the latter, it is sometimes clear and abundant; frequently whey-like, depositing a white sediment. Dr. Johnson very justly observes, however, that "there is no one pathological symptom, which can be depended on as characteristic of idiopathic cerebral fever, nor yet of the intestinal." Our conclusions must be drawn from the whole of the symptoms taken collectively. Dr. Alexander Monro has described a variety of hydrocephalus, which he calls the " hyper-acute form" of the disease, a form of very rare occurrence, and simu- lating, in some of its most striking symptoms, inflammatory croup. "This rare form of the disease is very sudden in its attack. There are no previous head- ache, drowsiness, stupor, nausea, vomiting, paralytic state of any part of the body, or any other symptom denoting a derangement of the functions of the nervous system. It begins like croup. The child awakens in the night in-a state of ex- treme agitation, and much flushed, and with a quick pulse; he is hoarse, and the sound of the voice when he inspires is similar to that of croup. The patient, at the onset of the disease, seems in a state of nervous irritation; often starts in his sleep, and in a short time the disease assumes the appearance rather of a spas- modic affection of the larynx than of the inflammatory croup. The matter thrown up by vomiting, consists generally of indigested food. The longer the disease continues, the shriller and hoarser the voice becomes." In the dissections which were made of children who died of "this form of the disease, Dr. Monro found in one instance, the vessels of the pia mater at the cor- pora quadrigemina and tractus optici, and at the origin of the eighth pair of nerves, much distended with blood. No morbid appearance was discovered in the larynx and trachea." In another case, " the upper part of the brain, parti- cularly the superior part of the posterior lobes, was covered with a transparent gelatinous effusion ;" and about an ounce of colored serum was found in the ven- tricles. " The vessels of the spinal marrow were turgid, those of the cervical portion of a vermilion-red color, and those of the lumbar portion of a dark-red hue. The eighth pair of nerves was of a deep uniform red color along its whole tract, as far as its branches, going to the lungs." Dr. Burns attributes this form of hydrocephalus " to an affection of the origin of the eighth pair of nerves, induced by the state of the extremity of the fifth pair in dentition acting on its origin, which is near the eighth."* Post-mortem appearances.—In some cases the arachnoid membrane is minute- * The Morbid Anatomy of the Brain. By Alexander Monro, M. D., 1827. INFLAMMATION OF THE BRAIN. 221 ly injected throughout its whole extent; in others it is opaque and thickened. On its surface, "a purulent, sero-purulent, or sero-gelatinous exudation" is a very common phenomenon; and it is still more common to find a greater or less por- tion of serum effused into the ventricles, between the lamina of the arachnoid, and into the cellular tissue between this membrane and the pia mater. (Martinet.) In some instances, however, little or no serum is found effused. Out of twenty- six cases related by Martinet and Duchatelet, there were eight, in which scarcely an'y trace of effusion into the cavities, or on the surface of the brain occurred. In some instances, the substance of the brain was altered in its consistence and color; and in a few cases the whole surface of the arachnoid was covered with a false membrane. Causes.—It would seem that in some instances a hereditary or constitutional predisposition to the disease exists. I have known families of which nearly all the children died during the period of dentition from arachnitis. It has been affirmed, also, that children of a scrofulous diathesis are peculiarly liable to this affection, an observation which appears indeed to be well founded. In general children of an irritable habit, with weak or deranged digestive powers, seem to be most liable to this* disease. Dr. Mills* states that in a large proportion examined, the appearances of scrofula were evident. And Percival observes that out of twenty-two, eleven cases " were decidedly scrofulous."! Among the most common exciting causes are, blows, falls, or other injuries of the head, causing more or less concussion; insolation (ictus solus), suppressed habitual evacuations or repelled chronic cutaneous eruptions ; metastases of dif- ferent kinds, intense and long-continued mental application, the intemperate use of ardent liquors, the protracted influence of the depressing passions, dentition, intestinal irritation, hooping-cough, cold, and, in short, whatever is capable of at once deranging the digestive organs and causing a preternatural determination of blood to the brain. The most common cause of arachnitis during childhood, however, is the combined influence of dentition and intestinal irritation on the brain. If, while painful dentition is going on, the digestive functions suffer derangement from improper diet or some other circumstance, there will be two powerful causes of cerebral irritation and congestion present, which, under the general derangement of health which necessarily attends, will tend peculiarly to develop this fatal malady. Intestinal irritation is, indeed, very frequently the exciting, or perhaps, rather the predisposing cause of infantile arachnitis. The variable appetite, the irregular action of the bowels, and frequent unnatural appearance of the stools, the tumid abdomen and gastric tenderness, the picking and rubbing of the nose, and the pale and sickly aspect of the countenance which so often precede the development of the disease, all point to the aliment- ary canal as the probable source of the primary irritation with which the brain sympathizes. When such gastric irritation exists, the supervention of any addi- tional exciting cause, such as a severe fall, or blow on the head, painful dentition, * A Pathological Inquiry into the Nature of Hydrocephalus. By Thomas Mills, M. D., &c. Dublin Hospital Reports. X [It has long been understood that a scrofulous diathesis'is peculiarly liable to hydrocepha- lus. Indeed, Dr. Cheyne suggested that the hereditary disposition to this disease is altogether derivable from that source. He also, with Sprengel, considered hydrocephalus and scrofulous affections as mutually convertible into each other. Careful practitioners have always been in- fluenced by this idea to refrain from repelling strumous eruptions, and of suddenly healing up ganglionic abscesses and fistulas in young children. Laennec and others pointed out the exist- ence of granular tubercles in the cerebrum, cerebellum, and spinal cord; and the appearance of small opaque tuberculous masses along the course of the large veins of the pia mater and the longitudinal sinus, compared by some to the glands of Pacchioni, has long been recognized in hydrocephalus and other diseases of the brain. Dr. Gerhard, of this city, has lately called the attention of the profession to this subject more particularly, and gives strong countenance to the idea that the development of scrofulous tubercles is universal in the brains of hydrocephalic children. In conjunction with Dr. Rufz, in Paris, he derived this idea from an examination of about forty cases which terminated fatally in the children's hospital of Paris. He proposes to denominate the disease tubercular meningitis.—Mc] 222 INFLAMMATION OF THE BRAIN. cold, &c, will often speedily develop this fatal malady. An interesting fact, corroborative of the observation that arachnitis and consequent effusion into the cavities of the brain are especially apt to result from intestinal irritation, is the circumstance that cholera infantum, when it assumes somewhat of a chronic form, terminates not unfrequently in death, under all the characteristic symp- toms of the last stage of hydrocephalus. In two instances of this kind, in which I had an opportunity of a post-mortem examination, I found the traces of arachnoid inflammation unequivocal, with copious serous effusion into the ven- tricles, and between the circumvolutions of the brain.* While we give all the importance to intestinal irritation, as a cause of arachnoid inflammation, which it unquestionably demands, we must bear in mind that this same cause some- times gives rise to a form of cerebral oppression strongly resembling the last stage of arachnitis, but which is, nevertheless, wholly unconnected with cephalic inflammation. The determination to the head, in such cases, results merely in a state of strong venous congestion of the brain, giving rise to a somnolent and oppressed state of the system, which may be readily mistaken for hydrocepha- lus. (Cheyne.)! Treatment.—There are three principal indications to be kept in view in the treatment of arachnoid inflammation—viz: 1, to moderate the general arterial action; 2, to obviate the local congestion and inflammatory action in the brain; and 3, to remove those causes of irritation which tend to keep up a preter- natural determination of the blood to the head. When the disease becomes the object of medical attention in its early and incipi- ent stage, the chief indication is to obviate local and general irritation, and to prevent undue determination of the blood to the head. With this view, the attention is to be particularly directed to the alimentary canal, for it is here that the primary irrita- tion and immediate cause of cephalic congestion most commonly exist. Laxatives are, accordingly, among our most valuable means for preventing the full develop- ment of the disease whilst it is yet in its incipient stage ; and this is more espe- cially the case in those instances which are attended with well-marked signs of intestinal disorder. As the liver is usually inactive, or functionally deranged, in the commencement of the disease, calomel, in small doses, succeeded by small portions of some of the milder purgatives, constitutes a very appropriate aperient in this affection. From one to two grains of this preparation should be given in the evening, followed next morning with a weak dose of Epsom salts, or of powdered rhubarb, for a child of from one to five years old. In some instances of impending arachnitis, with manifest intestinal and hepatic derangement, in children, I have derived much benefit by giving a grain of blue pill every even- ing, followed by a few drachms of castor oil in the morning. The aperient and mercurial remedies should be continued daily until the alvine discharges exhibit a natural appearance. In addition to these means the greatest attention must be given to the dietetic management of the patient ; for without an appropriate diet little or no advantage can be derived from remedial treatment of this affection. The most simple and unirritating articles of food alone must be allowed, such as boiled milk, barley-water, arrowroot, boiled rice, oatmeal gruel, week beef or chicken tea, &c. When the arachnoid inflammation is once fully established, the plan of treat- ment should be promptly and decisively antiphlogistic, with revulsive and deri- * An interesting and striking case, in which .hydrocephalic symptoms were produced by organic disease of the intestinal canal, is related in the Med. and Chir. Rev., July, 1826, p. 1"2. X Some writers contend, that hydrocephalus is almost invariably a sympathetic affection. Dr. Yeates, in particular, thinks that this disease has almost invariably its origin in the irritation of some organ remote from the brain (a) Spurzheim admits that the primary irritation is frequently located in the abdomen ; " yet anatomical dissections have convinced me,'' he says, " that, in the greater number of cases, the morbid appearances of the abdomen are secondary of the cerebral disease." (a) Letter toDr Wall, kc—Med.-Chir. Jour., Jan. 1819. INFLAMMATION OF THE BRAIN. 223 vative application. Blood-letting ranks of course among our most efficient remedial means at this period of the disease, particularly when the inflammation is the consequence of some injury inflicted on the head, or where it results from general causes, such as cold. In such instances, the pulse is tense, quick, resist- ing and sharp; and in this case, the efficient abstraction of blood is indispensable. In those cases which arise sympathetically from disorder in the alimentary canal, the arterial excitement is not generally very active. Here blood-letting, though usually indicated, must be employed with more caution, for it is well ascertained that the copious abstraction of blood, by weakening the powers of vital resistance, greatly favors the morbid sympathetic affections arising from intestinal irritation. (Armstong, Marshall Hall, Travers.) In all instances, however, where the pulse indicates blood-letting, a sufficient quantity of blood should be taken away at once, to check, conspicuously, the activity and momentum of the circulation. After the symptoms of cerebral compression have ensued, sanguineous evacua- tions can be of little or no service; nevertheless, should the arterial excitement and cephalic congestion be considerable, blood should be abstracted even in this advanced stage of the disease. With regard to the utility of local bleeding in this and other forms of ence- phalic inflammation, different opinions are expressed by practitioners. Nearly all the French writers on this disease are decidedly in favor of the local abstrac- tion of blood. It appears, indeed, very reasonable to expect peculiar advan- tages from a mode of depletion which abstracts the blood more immediately from the affected parts ; and yet, in relation to the present disease, a contrary opinion has been expressed by several eminent practitioners. Mr. North, in his work on the convulsive affections of infants, observes, " that he never found well-marked symptoms of determination to the head removed by leeches, however freely they were applied." In cases in which the cephalic determination depends on intes- tinal irritation, this observation is no doubt well founded ; for the blood which may be thus removed from the capillaries of the head, will be immediately re- placed by the continued preternatural afflux of this fluid. It must be observed, moreover, that so long as the momentum of the general circulation is considerable, local bleeding can scarcely produce any other advantages than such as would result from abstracting the same quantity of blood by means of the lancet. Gen- eral and adequate bleeding is, therefore, an essential preliminary to the beneficial employment of leeches or cupping. After the impetus of the circulation has been moderated by the use of the lancet, leeching the temples, and along the posterior parts of the ears, is a valuable auxiliary in the treatment of arachnitis. Cupping is, perhaps, preferable to leeching in adults, for this operation seems to be better calculated to derive the circulation from internal inflamed parts than leeches. Purgatives are among our most useful means for subduing this disease. When the bowels are loaded with irritating substances, and the cerebral affection is symptomatic of intestinal irritation, laxatives are, in truth, the main stay of our hopes. They are, indeed, almost equally useful in idiopathic arachnitis ; for, besides their effect in evacuating irritating causes, they tend, very particularly, to diminish the afflux of blood to the brain, and to moderate the general mo- mentum of the circulation. In cases depending on a primary irritation of the alimentary canal, the milder laxatives, after the first thorough evacuation of the bowels by an active purge, should be employed in such a way as to keep the bowels in a relaxed state throughout the whole course of the disease. Repeated doses of the more active purges, though at first apparently useful in such cases, tend ultimately to increase the intestinal irritation, and consequently the cephalic affection. The first purge should be sufficiently active to evacuate the bowels well. Four or five grains of calomel, followed in a few hours by the occasional use of the infusion of senna and manna until free purging is produced, will answer well as a first purgative. The bowels must afterwards be regularly evacuated three or four times daily, by the use of small doses of calomel, promoted by 224 INFLAMMATION OF THE BRAIN. castor oil and laxative enemata. It must be recollected that intestinal irritation is not always dependent solely on the presence of acrid or irritating matters in the bowels. The mucous membrane of the alimentary canal may be in a state of subacute inflammation, with more or less of abrasion, or perhaps ulceration. Under these circumstances, the milder laxatives are manifestly more appropriate than the more irritating articles of this class, since they are sufficient to evacuate the contents of the bowels, without causing injurious irritation. In idiopathic arachnitis, however, the bowels are almost always very torpid, and can seldom be adequately moved, without the employment of the more active purgative remedies. In cases, too, that are attended with a great accumulation of fecal matter in the bowels, brisk and frequent purgation is particularly necessary. "Should we ascertain," says Dr. Cheyne, "that the alimentary canal is torpid, and imperfectly performing its functions, and admitting an accumulation of fecal matter, or that the secretions flowing into it are vitiated or diminished in quan- tity—circumstances which we ascertain by the peculiarity in the appearance or the pungent fetor of the stools, we must, by steadily pursuing the purgative plan, endeavor to effect a change; for while this is produced in the appearance of the stools, we are effecting a more important change in the hepatic system of the alimentary canal, and of all the parts which are connected with them." Calomel should enter largely into the purgatives employed in this disease. From one to three grains, according to the age of the patient, may be given every two or three hours, until from ten to twelve grains are administered, and followed by a dose of infusion of senna, or sulphate of magnesia, or castor oil. In cases where there is reason to suspect the presence of worms in the bowels, anthel- mintics should be employed in conjunction with purgatives. An infusion of spigelia, and senna may be used in such instances. The stomach, however, is often so extremely irritable in this disease, that no articles will be retained a suf- ficient time to operate on the bowels. Where this state exists we must endeavor, in the first place, to allay the gastric irritability, and this may, in general, be ef- fected by minute doses of calomel and ipecacuanha; the one-sixth of a grain of the former, in union with one-fourth or one-third of a grain of the latter, has re- peatedly succeeded in my hands to restrain the tendency to vomiting in this disease. Mercury has been much recommended as a remedy in this affection. One of the only two cases of recovery from apparently completely developed arachnitis, which have occurred in my practice, appears to have been brought about by the mercurial influences. Drs. Percival, Dobson, Rush and Cheyne, mention cases which yielded to the powers of this article. Employed with a view to its con- stitutional influence, mercury often contributes very decisively to the reduction of visceral inflammation, and experience has shown, that in the present affection, its powers are sometimes unequivocally beneficial. The best mode, perhaps, of employing mercury in this disease, with a view to its salivant operation, is in the form of friction with the ungt. hydrar. In whatever way mercurials are used, it is always extremely difficult in children to procure its salivant effects. Almost the whole surface should be frequently rubbed with the mercurial ointment, where this effect is desired. Nothing is more common in the treatment of this disease than the application of blisters to the shaven scalp; but this practice is, I conceive, of very doubtful propriety. I have always preferred placing them on the back of the neck or behind the ears, while ice or cold water is applied to the top of the head, and warm or rubefacient applications made to the feet. Dr. North, whose interest- ing work I have already mentioned, observes, "that blisters to the head are de- cidedly prejudicial in the convulsive diseases of infants ;" and the same observa- tion is applicable, I think, to the disease under consideration. The application of ice or iced water, in the manner mentioned in the last chapter, may be accounted a very useful auxiliary in the treatment of arachnitis, and to favor its revulsive influence, warm or stimulating applications to the feet may be usefully employed. INFLAMMATION OF THE BRAIN. 225 Dr. Regnault recommends, in very strong terms, the application of moxa in this complaint;* and its known efficacy in subduing deep-seated articular inflamma- tion, justifies the expectation of considerable advantage from its use in arachnoid inflammation. Neither this application nor blisters, however, should be resorted to, until the activity of the circulation is reduced by general and local blood-letting. The tartar emetic ointment, also, may be very beneficially applied. (Monro.)! Dr. Stocker,J of Dublin, speaks much in favor of the use of James's powder in hydrocephalic affections. He asserts that this preparation possesses peculiar powers to diminish the determination of the blood to the head ; and of its tend- ency in this way, I have myself known several examples in other cephalic diseases. It may be conveniently given in small but frequent doses, in union with calomel, in this affection. Drs. Cheyne and Monro speak in equally favor- able terms of this preparation in this dangerous disease. The latter states that he has cured several cases of this disease by a plaster composed of tartar emetic and wax ointment applied to the head, and the use of calomel combined with James's powder. This combination, he says, is particularly useful in restoring the healthy action of the bowels. Dover's powder, also, has found advocates as a remedy in this disease. Drs. Brooke, Percival, Cheyne and Crampton,§ all speak favorably of its employment in hydrocephalus. After adequate depletion and purgation, in cases connected with intestinal irritation, small doses of this composition often prove serviceable, by allaying general irritability, and inducing a gentle diaphoresis. In the idio- pathic form of the disease, however, opiates of every description must be care- fully avoided, as their tendency to increase the flow of blood to the brain could hardly fail to prove injurious. When preternatural determination to the head depends on a remote focus of irritation—as in the mucous membrane of the bowels—opiates, by diminishing nervous excitability as well as local irritation, will occasionally reduce also the irregular determinations which depend on such irritations. It is in cases of this kind only that we may venture on the exhibition of Dover's powder, and not in these instances until the impetus of the circulation has been moderated, and the alimentary canal well evacuated. It would seem, from the observations of Mr. Newnham, that green tea has a powerful tendency to lessen the morbid vascular action, not only of the system generally, but especially of the brain. " In the acute irritation of the membranes of the brain in children," he says, " the efficacy of green tea has been strongly marked in my practice. Exhibited during the early symptoms, as soon as a sufficient quantity of blood has been taken, and before effusion occurs, it has proved a more powerful means than any other we possess, of controlling the morbid action, which, if suffered to proceed to its second stage, is scarcely to be overtaken by any treatment."|| Sect. III.—Of Cerebritis—Softening of the Brain. (Ramollissement du cerveau.) This form of cerebral disease has of late been particularly investigated by the French pathologists. Recamier, Bayle, Cayol, Bricheteau, Rostan, and Lalle- mand.l have published numerous and interesting observations concerning its * Medical and Physical Journal, vol. xl. p. 16. X [In the last stage of arachnitis I am confident that blisters over the scalp are most advanta- geous.—Mc.J Dublin Medical Essays, anno 1806. Transact, of the Associat. of Fellows and Licentiates of the Queen's College of Physic, in Ireland, vol. vii. || Med. Chir. Rev., July, 1827. IT Recherches Anatomies Pathologiques sur I'Encephalite. Paris, 1820. 15 226 INFLAMMATION OF THE BRAIN. symptoms and pathology. The disease, as it is manifested on dissection, consists of a softening or a kind of liquefaction of a portion of the cerebral mass, with vascular injection of the surrounding substance. Rostan divides the disease into two periods. The symptoms of the first period are : a fixed and violent pain in the head, often continued for several months ; vertigo ; obtuseness of the mental faculties ; confusion of the ideas ; and weakness and temporary loss of memory ; questions are answered after long hesitation : and the patient appears at times dejected, querulous, and wholly indifferent to surrounding objects. There is generally a sensation of tingling and numbness in the extremities of the fingers; vision is often perverted, and in some instances, total blindness occurs at times. The hearing is almost always dull, but in some cases the reverse obtains, the sense of hearing being morbidly acute. Some complain of tenderness of the epigastrium, with constipation and variable appetite. The pulse is often full and hard, and sometimes intermitting. Occasionally, there is temporary delirium, with fever and much agitation. The second period is characterized by the gradual or sudden supervention of paralysis of one limb, sometimes of half the body ; but consciousness and intel- lect remain. Questions are now answered with very great difficulty, the patient generally expressing his desires by automatic movements. In some instances a complete state of coma occurs, followed occasionally with convulsions. In most instances, a sudden attack of convulsions is the first symptom that ex- cites alarm. These convulsions often continue for many hours, followed, in some cases, with deep coma and a contracted state of the flexor muscles of the limbs. Occasionally, the paroxysms of convulsions recur repeatedly at short intervals, "the patient being sensible in the intermediate periods; and complaining of head- ache, till after twelve or twenty-four hours, coma supervenes. From this state there is often a complete recovery for several days, when, without any warning, the convulsions return, and end in fatal coma." In a case which came under my care, the patient complained at times of a deep-seated pain in the head ; his memory for particular names and things was greatly weakened—so much so that he forgot the name of the street he lived in; and was several times obliged to inquire the way to his own house, although but a square from it. He became taciturn, and uttered his words with a kind of hesitating doubt. He continued in this condition for five or six weeks before he was confined to his room. The pain, however, at length became very severe; ihe pulse was very hard and strong; the countenance flushed; and the bowels costive ; but there was no delirium, and he experienced short intervals of perfect ease from the cephalic pain. After five or six days longer, double vision, great confusion of mind, and hesitancy of speech occurred, and at last deep coma, con- traction of the extensor muscles of the forearms, convulsions, and death ensued. In this instance, the membranes of the brain did not exhibit any morbid ap- pearances, except much vascular congestion. On slicing away the superior part of the brain, it appeared to be in a perfectly natural state; on making a deeper section, however, three portions of the cerebral substance were discovered in a state of complete disorganization—being of a soft pap-like consistence, of a yel- lowish color, and in one place of a darkish hue, as if dissolved blood had been mixed up with the softened portions of the brain. One of these disorganized por- tions was in the left posterior lobe of the cerebrum, and the other two near the corpora striata and thalami opticorum.* * [I made this postmortem examination, and attended the patient in consultation with the late Drs. Eberle and Parrish. It is stated correctly, with the omission, however, that the cere- bral substance was everywhere studded with red puncta under the knife, and exhibited the most decisive signs of long-continued vascular engorgement. My son and Dr. Leidy have this very day examined the body of a patient whom Ur. Bacon and I attended for some weeks before death, under nearly the same symptoms. The left side had become totally paralyzed during the last two or three days, and the ramoUissement was found to be located in the right crus INFLAMMATION OF THE BRAIN. 227 The inflammatory nature of this softening of the brain has been much doubted by some. It has been supposed to be the consequence of a process similar to that which occurs in the softening of tuberculous matter in the lungs, and which, according to Laennec and some other writers, is sui generis, and wholly inde-* pendent of inflammation. The facts and arguments adduced by Lallemand, however, render the opinion of its inflammatory character, in most instances, at least, extremely probable. The writer thinks that the softening is the " effect of inflammation arrested in its course by death, before purulent suppuration has had time to take place." It is most probable, as Dr. Abercrombie* observes, that this affection occurs under two modifications, one unequivocally attended with cerebral inflammation, and the other a species of cerebral gangrene from defect of circulation, in con- sequence of a diseased state of the arteries of the brain—an opinion which, he thinks, is confirmed by the fact, that the peculiar softening of the brain mentioned by Rostan, as unconnected] with symptoms indicating an inflammatory action, occurs almost exclusively in very aged individuals, inasmuch as ossification of the cerebral arteries is very common in elderly people. " In the cases of Rostan," says Dr. Abercrombie, " the disorganization was observed chiefly in the external parts of the brain; it occurred almost entirely in very old people, few of his cases being under sixty years of age, many of them seventy, seventy-five, and eighty. It was found in connection with attacks of a paralytic or apoplectic kind; many of them protracted ; and was often found combined with extravasation of blood, or surrounding old apoplectic cysts. On the contrary, the affection which I had been anxious to investigate, was found chiefly in the dense central parts of the brain, the fornix, septum lucidum, and corpus callosum, or in the cerebral matter immediately surrounding the ventricles ; and occurred in persons of various ages, but chiefly in young people and in children. It took place in connection with attacks of an acute character, chiefly of the character of acute hydrocephalus ; and it was in many cases distinctly com- bined with appearances of an inflammatory character, such as deep redness of the cerebral matter surrounding it, suppuration bordering upon it, and deposition of false membrane in the membranous parts most nearly connected with it. We may even observe in different parts of the same diseased mass, one part in the state of ramoUissement or softening, another forming an abscess^while a third retains characters of active inflammation, and probably exhibits, as we trace it from one extremity to the other, the inflamed state passing gradually into a state of soften- ing. This is the infection which I have endeavored to investigate, and which I consider as one of primary importance in the pathology of acute affections of the brain, and which I cannot hesitate to consider as the result of inflammation." One of the most characteristic phenomena of softening of the brain, is a rigid contraction of the flexor muscles of the limbs. " Sometimes," says Lallemand, " this amounted only to simple rigidity of the limbs; at others, it was carried so far that the patient's fist was kept rigidly applied to the shoulder and the heel to the buttock;" and, contrary to what takes place in apoplexy, the mouth is drawn towards the paralyzed side. In general, the function of respiration re- mains entirely free from disorder, till within a few days of the fatal conclusion of the disease. The exciting causes of this form of cerebral disease are, no doubt, very various. Aneurism of the heart appears to be capable of exciting the disease. cerebri, and in the external portion of the adjacent thalamus opticus. The whole medullary substance of both hemispheres was of a dark or dusky hue, and studded with numerous and large bleeding puncta throughout. The pia mater was everywhere deeply loaded with blood, and the arachnoid in the fourth ventricle very much thickened and opaque. Indeed, I have never seen a case of ramoUissement that did not exhibit all the signs of vascular engorgement and cerebral inflammation.—Ma] * Pathological and Practical Researches on the Diseases of the Brain, &c. By John Aber- crombie, M.D. London, 1827. 228 PNEUMONIA. In many cases, says Lallemand, suppression of some habitual sanguineous eva- cuation preceded the attack of this affection; the depressing mental emotions seemed, in some instances, to have favored its occurrence; and many of the vic- tims had been greatly addicted to the immoderate use of vinous and other fer- mented liquors." Dr. Johnson states that he has seen several cases which in- duce him to believe that " venous congestion of the meninges of the brain has a very considerable effect in producing softening of the brain as well as sudden death."* I have seen a case of a pap-like and yellowish-brown disorganization of an internal portion of the brain, which occurred in consequence of a severe blow received on the head six months before the supervention of the disease. Treatment.—General and local blood-letting; sinapisms to the feet; cold ap- plications to the head ; active cathartics ; blisters to the back of the neck ; and calomel, with a view of its salivant operation, constitute the efficient means for combating this formidable malady. Unfortunately, however, the disease often proceeds to a state of disorganization before it becomes the object of medical attention, and then, of course, all remedial treatment must be abortive. CHAPTER XII. OF THE PHLEGMASIA OF THE RESPIRATORY ORGANS. Sect. I.—Pneumonia. The term pneumonia is employed, in a general sense, to designate acute in- flammation within the cavity of the thorax, whether seated in the pleura, the mucous membrane of the bronchia, or in the proper substance of the lungs. The general characteristic symptoms of acute inflammation in the chest are:— cough, difficult and painful respiration, fixed pain in the thorax, and fever. Con- siderable difference occurs, however, in the character of these symptoms, as well as in the other usual concomitant phenomena, according as the one or the other of these three structures just named is the principal or exclusive seat of the in- flammation. Cullen was of opinion that the pleura can never be inflamed with- out an extension of the inflammation to the pulmonary structure; pleuritis, according to his views, being always accompanied with more or less of peripneu- monic inflammation. The observations of later pathologists,! however, have proved that the pleura is often exclusively inflamed, and that pleuritic inflamma- tion is generally marked by symptoms sufficiently characteristic to enable us to distinguish it from acute inflammation of the proper pulmonary substance. With- out doubt pleuritis is very generally attended with inflammation of the subjacent tissues; but its occasional separate existence is equally unquestionable. Pleuritis—Pleurisy. In pleuritis, a violent and pungent pain is felt in the chest, generally on one side, which is always greatly increased by a full inspiration, or on coughing. Respiration is hurried, short, and generally most oppressed when the patient lies on the affected side. The cough is short and dry, or attended with a glairy and nearly colorless sputa, and stifled as much as possible, to avoid the great increase of pain which it occasions. When the inflammation extends to the lungs, the expectoration is generally mixed with more or less of blood. The face is usually * Medico-Chirurgical Review, December, 1822, p. 485. t Laennec. PNEUMONIA. 229 suffused with a vivid flush ; the pulse very hard, full, vigorous and frequent; the tongue covered with a thick white fur; the skin hot and dry; and the urine of a deep red color, and small in quantity. The act of respiration is performed chiefly by the action of the diaphragm and abdominal muscles, the motion of the ribs being restrained by the patient, on account of the increase of pain which it always causes. Acute inflammation of the pleura is, however, not always attended by the fore- going unequivocal manifestations of its presence. In some instances, the disease, though rapid in its course and violent, is attended with scarcely any pain or cough. Baglivi mentions examples of this kind; and Schmidtmann has given the history of several cases of what he calls pleuritis occulta.* M. Tacheron gives an account of a fatal case, in which there was but little pain, and no cough, although the pleura was found, on dissection, coated with a yellow albuminous matter, a line in thickness, and a large quantity of fluid effused into the thorax.! Bichat also refers to the circumstance of the occasional absence of pain in the chest in acute inflammation of the pleura. Causes.—Pleuritis is most apt to attack persons of a vigorous and plethoric habit of body. The influence of cold, when the body is in a state of perspiration from active exercise or confinement in a heated room, is its most common exciting cause. Pleurisy may also arise from metastasis of other affections—particularly of rheumatism, gout, and erysipelas ; and it has been known to occur in conse- quence of suppression of the catamenial and hemorrhoidal discharges. Pleurisy from translated rheumatism or gout, is by no means an uncommon occurrence. I have met with a considerable number of cases of this kind, and one recently which was a strongly-marked instance. The patient was affected for several weeks with severe rheumatic inflammation of the left elbow-joint. A cold poultice was applied to the joint in the evening, and on the next morning the pain and redness had in a great measure subsided. In the afternoon, a severe pain came on in the left side of the thorax, which rapidly increased in violence, and soon exhibited all the characteristic phenomena of pleurisy, whilst the pain in the elbow disappeared entirely. It was successfully treated with blood-letting, blisters, and the internal use of calomel and opium. In a few weeks after reco- vering from this attack, subacute rheumatic inflammation occurred in the elbow of the right side.J Pleurisy and depots of pus in the lungs are sometimes rapidly developed after capital surgical operations. M. Velpeau, in a very interesting memoir, has given the following as the result of his observations on this subject: 1. "Those who die of acute diseases succeeding surgical operations or profuse suppurations, generally fall victims to pleuris)r, and the formation of abscesses more or less numerous in the lungs. 2. That the kind of pleurisy, hitherto undescribed, is of a peculiar nature, and might be denominated the pleurisy succeeding surgical operations. 3. That this disease differs from simple pleurisy in the latency of its progress, the rapidity of its course, and the almost invariable certainty of its fatality. 4. That the pleurisy and formation of depots of matter are rarely accompanied by characteristic local symptoms sufficient to give notice of their existence." M. Velpeau ascribes these secondary pneumonic affections to the absorption of pus, and its passage into the current of the circulation.§ Post-mortem appearances.—On dissection, the pleura is generally found uni- formly red, or punctuated with small red specks of irregular shape and very close together. Laennec states that these red points " occupy the whole thickness of the pleura, leaving small intermediate spaces retaining the natural white color." * Summa Obs. Med, vol. i. p. 108. ! Recherches Anatomies Pathologiques, &c.—Vide Med.-Chir. Rev., March, 1824. X For much interesting information concerning rheumatic pneumonia, the reader is referred to Stoll's Ratio Medendi, &c., part i. p. 82, and to Schmidtmann s Summa Obser v. Medicarum, torn. i. p. 62, et seq. § Revue Medicale, December, 1826. 230 PNEUMONIA. The pleura is not often found thickened in consequence of inflammation. Ex- travasation on the inner surface of this membrane is a never-failing occurrence in fatal cases of this disease. Laennec thinks that this extravasation commences with the inflammation. The matter thus thrown out by the vessels of the in- flamed pleura, consists of a semi-concrete or pseudo-membranous substance, or of coagulable lymph, or of sero-purulent fluid effused into the cavity of the chest. This fluid generally contains small flocculi or filaments of coagulable lymph, or of concrete pus, and is either of a light yellow color and nearly transparent, or reddish, as if a small portion of blood were mixed with it. Adhesions between the costal and pulmonary portions of the pleura occur in nearly all instances through the intervention of false membranous substances.* Prognosis.—Acute pleuritis is not, in general, a very dangerous affection in subjects of a good and vigorous constitution. There is no inflammatory affection which is more under the control of an active antiphlogistic treatment. In sub- jects, however, of a weak habit of body—and especially in such as are predis- posed to phthisis pulmonalis—pleurisy, if not a disease of much immediate danger, is to be dreaded on account of its tendency to develop pulmonary con- sumption. When the inflammation extends to the substance of the lungs, the patient may sink at an early period from effusion into, or disorganization of its structure. The following circumstances may be regarded as indicative of im- minent danger in this affection. A frequent effort to sit up, particularly when there is a wheezing sound in the trachea, bloody expectoration,! and an ob- structed pulse. The supervention of diarrhoea is a most unfavorable sign; con- vulsions and coma are no less ominous of a fatal tendency. Schmidtmann asserts, that he has never known an instance of recovery from this disease, after convul- sions and coma had supervened. Pneumonia.—Inflammation of the Lungs. When the parenchymatous substance of the lungs is the principal or sole seat of the inflammation, the disease is designated by the term peripneumony. In this variety of thoracic inflammation, the breathing is much oppressed, particu- larly when the patient is in a horizontal posture; an obtuse pain is felt in the chest, generally in the region of the sternum, sometimes in the epigastrium, and occasionally in the side or scapular region. The cough is attended with a copious viscid expectoration, mixed more or less with blood. The skin is hot and dry; the urine high colored and scanty; and the pulse frequent, full, obstructed, la- boring, but rarely very hard; but in the advanced stage of the disease, it usually becomes weak, soft, obstructed and irregular. In violent cases, tending to effu- sion or disorganization of the inflamed portion of the lungs, the countenance acquires a livid aspect, and the veins of the neck become turgid. The patient generally lies on the affected side, although, in some instances, the reverse posi- * The false membranes produced in pleurisy generally change after some time into a kind of cellular tissue, "or rather into a true serous membrane, like that of the pleura. This change," says Laennec, "is produced in the following manner: the serous effusion which accompanied the membranous exudation is absorbed; the compressed lung expands,and the false membrane investing it and the costal pleura become united in one substance. By degrees, this substance becomes divided into layers pretty thick and opaque, which are separated by a very small por- tion of serosity. About this time the blood-vessels begin to make their appearance in it, the first rudiments of which have the aspect of,irregular lines of blood, much larger than the vessels which are to take their place. After a time the pseudo-membranous layers become thinner and less opaque; the lines of blood assume a cylindrical shape, and ramify in the manner of blood- vessels. Eventually the layers of the false membrane become quite transparent, and nearly as thin as those of the ordinary cellular tissue. By degrees, it acquires the firmness of the natural cellular substance, and becomes the bond of a firm union between the lungs and the costal pleura." f Baglivi says, "Erectum sedere velle in morbis acutis pulmonnm perniciosum ac ferme lethale, praesertim, si adsit sibillus in aspera arteria, et difficultas excreandi sputi, et licit cum talibus signis pulsutn bonum videris, noli credere, nos fallit."—Opera Omnia, p. 42. PNEUMONIA BILIOSA. 231 tion is preferred. " The sputa are white, slightly yellowish or greenish, some- what diaphanous, and intermixed with bubbles of air. The tenacity of the matter expectorated is so great, that we may often reverse the vessel which con- tains it, and retain it in this position for a time without detaching it from its sides." Laennec regards this kind of sputa as pathognomonic of this affection, " since it is the only one," he says, " that is found exclusively in it." In this, as in the former variety of pneumonic inflammation, the symptoms are sometimes so inconspicuous and equivocal in their character, that the true nature of the disease may remain doubtful, or be entirely mistaken, until fatal disorgan- ization has occurred in the pulmonary structure. An instance of rapid fatal pneumonia is reported by Dr. Damiron, one of the physicians of the Hospital Val de Grace, in which no pain whatever was complained of by the patient, nor did epigastric pressure produce any uneasiness. The breathing was difficult, the cough frequent, the expectoration ropy and copious. On dissection, three- fourths of the right lung was hepatized, and the left lung was black and crepi- tous.* M. Andral has related seventeen cases, in which one or more of the characteristic signs of the disease were absent. In several instances, there was neither pain nor cough.! Pneumonia Biliosa.—Bilious Pleurisy. There is a modification of pneumonia, which, from the prominent symptoms of hepatic disorder which it exhibits along with the ordinary phenomena of pneu- monic inflammation, has been termed bilious pneumonia. This variety of the disease occurs during cold and variable seasons, in districts abounding in sources of miasmatic exhalations. It appears to be the result of the combined agency of koino-miasmata and atmospheric vicissitudes. The initial symptoms of this modification of the disease differ very little from those which usually usher in an attack of ordinary bilious remittent fever. In some instances, a sense of full- ness and tension is experienced in the right hypochondrium, a few days previous to the supervention of the disease, and occasionally dysenteric symptoms occur before the fever commences. In almost all cases, considerable pain is felt in the back and extremities during the premonitory period. The skin from the begin- ning is more or less tinged with bile, and the conjunctiva, especially, is often conspicuously icterode. The face is flushed, " and a sickly mixture of red and yellow, upon close examination, betrays the existence of a disturbed state of the liver." (Potter.) Acute pain in the forehead is almost constantly present. The pain in the chest is sometimes extremely severe and pungent; but more com- monly it is obtuse, and attended with a sense of weight or oppression in the breast. In some cases the fever continues for several days before the pectoral pain supervenes. The expectoration is not very copious—the sputa being of a frothy yellowish appearance, marked frequently with streaks of blood. The fever is generally attended with manifest evening exacerbations and morning remissions. When vomiting takes place, an occurrence very common in this affection, more or less of bilious matter is generally thrown up, although, in some instances, the secretion of bile appears to be entirely suspended; the ejections consisting of nothing else than gastric mucus and the ingesta. The tongue is at first white, with a yellowish streak along the middle, which, as the disease ad- vances, becomes dark-brown and dry. The urine is always of a deep yellow or bilious color; and the pulse is generally small, frequent and quick, with a slight degree of preternatural tension. Post-mortem appearances.—The morbid structural changes produced in the lungs by inflammation are : * Med.-Chir. Rev., October, 1825. X Clinique Medicale, &c. Par G. Andral. Paris, 1824. 232 PNEUMONIA BILIOSA. 1. Engorgement, the inflamed portion of the lungs exhibiting externally a brown mottled or violet color, " which forms a strong contrast with the gray or pale rose-color of the healthy part." It is of a firmer texture, and heavier than in the sound state—feels crepitous under the finger, though less so than in the healthy condition ; and on being pressed between the fingers, the air-cells will be perceived to contain a considerable portion of extravasated fluid. When the engorged portions of the lungs are laid open with the knife, a large quantity of a frothy reddish serosity runs out, and the internal structure exhibits a livid and red appearance. If portions of the engorged lung are pressed until all the fluid has been squeezed out, they become as elastic and crepitous, and of the same color, as the healthy part, if air be blown into them. Simple engorgement ap- pears to be the result of the weakest grade of acute inflammation, and may even arise mechanically from mere sanguineous congestion during the last moments of life, or in artictdo mortis. (Andral.) WThen the inflammation is intense, and terminates in the above engorged condition, the structure of the lungs is at the same time rendered soft or friable, being readily broken down when pressed be- tween the fingers. To distinguish mere engorgement by extravasated fluid from sanguineous congestion and engorgement from inflammation, we must judge less, says Andral, from the color than the degree of firmness of the pulmonary struc- ture. In almost every instance arising from inflammation, the substance of the lungs is rendered more or less friable. 2. Hepatization, presenting at first sight the appearance and consistence of liver. In this variety of structural change, the lung is impermeable by air, and is entirely deprived of its crepitous feel under the finger, and sinks when put into water. When cut into, a small portion of a reddish fluid issues, without exhibiting any frothy appearance. If we examine the incised surface with a lens, we perceive that the lung has lost its cellular structure—the pulmonary sub- stance exhibiting a red granulated appearance; and on being pressed between the fingers, is found to be readily broken down and reduced to a reddish pulp. (An- dral.) When a lung is hepatized, its volume seems much greater than natural, " but this apparent enlargement is caused merely by the diseased lung not col- lapsing." This morbid condition has been called red hepatization. 3. Gray hepatization.—This seems to be the result of a more intense degree of inflammation than that which gives rise to red hepatization. In the present morbid condition, the pulmonary structure is granular, condensed, and imperme- able to air, as in the preceding variety ; but its color is grayish or yellowish pale, and when cut into, discharges copiously an opaque-yellowish or grayish fluid, which is manifestly purulent, and almost entirely without smell. In some cases, the pus does not issue spontaneously from the incised surfaces, but on pressing the tissue moderately, small drops of purulent fluid are forced out. In this variety of disorganization, the pulmonary tissue is softened, and readily con- verted into a grayish pulp by pressure between the fingers. Acute inflammation of the lungs never terminates in induration of its structure ; this termination is peculiar to chronic pulmonary inflammation. According to Andral, there are two varieties of induration, the red and gray. 4. Gangrene.—This is a very rare termination of acute inflammation of the lungs. Andral gives an account of two instances of this kind. In a late num- ber of the Journal Hebdomadaire, there are several cases reported, which ter- minated in gangrene of the pulmonary structure. These cases were attended with an intolerable fetid and gangrenous breath, particularly during the fits of coughing, and the matter expectorated was of a chocolate color, and emitted a most offensive smell. On dissection, a considerable portion of the lung was found converted into a putrid mass, containing fragments of pulmonary texture, of a black or violet color. The surrounding portions of lungs were infiltrated and partly hepatized. Dr. Chambers, also, has published some cases of gangre- nous suppuration of the lungs, in which he refers particularly to the intolerable fetor of the breath as a diagnostic sign of this mode of termination. Andral PNEUMONIA BILIOSA. 233 states, that at first the expectoration is a greenish liquid, then dirty gray, at times reddish, and exhaling an extremely fetid smell.* The formation of abscess from pneumonic inflammation is also a very rare occurrence. Both Laennec and Andral assert, that pulmonary abscess is among the most uncommon terminations of acute inflammation of the lungs. The former met with but four or five instances in several hundred cases which he examined; and the latter writer states that he has met with one case only. Laennec observes, that " nothing is more uncommon than to find the inflam- mation confined to the superior lobes of the lung." This, however, is contra- dicted by the observations of Andral, who, in 88 cases, found 47 with inflamma- tion of the inferior lobe, 30 of the superior lobe, and 11 instances in which the whole lung was affected. Diagnosis.—The most important diagnostic signs between pleurisy and peri- pneumony are those obtained by percussion of the chest, and by pressure made on the abdomen. In peripneumony, percussion made with the extremities of the fingers brought together in a line, produces an obscure dull sound, which is best estimated by comparing it with the sound produced by percussion of the healthy side of the chest. In pleurisy, on the contrary, no difference can be perceived in the sound produced by percussion of the two sides of the thorax. In peripneumony, firm pressure on the abdomen with both hands, so as to push up the diaphragm against the lungs, almost invariably excites cough, great oppres- sion, and a sense of suffocation; whereas in pleurisy no such effects result from abdominal pressure. " If, then, we find united in the same patient a clear sound of the painful side on percussion, insensibility to abdominal pressure, smallness and rapidity of the respiration, an increase of pain on full inspiration, particular uneasiness upon lying on the affected side ;! and, lastly, pain upon firm pressure of the intercostal spaces of the affected side, we have little reason to doubt of the existence of pleuritic inflammation." (Roux.) Peripneumony is characterized by an obscure pain in the chest; great efforts at inspiration, in order to supply the suspended functions on one part of the lungs ; increased suffering on firm abdominal pressure, and a dull obscure sound on percussion of the chest. Difficulty of lying on the sound side is generally mentioned among the characteristic symptoms of peripneumony ; but Andral asserts that this observation is by no means generally correct. The most com- mon position is on the back. Auscultation, or the employment of the stethoscope, has of late years attracted much attention as a means for obtaining a correct diagnosis in pectoral diseases. Interesting information with respect to the particular condition of thoracic affec- tions is no doubt to be obtained from this mode of examination; but it requires much careful experience before a sufficient tact is acquired to procure satis- factory information in this way. M. Andral, who has paid much attention to this subject, has given the following account of his experience in auscultation in pneumonic inflammation. " No sooner does the pain and difficulty of breathing come on, than the ear, applied to the thoracic parietes, recognizes a notable modification in the nature of the noise heard at each inspiration, and as the inflammation advances, the noise undergoes fresh modifications, which indicate, with more or less precision, the situation and degree of the affection. The voice is also modified. " At the commencement of the disease, whilst the lung is in the state of simple inflammatory engorgement, the noise of respiration in the affected part * Schmidtmann, in an account of a case of pneumonia which terminated in gangrene of the lungs, says, "impar sputes saniosis, fuscis, nigris. putentibusque reddendis."—Sum. Ob. Med., vol. i. p. SO. Cases of gangrene of the lungs are also reported by MM. Martinet and Recamier in their Hospital Reports.—See Revue Medicate, for 1827. X This arises from the lungs pressing on the inflamed pleura when the patient lies on the affected side. 234 PNEUMONIA BILIOSA. loses its clearness, and is more or less mixed with the dry-rattle, which Laen- nec terms crepitous, from the resemblance it bears to the noise emitted by com- mon salt when thrown upon hot coals. It also bears considerable resemblance to the peculiar noise occasioned by folding or doubling a piece of parchment. The noise of natural respiration is always altered and obscured by this rattle, but is not always entirely masked or concealed by it. As the inflammation increases, the rattle becomes more and more manifest, until at length it entirely conceals the inspiratory murmur. The presence of crepitous rattle indicates engorgement, or the first stage of inflammation ; and so long as it continues, it shows that the inflammation (in a great part at least) has not advanced beyond the first degree. From its greater or less intensity, and from its more or less strong admixture with the natural respiration, we may derive indications of the degree to which the engorgement extends, and whether it is passing into the state of hepatization or otherwise. Whilst the noise of natural respiration pre- dominates over the crepitous rattle, we may conclude that the inflammation is slight; but if the rattle increases, and predominates in its turn, until at length it completely masks the respiration, we may be certain that the inflammation is advancing, and that it is passing on to the second degree. "At a more advanced period, the crepitous rattle gradually ceases to be heard; and if the natural respiration then returns, we know the disease is subsiding; but if there be no respiratory murmur audible, or if the natural respiration is replaced by another kind, hereafter to be described, we may be certain that the disease is becoming more serious, and that the lung is hepatized. " M. Laennec has established the fact, that in many cases when engorgement of the lungs is succeeded by hepatization, the ear applied to the chest feels the motion of the thoracic parietes, but does not hear any respiratory noise, either natural or pathologic. We have often verified this statement; but we have also frequently observed, in the same stage of the disease, another very remarkable phenomenon, which appears to have escaped Laennec's attention. In certain cases, where the lung is in the state of red or gray hepatization, the noise of respiration does not disappear, but is modified in a singular manner, and is evi- dently different from the natural kind. It seems as if a person placed near the auscultator's ear breathed forcibly through a brazen tube ; there is at the same time a peculiar kind of resonance of the voice wherever this kind of respiration is audible. The modification of the voice is not properly either egophony or pectoriloquism; it approaches more nearly to that form of resonance which is observed in dilatation of the bronchia. Whenever cases presenting this double modification of the voice and respiration have proved fatal, dissection has con- stantly presented either red or gray hepatization, or pleuritic effusion. " The explanation of this modification of the voice and respiration seems easy. It appears to us to depend upon the air not being able to penetrate farther than the large bronchial tubes; and, for this reason, the phenomena are mani- fested not only in pulmonary hepatization, but also where the lung is compressed by pleuritic effusion: and, in short, wherever the air is prevented reaching the air-cells of the lungs. " Whilst auscultation of the diseased side affords the different signs already enumerated, the respiration of the healthy side is heard with much greater in- tensity than in the physiological state;—as if it were necessary for the healthy lung to receive a greater quantity of air in a given time, in order to supply the deficiency of the diseased one. " When the inflammation occupies a circumscribed portion situated at a dis- tance from the surface of the lung, more especially a part of the base of the centre or of the root, auscultation teaches us nothing concerning the seat or de- gree of the disease."* Prognosis.—A copious expectoration of a thick uniform yellowish matter is * Med.-Chir. Rev., October, 1826, p. 514. PNEUMONIA BILIOSA. 235 one of the first, and perhaps most encouraging indications of a favorable turn of the disease. When this symptom occurs in connection with an increased flow of sedimentous urine, and gentle diaphoresis, we have good grounds for predict- ing a favorable issue of the disease, more especially, if at the same time the op- pression and pain in the chest abate, and the cough is less troublesome. When, on the contrary, the pain and oppression become more generally diffused through- out the thorax; when the cough is dry, or attended with dark or red liquid sputa; when, along with a sense of suffocation and great anxiety, the countenance and lips become livid, and the pulse soft, irregular, and laboring; and, finally, when delirium, coma, or convulsions supervene, or a sense of coldness is felt in the interior of the body, whilst the surface is very warm, the danger is to be con- sidered as very great. A rattling respiration, accompanied with lividity of the countenance, and a constant effort by the patient, to bare the breast and to raise his head and shoulders from the bed, are almost certainly fatal indications.* The supervention of diarrhoea, in this disease, is a very unfavorable circumstance.! The prognosis in pneumonia is nevertheless attended with considerable uncer- tainty. Instances of unexpected recovery occur, after the most dangerous symp- toms have made their appearance; and, on the other hand, death sometimes speedily supervenes, in cases apparently free from particular danger.J Treatment.—Both in pleuritic and peripneumonic inflammation, bleeding is the first and most important remedial means. The extent to which it is to be carried must be entirely regulated by the degree and obstinacy of the pain, and the state of the pulse. In pleurisy, we are generally obliged to abstract more blood than in peripneumonia, before the arterial reaction is sufficiently moderated. Whether the pleura or the proper substance of the lungs be the seat of ihe in- flammation, however, a sufficient quantity of blood should be drawn at once, to make a very manifest impression on the pulse. The blood should be suffered to flow without any regard to mere quantity, until a diminution of the pain and oppression in the chest, as well as of the action of the pulse, ensues. If the action of the pulse and the pain increase again, more blood must be drawn, and again to the extent of producing a decided impression on the system. The blood should be drawn in a full stream from a large orifice. In pleurisy it is sometimes necessary to repeat the venesection three or four times in the course of the first twenty-four hours, before the violence of the disease is broken down. More caution, however, is necessary in the employment of the lancet in peri- pneumonic inflammation. Here, although prompt and very efficient blood-letting is decidedly beneficial, and without the least risk in the commencement of the disease, yet it is necessary to proceed with caution in the repetition of this meas- ure, as the disease advances, lest dangerous prostration be induced. In violent attacks of peripneumony, the pulse is sometimes small, frequent, oppressed, and but slightly tense from the beginning of the disease. This state of the pulse may be owing to an oppressed or congested condition of the heart and large in- ternal venous trunks; but it depends, also, occasionally, on an impaired state of the vital powers, particularly in what has been called nervous or typhoid pneu- monia. In such cases a vein should be opened; and if the pulse rises while the blood is flowing, we may proceed with confidence in the further abstraction of blood. Should the pulse become still weaker, however, the bleeding must be immediately stopped. Richter observes, that where the pulse is small in the commencement of peripneumonia, the physician should place his fingers on the artery, and request the patient to make two or three strong inspirations, or to excite him to cough, by causing him to inhale the fumes of vinegar. If, by these * Richter, Specielle Therapie, band, i., p. 415. Baglivi, Opera, p. 42. ! Baglivi, Opera, p. 35. Riverius, Praxis Medica, t. i. p. 72. t "Plus una vice vidi laeta morbi facie, et aegroto atque adstandibus sibi gratulantibus, ex pneumonia subito mortem accidisse. At non raro etiam contrarium observavi: rebus ferme conclamatis et segroto ad stygis confinia posilio, prudenti atque audaci medicatione cum e mani- bus libitinaj evacisse."'—Schmidt7iiann, Ob. Med., t. i. p. 25. 236 PNEUMONIA BILIOSA. exertions, the pulse becomes fuller and more active, we may be assured, he says, that there is still sufficient energy in the heart and arteries to justify the abstrac- tion of blood.* The blood drawn in these affections exhibits a thick, sizy, or buffy coat, on the surface of a more or less cupped coagulum ; and so long as the blood exhibits this appearance, bleeding may be regarded as a proper meas- ure. The disappearance of the buffy coat is not, however, to be considered as a certain indication that blood-letting is no longer proper; for where the action of the pulse and the degree of pain in the chest are such as to indicate the propriety of further abstractions of blood, bleeding may be confidently employed, notwith- standing the absence of the buffy coat on the drawn blood. "Some practition- ers," says Dr. Millar, " have directed blood to be drawn, till the sizy crust which generally covers its surface, disappears. But this rule is extremely equivocal: in some, the blood puts on this appearance at the beginning; in others, not till towards the decline of the disease, and sometimes no crust is observed through the whole course of the disease. The only certain indication, therefore, arises from the mitigation or violence of the symptoms." Local bleeding by leeches seldom procures any particular advantages in the early periods of these affec- tions, beyond that which arises from its general depleting effects. After the dis- ease has been in a great measure subdued, and venesection is no longer indicated, leeching may no doubt be occasionally beneficial. In this case, small and re- peated doses of digitalis, also, sometimes contribute materially to the further reduction of the general and local inflammatory action. A half a grain, in union with six or eight grains of nitre, may be given every three hours, until its effects on the pulse or stomach are manifested. Although gentle aperients are decidedly beneficial in pneumonic inflammation, yet general experience goes to show that active and repeated purging is much more apt to prove prejudicial than useful. This is more particularly apt to be the ease after free expectoration has been established. Before the complete estab- lishment of the expectoration, Dr. Johnson states that he has known purgatives very beneficial in common pulmonic inflammation. Dr. O'Halloran also em- ployed active purges with advantage in pneumonia, among the British troops at Gibraltar. (Med. Repos., No. 8.) Nevertheless, as a general rule, active cathar- sis may be regarded as improper, unless, perhaps, in the very commencement of the disease. Small doses of one of the purgative neutral salts, or of castor oil, may be given, from time to time, so as to keep up a regular but moderate action of the bowels; or laxative enemata may be used with advantage for this purpose. Emetics are equally improper in pleurisy and in peripneumony ; but in bilious pneumonia, they may be accounted as among our most useful curative means. Richter states, that in this variety of the disease, emetics will often remove the pain in the chest as by a charm ; and Stoll makes the same observation. (Ra- tion. Meclen., t. i.) In the few cases of this modification of pneumonia in which I have prescribed, I have had the most satisfactory evidence of the utility of emetics in its treatment. They generally bring on a uniform diaphoresis, pro- mote expectoration, and allay the pain in the thorax, often almost immediately. They usually bring up an abundance of bilious fluid from the stomach. Cooling diaphoretics are very useful auxiliary remedies in these affections.— Nitrate of potash with minute portions of antimony, the pulvis antimonialis, and the muriate of ammonia, are the best articles of this kind in the present diseases. Richter particularly recommends the last-mentioned article in the treament of inflammatory pectoral affections ; and my own experience coincides entirely with his observations concerning its usefulness. It may be given according to the formula mentioned under the head of intermitting fever. With a view both of diminishing the action of the heart and arteries, and of promoting expectoration, nauseating doses of tartar emetic are generally highly useful. In Italy, large doses of this article are almost exclusively relied on in * Specielle Therapie, band. i. p. 418. PNEUMONIA BILIOSA. 237 the treatment of pneumonic inflammation. Rasori and his followers make this the principal, and, in some instances, almost the sole remedy. They exhibit it to the extent of from a scruple to several drachms in twenty-four hours ; and they assert that when given thus freely, it seldom excites either vomiting or strong purging, but always a most decided sedative or contra-stimulant impres- sion on the sanguiferous system. M. Laennec speaks strongly in favor of large doses of this antimonial in acute pulmonary affections. He asserts, that in cases treated solely by bleeding, the pulmonary engorgement, discoverable by the stethoscope, continues much longer than in cases that are treated with large doses of tartar emetic. He thinks that, given to the extent of from twelve to twenty grains during the day, this article acts specifically in subduing inflammation, and powerfully promotes absorption.* Dr. Fontaneilles, of Milan,! whose expe- rience confirms the observations of Rasori on this subject, observes, that the power to sustain large doses of tartar emetic, depends wholly on the system being in a morbid condition ; for in a healthy state, or after the disease is re- moved, the ability of taking large doses of this medicine without injurious conse- quences, does not exist. It would seem, moreover, that the power of bearing large doses of antimony in peripneumony, varies in the different stages of the disease. It is greatest at the acme of the disease—being less prominent in the beginning and in the decline of the inflammation. Dr. Fontaneilles gene- rally gives about twelve grains per day in the first stage of the inflammation ; but after the disease has advanced to its acme, from a scruple to half a drachm is administered in the same period. If the medicine produce active vomiting, the dose must be diminished ; but so long as the power of bearing it without great nausea or vomiting continues, the dose should not be lessened, although the symptoms of the disease may be declining. Many practitioners have strongly recommended the employment of calomel and opium in peripneumonic inflammation ; and my own experience has fur- nished me with repeated examples of the utility of this practice.^ After the disease has continued for three or four clays, and the action of the heart and arte- ries has been duly moderated by^deplelion, opium often does much good by allaying the pain and cough, and powerfully promoting a salutary expectoration. There is nothing to be apprehended from its stimulating effects. When given in combination with minute doses of tartar emetic, or with calomel, after ade- quate abstractions of blood, this article has a more decided tendency to increase the expectoration and complete ihe resolution of the disease, than perhaps any other internal remedy we possess. When the pain and cough continue to be troublesome after venesection has been efficiently practised, a grain of opium in union with two grains of calomel, given every three or four hours, will seldom fail to bring great and permanent relief. Where, however, the expectoration is free, and of a proper consistence, opium, if it be at all used, should be/given in much smaller doses. One-fourth of a grain of this narcotic, with one-tenth of a grain of tartar emetic, or two or three grains of pulv. Doveri, may, under such circumstances, be given every four or five hours. In pneumonic inflammation from metastasis of rheumatism or gout, this article is especially beneficial. In such cases it ought to be given in large and frequent doses—two grains with the same quantity of calomel every two or three hours, until the system is com- pletely under its influence. Richter states, that when pneumonia is the conse- * Revue Medicale, Mai, 1824.—Hospital Reports from La Charite. ! Archives Generates, February, 1824. X " Methodi HamiltonianEe commendatio ab illustri Sam. Gottl. Vogel (a), cujus auctoritatem tanti semper feci, me movit earn tentare; et tentando edoctus sum ejus inventum et vulgationem magnum praxeos medicse esse incremental Prima pericula omnem longe superabant expee- tationem meam; quare viginti abhinc annis et ultra non facile morbus inflammatorios mihi obvenit—et multi centeni mihi obvenere—cui opium et calomel faustissimo cum successu non opposuissem."—Schmidtmann, Sum. Obser. Medicar., t. i. p. 27. (a) Handbuch der Pract. Arzneywissenshaft, 4 ter. theil. s. 25, u. 231. 238 PNEUMONIA BILIOSA. quence of repelled cutaneous eruptions, of measles, scarlatina, or of irregular gout, camphor, given in combination with ipecacuanha and opium, is, in general, a highly useful remedy. After blood has been decisively abstracted, one grain of camphor in union with the same quantity of opium and two grains of ipecacuanha, will often, he says, remove the pain and cough as by enchant- ment. If the pain returns, the dose must be repeated. Expectorants may be employed with advantage after the violence of the in- flammation has been reduced by blood-letting ; but the benefit to be derived from this class of remedies is, upon the whole, much less considerable than might be inferred from the known salutary influence of a free expectoration in this affec- tion. In the early or active stage of the disease, all articles of this kind, with the exception of tartar emetic, kermes mineral* or mucilaginous fluids, are liable to do mischief. When the violence of the disease has been moderated, and the inflammation is about terminating in resolution, opium with tartar emetic, as has just been mentioned, will, in general, assist materially in establishing the expec- toration. An infusion of the rad. poly gal., sweetened with honey, may be beneficially given during convalescence from pneumonic inflammation. The patient should be allowed the free use of demulcent drinks—such as barley- water, flaxseed-tea, or a solution of gum Arabic, to which honey or currant jelly may be added. Blisters are among our most valuable means for subduing pneumonic diseases. As soon as the firmness and activity of the pulse have been reduced, a large vesicatory should be applied over the region of the affected part. Baglivi ob- serves, that in some instances of pleurisy, great difficulty of breathing and sup- pression of the expectoration occur about the fifth or sixth day. In such cases, two blisters, he says, applied to the inside of the thighs, will generally produce a favorable change in all the symptoms. Triller recommends the same prac- tice.! In protracted cases of pleuritic inflammation, where symptoms of effusion are present, a combination of calomel, digitalis, and squills, has been found particu- larly serviceable.^ I have found the diuretic mentioned under the head of chronic peritonitis, very useful under circumstances of this kind. (See p. 199.) In cases that terminate in empyema, paracentesis thoracis is recommended; and we are not without a considerable number of examples of the successful performance of this operation, both in empyema and vomica. Dr. Samuel Col- noun, in his edition of Gregory's Practice of Medicine, states, that "he has known a case in which this operation had the happiest effect, though the opening into the cavity of the abscess was deep, and penetrated far into the lungs."§ * R.—Kermes mineral grs. xv. Extract, glycyrrh. gij. Aq. fontanae Jvij. Syrup, scillse ^iij.—M. S. Take a tablespoonful every two hours. ! De Pleuritide. p. 48. X R.—Calomel 9 i. Pulv. scillae Qiij. ---- digitalis >}i. Conserv. rosar. q. s.—M. Divide into twenty pills. S. Take one three times daily. § [Dr. Colhoun alluded to an operation which I performed many years ago in his presence. The discharge was in that case decidedly purulent, consisting of more than 30 ounces of pure globular pus. As it was not like the serous contents of a distended pleura, we concluded that the case was one of interstitial pulmonary abscess; and that it militated against Laennec's idea that such collections are always pleural. There was also much substance of a fleshy kind to penetrate with the trocar on the inner surface of the ribs, which induced Dr. Colhoun to con- clude that I penetrated " far into the lungs." I have repeatedly performed the same operation since and evacuated pleuritic effusions after cuttin^through a very thick false membrane behind the intercostal space, which gave the same sensaTOn as my cutting into the substance of the Lungs. The operation of paracentesis after pleurisy has now become very common, and if per- formed before the lung has become greatly shrunken, is generally successful. At all events, it enables the subsequent applications of blisters and mercurials to excite the reabsorption of false membranes on the pleura, and thus prevent a return of the effusion.—Mc] CYNANCHE LARYNGEA. 239 For similar instances of successful paracentesis thoracis, the reader is referred to the works of Werlhoff,* Donald Monroe, Stoll,! Richter4 Hoffman,§ B. Bell, and Aug. Gott. Richter.|| M. Jowett has reported a very interesting case of empyema successfully treated by this operation ;^f and we might go on to cite many more instances of this kind. I have been thus particular in referring to authorities in favor of this operation in cases of empyema or thoracic effusion, from the equivocal manner in which it is spoken of by Dr. Gregory in his practice. "Paracentesis thoracis" he says, "is probably advisable in certain cases both of vomica and empyema ; but the observations of authors on this piece of practice are very scanty."** When there is reason to believe that hepatization of a portion of the lungs has taken place, benefit may still be obtained, in some instances, from external irritating applications. Frictions with tartar emetic ointment, or with an oint- ment made by mixing two drachms of the white precipitate with an ounce and a half of lard, will answer well for this purpose. Setons, and caustic issues, also, are useful in cases of this kind ; or continued blistering with emplast. lyttae. Internally, advantage may probably be derived from small doses of muriate of mercury in union with conium or belladonna. One-tenth of a grain of this mer- curial, with from two to three grains of the extract of conium, may be given three times daily. Diuretics, also, have been recommended both in hepatization and in suppuration of the pulmonary tissue—more especially in thoracic effusion. When suppuration has occurred, the strength of the system should be supported by digestible and nutritious diet, opium, or extract of conium—but the more diffusible stimulants must be avoided. Sect. II.— Cynanche Laryngea.—Laryngitis. Until within a comparatively recent period, laryngitis was generally con- founded with croup, to which, indeed, it bears a considerable resemblance. Boerhaave refers to this disease in section 802 of his aphorisms, and Van Swie- ten quotes a strongly-marked case from Tulpius.H" More recently, Drs. Farr, E. Percival and Home4J have published interesting papers on the pathology and treatment of this severe and dangerous variety of cynanche; and the chapter on * Opera Hanov., 1775, p. 775. ! Ratio Medendi, vol. iii. p. 155. X Chirurgische Bibliothek, band. 3, s. 464. Band. 4, s. 476; Band. 6, s. 590; Band. 7, s. 311; Band. 8, s. 728. § Unterricht von dem Collegium der Aertze in Munster. || Medico-Chirurg. Observations. IF Med.-Chir. Rev, July 1826. M. Jowett observes, "I have twice very recently had occa- sion to resort to paracentesis of the thorax, in hopeless cases of effusion arising from pleurisy. In both instances, the operation was the means of prolonging, although it did not eventually save, the lives of the individuals." To prevent the admission of air into the cavity, M. Jowett recommends the operation to be performed in the following manner: "Having made a small incision through the integuments only, in the place selected for the operation—which will most commonly be in the back, in the sixth or seventh intercostal space—thrust a small trocar carefully through the muscles and costal pleura; having withdrawn the trocar and left the canula in the wound, join a tube, connected with a Reid or Weiss' syringe to the canula, and slowly abstract the fluid by the syringe, con- tinuing to work it as long as the piston moves freely, or until symptoms come on which render it necessary to desist. Then remove the canula from the wound without previously separating it from the syringe; approximate the edges of the integuments by plasters, and apply a compress to make it more secure." ** "The history of the operation of paracentesis thoracis for empyema or hydrothorax, would well deserve an article in a periodical journal. Kurt Sprengel has given a most erudite history of this operation, from the days of Hippocrates to the close of the last, century, occupying eighty- seven pages of letterpress."—Dr. Johnson's Med.-Chir. Rev., vol. v. p. 273, XX Observ. Medicar, lib. i. cap. 57, p. 96 XX Medico Chirurg. Transact., vol iii. p. 2G8. 240 CYNANCHE LARYNGEA. this subject in Dr. Armstrong's work on typhus, may be advantageously con- sumed. The disease usually commences with the ordinary initial symptoms of inflam- matory fever ; the patient experiencing at first slight sensations of chilliness alternating with flushes of heat. A feeling of soreness in the fauces, attended with more or less tenderness to pressure in the larynx, and uneasiness in swal- lowing, are among the first symptoms. The voice soon becomes changed into a thick, slightly hoarse whisper, and on strong inspiration, the air seems to enter impededly, as if it were forced through a very narrow aperture, and is attended with a hoarse, dull, hollow sound. On examining the fauces, they exhibit a pale red, tumefied, and cedematous appearance. The expectoration is not abund- ant, and consists almost wholly of saliva of a ropy character. The pulse is generally frequent, contracted, and tense; but in some cases it is but very little disturbed. The face is for the most part pale, and the tongue white, punctuated with red points, and covered with a layer of transparent mucus. When the dis- ease is fully developed, deglutition is very difficult and painful, and apt to excite alarming and distressing paroxysms of suffocative breathing. The temperature of the surface is unequal, being higher than natural in some parts, and lower in others. One of the most peculiar and characteristic symptoms of this affection, says Dr. Armstrong, is the inability of patients to cough out, as is done in pul- monic or catarrhal affections ; the attempt to do so resulting in a kind of suf- focating effort, terminating " in a low, grumbling, and almost grunting sort of noise in the throat." Respiration somewhat impeded from the onset of the dis- ease, becomes more and more oppressed and laborious as the disease advances, with occasional violent and distressing paroxysms of dyspnoea, until at last, in unsubdued cases, death occurs by actual suffocation.* In some instances, laryngitis is as insidious in its approach as it is rapid and fatal in its progress. Mr. Porter knew two instances of young men who went to bed at Right, without complaining of any illness, "and were found dead from this affection the next morning." M. Leveille has reported a case of laryngo-bron- chitis, which was so masked by erysipelas of the face, as to escape observation until within a few hours of its fatal termination.! "The seat of this affection," says Mr. Porter, " is more in the cellular tissue, connecting the mucous membrane with the adjacent parts, than in the membrane itself, although this latter structure is very frequently found to have been in- flamed." The epiglottis, rima-glottis, soft palate and larynx, are always tumefied and cedematous by inflammation and serous effusion into the submucous cellular tissue, so as to approximate the sides of the glottis and prevent the passage of air into the lungs. In some instances the inflammation is confined to the larynx, but it occasionally is found to have extended down the trachea and even into the bronchia. (Armstrong.) Porter, however, observes, "I can find no satisfactory examples of the inflammation having extended beyond the larynx and into the trachea; on the contrary, the chief intensity of the disease has been in the epi- glottis, which is found red, erect, thickened and swollen, and during life resem- bles a piece of raw meat."| In the case reported by Leveille, the inflammation was manifest from the larynx down along the trachea and in the bronchia. The inflammation has been known to terminate in the formation of one or more abscesses in the parts surrounding the larynx. Armstrong mentions a fatal case in an old woman, in which "a considerable abscess was found between the * [''This formidable malady has always existed, for you may trace examples of it, under various names, even in the writings of the ancients. But it is only in recent times that it has been singled out from the rest of the angina?, and made a separate object of study. It has num- bered some distinguished medical men among its victims: Dr. David Pitcairn, Sir John McNa- mara Hayes, Sir George Tathill. The celebrated General Washington died of it."—Watson's lectures, p. 443.] ! Gazette de Sante, 1827. j Observations on the Surgical Pathology of the Larynx and Trachea, &c. By Wm. Henry Porter, p. 98. CYNANCHE LARYNGEA. 241 muscles of the pharynx and thebodies of the cervical vertebrae." In some instances false membrane is found on the epiglottis, tonsils and trachea. Treatment.—Laryngitis is to be regarded as one of the most rapid and dan- gerous affections. It often terminates fatally in less than twenty hours, under the most prompt, energetic and judicious modes of treatment. Blood-letting is unequivocally indicated, and yet its effects in arresting the progress of the inflam- mation in this affection, do not appear to equal those it manifests in other varie- ties of tracheal inflammation. Dr. Armstrong asserts, that in one instance, " one hundred and sixty ounces of blood were drawn within the space of six hours," by venesection and leeches, yet " so far from arresting the inflammation, the patient died within twenty-four hours." In only one case out of six, he says, did blood-letting appear to afford unequivocal advantage. It must be admitted, indeed, that bleeding does not often procure any prominent benefit in this affec- tion ; and yet who would undertake to treat the disease without resorting to prompt and efficient depletion ? Dr. Beck, of New York, attributes the want of success of this measure in laryngitis to the inefficient manner in which it is usu- ally employed. When carried to the extent of producing syncope, it is, he thinks, as likely to do good in this as in other inflammatory affections of the respiratory passages. My own experience does not, however, entirely confirm this observa- tion. Nevertheless, blood-letting to the extent of producing fainting must be regarded as an indispensable auxiliary in the treatment of this affection.* Leeches should be largely applied to the throat. Martinet has reported a case which ter- minated successfully under the employment of general and local bleeding and blistering. In the course of three days upwards of forty ounces of blood were drawn with the lancet, and 110 leeches applied to the throat and back of the neck. Blistering the throat or the back of the neck, while leeches and emollient poultices are applied to the throat, will in general assist materially in the reduc- tion of the disease. Armstrong places more reliance on the repeated employ- ment of antimonial emetics in this disease, than on any other remedial measure. After having found blood-letting and local applications ineffectual in the majority of cases that had come under his care, he was induced to try the effects of eme- tics, " given in repeated doses, till free and frequent vomiting was produced." He accordingly gave antimonial emetics in five cases, for which he was subse- quently called to prescribe. "No circumstance in my professional life," he says, "ever gratified me more than the great and sudden relief which vomiting afforded ; in reality it removed all the urgent symptoms at the time, and being re-excited as soon as ever the slightest signs of stricture in the larynx returned, at last com- pleted the recovery." In a well-marked case which I recently attended, in a child about four years old, blood-letting, to the extent of about ten ounces, with a blister to the throat, and three active emetics, effected a cure. Purgatives must not be neglected in the management of this affection. Calomel either by itself in large doses, or in union with rhubarb or jalap, should be given so as to keep up a free action of the bowels. Some advantage may, perhaps, be derived from warm and stimulating applications to the feet, such as warm pediluvia or sina- pisms. Dr. Good recommends the use " of gargles of ice water acidulated, and * ["How and when are we to employ the great remedy for acute inflammation—blood- letting? or are we to employ it at all? These are points concerning which it is quite necessary that our minds should be prepared and prompt to decide. If you look merely at the results of the recorded cases of this fearful complaint, you will scarcely find an answer to the question. In some of them, copious bleeding appeared to save the patients; in others, it was of no service, but rather seemed to accelerate their death. fir John McNamara Hayes suffered two attacks of cynanche laryngea. In the first he was bled freely. Dr. Roberts, of Stanford, informs us that the first bleeding was attended with considerable relief, the second also with manifest advan- tage, and by the third, his safety appeared to be ensured. Fifteen years after, he died of the same disorder, for which he was again bled and leeched under the care of the late Dr. Baillie. Washington was largely bled and died. Again, Dr. Francis, of New York, recovered from acute laryngitis after copious venesection. It is evidently needful to consider and determine the cir- cumstances under which we are to use or to withhold the lancet."— Watsons Lectures, p 444.] 16 242 CYNANCHE TRACHEALIS. epithems of pounded ice applied externally," in preference to blisters to the throat. I have seen an instance of this disease in which the application of a solution of lunar caustic, by means of a soft pencil to the inflamed fauces, (as is recom- mended by Mackenzie in the somewhat similar affection, recently described by Bretonneau, under the name of diphtherite,) was evidently beneficial. It is probable that the insufflation of very finely powdered alum into the fauces, (a practice successfully adopted by Laennec in cynanche trachealis,) would prove beneficial in this affection. The powdered alum may be blown into the fauces through a small tube or quill. The operation of bronchotomy is recommended by some writers, where the remedies already mentioned do not make any effectual impression on the disease. " Besides the uncertainty that must prevail as to the precise nature of the morbid action that is going on in acute laryngitis, and the consequent hazard a practi- tioner will run of losing his patient, whilst he is attempting a treatment that may be unsuccessful, there are many reasons why he should in the present instance decide at once on the performance of bronchotomy. Thus it allows the organ in which the diseased action is situated to remain in a perfect state of repose. Considered as a wound, it adds nothing to the patient's danger; and as the relief it affords is, at least for a time, complete, it imparts confidence to the surgeon, and allows him more leisure to examine the symptoms and adopt the remedies accordingly. If, however, the operation be not early performed, it had much better be let alone altogether."* A highly interesting instance is related of the successful performance of tra- cheotomy, in a case of laryngitis, by Dr. Crampton, in the fourth volume of the Dublin Transactions. Professor Regnoli, also, has reported two successful instances of this operation in chronic laryngitis. The acute form of the disease, he observes, sometimes terminates in chronic cedematous tumefaction of the epiglottis, and the mucous membrane of the larynx, with or without thickening of the submucous cellular tissue, which will ultimately render respiration ex- tremely difficult, and even cause death by suffocation. Here bronchotomy is the only means of relief in our power.! Sect. III.—Cynanche Trachealis.—Croup, Hives. Symptoms.—This disease sometimes comes on suddenly, and acquires the utmost degree of violence in the course of a few hours. More commonly, how- ever, its approach is gradual, the first symptoms being those of ordinary pulmo- nary catarrh. A dry and hoarse cough, with slight difficulty of breathing, and a change of the voice, are generally the first intimations of its invasion. This very peculiar hoarse and rough cough, with its accompanying slightly oppressed breathing, continues sometimes, with occasional remissions, for several days, before the disease assumes its characteristic form and violence. More or less febrile excitement is generally present, from the very commencement of the dis- ease. Sooner or later the respiration becomes more difficult and distressing; the febrile reaction rises higher; the voice becomes more indistinct, whispering, or annulled; slight pain and uneasiness are felt in the larynx; and the cough be- comes more sonorous. The disease now advances rapidly to its state of full development, and all the symptoms acquire a most alarming and distressing de- gree of violence. The countenance is flushed; the eyes prominent, injected and heavy; the pulse frequent, tense, and quick; the skin dry and hot; and the respiration extremely difficult and anxious. Inspiration is especially difficult, and accompanied with a very peculiar ringing or stridulous sound. The cough at this time is often quite dry; but in some instances, there is a copious and * W. H. Porter. Loc. chat., p. 100. f Nuovo Mercurio delle Scienze Mediche. Mazo, 1S29.—See Rev. Medicate, Juin, 1829. CYNANCHE TRACHEALIS. 243 very tenacious albuminoid fluid secreted in the larynx and trachea, from the very onset of the disease, and in all cases this viscid secretion occurs in the advanced stage of the malady. If the disease be not checked in its violence and progress, the breathing acquires, at last, a degree of oppression inexpressibly distressing; the little patient manifests, in the expression of its countenance and actions, the utmost degree of anguish and suffering; the head is thrown backwards, and the mouth kept open ; the eyes are half closed or cast about with an imploring ex- pression for relief; the voice is extinct; the lips livid ; the face pale and covered with large drops of sweat; sensibility rapidly diminishes; slight coma ensues; the extremities become cold and clammy; and finally breathing stops and closes the agonizing scene. Such are the ordinary course and symptoms of this frightful malady. Much diversity, however, occurs in relation to the degree of violence and rapidity of these phenomena. In some instances, not more than a few hours elapse between the commencement and fatal termination of the disease. In other cases, the symptoms proceed slowly to their acme, and the disease is protracted for many days, and occasionally even for several weeks, assuming a chronic character, without, perhaps, having at any time manifested a very alarming degree of vio- lence. The ordinary period occupied by this disease, is from two to five days. Causes.—Cynanche trachealis is one of those inflammatory affections for which a predisposition appears not unfrequently to be congenital. It is certain, at least, that the children of some families are particularly predisposed to the disease, whilst in others it never makes its appearance. In what this predispo- sition consists, we cannot tell. To say that it depends on a peculiar organization of the mucous membrane of the larynx and trachea, may be correct; but what these organic peculiarities are, it would be in vain to inquire. Besides this original or natural predisposition, there is another one much more universal and influential in its agency, namely, age. Cynanche trachealis is, indeed, almost peculiar to the age of childhood, being vastly more common in children between the first and fifth year of age than in the whole subsequent and anterior periods of life. It is, nevertheless, not wholly confined to the years of infancy and childhood; for occasionally, though rarely, it occurs in adults, and sometimes even in very advanced age. This aptitude to the disease in early childhood may depend, in part, on the peculiar condition of the glottis or larynx at this age; for, that there exists some peculiarity in this portion of the respiratory pas- sage, during infancy and childhood, unconnected, probably, with mere size of aperture, is manifest from the characteristic voice, at this early period, and its remarkable change during the period of pubescence. But there is another cir- cumstance which may have a large share in the so common occurrence of this malady during infancy, namely, the almost universal custom of dressing children so as to keep the neck and upper part of the thorax perfectly bare, and thus ren- dering them more liable to the injurious influence of cold in these parts. Certain exanthematous affections, also, often give rise to an increased aptitude for this disease. This is especially the case with scarlatina, measles and miliary fever. Observation would seem to show that florid, robust and fat children are much more liable to the disease than those who are of an opposite habit. The principal exciting cause of this disease is cold or sudden vicissitudes of atmospheric temperature; and hence its greater prevalence during the variable, damp, and cold months of autumn and spring, than in the more temperate and uniform season of summer. Cynanche trachealis is said to have prevailed epi- demically; but contrary to what obtains, in this respect, with epidemic catarrh, these epidemic cynanche are always of a very limited sphere, with regard to the extent of country which they embrace. In general, this disease is most apt to prevail after, or during the prevalence of measles or scarlatina. During conva- lescence from these affections, there exists an especial aptitude to cynanche from the influence of cold. It would seem, too, that the liability to this disease is often considerably increased, by having suffered an attack of it. I have known 244 CYNANCHE TRACHEALIS. the same individual suffer five or six attacks of the disease, during the period of childhood. Cynanche trachealis is a phlegmasial disease, consisting essentially of inflam- mation of the mucous membrane of the superior portion of the respiratory tube. The correctness of this pathology is confirmed not only by the known character of its most common exciting cause, but especially, also, by the more direct evi- dence of the symptoms of the disease, and the appearances discovered on post- mortem examination.* The observations of Bretonneau in France, and of Mackenzie in England, published within a few years past, go directly to the establishment of this view of the nature of the disease. Both these observers assert that the inflammation often commences in the fauces and on the tonsils, and descends thence into the trachea; a progress of the disease, which may be verified by ocular inspection. I have myself seen several cases of croup, which commenced by a kind of ery- sipelatous or superficial inflammation, about the tonsils and soft palate; and in one instance, this inflammation continued for four days, and was the object of medical attention before it extended into the trachea and gave rise to the symp- toms of croup.! The inflammation which occasions the characteristic pheno- mena of this disease, rarely remains confined to the larynx and trachea. In many instances, it extends downwards into the bronchia, and sometimes even into the small ramifications, giving rise to the simultaneous existence of acute bronchitis and laryngeal inflammation. The danger from this disease is always greater, cseteris paribus, in proportion as the inflammation passes down into the * [Although croup consists essentially in an inflammation of the lining membrane of the tra- chea, (i.e., in the part below the larynx and above the bifurcation into the bronehi,) the disease sometimes extends higher up so as to affect directly the larynx, and still more frequently lower down so as to occupy the extreme ramifications of the bronchi. When the inflammation does not extend upwards into the larynx, the muscles of the glottis may nevertheless be thrown into spasmodic contraction by reflex sympathy. Dr. Watson, in his lately published lectures, makes the following excellent observations. " Cullen makes no distinction between cynanche trachea- lis and cynanche laryngea. Yet they are separated from each other by very definite boundaries. They differ in anatomical position; they differ in gravity. Both, indeed, are serious diseases, but croup is the more serious, because it seldom admits that mechanical relief (tracheotomy), which, when rendered in time, deprives cynanche laryngea of its dangerous character. The two disorders differ also in respect to the period of life at which they occur. Idiopathic laryn- gitis is seldom met with except in adults, croup seldom after the age of puberty. Cynanche trachealis is, indeed, a very remarkable disease—for it exhibits an event of inflammation which does not usually belong to that process when it affects the mucous tissues. In this, too, it differs from laryngitis. I say that croup is peculiarly a disease of early life. The interval that lies between the two periods of weaning and puberty is the time during which its visitation is chiefly to be apprehended. Comparatively few cases of it occur during the first year of infantile life. There are more in the second year than in any other."—" Some of the cases recorded of croup in the adult were probably in reality cases of laryngitis. It is curious that inflammation should thus at different epochs of life fix itself upon limited portions of the same continuous sur- face, and give rise to consequences so diverse. We are unable to give any account of this." -Mc] ! It is surprising that a disease so manifestly phlogistic in its character should still be viewed by some of the German and French writers as essentially spasmodic in its nature, or, at least, as wholly independent either of a local or general inflammatory condition. Several of the late continental writers on this disease regard the fever and inflammation, which they acknowledge sometimes to exist, as wholly accidental, and as in no manner essential to the perfect constitu- tion of the malady. Among the principal antiphlogistic pathologists, in relation to this affection, may be mentioned Des Essartz, Banafox,(a) Ruette,(6) Schneck,() Cook on iMervous Diseases. APOPLEXY. 443 the observations of Morgagni give nearly the same result.* Extravasation of blood into the cerebellum 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 instance, into the ventricles. During ten years' observation in the different hospitals, M. Bri- cheteau saw only two cases of this kind. The fluid is generally extravasated in the neighborhood of the ventricles, and bursts into them by a ragged opening." (Med. Chir. Rev., loc. cit.) Occasionally blood has been found effused on the surface of the brain. Rochoux relates a case of this kind; and Richter states that sometimes the brain, on removing the cranium, appears dark, brown, or blackish, through the membranes, from extravasated blood underneath. (Loc. cit.t 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 proba- bly not the immediate cause of the apoplectic seizure, but one of the results of the vascular engorgement, upon which the apoplexy depends. There are, never- theless, some circumstances connected with this distinction, 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 extravasation 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 the cerebral apoplexy, from the cerebral mass itself being the principal seat of the morbid changes. The latter, or uncomplicated variety, he denominates meningeal apo- plexy, on account of the manifest traces of vascular irritation and congestion, discovered by dissection, in the meninges. It appears 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 para- lysis 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 animals do which have the pneumogastric 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 apo- plectic 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 treatment 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. In the actual paroxysm of apoplexy, the patient should be immediately removed to an airy and cool situation, and placed in a position which least favors * In explanation of this fact, M. Bricheteau observes, "An attentive study of the vascular sys- tem 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. 444 APOPLEXY. 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 fomentations, sinapisms, or frictions with tincture of capsicum—made to the legs and feet. Cups may also be very beneficially 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, nevertheless, 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 constitutes 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 quantity 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 we 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 constitutional habit of the patient. I have met with a case of apoplexy which ultimately proved fatal, in which the loss of thirty ounces of blood pro- duced, 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 general diminution of the circulation. Cupping, however, is a most important 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.*. The application of ice, or very cold water to the scalp, is one of the most use- ful remedies in this disease. This was a favorite measure with Thilenius,§ and his praise of its powers, though great, can scarcely be deemed extravagant. Its efficacy will be much enhanced 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 stimulating and warming applications to the lower extremities are always proper. Formerly, * Cheyne. X I very much admire the mode of Clipping recommended by Mr. Wallace.(a) It is as fol- lows :—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 superficial incisions about the sixth of an inch from eaeh#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 6tream from them with surprising rapidity. Dreysiir, loc. cit., p. 481. 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. 0:2. APOPLEXY. 445 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 in- testines, and to excite a free secretion from their internal surface, and conse- quently to diminish 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 ac- count, 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 impos- sible to administer cathartics by the mouth, from the paralyzed state of the or- gans 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 excellent effect in two instances of apoplexy. This article generally acts with much energy, and from its small bulk and fluidity, is more easily intro- duced into the stomach than other remedies of this kind. Castor oil with tur- pentine, 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 solution may be peculiarly service- able, 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 improvement took place. Where the inordinate flow of blood to the brain is caused or supported by intestinal irritation from accumu- lation 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 remedial 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.! Unquestionably, as a general rule, emetics must be regarded as hazardous reme- dies in apoplexy; for the tendency of vomiting to propel the blood to the head is always very considerable. Nevertheless, this disease may occur under circum- stances of gastric irritation, which may not only render emesis useful, but abso- lutely 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 eme- tic, 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 apo- plexy, under the circumstances just mentioned. 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 * Burserius. Inst. Med. Pract., vol. iii, § 131, p. 106. X See Loud. Med. and Phys. Journ., vol. v. and vi., for an ample discussion on this subject. 446 APOPLEXY. profound, and the respiration stertorous and sputtering. He was immediately bled to the extent of about forty-eight ounces, but although the pulse was con- siderably reduced, no perceptible improvement ensued. Twenty grains of sul- phate 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, enemata, 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 the 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 indicated. Heberden gave a weak infusion of chamomile: Cheyne used lukewarm water with hartshorn ; and others recommend warm water with mus- tard. It is very questionable, however, whether any peculiar advantages attend the use of these milder emetics. Indeed, the system is almost always so insen- sible to the impressions of medicines 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 bet- ter. Richter, who speaks very favorably of the employment of emetics in cases of this kind, advises the most active articles of this class.*. Blisters do not appear to afford any advantage in apoplexy, unless the pulse is weak, small, and quick, which, though rarely, is sometimes 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 improper in the early period of apoplexy. Where, after copious evacuations, some degree of consciousness and a power of voluntary motion return, with much prostration and a feeble pulse, some benefit may, perhaps, be obtained from the cautious ex- hibition of the carbonate of ammonia or camphor, (Richter,) in the form of a mucilaginous mixture. The prompt and judicious employment of the foregoing means embraces every- thing that may be deemed efficient in the remedial management of apoplexy. From whatever cause the disease may arise, our whole efforts should be directed to the removal of the inordinate 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 character of the exciting causes, will of course be necessary. Thus, in cases which succeed the sudden suppres- sion 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 occasion to the apoplectic seizure, blisters, issues, or sinapisms to these parts will be proper; and I have already spoken of the usefulness of emetics when the attack takes place soon after a surfeit, and the indispensableness of cathartics when the bowels are loaded with feculent and other irritating matters. During convalescence from apoplexy, nothing but the lightest unirritating diet should be allowed; and unless great prostration exists, all kinds of vinous liquors should be interdicted. * [I have repeatedly met with such cases. Indeed, in the majority of violent apoplexies I have observed that undigested crudities have caused the disease. A robust and corpulent gen- tleman of this city has experienced three violent seizures under my care, from all of which he has been promptly relieved by active emetics following previous venesection. No paralysis occurred after these attacks. A patient of the late Dr. Klapp had been several days totally insensible and prostrate from a severe attack, when he was suddenly and completely relieved by the discharge of a soused pig's ear, under the action of an emetic.—Mc] ! MS. Lecture as quoted in the Med-Chirurg. Rev., June 1820, p. 26. X Med.-Chir. Bemerkungen, b. ii. p. 109. PARALYSIS. 447 The prophylactic management, in persons laboring under the usual premonitory symptoms of apoplexy, or constitutionally predisposed to this affection, consti- tutes a very important point of medical 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 important 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 neces- sary to use an occasional dose of some mild laxative, as castor oil, or small por- tions of rhubarb; and where there is reason to suspect hepatic torpor or derange- ment, 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 alarming 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 fre- quent venesection will do little or no good in preventing that general plethoric habit which is 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 hemorrhoidal discharges, un- less they become excessive. The same precaution is necessary with regard to epistaxis in individuals of the apoplectic habit, as well as with other habitual evacuations. Drs. Cheyne* and Stoker! 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 diminish- ing or obviating cephalic congestions. Drs. E. Percival± and Stoker strongly recommended it for this purpose in comatose affections; and my own experience leads me to think that it possesses considerable powers in this way. Coffee, however, is decidedly injurious where there is an apoplectic tendency. Some eight years ago, a gentleman in this city, of a strongly developed apoplectic habit, was seized with an attack of this affection. He was in the habit of taking large quantities of very strong coffee twice daily. I advised him to leave off taking this beverage entirely. He did so; and has not since experienced 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 motion, or of sensation, or of both, in certain parts of the body, without coma, or a loss of consciousness. Cases in which both sensibility and the power of motion are at once destroyed, are however, extremely rare. Instances even occur in which the sensibility of the palsied part is morbidly increased. I have met with a case * Dublin Hospital Reports, vol. i. p. 315. ! Dublin Medical Esstys, anno 1806. Transactions of the Association of Fellows and Li. centiates of the Queen's College of Physic. Dublin, vol. ii. X Dublin Medical Essays, vol. ii p. 44. 448 PARALYSIS. of this kind.* The patient had lost all command over the muscl?s 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 para- lyzed limb was entirely insensible, but the muscles beneath were the seat of acute pain, which was always much increased by pressure.! In general the paralyzed parts become soft and flaccid, and at last usually emaciated, or occasionally oede- matous. Sometimes a peculiar tingling, or creeping sensation (formicatio) is felt in the affected parts, " as if small insects were creeping over them." The opinion generally 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.*. Patients sometimes complain of a sense of severe cold in the affected parts, although to the touch the temperature does not appear to be materially diminished. In some instances the pulse is smaller and weaker in the paralyzed 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—amounting, in some instances, to complete imbecility. The memory especially 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, local- ities, 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 Me. de cine Physiolog., Decem- ber, 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 entirely 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 paralyzed limb are often the first that manifest any degree of returning muscular power. I attended a hemiplegic patient about two years ago, for three weeks, without any apparent amendment; at last, however, he found that he could move his toes; * [This is satisfactorily explained by the anatomy of the two classes of nerves__muscular and sensitive. The cause of paraly.-is may act on the tractus of the spinal cord, which gives origin to the muscular roots, and paralyze the motions alone, while the sensibility is unim- paired. The opposite condition may also be. the case. Moreover the origin of one class of nerves may be irritated, and the other compressed, or otherwise paralyzed. °Thus the muscles maybe thrown into inordinate contractions when they are destitute of all feeling- and the limbs may be very painful when they are totally deprived of all the power of motion'. I was accustomed, in my lectures on surgery, to divide paralysis into two kinds—neuralgic or rigid paralysis, and atonic palsy or paralysis attended with relaxation. The first arising from irritation or inflammation of the nerves or cerebral substance which gives them origin, and the second species from compression or loss of tone in the same parts —Mc 1 ! Med.-Chir. Rev., October 1829, p. 168. X Dr. Abercrombie.—See Cook on Nervous Diseases, p. 227. Boston, 1824. HEMIPLEGIA. 449 by degrees he regained the power of moving the foot, then the leg, and finally the thigh. The same progress of amendment occurred in the paralyzed 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 hemi- plegia; if both the inferior extremities, from the hips downwards, are paralyzed, 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. A very curious instance of general palsy occurred 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, became paralyzed. The patient's general health was good, and his intellect per- fect.* Tissot relates an instance of a boy who, apparently in consequence of a repelled scabby affection of the head,! became paralytic throughout nearly the whole of the muscular system, attended with much torpor of the sensorial func- tions, and mental weakness, though wholly free from coma or somnolency.*. M. Bretonneau has related a somewhat similar case. " A lady was seized witb paralysis of the little finger of the left hand, which gradually extended to the whole of that side; the right became similarly affected, with the exception of the thumb and two fingers. The whole body was thus palsied—the tongue was motionless, and deglutition extremely difficult: but her intellectual faculties re- mained unimpaired."§ 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." I. 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 concomitant of this disease. Hemiplegia is almost always ushered in with more or less distinctly marked apoplectic symptoms. Occasionally the hemiplegic attack occurs suddenly, without any distinct mani- festations 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 fullness, weight, and sometimes pain in the head; ringing in the ears; drowsiness ; im- peded 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 * Medico-Chirurg. Rev., Oct. 1829, p. 168. ! [The late Mr. D. Perrine, of this city, had been cured of a chronic rheumatism, which was followed by a troublesome papulary eruption and pruritus over the trunk. As I attributed these symptoms to the previous use of the tincture of guaiacum, I advised him to avoid external appli- cations, and depend upon the mineral waters of Virginia, which he was about to visit. A phy- sician there, however, recommended astringent washes, and other repellents, which speedily relieved the eruptions and the irritation In a few days afterwards he attended a trial in court, and found himself unable to rise or move as the audience were going out. A severe attack of hemiplegia followed, from which he could not be recovered until I re-excited the eruptions and pruritus by the internal use of tr. guaiacum and external irritants. Severe pruritus continued for several years after, especially in his nose, and the paralysis did not return. He eventually died of hydrothorax —Mc] X Medical Works, vol. iv. p. 552. § Med.-Chir. Rev., Oct. 1826, p. 604. Clinical Report of the Hospice de Perfectionnement. Rev. Medicale, 1S26. 29 450 PARAPLEGIA. 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 whole track of the ali- mentary canal is extremely torpid, and it would appear that the liver is sometimes affected.* The countenance 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 diffi- cult and indistinct; the 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 dis- ease. General impairment of the intellectual powers usually occurs ; but ihe memory is most apt to become conspicuously enfeebled, and even wholly effaced. Very remarkable anomalous circumstances are sometimes connected with hemiplegic 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.,\o\. 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 insensibility 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 forearm were in a perfectly natural state, both as to fullness 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 forearm 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 commonly, however, more or less amend- ment slowly occurs, until the patient is perhaps able to support himself with but little aid in a sitting posture, or even to walk about, with some assistance, with- out any further improvement. Occasionally the paralysis passes off almost en- tirely 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 paralyzed part. 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 effect the superior parts of the body ; but the term paraplegia is generally restricted to palsy of the inferior extremities, and parts about the pelvis.! * Morgagni, Epist. xi., art xiv. t [Paraplegia of the superior extremities alone is a very rare disease. It can only arise from PARALYSIS PARTIALIS. 451 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 numbness 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 gradu- ally 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 paralyzed, 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 affec- tion was experienced in the lower extremities. Sometimes the palsy is complete, the patient being unable to maintain even a sitting posture; in other cases the power of motion 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 involun- tarily thrown across each other, causing frequent tripping or stumbling. By degrees the insensibility and loss of muscular power in the legs and thighs be- come 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 attend- ing symptoms of cerebral disturbance, depended, I presume, on some affection of the brain. In the course of about ten days after the accession of the paraly- sis, the heel first, and then 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 affections 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 paraplegia which depends on disease or injury of the spine, is most common in childhood, and seldom comes on spon- taneously 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 instances the palsy is confined an injury, or disease of the brachial nerves, after they have left the spinal cord. If the cervical portion of the cord itself is injured, a paraplegia of all the parts below must follow, I have met two cases of paraplegia of the arms, both of which followed concussions from falls on the shoulders. The spinal cord could not have been seriously injured, or the patients could not have walked to visit me at my office. I took it for granted that a concussion must have been communicated to the brachial plexus on each side, for both arms were paralyzed. One of them was a gentleman in Roxborough; the other was the late Mr. Somerdyke, of this city. I will take some future opportunity to communicate the details of these interesting cases to the profession. I will now merely remark that, although relaxed and flabby at first, their arms became rigid and painful in a few days, plainly exhibiting the development of inflamma- tion in the brachial nerves, and converting the original atonic paralysis from concussion into a rigid or neuralgic paralysis from irritation.—Mc] * Observations upon Paraplegia in Adults. By Matthew Baillie, M. D., in the sixth volume of the Medical Transactions of the London College of Physicians. X Dr. C. Meigs has reported an interesting instance of paralysis of the inferior extremities, occasioned by the sudden repulsion of crusta lactea by some drying ointment.—(North Amer. Med. and Surg. Journ., vol. x. p. 376.) 452 PARALYSIS PARTIALIS. to a particular organ, but when the muscles are the seat of the affection, it gene- rally 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 olfactory 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 paralyzed.* 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 impro- bable 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 chief im- mediate 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 powerfully," 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 apoplexy; and, on the contrary, paraly- sis 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 should be led, a 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 sub- ject of paralysis from sudden exposure to cold, has adduced some cases which would seem to show that both general and local palsy sometimes depend on a morbid condition of the nerves alone, independent of any affection of the en- cephalic mass. So far, however, as post-mortem examinations can throw any light upon the nature of the proximate cause of general 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 con- nected with sanguineous extravasation into the brain, but also sometimes with serous effusion; or with traces of recent inflammation and vascular turgescence; 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 por- tion of it; and with other morbid conditions of this organ. (Abercrombie.) Willis states, that in cases of protracted 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 • [The deltoid is especially liable to this affection.—Mc] PARALYSIS PARTIALIS. 453 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 iis immediate vicinity. M. Serres mentions a case of apoplexy attended with palsy, in which every part of the brain was perfectly sound, except the tuber annulare, which was completely destroyed by a central cavity containing a clot of blood. Although some of these phenomena usually present themselves on the dissection of paralytic sub- jects, 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 the apparently similar morbid states within the brain. In one patient, 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 hemi- plegia; in a third patient, perhaps, with paraplegia; 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 obser- vations 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 precise information on this interesting subject. The general fact, that pressure or organic lesion of the brain is often attended with paralysis, 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 cerebral disease. Paraplegia in adults, says Dr. Baillie, is by most pathologists 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."! He denies the correctness of this opinion, and expresses his conviction that, like hemiplegia, this form of palsy "depends most commonly 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 ;+. 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 arach- noid was much thickened and opaque ; the substance of the brain was conside- rably 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 verte- bralis, and between the membranes of the brain. Dr. Baillie thinks that the serum which is sometimes found in the theca vertebralis in this affection, de- scends into it from the brain. We cannot doubt that paraplegia may sometimes 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 paraplegic affection; and in children this is unquestionably by far the most common source of the disease. In rela- tion to the disease in adults, a great number of well-authenticated dissections might be adduced, presenting unequivocal evidence of its spinal origin; and facts illustrative of this point, in reference to the disease in children, must be familiar to every one. It has already been observed, that paralysis depending on the 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, bul these are extremely rare. Mr. Bayle has * Med. Repository, No. 1, New Series. ! Loc. cit., p. 17. X Med.-Chir. Rev., December 1820, p. 392. 454 PARALYSIS PARTIALIS. collected, from different authorities, eight cases in which palsy took place on the same side of the cerebral affection.* When paraplegia depends on disease seated within the head, the primary affection 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 probably the most common. Local paralysis is sometimes excited apparently by intestinal irritation in children. In cases of this kind, the palsy is usually confined to one of the arms.! 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.*. The occa- sional 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 disorganization 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 trige- minus, namely, the action of the orbicularis oris, of the eyelids, of the buccina- tors, 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 reverse condition in this respect obtains—the actions just enumerated 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 influence 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 sometimes occurs, apparently from pressure of the nerves which go to these muscles. Cases of * Revue Medicale, Janvier 1824. ! 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. || [This is not exactly correct. The portio dura supplies all the voluntary and involuntary motions of the muscles of the face and brow—including the frontal., the corrugator, the orbicu- laris, the buccinator, &c. The only exceptions are the muscles of the eyeball, the levator pal- pebrae superioris, and the masticators. Mr. Bell's original statement that the portio dura only controlled the associated or involuntary motions, was incorrect. The fifth pair supplies common sensibility alone to the forehead, eyes and face. The small anterior root of its third branch alone is muscular, and that supplies the masticator muscles solely. The phenomena dependent upon a partial paralysis of the portio dura correspond exactly with this anatomy; and the state- ments in the text of our author must, therefore, be taken with some modification.—Mc] PARALYSIS PARTIALIS. 455 this kind generally come on during sleep, and seem to be occasioned by a par- ticular position of the arm, while the head is resting upon it, and compressing, perhaps, its principal arteries 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 physiolo- gists. 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 mus- cles the power of voluntary motion. What was thus alleged from mere theo- retical views 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 sensi- bility 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 mo- tion is destroyed in the parts to which it is distributed, bu^ the sensibility remains unaffected. This physiological fact throws much light on the curious phenome- non in question, 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 hemiplegia does not differ from that which is proper for warding off an attack of apoplexy. In the apprehensions of a stroke of palsy, a low diet, gentle exercise in the open air, and the avoidance of all kinds of stimulating liquors, as well as of full and heavy meals, should be enjoined; and the bowels kept in regular motion by gentle lax- ative medicines. Where predisposition to apoplexy exists, and particularly when the ordinary premonitory symptoms of this affection occur frequently, a drain by means of setons or issues established in the neighborhood of the head, will contribute ma- terially 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 sweeping declarations either in favor of or against this measure. We meet with cases, for instance, in which there are unequivocal manifestations 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 extrava- sation into the brain ; or in a slow disorganization 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 obviously contra- indicated. In a few cases, I have extracted from forty to fifty ounces of blood in the course of twelve hours after the hemiplegic attack with decided benefit; but I have met with cases, also, in which even a moderate bleeding brought on faint- ness and alarming weakness, without any favorable impression on the paralytic affection. Of course, even where the state of the circulation indicates the pro- 456 PARALYSIS PARTIALIS. priety of this evacuation, regard must be had to the age of the patient, his con- stitutional 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 re- frigerant 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." An excellent mode of giving purgatives in habits of this latter kind, is to administer them in combina- tion 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 ope- rate 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 treatment of hemiplegia. In recent instances, ushered in by apoplectic symptoms, and par- ticularly in robust and plethoric subjects, they are of doubtful propriety. When hemiplegia comes on during a dyspeptic condition of the stomach, or soon after taking food of difficult digestion, an emetic may, no doubt, prove very service- able. 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, besides 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 purgative salts. When all the symptoms of undue determination to the head have disappeared, or the disease has assumed a strictly chronic character, antiphlogistic and de- pletory remedies are no longer appropriate means. Exciting remedies must now be resorted to. Frictions, stimulating liniments, sinapisms, blisters, stimu- lating baths, cold affusions, electricity and galvanism, are the principal external exciting applications; and, under proper management, they often prove decidedly beneficial. Frictions with the flesh-brush, or a piece of dry flannel, will some- times answer better than the more irritating or rubefacient 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 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 application of nettles was much recommended; and from the very pungent irritation they pro- PARALYSIS PARTIALIS. 457 duce in the skin, they may, no doubt, be serviceable. I have known the appli- cation of dolichos pruriens to 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 observes, that electricity has often proved wholly inefficacious in paralysis, 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 remarks, that this agent " is only to be considered safe when its operation is confined to parts somewhat re- mote 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 affection; and it is said to be safer, and in general, more, effectual than electricity. Dr. Bardsley, from considerable experience with the use of galvanism in paralysis, concluded, 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 discon- tinued ; 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 secretions improved, we may per- sist in the application of this agent, with the prospect of ultimate and permanent advantage. When the affected parts are so torpid as to render them insuscepti- ble of the galvanic stimulus, the cuticle ought to be removed by a small blister, and the metallic points applied to the raw skin. (Bardsley.)* M. Roux has 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 vertebrae, 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 introduced 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 vertebrae, procured immediate benefit. Larry men- tions 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 forearm 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 pre- vented by the application of ammonia.! The instances on record of the success- ful 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 strychnine, has of late * Medical Reports, p. 183. Cook, 1. c. p. 296. X Recueil des Memoires de Chirurgie, par le Baron D. L. Larrey, p. 94. 458 PARALYSIS PARTIALIS. years been a good deal used in palsy, and occasionally with decided benefits- Mr. Pureell has recently reported a case of paraplegia, in which this article, in conjunction with the application of moxa, was successfully used.! Professor Giddings, of the University of Maryland, has also reported several highly in- teresting cases, which yielded to the influence of the strychnine. One of these cases was manifestly the result of sanguineous extravasation into the brain, as its acception was attended with decided apoplectic phenomena. The second was a case of general paralysis, and the consequence, as was believed, of the in- jurious influence of lead. This article may be given in doses of from one-six- teenth 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. 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 convulsive motions which result from the operation of this'narcotic, appear early in the palsied limb, in connection with transient tremors, formica- tion, 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 san- guineous extravasation into the cerebrum, this remedy cannot be employed with- out 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 strychnine, 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 occa- sional effects in paralytic disorders. This article was formerly highly extolled for its remedial powers in affections of this kind, and in Germany it has lately again attracted considerable attention in this respect.*. In two instances of hemi- plegia, I prescribed the saturated tincture of the leaves of the rhus with un- equivocal benefit. In a letter to me from Professor Osann, of Berlin, I am in- formed that the following mixture has been used with decided benefit at the Poly- clinic Institute, in paralysis of the lower extremities: R.—Tinct. rhois. toxicodend. Jss. ---- aconiti • ---- guaiaci volat, aa, Jii.—M. S. Take forty drops every three hours. The effects of this article are often very similar to those which result from the * 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 mix 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. ! Medico Chirurg. Rev., November 1829, p.203.—Prov. Med. Gazette, No. xi., July 1829. X M. Dufresnoy, Professor of Botany at Valencia, was, I believe, the first who used the rhus toxicodendron in palsy.(a) 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 benefited 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), Gisovius (Rust's Magazine, bd xiv. s. 386), D'Alqnen (Harles Rhein-Westphal. Jahrb. ect. bd. x. st. i. s. 135), Osann (Hufeland's Biblioth. d. Heilkund, 1823, Mai, s. 324), Buchheim (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 remedial powers of this article in different forms of palsy. (a) [Dr. Senter, of Rhode Island, first introduced the rhus toxicodendron to the. notice of the profession ; and his experience, originally published betore the American Revolution, was afterwards noticed in Dun- can's Medical Commentaries.—Mc] PARALYSIS PARTIALIS. 459 full operation of the nux vomica. In one of the cases in which I used it, the patient experienced occasional convulsive 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 headache, 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 depletory 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 particularly 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. Hufe- land states that he cured a case of scrofulous deafness with this article, in con- junction with antimonials.*. 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, has also been recom- mended 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 parti- cularly useful in paralysis of the inferior extremities, and of the bladder. Kolpin 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., 1804.) The chenopodium ambrosioides is said to have produced excellent effects in aphonia from paralysis of the muscles of the la- rynx.^[ It is given in substance, in doses of from a scruple to half adrachm, twice or thrice daily. Jahn (Klinik. der Chron. Krank.,\>. i. p. 365) says the belladonna is one of the most efficacious remedies in paralysis. Besides the foregoing reme- dies, 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 affec- tions, 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 re- peated application of blisters, or other active irritating substances to the wrists, and the use of the splint or battledore, recommended by Dr. Pemberton,** with mild aperients, and occasional warm bathing, constitute our most useful remedial means. Dr. Gregory is not willing to attribute any powers to mercury against * Medical Researches on the Effects of Iodine, &c.—Lond. 1825, pp. 87-90. ! 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, Plenck, and others. (Cook.) || Hufeland's Journal, bd. ii. st. iv. p. 570. IT Borries. Ibid., bd. xiv. st. ii. p. 201. ** This consists simply in applying a carved splint to the inner side of the arm, so that the broad surface supports the hand. 460 EPILEPSY. this affection, notwithstanding the authority of Dr. Clutterbuck in it's 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 local irritating applica- tions.* In paralysis of the tongue, we may direct the patient to chew the root pyrethrum, or other irritating and pungent substances ; such as cloves, senega, squills, pep- per, 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 being 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 remedial 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, produced, or at ieast 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 distressing and deplorable of human maladies. Its tendency to impair the understanding, to produce hebe- tude, and even total abolition of the rational powers, leads often to a condition infinitely more lamentable than death itself. So frightful and distressing a dis- ease 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 Roman physicians.§ The soporose and convulsive affections are so closely allied to each other, both in relation to their general phenomena and their pathological character, that it is extremely difficult to give an unexceptionable definition of any of them. Epilepsy may, perhaps, be defined a disease primarily seated in the nervous system, manifested by convulsions recurring at uncertain periods in paroxysm, accompanied by a temporary loss of consciousness, sense, and voluntary motion, and terminating in somnolency. The epileptic attack sometimes comes on suddenly without any manifestations * 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 effectual means we possess in this affection. ! New York Med. and Phys. Journ., Dec. 1834. X [The portia dura nerve is frequently affected by the influence of a current of cold air, so as to produce a muscular paralysis at the side of the face and forehead. I have known patients afflicted with it on coming up from a damp cellar, and then their friends became alarmed at the distortion of the countenance, and indulged the fears of an apoplexy. I have always succeeded in curing this form of palsy in a few days, by diaphoretics and counter-irritants. Enveloping the whole face and side of the head in carded cotton, and rubbing croton oil occasionally over the course of the nerve, will generally afford speedy relief.—Mc] § Hippocrates describes epilepsy under the name of morbus saver—a name which was given to it from its supposed origin; it being generally regarded at his day as an 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 comitialis. We nevertheless find it mentioned also under various other names in their writings—such as morbus sonticus, morbus cadueus, morbus puerilis, morbus insputalus, seleniacus, major, magnus, vitriolatus, mensalis, &c. In the sacred writings, epileptic persons are called lunaticos. EPILEPSY. 461 of its approach. More frequently, however, certain symptoms precede the oc- currence of the paroxysm, and of these the following are the most common:— A peculiar confusion and distressing 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 restlessness in the extremities ; an anxious feeling in the praecordial region ; restlessness and start- ing 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 gloom- iness with an irritable temper is manifested by some patients. In some cases, the mind falls into a kind of reverie from which it cannot be drawn, which ter- minates often speedily in total insensibility. Some epileptics evince an unusu- ally timid disposition ; others are spiteful, resentful 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 precur- sors 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 ap- plied, and which, I believe, occurs in no other disease, is compared by patients to the feeling which is communicated by a gentle stream of cool air directed on the part. This sensation generally commences in the feet or legs, and gradually ascends until it reaches the head, when the patients instantly become insensible 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 dur- ing 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 singu- lar sensation.* The primary irritation is, however, almost invariably seated elsewhere, and transferred sympathetically to the part in which the aura com- mences. In many instances, the attack always occurs at night while the patient is sleep- ing. In this respect epilepsy differs conspicuously from chorea, the convulsive motions of which, however violent during 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 immediately becomes more or less violently convulsed. In some cases, the convulsive actions of the mus- cles, 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 spasmodically thrust from the mouth, which, with "gnashing of the teeth, and foaming at the mouth, give the countenance a horridly wild expres- sion." 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 towards the spine. In many instances, there are strong erections of the penis, with spasmodic retraction of the testicles, and occasional seminal discharge. (Richter.) The face is occa- sionally pale, but more commonly livid with a turgid slate of the veins of the head and neck. The heart palpitates rapidly ; the pulse is usually contracted, * Van Swieten's Commentaries, vol. iii. p. 419.—See also Medical Experiments and Obser- vations by a Society, &c, at Edinburgh, vol. iv. p. 334. 462 EPILEPSY. irregular and frequent;* and respiration oppressed, laborious, and, in violent cases, sonorous. About the termination of the paroxysm, a considerable quan- tity 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 vacant and stupid expression, and the eyes are dull, staring and wandering. 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.! The sweating has been known to be distinctly confined to one side of the body only.J Epi- lepsy does not, however, always assume the violent grade just described. Some- times the attack supervenes suddenly, and after a few moments of partial con- vulsions 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 diver- sity. The convulsive stage generally continues from ten to fifteen minutes, some- times 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 pa- tient passing from one to 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 sudden 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 returns almost daily; in others at various intervals, from a few days 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 paroxysms recur regu- larly at the periods of a new or full moon. Nearly twenty years ago I treated a case successfully, in which for several years previously the paroxysms had re- turned 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. [| 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 idiot- ism 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 * 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. De Haen, Ratio Medend, torn. v. p. 123. "Voigtel's Handbuch der Patholog. Anatom., b. i..p. 70. § Specieile Therapie, bd. vii. p. 570. || For a full discussion of this point, the reader may consult Mead, de Imperio Solis et Lunfe 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, Aretams, and Alexander Tral- lianus entertained this opin'ion.—(Cook on Nervous Diseases.) EPILEPSY. 463 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 inde- fatigable anatomist, it was generally thought that the cerebrum is the chief seat of the proximate cause of epilepsy. M. Wentzel, however, in a very great proportion 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, yellow, 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 materially diseased in epilepsy. This, indeed, Wentzel does not deny, but his observations convinced him that it is much less frequently the case than we might be led to believe from the obser- vations previously published on this subject.! Both GredingJ and Roederer re- late cases in which the cerebrum was disorganized 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. Cannes.—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 secondarily, through the medium of the nerves. It is evi- dent, 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 remedial treatment than the former. In some individuals there appears to exist a constitutional predisposition 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 remarkable 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 disease 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 * [Mr. Solly has discovered the connection of fibres between the cerebellum and the anterior fasciculus of the spinal cold, and similar commissures can be traced from the same column to most parts of the cerebrum. The involuntary control of the passions and propensities over the muscular powers can thus be explained, and also the influence of irritation and organic lesions of these fibres in the way of developing the paroxysms of epilepsy. The intellectual powers are supposed to be chiefly affected by derangement of the cineritious or pulpy substance of the brain, while the muscular system is influenced by the medullary fibres which are connected with its spinal apparatus of muscular motion.—Mc] ! Cook on Nervous Diseases, &c, p. 342. X Sammtliche Med. S diriften, ii. Tlieil. § Pra;lectiones in Prax. Med., torn. v. p. 30. || De Hereditar. Dispos. ad Varios Affectus. Halle, 1706, p. 48. Also in his Dissertatio de Epilepsia Hujreditaria Casum Exhibens, as quoted in Richter's Specieile Therapie, bd. vii. p. 594. 464 EPILEPSY. given rise to this opinion. Those who have once had this disease, and have been freed from it by remedial treatment, generally retain a particular predisposi- tion 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 distension of the cerebral vessels; various organic affections of the brain, and effusions of dif- ferent kinds within the cranium. (Cook.) Sudden and violent mental emotions frequently produce this disease by a morbid excitement originating in the brain. Fear, terror, grief, and other dis- agreeable sensorial and mental impressions, have been known to give rise to epilepsy. I have met with three instances 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 remarkable instances of epilepsy, excited by disagreeable and strong impressions on the senses, have been reported. Strong odors, sudden and vivid light, loud and pe- culiar 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 excited epileptic paroxysms.* The odor of the garden ranunculus has also given rise to this disease;! 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 present one. The mere recollection, or sight of the causes or cir- cumstances which attended the first attack of the disease, has re-excited the par- oxysm.;]: 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 related, which ceased entirely after the expulsion of a tape-worm.§ Leeches swallowed into the stomach have produced epilepsy. (Gudenklee.) 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, issues, &c, may give rise to epilepsy. Richter mentions the suppression of habitual sweating of the feet as a strong exciting cause of 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 * Hufeland's Journal, bd. xii. st. i. s. 174. ! Acta. Natur Curios., Dec. iii. Ann. ix. x. Obs. 92, p. 170. X Van Swieten, 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 interesting observations of Prichard on this subject in his Treatise on Nervous Diseases. EPILEPSY. 465 out, or from its sudden retrocession, this form of convulsive disease is by no means uncommon. Excessive evacuations are also among the exciting causes of epilepsy; 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.! 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-Chirurgieal Trans- actions, 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 proceeds from the com- bined 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 preg- nancy. 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 epileptic 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 sup- pressed sanguineous and serous discharges.*. Atmospheric influences also have been supposed capable of exciting this disease. Great heat or cold, and sudden vicissitudes of temperature, are mentioned as exciting causes ; but their influence in the production of this affection is perhaps rather predisposing and exciting. 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 many of them absurd, I shall content myself with a statement of those circumstances 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 cha- acter may be, is always seated in the brain. 2. In the majority of fatal cases, organic and other obvious affections 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 irritations 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 predisposition to the disease and the * Zimmerman on Experience, vol. iv. chap. 10. ! Langsdarf in d. Weterauschen Annalen, bd. ii. hft. 2, (Richter, Spec. Ther.) t ("The inhalation of the vapor of sulphuric ether to produce the effects of nitrous oxide, has produced the worst form of congestive epilepsy I have ever seen.—Mc] § 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 superabundance of the nervous power in the sen- sorium commune. 30 466 EPILEPSY. 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 occasional strict periodicity of its recurrence. The influence of habit has been adduced in explanation of these mysterious points of pathology. 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 explanation 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 dis- tinguished 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 ^vhich indicate its character, such as the globus hystericus, involuntary laughing or weeping, and in many instances a continuation of some degree of consciousness, &c. Prognosis.—Although the immediate danger of the epileptic paroxysm is not in general very great, yet in relation to its sanability, 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 de- pends on organic disorder within the head, no remedial management can effect a cure. Epilepsy, however, unconnected with cerebral lesion, may sometimes be cured.* That variety of the disease which occurs in young females about the age of puberty, from menstrual irregularities, is not unfrequently curable, and indeed sometimes passes off spontaneously after the catamenia begin to flow re- gularly. 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 im- paired by its attacks, all hopes of a cure may be abandoned. Experience, too, has shown that those epilepsies which commence soon after birth, or during early infancy, rarely, if ever, yield to remedial treatment. From the period of dentition to that of puberty, is the most favorable age for the cure of this affec- tion. Hippocrates observes, that those who are attacked with epilepsy after the twenty-fifth year of age, will continue to have it as long they live—an observa- tion 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 * Dr. Dewees, in his work on the " Practice of Physic," has inadvertently expressed contra- dictory sentiments in relation to the curableness of this disease. Under the head of treatment, he asks, "What plan of treatment has ever succeeded in curing epilepsy"? Has epilepsy ever been cured V Under the head of diagnosis, however, he says, " When the disease is symp- tomatic, it is occasionally curable:" again, "those attacked between the fourth and tenth year may be cured by proper treatment." Most assuredly this latter sentiment accords with the ex- perience 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 observation, 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. s. 5.—Aphor. xlv. s 2. EPILEPSY. 467 occur in the exanthematous diseases, are seldom followed by serious conse- quences, and very rarely occur afterwards. When the premonitory symptoms consist of some affections in the head, it may be regarded as more unfavorable than if they manifest themselves in remote parts of the body, particularly in the extremities. Richter observes, that a long continuance of the sleep, and subsequent mental stupor and confusion after the subsidence of the paroxysm, are very unfavorable signs. 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. 276.) 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 expe- rience, that epilepsy occasionally ceases spontaneously on a change of climate.* Treatment.—There is, perhaps, no disease in which medical treatment is so frequently purely empirical as the one now under consideration. The causes are so multifarious, and generally so obscure, or so wholly beyond our cogni- zance, that we are seldom enabled to prescribe with any degree of reliance upon general and rational therapeutic principles. In this state of perplexity and un- certainty, 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 instances at least, sufficient lights in the symp- toms 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 patient, his age, previous or concomitant diseases, his habitual temper and disposition of mind, his manner of living, his probable hereditary predisposition—in short, into everything which can throw light on the particular character of the disease, and on the constitu- tional 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 effect- ually 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 prevention of a fit breaks the habit of the disease, and because the frequent compression renders the nerves less fit to propagate the aura."! Dr. Cook mentions an in- stance from the London Medical and Physical Journal, in which pressure made in this way prevented the paroxysm. Richter states, that when compression is thus made on a limb, above the ascending aura, the patient generally experi- ences great 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 epilep- tic paroxysm after it had actually supervened.*. In persons of robust and ple- thoric 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 palliating the impend- * Lentin, in Hufeland's Journal, bd. xiv. s. iii. p. 17. f [The late Mr. Loper, prompter of the Chestnut Street Theatre, could always prevent a monthly paroxysm of epilepsy by applying a tourniquet to his left thigh the instant he felt the aura creeping up from his left ring toe. On one occasion, however, he was prevented by the exigencies of his calling from applying this prophylactic, and the attack which followed proved fatal.—Mc ] X De artum ligaturis ad nonnullos morbos internos. Michaelis—in Medizin. Pract. Biblio- thek, bd. i. st. iii. p. 397—as quoted by Richter. 468 EPILEPSY. ing paroxysm, where the premonitory stage is protracted; but their tendency in this respect deserves little or no attention. Richter and other of the earlier Ger- man 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 ex- citing 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 admi- nistration of emetics a short time before the expected occurrence of the epileptic attack.* 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 regarded as of very doubtful propriety. Jahn, in his excellent work on chronic diseases, says that a draught of cold water will occa- sionally 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.! Some fifteen years ago, while practising in Lancaster, I 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 diminish 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 paroxysm 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 that may compress the veins of the neck, or impede the free return of blood from the brain to the heart. It is very doubtful, however, whether any treatment, during the epileptic paroxysm, can materially mitigate its violence, or shorten its duration. It is almost exclusively with the view of protecting the brain, that remedial 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. I 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 ap- propriate 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, flatu- lency, disturbed sleep, and other manifestations of indigestion are present in chil- dren affected with this disease, a course of emetics has 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.t Dr. Clark recommends a solution of sulphate of zinc, in an aqueous infusion of ipe- cacuanha, to be given every six, eight, or ten days. • Specieile Therapie, bd. vii. p. 630. f Hufeland's Journal, bd. x. st. ii. p. 133. X This case carne on after an attack of ague, which was cured by Fowler's solution. EPILEPSY. 469 Absorbents have also been recommended in the epilepsies of infants, attended with gastric disturbance ; and when used in conjunction with mild tonics, and an occasional aperient, they are sometimes beneficial, particularly where there is much acidity in the primae viae.* 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 parox- ysm. He mentions also a peculiar tremulous motion of the under lip, as a sign of gastric irritation, from vitiated 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 intestinal worms are present, anthelmintic remedies are decidedly indicated. 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 su i\\ cases. In verminous epilepsy, full doses of powdered valerian with the elutriated oxyde of tin, have been successfully used. From one to two drachms of the former, with thirty to forty grains of the latter, may be taken three times daily. Should it appear that the disease arose, in the first instance, from sudden sup- pression 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 stimulating 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 appropriate and occasionally beneficial remedies in such cases. When epilepsy arises from the repulsion of cutaneous eruptions, or the dry- ing up of old ulcers, the manifest indication is to restore these affections ; or, if this cannot be done, to establish others artificially in their stead. For this pur- pose we may employ issues, setons, blisters, and particularly frictions with tartar emetic ointment, together with diaphoretics, warm bathing, and stimulating fric- tions. 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 pro- ducing ptyalism, in this variety of the disease. One of his patients was perfectly cured by a copious salivation. In those cases which occur in young females, in consequence of an unsuccess- ful 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 men- strual 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 decidedly indi- cated by the condition of the pulse, the occasionally flushed countenance, and sense of fullness in the head. Dr. Prichard, speaking of this variety of the dis- ease, 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 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 * 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 possesses to its absorbent, tonic, and aperient virtues. It is composed of one ounce of powdered mistletoe, the same quantity of sugar, and half an ounce of the carbonate of magnesia The dose is a teaspoonful two or three times daily for a child under five years old.—Richter's Spec. 1'herap., bd. via. p. 645. •f Comment., t. iii. p. 439. 470 EPILEPSY. to come on. In addition to bleeding in cases of this kind, the warm semicu- pium is a valuable remedy.* We may also employ frictions about the loins, back, and pubic region, and stimulating enemata, with advantage. Prichard re- commends 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 ple- thoric or phlogistic state of the system has been reduced by the foregoing mea- sures, it will be proper to resort to emmenagogue remedies, if the menstrual evacuation has not already been restored. The following pill may be employed for this purpose.! According to the experience of Dr. Prichard, the best em- menagogue 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 re- commended. This variety of epilepsy is almost invariably suspended by preg- nancy. In epilepsy from onanism, besides the proper moral influences, Richter strong- ly recommends the use of camphor in regular and full doses. That this article possesses the power of lessening the venereal propensity I am fully persuaded, and its general influence, independent of this particular effect, renders it a suit- able remedy in cases of this kind. Patients affected with epilepsy from this cause, should sleep on a hard matress, rise early, take exercise in the open air, and use a mild and unirritating diet. The tepid shower-bath, and laborious oc- cupations, will sometimes assist materially in removing the habit upon which the disease depends, and without the discontinuance of this habit, nothing useful can be expected from remedial treatment.*. Epilepsy from local injuries of the head has been cured by surgical operations. Boerhaave, Thenier, Stalpart, and Van der Weil, relate instances in which tre- panning succeeded in removing the disease. Tissot also mentions several in- stances 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 paroxysms returned no more.§ Instances have also occurred in which epilepsy was cured by surgical opera- tions 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 pa- tient was cured by dividing the radial nerves.|| The disease has sometimes terminated spontaneously after the removal of spiculae of bones, balls, tumors, or other foreign bodies pressing upon particular nerves.^[ Dr. Dudley, of Lexing- ton, 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.** * The bath, says Prichard, should be about the temperature of 95° or 98° of Fahrenheit's scale.—Treatise on Diseases of the Nervous System. Lond. 1822. ! R.—Extract, sabinte 3Jii. G. aloes lace. Qi. Sulphat. ferri grs. x—M. Fiant pil. No. 40. Take one every six hours. X [In this class of cases, the application of solid nitrate of silver to the prostatic portion of the urethra is especially serviceable.—Mc] § Philadelphia Med. and Phys. Journ., 1809, No. 35. || Cours d'Anatomie Medicale, t. iv. pp. 247, 272. IT Memoires sur la Nature et le Traitement de Plusieurs Maladies. Par Ant. Porta], vol. xi. p. 229. (Richter) ** [I applied the trephine in one case, over the seat of an old injury of the skull, and extracted fragments of the internal table which had been driven inwards through the dura mater, so as to penetrate the cerebral substance. But a great deal of grisly induration existed around and below these fragments, so that, although the patient recovered from the operation, subsequent EPILEPSY. 471 This case is an extremely interesting one, and deserves to be consulted as a re- markable 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 instances, 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 one, or many, by turns, of that long list of remedies which, according to the reports of eminent practitioners, or our own experience, 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 Dioscorides 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 catamenia, terror, and repelled cutaneous eruptions. Quarin used it with success in epilepsy of infants. (Richter.)*. Biett generally 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 mistletoe also is a very old remedy in epilepsy; and if we are to place paroxysms of epilepsy were not prevented. He was relieved in some measure, however, from the violent spasms of the opposite side, with which he had been occasionally afflicted for several months before. From the experience of surgeons within my course of observation, I have not been able to form a favorable opinion of the operation of trephining, in cases of epilepsy follow- ing injuries. The operation of securing the common carotid artery has been recommended on the principle of diminishing the flow of blood through the brain in severe cases of epilepsy. Dr. M'Gill, of Hagerstown, is said to have performed this operation repeatedly, and in one case upon both the common carotids at two successive operations on the same subject. Whether his success was permanent or merely temporary, I have had no opportunity of ascertaining. In a case of vio- lent epilepsy, connected with the protrusion of a pulsating vascular tumor (aneurism by anas- tomosis) through the parietal bone, I took up the common carotid. The result was that the tumor shriveled away, and the epileptic paroxysms disappeared for about six months, when they reappeared with diminished violence The division of the sensitive nerves, which supply painful spots on the scalp, sometimes affords relief. I cured a young engineer of a bad epilepsy which had followed a blow on the upper region of the right side of the os frontis, received in the famous Bristol riot some three years before. A hard cicatrix remained over the principal branch of the frontal nerve, and pressure upon it would at any time excite a paroxysm. I cutout the cicatrix, and a portion of the nerve with it, and the disease never recurred.—Mc] * 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, regard it as of but little value in this disease. X The famous anti epileptic powder of Ragolai contains a large proportion of valerian. Accord- ing to Knopf's analysis, this nostrum is composed of one drachm of valerian, one scruple of orange leaves, two grains of muriate of ammonia, 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. Spec, vol. ii. 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. zingiberis. ----fol. salvias. ----sem. sinapi, aa ^i.—Dose—a teaspoonful three times daily. I have myself em- ployed this powder with advantage in a few cases, though never with complete success. 472 EPILEPSY. 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 probable, 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 Fothergill and Dr. Willan, in favor of this article as a remedy in epilepsy. Of late years, how- ever, 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 employed in the treatment of this disease ; and we have the testimony of Hoffman, Cullen, Bang4 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 metastatic 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 men- strual disorder, on the authority of Dr. Prichard. It has also been successfully used in other varieties, particularly in cases depending on intestinal irritation from worms and other offensive 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 disease, 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.|| and Thorn. Hufeland says, it is especially useful in the epi- leptic 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. Agaricus muscarius was first employed in this disease by Bernhard. Wist- ling and Gruner afterwards published statements illustrative of its powers in this affection. (Richter.) It is said to be most useftd in cases originating from re- pelled cutaneous eruptions. The dose is from a scruple to a drachm three times daily. Artemisia vulgaris, or mugwort, has been lately much commended for its virtues in this disease by several eminent German practitioners. About eight years ago, Dr. Burdach, an eminent physician 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 expe- * Dippel, Disquisitio de Vitm Animalis Morbis, p. 89. ! Acta. Societ. Med. Hav., vol. i. p. 5U0. t Transactions of the College of Physicians, Lond., vol. v. § Edinb. Med. and Surg. Journ., vol. ix. p. 271. || Klinik. d. Chron. Krankh., bd. i. p. 282. EPILEPSY. 473 rience of this physician, that in cases of epilepsy occurring in male subjects about the age of puberty, this remedy very seldom does any good. In young females about the same age, "its beneficial effects are often prompt and decisive." He occasionally found it very speedily successful in apparently very obstinate cases, while in others, seemingly quite similar, it was wholly inefficient. An interest- ing instance of the successful employment of this remedy is related by Dr. Wag- ner, in Hufeland's Journal, (vol. for 1824.) And in the twelfth Annual Report of the Berlin Polyclinic Institute, there is another case related which yielded under the use of the artemisia. It is usually given according to the following formula.* This is not a new remedy. Ettmuller mentions its use in epilepsy ; and Zwinger, speaking of this plant, says, mire in epilepsia valet. The internal ligenous 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 Pennsylvania.! Of the narcotics, belladonna,*, opium,§ camphor,|| and stramonium,^ have been most recommended in this affection. Some of the antispasmodics also have been employed with benefit in epilepsy. Among these, musk, castor, assafcetida, are generally supposed to be the most useful. Very commonly, however, no advan- tage whatever is to be derived from remedies of this kind ; and they are often manifestly injurious, by their tendency of increasing preternatural 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 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 ether. Of this, from eight to ten drops should be given three times daily in some mucilaginous fluid.** This article cannot, how- ever, be employed with propriety in cases attended with general plethora, or habitual congestions in the cepbalic vessels. Where symptomatic epilepsy is * R.—Pulv. rad. artem. vulg. ^ss. ----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 re- commended in this affection. Veratrum Album (Stark, Shulze, Greding). The roots of the white lily (Hufeland's Journal, b. xxxi. p. 30), Phelandrium aquaticum; faba St. Ignatii; the fresh juice of white onions (Hufeland's Annalen); Radix meu (Jahn) ; the juice of unripe grapes (L. Frank, Loebstein-Loebel); sedum aere (Zachorn, Hufeland's Journ., bd. xl. p. 19); folio aurantiorum (Van Swieten, De Haen, Stoerk, Werlbof, Stark, Hufeland, Thilenius). The carbonate of potash in large doses, is recommended in recent cases. (Hufeland's Journ., bd. viii. p. 170 ) X Stoll (Ratio Medend., vol. iii. p. 40G), Hufeland (Journal d. Prack. Heilk.. bd. ix.), Greding (Vermischte Schriften), and Jahu (Klinik. d. Chron. Krank., b. i. p. 282), speak favorably of this narcotic as a remedy in epilepsy. Richter says, it should never be given to children—or in cases attended with habitual congestion of the cerebral vessels. X 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 cases that arise from violent pain or mental excite- ment. 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 sleep, 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.) IT This article is much praised as a remedy for epilepsy by some of the Swedish 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.) ** In Horn's Archives of Medicine (bd. x. hft. ii. p. 270), the following formula is given for the administration of this article: J£.—Ol. tereb. ^ss; 01. olivar. giii; 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 $ Tart, emetic grs. xvi; Succ. glycyrrh. Ji. Fiant. pill, singul. grs. v. Of these pills three are to be taken every morning and evening for a month. Richter recommends the following pills : R—G. ammon.—Assafcetid.—Sapo. venet.—Rad. valerian.— Sumita arnica-, aa. gii; Tart, emetic grs. xviii. Fiant. pill. sing. grs. v. Six to be taken thrice dtiily for three or four weeks. The following combination forms an excellent purgative for this purpose : R.—Mass;i hydr gi; G. aloes ^ss. j Tart, antim. gr. ii. Fiant. pill. No. xx. Take one every night on going to bed. 576 AMAUROSIS. alkali; weak infusion of capsicum; vinous tincture of opium, &c. Electricity does not appear to possess any particular remedial powers in this affection ; and it is said to be even frequently injurious. Mr. Travers has not seen a single instance of benefit derived from electricity. Emetics were formerly much recommended in the treatment of amaurosis, not only for the purpose of evacuating the stomach, but also with a view to their general influence upon the nervous and sanguiferous systems. Mr. Travers does does not speak favorably of their effects in this disease. Richter, on the other hand, gives the most favorable account of their influence in amaurosis. That they have been employed with success in some instances, is unquestionable; and, under peculiar circumstances, may no doubt be again used with advantage ; although they are certainly not so efficacious as they were formerly represented to be by physicians of high authority. In complete amaurosis, of a chronic or asthenic character, the German writers recommend exposing the eye to a bright light, and even to the direct rays of a meridian sun, with a view of stimulating the palsied retina. Mr. Stevenson says, that he has heard of an instance of the success of this practice, although his own experience does not furnish him with an example of its usefulness. Mr. Stevenson recommends dry cupping applied to the ball of the eye and its ap- pendages. " By carefully fixing a well adapted strong glass, fitted with an ex- hausting syringe upon the edges of the orbit, the instrument may be made capable of exerting a more or less powerful influence upon the organ of vision, in pro- portion to the extent to which the atmospheric air contained in the cupping-glass is exhausted. The effect of this application is to occasion a great redness and tumefaction of the eyelids; an immediate distension of the conjunctiva; and a bulging forward, or protrusion of the whole globe of the eye, the obvious tend- ency of which must be to relieve the deep-seated vessels." He mentions a few cases, in which this practice was employed with the most decided advantage. Dr. Heathcote, of the Royal Infirmary of Edinburgh, has lately published some cases illustrative of the good effects of strychnine in amaurosis. The cases published by Dr. H., occurred in the practice of Dr. Short. The mode in which the strychnine was used in these cases, is as follows: A small blister, about the size of a crown piece, was applied upon the temple or forehead; when the part was vesicated, and the cuticle removed, one-fourth of a grain of strychnia, finely levigated, was dusted over the excoriated surface, and a piece of simple dressing placed over it. The quantity of strychnia applied is to be gradually increased, and the application made daily. Three cases, out of about sixteen, terminated successfully under this mode of management. In no instance did this remedy cause any injurious effects; although slight headache, giddiness and twitching of the limbs were experienced by some of the patients. " In one case, erysipelas of the face occurred, which immediately subsided upon the omission of the strychnia, and the use of opium, which is its proper antidote." One patient, after about seven grains of the strychnia had been applied, was seized with a numbness and immobility of the lower extremities; but these effects soon gave way to a few doses of opium and aperient remedies. We find, also, a statement in the London Medical Gazette, of five cases treated on this plan in the West- minster Ophthalmic Infirmary. In one case, evident and considerable benefit ensued.* Some modification in the treatment will, of course, always be made by the judicious practitioner, according to the occasional cause of the disease. Thus, when the disease appears to be the consequence of suppressed hemorrhoidal dis- charge, aloetic purgatives, stimulating enemata, and leeching round the anus, are indicated. If it be the result of an arthritic or rheumatic diathesis, advantage may probably be obtained from the internal use of the tinctura guaiaci, or col- chicum, and sinapisms and blisters to the ankles. In instances that arise from * Med. Chir. Rev., July 1830, p. 442. ASTHMA. 577 syphilitic irritation, a slow mercurial course, with infusion of sarsaparilla, &c, will be particularly indicated, and the same remedies are to be relied on where manifest hepatic disorder is present. If suppressed perspiration lie at the bottom of the disease, the warm bath, diaphoretics, particularly antimonials, both in nauseating and emetic doses, will be appropriate means. In short, the prac- titioner should always endeavor to ascertain the cause of the disease, and to counteract or remove this cause, if possible, by an appropriate course of remedial management.* CHAPTER IV. CHRONIC AFFECTIONS OF THE RESPIRATORY ORGANS. Sect. I.—Asthma. Asthma is a paroxysmal affection of the respiratory organs, characterized by great difficulty of breathing, tightness across the breast, and a sense of impending suffocation, without fever or local inflammation. In the majority of cases, certain symptoms, indicative of gastric derangement, precede, often for several days, the paroxysms of the disease. Among these symptoms, a sense of weight and fullness in the epigastrium, acid eructations, iuappetency, or voraciousness, heartburn, flatulency, weight over the eyes, anx- iety in the praecordia, and an itching of the skin, are the most common. The paroxysm generally comes on at night, during sleep. The patient is seized with great anxiety, difficulty of breathing, and stricture across the breast, and a short dry cough. These symptoms soon acquire a most appalling degree of violence. The breathing becomes wheezing, extremely laborious, gasping, and suffocative, the countenance expressive of intense anxiety and distress, and the heart generally palpitates violently. The desire for fresh and free air is inex- pressibly urgent; the patient insists on the doors and windows being thrown open; or he starts from his bed and rushes to the window for fresh air, and is wholly unable to remain in the recumbent posture. The extremities are gene- rally cool, sometimes of the natural temperature, and moist; the face is bloated, and livid or pale, and the veins of the neck and head are turgid. The pulse is often irregular, intermitting, accelerated, moderately full, and compressible; some- times it is nearly natural, and occasionally it is full, active, and firm. After these * [This last sentence in the chapter on amaurosis imparts a valuable hint to some practi- tioners There is no disease in which the treatment is conducted more empirically, or what is called systematically, than amaurosis. Accordingly there is not much greater success than in tetanus or even hydrophobia. The plan which I have always formed is founded on a careful study of the pathology of each particular case. When vascular engorgement attends an amau- rotic condition, a long continuance in the use of local depletion and derivation will sometimes succeed. An over distended cornea, in addition to diuretics and hydragogues, will often require punctures of the cornea to evacuate the humors. I succeeded in one case of total amaurosis attended by hydrophthalmia of the aqueous humor in the left, and of the vitreous in the right eye, by giving an active course of Clutterbuck's elaterium combined with calomel, and occa- sionally tapping the two over-distended humors in each eye. I cured an English gentleman of complete amaurosis in one eye, attended with syphilitic hemicrania and periosteal swellings of the scalp, by exciting a smart salivation, aided by the long continued use of a vapor bath and diaphoretic decoctions. Dr. Beesley, of Texas, was restored to tolerable vision by the use of lunar caustic to blacken the integuments over the forehead and lid, and by the daily use of pur- gative doses of croton oil. In the case of a young lady, after removing a severe form of attendant spinal irritation, and reducing the size of her over (Intended eyeballs by the use of elaterium, I restored perfect vision by the use of electro-magnetic apparatus,—Mc] 37 578 ASTHMA. symptoms have continued for an uncertain time, the breathing gradually becomes less laborious and anxious, and towards morning a copious expectoration of viscid mucus very generally ensues, which always brings with it considerable relief. During the ensuing day the patient usually experiences but little uneasi- ness or oppression in the chest. On the next night, however, the paroxysm of suffocative respiration returns; and in this way the disease proceeds, with remis- sions by day, and violent exacerbations at night, for three or four days in suc- cession, and in some instances much longer, before it finally subsides. During the paroxysm the urine is almost always pale and copious, and the abdomen distended with flatus. Breer states that the temperature of the body is generally considerably below the healthy standard. He has found the ther- mometer, placed under the tongue, as low as 82° during the asthmatic fit. He observes, also, that the violence and inconvenience of the paroxysm are equal, whether the stomach be full or empty; but that great distress is experienced immediately after the fit, if the stomach be completely empty. Patients often experience a sensation in the abdomen, about the commencement of the paroxysm, as if an evacuation from the bowels would certainly greatly relieve them ; but this feeling is almost invariably deceptive. No distinct pain is felt in the chest during the asthmatic paroxysm. Causes.—Asthma rarely occurs before the age of puberty; yet Dr. Gregory states that "the period of youth and manhood is most prone to it." If, indeed, we include the acute asthma of Millar, or as it is more commonly called in this country, spasmodic croup, under the head of genuine asthmatic affections, as is done by most of the German writers, there can be no doubt of the correctness of this observation ; but the spasmodic croup of children and the true asthma of adults are manifestly very distinct diseases. It is generally admitted that a pre- disposition to this affection is sometimes hereditary. This predisposition would seem to consist in a peculiarly irritable state of the pulmonary system ; or more correctly, perhaps, of the pneumogastric nerve. That this nerve is the seat of that peculiar condition which predisposes to asthma seems probable from the circumstance that, in persons who are subject to this disease, almost all the organs to which this nerve is largely distributed are particularly liable, from slight causes, to functional derangement. Thus, there are few asthmatic subjects who are not especially liable to gastric disorders; as indigestion, flatulent colic, and gastralgic affections. These facts would appear to show that the pneumo- gastric nerve which presides over the functions of the stomach and lungs is in a state peculiarly susceptible of being thrown into morbid excitement in asthmatic individuals, and that this condition has probably an important share in the pre- disposition in question. Authors have divided asthma into various species, founded principally on the different characters of the exciting or proximate causes of the disease. Bree has subdivided the disease into four varieties, namely : 1, those cases that are excited by the irritation of effused serum in the lungs ; 2, those arising from a gaseous acrimony in the pulmonary cells; 3, those resulting from gastric or abdominal irritation; and 4, those depending on habit. This division is, however, alto- gether arbitrary, as it is manifestly founded on gratuitous principles; for its dependence on an aerial acrimony in the lungs is a mere hypothesis; and the effused serum in the lungs is an effect, probably, and not the cause of the asth- matic paroxysm. It is certain, at least, that the difficulty of breathing always commences and continues for some time before the effusion of mucus into the bronchial cells becomes copious. Richter describes no less than eleven species of asthma, founded on the character of its prominent exciting causes, namely: Asthma hypochondricum et hystericum; A. plethoricum; A. urinosum; A. aereum; A. abdominale; A. nocturnum incubus; A. metallicum ; A. a causa specifica; A. ex debilitate; A. spasmodicum; and A. acutum periodicum millari. Some writers assume only three varieties:—the spasmodic, the dry, and the ASTHMA. 579 asthma from abdominal irritation. Dr. Good has admitted of but two species, namely: the dry or nervous, and the humid asthma. Such divisions do not, however, appear to possess any essential practical usefulness; and the mere dryness or humidity of the cough cannot, I think, be regarded as of sufficient importance to form the basis of a pathological distinc- tion. As symptoms, they unquestionably deserve attention; and it is no less proper, in a practical point of view, to attend to the nature of the exciting causes. The judicious and careful physician will not, however, require the aid of class- ification and subdivisions to bring these circumstances to his attention; and it may be reasonably doubted whetber any distinctions not founded on prominent and essential points of difference can be usefully admitted into the description and pathology of diseases. The exciting causes of asthma are— 1. Particular conditions of the atmosphere, in relation to its dryness or humidity, electricity, and temperature. In general, asthmatic individuals breathe easiest in a pure and unconfined air; but there are many who breathe better in the impure atmosphere of populous cities or crowded rooms than in the fresh and uncontaminated air of the country. Most persons subject to asthma, bear a dry and warm air much better than a cold and humid atmosphere; but here, too, the very reverse sometimes obtains in certain individuals liable to this affection. Some suffer most from this disease during the warm weather of summer ; whilst others experience its attacks only in the winter, or about the autumnal and ver- nal equinoxes. 2. Various irritating matters inhaled into the lungs are capable of exciting the disease in persons predisposed to it; such as dust, and the fumes of lead, arsenic, sulphur, nitric acid, tobacco, and other irritating and offensive vapors. 3. Gastro-intestinal irritation, from indigestible and irritating articles of food, vitiated secretions, or a loaded state of the bowels, is one of the most common exciting causes of the asthmatic paroxysm. Almost all asthmatic subjects are peculiarly liable to gastric disorders from causes of this kind, and even slight irregularities in diet are apt to give rise to oppressed breathing in individuals of this habit. 4. The suppression of habitual sanguineous and serous discharges frequently gives rise to this affection. I have, during the last eight years, occasionally at- tended an old gentleman, in whom the temporary drying up of a long-standing superficial ulcer on the left leg has invariably been followed by violent parox- ysms of asthma. I have seen an instance in which very distressing asthmatic symptoms alternated with the hemorrhoidal discharge. The suppression of the menses sometimes gives rise to nervous or hysterical asthma. 5. Metastasis of rheumatism and gout, and of various cutaneous affections, sometimes gives rise to more or less violent asthmatic symptoms. One of my patients, a rheumatic subject, has had several violent fits of asthma during the remission of his arthritic affections. M. Andral mentions an extremely violent case, which was produced by the sudden disappearance of a dartrous eruption. Leeches and blisters were applied to the part where the eruption had disap- peared ; and the asthma, by this measure, was completely removed in a few days.* 6. General plethora, in co-operation with causes that produce strong sanguine- ous determinations to the lungs, or increase the momentum of the circulation, is particularly favorable to the occurrence of asthma. Individuals of obese and robust habits, florid and full complexions, with large and turgid veins about the neck and head, are especially liable to asthmatic symptoms from over-exertion by exercise, loud speaking, singing, or violent mental emotions. 7. Cold, when the body is in a state of free perspiration, and particularly sup- pressed perspiration of the feet, may excite the disease. I attended a lady about * Med.-Chir. Rev., vol. vi. p. 447. 580 ASTHMA. ten years ago, who suffered exceedingly from a protracted and regular paroxysm of asthma, which was brought on by bathing her feet in very cold water. She was subject to profuse sweating of the feet. 8. Mental emotions, particularly violent anger and terror, will sometimes ex- cite asthma in those who are predisposed to it. 9. Particular odors and articles of diet, from peculiarity of habit, or idio- syncrasy, may give rise to asthmatic affections in certain individuals. Thus the odor of ipecacuanha has excited the disease in some persons ; and instances are mentioned in which asthmatic paroxysms have been caused by the odor of musk, roses, red beets, fresh hay, and sealing-wax. (Parry.) 10. But by far the most common exciting cause of asthmatic symptoms is organic affection of the heart and aorta. Ossification of the cardiac valves, hypertrophy, aneurism of the large arterial trunks within the chest, and other organic causes that disturb the action of the heart, are rarely wholly free from symptoms of asthma. It is, generally, in cases of this kind, that we find the disease to alternate with oedema of the extremities, both being merely symptom- atic of the cardiac affection. 11. Finally, asthma, like all other paroxysmal, nervous, and spasmodic affec- tions, may continue to recur under the influence of what Dr. Darwin calls associ- ation, or that tendency in the animal economy to repeat morbid actions, when once established in the system, without the renewed application of the original exciting cause. Pathology.—Various and very discrepant opinions have been expressed with regard to the pathology or proximate cause of asthma. Of late years, several French writers* have denied, or, at least, greatly doubted the possibility of asthma, independent of organic disease within the cavity of the chest. There can be no doubt, indeed, that the majority of cases usually called asthmatic affec- tions arise from causes of this kind, more especially from organic cardiac dis- eases, aneurism of the large arterial trunks, and pulmonary hepatization. The occurrence of purely spasmodic asthma, wholly independent of obvious structural disorder, is, nevertbeless, equally unquestionable. In relation to the immediate cause of the dyspnoea in spasmodic asthma, there are two doctrines which at present divide the sentiments of pathologists. Accord- ing to some, the suffocative breathing is caused by a spasmodic constriction of the air-cells and smaller bronchial tubes, in consequence of which the free ad- mission of air into the lungs is greatly impeded. Others believe that the op- pressed respiration depends on vascular engorgement of the mucous membrane of the bronchia, giving rise, by the tumefaction of this membrane, to a mecha- nical diminution of the bronchial tubes and cells, and consequent obstruction to the regular intromission of air to the lungs. Laennec, among many others, has adopted the former opinion, and has endeavored to prove that the bronchial rami- fications are furnished with a coat of circular fibres, beginning where the carti- laginous circles terminate. By the spasmodic contraction of these fibres, the air-passages are obstruced, and the phenomena of asthma produced. He asserts, that he has " met with many cases in which it was impossible, after the most minute examination, to find any organic lesion whatever to which the asthma could be attributed. I am convinced," he says, " that the asthmatic paroxysm may be induced equally by the supervention of a fresh catarrh, and by a de- ranged state of the nervous influence, occasioning pulmonary spasm, or an in- crease of the necessity of respiration, and sometimes by both causes at once. With the exception of ihe diflerent kinds of catarrh, the occasional causes of asthma and dyspnoea are almost always of a kind to give occasion to an immediate and evident disturbance of the nervous influence. Of this kind are strong men- tal emotion ; venereal excesses ; the influence of light and darkness; retroces- sion of gout (a disease which, from its mobility and various effects, can only be • Rostan. ASTHMA. 581 considered a nervous affection) ; certain odors, such as those of the tuberose, heliotrope, stored apples, &c.; changes of atmospheric air, electricity, and other less appreciable conditions of the atmosphere."* Mr. Abernethy appears to entertain a similar view of the nature of asthma. He contends, that one of the principal causes of this disease is a morbid irrita- bility of the mucous membrane of the air-cells. " A man," he observes " having irritable lungs, may be sitting comfortably enough at the fire-side, but a little smoke comes into the room, and he can breathe no more ; he gasps for breath; he cannot enlarge the chest, and he finds the utmost difficulty in respiring; but where is the difficulty? Where is the sensation of pain and contraction? Why, in the lungs themselves; the hinderance is there; I believe it is all irritability, and which proceeds from the state of the stomach."! Other writers of eminence have declared it as their opinion, that pure spasmodic asthma depends imme- diately on a constriction of the air-cells and smaller bronchial ramifications, by which the ingress of atmospheric air is impeded or prevented, and suffocative respiration produced. It has been objected to this doctrine, that we have no evi- dence of the existence of muscular fibres in the smaller branches of bronchia and air-cells; but M. Laennec observes that as such fibres do undoubtedly exist in the larger bronchial tubes, analogy must lead us to admit their existence in the ultimate ramifications. " Besides, it is by no means demonstrated," he says, " that muscular fibre is the only conlractible tissue ; indeed, the contrary is proved by the fact, that animals of almost a mucilaginous consistence are capable of evident contraction."! We are not, however, without direct evidence of the existence of contractile fibres in the minuter bronchial tubes. Professor Nasse, of Halle, has published some very interesting experiments on pulmonary contraction^ He asserts that in the lungs of sheep, he was able, with a good lens, to trace the longitudinal fibres of the internal surface of the bronchia, described by Scemmerring and Reiseisen,|| into the smallest bronchial ramifications; and by means of the galvanic influence, he demonstrated the contraction of these fibres in the most unequivocal manner. Morgagni has very particularly noticed the fibres of the bronchia;^ and although their apparent tendinous character would seem to oppose the idea of their pos- sessing contractility, yet we perceive that the contractile fibres of the bladder and uterus possess a somewhat analogous appearance and structure. From the experiments of Nasse, it appears that the bronchial fibres possess considerable contractility ; that by passing the galvanic influence through the pneumogastric nerves, these fibres and consequently the whole lungs, are thrown into a state of contraction ; and finally, that by dividing the par vaga, the power of pulmo- nary or bronchial contraction is destroyed, and dyspnoea produced. It is highly probable, therefore, that asthma consists essentially in a peculiar irritation of the pneumogastric nerves, in consequence of which the smaller bronchial tubes and air-cells are thrown into a state of spasmodic constriction, by which the regular ingress of air to the lungs is prevented. When we advert to the almost invariable antecedent and concomitant manifestations of funclional disorder of the stomach in this affection, we have good reason to conclude that the nerves which especially preside over the functions of this organ and the lungs, are in a state of irritation or morbid excitement. The suddenness with * On the Diseases of the Chest, last edition, p. 414. f Lectures, p. 375. J Loc. cit., p. 408. § Undersuchungen iiber die naechste ursache des hustens. Leipzig, 1829, p. 9. || TJeber den Ban der Lungen. IT Extant in tunica intiina ceu lacerti quidam insignes ex albicantibus fibrillis compacti. Hi digitos aliquot supra asperiye arteriae divisionem nitium capiunt, et secundum ejus longitudinem dispositi, interstitium illud, quod memorabam, tenentes, ubi ad secundum bronchiorum divisionem pervenerunt; ibi primum solent per omnem undique bronchiorum snperficiem ad istorem extrema versus decurrere. Quorum lacertorum usus nunc non existiino.—Adversaria Anatom. Advern i. § 25. 582 ASTHMA. which the asthmatic paroxysm is sometimes excited by mental emotions and other causes that act directly through the nervous system, and above all, the rapidity with which it is often dissipated by a few full doses of the lobelia inflata, are directly and strongly confirmatory of this view of the pathology of the dis- ease. The existence of a constricted slate of the ultimate branches of the bronchia, dependent, we may presume, on the functional derangement or irritation of the pneumogastric nerves, appears, moreover, to be confirmed by the good effects which, according to Dr. Chiarenti, result from the artificial insufflation of atmo- spheric air into the lungs in this affection.* Dr. Parry, however, considers this opinion of the nature of asthma as being without the least foundation, and ascribes the dyspnoea to great vascular turges- cence of the bronchial mucous membrane, by which the smaller respiratory passages are mechanically diminished or closed, until the vessels relieve them- selves by a copious effusion of serum. If, however, vascular congestion be the only or principal morbid condition upon which the peculiar symptoms of the disease depend, it seems extremely improbable that any impressions made on the stomach would be capable of speedily arresting the progress of the disease; and yet, in a considerable number of instances, I have known violent paroxysms of asthma greatly, and in one case completely allayed, in less than thirty minutes, by the use of the lobelia. There can be no doubt that congestion always takes place to a greater or less extent in the vessels of the bronchia and air-cells, after the development of the paroxysm ; but if this congestion were as great as Dr. Parry and others seem to think, is it not very likely that effusions of blood would occasionally show themselves in the expectoration 1 The mere circum- stance of the frequent inordinate secretion of mucus into the bronchia is no satisfactory evidence that great sanguineous congestion pre-existed in the mucous membrane of the lungs. It is well known that the process of secretion is wholly under the influence of the nerves, and we do no violence to correct physiological data, in presuming that the redundant secretion of mucus is determined by the irritation of the pneumogastric nerves. Prognosis.—An attack of spasmodic asthma seldom proves fatal; and although the frequent recurrence of the disease is apt ultimately to give rise to dangerous pulmonary congestions, effusions within the chest, and to general exhaustion, it is by no means uncommon to meet with persons of very advanced age who have been long subject to this disease. Where asthmatic symptoms are connected with, or symptomatic of, organic pulmonary or cardiac disorder, the prognosis is of course always peculiarly un- favorable ; for in such cases, fatal dropsical effusion into the cavity of the pleura or the pericardium is almost a never-failing consequence of the disease. Spas- modic asthma resulting from mental emotions, or some peculiar odor or vapor, is, in general, less obstinate and protracted than those cases that arise from gastric irrilation, or recur from the influence of habit. Treatment.—The treatment of asthma is either merely palliative, or radical, according as we prescribe for the mitigation and removal of the paroxysm, or the prevention of its subsequent recurrence during the intervals of the fits. A great number of remedies and modes of treatment have been recommended for palli- ating or allaying the asthmatic paroxysm; but the effects of remedies of this kind are extremely variable in different cases. Some will do much good in one per- son, and fail altogether of procuring relief in an apparently similar case in another individual. Nay, the same remedy will in one attack afford speedy relief, and fail entirely in another paroxysm in the same person. (Laennec.) According to the pathology advocated above, the principal indications of cure during the paroxysm are to diminish the pulmonary congestion, and especially to relax the spasm of the bronchial tubes and air-cells. Where the pulse is active, and the countenance livid, in young and vigorous subjects, blood should be freely * Journal de Progress. Vide Med.-Chir. Rev., Jan. 1828. ASTHMA. 583 drawn ; for although venesection will rarely by itself make any decisive or per- manent impression on the paroxysm, its employment is always proper in robust and sanguineous habits, to obviate any evil consequences that might result from the violent pulmonary and cardiac congestion, and as a preparatory measure to the employment of other remedies. Professor Potter, of Baltimore, expresses much confidence in the efficacy of blood-letting in asthma—more than seems to be warranted by general experience. He considers bleeding " not only the most effectual remedy" in strong subjects, but in many instances capable of effecting a radical cure.* Laennec observes that "we must never omit blood-letting, whenever the lividity of the countenance, the strength of the patient's constitu- tion, or the over-action of the heart, indicates pulmonary congestion; but we must be careful not to abuse this practice, which, in general, only produces a temporary advantage." In old persons who have suffered much from the dis- ease, it is not, in general, prudent to abstract blood. It must be observed, how- ever, that many writers regard this measure as always of very doubtful propriety and often injurious in its effects. Judging from my own experience, I am not inclined to place much reliance on its palliative effects, although, for the reasons stated above, I have very generally resorted to it, in robust and full habits, with- out having ever known any ill consequences to result from its employment. The narcotics have been a good deal employed with the view of allaying the asthmatic paroxysm. Laennec has found opium and colchicum the most power- ful remedies for mitigating and curtailing the paroxysm. Articles of this kind, he says, may act beneficially, both by lessening the necessity of respiration, and by relaxing the pulmonary spasm. Hyoscyamus and stramonium, also, may be used with occasional advantage. The latter article, in particular, has done much good in several instances of habitual asthma, under my own observation. In one case, a quarter of a grain of the extract given every four hours for two days, suspended the disease entirely for upwards of nine months. The leaves and roots of this plant, smoked in a pipe, will sometimes give much ease to habitual asthmatics; and it is said, that when used in this way, it will sometimes promptly mitigate the paroxysms of the complaint. I have prescribed it in a few instances in this manner, but never with any particular advantage ; and writers have men- tioned instances in which it proved injurious.t In cases attended with catarrhal irritation, and a very copious secretion of viscid mucus into the bronchia, emetics sometimes procure considerable relief. The production of emesis is particularly proper, where the paroxysm comes on soon after taking a full meal. It is not necessary, nor, in general proper, to excite strong vomiting. Dr. Akenside asserts that he has derived as much benefit from nauseating doses of ipecacuanha in this affection, as from full emesis. It is gene- rally admitted that ipecacuanha is decidedly the best article for this purpose. It is said that the union of distilled vinegar and ipecacuanha forms a particularly use- ful remedy in this disease. Three grains of the latter with three drachms of the former may be taken every fifteen minutes, until nausea or gentle vomiting is excited. The vinegar of squills, too, has been highly extolled in asthmatic affections, both for its emetic and expectorant powers. Sir John Floyer considered this preparation as a specific in asthma. He asserts, that he has often prevented the paroxysm, by taking a dose of it at bed-time. Dr. Bree, also, places much reli- ance on the powers of this remedy ; and he observes that its efficacy is in pro- portion to its emetic operation. I have known much relief obtained from this remedy, taken in two drachm doses every half hour until nausea was induced ; more frequently, however, no obvious advantage resulted from its use. Vinegar is much praised by Bree as palliative in the paroxysm of spasmodic * Gregory's Practice, vol. i. p. 187, second edition. f [In France much use is made of the different preparations of belladonna. Both the extract and the tincture, especially of the root of the plant, are combined with antispasmodics and tonics in the treatment of asthma.—Mc] 584 ASTHMA. asthma. He found it more frequently and decidedly beneficial, he says, than any other remedy he had tried. One of my patients, affected with occasional paroxysms of this disease, has in several attacks derived great relief from two or three tablespoonfuls of strong vinegar taken at intervals of half an hour, and from inhaling its fumes. In the last two attacks, however, he derived no benefit from its employment. Bree speaks very favorably, also, of the union of acids and narcotics as pal- liatives in the asthmatic paroxysm. He recommends the following formula as an excellent combination of this kind.* In the asthma of old people, attended with deficient urinary secretion, and oedema of the feet, diuretics sometimes answer an excellent purpose. It is in cases of this kind especially that the squill may be used with benefit. In gene- ral, a good deal of advantage may be derived from diuretics in habitual asthmatic affections. Dr. Ferriar speaks well of the powers of digitalis combined with small doses of opium in such cases; and Dr. Percival asserts that he has known this combination to produce very favorable effects. A copious flow of urine is always a favorable symptom in this affection. Some writers (Pringle, Percival) speak favorably of the use of strong coffee in this affection. I have met with a few individuals who derived advantage from its use during the paroxysm. In another person, however, subject to habitual difficulty of breathing with occasional violent fits of dyspnoea, the use of coffee has, of late years, invariably aggravated the difficulty of respiration. Expectorants may occasionally be employed with some benefit in this disease; and for this purpose, the different preparations of the squill appear to be the best remedy. I have known the following mixture to give much relief towards the termination of an asthmatic paroxysm.t Antispasmodics do not often produce any good effects ; yet in slight cases, considerable relief may be obtained from inhaling the vapor of ether; and in old and habitual cases, the aqueous solution of assafoetida has afforded temporary benefit. The only article of this kind which I have found to manifest any par- ticular powers, in allaying the violence of the asthmatic paroxysms, is the root of the skunk cabbage, (symp/ocarpus fcetida.) I have occasionally employed this article in attacks of spasmodic asthma, and in several instances, with much temporary benefit. From thirty to fifty grains of the powdered root may be taken every two or three hours during the paroxysms, according to the urgency and obstinacy of the symptoms. Of all the remedies we possess, however, the lobelia inflata is, I think, de- cidedly the most valuable in this affection. Within the last five years, I have had an opportunity of witnessing its good effects in four cases, and I can truly say, that in two of these it acted like a charm. I have known the most violent pa- roxysms of spasmodic asthma completely subdued in less than thirty minutes by this medicine. It appears to me that ergot does not more certainly act upon the gravid uterus during parturition, than the lobelia upon the pulmonary organs in asthma. I have even found it to mitigate the dyspnoea which occurs in conse- quence of organic affections of the heart. Since the publication of the first edi- tion of this work, I have had occasion to prescribe this article in a violent and inveterate case of this malady. The good effects, in this instance, were as prompt and decisive as in any case I had previously witnessed. In one hour after the exhibition of the remedy, the patient's respiration was entirely free from diffi- culty or oppression. * R.—Tinct. scill. gtt. x. Acid, nitric, gr. vi. Extract, hyoscyam. gr. iii. Aquae fontanae ^iss.—M. This draught is to be repeated thrice daily. ■j- R.—G. Ammoniac. £[. solve in Acid, scillae §iss. Tinct. opii camp. ^ss.—M. Take a teaspoonful every hour, in a little clear and strong coffee. ASTHMA. 585 The good effects of a full dose of this medicine are often experienced in the course of ten or fifteen minutes after it is taken. The Rev. Dr. Cuttler, in a violent paroxysm of spasmodic asthma, took a tablespoonful of the saturated tincture. "In three or four minutes," he says, " my breathing was free as it ever was. In ten minutes I took another spoonful, which occasioned sickness. After ten minutes I look the third, which produced sensible effects on the sto- mach, and moderate puking, with a kind of prickly sensation through the whole system, even to the extremities of the fingers and toes. Since that time I have enjoyed as good health as perhaps before the first attack."* In a case of spas- modic asthma, in which I employed this tincture, during the present summer, the dyspnoea was almost entirely allayed in fifteen minutes after the first dose was taken. I have not found it necessary to give it to ihe extent of producing emesis, though some evidence of its influence on the stomach, as nausea, is desirable. A tablespoonful of the saturated tincture may be given every ten or fifteen minutes. Within the last two years I have relieved two cases of long standing asthma by ordering a large teaspoonful of the tincture of lobelia to be taken upon the first approach of the paroxysm, and continued every ten minutes until nausea was occasioned. With the nausea the paroxysm immediately subsided. A great variety of other remedies have been employed with more or less ad- vantage in asthma. The prussic acid was successfully given by Dr. Oliver and Dr. Granville. Alkalies, particularly the carbonate of potash, will be proper where there is reason to suspect acidity of the stomach. Dr. Bree strongly re- commends the use of prepared chalk and rhubarb in combination, in cases of this kind—more especially after the operation of a gentle emetic. The use of laxa- tives, with some absorbent, will, in general, afford some advantage in habitual cases, attended with dyspeptic symptoms, and torpor of the bowels. Tonics, also, are said occasionally to produce very good effects in protracted cases, attended with much debility and general relaxation. The bark is espe- cially recommended by Sir John Floyer. During the intervals of the paroxysms, much benefit may, no doubt, be derived from this tonic, in individuals of ex- hausted and relaxed habits, but there are few physicians, I presume, who would venture on the exhibition of this remedy during the paroxysm, except under cir- cumstances especially indicating its employment. Dr. Chiarenti, an Italian physician, has lately published a statement, from which it appears, that the artificial insufflation of atmospheric air, by means of a common bellows, is capable of speedily removing the asthmatic paroxysm. "He introduced the pipe of the bellows into his mouth, (he was himself affected with the disease,) and closing the nostrils, he pushed the air forcibly into his lungs, and with instant relief." He afterwards tried the same means in other cases of this disease, and always with the same happy result.! Galvanism has, of late years, been employed with advantage in chronic asth- matic affections, by Dr. Philip and others. The galvanic influence must not, however, be communicated with much force. The two wires of a weak trough are to be attached, one to a piece of metal placed on the pit of the stomach, and the other on the side of the neck, over the par vagum. With the view of preventing the recurrence of the asthmatic paroxysms, re- course must be had to tonics, a regulated diet, a change of air or climate, and regular exercise; and the usual exciting causes of the disease must be carefully avoided. The tonics usually employed are bark, quina, arsenic, and the carbon- ate of iron. Laennec states, that he has derived much advantage from the latter article, during the intermissions of the disease. Whilst tonics are employed, attention must also be paid to the state of the bowels, and the hepatic functions. An occasional blue pill at night, followed by a gentle aperient in the morning, the use of the tepid shower-bath, where the system is relaxed or exhausted, or cold bathing in robust and full habits, together with regular exercise out of doors, * Thacher's Dispensatory. f Med.-Chir. Rev., January 1828, p. 221. 586 WHOOPING-COUGH. change of air or climate,* agreeable occupation of the mind, a light and simple diet, and the careful avoidance of the usual exciting causes of the disease, are the most effectual measures for preventing, or postponing and moderating the violence of the attacks. Attention must, of course, be paid to the character of the exciting cause in prescribing for asthma, both with a view to its palliation and radical cure. When the disease is attended with a rheumatic or gouty diathesis, colchicum, diuretics and opium are especially indicated. When it succeeds the healing up of an old discharging ulcer, blisters and sinapisms to the part are proper. An- dral succeeded in curing a violent case by means of this kind. Here diuretics, also, are generally peculiarly beneficial. Where catarrhal irritation has excited the disease, emetics, the warm bath, squills, and opiates, may be resorted to with a good prospect of success; and in cases that depend on gastric irritation, altera- tives, the warm bath, mild aperients, tonics, and regular exercise, are particularly proper. "Among the remedies best deserving notice in asthma," says Laennec, " I would mention a mild and spare diet, residence in a more temperate climate, and warm bathing. The first of these measures will be found very beneficial in cases complicated with gastric irritation; the two last are especially indicated in that class of cases which date from the disappearance of cutaneous eruptions, under the use of powerful external applications."t Sect. II.—Whooping-Cough. This is unquestionably one of the most remarkable diseases with which we are acquainted. A cough, which is highly contagious in its nature—which has its regular rise, progress and declension—and which completely destroys the susceptibility of the system to a subsequent or second invasion of the disease, is a phenomenon truly mysterious and striking. It is maintained by some writers, that whooping-cough is comparatively a modern disease; and some assert that it was first brought into Europe out of Africa, in the thirteenth century. By consulting the works of the ancients, how- ever, it would seem that this disease was known at a very early period of our science. Hippocrates, in the 6th book on Epidemics, and also in the 6th section of his Aphorisms, speaks of a cough, which, from a short description he gives of it, may, I think, be regarded as the same affection which is now known under the name of whooping-cough. The first distinct and comprehensive description of this malady, however, was given by Mezeray, in the year 1414, in his Chro- nological History of France. Since that time, a great many epidemics of this disease have been circumstantially recorded; and medical literature furnishes us with no inconsiderable number of elaborate monographs on its nature and treat- ment. Whooping-cough usually commences with the symptoms of ordinary catarrh. The patient at first experiences some degree of lassitude, headache and sneezing, with a slight hoarseness, and occasional oppression of breathing. The sleep is generally disturbed by dreams and sudden starts; the appetite becomes weak, the bowels torpid, and the pulse slightly febrile towards evening. For the first two or three weeks the cough is almost always dry and ringing; and ihe paroxysms are short, and free from that peculiar sound which is called whooping. At the end of this time the disease begins to assume more of a convulsive or spasmodic * [It is astonishing to witness the effects of a change of air in many cases. One of my patients could never sleep out of town without being seized with a paroxysm of asthma; while in the city, he was always in a great measure free from the disease. One of my relatives could never visit Philadelphia without an attack. Some patients are always worse in the upper stories of a house; and one old gentleman was sure to be attacked if he got up as high as the third story chamber in either of our cities. Such facts should always be looked after in the selection of a suitable residence for every individual afflicted with this distressing complaint.—Mc] t Loc. cit., p. 419. WHOOPING-COUGH. 587 character, so far, at least, as the mere cough is concerned. The paroxysms of coughing now come on more frequently, and are of longer duration tlian pre- viously. The inspirations during the fits of coughing are extremely difficult, slow, and stridulous, and attended with a sense of obstruction or spasmodic stric- ture of the glottis, rendering the paroxysms distressingly suffocative, and, in a manner, convulsive. The approach of a fit of coughing is generally announced by a peculiar sen- sation of tightness in the breast, and of titillation in the larynx and praecordia. These circumstances should be borne in mind, for they throw considerable light on the pathology of this remarkable affection. The duration of the fits of cough- ing is very various. In some instances, the paroxysms are generally over in less than half a minute; in others, they last from five to six minutes, and "often longer. The spell of coughing at this stage of the disease, is always terminated by the discharge of a large quantity of viscid mucus ; and the patient frequently expe- riences some pain in the chest immediately after the cough has subsided. In many cases, the cough continues until vomiting comes on, when it is immediately ar- rested, and the patient is greatly relieved. So violent, in some instances, is the fit of coughing, that it induces a state of partial insensibility, and a most dis- tressing sense of impending suffocation. Occasionally, the determination of blood to the head is so great, during the paroxysm of coughing, that it bursts out from the nose and mouth; and it is not uncommon for children to become convulsed, in consequence of the cerebral compression from this cause. In this aggravated state,, the disease usually continues from four to six weeks, before it begins to abate. The declension is always very gradual, continuing commonly from two to four weeks. Fever is not essentially connected with the disease, although in many instances there is a manifest febrile irritation present during some period of the complaint. Whooping-cough occurs almost exclusively during childhood. I have never- theless met with two instances of the disease in subjects beyond the fiftieth year of age, and several in persons beyond the thirtieth and fortieth year. It is highly contagious, and occurs almost universally in an epidemic form. I have never yet met with a sporadic case of this affection, although it cannot be doubted that such instances do occasionally occur. It would seem as if there existed some latent connection between the contagions of whooping-cough and measles ; for the former frequently prevails most extensively, either immediately previous, or in alternation, or directly after the occurrence of epidemic measles.* Spring and autumn appear to be most favorable to the occurrence of whooping-cough, and it is during the wet and variable periods of these seasons that the disease is most liable to become dangerous, from the pneumonic affections which atmo- spheric vicissitudes are so apt to produce. As is the case with all other epidemic diseases, considerable diversity occurs in the grade of violence which different epidemics of this affection assume. Some epidemics are so mild, that the dis- ease is attended with but little difficulty, and passes by numbers who are still susceptible of it. At other times the disease manifests a violent and dangerous character, and seizes on almost every individual, whether old or young, who has not yet had the disease. Prognosis.—Whooping-cough rarely terminates fatally, unless by the super- vention of bronchitis, hydrocephalus, pneumonia, cynanche trachealis, apoplexy, or marasmus. As these secondary and superadded affections are, however, by no means uncommon—especially in variable and humid seasons—the disease, upon the whole, deserves to be regarded as one of considerable danger. It would appear to be a vastly more dangerous affection in northern or cold climates than in the mild and equable regions of the middle and southern latitudes. Rosen- stein states, that in Sweden there were 43,393 deaths from this disease, between the years 1749 and 1764—and of these, 5832 deaths occurred in ihe year 1755 alone. (Richter.) * Richter, Specieile Therapie. 588 WHOOPING-COUGH. In general, the younger the patients, the more apt is the disease to terminate fatally. Cullen observes, that by far the greater number of those who die of this disease, are children under three years of age. When it attacks weak and delicate infants within the first few months after birth, it is always attended with great danger; yet robust and healthy infants, even at this early age, generally pass through the disease without much difficulty or danger. In children born with a scrofulous diathesis, whooping-cough is exceedingly apt to call the strumous affection into action. Scrofulous ophthalmia, and gland- ular tumors in the neck, frequently succeed whooping-cough. I know of no disease which is more to be dreaded than whooping-cough in subjects of an here- ditary consumptive habit. Where there is a predisposition to the formation of tubercles, or where these exist in an incipient and dormant state, an attack of whooping-cough will rarely fail to develop phthisis pulmonalis. In many instances, the disease terminates in chronic bronchitis, in which case the expectoration'becomes purulent, and symptoms of hectic supervene. This is especially apt to occur when the patient takes cold from exposure to a damp and variable atmosphere—a circumstance which always greatly aggravates the violence and danger of the disease. I have seen but few deaths from whooping- cough which were not attended with bronchitis, purulent expectoration, and hectic symptoms, from having taken cold. The matter expectorated in these cases has generally a very peculiar appearance, resembling more a mixture of cream and mucus, than anything else I know. In some instances, an accidental cold will renew the cough, and protract it for several months, in a state of great violence, after it had nearly disappeared. Cases are often thus protracted for five or six months. When the disease as- sumes a chronic character, from cold or some other casual circumstance, it some- times ultimately terminates in hydrocephalus—more especially if the patient labors under the irritation of difficult dentition, and in children habitually sub- ject to disordered bowels. Cynanche trachealis also frequently supervenes dur- ing whooping-cough, and this is most apt to happen in children of robust and full habits, during the early stages of the disease, and is almost always the con- sequence of cold. The occurrence of cynanche in this affection is attended wiih the greatest danger. It is observed by Richter, that a profuse watery diarrhoea coming on suddenly in this disease, when pneumonic symptoms attend, is always to be regarded as one of the most dangerous occurrences. Death, he says, often follows such a discharge very speedily. The appearance of aphthae in the mouth and fauces, in the latter period of the disease, is also a very unfavorable sign. CEdematous swelling of the feet and face is not an uncommon occurrence in this affection, and when it takes place towards the conclusion of the complaint, it is rarely followed by unfavorable consequences. When such swellings supervene in the commencement of the disease, however, they portend much danger—more es- pecially if they are accompanied with a turbid, milky urine. (Richter.) Hufe- land observes, that the occurrence of some degree of strangury in the advanced stage of the complaint, is generally soon followed by a manifest mitigation of the symptoms of the disease. A sudden cessation of the cough, it has been remarked, is an unfavorable occurrence, and is frequently followed by pulmonary inflammation. In general, the more fever there exists in this affection, the more violent and dangerous it may be considered. It is asserted by some writers, (Hufeland, loc. cit., p. 420; Lentin, Memora- bilia, p. 36; Jahn, Kinderkankn., p. 399,) that children affected with some chronic cutaneous affection, as tinea, itch, &c, very rarely take this disease; and if they do become affected with it, they almost invariably pass through it in the lightest manner. This however, is contradicted by olhers—particularly by Hoffman and Haase. Among the affections which are properly called sequela of this disease, the following are the principal. Strumous swellings, dropsy, epilepsy, ophthalmia, WHOOPING-COUGH. 589 rickets, general cachexy, aneurism, deafness, dementia, paralysis, and phthisis pulmonalis. I have known most of these affections to occur as consequences of whooping-cough; and of these, epilepsy, struma, phthisis pulmonalis, and oph- thalmia, appear to be the most common. When these and other consequences are taken in view—and they are by no means uncommon—we cannot but regard this disease as always one of very serious import. Whooping-cough is, indeed, as much to be dreaded on account of the many affections which are apt to super- vene during its course, or to remain after its disappearance, as for its own proper power, however violent it may be. When perfectly free from any adventitious complications, it cannot be regarded as a disease of much danger, unless in very young and feeble subjects. Causes.—There exists no other cause, so far as we know, capable of producing this affection, than the peculiar contagion which is generated by the disease itself. Richter observes, that besides this contagion, cold in conjunction with humidity, may give rise to this affection. For this opinion it does not appear that there exists sufficient grounds ; and it seems to me just as improbable, as that small- pox or measles should arise from accidental causes. It may be said that all these diseases must have primitively originated from accidental causes—for the first case could not have arisen from a contagion generated by the disease itself. Nothing, in truth, is more mysterious and incomprehensible than the origin of those diseases which we now find to be engendered and propagated by a specific agent alone, elaborated by the living body actually suffering under the disease. The only solution we can offer, and it is indeed vague enough, is, that in the in- finite combinations of which the material elements of the universe are capable, agents may have been evolved by a peculiar concurrence of circumstances, which had the power of originating these affections in the human system. It is in this way alone that we can give any plausible explanation of the occasional rise of new diseases—which, when once originated, propagate themselves by elaborating their own specific causes. Whatever may be our speculations in relation to this curious and interesting subject, the cause of whooping-cough, so far as we can ascertain, is in all instances a specific contagion. Riverius, Linnaeus, Dessault, Kosenstein, and more recently Clesius, maintain that whooping-cough is produced by the inhalation of microscopic animalcula. Whooping-cough does not appear to possess a contagious character until it has made considerable progress, (Richter;) or until the second or convulsive stage has supervened. The contagion of this disease, although very active, does not extend far from the body of the affected person. It is, accordingly, almost always prevented by separating the healthy from the affected portion of families. Autopsic phenomena. The appearances discovered on post-mortem examina- tion are various, and often quite contradictory. Much diversity must necessarily result in this respect from the various accessory affections which are so common in this complaint, and the different periods of the disease at which death occurs. We cannot, for instance, expect to find the same post-mortem appearances in a case which terminates fatally in consequence of pneumonia, as in one in which death occurs from apoplexy ; nor is it reasonable to presume that there should be much uniformity in the autopsic phenomena, where the immediate cause of death is so various, or dependent on such a diversity of accidental affections. As the respiratory organs are the parts most obviously implicated in the disease, the principal attention of pathologists has of course been always directed to them for a solution of the pathological character of this affection. Many writers speak particularly of the frequency of traces of inflammation in the mucous membrane of the bronchia and larynx. Strong, Cullen, Astruc, Lettson, and Danz, mention these appearances as by far the most common; and more recently, Whatt and Marcus have adduced striking instances of this kind. The former lost three of his own children by this disease, and in each, the marks of previous inflammation in the mucous membrane of the bronchia were very conspicuous throughout its whole extent. Marcus gives but two dissections in which bronchial inflammation 590 WHOOPING-COUGH. was discovered ; and in one of these a considerable quantity of pus was found in the air-passages, the smaller branches of which were in the most intense state of inflammation, approaching, in some parts, to gangrene. In some instances, the lungs have been found exceedingly congested, and the air-cells choked up with an extremely viscid mucus without any traces of bron- chitis whatever. Lobenstein-Doebel relates an instance in which a considerable portion of the diaphragm was covered with a number of small pustules containing a purulent fluid.* After all, it is incontestable, that in many cases of death from this disease, no morbid appearances whatever were discovered on dissection, and there are good grounds for believing, that the inflammation and other phenomena which have been detected on post-mortem examination, have no essential connection with the disease, but are altogether adventitious or secondary. Proximate cause.—The opinions that have been advanced concerning the nature or proximate cause of this disease, are extremely various and contradictory. Hoffman considered it as depending on an acrid serum in the lungs. Sydenham ascribes it to the effects of irritating effluvia, cast off from the blood into the lungs, in consequence of the suppression of the insensible transpiration by the skin, from cold and damp air. Huxham and others placed the primary seat of the disease in some morbid condition of the intestinal canal; Butler, in the liver; and some have considered it as the consequence of gastric irritation, or, accord- ing to Stoll, of crude and bilious matters in the stomach. The opinion which appears to be most prevalent at the present day is, that the disease depends on a peculiar bronchial inflammation ; and this doctrine would seem to receive much support from the appearances which are occasionally detected in the mucous membrane of the bronchia and trachea on post-mortem examination, as well as from the febrile movements which, in most instances, attend the disease. As, however, ordinary bronchial inflammation does not excite the train of symptoms which characterize this disease, the advocates of this doctrine are forced to assume the position, that the inflammation in question is of a specific kind, capable of exciting the peculiar convulsive cough which distinguishes the disease. What- ever plausibility this doctrine may seem to possess on a superficial view of the subject, strong, and in my opinion, insurmountable objections may be urged against its validity. It is true, indeed, that fever is no uncommon attendant of this disease, and that unequivocal cases of inflammation are sometims manifested on post-mortem examination. It is, nevertheless, equally true, that in many instances no febrile symptoms whatever occur during the early period, and occa- sionally none during the whole course of the disease; nor are the signs of previous inflammation in the respiratory passages always manifested on autopsical examin- ation. That inflammation must frequently supervene in the trachea and bron- chia in a disease in which the lungs are so violently and frequently agitated as they are in the present one, is indeed to be expected. Besides this accidental source of pulmonary inflammation in whooping-cough, there can be no doubt that the lungs are especially predisposed, by the same circumstance, to the inju- rious influence of atmospheric vicissitudes, and consequently to the supervention of pulmonary catarrh, or bronchial inflammation. From these circumstances, we have the strongest ground for believing that the inflammation which is frequently detected on dissection in the mucous membrane of the respiratory passages, is always accidental, and by no means essential to the perfect development of the disease. It may be observed, moreover, that bronchial inflammation is probably far from being so common in this disease as one might be led to think from the appearances discovered on dissection ; for it must be recollected, that death occurs chiefly in such instances only as are attended by unequivocal symptoms of inflammation, and we may, therefore, reasonably expect to find traces of inflammation in such cases, although in the * Richter's Specieile Therapie. WHOOPING-COUGH. 591 milder instances no such inflammatory condition may exist. If, however, bron- chial inflammation be the proximate cause of the disease, it must, necessarily, be present in all cases, in the mild as well as in the violent instances of the malady, a circumstance which is decidedly contradicted by almost universal observation. The only dissection I ever witnessed of a subject that had died of this disease, presented no evidence of the existence of previous inflammation in the bronchia. I'he patient died suddenly of convulsions during a violent parox- ysm of coughing. That inflammation of the mucous membrane of the bronchia is not essential to this disease, or its proximate cause, is proved, moreover, by the fact, that bronchitis is rarely, if ever, attended with a violent cough, much less with that peculiar cough which distinguishes this disease. Bronchitis, too, in its acute form, is always rapid in its course, and is attended with strong fever and a continued sense of tightness and oppression in the breast. In the chronic form, the expectoration is invariably purulent, and entirely distinct in its character from the ropy and transparent mucus which is expectorated in whooping-cough. It is also almost invariably attended with the usual symptoms of hectic fever. When cough depends on acute inflammation of the respiratory passages, it almost always begins to decline as soon as the secretion of the bronchial mucus becomes copious. In whooping-cough, however, the reverse very generally obtains. Dur- ing the first few weeks, there is seldom much mucus secreted in the bronchia; but as soon as this secretion becomes more abundant, which occurs after the se- cond or third week, the cough also acquires much more violence, and especially that convulsive character which distinguishes it from other varieties of cough. Very commonly, moreover, the slight symptoms of fever which accompany the development and first few weeks of the disease, vanish entirely in the second stage, when the cough becomes more spasmodic and violent in its paroxysms. (Richter.) This circumstance most assuredly does not favor the idea, that the disease is of an inflammatory.character; for if this were the case, the cough, one should think, would decline wiih the fever; instead of which, it is always found to acquire much more violence. It appears to me that whooping-cough is essentially a spasmodic or nervous affection, the proximate cause of which consists probably in a peculiar irritation of the eighth pair, or pneumogastric nerves. If we attend closely to the phenomena which immediately precede and accom- pany a paroxysm of whooping-cough, we cannot but perceive unequivocal mani- festations of a purely spasmodic condition of the respiratory apparatus. The sense of stricture in the breast and of the glottis, which is felt immediately be- fore the fit of coughing—the sudden and convulsive character of the couo-h—the peculiar constrictive feeling in the praecordia—the stridulous respiration, all point to a spasmodic state of the pulmonary system. That the irritation which calls forth the convulsive action of the diaphragm, and the other parts immediately concerned in the act of coughing, is seated in the eighth pair of nerves, may, I think, be inferred from the known agency which these nerves have in the pro- duction of the various phenomena manifested by the respiratory apparatus. The interesting experiments of Professor Nasse also afford strong support to this opinion. In a series of experiments, instituted for the purpose of elucidating the pathology of cough, this experimenter found that, on bruising or strongly pinching the par vagum so as to break down its structure, a violent convulsive cough was invariably excited. By injuring in the same manner the diaphrag- matic nerve, no such effect ensued. According to these experiments, the act of coughing is performed almost wholly by the sudden spasmodic contraction of the diaphragm. By opening the abdomens of various animals, and exposing the lower surface of this muscle, he saw distinctly its violent convulsive contractions during the cough, which was excited by bruising, with a pair of forceps, the pneumogastric nerves. The peculiar tone of the cough, and the sense of con- striction which is felt at the glottis, may arise from the irritation extending to the 592 WHOOPING-COUGH. recurrent branches of the vagus nerve; and that this irritation is peculiar or specific in its character, may be inferred from the nature of its exciting cause. Treatment.—It is very generally believed that whooping-cough, though sus- ceptible of much mitigation, is wholly uncontrollable in its progress, and that no treatment is capable of materially shortening its course. This, I am persuaded, is an unfounded opinion. Sydenham, Werlhof, Hufeland, and several later German, Italian, and French writers, admit that it may be arrested in its course; but it is asserted that this can never be done before the fourth week after its commencement. (Richter.) Be this as it may, my own experience does not per- mit me to doubt of its susceptibility of being curtailed in its progress; and many well-authenticated observations in confirmation of this fact, might be collected from recent publications. Although inflammation and fever do not constitute essential conditions of this disease, yet blood-letting may often be employed in the first stage of the disease with manifest advantage. An unusual or preternatural momentum of the circu- lation is not to be regarded as a harmless circumstance, even in diseases strictly spasmodic. Whatever may be the essential character of a disease, if the pulse is full and active, blood-letting may be regarded as proper, and its employment will generally be productive of some benefit. In the present disease, if the ab- straction of blood should even afford no direct advantage over its characteristic symptoms, it tends materially to lessen the danger which may result from the violent cephalic congestions during the paroxysms of coughing, as well as to diminish the liability to the accidental supervention of inflammation. In cases attended with bronchial or pneumonic inflammation, bleeding is obviously indis- pensable, and should be employed promptly and decisively both in a general and local way. To tamper with the ordinary remedies in cases of this kind, would be exposing the patient to great danger; for, when inflammation supervenes, it is this, and not the original disease, which claims our principal attention, since the danger and obstinacy of pulmonic inflammation must be especially great in an affection which, like the one under consideration, keeps up so constant and violent an irritation of the respiratory organs, by the frequency and violence of the cough. Leeching on the breast is particularly valuable in cases of this kind. The extensive sympathetic relations which subsist between the intestinal canal and the various organs of the body cause it to participate, in a greater or less degree, in almost every form of disease to which the human system is liable. Whatever be the nature of the malady, and in whatever system of structure it may be principally located, the alimentary canal, sooner or later, suffers func- tional disturbance, giving rise either to a remora of its recrementitious contents, or to a vitiated secretion of the fluids which are poured into it. These latter consequences become in their turn sources of intestinal irritation, and I need not say how great a tendency such irritation has to aggravate and sustain diseases, whatever may be their original source or character. The bowels are almost always in an unnatural condition in whooping-cough. The evacuations are sometimes bilious, or almost wholly mucous; and, in many instances, dark and exceedingly offensive stools are passed. In prescribing for whooping-cough, it is of much consequence, therefore, to attend to the condition of the bowels, and to keep them in a moderately loose state throughout the whole course of the disease. Very active purging, however, is improper, as it tends to increase, rather than to moderate the intestinal irritation when frequently re- peated. A grain or two of calomel in the evening, with a small dose of rhubarb on the following morning, will in general answer very well for this purpose. When there is considerable febrile irritation present, small doses of the sulphates of soda or magnesia may be preferable. Emetics constitute an important class of remedies in the majority of pulmonary diseases. They are especially indicated in those affections of the respiratory organs in which there is an abundant secretion of bronchial mucus. Much of the suffocative distress experienced by patients affected with whooping-cough, WHOOPING-COUGH. 593 arises from the large quantity of viscid mucus which is lodged in the trachea and bronchia; and it is chiefly by effecting the discharge of this impediment to free respiration, that emetics prove serviceable in this disease. It is not improbable, however, that a part of their beneficial operation may depend also on the impres- sion which they produce on the pneumogastric nerves in the stomach. They are particularly useful in the whooping-coughs of infants; these are unable to throw off the viscid mucus that clogs the respiratory passages; and instances of death by suffocation from this cause have frequently occurred. When, there- fore, the cough in very young children is violent, and attended with symptoms of impending suffocation, an emetic should be immediately administered; or the fauces irritated with a feather, so as to bring on speedy vomiting. In cases of this kind, the sulphate of zinc will generally answer better than any other article, from the promptitude of its operation. It. must nevertheless be observed, that the very frequent repetition of emetics, more especially antimony, is apt to bring on much weakness and irritation of the stomach, which may have a permanent injurious influence on the future health of the patient. I have in general pre- ferred the ipecacuanha to every other article of this kind. Dr. Fothergill speaks very highly of the following combination as an emetic in this affection: R.—Pulv. chel. cancror. gss. Tart, antimon. gr. ii. Misce. Of this 1, 1|, or 2 grains, may be given at a dose, according to the age of the patient. It has been supposed that the union of some absorbent with the emetic is peculiarly beneficial in this affection. The syrup of squills also forms an ex- cellent emetic in very young patients. I have frequently prescribed this prepa- ration, in union with a small portion of antimonial wine, with a very good effect. We may also prescribe the antimonial wine in union with an emulsion of assafoe- tida, with much advantage as a palliative. The narcotics furnish us with several very valuable remedies for the treat- ment of this disease. Of these the belladonna is the most celebrated, and unquestionably by far the best article of this kind we possess. Professor Borda, who, I believe, was the first who employed this remedy in whooping-cough, speaks of its powers with unqualified praise. He asserts that, in a number of instances, he has found it to remove every vestige of the disease in ten or twelve days; and that where it did not remove the disease entirely, it rarely failed to mitigate it very considerably. He observes, moreover, that he has known cases, which appeared to be beyond the hope of recovery, restored by this remedy. Hufeland and Alibert, not to add the testimony of many other writers, speak in terms nearly equally favorable, of the virtues of this nar- cotic in the present disease. A large mass of evidence might be adduced from the current medical publications, illustrative of the valuable powers of the bella- donna in this singular malady. From my own experience, I can testify with confidence to its virtues as a remedy in this affection. I have within the last six years prescribed it in perhaps twenty cases, and in the majority of them with manifest advantage.* Since the publication of my work on the materia medica, my good opinion of the value of this remedy has been considerably increased. In two cases it arrested the complaint almost wholly in the course of eight days, although the disease was in both instances exceedingly violent. It does not appear, however, to answer any useful purpose in cases that are attended with fever and bronchial inflammation. In instances of this kind, the lancet with blisters, or tartar emetic ointment rubbed on the chest, is the means upon which our reliance must be almost entirely placed. In the purely spasmodic form of * The dose should be one drop of the tincture for every year of the child's age, three times daily. When the narcotic effect is obtained, cease the remedy, and resume when it subsides. 38 594 WHOOPING-COUGH. the disease, however, and where all symptoms of inflammation are absent, it is often singularly efficacious.* The extract of conium. lactuca virosa, hyoscyamus and opium, have also been favorably mentioned as palliatives in this disease. Dr. Butler states that he has frequently used the following mixture with marked benefit.t Opium is objec- tionable, both on account of its constipating effect, and its tendency to determine the blood to the brain. Some writers recommend the tincture of cantharides.X Dr. Sutcliff asserts, that when given to the extent of producing strangury, it will sometimes, in a great measure, remove the disease in four or five days. This practice has also been pursued with success by Hufeland; and Lettson speaks very favorably of it. Sutcliff used it according to this formula.§ M. Fresnoi asserts that he has used the extract of the rhus vernix with much success in this disease. He gave half a grain, with half an ounce of syrup, every three hours. Antispasmodics are frequently prescribed in whooping-cough, and sometimes with temporary advantage. An aqueous solution of assafoetida will occasionally palliate the symptoms in cases unattended with fever or strong pulmonary irrita- tion. This article answers the double purpose of an expectorant and an anti- spasmodic. I have, in a few instances, known material relief obtained from a mixture of the vinegar of squills, and an emulsion of assafoetida. Expectorants also will occasionally mitigate the violence of the symptoms. Dr. Pearson strongly recommends the following mixture, and I have myself known it to give considerable temporary relief.|| Tonics may, in some instances, be used with much benefit in whooping-cough. The Peruvian bark is particularly extolled by Dr. Cullen as a remedy in this disease; but its good effects are in a great degree confined to the latter stages of the disease. In some instances, the cough assumes a chronic character—con- tinuing long after the usual period of its termination ; and these cases are fre- quently connected with chronic bronchitis. If they are not subdued by efficient measures, they gradually undermine the constitution, until the system is worn down, and the patient dies in a state of marasmus, or under symptoms of phthisis pulmonalis. In such cases strong doses of cinchona, or quinine, are often pecu- liarly serviceable. This tonic may also be very beneficially used in cases of a purely spasmodic character, where the disease becomes protracted, and kept up by habit. Among the mineral tonics, arsenic has been most commended for its powers in this affection. It is, however, wholly inadmissible in cases attended with febrile irritation or bronchial inflammation. Dr. Ferriar placed much reliance on this remedy in cases free from fever. He asserts that, according to his own experience, "arsenic is the only remedy which promises to shorten the disorder effectually. I have," says he, " employed this article in several cases of infirmary * [Dr. Jackson, formerly of Northumberland, once published some excellent observations upon the influence of belladonna in curing whooping-cough. He found the remedy very effi- cacious in this disease.—Mc] t R-—Extract, conii gr. iii. Magnes. sulphat. ^i. Aq. carui £v. Syrup, rhasd. £i.—M. Take thirty drops three times daily. X Armstrong, Chambers, Millar, Buchholtz, Loder and others, speak much in favor of this remedy in whooping-cough. § R.—Tinct. Peruv. spirit. !|i. Tinct. opii camphor, ^ii. Tinct. cantharid. Qh. Two drachms of this mixture are to be taken thrice daily. || R.—Aq. fontana? %i. Syrup, giii. Subcarbonat. sodae gr. xxv. Vin. ipecac, gi. Tinct. opii gr. vi.—M. The sixth part, every four or five hours, is the proper dose for a child between one and two years old. WHOOPING-COUGH. 595 patients, with tolerable success; and I have occasionally given it in private prac- tice with so much advantage, that I think it deserving of further trials." I formerly employed this remedy frequently; and in some instances its good effects were very obvious. The proper dose for a child between one and two years old, is two drops of Fowler's solution, twice or thrice daily. I have usually given it in union with small doses of the extract of belladonna, or conium. The lobelia inflata has proved an excellent remedy in my hands, in whooping- cough. Within the last four years, I have prescribed this article in a very con- siderable number of cases, and very generally with some advantage, and in several instances with the most decided success. It not only often mitigates the violence of the cough, but it has appeared to me unequivocally to have shortened the course of the disease in several cases. I have usually given the saturated tinc- ture in union with the syrup of squills, in doses of ten drops of each, four or five times daily, to a child about two years old. To several children about this age, I gave as much as twenty drops of the tincture of lobelia, and I have always found it strongly palliative when it excited sickness or slight vomiting. External rubefacient or revulsive applications are particularly valuable in cases attended with bronchial inflammation, or strong and dangerous sanguineous con- gestions in the head. Dr. Gregory advises frictions with the following embroca- tion, along the whole track of the spine, and over the chest.* Frictions with tartar emetic ointment over the praecordial region, will, in many cases, make a powerful impression on the disease. This practice originated with Autenreith, and has been much employed by the German physicians. Dr. Meyer has re- moved all the symptoms of whooping-cough, in a few days, by the application of morphium to the external surface. He applies a small epispastic to the epigastric region, and after removing the epidermis, he applies to the denuded surface half a grain of morphium, triturated with a small portion of starch. The application is to be renewed every evening. An occasional emetic should also be administered, particularly in infants, in order to free the bronchiae from the viscid mucus.t When the disease is complicated with pneumonic affections, blisters and rubefacients, in conjunction with venesection, and especially leeching on the breast, are indispensable. When the disease becomes complicated with chronic bronchitis, in the advanced stage of its course, the balsam copaiva is a very valuable remedy. I have, in a few cases of this kind, prescribed this article with the most decided benefit; and I know, indeed, no other remedy that promises so much as this one, where chronic bronchitis attends. Various inhalations, also, have been extolled for their good effects in this dis- ease. The nitrous acid vapor, and the fumes of tar, have been particularly recommended for this purpose. I have employed the nitrous acid vapor, in a few cases, with some benefit. Dr. Gregory states, that he has derived great advantage from small doses of calomel, (a grain twice a day,) with a few grains of scammony in the latter stages of whooping-cough, attended with symptoms of marasmus. Change of air, and exercise by gestation, generally have an excellent influence in tedious and obstinate cases, attended with much exhaustion. In instances of this kind, a change of air, says Dr. Gregory, "is often the only thing that gives the patient a chance of life." I have seen one very remarkable recovery effected by removing the patient into the country, and the free use of a milk diet. In cases attended with bronchial inflammation, this measure is inadmissible, as it rarely fails to aggravate the symptoms immediately. * R.—Antimon. tart. £)ii. Tinct. cantharid. Ji. Aq. rosar. gii.—M. The tartar emetic is to be dissolved in the rose water, and then the tincture of cantharides added to it. "f Archives Generates, Oct. 1829. 596 ASPHYXIA. The diet should be light and digestible, and it is particularly important to guard the patient against the influence of a cold, variable, and damp atmosphere. Sect. III.—Asphyxia.—Suspended Animation. The term asphyxia is here used to designate two varieties of suspended animal tion; namely, those cases which result from the total suspension of the function of respiration, by preventing the ingress of the atmospheric air to the lungs, or by breathing an air incapable of converting venous into arterial blood; and those cases of apparent death which result from the temporary destruction of the sensi- bility and irritability of the system, by the influence of certain external causes. The first variety includes those cases that are produced by hanging, drowning, or strangulation, and by the inhalation of carbonic acid; or some other irrespira- ble gas. The second variety embraces the cases that are produced by a stroke of lightning or electricity, and by the protracted influence of intense cold.* 1. Asphyxia from drowning.— When a person who has been submerged in water until all manifestations of life are destroyed, is taken out, the face exhibits a tur- gid and livid appearance; the eyes are open and staring; the limbs somewhat stiff; the tongue usually thrust a little beyond the teeth; and, in most instances, the epigastrium is tense and tumid. Considerable controversy has existed concerning the mode in which drowning causes death. Many have contended that suffocation is produced by the water rushing into, and filling up the cavity of the lungs. Haller, P. Frank,t Louis and PortalJ mention cases in which the lungs were charged with an abundance of water, sometimes frothy and bloody. On the other hand, it has been satisfacto- rily ascertained, that in many instances of death from drowning, very little or no water whatever gains admission into the lungs. Tissot,§ Goodwin,|| Kite,1 Roesler,** and many other later writers, have published numerous observations in illustration of this fact; and it is now, I believe, universally admitted that so long as the larynx retains any degree of irritability, no water can enter into the respi- ratory passages ; and, consequently, that whenever water is found in the lungs, it must have entered into them after life was destroyed. Such is the peculiar sen- sibility of the respiratory passages, that the moment water or any other substance not in harmonious relation with them comes in contact with the mucous mem- brane of the larynx, the glottis is instantly thrown into a state of spasmodic con- striction, which wholly prevents the ingress of the irritating fluid into the trachea. When the sensibility and contractility of these parts are extinguished, however, the water may gain admission into the lungs, and hence it is not uncommon to find more or less of this fluid in the air-passages of those who have lain a long time under water. Some have supposed that drowning destroys life by apoplexy—that the func- tions of the brain are at once destroyed by strong vascular congestion and extra- vasation. Portal,tt who entertained this opinion, states that he found the vessels of the brain, as well as the right auricle and ventricle of the heart, jugulars, and descending cava, exceedingly turgid with blood in subjects that had died by drown- ing. This opinion is also advocated by Littre, Kite, Walter,;^: and Boerhaave. * Good's Study of Medicine, vol. iii. p. 367. f System ein. Vollstiindiger Med. Polizei, vol. i. p. 186. X Instruction sur le Traitement des Asphyxies. § Avis au Peuple, p. 426. || On the Connection of Life with Respiration, &c, p. 14. ir An Essay on the Recovery from apparent Death. ** Diss. Inaug., &c. See Ed. Med. and Surg. Journ., No. Ixxxii. Dr. Roesler states, that in forty-five experiments he made on animals, he did not in a single instance find anything more than a very small portion of frothy mucus about the bifurcation of the trachea. ft Loc. citat. See also Observ. sur les Effets des Vapeurs Mephitiques. XX De Morbis Peritonei et Apoplexia. ASPHYXIA. 597 On the contrary, however, many observations have been published, which go to show that vascular congestion within the head, though an occasional, is by no means a common or general phenomenon. Champreax and Faissole assert, that they found no marks whatever of an unusual sanguineous congestion in the brains of persons who had died by submersion.* Schraget and KuehnJ state that they even found the vessels of the brain almost entirely empty. Fothergill, in a number of experiments made on animals with a view of illustrating this subject, fully confirms these observations ;§ and Dr. Currie states that in every instance he examined, he found the vessels of the brain entirely free from distension. In nearly all instances, however, the lungs are strongly engorged with blood, and the bronchial tubes generally contain more or less of a frothy and bloody mucus. Bichat has given a very interesting and satisfactory explanation of the mode in which death is brought on by submersion, and other analogous causes of asphyxia. When respiration is interrupted, the blood ceases to undergo the necessary chemical changes in the lungs ; and black or venous, instead of florid and arterial blood, is immediately sent to the left side of the heart, and thence throughout the system. Now it is well ascertained that the regular transmission of arterial or red blood to the brain is indispensable to the performance of its functions; and, therefore, one of the first effects of interrupted respiration towards the destruction of vitality is a cessation of cerebral action, for want of red or arte- rial blood to excite the brain. The direct and instantaneous consequence of this cessation of cerebral action is cessation of the animal functions, from want of excitement in the organs of these functions by the nervous influence and the red blood; and from the same causes the heart soon ceases to act, and the circulation stops. Death from asphyxia, by submersion, strangulation, or the inhalation of mephitic gases, commences, therefore, in the brain, and those vital actions that are immediately dependent on the exercise of its functions—namely, sensation, voluntary motion, thought, and the mechanical effort of respiration—cease a short time before those actions which constitute what are called the organic functions; that is, the circulation, absorption, exhalation, &c, are obliterated.|| Much difference of opinion has been expressed as to the time a person may remain under water, in a state of asphyxia, with sufficient vitality remaining to afford a chance of being resuscitated by proper restorative measures. Mr. Brodie thinks it extremely improbable that resuscitation can be effected after the heart has ceased to act; and this, he supposes, always occurs within a few minutes after the cessation of the respiratory function. Dr. Paris, and other late writers, have expressed the same sentiments on this point. Unless, however, we reject no small amount of evidence from sources of unquestionable credibility, we are forced to admit that there is, in some instances, a possibility of resuscitation after a much longer period of submersion than Mr. Brodie and Dr. Paris are willing to allow. The experiments that have been performed on animals, in relation to this point, afford us no satisfactory results. Dr. Davy informs us that he has never been able to resuscitate dogs after they had been under water tivo minutes; and Dr. Colhoun, of this city, states that in some experiments he made on cats, " they invariably died after six minutes' submersion."^ Dr. Roesler asserts that he succeeded in resuscitating two rabbits, one after 5f, and the other after 9| minutes' submersion; and a cat after having been submersed 1 If minutes. He observes, however, that he " several times failed when the animals were taken out of the water instantly after they seemed to have expired." Experiments on inferior animals cannot, however, furnish us with any certain data with regard to the human subject. We learn, nevertheless, from these experiments, that very * Erfahr u. Warneh iiberd. Ursach d. TodesbeiErtruuk. Dantzig, 1772—as quoted by Richter. t Diss.de SuhmerMs, 179.—Richter, Sp. Therap. j Diss, de Causa Mortis Submersorum.—Richter, Sp. Ther. § A New Inquiry into the Suspension of Vital Actions, &c. || Bichat on Life and Death, p, 136. Ii Gregory's Practice, second American edition, p. 247. 598 ASPHYXIA. considerable diversity occurs as to the time that animals may remain under water and still retain sufficient vitality to render resuscitation possible. We see it vary in the same species of animals, and in experiments conducted under precisely the same circumstances, from a few to ten or eleven minutes; and we cannot doubt that a corresponding diversity occurs, in relation to this point, in the human subject. Instances of resuscitation after a period of submersion varying from fifteen to thirty minutes are on record; and although doubts have been expressed as to the accuracy of these statements, we can scarcely, with propriety, permit our skepticism on this point to carry us so far as to reject, positively, the testi- mony upon which they are made. That such instances of recovery are, how- ever, extremely rare, is sufficiently evident from the fact that the possibility of resuscitation after such protracted periods of submersion is now very generally doubted. Various circumstances may contribute to hasten or retard the complete destruc- tion of vitality from drowning. Submersion in very cold water will no doubt destroy life sooner than when the water is warm, or near the temperature of the body; for, in the former case, the animal temperature will be much more rapidly and completely abstracted than in the latter. Previous debility from disease, spasms and convulsions, injuries sustained in falling into the water, asthma, an apoplectic predisposition, intoxication, torpor from excessive cold, an overloaded stomach, &c, may all have a tendency to lessen the chance of resuscitation from asphyxia by submersion; and it is*not improbable, moreover, that some diversity may exist in different individuals as to their respective powers of vital resistance under similar circumstances of submersion. The morbid appearances observed on dissection, in persons-who have died by drowning or strangulation, are: turgescence of the jugulars, venae cavae, right auricle and ventricle of the heart, pulmonary arteries, and of the pulmonary ves- sels. The left auricle and ventricle are generally empty and flaccid; and in some instances there is considerable vascular congestion of the brain, but very rarely so much as to justify the belief that any apoplectic torpor proceeded from this cause. In nearly all instances a considerable portion of water is found in the stomach, but the lungs very generally contain very little or no water whatever. Inquiries have been made to discover some mark by which we may decide whether dead bodies found in water have died by drowning, or whether they have been thrown into the water after they had been deprived of life. M. Orfila has paid particular attention to this subject, and has examined in detail all the indications that have been mentioned as available guides in making up a judg- ment on this point. According to his observations, more or less water always enters into the stomach when death occurs by drowning, but never when the dead body is thrown into water. The result, therefore, of his inquiries on this subject is, that the only certain sign of submersion during life, is the presence in the stomach and respiratory passages of water similar to that in which the submer- sion took place; provided that it has not been injected into the stomach after death, and that the water in the lungs is found in the ultimate ramifications of the bronchia; and provided, also, that the body was not found in the vertical position. The pressure of a frothy fluid in the air-passages, he says, is only to be regarded as a presumptive evidence of submersion during life, and this is strength- ened by the appearance of an unusual portion of water in the pulmonary tissue, since this fluid never penetrates so deeply after death as during life by the efforts of respiration. The absence of a frothy mucus in the respiratory tubes does not, however, afford any proof that death did not occur by submersion.* Treatment.—When a person is taken out of water, and it may still be deemed proper to make attempts to effect resuscitation, he should be immedi- ately well dried, wrapped in blankets, and conveyed to a place convenient for the necessary applications. The principal object to be aimed at, is a restoration of * Revue Medicale, torn. xiii. p. 347^ ASPHYXIA. 599 the action of the lungs, at the same time that warmth is gradually communicated to the body. With this view, artificial inflation of the lungs has always been regarded as the most important resuscitating means we possess in cases of this kind. The inflation may be made by blowing the air in the mouth through a tube, or by a common bellows, whilst the nostrils are held close, to prevent the return of the air by that channel. It is to be particularly recollected, however, that very for- cible inflation is calculated to defeat our purpose, even in cases where the chances of resuscitation may be presumed to be considerable. M. Leroy d'EtiolIes has recently paid particular attention to this subject, and has strongly set forth the injurious consequences of forcible insufflation into the lungs in asphyxia. Leroy, Dumeril and Magendie have ascertained by repeated experiments, that sheep, foxes, deer, rabbits, &c, may be speedily killed by rapid and strong inflation of the lungs, even when the insufflation is made with the mouth. When air is for- cibly thrown into the lungs, it may lacerate the delicate structure of the air-cells and cellular texture of the lungs, and thus destroy all possibility of restoring the pulmonary functions ; for it appears from experiments performed by the same gentleman on dead human subjects, that the pulmonary tissue may be readily ruptured by forcible inflation.* In endeavoring to restore the action of the lungs, the air should therefore be but moderately forced into the trachea—alternating the acts of inflation with compression of the thorax and abdomen, so as to imi- tate the mechanical process of respiration. M. Leroy proposes to introduce two fine needles, so as to penetrate the edge of the diaphragm, and to pass a gentle current of galvanism through this muscle. This has been practised on inferior animals in a state of asphyxia, with complete success, after more than five minutes of submersion. The galvanic circle must be alternately interrupted and closed, so as to imitate the act of respiration. Whenever the circle is closed, the diaphragm contracts, and enlarges the thoracic cavity, and the air is drawn in on taking off the communicating wires, the diaphragm resumes its former position, and expiration takes place. The practice of compressing the chest and abdomi- nal parietes in alternation with gentle insufflation is particularly recommended. By this method the blood in the vessels of the abdomen and breast is put in mo- tion, and propelled towards the heart and lungs, and the contractibility of the diaphragm is excited. At the same time that the efforts to carry on artificial respiration are made, heat should be gradually communicated to the body, by wrapping it in dry and warm flannel, and by applying heated cloths, or warm bricks wrapped in flannel, or bottles filled with warm water, to the lower extremities and body. Care must be taken, however, that the warmth be communicated in a gradual manner, for the sudden application of a high degree of heat could not fail to do irreparable injury, by destroying the small degree of remaining excitability of the organiza- tion. Frictions with dry flannel or stimulating substances, such as powdered mustard or capsicum, will contribute to excite the circulation and impart warmth to the body. The injection of stimulating fluids into the rectum will be proper, more especially when some manifestations of returning life have been established by the foregoing measures. For this purpose, a solution of ammonia, with wine, or camphor, or warm diluted brandy, may be used ; and where the abdomen is tense and tumid, we may inject a warm infusion of senna, in wine, with the view of exciting the action of the bowels. Galvanism, also, has been employed as a resuscitating agent in cases of this kind. Wiedemann speaks highly of this influence, more especially when di- rected upon the external organs of generation. He asserts that he has known the most excellent effects produced by it when employed in this manner. It must be observed, however, that both electricity and galvanism can be employed * Rapport sur un Memoire de M. Leroy d'EtiolIes, relatif a rinsufflation du Poumon, &c.— Revue Medicale, vol. xiii. p. 328. 600 ASPHYXIA. with a prospect of advantage only when communicated in a very weak state, for when strongly applied, they tend to exhaust rather than to increase the vital energies. Various other modes of exciting the vital powers have been recommended; such as exposing the eyes to the direct rays of the sun; applying volatile and stimulating fluids to the Schneiderian membrane; plucking the hairs; tickling the soles of the feet, sides, and arm-pits; acrid substances applied to the tongue; burying the patient up to the head in warm ashes or sand, &c. Venesection has been much recommended in asphyxia from submersion ; and some have particularly advised opening one of the jugulars. Some advantage may, perhaps, be occasionally obtained from this measure, where a flow of blood can be procured, by its tendency to relieve the oppressive venous congestion of the lungs. In general, however, no blood can be obtained by opening a vein, except in cases of very transient submersion, or where the action of the heart has been re-excited by the means already mentioned ; and here there is much reason to apprehend that injury rather than advantage would generally result from this operation. The return of the vital actions is at first manifested by transient and weak twitches of the muscles of the face, particularly of those about the lips; succeeded by feeble, irregular and convulsive efforts to breathe; spasmodic tremor and agi- tation of the extremities; a small and weak pulse, beating at very long intervals; and a discharge of frothy fluid from the mouth. By degrees, sensation and the power of motion return ; the lips assume a red hue, the skin becomes soft and warm, particularly about the scrobiculus cordis, and in some instances vomiting takes place. When recovery has been so far effected, the utmost degree of caution is neces- sary to prevent, on the one hand, over-excitation by stimulants, and on the other, sinking from deficient support of the vital energies by appropriate excitants. I knew an instance where a person, after much exertion, was so far resuscitated from a state of asphyxia by submersion as to breathe freely, and to manifest con- sciousness and the power of voluntary motion. The persons about him were directed to give him, from time to time, certain portions of warm wine whey. This was wholly neglected, and in four or five hours he sunk and expired. Warm wine, or weak brandy toddy with warm aromatic ptisans, as infusions of balm, sage or catnep, should be given from time to time, according to the state of the pulse, and the patient must be kept perfectly at rest in a dry and warm bed, with the air freely circulating through the room, if the weather be warm. Our efforts to effect a resuscitation in cases of this kind, where the period of submersion has not been so protracted as to preclude all reasonable hopes of ultimate success, should not be too readily abandoned. Instances have occurred in which the signs of returning life did not manifest themselves for more than an hour after commencing with the resuscitating measures. It has been said, and the observation appears to me very correct, that there is much reason to believe that some lives are lost in this way for want of duly continued exertions to re- establish the vital actions. In still-born infants, 1 have known two instances of ultimate resuscitation, where the signs of returning animation were not noticed for above forty minutes after the commencement of the usual measures. It should also be observed, that well-authenticated instances of recovery are on record where the resuscitating means were not applied until many hours after the person had been taken out of the water; and hence, where the time of sub- mersion has been short, and for want of assistance, means are not employed, it may still be proper to make suitable efforts to effect a resuscitation, although several hours have elapsed before this can be done. De Haen, whose authority cannot be questioned, asserts that he resuscitated a person seventeen hours after he had been taken out of the water ; and other similar instances might be adduced, which, though less remarkable, perhaps, are equally encouraging to late attempts of this kind. ASPHYXIA. 601 2. Asphyxia from the inhalation of irrespirable gases.—The most common cause of this variety of asphyxia is the inhalation of carbonic acid gas. When this aeriform poison is undiluted with atmospheric air, it will destroy life almost instantaneously, by abolishing, at once, all the sensibility and irritability of the nervous system. When mixed with a portion of atmospheric air, its sedative effects on the brain are less vehement and sudden ; giving rise to vertigo, faintings, insensibility, asphyxia, or death, according to the degree of its purity and the length of time during which persons are exposed to its influence. When life is suddenly destroyed by inhaling this gas in an undiluted state, the dead body is pale, collapsed, and flaccid. In instances, however, where death or asphyxia is caused by a gradual destruction of the vital powers, from the gas being more or less mixed with atmospheric air, the face exhibits a tumid and livid appearance, the veins about the neck and head are turgid, the tongue somewhat swollen, the lips blue, with suggilations on different parts of the surface, and the body remains warm for many hours, or even for several days. On dissection, the sinuses of the brain, the jugulars, right side of the heart, pulmonary arteries, the lungs, and the eavae, are always strongly congested with black and generally fluid blood. The pulmonary veins, left side of the heart and aorta, on the contrary, are empty, or contain but a small quantity of blood. The ventricles of the vein are commonly charged with a considerable portion of bloody serum, and the cellular structure about the head and neck is oflen found infiltrated with the same kind of fluid. The bronchia are filled with a frothy mucus more or less tinged with blood; and the mucous membrane of the stomach and intestines usually exhibits a dark red, ecchymosed, and distended appearance. The epiglottis is generally erect, and the glottis patulous.* Carbonic acid gas produces its fatal effects on the animal economy both by excluding the requisite portion of oxygen or respirable air from the lungs, and thereby preventing the conversion of venous into arterial blood, and by a pecu- liar and exceedingly powerful sedative principle independent of its mere irrespir- able character. Animals die much more speedily when confined in this and other mephitic gases, than when placed in an exhausted receiver, or when the atmospheric air is otherwise excluded from the lungs ;t and frogs, worms, leeches, and snails, are killed in a few hours by being placed in carbonic acid gas, although capable of living a long time when simply deprived of atmospheric air.J These facts show conclusively that in addition to the mere exclusion of respirable air, there is also a deleterious impression made on the vital powers by inhaling this gaseous poison ; and it acts, therefore, at once like submersion or strangulation, and as a powerful sedative poison. There are several other gaseous substances, which, when inhaled in a concen- trated form, produce immediate asphyxia or death. The fumes of sulphur, sul- phureted hydrogenous gas, nitrous gas, azote, hydrogen, and certain gaseous poi- sons, generated by putrefying animal and vegetable substances, destroy life with more or less rapidity. Of these gases, azote, and pure hydrogen, appear to de- stroy life simply by their not being respirable, or by preventing the chemical changes of the blood in the lungs, in the same manner lhat submersion or ob- struction of the trachea produces this effect.§ Treatment.—When the asphyxia from this cause (carbonic acid gas) is incom- plete, with some degree of sensibility remaining, the patient may be generally soon recovered by conveying him immediately into the open air, supporting him in a sitting posture, dashing a little cold water upon his face and breast, applying dry frictions to the extremities, and, as soon as he can swallow, giving him small portions of cold wine and water. * Portal. Observations sur les Effets des Vapeurs Mephitiques. X Fothergill. A New Inquiry into the Suspension of Vital Action in cases of Drowning and Suffocation. X Carminati. De Animalium ex mephitibus, et noxiis halitibus interim ejusque Causae, p. 89. § Bichat on Life and Death, p. 2±Z. 602 ASPHYXIA. If the unfortunate individual is in a state of perfect asphyxia, without any manifestations whatever of life, we may sometimes succeed in effecting resusci- tation by the following course of management. He should be speedily carried into a free and cool air, divested of his clothes, and laid upon a sheet spread on the floor, or the ground, with his head and shoulders somewhat raised. Cold water must now be dashed upon his breast, and cloths dipped in cold water ap- plied to the head; or he may be supported in a sitting posture, and the water poured on the head. In some cases, the moment the cold affusion is made, a convulsive respiratory effort is excited. In an instance to which I was called about a year ago, I found the patient without the slightest indications of vitality. Having stripped off his clothes, I dashed a bucket full of cold water over the head and breast, and almost at the same moment, I observed a short convulsive gasp. By continuing the affusions at short intervals, the respiratory efforts were repeated, at first very weak, and at intervals of nearly a minute, and by the ad- ditional aid of stimulating frictions, the respiration was fully established in about an hour after the first symptoms of returning life. Frictions with the flesh-brush, or with stimulating embrocations, are important auxiliaries in re-exciting animation in cases of this kind. We may also derive advantage from volatile stimulating applications to the mucous membrane of the nose, by means of a feather—such as aqua ammonia, ether, and camphorated spirits. At the same time, also, stimulating enemata should be used, particularly a solution of the carbonate of ammonia in a mucilaginous fluid. Richter speaks favorably of the injection of cold water and vinegar for this purpose. If the act of respiration be not soon excited by the cold affusions, artificial inflation of the lungs must be resorted to, in the way mentioned above. Upon these two means we must chiefly rely in our efforts to effect resuscitation. When the respiration is partially established, but continues very laborious, and with a rattling noise in the bronchia, considerable benefit will sometimes result from the abstraction of from eight to ten ounces of blood from the arm. As soon as the respiration is fully established, the patient should be wiped dry, and laid in a comfortable bed, and small portions of warm wine, or wine-whey, or some other gentle stimulat- ing beverage allowed. Galvanism has been employed, and, in some instances, with manifest advan- tage, in asphyxia from mephitic gases. The galvanic current should be weak, and passed along the course of the pneumogastric nerves, by placing the nega- tive conjunctive wire in contact with the scrobiculus cordis, and the positive pole with the part immediately over the par vagum in the neck, just below the sterno- mastoid muscle. After the vital actions have been re-established, the arterial excitement, in some instances, becomes violent and tumultuous. The heart palpitates vehemently; the pulse is full, strong, and hard ; the vessels of the head turgid, and a disposi- tion to heavy sleep ensues. Under these circumstances, venesection is indispens- able, and the blood should be suffered to flow until the activity of the circulation is considerably moderated. In general, much caution is necessary after resusci- tation is effected, neither to excite the vital powers too much—which may readily be done—nor to suffer them to languish for want of some gentle stimulus. 3. Asphyxia from electricity.—When electricity is passed through the ani- mal system, in currents of moderate intensity, it excites and invigorates the vital energies; but when its intensity is great, it suddenly suspends, or entirely de- stroys the sensibility and irritability of the nervous system, and gives rise to more or less complete asphyxia, or immediate and irrecoverable loss of vitality. The appearances exhibited by persons who have been struck by lightning, vary considerably. In most instances, red streaks may be noticed on the breasts and arms, of an ecchymosed and highly irritated appearance, and generally of a zig- zag form. The hair is usually singed on some parts; and small blisters, like those produced by a scald, occur on diflerent parts of the body. Sometimes blood is discharged from the ears, and suggilations of large extent are frequently ASPHYXIA. 603 found on the trunk and extremities. Internally, structural lesions are but rarely detected in persons who are killed by lightning. In general, the heart is turgid with blood, but the lungs are usually collapsed, and entirely free from vascular congestion. The blood is always deprived of its coagulability by a fatal stroke of electricity ; and the body commonly enters into putrefactive decomposition with extraordinary rapidity. When the electric stroke does not entirely destroy the vital powers, the face is generally red and bloated ; more or less blood often is- sues from the mouth and nose; respiration is slow and very laborious ; the pulse is extremely weak and irregular, or entirely absent; and spasmodic twitches of the muscles of the eyelids, mouth, and throat, sometimes occur. Persons who are recovered from a state of asphyxia caused by lightning, generally suffer for a long time afterwards with tremors, painful sensations, swellings, and some de- gree of numbness in the extremities, more especially in the legs. Such indi- viduals usually retain a particular susceptibility to the electric influence, and are apt to feel a peculiarly uneasy feeling on the approach of a thunder storm. The treatment of asphyxia from this cause does not differ from that which is mentioned for asphyxia from mephitic gases. Cold affusions are particularly valuable to re-excite the latent vital energies in cases of this kind. Cold water should be copiously and frequently dashed over the whole body, and frictions diligently made with the flesh-brush or pieces of rough flannel. Galvanism and electricity also have been especially recommended in asphyxia from a stroke of lightning. Stoll asserts, that animals in a' state of asphyxia from an electric shock, have been speedily recovered by a second shock of this power;* and Bernt assures us that in a case produced by a stroke of lightning, a second shock affected a resuscitation.! M. Abilgaard also has related some instances of as- phyxia from this cause, in inferior animals, in which resuscitation was effected by a second shock of electricity4 4. Asphyxia from cold.—When the body is subjected to the influence of intense cold, the superficial blood-vessels shrink; the surface becomes pale and • contracted; respiration oppressed; the extremities benumbed and weak; and finally, an irresistible desire to sleep comes on ; and, unless speedy aid be ob- tained, insensibility, asphyxia, and death, inevitably ensue. For the mode in which these effects are produced by low temperature, the reader is referred to the article Cold, page 40. Instances of resuscitation from asphyxia, caused by intense cold, are by no means uncommon; and cases are related in which reanimation was effected many hours, or even several days, after the asphyxia was produced.§ The principal resuscitating means in cases of this kind is the gradual communication of warmth to the body. The introduction of warmth requires, however, the utmost degree of caution ; for, if the heat be rapidly communicated, it will inevitably destroy the remaining vitality, or should a partial recovery ensue, fatal gangrene would be the certain consequence. When a person is found in a state of insensibility from cold, he must on no account be immediately conveyed into a warm cham- ber, or placed near the fire. His body should be immersed in spring water, or water fresh drawn from a well. Burying the body in fresh snow has also been recommended for this purpose. Richter states, that the snow-bath is decidedly the most important resuscitating means we possess in cases of this kind. After the body has been suffered to lie in water or snow for forty or fifty minutes, it should be carefully dried with soft pieces of flannel, wrapped in blankets, and conveyed into an unheated chamber. Gentle frictions with flannel should now be resorted to, and if no manifestations of respiration occur, artificial inflation of the lungs should be practiced. If these efforts succeed in restoring symptoms of * Rettungsmittel in plotz. unfiillen., p. 63. f Vorlesungen fiber, d. Rettungsmittel beim Scheintode, p. 121; as quoted by Richter, Spec. Therap., vol. viii. p. 647. X Loc. Med. Havnien. Collectan., &c, t. ii.—Good. § Kruinitz. Oekonom. Encyclopaedia, Th. xv. p. 261. Richter, Sp. Ther. 604 PNEUMOTHORAX. life, the temperature of the room should be very gradually increased, and bottles filled with lukewarm water laid to the feet, and about the body. When the power of deglutition is restored, moderately warm ptisans—such as balm, sage, or elder-blossom tea, and diluted warm wine, may be given with advantage; but the stronger stimulants must be rigidly interdicted. Sect. IV.—Pneumothorax. The collection of aeriform fluids in the cavity of the pleura, is termed pneumo- thorax. This is no very uncommon occurrence, and is always attended with the most distressing effects on the action of the lungs and heart. In most cases the confined air is fetid, resembling the smell of sulphureted hydrogen. This is always the case when the passage formed between the cavity of the pleura and the air-cells is the result of a gangrenous eschar of the surface of the lungs, and where more or less purulent matter is effused into the cavity of the chest. When such a communication is effected by ulceration, tuberculous softening, or other- wise, the air is forced into the cavity of the pleura during the acts of respiration, and as its return into the lungs must always be very slow, and often wholly im- possible from the valvular form of the opening, it accumulates with more or less rapidity, until the lungs are so greatly compressed as to render respiration ex- tremely difficult, and finally to arrest it entirely. The lung of the affected side becomes, at last, compressed into a very small and nearly solid mass; and when the disease occurs in the left cavity, the heart and mediastinum are usually forced completely into the right side of the chest. The affected side of the chest be- comes manifestly bulged out and the intercostal spaces wider and more raised or puffy than natural. The abdomen, also, usually becomes more prominent in consequence of the depression of the diaphragm against the abdominal viscera by the distending force of the confined air. Patients affected with pneumothorax experience great pectoral oppression and * difficulty of breathing, attended generally with more or less palpitation of the heart, and often with severe pain under the sternum or the affected side of the ehest. They are usually obliged to remain in a sitting posture, and can never rest even for a moment recumbent on the sound side. M. Rayer has related a case in which the patient was forced to remain day and night resting on his knees and elbows in bed. When the pneumothorax occurs in the left side of the chest, the palpitation of the heart is usually felt in the right side only; but this can take place only in very violent cases, where the confined air is so abundant as to force the heart completely into the right cavity of the thorax. The diagnosis of this affection is not attended with difficulty except to those who are not experienced in mediate auscultation and percussion. By these diagnostic means, the practiced ear may arrive at certain conclusions as to the existence of air in the cavity of the chest. " Whenever we find one side of the chest sounding more distinctly than the other, and at the same time perceive the respiratory murmur distinctly in the least sonorous side, and not at all in the other, we may be assured that there exists pneumothorax in the latter side of the chest." Even when, on percussion, we find both sides equally sonorous, the existence of this affection may be inferred, if auscultation do not enable us to perceive the respiration on one side whilst it is audible on the other. When the disease supervenes on pleuritic effusion into the cavity of the pleura, the affected side will yield a dull sound when percussion is made, before the pneumothorax commences. " As soon, however, as the air begins to accumulate, the resonance of the chest returns in some degree, in the situation occupied by the air, without, however, being as distinct as in the sound side. Day after day the extent and intensity of this resonance increase without any return of the sound of respira- tion ; and if there had previously been any remains of the respiratory murmur, even this now totally vanishes." But when the lung of the affected side is PNEUMOTHORAX. 605 attached to the costal pleura by means of a very short cellular tissue, the diag- nosis, even by auscultation and percussion, is rendered more uncertain; for at the point of adhesion the respiration will still be audible. (Laennec.) When, on examining the chest with the stethoscope, that peculiar metallic sound is heard, which Laennec calls metallic tinkling, and which has been compared to the sound of a drop of water falling into a bottle half full, it indicates the existence both of air and a puriform matter in the cavity of the pleura, with a fistulous opening between the cavity of the chest and the bronchia. This metallic sound, says Laennec, " exists only in that variety of pneumothorax which is complicated with empyema; and may be considered as a pathognomonic sign of this combi- nation in conjunction with a fistulous opening into the bronchia." The metallic tinkling of pneumothorax may be distinguished from that which occurs from a large tuberculous excavation in the. lungs partly filled with a purulent fluid, by the greater weakness of the sound, and the narrow space to which it is confined in cases of this latter kind. There is some risk in mistaking emphysema for pneumothorax in examining by percussion and auscultation ; particularly by those who are not accustomed to this mode of exploration. M. Laennec points out the following difference in the results obtained by the employment of these diagnostic means in these two affections. " In pneumothorax, the respiratory murmur is wholly absent, except at the point between the scapula and spine, corresponding to the roots of the lungs. In emphysema; the respiratory sound is never completely inaudible, and there is a slight rattle which never occurs in the former complaint. Pneumo- thorax comes on rapidly, and cannot continue long without giving rise to dan- gerous symptoms, or even proving fatal; emphysema, on the contrary, comes on slowly, and is never so severe as to confine the patient to bed, or incapaci- tate him for his ordinary occupation." Post-mortem appearances.—On cutting into the cavity of the pleura, the air usually rushes out with very considerable force. In many cases there is a small portion of sero-purulent fluid found in the chest; and in nearly all instances, the surface of the pleura is more or less extensively covered with a thin layer of pseudo-membranous matter. Not unfrequently, slight adhesions occur between the costal and pulmonary pleura of the affected side. The lung of the side affected is usually compressed into a small, irregular, and compact mass ; and if the disease is in the left cavity, the heart and mediastinum are pushed completely within the right cavity of the thorax. Frequently a fistulous opening may be detected between the cavity of the pleura and the bronchia. Causes.—Pneumothorax frequently occurs in consequence of tuberculous ex- cavation near the surface of the lungs, and the formation of a fistulous opening into the bronchia. Chronic pleuritis, also, may give rise to this affection. Some of the cases related by M. hard, originated from chronic pleurisy. When the disease arises from chronic inflammation of the pleura, it is always preceded by the effusion of sero-purulent matter into the cavity of the chest, and in such cases no opening into the bronchia usually occurs. It would appear that in cases of this kind, the air within the cavity of the pleura " is the product of a chemical decomposition of the effused albuminous and puriform fluid. In proportion as the gas is thus developed, the effused fluid becomes absorbed, until the disease has acquired the character of complete pneumothorax. The rupture of a vomica, giving rise to a communication between (he bronchia and the cavity of the pleura, appears to be no uncommon cause of this affection. When the disease occurs in this way, the air in the thorax is generally associated wilh a purulent fluid. Pneumothorax may also arise from the extrication of fetid gas, by the decomposi- tion of a gangrenous eschar dissolved and discharged into the cavity of the chest." (Laennac.) Treatment.—This is always an extremely dangerous affection; for although the mere accumulation of air in the cavity of the pleura may no,t of itself be so formidable, yet the organic lesions with which it is almost invariably connected, 606 PNEUMOTHORAX. are generally of such a nature as to admit of but slender hopes of cure, or even of a considerable prolongation of life. It would seem, nevertheless, that sponta- neous cures of this affection have taken place. Such a favorable termination is, however, an extremely rare occurrence, and is supposed to take place in the fol- lowing manner. The lung being strongly compressed by the air that rushes into the cavity of the pleura, through the aperture made into the bronchia, gradu- ally collapses, if no adhesions exist, until it remains quiescent. In this state of collapse and rest, the lung is in the most favorable condition for the healing of the opening through which the air passed. " If the opening heals, the air will be absorbed, and the patient gradually recover." The general remedial management must, of course, be modified according to the nature of the lesion or primary affection, upon which the pneumothorax de- pends. When there is reason for believing that the air compressing the lungs is the result of chronic inflammation of the pleura, some advantage may be expected from counter-irritating applications to the chest; such as blistering, pustulation with tartar emetic ointment, cupping, moxa, issues, setons, &c. Some benefit may also result from gentle courses of mercury, and from the internal exhibition of diuretic remedies. In cases manifestly connected with tuberculous softening, and fistulous opening into the bronchia, little or no advantage can be looked for from any remedies of this kind. Different opinions have been expressed as to the propriety of puncturing the thorax for the purpose of giving exit to the confined air in this affection. Laen- nec speaks favorably of this operation, although it does not appear that he has himself resorted to it with success in any case of this kind. The only instance in which he performed this operation, terminated fatally in a few hours after the puncture was made. The opening was made between the fifth and sixth ribs, and very little air, and no purulent matter, escaped from the incision. This ap- pears to have been a case of empyema conjoined with pneumothorax, for when after the death of the patient, an incision was made about the middle of the fourth intercostal space, a considerable quantity of pus was discharged; and on making an opening into the chest near the junction of the third rib with its carti- lage, much fetid gas rushed out. This case cannot, therefore, be regarded as a fair test of the value of this operation in pneumothorax. Riolan states that he has seen several instances of the successful operation of paracentesis on patients who were supposed to labor under dropsy, without anything having been evacu- ated from the chest but air. (Laennec.) These, doubtless, were cases of simple pneumothorax, and may be regarded as encouraging examples of the usefulness of this operation in the present affection, when uncombined with empyema. " Pneumothorax," says Laennec, " complicated with liquid effusion, and still more, with pulmonary fistula, is a case of a most serious nature, and leaves little hopes of a cure being effected. This, however, must not be regarded as quite impossible even in the severest cases. I formerly proved the possibility of the cicatrization of tuberculous excavations; and the observations of Bacqua, Jaymes, and Robin (Journ. Gen. de Med., 1813), to which I could add a more recent case of the same kind, sufficiently prove, that even in such cases, we may attempt this last resource with some prospect of success." That the operation in question is a proper one, in perhaps every variety of pneumothorax, can scarcely be doubted; for even where the prospects of an ultimate cure cannot be entertained, we may at least reasonably expect to prolong the patient's life by giving exit to the confined air, and thereby preventing suffocation from the com- pression of the lungs. The object of the operation is to prevent the fatal com- pression of the lungs, by the confined gas, and to place this organ in a state of quiescence, so favorable to the healing of the aperture through which the air passes from the bronchia into the cavity of the pleura. Although the propriety of this operation seems to be obvious in this affection, yet we find but very few instances recorded of its having been performed in pneumothorax. There is a highly interesting case reported in the Medico-Chirurgical Review, (January, DISEASES OF THE HEART. 607 1829,) in which the chest was punctured; but although great relief was the im- mediate consequence of the evacuation of the air, the patient in a few days sunk under the disease.* A case of pneumothorax is related by Dr. Davy, in which this operation was performed with entire success. The patient was affected with haemoptysis, which came on after " a severe fall on the left side of the chest, received eighteen months previously." While under treatment for this affection in the Military Hospital at Chatham, he was one morning seized with a violent fit of coughing, and symptoms of pneumothorax immediately succeeded. The iborax was punctured with a trocar between the eighth and ninth ribs, " the integuments and intercostal muscles having been previously divided with a scalpel." As but little air escaped by this opening, it was " concluded that its escape had been prevented by adhesions of the pleura at the point where the puncture was made;" and on the following day the operation was repeated just below the left papilla. From this orifice a large quantity of air rushed out " as if from a blow-pipe." The relief obtained was immediate and great, and the patient continued to improve regularly. This and the preceding case, says Dr. Johnson, are the only instances in which this operation was performed for pneu- mothorax in England. CHAPTER V. CHRONIC DISEASES OF THE HEART. Sect. I.—Of the Diseases of the Heart. There is scarcely a subject in pathology that has attracted so much attention of late years, as the chronic affections of the heart. The researches of Corvisart,t Kreysig,J Testa,§ Laennec,|| Burns,If and Abercrombie,** have thrown great light on this important class of diseases, and it is from these sources chiefly that the following observations are drawn.tt Symptoms.—The general symptoms are nearly the same in every variety of structural disease of the heart. More or less habitual dyspnoea almost universally attends in affections of this kind; and a careful attention to the particular modi- * The patient was a member of our profession, and was visited during his illness by the majority of the most eminent physicians and surgeons of London. The incision was made between the sixth and seventh ribs, anteriorly. When the pleura was punctured, "a rush of air instantly issued forth with a loud hissing noise, and strong enough to extinguish several candles. The relief was almost instantaneous. The patient turned on his back, and breathed with comparative freedom." On the fourth day after the operation, the patient was found to be sinking, and, after a strong paroxysm of convulsions, expired on the afternoon of this day. On dissection, an aperture was discovered at the division or cleft between the two lobes. This aperture was circular, about the size of a crow-quill, and evidently fistulous. It communicated with a small tuberculous excavation. The right lung was much more tuberculous than the left; but the tubercles were in a quiescent state. Med. Chir. Rev., Jan. 1829, p. 48:2. f Essai sur les Maladies et les Lesions Organiques du Cceur. Die Krankheiten des Herzens. Berlin, 1814-17. Delle Malattie del Cuore. || Treatise on the Diseases of the Chest, translated by J. Forbes, M. D.; 3d edition. TT Observations on some of the most frequent Diseases of the Heart. By Allan Burns, 1809. ** Contributions to the Pathology of the Heart. Transact. Med.-Chirurg. Society of Edinb., vol. i. 1824. ft [The late Dr. Hope, of London, published at a later date an excellent work on this sub- ject—Mc] 608 DISEASES OF THE HEART. fications of this symptom, is of great importance in a diagnostic point of view (Corvisart). The acts of inspiration are either very quick, and effected more by the action of the ribs than by the diaphragm, and somewhat wheezing; or the patient breathes as if he had been walking rapidly, and appears to make unusual efforts in filling the lungs; or, finally the respiration is calm, and without any particular effort, but the air does not appear to enter into the lower portion of the lungs. Mental agitation, or corporeal exertions, particularly walking, or ascend- ing acclivities or stairs, never fail to bring on more or less violent paroxysms of dyspnoea; and in the latter stages of the disease, the most trifling excitements of this kind give rise to extremely distressing spells of suffocative breathing, attended with great weight and constriction in the breast, inexpressible anxiety, a turgid and usually livid hue of the face, particularly of the lips, which are swollen and purple; distension of the veins in the neck and head, and an expression of ex- treme distress and suffering in the countenance. These paroxysms of dyspnoea often last but a few minutes, and rarely continue beyond half an hour, and sub- side rapidly to the ordinary state of respiration. During the early period of the disease, or in cases of a less serious character, the patient is able to lie down, (though rarely with any degree of ease on the right side,) but the sleep is much disturbed by alarming dreams, frequent startings, and spells of palpitation—obliging the patient suddenly to sit up in bed. In violent or inveterate cases, however, the patient is sometimes obliged to remain day and night in a sitting or half-sitting posture—every attempt to lie down being immediately followed by the most harassing paroxysm of palpitation of the heart and suffocative breathing. One of the most frequent symptoms of cardiac diseases is irregular action of the heart. Sometimes the heart beats tumultuously and indistinctly, which has been com- pared to the bubbling of boiling water; and at others it seems to be in a state of tremulous agitation. More commonly, however, it beats vehemently against the side of the thorax, so as to enable a person distinctly to hear its throbs, and to communicate a motion to the whole superior part of the body. Syncope, too, is no uncommon occurrence in diseases of this kind. The patient is liable to occasional attacks of partial fainting, often of long continuance, during which he experiences a feeling of great oppression and constriction in the region of the heart, a partial loss of consciousness and sensorial power, inexpressible anxiety in the praecordia, with an extremely feeble and fluttering or intermitting pulse, and scarcely any perceptible respiration. From this state of adynamia, he sometimes passes suddenly into deep syncope, approaching the character of asphyxia, and after a short period, again suddenly recovers his entire conscious- ness.* In some cases, paroxysms of angina pectoris occasionally supervene; and instances occur in which the cardiac disease gives rise to convulsions and apoplexy.t The habitual aspect of the countenance, during the intervals of the exacerbations of the dyspnoea, is usually pale and cachectic, with a leaden livi- dity of the prolabia, and puffy swelling under the eye. (Edema of the feet and legs is usually one of the earliest symptoms of organic affections of the heart. In the progress of the disease, oedema gradually extends higher, and often invades the scrotum, labia, and even the trunk. In some instances, the pulse differs but very little from its natural state, except during the occasional paroxysms of the dyspnoea and palpitation; but more frequently it is irregular, intermitting, and often has a peculiar jarring beat, or is sharp, exceedingly firm, and incompressi- ble. Organic diseases of the heart are very generally attended with a peculiarly irritable temper, and a disposition to melancholy and hypochondriasis.:]: Symp- toms of indigestion, too, are very apt to occur in diseases of this kind ; and in many instances there exists a strong tendency to hemorrhage, particularly from the lungs and nose. Patients laboring under cardiac affections are liable to sud- den and severe pains in different parts of the body. * Kreysig, loc. cit, b. i. p. 332. Dr. Forbes. Edition of Laennec on the Diseases of the Chest. Testa, loc. cit. DISEASES OF THE HEART. 609 Dr. Adams has given the history of a very remarkable case, in which no pulse was to be felt in any artery of the body for six weeks; neither were the move- ments of the heart perceptible by the hand applied to the chest; but an obscure, undulating motion could be heard by applying the ear to the region of the heart. On dissection, the heart was found large and flabby ; the semilunar valves of the aorta were completely ossified; and the coronary arteries " were so completely converted into bone as to be quite solid, having no perceptible cavity except at the distance of an inch from their origin."* Dissection shows that cardiac diseases have a particular tendency to produce great engorgement of the capillary vessels, and it is to this circumstance, no doubt, that we have to ascribe the dropsical effusions into the cellular structure of the cavity of the chest, so common in these affections. In almost all those who die of organic disease of the heart, the mucous membrane of the alimentary canal exhibits a deep red, or violet color, and, in most instances, " the liver and capillaries situated beneath the serous, mucous, and cutaneous tissues, are strong- ly gorged with blood.t A very vivid redness of the internal surface of the heart and large vessels is also a very common phenomenon in subjee's who have died of such affections, and this is particularly noticed where the affection consists in a morbid dilatation of the ventricles of the heart. Causes.—The etiology of the diseases of the heart is enveloped in much ob- scurity. There exists, no doubt, a natural predisposition in some individuals to affections of this kind; but our notions concerning the nature of this predisposi- tion amount only to some plausible conjectures.^ An inordinate irritability of the heart and arteries has been mentioned as a circumstance predisposing to cardiac affections ; and an original defect in the muscular energies of the heart, as well as a disproportion between the activity of this organ and the blood-vessels, may also, occasionally, be the foundation of such diseases. It is said, that the pre- disposition to organic affections of the heart is, in some instances, manifestly hereditary, and its occasional prevalence in certain families renders this opinion very probable. Dr. Forbes refers to Lancisi, Albertini, Morgagni, Portal, Cor- visart, and Testa, for striking examples of this kind ; and a remarkable instance is related in the eleventh volume of the Medical Commentaries. A strumous habit is considered by Testa as a strong predisposing cause of organic affections of the heart; and Dr. Forbes says, that his own experience has led him to the same conclusion. " In this case," he observes, " I have thought that the disease is developed at a more early period than under other circumstances. Perhaps in this case an original disproportion of the parts usually exists." The remote causes of the diseases of the heart appear to be numerous, and very diverse in their characters. The following have been mentioned as the most common and powerful. 1. Moral Causes.—Corvisart, Kreysig, and others, assert that mental emo- tions are among the most frequent and powerful causes of structural diseases of the heart; and from the well-known influence of violent affections of the mind on this organ, there can be no doubt, indeed, of their tendency, when frequently repeated, or of protracted duration, to give rise to such diseases. Dr. Forbes states, that he attended a poor woman " affected with organic disease of the heart, of many months' standing, which was suddenly produced hy horror at seeing her infant scalded to death."X Instances have occurred, in which sudden terror, anger, or excessive joy, has determined the blood so vehemently to the heart as to cause immediate rupture of its ventricles.§ 2. Gout and rheumatism.—Organic diseases of the heart are probably more * Cases of Diseases of the Heart, &c. By Robert Adams, M. B., &c. &c. Dublin Hospital Reports. f Laennec, loc. cit., p. 592. X Laennec on the Diseases of ihe Chest, third edition. § Richter, Specieile Therapie, b. v. p. 129. 39 610 DISEASES OF THE HEART. frequently occasioned by metastasis of gout or rheumatism, than by any other cause. Sauvages mentions instances of cardiac affections, alternating with pa- roxysms of gout;* and Dr. Scudamore has related a remarkable case of palpita- tion of the heart of three years' standing, which suddenly disappeared on the supervention of an attack of articular gout.t Rheumatism., however, appears to be still more frequently concerned in the production of cardiac affections. Dr. Cox has adduced some interesting examples of the dependence of the dis- eases of the heart on metastasis of rheumatism. Numerous cases of organic diseases of the heart and pericardium, which he met with during his connection with Guy's Hospital, were referable to, or connected with rheumatism.^ Dr. Cox stales, moreover, that his observations have led him to believe, that " the majority of cases of organic diseases of the heart in young people" are con- nected with rheumatism. Dr. James Johnson also observes, that "long and attentive observation" has convinced him, " that a very considerable proportion of those active enlargements or hypertrophiae of the heart which are now so frequently met with in practice, are dependent on rheumatism." Dr. David Dundas,§ and Dr. Havvkins|| also, have published observations illustrative of the rheumatic origin of organic cardiac diseases; and Dr. Forbes has related several interesting instances of this kind.lj 3. Cutaneous diseases.—The repulsion of chronic cutaneous eruptions may give rise to organic diseases of the heart. Kreysig says, that when cardiac affec- tions arise from causes of this kind, the disease is apt to occur in the external or internal membranes of the heart; and according to the observations of Testa, the most common structural lesions resulting from repelled cutaneous affections, are thickening and induration of the pericardium. Osiander mentions ulcerations of the external surface of the heart and of the pericardium ;** and Meckel has related a similar instance of disorganization of these parts, apparently the consequence of repelled cutaneous eruptions. Cardiac affections have also been known to result from the suppression of habitual perspiration of the feet, and from the healing up of old ulcers and issues. (Richter.) 4. Syphilis is also mentioned as no uncommon cause of diseases of the heart. Corvisart was of opinion that the excrescences which are sometimes found on the valves, usually depend on a syphilitic taint; and Lieutaud particularly refers to this disease as a cause of various structural disorders of the heart.tt Mr. Bertin, however, thinks, that the influence of this cause, in relation to cardiac diseases, has been much overrated ; an opinion which he was led to adopt after an experience of twenty years in the venereal hospital. Laennec also rejects the opinion of Corvisart with regard to the syphilitic origin of the excrescences on the valves. 5. Diseases of other organs, particularly such as are attended with long- continued and severe dyspnoea, are especially apt to give rise to hypertrophy or dilatation of the heart, through the constant efforts this organ is called on to per- form, in order to propel the blood into the lungs, against the resistance opposed to it by the cause of the dyspnoea." Chronic pulmonary catarrh, phthisis pul- monalis, chronic peripneumony, empyema, and emphysema of the lungs, fre- quently give rise to these cardiac affections, and, almost necessarily, where there exists a congenital disproportion between the size of the heart and the diameter * Nosologia Method , torn. i. p. 518. t A Treatise on Gout and Rheumatism, fourth edition, p. 44. X Observations on Acute Rheumatism and its Metastasis to the Heart, by Thos Cox, M. D., Lond., 1824. § Med.-Chir. Transact., vol. i. || Rheumatism and some Diseases of the Heart Lond., 1826. If Original Cases, &c, p. 112, and p. 1G5. See also a note at p. 597 of his Translation of Laennec on the Chest, fourth edition. ** Denkwiirtigkeiten, &c, Th. i p. 146, as quoted by Richter. j-J- Hist. Anatom. Med., torn. ii. ob. 510-510.—Sprengle. DISEASES OF THE HEART. 611 of the aorta. (Laennec.) Chronic diseases seated in the abdomen, are also mentioned among the occasional causes of organic affections of the heart. Testa thinks that induration and enlargement of the liver may give rise to diseases of this kind ; but Corvisart, more correctly I think, regards the hepatic affection as the consequence, rather than the cause, of disease of the heart. " More pro- bably," says Forbes, "it may be merely a concomitant, and the consequence, of those chronic disorders of the stomach and upper bowels which are too frequent in all classes of people to be safely admitted as either a common cause or effect of affections of the heart." It is supposed that visceral enlargements within the abdomen tend to produce cardiac diseases by compressing the large vessels, and by impeding the circulation through the affected viscus, in consequence of which greater efforts of the heart are made to oppose these causes of obstruction. 6. Scurvy has also been supposed to be capable of giving rise to structural disease of the heart, more especially to a morbid softness and flabby state of its structure. 7. Congenital disproportion of the different parts of the heart, and particu- larly between the left ventricle and the aorta, is no doubt at the bottom of the majority of the instances of hypertrophy and morbid dilatation. Where such a condition of the central organs of the circulation exists, everything which is capable of causing a long-continued preternatural momentum of the circulation, or an impediment to the free passage of the blood through the lungs, or sudden and forcible determinations to, and congestion of the heait and large vessels, may readily give rise to aneurismal dilatation of this organ. Playing wind instru- ments, carrying heavy burdens, or straining in lifting heavy weights, running, the inhalation of suffocating vapors, protracted rigors of intermitting and other febrile diseases, intoxication, mental emotions, lymphatic and other tumors press- ing on the carotids or some other arterial trunk, and a great variety of other causes of a like tendency, will be apt to produce a structural disease of the heart in individuals thus predisposed by a congenital conformation of this organ. Blows, falls, and external injuries of the chest, may likewise give rise to organic cardiac diseases. Inflammation of the heart, too, is frequently con- cerned in the development of affections of this organ. Indurations, morbid softening, excrescences, pseudo-membranous formations, adhesions, effusions into the pericardium, ulcerations, &c, may be regarded as the immediate conse- quences of cardiac inflammation, in whatever way this latter condition may be produced. Diagnosis.—The diagnosis of the diseases of the heart is attended with much difficulty. The symptoms of organic affections of this organ are particularly liable to be confounded with simple hydrothorax, hydro-pericardium, neuralgic angina pectoris, and even with asthma. Laennec asserts that none of the symp- toms mentioned above can at all be regarded as pathognomonic, or sufficient to indicate disease of the heart, " since they are common to many other affections, and particularly to almost every chronic disease of the lungs." There is much truth in this observation ; but 1 apprehend, nevertheless, that the uncertainty of the diagnosis, founded merely on the symptoms, is not in general so great as might appear from the sentiments expressed by Laennec. When we find a patient complain of more or less habitual dyspnoea, greatly aggravated on cor- poreal exertion; slight oedema of the feet; a puffy and anxious appearance of the countenance, with a livid hue of the prolabia ; frequent palpitations or tumul- tuous action of the heart; an inexpressible feeling of anxiety in the region of the heart during the paroxysms of dyspnoea; the occasional sudden occurrence of elastic puffy swelling of the lower eyelids and the upper lip ; an irascible and gloomy temper ; quick and short inspirations; a deep purple and bloated aspect of the face during the paroxysms of dyspnoea; with an absence of the peculiar wheezing and rattling noise in the lungs ; and a free secretion of urine; when these symptoms are noticed, we have strong reasons for presuming that there exists some disease of the heart. The sudden and exceedingly distressing 612 DISEASES OF THE HEART. effects that arise from bodily exertions in diseases of the heart, are often suffi- ciently characteristic to distinguish them from simple hydrothorax. Every mus- cular effort, or unusual exercise, aggravates to an extreme degree the dyspnoea and distressing anxiety and agitation in organic cardiac diseases. Going up stairs or walking up arising ground almost immediately excites the most alarming and suf- focative paroxysms of dyspnoea. Although these causes also aggravate, in some degree, the difficulty of breathing in simple hydrothorax, yet these consequences are by no means so violent and agitating in this disease as in the affections of the heart. Without doubt, however, mediate auscultation affords the most cer- tain means for recognizing the presence of organic cardiac diseases ; but the tact for profiting by this diagnostic test can only be acquired after a long course of careful experience; and it must, moreover, be observed, that even in the most experienced hands, the stethoscope more frequently gives fallacious indications with regard to the affections of the heart, " than in any of the other diseases which it is calculated to discover." (Laennec.) Prognosis.—In general, the prognosis in diseases of the heart is particularly unfavorable. Nevertheless, much relief may sometimes be procured even in cases of great severity. We " sometimes," says Laennec, " see the judicious combination of blood-letting, diuretics, and tonics, remove the impending suffo- cation, the palpitation, and the dropsy, and restore the patient frequently for a long period to a tolerable degree of health: and it is commonly only after a great many attacks recurring after considerable intervals, that the disease at length proves fatal." Death almost always occurs very suddenly, and not unfrequently when the patient seems to be free from any unusual disturbance from the disease. Indeed the mere degree of severity of the symptoms is often very fallacious in a prog- nostic point of view. In some instances, much continued uneasiness, with fre- quent exacerbations of distressing violence, will continue for many years before the disease terminates in death. In other cases, with less structural disorder of the heart, and no very severe symptoms, the disease will unexpectedly terminate fatally in a short period after the first manifestations of its presence. Dilatation and attenuation of the parietes of the ventricles ; hypertrophy with softness of the muscular structure ; and contraction or diminution of the openings of the heart, appear to be most apt to prove suddenly and unexpectedly fatal. The occurrence of other diseases in persons laboring under organic affections of the heart, always enhances the liability to a speedy unfortunate termination very considerably. Pregnancy, parturition, intermitting fever, &c, are especially cal- culated to increase the sufferings and dangers of structural cardiac affections. In some instances, diseases of this kind give rise to a protracted state of asphyxia, and cases of spontaneous resuscitation have occurred after the patient had been supposed to be dead. Forms of structural cardiac disease.—A great variety of organic affections of the heart, and its immediate appendages, are mentioned in the works on this subject. The following are the principal forms of these diseases : 1. Thickening and enlargement of the heart, or hypertrophy; 2. Attenuation of the parietes of the ventricles ; 3. A morbid softness and flabby state of the structure of the heart; 4. Dilatation of ils cavities; 5. Aneurismal pouches of its ventricles; 6. Ossi- fications of the valves, and other parts; 7. Excrescences of a warty character on the valves, and from the internal surface of the ventricles; 8. Contraction of the openings of the heart; 9. Absence of laceration, or ulcerative destruction of the valves; 10. Adhesions between the pericardium and the heart; 11. Tumors on the heart, pericardium, or aorta; and 12. Polypous excrescences. Of these affections, the severest and most common are: dilatation of the ventricles; hy- pertrophy, or enlargement and thickening of the parietes, or the connection of bolh these conditions. The following observations on these affections are drawn from M. Laennec's work on the diseases of the chest. DISEASES OF THE HEART. 613 1. Hypertrophy of the Heart. The term hypertrophy is employed to designate an unnatural thickening or increase of the muscular structure of the heart, without a proportionate dilatation, though frequently with considerable diminution of its cavities. (Laennec.) In general this thickening is at the same time attended with an increased firmness of the structure of the heart; but it is also sometimes found connected with a morbid softening of its substance, though the latter condition appears to be the consequence of a distinct disease, as it frequently exists independently of hyper- trophy. In some cases, the hypertrophy is confined to a single ventricle; some- times both ventricles are affected, with or without a similar condition of the auricles; and occasionally, though very rarely, the auricles alone are found in a state of hypertrophy.* M. Laennec states that he has seen the walls of the left ventricle more than an inch thick, and even as much as eighteen lines at the base. The thickening generally " diminishes gradually from the base to the apex. The columnae carneae of the ventricles, and the pillars of the valves, acquire a propor- tionate enlargement, and the septum between the two ventricles becomes also considerably thickened in the disease of the left ventricle." In many instances the cavity of the ventricles is diminished in size. Laennec has found the left ventricle so small in hypertrophy as "scarcely to be capable of containing an almond with its shell." The symptoms of hypertrophy of the left ventricle are: A strong and full pulse; violent beating of the heart against the chest: and a violet or red tint of the face. The patient almost constantly feels the action of the heart; though very violent and tumultuous palpitations are less apt to occur in this than in some other affections of the heart. These symptoms, though frequently present, are not invariably so; for in some very severe cases, the pulse is small and weak. The signs furnished by immediate auscultation, however, in conneclion with the state of the pulse, and the appearance of the countenance, will in general enable us to recognize the presence of this affection. Between the fifth and sixth car- tilages of the ribs, the heart "gives a very strong impulse, and is accompanied by a duller sound than natural, and prolonged in proportion as the thickening is more considerable. The contraction of the auricle is very short, productive of little sound, and consequently scarcely perceptible in extreme cases. The sound of the pulsation of the heart is confined to a small extent, being in general scarcely perceptible under the left clavicle, or at the top of the sternum; some- times it is confined to the point between the cartilages of the fifth and seventh ribs; and the impulse of the heart is rarely perceived beyond the same limits except during palpitation." Laennec, Bertin, Richerand, and others, consider simple hypertrophy of the left ventricle as peculiarly apt to produce apoplexy ; but Dr. Kelly has very in- geniously, though certainly not satisfactorily, controverted this opinion. When the right ventricle is in a state of hypertrophy, there is more dyspnoea and the countenance is of a deeper hue, and in nearly all instances the external jugular veins are turgid, and have a manifest pulsating action communicated to them by the regurgitation of the blood. Laennec states that he has never found this symptom absent in hypertrophy of the right ventricle. The stethoscope gives the same results as when the left side is affected, with the exception that the heart is felt beating with most force at the bottom of the sternum, instead of the space between the cartilages of the fifth and sixth ribs. Laennec asserts, that the place where the action of the heart is most distinctly felt, may be regarded as a certain diagnostic in relation to this subject. When the hypertrophy exists in both ventricles, " the signs consist in a reunion of those that belong to hyper- trophy of each side; but those of the right side are almost always more marked." • Laennec. 614 DISEASES OF THE HEART. 2. Dilatation of the Ventricles. This constitutes the passive aneurism of the heart of Corvisart—the ventri- cles being preternaturally dilated, their parietes attenuated, and the muscular structure, in many instances, so soft lhat it may be readily broken down by mere pressure between the fingers. The walls of the left ventricle have been found so thin as to measure scarcely two lines at the thickest part, and not more than half a line at the apex; while the right ventricle is sometimes so completely extenu- ated as to appear merely composed of a little fat and its investing membrane." Though sometimes confined to one ventricle, dilatation usually affects both at the same time. This condition of the heart is very commonly accompanied by other organic affections of this organ—particularly ossification of the valves, and congenital narrowness of the openings into the aorta or pulmonary artery; and Bertin thinks that the morbid dilatation is always caused by these and other cir- cumstances capable of impeding the free course of the blood as it is thrown out by the ventricles. This appears to be the most common of all the organic car- diac diseases, and seems generally to be produced in a very gradual manner. In dilatation of the ventricles, the pulse is usually soft and weak, and the pal- pitations of the heart feeble and indistinct. Mr. Forbes thinks that pain, or a peculiar feeling of distress in the region of the heart, extending sometimes to the top of the sternum, between the shoulders and the left arm, as in angina pectoris, deserve notice as signs of dilatation of the heart. He refers also to headache, an affection which he thinks " he can trace in a great number of cases to this condition of the heart as its exciting cause." When the left ventricle alone is thus affected, the contractions of the heart will be heard very distinctly with a clear and sonorous sound between the cartilages of the fifth and seventh ribs, through the medium of the stethoscope; and "the degree of distinctness of the sound, and its extent over the chest, are the measure of the dilatation. Thus when the sound of the contraction of the ventricles is as clear as that of the con- traction of the auricle, and if it is, at the same time, perceptible on the right side of the back, the dilatation is extreme." (Laennec.) When the right ventricle is in a state of morbid dilatation, the pulse and action of the heart " are nearly the same as in dilatation of the left ventricle." In general the jugulars are dis- tended ; the oppression in the chest is apt to be great; anasarcous effusions oc- cur; the countenance is usually livid, and bloody expectoration is very common. Laennec states that an habitual turgid state of the jugulars, unattended with a pulsatory motion, is the most constant and characteristic "of the equivocal signs of this affection. The only constant and truly pathognomonic sign is the loud sound of the heart, perceived under the lower part of the sternum, and between the cartilages of the fifth and seventh ribs of the right side. The palpitations which accompany this affection consist principally in an increase of the frequency and sound of the contractions, while at the same time, the impulse of the heart's action is frequently feebler than in the ordinary state of the patient. Laennec places but little reliance on percussion, as a means of forming a diagnosis in cases of this kind. In general, percussion at the bottom of the sternum elicits a dull sound. Dilatation with hypertrophy of the ventricles, is much more common than either of these affections separately, and may exist in one or both ventricles. The contractions of the ventricles in this affection may be very distinctly felt by the hand ; " and if we attentively observe the patient, we frequently perceive the head, limbs, and even the bed-clothes, strongly shaken at each systole of the heart. If we press on.the region of the heart, this organ seems to be irritated by the pressure, and beats more forcibly still." The pulse is full, hard, strong, frequent, and vibrating; the pulsation of the superficial arteries are often visible. Percussion on the region of the heart almost always elicts a dull and obscure sound. With the stethoscope, the pulsations of the heart are heard distinctly DISEASES OF THE HEART. 615 over a great extent—they may be perceived below the clavicles, on the sides, and a little to the left side of the spine. In some instances, when the heart palpi- tates strongly, besides the impulse of the heart, which seems communicated by a large surface, we can distinguish another shock which is sharper, clearer, and shorter, although occurring at the same time, and which seems to strike the walls of the chest with much smaller surface. This blow seems evidently occasioned by the apex of the heart. 3. Aneurism of the Aorta. Aneurismal dilatations of the aorta are very common. In some instances the dilatation exists without rupture of any of the arterial coats, constituting what authors call true aneurism ; in others, the internal coat is ruptured, forming the kind of arterial dilatation denominated false aneurism. Sometimes a large ex- tent of the aorta is in a state of morbid dilatation ; but much more commonly the dilatation is confined to the ascending portion and arch. These aneurismal tumors often acquire a very large size. Laennec has seen them "as large as the head of a full grown foetus." By compressing the heart and lungs, these tumors are apt to give rise to very alarming and distressing affections. When the coats of the artery are much diseased, or the dilatation becomes very great, the tumor sometimes bursts and causes immediate death. In some cases the "aneurism compresses the trachea, or one of the two bronchial tubes; flattens and eventually destroys a part of them, and death ensues from the rupture of the tumor." The oesophagus may also be thus compressed, but this occurs but sel- dom. The heart is usually pushed to one side or downwards. Sometimes the aneurism bursts into the air-cells of the lungs ; but rupture into the left cavity of the pleura is by far the most common. Aneurismal tumors of the aorta often destroy the vertebral column to a great depth, by causing gradual absorption without leaving any other marks of disease, such as caries, &c. When this takes place, the tumor becomes entirely destroyed on the side next the vertebrae—the naked bone forming the posterior wall of the sac. The sternum is also in some cases destroyed, when the aneurism is in the ascending aorta. When the arch of the aorta or the arteria innominata is the seat of the aneurism, the tumor often projects at the top of the sternum, or under the cartilages of the first false ribs of the right side. It is not always the largest aneurisms that most readily make their way externally. Sometimes those of the size of an egg produce this effect, whilst occasionally, those of the size of the head of a full grown foetus remain quite covered, and even compressed by the sternum. (Laennec.) Diagnosis.—The signs of aneurism of the aorta, according to Corvisart, are: inequality of the pulse in both arms; obscure sound on percussion; a rattling noise in the throat, " and dragging downwards of the larynx when the tumor presses upon the trachea; and a whizzing or rushing at the top of the sternum perceptible by the hand." Laennec, however, places no reliance on these signs, and observes that aneurism of the aorta has no symptoms peculiar to it—the symptoms just noticed "being indicative merely of the change or compression of the adjoining organs." If, however, we find under the sternum or below the right clavicle, the impulse of the circulatory organ isochronous with the pulse, and perceptibly greater than that of the ventricles examined in the region of the heart, we have reason to suspect dilatation of the ascending aorta or arch—the more so as it is extremely rare to feel the impulse of the organ of the circulation beyond the region of the heart, even in cases of the most marked hypertrophy. If this phenomena is found constant after repeated examinations, we may consider the diagnosis as certain. Examined with the stethoscope, the aneurismal tumor usually elicits a peculiar purring thrill, and bellows-like sound. In general, how- ever, aneurism of the aorta can only be recognized with certainty when it shows itself externally ; but even when it passes through the walls of the chest, "it is not always distinguishable from other tumors. The origin and progress of this 616 DISEASES OF THE HEART. affection are, indeed, sometimes so obscure as scarcely to give any reason for sus- pecting its existence ;" and the first indication of its presence is often the death of the individual as instantaneously as if by a pistol-bullet. Treatment of the Organic Diseases of the Heart. The greater number of organic diseases of the heart must be regarded as abso- lutely incurable. This, however, does not apply to hypertrophy and dilatation, whether existing singly or concomitantly with each other; for by a judicious and energetic course of treatment, both these cardiac affections may occasionally be entirely removed, and almost invariably greatly mitigated. M. Laennec observes that "the greater number of practitioners are too much in the habit of despairing of success in cases of this kind, and therefore content themselves with attacking such urgent symptoms as may arise in its progress; and yet, I believe, there is no one who has not succeeded every now and then, even by this symptomalizing treatment, in prolonging for fifteen or twenty years the lives of individuals affected with organic diseases of the heart." Organic affections of the heart are, indeed, much more generally regarded as mere subjects of pathological speculation than as diseases, in some instances at least, susceptible of cure or melioration by proper remedial management. "We think such an estimate," says Dr. Johnson, "not only a false one, but pernicious in iis consequences both to the patient and practitioner." The general and paramount indication in the treatment of organic cardiac affec- tions—more especially of hypertrophy and morbid dilatation, is to reduce and keep down uninterruptedly the momentum of the circulation; and this is to be fulfilled by lessening the mass of the blood by venesection, and a reduction in the quantity and nutrient qualities of the food, and by carefully avoiding everything which has a tendency to increase the action of the heart and arteries. When there is reason to believe that there exists hypertrophy, the volume of the circu- lating fluid should be at once decisively diminished by as large a blood-letting, "as the patient can bear without fainting;" and this is to be repeated at intervals of three or four days, until the "palpitations have ceased, and the heart yields up a moderate impulse under the stethoscope." In cases where there is simple dilatation, without an increased thickness of the muscular structures of the ven- tricles, the abstractions of blood can scarcely be carried to a very great extent, or at least be very frequently repeated, wilhout the risk of great prostration, or fatal syncope. In cases of this kind, it will nevertheless be highly proper to keep down the mass of the blood ; but after one or two effectual bleedings this may be most prudently done by an extremely abstemious mode of living. A reduction of the ordinary quantity of food is indispensable to full success in cases of this kind. The good effects of blood-letting will be but temporary, and in general wholly inadequate, unless the rapid generation of new blood be at the same time obviated, by putting the patient on a very spare and diminished allow- ance of diet. Laennec advises that the food should be diminished to one-half at least of the ordinary quantity taken by the patient; and it should consist of mild and unirritating articles of diet, at the same time that the mass of the blood is kept down by repeated bleedings. All kinds of stimulating liquids must be rigidly forbidden. This course of depletion and low diet must be steadfastly pursued, the patient at the same time avoiding, as much as possible, everything which may cause inordinate excitement of the circulatory system, particularly ex- ercise, strong mental emotions, and stimulating ingestion. " When the patient has been two months without experiencing palpitations, and without increased impulse of the heart, we may lessen the frequency of the bleedings, and diminish in some degree the severity of the regimen, if the patient is not at all habituated to, or satisfied with his allowance. But we must return to the same means, and with the same rigor, if the augmented impulse of the heart should return." (Laennec.) This method of treating organic affections of the heart was first practiced by DISEASES OF THE HEART. 617 Valsalva and Albertine.* In addition, however, to the foregoing measures, they kept their patients in bed during a period of forty days, and directed the frequent use of laxative enemata. Dr. Forbes states that he has resorted to this method of treatment with much temporary advantage, and he cites the names of Lancici, Guattini, Sabatier, Pelletan, Corvisart, Hodgson, Bertin, and others, in favor of its usefulness in organic cardiac affections. Morgagni also speaks of this reduc- ing plan of treatment in affections of this kind with decided approbation;! and there can be no doubt, indeed, of its direct tendency to lessen the violence of the symptoms, or to effect a cure in hypertrophy of tbe heart. Laennec observes, that even where the disease has advanced so far as to have induced great dys- pnoea, anasarca, and a general cachectic state of the system," we must neverthe- less fearlessly prosecute the plan of starvation and bleeding." When the symptoms just mentioned, namely, habitual dyspnoea and dropsical effusions occur, diuretics will generally assist materially in alleviating the suffer- ings of the patient. Dropsical effusions into the cavity of the pleura or pericar- dium, almost invariably occur in the progress of organic affections of the heart, and it would appear that the immediate cause of death in many instances are effusions of this kind, impeding the actions of the lungs and heart. Diuretics can therefore rarely be dispensed with in affections of this kind, and they are in fact often decidedly palliative. We may frequently succeed in removing the dropsical effusions from the chest, by the judicious employment of this class of remedies, so as to procure much temporary relief. The effusion, it is true, will generally soon return again, but I have known the life of an individual protracted for four or five years, by occasionally effecting a removal of the dropsical accu- mulation. I attended an old lady some years ago who labored under symptoms of hydrothorax; by low diet and the use of the squill and nitre, in doses of about two grains of the former to fifteen of the latter, I succeeded in removing the water from her chest three times in the course of about fifteen months. She finally died suddenly, and on dissection, the heart was not only in a state of remarkable hypertrophy, but the mitral valves were completely ossified. Some writers have strongly recommended digitalis as a diuretic in organic cardiac affections, attended with dropsical effusions ; and from the known powers of this article to curb the action of the heart, it would seem to be peculiarly applicable in cases of this kind. Laennec, nevertheless, does not speak very favorably of its powers in the class of diseases now under consideration. He observes, that he has never found it to control the action of the heart, "even when the dose was carried to the extent of producing vomiting and vertigo." Its diuretic powers are equally uncertain, but of its occasional sedative, as well as diuretic influence, no doubt can be entertained, and as both these effects are peculiarly desirable in cases of this kind, it unquestionably deserves a fair trial, where we find other articles inefficient. I have known the infusion of the erigeron heterophyllum to produce very active diuresis, and of course advantage, in one instance of cardiac disease accompanied by hydrothorax. Purgatives may also be resorted to with advantage, where the dropsical accu- mulations become considerable in cardiac affections; and they are more espe- cially necessary where diuretics fail to procure relief. One of the best medicines for this purpose is the following combination, which rarely fails to procure copious watery discharges from the bowels, and at the same time free diuresis.^ When the cardiac affection consists in simple dilatation, the pulse, as has already been stated, is generally feeble and compressible, and the depletory mea- sures must therefore be employed with caution. But even in cases of this kind * Morgagni. De Sedibus et Causis Morbor., &c. Epistol. xvii. art. 3. f Loc. citat. Epistol. xviii. art. 30. X R.—Tart, potass. 5iss. Sulph. potass, ^ss. Pulv. scillae ^ii. Tart, antimonii grs. ii.—M. S. Take a teaspoonful four or five times daily. 618 DISEASES OF THE HEART. we must endeavor to obviate a plethoric state of the vessels, by an occasional small blood-letting and an abstemious diet. The principal remedies here are the ferruginous preparations and the vegetable bitters. These may be beneficially given in union with some of the milder aromatic substances, particularly the in- fusions of valerian, cat-mint, and of orange flowers. (Laennec). To curb the action of the heart, digitalis is particularly useful in instances of (his kind.— From one-fourth to half a grain of the powder of this vegetable may be given every two hours until the frequency of the pulse is moderated, and it should be repeated afterwards in such a way as to keep up a slight sedative impression on the circulatory system. Cases of mere dilatation, however, are seldom per- manently benefited by remedial treatment; and the prospect of effecting an entire cure is always exceedingly small. By the employment of chalybeate waters, or some of the officinal preparations of iron, and weak infusions of the tonic vegetable bitters, and a simple and abstemious course of living, with a careful avoidance of all unusual corporeal exertions and spirituous potations, a consider- able degree of comfort may be obtained by patients affected in this manner.* Baron Larrey, in his recent work,t has related some cases, from which it would appear that counter-irritation by means of moxa is capable of doing much good in dilatation and enlargement of the heart. He insists upon it, in opposition to Corvisart and others, that hypertrophy cannot be removed by the most rigorous system of depletion. He assures us, however, that during a period of more than thirty years, he has had frequent opportunities of witnessing the beneficial effects of counter-irritation. Adopting the opinion that in organic affections of the heart, the remote cause almost always consists in "some morbific principle, whether syphilitic, scrofulous, herpetic, or otherwise," he lays down two indications to be pursued in the treatment of these cardiac affections, namely, to counteract or de- stroy the primary specific cause, by specific remedies; and draw off the irritation from the heart, by establishing an external counter-irritation by means of moxa. Against the supposed specific cause he employs mercurial remedies, and he avers that these are always highly beneficial when combined with counter-irritation.— In active hypertrophy he uses local depletion over the cardiac region, after which he applies the moxas. He speaks also very favorably of cold in the form of ice applied to the region of the heart. The moxas are to be applied first to the track of the intercostal nerves behind the left hypochondrium, and then gradually brought round and forwards to the anterior cardiac region. His favorite formula for administering the mercurial remedies is the following: R.—Muriat. hydrarg. corros. Muriat. ammon. G. opii, aa. ars v. Aq. destillat. Ibi. Misce ft. solutio. Of this, a dessertspoonful is to be taken several times, we presume, daily, for he does not state the frequency of the dose. " One great principle," says Dr. Forbes, " is always to be kept in view, in the treatment of diseases of the heart, namely, the removal of all disorders in other organs which can act as a source of irritation to the heart." It is particularly important to attend to the gastric and hepatic functions; and hence we find that patients almost always experience some relief when these functions are brought into a healthy condition. " I would lay it down," says the writer just quoted, * [By a long perseverance in the gen"ral course of treatment described by our author, I have witnessed apparent cures of several cases of hypertrophia of the heart Certainly I have suc- ceeded in the cure of three case.- of aneurism of the ascending aorta even after the tumors had begun to protrude externally through the cartilages of the ribs, on the right side, in two cases, and at the top of the chest, through the sternum and right clavicle, in the other. The blood gradually became coagulated within the sacs in all these cases, and finally confined the current of circulation within its natural channel. The solid tumor which resulted was by degrees reab- sorbed in each of these cases, and the patients lived for years afterwards engaged in active em- ployment.—Mc ] t Clinique Chirurgicale. DISEASES OF THE HEART. 619 " as a general rule in chronic affections of the heart, that previously to having recourse to any remedies intended to act directly on it, we ought to be assured that the digestive organs are in a healthy state—that their mucous surfaces are free from irritation—their vascular system not morbidly distended, and that the liver is performing the secretory functions freely and regularly. When derange- ments of this kind are present—a few leeches to the praecordia or anus, some small doses of oxyde of mercury and castor oil, a mild and spare diet, and bodily and mental repose, will often do more to tranquilize the circulation than more active and rougher means. And, indeed, in many cases, more especially in the earlier stages, when the stethoscope gives but little information, it is not until we have restored the organs to a comparatively healthy condition, that we can know how far the disordered action of the 'heart depends on sympathy with these, or is the consequence of incipient organic lesion of the heart."*' Con- comitantly with the employment of the above-mentioned tonics, very considera- ble advantage may in general be derived from an occasional dose of three or four grains of blue pill at night, and a mild laxative in the morning; and to keep up the regular action of the skin, the tepid shower-bath will generally be useful. Sympathetic Affections of the Heart. Symptoms differing in no material circumstance from those which have already been mentioned as belonging to organic affections of the heart, are not unfre- quently the result purely of a sympathetic irritation of this organ without any structural lesion whatever. I do not now allude to those cases of angina pectoris which arise from metastatic or sympathetic irritation, and which are probably always of a strictly neuralgic character. The heart is liable to be excited inlo vehement and tumultuous action, by a variety of causes not immediately con- nected with lesion or disorder of its structure; and the most alarming instances of this kind often result from an irritation located in some remote part of the sys- tem. It is of much consequence, in a practical point of view, to keep this, indeed, well-known fact in mind, in prescribing for cardiac affections. I have, in several instances, been consulted by persons subject to extremely violent paroxysms of palpitation, who were supposed to be laboring under chronic affection of the heart, and who were completely relieved by a course of treatment calculated to restore the healthy condition of the digestive functions and of the liver. When we find paroxysms of palpitation come on while the patient is quiet, perhaps lying down, without pain in the region of the heart, at the same time that there are symptoms of indigestion, particularly eructations of flatus, there can be but little doubt that the cardiac affection is symptomatic of gastric irritation. Habi- tual debility and irritation in the digestive organs are particularly apt to give rise to such affections in persons of a plethoric and nervous habit of body. I was consulted, about eighteen months ago, by a gentleman of a very nervous temper- ament and weak digestive powers, for aid, in what he was led to regard as a local affection of the heart. The slightest mental agitation would, occasionally, immediately excite vehement palpitations ; and frequently similar paroxysms came on about two hours after taking his meals. He had paid little or no atten- tion to the regulation of his diet, although often disturbed with flatulency, acidity, and other unpleasant sensations in the stomach. He was directed to take four grains of blue pill every other evening, an occasional dose of rhubarb in the morning, and put on a light and digestible diet, with exercise on horseback. In four weeks his complaint left him, and he has not had any return of it since. Irritation located in other organs, as the kidneys, intestinal canal, uterus, liver, and probably the spleen, sometimes gives rise to severe fits of palpitation. They are particularly apt to occur about the age of puberty in young females, or just before the eruption of the menses. Nervous females, more especially those who * Laennec on the Chest, by Dr. Forbes. 620 DISEASES OF THE HEART. labor under chronic hysteric affections, are also especially subject to palpitations of the heart. These cases are in general easily distinguished from organic affec- tions of the heart, but as structural disease of this organ may be associated with mere sympathetic irritation, it may be well to slate more explicitly the signs by which nervous palpitation may be distinguished from hypertrophy or dilatation of the heart. Violent and extremely alarming cases of cardiac disease, unconnected with organic lesion, sometimes result from the unnatural and enervating practice of onanism. I have met with a most deplorable instance of this kind, in a young man, which was finally removed by discontinuing this degrading habit, in con- junction with mild tonics, active exercise, and a regular, digestible, and nourish- ing diet. Dr. Krimer has, within a few years past, published several remarkable cases, illustrating the injurious effects of self-pollution on the heart. The usual symptoms in cases of this kind, are: pale and dejected countenance ; eyes sunken and haggard; taciturnity or pusillanimity; general languor of the body, and men- tal apathy; more or less tenderness in the epigastrium ; and irregular action of the heart, with frequent paroxysms of tumultuous palpitation, dyspnoea, and praecor- dial anxiety.* As the subject is one of great importance, I subjoin the following observations from Dr. Krimer's paper, as diagnostic of cardiac affections arising from onanism. The hair is dry, not glossy, split at the extremities, and apt to fall off, especially from the fore part of the head. The eyes dull, sunken, watery, and apathetic; the edges of the lids are often red, and the lower margin of the orbit surrounded with a bluish streak; the countenance is unsettled, timid, and the patient " cannot bear the steadfast gaze of another person." There is often headache, which returns, in most instances, at nearly the same time daily—the pain of which radi- ates from the occipital to the frontal region. Vision is, at times, confused or dim ; the appetite weak and capricious; the tongue lightly covered with white fur; and the breathing is usually short. Pain in the stomach is almost continually pre- sent, and the epigastrium is extremely tender to pressure " without any other symptoms of mucous inflammation of the stomuch." Great lassitude with pain in the loins and lower extremities, are very common symptoms. There is often a considerable drowsiness, and always a remarkable disinclination to mental and corporeal action.! " In nervous palpitation, the first impression conveyed by the stethoscope is, that the heart is not enlarged. The sound, though clear, is not heard loudly over a great extent of the chest; and the impulse, though appearing considerable at first, is really not great, as it never sensibly elevates the head of the observer. This last sign seems to me the most important and certain of any, when taken in conjunction with the frequency of the pulsations. These are always quicker than natural, being most frequently from eighty-four to ninety-six in the minute. Nervous palpitations are rarely accompanied by any sign of determination of blood to the head or chest, except in old persons. A feeling of internal agitation, particularly in the head and abdomen, always accompanies nervous palpitation; and the urine is generally limpid and watery." (Laennec.) Treatment.—The treatment must of course be regulated according to the par- ticular condition of the general system, and the local organic irritations that may exist. The digestive functions must be particularly attended to, and the sources of intestinal irritation obviated by gentle aperients. In relaxed and weak habits, the tepid bath; a mild, digestible, and nutritious diet; gentle tonics, especially * The reviewer of Dr. Krimer's paper observes: "The disgusting nature of the subject has prevented English writers from any description or investigation of the phenomena; but we are well convinced, from many cases which have presented themselves to our observation, and where the cause has been voluntarily confessed, or unexpectedly drawn forth, that a great num- ber of cardiac affections, as well as anomalous symptoms of disorder in other parts of the system, are owing to this destructive vice "—Med.-Chir. Rev., April IbvJS, p 149. j- Hufeland's Journai der Heilkunde, Jan. 1827. ANGINA PECTORIS. 621 bitters and iron, gentle exercise by gestation ; and in young and plethoric subjects, small abstractions of blood, warm pediluvium, and digitalis, will, in general, prove beneficial. Antispasmodics very rarely procure any relief, and indeed much more frequently do injury. Although small portions of blood may sometimes be beneficially abstracted in robust and plethoric subjects, yet blood- letting, to any considerable extent, is generally detrimental, in the sympathetic affections of the heart. I have met with several instances, where repeated abstractions of blood had reduced the patients to the most deplorable condition; and which were afterwards cured by tonics, gentle exercise by gestation, the tepid shower-bath, and a digestible and nourishing diet. One young man, of a dyspeptic habit, was affected at times with alarming palpitation, and dyspnoea. His physician, regarding it as active hypertrophy, bled him copiously. The disease, however, gradually became more distressing, and the blood-letting was repeated from time to time. Finally the patient was obliged to remain in his room, and could not walk across the floor without bringing on a violent paroxysm of palpitation and praecordial distress. A consultation was called, and the plan of treatment changed. Mild tonics, dry frictions of the extremi- ties, the tepid shower-bath, a nourishing, but light and digestible diet, were ordered. In a few weeks he could leave his room ; soon was able to take exercise in a carriage, and in about three months had his health perfectly restored. Physicians are too apt to resort to the lancet when they find the heart in a state of tumultuous action. The minutest inquiry into the origin and character of the disease should always be instituted before this practice is adopted ; and where there is reason to believe that the cardiac disorder is the result of a sym- pathetic irritation, blood should not be extracted unless some especial indications exist for the reduction of the mass of the circulating fluid. When sympathetic disease of the heart is intimately connected with general plethora, which is, indeed, frequently the case, it may be proper to practice one bleeding in the commencement of the treatment; but even in cases of this kind I should prefer reducing the volume of the blood by a more spare diet and the encouragement of the ordinary secretions, particularly those of the skin and kidneys. Sect. II.—Angina Pectoris.* Angina Pectoris was not noticed as a distinct disease until the attention of the profession was directed to it by Dr. Heberden, in a very perspicuous and full account of its peculiar character, published in the second volume of the Medical Transactions of the London College of Physicians. Since that time it has been frequently and minutely described; and of late years, especially, its phe- nomena and pathology have received much attention. This disease consists of sudden paroxysms of pain and pressure at the lower part of the sternum, or about the region of the heart, extending across the breast to the left shoulder, and to the arm as low as the insertion of the deltoid muscle, or the elbow, or even to the fingers ; accompanied with some difficulty of breath- ing, great anxiety, and a sense of impending suffocation. The attack usually commences without any premonitions of its approach, by sudden pain and constriction in the left side of the chest, or near the scrobiculus cordis, and a peculiar numbness with more or less pain in the left arm, particu- larly on the inside, as low as the elbow. If the paroxysm comes on while the patient is walking, he is instantly obliged to stand still. The least exertion gives rise to intense darting and constrictive pain in the cardiac region, and the patient * This disease has been described under a great variety of names, as asthma convulsium, by Eisner; arthritis diaphragmatica, by Butler; syncope angiuosa, by Parry; asthma spastica arthrili- cum inconstant, by tstoeller; strenalgia, by Baumes; sthenocardia, by Breia; asthma dolorificum, by Darwin; sternodynia syncoptica el palpitanle, by Sluis: puigophobia, by Swediaur; and cardodyne spasmodica, by Harles. 622 ANGINA PECTORIS. feels as if an attempt to move would inevitably cause immediate death. During the paroxysm the countenance is pale and expressive of great anguish, the ex- tremities are cold, the heart palpitates violently, there is more or less dyspnoea, turgidity of the vessels of the head, and in some instances syncope, and even convulsions, ensue. Sometimes the pain passes up along the neck and face, or back to the spine, with a sense of retraction at the lower end of the sternum ; and occasionally it is felt in both arms at once. At first the paroxysms last but a few minutes, and recur at remote intervals, generally in walking up hill, or rapidly ascending stairs soon after taking a full meal. By repetition, however, they become more and more violent and protracted, and return, in aggravated instances, on the slightest bodily exertion. When the attack has passed off the patient usually feels only numbness of the left arm, with some degree of palpi- tation, and occasionally slight headache, hurried respiration, and anxiety of feel- ing in the praecordia. Pathology.—This disease is very rarely met with in young people ; and it occurs, indeed, but seldom in individuals under forty years of age. I have, nevertheless, seen a well-marked case in a young man of an arthritic, habit, who was not more than twenty-three years old; and I am now attending a girl under eleven years of age, who is occasionally seized with paroxysms which appear to me genuine instances of this affection.* The majority of cases of angina pectoris occur in individuals of a gouty or rheumatic habit. Jahn states, that in the summer of 1814 he met with several instances of this disease, which supervened apparently as sequelae of typhus fever.t In relation to the immediate or exciting causes of this affection, pathologists have expressed very different opinions. Heberden, KreysigJ and Parry§ attri- buted the disease to ossification of the coronary arteries, and this opinion is still entertained by many physicians. Others have ascribed it to ossification of the semilunar valves of the heart; and various other organic affections of this organ and of the adjoining parts have been mentioned as its cause, such as morbid dilatation and softening of its structure ; ossification of the cartilaginous portion of the ribs; suppurative inflammation of the mediastinum, and disease of the pericardium. That no one of these morbid conditions, however, can be regarded as the proximate or essential cause of angina pectoris, is evident from the fact, that in many fatal instances of the disease, no such structural disorders are discovered on post-mortem examination.|| M. Recamier, principal physician at the Hotel Dieu, has never witnessed an instance of ossification of the coronary arteries in the bodies of those who have died of angina pectoris ; and he wholly rejects the idea of its depending on organic cardiac disease.^} M. Laennec, also, denies the necessary connection between organic affections of the heart and angina pectoris. " In a slight and middling degree," he says, " this disease is very common, and exists very frequently in persons who have no organic affection of the heart and large vessels."** It must, moreover, be observed, that ossification of the coronary arteries, and other structural diseases of the heart, are frequently met with in subjects who had never experienced any of the characteristic symp- * [I once attended a young gentleman of this city, 21 years of age, who had been intemperate in his habits, and subject also to inflammatory rheumatism which had been translated to his heart, and produced the symptoms of pericarditis. The consequence was the development of a genuine angina pectoris, which came on in frequent and terrible paroxysms, and finally de- stroyed him on a voyage for the recovery of his health in the Gulf of Mexico.__Mc ] J Klinik der Chronischen Krankheiten, bd. iv. p. 40G. Die Krankheiten des Herzens, 2 Th., 2 abhand.. 5 Kap. § Treatise on Syncope, Anginosa, &c. || [An eminent gentleman of the bar in Philadelphia, died some years ago of a paroxysm of this disease, and on a post-mortem inspection I could discover no other signs of organic disease than a small patch of opacity in the serous membrane covering one of the ventricles. He had been subject, in previous years, to regular attacks of gout.—Mc] IT Medico-Chir. Rev., March 1829, p. 573. ** On the Diseases of the Chest, last edition; translated by Dr. Forbes, ANGINA PECTORIS. 623 toms of angina pectoris. Mr. Cook says, "I have met with numerous instances of ossification in the coronary arteries, which had never been attended with symp- toms of angina ;* and Mr. Shaw observes, in relation to this subject, that he had often found the coronary arteries like tubes of bone in old people who never had the slightest symptoms of this disease.t The occasional spontaneous removal of the disease, and its susceptibility, in some instances, of being cured, militate also directly against ihe doctrine of its necessary dependence on organic affections of the heart. Laennec avers that "he has known many individuals who had suffered a few very severe but short Attacks of angina pectoris, and had had no further return of it." Dr. Parry, who believed that the disease was always caused by ossification of the coronary arteries, nevertheless mentions a severe case, that was wholly or nearly cured by the use of the Bath waters. Dr. Baillie also met with two patients affected with symptoms " exactly resembling those of angina pectoris, who ultimately recovered entirely."J Unquestionably, however, ossification of the coronary arteries, and other organic cardiac affections, are very frequently connected with angina; "but nothing proves, even in such cases," says Laennec, " that the disease depends on affections of this kind, inasmuch as they are of various kinds, and as the angina exists without them." A softened structure, or flabby and dilated state of the heart, is almost as com- mon in this affection as ossification of the coronaries. In a most severe case, which was seen by Dr. Latham, Dr. Bree, and Dr. Johnson, the heart on dissec- tion was found " pale, flabby, and so lacerable as to be easily mashed between the fingers like wetted paper orputrid meat."§ Dr. Johnson states, that in all the cases which occurred in his own practice, where post-mortem examination was made, there was a flabby and softened state of the muscular structure of the heart, connected in a few instances with ossification of the coronary arteries.|| Dr. Cook also mentions a peculiar flaccidity and softness of the structure of the heart, "as a phenomena usually found after this disease," sometimes with, and at others without the ossification of the coronaries or cardiac valves.^ Hyper- trophy or dilatation of the heart, without any other organic disorder, is mentioned by Laennec as no uncommon condition in this affection. About six years ago I attended a gentleman in consultation with Dr. M'Clellan, who was frequently affected with violent paroxysms of angina pectoris. In one of the attacks he suddenly expired. On dissection, the heart was found very large, and its struc- ture so soft as to be easily broken down by pressure between the fingers. From these facts, it appears evident that organic affections of this kind are to be regarded rather as the exciting than as the essential and proximate cause of the disease. It is now believed by many that angina pectoris consists in a neuralgic affection of the heart, or of the cardiac plexus ; and there can, I think, scarcely exist a doubt of the correctness of this opinion. Laennec conceives that the location of the nervous irritation may vary according to circumstances. " For instance," he says, " when there exists at the same time pain in the heart and lungs, we may presume that the affection is principally seated in the pneumo- gastric nerves ; on the other hand, when there is simply a sense of stricture of the heart, without pulmonary pain or much difficulty of breathing, we may con- sider its seat to be in the nervous filaments which the heart receives from the grand sympathetic. Other nerves are also simultaneously affected, either by sympathy, or from direct anastomosis ; for example, the branches of the brachial plexus, particularly the cubital, are almost always so; the anterior thoracic nerves originating in the superficial cervical plexus are also frequently affected; and it is also sometimes the case with the branches derived from the lumbar and sacral * Treatise on the Digestive Organs, p. 274. f Manual of Anatomy. X Lectures and Observations on Medicine, p. 185. § Med.-Chir. Rev., April 182G. p. 497. || Ibid., March 1828, p. 430. H Loc. cit. 624 ANGINA PECTORIS. plexuses, as we find the thigh and leg now and then participating in the pain and numbness." M. Recamier also considers this disease as a species of neuralgia; and the same opinion is expressed by Dr. Johnson, Jahn,* Jurin,t Desportes, and other writers. Mr. Teale refers the various symptoms of angina pectoris to a primary affec- tion of some portion or portions of the spinal marrow, and the corresponding ganglia of the sympathetic. His reasons for adopting this opinion are: 1. The fact that most of the morbid phenomena exhibited in the extreme branches or filaments of nerves, are seldom owing to disease in the nerves themselves, but to an affection of the nervous mass from which they are derived; 2. The ten- derness or pain on pressing some portion of the spine, in most cases of angina pectoris; and the correspondence of the tender part of the spine with the parti- cular symptoms which are present—namely, tenderness in the lower dorsal portion of the spine, in conjunction with constriction and other affections of the stomach ; and tenderness in the cervical part of the spinal column, with pains in the arms, breast, and shoulders, and palpitations ; 3. The relief obtained, by counter-irritating and depletory measures applied to the spine—that is, to the lower dorsal portion, when the stomach is particularly affected, and to the cer- vical portion, when there are palpitations and affections of the arms, shoulders, &c.| Although this neuralgic affection of the heart may often depend on primary spinal irritation, as well as on organic cardiac disease, it may doubtless, also, be excited by other remote causes or irritations of the system. There are some well-authenticated facts on record, exemplifying the occasional dependence of this disease on dyspeptic irritation. I have already adverted to the two cases mentioned by Dr. Baillie, which ultimately recovered, and were evidently de- pendent " upon an imperfect digestion." Mr. Cook, also, to whose excellent work on the diseases of the digestive organs I have referred above, thinks that angina pectoris is occasionally excited " by derangement of the digestive organs, especially by dyspepsia." Several eminent writers have supposed that the dis- ease depends on gouty irritation ;§ and Lentin|| maintained that it is always of rheumatic origin. This, with some modification, appears, also, to be the opinion of Dr. Chapman ; and there can be no doubt that a gouty or arthritic diathesis is often manifestly present, in those who are subject to this alarming cardiac affection. From all that has been ascertained, therefore, in relation to this sub- ject, it would seem that angina pectoris may be excited by various causes, both organic and dynamic, and that it consists essentially in a peculiar irritation of the cardiac nerves, giving rise to pain, and more or less spastic action of the respira- tory muscles. Treatment.—When once fully developed, angina pectoris is an extremely unmanageable affection, and almost always sooner or later terminates in death. It must not, however, be regarded as a hopeless affection, even in its most ag- gravated form; for instances of complete recovery have occurred, after the dis- ease had continued for several years in occasional paroxysms of great severity. For the relief of the paroxysm, we may have recourse to small bleedings, anodynes, and antispasmodics. Ether, camphor, opium, hyoscyamus, and the liquor ammonias succinata?, have been most recommended for this purpose. I attended a patient some years ago, who was frequently seized with violent paroxysms of this affection, and who generally obtained considerable relief from a draught of very cold water. This patient died suddenly in one of the attacks; and on dissection, the semilunar valves of the heart were completely ossified. * Med.-Chir. Rev., Nov. 1828, p. 197. X Loc. cit, bd. v. p. 407. X A Treatise on Neuralgic Diseases, &c. By Thomas P. Teale, Esq. § Berger, Abhandl. f. Pract. Aerzte., b. x. p. 715. Hesse, Specimen Inaugurate Medicum de Angina Pectoris. || Beitriige sur Ausiibenden Arzneiwissenschaft, b. i. ANGINA PECTORIS. 625 Perfect rest need scarcely be enjoined, for patients are irresistibly constrained to remain quiet during the paroxysm. It would appear even that where the patient can summon up sufficient firmness of mind to continue walking when the attack comes on, the exertion has a tendency, in some instances, to mitigate the pain and constricted respiration.* Dr. Good advises that the patient be immediately placed in an inclined position, with the head raised high ; and an emetic instantly administered. If the pain and difficulty of respiration continue after the vomit- ing, " opium intermixed with camphor, ether, or other diffusible antispasmodics, should be freely employed." Emetics were, 1 believe, first recommended in the paroxysm of this disease by Percival.t Richter admits that much relief may sometimes be obtained from vomits; but he asserts that they may also readily do a great deal of harm. Where the oppression in the chest is great, and the habit robust and plethoric, blood-letting will occasionally afford some relief. According to Laennec, however, leeches applied to the epigastrium or region of the heart, sometimes prove more beneficial than venesection. Indeed, venesec- tion may very readily prove injurious in this complaint, and it ought not to be used, unless the indications for its employment are unequivocal. Dr. Parry, who particularly advocates the practice of venesection in this complaint, advises that the blood " should be taken from a small orifice, the patient being placed in the horizontal position, while the physician is to keep his finger on the pulse, to decide the limits to which venesection is carried." Advantage may also be ob- tained, during the paroxysm, from derivative applications, such as sinapisms to the legs or soles of the feet, and over the epigastrium, and rubefacient frictions to the lower extremities.^ For preventing the return of the paroxysms, various remedies and modes of treatment have been recommended. As the cardiac irritation may be wholly symptomatic of gastric disorder, it will be proper, in all instances, to pay par- ticular attention to the biliary and digestive functions. A mild diet, the occa- sional use of small portions of blue pill, chalybeate mineral waters, and tepid or cold bathing, are particularly indicated in cases attended with dyspeptic symp- toms. In individuals of a gouty or rheumatic habit, much advantage, it is said, has been obtained from the protracted use of guaiacum.§ Goodwin states that he derived very great advantage from the frequent appli- cation of a strong solution of tartar emetic in spirits of camphor ;|| and cases have been published which go to show that the establishment of a permanent drain from the region of the heart, by a seton or issue, may be resorted to with considerable prospect of benefit.^! Baumes speaks highly of the internal use of phosphoric acid in this complaint; and thinks it capable of arresting the process of ossification ;** an opinion which was also entertained by Richter.tt It is given to the amount of a drachm and a half daily in the form of lemonade. In Hufe- land's Journal, a writer speaks in the highest terms of praise of the extract of lactuca virosae. Sixteen grains of this extract are to be dissolved in two drachms of cinnamon water, of which fifteen drops must be taken every two hours.}! Arsenic has been used with considerable benefit by Richter ; and Smith employed small doses of James's powder in union with castor and assafoetida, with very good effects in some cases of this complaint.§§ The celebrated Odier of Geneva * Parry's Treatise on Angina Pectoris. f Medical and Philosoph Comment., vol. iii p 180. X [f have sometimes derived gr«at advantage from cupping between the shoulders and over the epigastrium. In debilitated subjects, dry cupping by the use of common tumblers, exhausted of air by the aid of combustible matters in a state of flame, is the best application.—Mc] § Berger, loc. cit., bd. p. 708. || Annales de Literature Medicale Etrangere, vol. iv. as quoted by Richter. IT New York Medical and PhysicalJournal, Deo. 1814. ** Annales de la Societe Pratique de Montpellier, torn. xii. ff Specieile Therapie, vol. v. p. 195. Jf Journal, &c, 1809, st. i. p. 57. §§ Medical Commentaries, Edin., vol. v. p. 78. 40 626 INDIGESTION. restricted his patients to an extremely spare and simple diet, as the best means, in his opinion, for preventing the return of the disease. Laennec asserts that the m,agnet is one of the best means for palliating or preventing the paroxysms of angina pectoris that we possess. He uses it in the following manner: "I apply," he says, " two strongly magnetized steel plates, of a line in thickness and of an oval shape, and bent so as to fit the part, one to the left praecordial region, and the other exactly opposite on the back in such a manner that the magnetic current shall traverse the affected part. This method has succeeded better in my hands in the case of angina than any other, as well in relieving the paroxysm as in keeping it off. After a certain time, the magnetism most com- monly produces an eruption of small pimples, which are sometimes so painful as to oblige us to interrupt the process for some days. This eruption almost always takes place under the anterior plate, and cannot, therefore, be attributed to the action of the oxydized pieces of steel on the skin. By means of these plates, applied to the epigastrium and spine, I stopped at once a hiccup which had lasted three years. At the end of six months, the patient having one morn- ing neglected to put on the plates, the hiccup returned, but was removed on their being replaced." When, in angina, the relief obtained from the magnet is but small, its good effects may be increased by previously blistering the part to a small extent, to which the anterior plate is applied. In the management of this affection, it is all important that the patient abstain from spirituous drinks, and avoid strong mental emotions of every kind. Inordi- nate venereal gratifications, too, are in general decidedly injurious ; and strong corporeal exertions, particularly walking up hill, or rapidly ascending stairs, as well as sudden atmospheric vicissitudes, indigestible and irritating articles of food, must be carefully avoided. CHAPTER VI. CHRONIC DISEASES OF THE ALIMENTARY CANAL. Sect. I.—Indigestion. Indigestion occurs so frequently, and is attended with so discomforting a train of symptoms, that it has the strongest claims upon the attention and sympathy of the physician. The habitual dyspeptic is indeed truly miserable. His sal- low and anxious countenance, his irritable and sullen taciturnity, his aversion to social enjoyments, and the occasional overwhelming despondency of his mind, show him to be the prey of deep and harassing sufferings, of which none but those who have experienced them can form an adequate idea. Common, how- ever, as indigestion is, and serious as are its consequences upon the health and happiness of man, there is perhaps hardly any other malady which is so com- monly misunderstood, and consequently mismanaged. In order to obtain a correct view of the pathology of indigestion, and of the true indications for its remedial management, it is necessary to be acquainted with the physiology of the process of digestion. I can here, however, advert only to the prominent and essential circumstances in relation to this subject. It ap- pears, then, to be satisfactorily demonstrated, that the two following conditions are essential to the regular and healthy performance of the functions of digestion. 1. A due tone and peristaltic action of the muscular coat of the stomach, in order that the food may be uniformly embraced by the parietes of this organ, and as it successively undergoes chymification, where it is in contact with the stomach, be pushed forward towards the pylorus into the duodenum. INDIGESTION. 627 2. The regular secretion of a sufficient quantity of healthy gastric juice. That the fluid called gastric juice is really the solvent which converts the aliment into that pultaceous mass called chyme, and that, therefore, digestion, so far as chymi- fication is concerned, js chiefly effected by the agency of this fluid, is, I think, established beyond all dispute. The experiments of Spallanzani, of Stevens, of Gosse, and those quite recently performed by Tiedemann and Gmelin of Heidel- berg, and by Leuret and Lassaigne of Paris, have placed this physiological fact beyond all reasonable doubt. It does not appear, from some late experiments, that the bile has any material agency in the process of chymification. According to the experiments performed in relation to this point by Mayo, Brodie, Leuret, Lassaigne, Tiedemann, and Gmelin, chymification appears to go on perfectly in animals after the biliary duct has been tied. The principal agency of the bile in digestion, it would seem, is to render the fatty substances of the chyme soluble in the chyle. It is the fat or oil thus suspended, by means of the alkaline properties of the bile, that gives to the chyle its milky color. When the common duct is tied, chymification goes on regularly, but the chyle in the lacteals and thoracic duct is transparent and of a yellowish hue. Causes of indigestion.—It has just been said that the immediate cause of indi- gestion consists in a vitiated or deficient secretion of the gastric juice, and in defi- cient or irregular action of the muscular coat of the stomach. Now as both muscular motion and secretion are under the immediate influence of the nervous power, it is obvious that whatever causes morbid excitement in the nervous structure of this organ, must necessarily tend to derange the healthy performance of these two functions. Accordingly, everything which is capable of causing indigestion does so either by interrupting the regular supply of nervous influence to the stomach, or by irritating the nervous extremities of the mucous membrane of this organ; or by producing both these effects simultaneously. Of these former kinds of causes, namely, those that interfere with the regular transmission of nervous influence to the stomach, are the mental emotions. It is surprising how suddenly any temporary mental agitation depresses, nay, often wholly suspends for a time the keenest appetite and powers of digestion. These temporary depressions of appetite and powers of digestion from sudden emotions of the mind, are converted into protracted and exceedingly unmanageable cases of dyspepsia, when the mental perturbations are of a chronic and depressing character. Protracted grief and despondency seldom fail to weaken the digest- ive powers and to bring on, ultimately, confirmed and unyielding indigestion. Protracted and intense application of the mind, especially when attended with a sedentary mode of life, is another of those causes which act through the me- dium of the general system. Such, indeed, are the sympathetic relations of the stomach with the whole and every part of the organization, that its functions be- come disturbed by whatever causes either general debility or organic disorder of any of the principal organs of the body. But by far the most common and powerful causes of indigestion are those that act directly upon the nervous extremities of the mucous membrane of the stomach. Whatever is calculated to cause permanent irritation in this membrane, has a direct tendency to produce this disease. I think it may be assumed as a patho- logical axiom, that the functions of secretion can never be deranged without the existence of irritation in the secreting organ. Irritation of the vascular extremi- ties that secrete the gastric fluid, exists, therefore, in every case of indigestion. The causes which most frequently give rise to this irritation consist of over- distension of the stomach and indigestible and irritating articles of food. The manner in which food of this kind produces the irritation in question, is easily to be understood. When the food resists the digestive powers too long, besides its direct irritating impressions upon the stomach, it enters more or less into the fermentative process, and evolves new combinations, such as gas, acidity, &c, which enhance the irritating qualities of the contents of the stomach. Besides 628 INDIGESTION. these consequences of too long a retention of imperfectly digested food in the stomach, the muscular powers of this organ will be diminished by the long and continued exercise to which it is subjected, as well as by the over-distension and irritation caused by the gas. Portions, too, of the half-digested food will pass into the duodenum, which, being altogether uncongenial to the sensibility of this organ, will give rise in it to irritation, spasm and pain, and by sympathy, func- tional derangement of the liver. When this state of things is once produced by some error in diet, assisted, perhaps, by general causes, the slightest causes— even the ordinary digestible and plain diet taken in health—will not only sustain it, but often increase its violence, if favored by other circumstances of a debili- tating character. Dr. Philip thinks that over-distension of the stomach, by eating too much, is one of the most common causes of dyspepsia, and there can be no doubt as to its decided tendency in this way. It is probable, however, I think, that it is not so much by an over-distension of the muscular coat of the stomach which a superabundance of ingesta produces, that indigestion is caused, as by the mere excess of food beyond what the stomach is capable of digesting. Suppose the utmost powers of the stomach to be capable of digesting sixteen ounces of food at a time; it is manifest, that if twenty ounces are taken, some of it will remain either in a partially digested, or wholly undigested state in the stomach, a longer time than is compatible with the healthy condition of the organ. The portion will, therefore, irritate the gastric nerves—enter more or less into a state of chemical decomposition, and give rise to deficient or vitiated secretions in the stomach, as well as debility of its muscular tunic. The effects which follow the reception into the stomach of an undue proportion of food, besides those of mere over-distension, do not differ from those which are caused by indigestible articles of diet. A small portion of food which resists the digestive powers, is capable of bringing on violent dyspepsia, by remaining in the stomach beyond the period which is allotted by nature to the process of digestion, and becoming thereby a source of irritation in the manner already mentioned. Just so does it happen when the portion of food, however digestible, is greater than the stomach is capable of digesting at a time: for the portion which remains in an undigested slate, and which the stomach is no»longer able to convert into chyme, will act like so much indigestible food, and give rise to the distressing consequences which often result from such articles of diet. The causes which most commonly occasion the reception of more aliment into the stomach than its powers are capable of converting into chyme, are : 1. Eating too fast.—Dr. Philip has satisfactorily explained the way in which rapid eating tends to cause persons to take more food than they are able easily to digest. "The appetite subsides only in proportion as the gastric juice becomes mixed, and, as it were, neutralized by the food. When we eat rapidly, time is not given to the gastric liquor to combine with that part of the food which is presented to it; the sensation of hunger therefore continues, and we continue to eat until so much food is taken that the whole gastric fluid which the stomach is capable of supplying during the digestive process, is not sufficient to effect the due chymification of it. Whereas, when we eat slowly, so that a proper time is given for the combination to take place, the appetite abates before the stomach is overcharged. Every one has occasionally observed, that if his meal is inter- rupted for ten or fifteen minutes after having eaten perhaps not one-third of the usual quantity, he finds that he is satisfied. The gastric fluid which had accu- mulated has had time to combine with, and be neutralized by the food he has taken. It is for the same reason that a few mouthfuls of food taken a little be- fore dinner, will often wholly destroy the appetite, especially in delicate people in whom the gastric fluid is secreted in small quantity, or of a less active quality." 2. Imperfect mastication acts in the same manner, and as it is always con- nected with rapid eating, contributes greatly to this latter cause. 3. The use of condiments, stimulating drinks, and high-seasoned food. These INDIGESTION. 629 excite an artificial appetite, and keep up the desire for food longer than it would be sustained by the impressions simply of the gastric fluid. The free use of very cold or warm drinks, particularly during meals, tends much to weaken the digestion, and to aid other causes in the production of dys- pepsia. By drinking freely, the gastric fluid is so much diluted that its powers are weakened, and of course the process of digestion more or less retarded. A very mixed diet—especially if the articles are of unequal degrees of digestibility —is a frequent cause of indigestion. I have stated above, that a tardy peristaltic action of the muscular coat of the stomach, by which the digested portions of food are too long retained in this or- gan, is very often concerned in the production of dyspeptic symptoms. I am persuaded, however, that the reverse condition also very frequently obtains, in cases of painful and imperfect digestion—namely, that the food is too rapidly hurried through the stomach into the duodenum, before it has had time to undergo the full action of the gastric fluid. This appears most commonly to be the case in confirmed instances of the disease—or in such as are attended with a high degree of irritation, or a sub-inflammatory condition of the mucous membrane of the primae viae. That a morbid peristaltic activity of the stomach often exists in dyspepsia, may be inferred from the consequences which are known to result from high irritation or phlogosis of the mucous membrane of the intestinal tube. The phenomena of indigestion in aggravated cases also confirm the correctness of this opinion. It is a common circumstance, for instance, to hear dyspeptics complain of a sense of fullness in the stomach after eating even a small portion of food. But not- withstanding this feeling of repletion, they soon complain again of the customary sense of emptiness in the region of the stomach, and crave more food. It is to be observed, likewise, that the chief distress or uneasiness in such cases, is not experienced in the stomach, but rather in the region of the duodenum. Many dyspeptics feel no particular uneasiness until an hour or two after eating, when they begin to experience pain and distension in the duodenum. In some cases the food is speedily hurried off by the bowels in an imperfectly digested condi- tion, under very severe suffering from tormina and flatulent distension of the in- testines. In some instances, severe and obstinate dyspeptic affections depend on a pri- mary irritation of some portion of the spinal marrow, or of the roots of some of the spinal nerves. "Many cases of dyspepsia," says Mr. Teale, "which had resisted the usual mode of treatment, I have found to be connected with tender- ness, on pressing some of the middle or lower dorsal vertebrae, and on removing the tenderness in the spine and neighboring parts, by proper remedies, the stomach affection and attendant symptoms have been almost immediately removed." In addition to the ordinary symptoms of indigeslion, patients affected in this way usually complain of a peculiar sense of faintness or sinking at the epigastrium, and a tightness or constriction along the inferior margin of the chest. In some instances, also, the patient is frequently much harassed with flatulency of the stomach. This flatulency, says Mr. Teale, differs from that which arises from the decomposition of food so common in disorders of the stomach, by the rapid and copious formation of the air. The stomach is often, almost instantly, greatly distended with flatus, even where there is no obvious cause for its production. Sometimes the collection of air occurs more slowly, continuing for many hours or even days. Mr. Teale states that he has in some instances known firm pres- sure on the painful or tender part of the spine instantly to cause a sudden copious formation of flatus in the stomach. Symptoms and course.—The symptoms of indigestion differ considerably ac- cording to the stage of the complaint, or the degree and extent of the irritation. In the commencement the appetite is variable, generally weak, and often entirely destroyed; the patient is troubled with flatulency, distension, acid eructations, and colic pains ; the mind is, at times, depressed and languid ; the tongue covered 630 INDIGESTION. with a white fur; the bowels usually constipated ; the whole system languid, particularly during the process of digestion; and there is almost a constant uneasy feeling in the epigastrium. Sometimes the appetite is morbidly craving, but if the patient indulges freely in taking food, he becomes much oppressed, and gene- rally suffers severe pains some hours after eating. After the disease has con- tinued for some time, or has been aggravated by some unusual irritating cause applied to the stomach, the pulse becomes tense and quick; the epigastrium tender to the touch; the mind irritable, discontented and gloomy. The colic pains, some time after taking food, are more frequent and severe ; the bowels become irregular—being sometimes constipated ; at others affected with diarrhoea, during which, portions of food are occasionally passed off in an imperfectly di- gested state—the stools varying in color, consistence, and character. The body now begins to waste, and the strength fails ; the epigastric distress becomes severe and constant; the countenance assumes a haggard and sallow aspect; the patient complains of more or less difficulty of lying on the left side; the skin becomes dry and shriveled, and there is usually a morbid sensibility to low temperature. From the extensive sympathies which subsist between the stomach and every other part of the living body, dyspeptics are frequently much harassed by painful and other distressing affections in parts situated remotely from the stomach. Among these sympathetic affections of indigestion, headache is the most common and annoying. Dr. Warner observes, that there are two sorts of dyspeptic head- ache, the one occurring while the process of chymification is going on slowly and imperfectly in the stomach, and the other after the chyme has left the sto- mach and passed into the duodenum. The former is distinguished by a languid and feeble pulse, a slightly coated and whitish tongue, with very pale red edges, mistiness before the eyes, slight vertigo, and an apprehension of falling; slight nausea and uneasiness in the stomach; a sense of constriction about the fauces; and sometimes a coldness and numbness of the fingers; and generally a feeling of weight in the brain. The second, or as Dr. Paris calls it, duodenal dyspeptic headache, is characterized by brilliant ocular spectra which constantly distress the patient; by the chilliness of the body, and the coldness and dampness of the hands and feet. The pain in the head is very severe, and is attended with a sensation of coldness and tension of the scalp, and a sense of weight and disten- sion in the eyeballs. The tongue is commonly covered with a yellowish-white fur, and is often much coated. The pulse is natural in frequency, but always languid. There is usually flatulency, and Dr. Paris states that a peculiar feeling of dryness and inactivity of the bowels, as if the intestines had lost their sensi- bility and were unable to propel their contents, giving rise to a peculiar sensation of weight and obstruction, may be regarded a pathognomonic of this variety of the affection. These headaches rarely continue longer than two or three hours, and are usually diffused throughout the whole head. In a practical point of view, it is of great importance to bear in mind that dys- pepsia may depend on two distinct morbid conditions of the digestive organs : namely, 1. On functional debility of the stomach from deficient or vitiated secre- tion of the gastric fluid, and muscular inactivity, independent of vascular irritation or inflammation. 2. On deficient or vitiated secretion of the gastric fluid, with vascular irritation or chronic inflammation of the mucous membrane of the stomach and duodenum, and a morbidly increased peristaltic action of these or- gans. The characteristic symptoms of the former grade of indigestion are, weak ap- petite; tongue covered with white fur; absence of epigastric tenderness, except after a paroxysm of colic from flatulent distension ; costiveness ; acid and fetid eructations ; absence of habitual tension and febrile irritation of the pulse; and the ability of bearing lean and tender animal food better than vegetable and fari- naceous articles of diet. The phenomena which characterize the second or inflammatory grade of the disease, are tenderness to pressure of the epigastrium, and particularly about the INDIGESTION. 631 region of the pylorus and duodenum ; a red, chapped, granulated or glossy ap- pearance of the tongue ; a firm, tense, small, and somewhat accelerated pulse, with slight manifestations of febrile exacerbations towards evening; emaciation; irre- gular action of the bowels, with frequent attacks of mucous, bilious or watery diarrhoea; violent and protracted pain in the lower part of the epigastrium during the process of digestion : fullness about the edge of the false ribs on the right side; and anxious and discontented expression of the countenance: and inability, without great suffering, to endure animal food and stimulants. It appears that the irritation or chronic inflammation of such cases is seated in the mucous mem- brane of the pyloric extremity of the stomach and of the duodenum, connected usually with a congested state of the liver, and often with fecal accumulations in the colon. Hence the region of the duodenum and pylorus is almost invariably somewhat distended, and very tender to pressure in such cases ; and these cir- cumstances, together with the tense and quick pulse, furnish the most certain diagnosis of the existence of high mucous irritation or chronic inflammation in dyspeptic complaints. In some instances, the pain and tenderness extend across the epigastrium into the left side, and become fixed in the region of the spleen, or where the colon turns down to form the descending arch. The pain and tenderness in the left side appear to depend on various causes, "all of which," says Dr. Philip, "are more unfavorable than the circumstances which cause its existence in the region of the pylorus and duodenum."* It may depend on an inflamed and engorged condition of the spleen, in which case this viscus is generally found in an enlarged condition. It arises, also, sometimes, from enlargement of the left lobe of the liver, " which is always the part of this organ most affected in indigestion." Ac- cording to the observations of Dr. Philip, however, the most common cause of the pain and tenderness in the left side is the extension of the chronic inflamma- tion from the pylorus to the other parts of the stomach. There is generally much difficulty in distinguishing pain and tenderness seated in that part of the colon which lies over the pylorus, from the same affections in this portion of the stomach and duodenum. " The best means for distinguishing affections of the stomach from those of the colon are, the digestive process in the latter case being better performed ; the state of the bile being less disordered ; the patient not experiencing the increase of uneasiness which often conies on after meals, for a considerable time after eating, and often experiencing more or less pain, or some other uneasiness in the region of the stomach a short time before the bowels are moved, and more or less relief soon after their action." (Philip.) Pain and tenderness on pressure cannot, however, be regarded as an unequivocal sign of inflammation in the pylorus and duodenum. This part sometimes be- comes morbidly sensitive, without capillary congestion or inflammation. Never- theless, where we find this tenderness a little below and to the right of the pit of the stomach, at the same time that the sides and tip of the tongue are red, with a granulated surface and a dry streak in the middle, together with a tense and quick pulse, we may be assured that the parts just mentioned are in a state of inflammation. Treatment.—One of the first things to be attended to when we are called to prescribe in a case of dyspepsia, is to obviate, as far as possible, the usual exciting causes of this distressing affection; and with this view, we must direct our atten- tion chiefly to the adoption of proper dietetic regulations. In all cases of dys- pepsia, whether simple or complicated, mild or violent, an undeviating observance of suitable regulations in relation both to the quantity and quality of the aliment, and the manner of taking it, is absolutely indispensable to success in the manage- ment of the disease. The patient should be directed to masticate well and slowly ; lo take his meals at regular hours; to eat no more at a time than is just sufficient to sustain the powers of the system; to drink but little during and for a short * On the Treatment of the more Protracted Cases of Indigestion. London, 1827, p. 19. 632 INDIGESTION. time after taking food ; and he must avoid taking any active exercise during the 'first stage of the process of digestion. The presence or absence of symptoms indicative of high irritation or sub-inflammation in the mucous membrane of the stomach and duodenum will enable us to say, almost with certainty, whether an animal or vegetable diet will procure most relief to the patient; but in relation to the particular articles of these two kinds of aliment, no specific directions can be given which are applicable to all cases: for some dyspeptics are benefited by certain articles of food that are altogether intolerable to others. This is more especially apt to be the case in those habitual dyspeptic cases which depend on mere functional debility, with morbid sensibility of the stomach, unconnected with inflammation. In some cases the dyspeptic symptoms are excited only by par- ticular aliments; "and we must endeavor to ascertain whether a peculiar idiosyn- crasy of the stomach prevails in such instances, or whether there is a debilitated condition of the organ that incapacitates it from digesting any food demanding considerable powers for its chymification." Every individual affected, and suf- fering under this grade of dyspepsia, must in a great measure learn from his own experience, what articles of diet will or will not agree with him. In general, however, where the disease depends more on debility of the digestive organs, without a fixed tenderness and fullness in the epigastrium, the more digestible kinds of animal food are decidedly the most proper. In such cases, a plain abstemious diet of this kind, together with the occasional use of gentle aperients, mild tonics, regular exercise, and a rigid avoidance of the usual exciting causes of the complaint, will rarely fail to establish a cure, or at least to procure an exemption from its more disturbing symptoms. Animal is undoubtedly much more digestible than vegetable food; and where the gastric irritation is not con- siderable, it will very generally be taken with the least inconvenience by dyspeptic persons. We may lay it down, therefore, as a general principle, that animal food is the most proper; and of this the most tender muscular parts are to be selected. There is nothing to be apprehended from the stimtdant qualities of animal food, in cases depending on debility, without any particular morbid irritability or phlo- gosis of the digestive organs. Our object here is to obtain the most digestible food, and which is, at the same time, the least apt to enter into fermentative decomposition. By a food of this kind, the debilitated stomach is moderately excited, and subject to less labor; while the chyme is more speedily and per- fectly formed, and the development of acid flatus, &c. thus, in a great degree, prevented. It is very different, however, with those cases of protracted and inveterate dyspepsia that are attended with a red tongue, tender and somewhat tumid epigastrium, and a firm pulse. Here the food, as I shall presently state more particularly, must be as bland and as unirritating as possible. Much attention has been directed to inquiries concerning the comparative digesti- bility of the various customary articles of food. All agree that the flesh of old animals, with the exception of beef and veal, is more digestible than that of young animals. The latter contains much more mucilaginous matter than the former; and all mucilages are of difficult digestion. Animal jellies, and young meats, observes Dr. Philip, are what is commonly called light food, with a reference to their stimulating qualities, or tendency to excite fever—and hence, in persons recovering from fever, or in extremely irritable habits, we prescribe the animal jellies, or young meats which contain them in abundance, in preference to the meats of old animals. In dyspepsia, however, from mere gastric debility, animal jellies remain long in the stomach, from their indigestible nature, and cause, therefore, more disturbance and distress than beef or mutton. Tender beef, mutton, and all kinds of game, more especially vension, are usually of easy digestion, and generally agree much better with dyspeptics, during the early stages of the disease, than any other article of diet. Pork and veal are, with most persons affected with indigestion, altogether inadmissible ; and fish, loo, seldom agrees well except when taken in very small portions, and in a boiled state. The most oppressive kinds of poultry are geese and ducks; and " turkey is more INDIGESTION. 633 oppressive than fowl, which, next to mutton, is, perhaps, upon the whole, the lightest animal food in common use, if the skin be avoided." Pheasant is the least easy of digestion of the different kinds of wild game ; but partridge and hare are in general readily digested by weak stomachs. Soft-boiled eggs will sometimes agree very well with dyspeptics ; but care must be taken not to eat the coagtdated portions of the albumen. Simple roasting or boiling is the best way of preparing meats for persons laboring under indigestion—-fried articles of food being in general very oppressive. There is no aliment more offensive to a weak stomach than new made bread. By mastication it is converted into a tenacious paste, which " is not easily pervaded by the gastric juice," and is, therefore, always very slowly converted into chyme. The bread used by a dys- peptic person should always be several days old; and, for a change, crackers, or " pilot-bread," may be used. Some individuals derive much advantage from the employment of bran-bread, but I have reason to think that, where there exists a morbid sensibility of the stomach, it is generally decidedly injurious. The only benefit that can be obtained from bran-bread beyond what may be derived from common bread, arises from its gently stimulating the bowels, and keeping up regular alvine evacuations ; but I have known it to produce disagreeable irritation both in the stomach and bowels, by the small cuticular scales of the grain which it contains, and which are almost insoluble in the gastric fluid. Cheese, milk, cream, and butter, unless taken in very moderate portions, are apt to become oppressive. I have known dyspeptic individuals, however, who were much benefited by the habitual use of cream and crackers at their meals. Fresh vegetables are very generally injurious, particularly cabbage, peas, beans ; and, above all, cucumbers, lettuce, celery, and other articles of this kind taken in the form of a salad, or in an uncooked state.* Of fruits, pears, currants, goose- berries, whortleberries, and melons, are generally most apt to prove injurious. Mealy potatoes and turnips are among the best articles of this kind for dyspeptic subjects. All kinds of pastry, such as hot cakes, pies, puddings, &c, are entirely out of the question. The food of a person laboring under dyspepsia from gastric debility, should be chiefly taken in a solid state. Soups and broths very rarely do well in cases of this kind. I have already stated, that slow eating and perfect mastication are all-important observances in dyspepsia, and that but very little drink should be taken during, or soon after meals. Moderate portions of brandy and water usually answer well in slight cases of indigestion, but in the more aggravated forms of the disease they are exceedingly improper. Simplicity in diet, too, is of great importance to the comfort of dyspeptics; and what is of equal, if not still greater importance, is, to take but moderate portions of food into the stomach at each meal. It must not be forgotten that the foregoing dietetic observations apply only to those cases of indigestion which are free from a morbidly sensitive and irritable or an inflamed condition of the digestive organs. The signs by which these conditions may be detected have already been mentioned; and it is of the utmost importance to form a correct diagnosis on this subject. So far from solid animal food being the best aliment in cases of this kind, nothing but the lightest fari- naceous articles of diet can be borne with any degree of comfort, or are com- patible with the restoration of the healthy state of the stomach. These cases must indeed be treated in every respect as instances of chronic gastro-enteritis, and the observations that I have made with regard to the diet in these affections, are therefore fully applicable to inveterate cases of dyspepsia. Medicinal treatment.—When the disease depends on functional derangement from mere debility or inactivity of the digestive organs, the bowels are generally * [The capriciousness of some dyspeptic stomachs is remarkable enough. I have known several cases in which raw turnips and radishes, and even cucumbers, could be eaten with impunity when the best selected articles of diet would always disagree. Dr. Chapman, in his excellent chapter on indigestion, relates a curious case of this kind, in which an exclusive diet of green corn effected a cure after everything else had been rejected.—Mc] 634 INDIGESTION. torpid, and loaded with feculent matter, and hence an important indication in cases of this kind is to procure regular alvine evacuations by diet, if possible; if not, by the occasional use of gentle aperients. When first consulted in dys- pepsia of this grade of gastric disorder, it will, in general, be necessary to pre- scribe a laxative sufficiently active to evacuate the bowels freely ; but when the infarcted state of the alimentary canal has once been removed, the gentlest articles of this kind, and in doses barely sufficient to procure one or two consistent evacuations, should alone be employed. If, indeed, the action of the bowels can be regularly maintained by dietetic regulations, it ought always to be preferred to the exhibition of laxatives. This, however, can rarely be adequately done, and almost all dyspeptics find it necessary to resort, more or less frequently, to remedial means for procuring regular alvine evacuations. Rhubarb, in union with some aromatic or stimulating substance, will in general answer well as an aperient in such cases. The following pill* may be taken a short time before the principal meal; and where there is much acidity in the stomach, the rhubarb may be advantageously given in combination with from ten to twenty grains of the car- bonate of soda, or with thirty or forty grains of magnesia. No remedy, however, has appeared to me to act more favorably as an aperient in the milder grades of habitual dyspepsia than small doses of ipecacuanha in union with aloes and the extract of hyoscyamus. From personal experience, I know that in some in- stances, at least, the effects of this combination are peculiarly soothing and sufficiently aperient.t Emetics were formerly much employed in dyspepsia; but except in recent attacks from a surfeit or very irritating and indigestible ingesta, their use is now very properly almost universally condemned. Where it may be deemed advisable to excite vomiting we may generally effect this purpose by copious draughts of lukewarm water, or what is still better, strong infusions of chamomile flowers, or of the eupatorium perfoliatum. When these do not procure adequate emesis, an ordinary dose of ipecacuanha may be administered. Tartar emetic is decidedly objectionable, even under the strongest indications for the employment of an emetic in dyspepsia. Where the disease is connected with morbid sensibility of the stomach, or with chronic inflammation, no circumstance, perhaps, can justify the exhibition of an emetic. In the grade of indigestion now particularly under consideration, besides the dietetic measures already indicated, and an attention to the regular maintenance of the alvine evacuations, mild tonics in combination with alkalies, gentle exercise, and the avoidance of the usual exciting causes of the disease, will generally restore the healthy functions of the digestive organs. A weak infusion of columba or of gentian, with a portion of the carbonate of soda, or of potash, may be employed for this purpose. The ferruginous preparations also are often peculiarly beneficial in cases of debilitated digestive powers, without any promi- nent hepatic derangement. The tartrate of iron, given in union with a small portion of ipecacuanha, has done much good in my hands in no inconsiderable number of cases.£ The chalybeate mineral waters, also, will occasionally pro- cure more benefit in instances of this kind than any other tonic. The white mustard seed has of late years been a very fashionable remedy for dyspepsia, and in cases of simple languor and weakness of the stomach, very considerable * R—Pulv. rhcei gr. ii. ---- aloes gr. ss. ---- capsici gr. i.—M. To be made into a pill. X R.—G. aloes Socot. ►) i. P. ipecac, ^ss. Extract, hyoscyamus ^i.—M. Divide into twenty pills. Take one at night on going to bed. X R —Tart, ferri 7,1 Pulv. ipecac, gr. v.—M. Divide into three equal parts. Take one every morning, noon and evening. INDIGESTION. 635 advantage may in general be derived from them. Four or five teaspoonfuls of the unbruised seed should be taken during the course of the day. I have known several individuals hahitually subjected to slow and painful digestion with torpor of the bowels, much benefited by this remedy. It need scarcely be observed that where the stomach is morbidly irritable and tender to pressure, this article cannot be taken without injurious consequences. Tonics are frequently much abused in this affection, and may readily do much mischief where there is great irri- tability of the stomach or a state of phlogosis, and especially where the hepatic functions are prominently deranged. They can be employed with a prospect of advantage only in cases of torpor or weakness of the digestive organs. Indiges- tion seldom continues long, even in its milder grades, without involving the liver in functional disorder; and hence, alterative doses of mercury have of late years been among the most common means in dyspeptic affections. Where, from the icterode state of the eyes and skin, and the* appearances of the stools and urine, there is reason to suspect the existence of functional disorder of the liver, the use of alterative portions of the blue mass is decidedly indicated, and will gene- rally afford benefit. From four to six grains of the blue pill may be taken every second or third night, with an occasional dose of some gentle laxative—such as small portions of rhubarb, or one or two Seidlitz powders, or a few of the laxa- tive pills already mentioned. I have been much in the habit of giving the blue mass in union with a laxative, according to the following formula ; and generally, as it appeared to me, with more advantage than when they are given separately and at distinct periods.* Care must be taken, however, in prescribing mercury in this affection, not to continue its use until the general system becomes affected ; for general mercurial excitement is always improper in dyspepsia. Some indi- viduals are always very disagreeably affected by the blue pill. I have met with dyspeptic patients in whom this mercurial invariably excited the most unpleasant sensations in the stomach, as well as great general restlessness and nervous irri- tation. When this is the case, we may generally gain our object by the internal use of nitric acid diluted in a large portion of water; or what has appeared to me still more advantageous, the nitro-muriatic acid bath, in the way mentioned under the head of chronic hepatitis.t As palliatives, alkalies and opium are the best remedies we possess—the former for removing the burning and aching sensations which are caused by acidity in the stomach, and the latter for allaying the cholic pains that result from the irritation of ihe food, flatus and acid in the stomach and duodenum. It is to be observed, however, that opium cannot be frequently employed in this affection without still further impairing the digestive powers of the stomach ; but the pains are so often extremely violent, that we are obliged to resort to this narcotic for relief. In those cases of dyspepsia which are connected with a high degree of morbid sensibility of the mucous membrane of the stomach and duodenum, the occasional use of this anodyne is peculiarly valuable. Without it, indeed, patients laboring under this variety of dyspepsia would enjoy but few moments of exemption from suffering. Dr. Philip recommends Dover's powder, and advises that from two to four grains of it should be given every six or eight hours. This will commonly be sufficient to allay the general nervous irritation which is apt to occur in cases of this kind; but when those violent gastric and duodenal pains come on, which at times rack the unfortunate dyspeptic, nothing but the largest doses of laudanum will be * R.—Massae hydrar. %i. G. aloes Socot. ^ iss. Tart, antimonii gr. ii.—M. Divide into twenty pills. Take one every other night on going to bed. t [The domestic remedy for dyspeptics which was so generally prescribed by the late Dr. Physick, has become quite popular in this country. It consists of a U.rivium of one quart of hickory ashes and a teaspoonful of soot in a gallon of water. A wineglassful of this ley given three times a-day, is supposed to afford all the advantages derivable from a combination of potassa and creasote.—Mc] 636 INDIGESTION. sufficient to allay his extreme suffering. I have known persons in the utmost degree of agony for hours, from irritation in the stomach and duodenum, who were obliged to take several hundred drops of laudanum before relief was pro- cured ; and in this respect, I may, indeed, truly say with the poet— Atque utinam numero ne nos essemus in isto. Weak and slow digestion is frequently connected with a morbid sensibility of the nerves of the stomach and duodenum, independent of chronic inflam- mation of these organs. When the patient is subject to severe pains an hour or two after taking a meal—and more especially when the gastric distress is particularly excited by certain articles of food which usually agree with other dyspeptics, and when, moreover, the edges of the tongue remain of a pale red, with a thin white fur over the middle, and the pulse is free from tension, though quick and small, and the skin generally soft, and below the natural temperature; and, finally, when with these symptoms there is a disagreeable or painful feeling of emptiness experienced in the region of the stomach four or five hours after taking food, without any particular tenderness to pressure on the epigastrium— when these symptoms exist, there is reason for believing that an exalted sensi- bility of the gastric nerves is present without phlogosis. The diagnosis in relation to these circumstances, is of much more importance, in a practical point of view, than seems to be generally supposed. Dr. Philip speaks particularly in favor of the employment of ammonia, in what he calls the second stage of indigestion, and it is, indeed, in many cases, deserving of all the encomiums which he has bestowed upon it. The instances, however, in which, according to my own ob- servations, it is most apt to prove beneficial, are those in which there is a con- stant tendency to the generation of acid in the primae viae, in connection with morbid sensibility of the mucous membrane of the stomach and duodenum. In cases of this kind, eight or ten grains of the carbonate of ammonia with five or six grains of Dover's powder may be taken several times during the day with much temporary benefit. Dr. Philip observes, that in cases of dyspepsia, where the surface is cold, the pulse feeble, with a feeling of general depression and chilli- ness, " the ammonia is invaluable; being less apt than any other stimulus of the same power, with respect to the nerves, to excite the heart and blood-vessels; which, from the tendency of the disease, (in this the second stage,) are inclined to a degree of excitement beyond that undue proportion to the state of the other powers." Much relief may also be obtained, in cases where the disorder is attended with much irritation and sensibility of the gastric nerves, from the liq. acetat. ammonias, in union with small doses of laudanum, or of the tincture of hyoscyamus. A tablespoonful of the former, with ten drops of either of these narcotic tinctures, may be taken two or three times daily. When there is much gastric irritation, with slight febrile symptoms towards evening, such as dryness and heat of the skin, burning in the palms of the hands and the soles of the feet, and tension of the pulse, the nitrate of potash will gene- rally afford considerable relief. It may be advantageously given with minute portions of the tincture of ipecacuanha,, dissolved in some mucilaginous fluid. From five to ten grains of the nitre, dissolved in a few ounces of barley-water, or of a solution of gum Arabic, with fifty drops of tinct. ipecac, may be given every four hours. When the gastric irritation has assumed the character of chronic inflammation —that is, when in addition to the general symptoms just mentioned, the epigas- trium becomes tender to pressure, the pulse tense and firm, and the edges and tip of the tongue red, tonics, purgatives, animal food, and all stimulating remedies, are no longer admissible. Leeching or blistering over the region of the pylorus and duodenum is here one of the most important remedial measures. The latter, indeed, will often be found particularly beneficial in cases attended only with high irritation, without actual inflammation. For the removal of that morbidly sensi- tive condition of the gastric nerves noticed above, there is, perhaps, no remedy INDIGESTION. 637 so effectual as the application of a blister over the epigastrium. I have known patients who could scarcely take even the blandest articles of food without.suffer- ing a great deal of pain, enabled to digest light aliment with tolerable comfort after having the region of the stomach blistered. Pustulation with the tartar emetic ointment, may also be resorted to with a fair prospect of advantage in such cases. Leeching, however, is always an excellent preliminary to vesicating or counter-irrilating applications. There is but little advantage to be obtained from internal remedies in cases of this kind ; yet the nitrate of potash, dissolved in a large portion of some mucilaginous fluid, will occasionally assist in removing the dry and constricted state of the skin, and the distressing sense of internal heat. Dr. Philip advises the exhibition of small doses oftartarized antimony. I have oc- casionally, derived some benefit from its administration in cases attended only with gastric irritation ; butl doubt much of the propriety of employing this remedy where unequivocal signs of mucous inflammation of the stomach are present.* Some writers recommend laxatives in this as in the milder varieties of the disease ; but their tendency to irritate the tender and phlogosed mucous membrane of the stomach and intestines, renders them, I think, decidedly objectionable. Slight relief will, it is true, usually follow the operation of a purgative, but this relief is always but temporary, and is very often succeeded by an aggravation of the gas- tric distress and tenderness. The same objections do not, however, exist against the use of laxative enemata, and I do not, indeed, know any measure which is better calculated to afford ease, in cases of this kind, than the daily use of one or two mild laxative clysters. Functional disorder of the liver is a constant attend- ant in cases of this kind; and it becomes necessary to employ mercurials either internally or by frictions on the right hypochondrium. The employment of mer- curials, however, requires great caution in the severer cases of the disease ; for it is not uncommon to find the blue pill, even in small doses, to excite consider- able intestinal irritation and general uneasiness. To avoid this occurrence, we may give this mercurial in union with a small portion of opium, or of the extract of conium. In general, it will be sufficient to administer one grain of the blue mass, with half a grain of opium, every night on going to bed, and care must be taken not to carry it to the extent of causing even a soreness of the gums. The correction of the biliary secretion, by a gradual introduction of mercury into the system, is generally attended with the additional advantage of an abatement in the tension and contraction of the pulse, and a diminution of the temperature and dryness of the skin. After all, however, our principal reliance in cases attended with a high grade of irritation or chronic inflammation, consists in the use of a bland and unirritat- ing liquid diet, local depletion, revulsive applications, and the occasional use of alterative doses of blue pill or calomel, with laxative enemata and gentle exercise by gestation or where the strength of the system will admit of it, walking regu- larly every day, until a slight degree of fatigue is induced. Let it be constantly borne in mind, that functional derangement of the stomach may be the consequence of mere debility and relaxation—or of high irritation and morbid sensibility—or finally of a chronically inflamed condition of the mucous membrane of the digestive organs; and that, therefore, the mode of treatment, both medicinal and dietetic, which is proper in the first, will not answer in the second, and will prove decidedly pernicious in the third of these varieties. In the first, our object is to increase the tone and activity of the stomach ; in the second, to soothe the irritation and morbid activity of this organ ; and in the third, to subdue inflammation, and obviate its consequence—structural disorder. It should also be recollected that disorder of the stomach, attended with * [No internal remedy can be brought into competition in this condition of things with small doses of the nitrate of silver, made into a pill with simple bread or gum Arabic. I have fre- quently given it in combination with extract of hyoscyamus, \ to \ gr. of the former to 1 gr. of tiie latter in each pill, repeated three times a day.—Mc ] 638 DIARRHCEA. harassing symptoms of indigestion, may be the direct consequence of spinal irritation. (Teale.) In all obstinate cases of indigestion, therefore, the spinal column ought to be carefully examined, in order to ascertain whether any portion of it be tender or painful to pressure. It cannot be doubted that spinal irrita- tion sometimes produces great disorder of the digestive organs ; and in such cases, it would be in vain to expect any relief, so long as the spinal affection continues. In cases of this kind, the tenderness to pressure is generally confined to the lower dorsal vertebrae. Should such tenderness or soreness be found to exist, cupping over the affected part of the spine, repeated, at intervals of four or five days, according to the obstinacy of the spinal irritation, will seldom fail to remove all the dyspeptic symptoms. Blisters, or rubefacient frictions, also, over the af- fected portion of the spine, will sometimes afford complete relief in instances of this kind. Sect. II.—Diarrhoea. Diarrhoea is an affection of the bowels, the characteristic symptoms of which are: frequent and usually copious liquid stools of a feculent character—attended with more or less griping without tenesmus, and generally without febrile irri- tation. The proximate cause of diarrhoea consists, according to the sentiments of Cullen and some other writers, in increased peristaltic motion of the intestinal tube. Unquestionably, an inordinate peristaltic action does take place in this affection ; but this increased action does not constitute the essential pathological condition of the disease, and cannot therefore be properly regarded as its proxi- mate cause. Increased action of the intestinal canal may arise in two ways, namely : 1. The irritability of the bowels may be in a natural state, whilst the substances which are brought to act on them are of a peculiarly irritating or ex- citing character. In this case the alvine discharges will generally cease soon after the irritating substances which have excited them are expelled, or their acti- vity is destroyed—as is the case with the purging produced by cathartics, or the action of other transient irritants. 2. The irritability of the bowels may be pre- ternaturally increased ; in which case, the ordinary secretions and contents of the intestinal canal, and even the mildest substances, will produce excessive peristal- tic action, and of course frequent alvine discharges. Irritation of the mucous membrane of the bowels, therefore, constitutes the primary morbid condition in diarrhoea, of which the increased peristaltic motion and the inordinate alvine evacuations are the consequences. When the diarrhoea continues long, or assumes a chronic form, the mucous irritation becomes fixed, and unless it be counteracted by an appropriate treatment, gradually passes into a state of chronic inflammation—more especially of the mucous membrane of the colon, and finally terminates in ulceration, and other forms of disorganization of this membrane. Broussais observes that when diarrhoea continues beyond the thirtieth day, it is almost invariably connected with organic derangement of the mucous membrane of the colon. When the disease continues until the irritation passes successively into chronic inflammation and disorganization of the mucous tissue of the bowels, slight febrile irritation occurs—particularly towards even- ing, and a few hours after eating; the pulse becomes quick, small, and frequent; the skin dry and harsh ; the body emaciates more or less rapidly; and at last oedema of the feet and legs, and occasionally dropsical effusions into the cavity of the abdomen, ensue. In this aggravated form, the patient is apt to experience extremely severe colic pains an hour or so after taking food, and in general even the mildest ingesta are followed by tormina, flatulency, and diarrhoeal dis- charges, and articles of food are sometimes passed in the stools in an imperfectly digested state. The appetite is generally very variable and capricious ; being sometimes voracious, and at others entirely depressed. The stools, too, vary DIARRHCEA. 639 much both in relation to frequency and appearance. They are sometimes slimy, mixed with more or less fecal matter; at others abundant and watery—occasion- ally dark, reddish, or whitish, and often contain small portions of undigested food. On post-mortem examination of subjects who have died from chronic diarrhoea, or from some other disease accompanied with this bowel affection, we sometimes discover irregular patches of a fungoid appearance, and of a livid or dark red color, slightly elevated above the surrounding parts, on the mucous membrane of some portion of the intestinal canal. In other instances, small, well-defined ulcers with elevated edges, or extensive irregular ulcerations with ragged edges, are met with. Not unfrequently the coats of the intestines are thickened at the parts where these ulcers are situated ; and in some instances this thickening is so great as to diminish the area of the intestinal tube very considerably. In cases of this kind, says Broussais, the usual diarrhoeal symptoms are apt to alternate with attacks of costiveness, and death occasionally occurs under symptoms re- sembling those of ileus. Sometimes, instead of ulcers, the mucous membrane is covered with numerous tuberculous elevations of different sizes; and occasionally extensive portions of this membrane are found covered with smooth cicatrices of ulcerations which have healed. Broussais observes that these ulcerations are always found most numerous in the caecum, and about the lower portion of the colon. He thinks, and with great probability indeed, that when the feculent matters become fetid and putrid, whether from long retention or imperfect diges- tion, they cause irritation, and ultimately inflammation, in that part of the mucous membrane where they are most apt to become accumulated. When death occurs at an earlier period of diarrhoea, the mucous membrane of the colon, and of the ileum, is usually found in a more or less reddened or injected state, with slight thickening of its structure. This is particularly observed in those chronic dis- eases which, during the latter period of their course, are accompanied with colliquative diarrhoea. In the chronic diarrhoea of children, attending what is usually called marasmus, I have found in several instances on dissection, the mucous membrane of the lower portion of the small intestines and of the colon, exhibiting extensive tracks of a congeries of minutely injected vessels. Causes.—The remote or occasional causes of diarrhoea are exceedingly vari- ous. They may be divided into those which act directly on the mucous mem- brane of the intestinal canal, and those which act indirectly through the medium of the general system. Of the former kind are all irritating substances received into or generated in the alimentary canal; and of these the most common are: irritating and indigestible articles of food and drink; acrid and vitiated secretions from the liver and intestinal exhalents; worms; acid generated in the bowels; fresh fruit, particularly such as are very sweet, or acid, &c. Limestone water is particularly apt to give rise to copious diarrhoea in those who have not been accustomed to its use; and new made cider, before it has undergone the fer- mentative process, is also extremely apt to excite this affection. Much, how- ever, depends on the previous or habitual state of the irritability of the intestinal canal, with regard to the power of different articles to excite this affection. Some individuals, apparently in a state of good health, cannot take particular articles of diet or drink without suffering more or less from griping and diarrhoea, whilst in others no unpleasant effect whatever will result from the same articles. Idiosyncrasy, also, appears occasionally to be concerned in the production of this affection by causes of this kind. Thus, in some persons, fresh milk almost invariably excites diarrhoeal discharges ; and I know an individual who generally becomes affected with diarrhoea when he eats fresh oysters. Diarrhoea produced by causes of this kind is, however, almost always of temporary duration, and depends on simple irritation, which generally readily subsides after the offending matter has been discharged, and other exciting causes do not supervene. Never- theless, if the bowels have previously been in an irritable condition, or if the patient be laboring under some organic visceral affection, instances which com- mence from such local irritating causes are apt to continue, and, unless particular 640 DIARRHCEA. attention be paid to a careful avoidance of the further influence of the exciting causes of this affection, to give rise to high irritation, inflammation, and finally ulceration in some portion of the intestinal canal. Among the causes of diarrhoea that affect the alimentary canal through the medium of the general system, cold, particularly when applied in a humid way to the feet or abdomen, is one of the most common and powerful. When pro- duced by this cause it constitutes the diarrhoea rheumatica or catarrhalis of the German writers. Cases of this kind are most apt to occur during damp and variable weather, and the evacuations are generally very liquid or watery. Slight rheumatic or catarrhal symptoms are apt to accompany the disease—such as toothache, transient pains in the extremities, short cough and coryza, together with slight febrile irritation towards evening, attended with a dry mouth and great thirst. The tormina are usually exceedingly severe. The occurrence of diarrhoea from cold, or the conjoined agency of humidity and cold, depends, no doubt, on the centripetal direction given to the circulation; in consequence of which the liver and capillaries of the mucous membrane of the bowels become engorged with blood, giving rise to a vitiated, or perhaps a superabundant secre- tion of bile and intestinal mucus, at the same time that the irritability of the bowels is morbidly increased. Diarrhoea appears also sometimes to arise from an epidemic condition of the atmosphere, independent of its thermometrical or hydrometrical states. This variety of the disease usually occurs in the autumn when the nights begin to be cool, and after a very dry and hot summer, and generally during the prevalence of other forms of intestinal diseases—particularly dysentery and cholera. Cases that proceed from causes of this kind are commonly preceded by the same train of premonitory symptoms that usher in miasmatic fevers—such as a feeling of weight and anxiety in the praecordia, loss of appetite, bitter taste, tension and fullness of the abdomen, disturbed sleep, headache, some lassitude and aching pain in the back, and slight sensations of creeping chilliness. (Richter.) Diar- rhoea arising from this cause frequently passes into the dysenteric form of the disease. It is probable that these cases depend on the conjoined influence of koino-miasmata and atmospheric vicissitudes—giving rise to increased irritability, functional disorder, and sanguineous engorgement of the liver and intestinal canal, in a way which will be more particularly referred to under the head of Cholera. Besides these there are many other general causes capable of producing violent and protracted diarrhoea. The repercussion of acute and chronic cutaneous eruptions sometimes gives rise to obstinate attacks of this disease. It may also be produced by violent affections of the mind, particularly sudden terror and grief. Diarrhoea occurs very frequently in visceral and other local affections at- tended with suppuration and ulcerative disorganization. Thus, in the latter period of pulmonary consumption, colliquative diarrhoea almost invariably occurs; and the same may, indeed, be said of every variety of disease attended with hectic fever, or extensive suppurations. In febrile diseases, diarrhoea sometimes occurs as a critical evacuation.* It can never be regarded as salutary, however, where it depends on the superven- tion of phlogosis, or high vascular irritation of the mucous membrane of the bowels. When the discharge is watery, reddish or muddy, mixed with flocculi of mucus, and ihe abdomen is tender and the tongue dry and red along the edges, it always indicates an aggravated condition of the disease, and the existence of mucous inflammation, and is of course a highly unfavorable occurrence. Criti- cal diarrhoea appears generally to depend on a copious secretion of bile, or an increased discharge from the intestinal exhalents, co-operating, probably, with a morbid irritability of the bowels; and hence salutary discharges of this kind are almost invariably bilious, mixed with more or less feculent matter and intestinal » Fr. Hoffman. Dissert, de Diarrhoea in Febribus Malignis Morbis Acutus Salutari. Buchner, Dissert, de Diarrhoea in Febribus Exanthematicis Salute et Noxa. DIARRHCEA. 641 mucus. Watery discharges, free from bile, are rarely, if ever, indicative of a favorable, tendency of the disease. During dentition, children are very liable to diarrhoea; but as this discharge, when moderate and unaccompanied with much gastro-enteric irritation, is calculated to lessen the tendency to preternatural de- terminations to the brain, it should not be checked in instances of this kind, unless it becomes excessive and very exhausting. Prognosis.—When the diarrhoeal discharge has been brought on by indigesti- ble or irritating articles of food or drink, and consists principally of feculent matter and vitiated secretions, it may in general be readily checked, and unless greatly mismanaged, will rarely assume a dangerous character. In general diar- rhoea is most apt to assume a chronic and dangerous character when it arises from the influence of cold and damp air, or from the habitual use of unwhole- some and indigestible diet, in individuals laboring under some chronic visceral affection, or whose general health has been much impaired by previous diseases, hardships, or a course of intemperate living. When we find the disease to con- tinue long, with frequent, watery, and acrid discharges, attended with tenderness in the abdomen on firm pressure, and extremely severe tormina, we may pre- sume that there exists chronic inflammation, or at least high irritation in the mucous membrane of some portion of the bowels—and consequently that there is much danger of the occurrence of structural disorder in this tissue, if the dis- ease be not soon removed by appropriate measures. Those cases of diarrhoea that assume a strictly chronic character, and in which scanty and painful diar- rhoeal evacuations of an unnatural appearance occasionally alternate with short periods of constipation, and severe pains are experienced in the track of the colon an hour or two after eating, may be regarded as certainly dependent on mucous inflammation, and most probably attended with more or less ulceration, and con- sequently with great danger and difficulty in effecting a cure. Diarrhoea from the irritation of dentition, as has just been remarked, is rather a salutary than a dangerous affection; but when this symptom of enteric disease is accompanied with a pale and fretful expression of the countenance, a hard and tumid abdomen, frequent picking at the nose, voracious appetite, and the dis- charge of undigested portions of food in the stools, it must be considered as an affection of very serious import. Treatment.—In the treatment of diarrhoea it should always be recollected that the characteristic alvine discharges, by which this affection is recognized, and from which its name has been derived, are mere symptoms of a primary intes- tinal disorder, and that our remedies must be especially directed against this, the essential malady. If, then, we reflect that the local intestinal disease consists either in simple irritation; or in irritation with chronic inflammation; or finally, in irritation with chronic inflammation and disorganization of the mucous mem- brane of a greater or less proportion of the bowels, according to the grade of violence and duration of the malady, we shall have no difficulty in instituting a rational plan of treatment. In this, as in other affections, our remedial mea- sures must be modified according to the nature of the exciting cause. Thus, where the disease is produced by suppressed perspiration from cold, the restora- tion and maintenance of the cutaneous exhalation, along with the remedies to be presently mentioned, will be peculiarly proper; where the irritation is pro- duced by vitiated or redundant bile, mercurial remedies are especially applicable; and where a surfeit, or acrid and offensive ingesta have given rise to the disease, laxatives are indispensable in recent cases. The principal indications in this form of intestinal disease, therefore, are, 1. To remove as much as possible every source of intestinal irritation ; 2. To allay the morbid irritability of the mucous membrane of the bowels; and 3. To di- minish the determination of the blood to the vessels of the intestinal canal. In recent cases where there is reason to presume that the intestinal irritation is kept up by vitiated secretions, or other irritating matters lodged in the bowels, recourse must be had to mild purgatives. This is especially necessary where 41 642 DIARRHCEA. diarrhoea is the consequence of indigestion, or of the reception into the stomach of indigestible and irritating articles of food ; or where the bowels are infarcted, or loaded with fecal matter, as occurs in the marasmus of children. It must be ob- served, however, that it is only in the earlier periods of diarrhoea, or where the mu- cous irritation has not passed into the state of inflammation, that any material ad- vantage may in general be obtained from purgatives; and even in cases depending on simple irritation, the gentlest laxatives alone ought to be employed. Purga- tives are, indeed, very often greatly abused in affections of this kind. Nothing is more common than the repeated use of active purgatives in diarrhoea. An individual becomes affected with looseness of the bowels. If it does not soon cease spontaneously, he takes a purge. The bowel-complaint, however, con- tinues, and convinces him that there is still something left which must be removed. To make himself sure of his object he takes a more active dose; but the tormina and discharges, instead of being mitigated, acquire greater violence. Astonished at the obstinacy with which the offending matter sticks to the bowels, he deter- mines, once and for all, to get rid of the cause of his complaint, and swallows a double dose of the most active cathartic. He now begins to experience tender- ness in the abdomen ; the tormina and diarrhoeal discharges continue; in short, he has developed inflammation, which the most judicious management may not be capable of removing. We cannot, however, always abstain from laxatives in instances manifestly connected with inflammation of the internal membrane of the bowels. Thus, where phlogosis or a state of irritation closely approaching inflammation exists in connection with an accumulation of feces and vitiated secretions, with a hard and tumid state of the abdomen—a combination of circumstances frequently met with in children—no hopes of procuring relief can be reasonably entertained, until these irritating matters are removed out of the bowels by a course of gentle aperient remedies. Fortunately, in cases of this kind, we may, in general, gain our object in this respect much more readily, by mild, than the more active arti- cles of this kind, when assisted by an appropriate diet. A grain of calomel at night, and a moderate dose of castor oil on the following morning, assisted with three or four laxative enemata during the day, will in general answer well in such cases (marasmus), without doing any injury to the inflamed bowels. Castor oil is decidedly the best purgative in cases of diarrhoea, attended with a high degree of irritation or phlogosis. One or two grains of calomel, or three or four grains of blue pill, with from one to two grains of ipecacuanha, may be occasionally given to an adult, both with a view to its aperient effects, and its influence upon the biliary organs, which always become more or less deranged in diarrhoea of protracted continuance. Many writers recommend rhubarb as a suitable purge in this disease; and in recent cases, from irritating matters lodged in the bowels, it will, no doubt, answer all the purposes that may be obtained from a remedy of this kind. In protracted instances, however, where there is high intestinal irrita- tion, or chronic inflammation, it is much inferior to the cold pressed castor oil. From its tonic, along with its aperient powers, rhubarb was formerly thought to be peculiarly suited to the treatment of this affection, under the erroneous notion that diarrhoea is generally the consequence of a relaxation or loss of tone in the intestinal tube. Where it may be deemed necessary to administer an aperient in cases manifestly connected with chronic inflammation, or a highly irritated condition of the bowels, the castor oil may be very advantageously given in union with from fifteen to twenty drops of laudanum. In all bowel affections attended with inordinate discharges, a preternatural determination of blood takes place to the vessels of the intestines, with more or less torpor of the cutaneous exhalents. This is more especially the case in in- stances of long standing, and contributes very materially to the support of the intestinal irritation. Remedies which are calculated to counteract this centripetal direction of the humors, are therefore especially proper in affections of this kind. For this purpose, opium, in combination with small doses of calomel and ipeca- DIARRHCEA. 643 cuanha, constitutes an excellent remedy, after ihe irritating contents of the bowels have been evacuated by suitable laxatives. Opium and calomel have a direct tendency to allay the morbid irritability of the mucous membrane of the aliment- ary canal, and when given in conjunction with small portions of ipecacuanha, seldom fail to excite the activity of the cutaneous exhalents. In recent cases of diarrhoea, where the discharge depends on simple irritation of the bowels, the exhibition of one of the following pills every four hours, after the operation of a dose of castor oil, will seldom fail to check the complaint.* Minute portions of calomel, too, will frequently arrest the progress of the disease. (Dr. Ayre.) From a sixth to a fourth of a grain of calomel may be given every hour or two. In the diarrhoea of infants, arising from acidity of the primae viae, and deficient biliary secretion, this article given in union with two or three grains of prepared chalk, is often peculiarly beneficial, but as the irritation is apt to be transferred from the bowels to the brain in young children, opium may do mischief, by promoting the determination to the head. Very frequently diarrhoea is induced and sustained by impaired digestion in consequence of a weakened state of the stomach. Here alterative doses of calomel and the use of mild tonics, together with simple, unirritating and digest- ible diet, will commonly prove beneficial. Astringent remedies have been much employed in diarrhoea ; but where the mucous membrane of the bowels is in a state of high irritation or inflammation, articles of this kind are almost always decidedly pernicious. In instances where the discharge is kept up by a slight degree of irritation and relaxation of the in- testinal exhalents, benefit may occasionally be obtained from remedies of this kind ; but even in such cases, they may in general be very properly dispensed with. The astringents most commonly employed in diarrhoeal affections are kino, alum, acetate of lead, sulphate of zinc, and the infusions of logwood, blackberry-root, the root of geranium maculatum, &c. Astringents should never be resorted to where the tormina are very severe, and there is a tenderness or soreness to the touch in the abdomen. I have repeatedly known great injury done by the use of such articles in the ordinary bowel-complaints of children ; and there can be no doubt that, as a general rule, astringents deserve to be repro- bated in affections of this kind. Judging from my own experience, opium and ipecacuanha are much more efficacious than astringents, even in instances which may be deemed favorable to the beneficial operation of the latter class of reme- dies. What I have hitherto said, refers more particularly to recent cases of diarrhoea, before the intestinal irritation has become fixed or converted into inflammation and its consequences. When the disease assumes a chronic character, it gen- erally becomes exceedingly obstinate, and often resists every mode of remedial treatment. One of the most important measures in such cases is the avoidance of every kind of stimulating aliment. The food should consist wholly of farina- ceous fluids, light broths, animal jellie3, rice, barley, oatmeal gruel, milk &c.— In all cases, indeed, whether recent or chronic, such a diet is decidedly the most proper; but in the latter form of the disease, it is absolutely essential to success in its treatment. In some instances of chronic diarrhoea, we may succeed in removing the disease by a rigid adherence to this simple and unirritating diet in conjunction with the employment of small doses of calomel and opium, the occasional use of the warm bath, leeching, and counter-irritating applications to the abdomen. I have in several instances derived great advantage from the employment of small doses of Dover's powder, in union with the acetate of lead, according to the • R.—G. opii gr. iii. Pulv. ipecac, gr. xii. Calomel gr. ii. Conserv. rosar. q. s.—M. Divide into 12 pill* 644 DIARRHCEA. following formula.* Not unfrequently, all the means just mentioned, however judiciously employed, will entirely disappoint us in our attempts to remove the disease. I have known instances of this affection to continue for nine or ten months, although all the foregoing remedies, together with an appropriate diet, had been diligently used. In cases of this obstinate character, the internal use of balsam copaiva will sometimes do much good. What I have already said under the head of chronic enteritis, in relation to this remedy, applies fully to the chronic form of the present affection. It is not probable, however, that it can procure any permanent relief in cases attended with ulceration of the intes- tinal mucous tissue; yet even in cases of this kind, I have known considerable temporary benefit derived from this article. In a case of pulmonary hepatization, with purulent expectoration, attended for nine months with continued and ex- tremely painful diarrhoea, the balsam copaiva emulsion generally gave very con- siderable relief for four or five days, after which the symptoms recurred with their usual degree of violence, notwithstanding the use of this medicine. On dissection, a number of irregular ulcerations were detected in the mucous mem- brane of the colon and the lower portion of the small intestines. In a case of chronic diarrhoea of upwards of six months' continuance, I succeeded in effecting a perfect cure by means of this remedy, given to the extent of from thirty to forty drops three times daily, and fifteen drops of laudanum with each dose. In this case, the diarrhoeal discharge depended, no doubt, on simple chronic inflam- mation, without ulceration of the mucous tissue. Dr. Elliotson has lately in- troduced a new remedy to the notice of the profession, for the cure of chronic diarrhoea, dependent on ulceration, which has been employed with much success at St. Thomas's Hospital in London—namely, the sulphate of copper in union with opium. Cases that had resisted almost all the remedies usually accounted the most efficacious in this affection, yielded readily to this remedy. The dose is half a grain twice a day, with a grain of opium, increasing the quantity of the former article gradually to two and even three grains in a day. From the known good effects of weak solutions of this preparation when applied to chronic ulcer- ations, it is not improbable that its operation in this way may occasionally prove very serviceable in diarrhoea depending on ulcers of the mucous membrane of the bowels; and although the vegetable astringents are always unequivocally inju- rious in such cases, some benefit may also arise from its peculiar astringent influ- ence on the engorged and dilated capillaries of the mucous membrane. Mr. Kerr speaks very favorably of the effects of the persesquinitrate of iron in this affection. Several very long-standing cases yielded in a short time to the influ- ence of this article. The dose, for an adult, is from twelve to twenty drops twice daily.t Whatever internal remedies may be resorted to in cases of this kind, it will always be proper to keep up the regular action of the cutaneous exhalents—and it is especially useful to excite the extreme vessels of the external surface of the abdomen. For this purpose, a broad flannel roller should be con- stantly worn round the body, and the patient must be particularly careful not to expose himself to the influence of damp and cold weather, and above all, to avoid getting wet and cold feet. All kinds of alcoholic liquors must also be avoided. Mucilaginous fluids, such as infusions of mallows, or flaxseed, or barley water, slightly acidulated with sulphuric acid, form the best drink. * R.—Pulv. ipecac, compos, ^i. ---- acetat. plumb, gr. vi.—M. Divide into six equal parts. S. Take one every four hours. f The following is his method of preparing this nitrate: "Take of small chips or pieces of iron wire, an ounce and a half; nitric acid three ounces by measure; water, twenty-seven ounces; muriatic acid, one drachm. Put the iron into an earthenware vessel, and pour on the nitric acid, previously diluted with fifteen ounces of water. Set the vessel aside till the whole of the acid has united with the iron, so as to form a persesquinitrate; then decant the liquid from the portion of iron which remains undissolved, strain and filter. Add the muriatic acid with the remainder of the water, or with as much of that liquid as shall increase the whole solution to thirty ounces.—Edin. Med. Sc Surg. Journ., vol. xxxvii. p. 99. CHOLERA. 645 Sect. III.—Cholera—(Cholera Morbus.) Cholera is an affection of the alimentary canal, characterized by very frequent and violent vomiting and purging, and severe tormina, and cramps in the muscles * of the abdominal parietes and extremities. The disease almost always comes on suddenly. Pain, and a sense of tension in the epigastrium, are generally the first symptoms by which it makes its attack. This is soon followed by violent colic pains about the umbilical region, accompanied with exceedingly distressing nausea. In a few moments after the occurrence of these symptoms, vomiting and purging commence with extreme violence, and continue, with but very short intervals, until the system is exhausted, if speedy relief be not obtained. During the intervals between the attacks of vomiting, the patient is usually harassed with continual nausea, and an indescribable feeling of distress in the epigastrium. The alvine discharges are at first thin and watery, and generally with little or no admixture of bile; nor is the fluid ejected from the stomach usually of a bilious character, during the early period of the disease. After the disease has continued for an hour or two, however, the bile begins to make its appearance pretty copi- ously in the evacuations, and towards the conclusion, the fluid discharged con- sists, in many instances, almost entirely of bilious matter. As the disease ad- vances, the tormina become more and more severe and continual, and the purging and retching are almost incessant. One of the most distressing affections belong- ing to this disease are the extremely painful cramps which, in severe cases, occur in ihe abdominal muscles, and in those of the inferior extremities. In cases of no great violence, the cramps occur principally, and sometimes exclusively, in the muscles of the legs; but in rapid and very severe attacks, the muscles of the trunk, as well as of the upper and lower extremities, are alike affected in this way. The thirst is always exceedingly urgent; but everything received into the stomach is almost immediately thrown up again. As soon as the disease is completely developed, the pulse is small, feeble, irregular or intermitting; the hands and feet become cold, the countenance pale, shrunk, and expressive of great distress; a cold sweat breaks out on the extremities and face; and extreme prostration speedily ensues. Cholera is one of the most rapid and fatal forms of disease. It seldom con- tinues beyond twenty-four hours, without terminating favorably or fatally; and in many instances it ends in death, in the course of three or four hours, and sometimes in a much shorter period. In the cholera of India, death generally takes place within two or three hours after its commencement. In this ex- tremely fatal variety of cholera, the patient is generally suddenly seized with great prostration, unquenchable thirst, a scarcely perceptible pulse, cold and clammy sweats, cramps in every part of the body, inexpressible anxiety of feel- ing, extreme restlessness, syncope, excruciating tormina, constant retching, and very frequent stools of a thin, whitish, or starchy fluid. If the patient survive this, the first stage of the disease, which is by no means common, some degree of reaction usually ensues in the course of from twenty to forty hours; and the liver begins to pour out an abundance of dark, thick, vitiated bile, which is dis- charged in the stools, and which may be regarded as an indication of a favorable crisis in the disease. Etiology and pathology.—A superabundance of vitiated bile in the stomach and bowels was formerly, and, by some, is still regarded as the immediate cause of this very dangerous malady. The term cholera* is, indeed, sufficiently ex- pressive of the notions once universally entertained concerning the nature of these affections. Dr. Cullen says, " the matter ejected, both upwards and downwards, appears manifestly to consist chiefly of bile;" and Dr. Gregory, though he rejects * From yj>\n, bile, and enu, to flow. 646 CHOLERA. the idea of its dependence on a redundant and vitiated secretion of bile, says that the disease " commences with nausea and unremitted bilious vomiting," &c. In truth, almost all writers, up to the time of Dr. Bateman and Dr. James John- son, mention a copious and vitiated bile as the exciting cause of this affection ; but the erroneousness of this sentiment is now well known by all who have kept pace with the progress of pathological science. So far, indeed, from there being a redundant secretion of bile in cholera, there is actually a deficient formation of this fluid, from functional torpor of the liver; and it would appear that the hepatic torpor is in direct proportion to the violence of the disease. No one, indeed, who has attentively observed the early symptoms of cholera, can for a moment doubt the correctness of this statement; for, however abundant the discharge of bile may be after the disease has continued for some hours, this fluid never ap- pears in the evacuations during the early period, or what may be termed the first stage of the disease. The observations and researches that have been published of late years—and they have not been limited—in relation to the pathology of cholera, render it evident that the liver, and indeed the whole system of the portal circulation, are extremely engorged with blood. In the cholera of India, the liver, in subjects who die during the first stage of the disease, is always found enlarged, and greatly engorged with blood, and the internal surface of the stomach and bowels marked with large patches of highly injected and distended vessels. In the cholera of infants, I have never seen an instance in which bile appeared in the evacuations, except after the disease had taken a favorable turn ; and in the few dissections which I have witnessed of subjects who had died of this disease, the sanguineous congestion of the liver and mucous membrane of the alimentary canal was very conspicuous. So far, therefore, our knowledge of the pathology of this affection appears to be sufficiently certain; but how are we to account for the extreme irritability of the stomach and bowels, and the excessive vomiting and purging? Can hepatic torpor and congestion in the por- tal system of vessels give rise to this morbid condition of the alimentary canal? or are we to consider this state of the liver, and the general engorgement of the portal vessels, only as concomitant phenomena, and in no way causative of the characteristic gastric and intestinal affections? From some of the circumstances just mentioned, it would appear, indeed, that the hepatic torpor and congestion have no small share in the production of gastro-intestinal disorder. The fact, that the symptoms almost always begin to abate as soon as the liver resumes its functions, and pours out a copious flood of bile, strongly favors this opinion. Strong sanguineous congestion, and torpor of the liver, are almost always attend- ed with great irritability of the stomach. In the malignant grades of bilious fever, the vomiting, during the first stage, is often incessant, and extremely distressing, whilst the fluid ejected is wholly free from bilious matter. If death takes place in this stage, the liver is always found exceedingly engorged with blood, and the vessels of the stomach are in a similar state of congestion; but when the disease continues until large evacuations of black and pitch-like bile take place from the bowels, an abatement of all the symptoms usually ensues. With regard to the remote causes of cholera, it is manifest that high atmo- spheric temperature constitutes the principal agents concerned in its production. In our own climate this affection appears almost exclusively during the warm months of summer; but it is nevertheless probable that elevated temperature acts rather as an essential predisposing, than as an exciting cause of the disease. Cool and damp night air, or exposure to a current of fresh air after the liver and skin have been over-excited by the previous influence of solar heat and exercise, is one of the most common exciting causes of this affection. When the cutane- ous and hepatic functions, while in a state of inordinate activity, are suddenly arrested by the influence of cold, the blood retreats from the surface to the inter- nal vessels; the portal circulation becomes engorged, and the capillaries of the mucous membrane of the bowels strongly congested. This injected or engorged state of the capillaries of the mucous membrane of the alimentary canal gives CHOLERA. 647 rise, we may presume, to morbid irritability of this structure, and, consequently, to the characteristic phenomena of the disease. Much may also depend on the influence of koino-miasmata in the production of this affection. The tendency of this agent to excite and derange the functions of the liver is well known, and when operating in conjunction with high atmospheric heat, as it always does, its tendency to enhance the predisposition to this affection is, no doubt, very con- siderable. In some instances of intermitting fever, the paroxysms are ushered in by vio- lent attacks of cholera, the vomiting and purging usually coming on towards the termination of the cold stage, and continuing until the febrile reaction is fully developed. Sometimes cholera returns in quotidian paroxysms, commencing with a slight cold stage, and terminating in free perspiration, without any distinct hot stage. Cholera may also be excited by the direct irritation of indigestible and irritating articles of food and drink ; but causes of this kind rarely produce the disease un- less the system is predisposed to it by a debilitated state of the digestive organs, or by general relaxation and exhaustion from the influence of high atmospheric temperature. Cholera Infantum. The cholera of infants differs in several essential points from the ordinary cholera of adults. It is almost always distinctly febrile, and very frequently commences in a gradual manner, with more or less diarrhoea, of several days' continuance, before the vomiting supervenes. It is also particularly liable to become protracted in its duration, or to assume a chronic form, a circumstance which is scarcely ever noticed in the other varieties of the disease. The liver appears to be as inactive in this as in the preceding form of cholera; for when once fully developed, the evacuations, during the early period of the disease, are wholly devoid of any appearances of bilious matter, consisting either of a whitish, frothy, or of a watery, and almost colorless fluid. If the disease does not rapidly exhaust the vital powers, and terminate fatally during the first few days, the patient begins to emaciate ; the extremities become cold; the head and surface of the abdomen extremely warm ; the skin dry and harsh; the countenance pale and shrunk ; the eyes dull and sunk; and the pulse small, irritated, and frequent. If the disease be not vanquished by proper remedial measures, the little patient, by degrees, becomes somnolent; he sleeps with the eyes half open, rolls about his head when awake, and at last sinks into a state of insensibility and coma, and dies, under symptoms resembling those of the last stage of hydrocephalus. When the disease is very protracted in its course, aphthae usually appear on the tongue and inside of the cheeks; the face acquires an cedematous appearance; the alvine discharges become so acrid as to excoriate the parts about the anus ; and towards the fatal conclusion, spots of effused blood under the cuticle some- times appear on various parts of the surface. The duration of this variety of cholera is exceedingly various. It may prove fatal in five or six hours, or continue for several weeks, and even months, until the body is reduced to a state of extreme emaciation, and yet terminate favorably. The majority of deaths take place before the termination of the ninth day. When death takes place early, in violent and rapid cases, the liver and vessels of the mucous membrane of the alimentary canal are found, on dissection, strongly engorged with blood; "and where the disease had continued for some length of time before death, ulceration, and even abrasion of the lining membrane of the stomach and bowels," are usually discovered.* The etiology of the cholera of infants differs in some important circumstances * Dr. Condie. Observations on the Pathology and Treatment of Cholera Infantum, &c, in the Philadelphia Journal of Med and Phys. Sciences, May 1825. 648 CHOLERA. from that of the ordinary form of the disease in adults. Both these varieties of cholera are almost exclusively confined to the hot months of the year; but cho- lera infantum is vastly more prevalent in large and crowded cities than in the country—a circumstance which does not obtain in relation to the cholera of adults. During a practice of twelve years in the country I met with but two or three cases of this disease in infants. Again, cholera infantum occurs almost exclusively between the third and twenty-fourth months of age; in other words, during the period when the process of primary dentition is going on. There are, therefore, three causes whose concomitant influence is extensively concerned in the production of this variety of cholera, namely, high atmospheric heat, the con- taminated air of crowded cities, and the irritation produced by dentition. From the great prevalence of this disease during the hot months of summer in the more filthy parts of crowded cities, it has been supposed that it is of malarious origin, and " a mere variety of the bilious fever of our climate, the force of which is turned inwards upon the intestines." (Condie.) In support of this sentiment, it has been alleged by the respectable physician just quoted, that though seldom met with in salubrious districts of the country, "a majority of the children fall victims to cholera infantum in the neighborhood of marshes, or in low, wet, and otherwise unhealthy situations." This, I apprehend, will not be confirmed by the observations of those who practice in the neighborhood of paludal districts. Unquestionably, cholera is much more common, both in infants and adults, in such localities than in high and salubrious parts of the country; and there can be no doubt that miasmata have a considerable tendency to favor the occurrence of cholera, whether in adults or in infancy. If, however, koino-miasmata be the principal agent concerned in the production of this malady, why is the disease so exclusively confined to a particular period of infancy in our cities? And why, we may further ask, does it commence so early as in the latter part of June, and usually acquire its most extensive sway in July, before the ordinary paludal dis- eases are wont to make their appearance, except here or there, perhaps, a few instances? Let it be observed, too, that we frequently find this fatal disease of infants extremely rife in this city, when scarcely any of the other diseases justly ascribed to the miasmata in question occur among our inhabitants. High atmo- spheric temperature and the irritation of dentition appear to be the principal remote causes of this affection. But as these causes very seldom produce cho- lera in infants enjoying the pure air of the country, there must be some other circumstance peculiar to populous cities which especially favors their tendency to develop this disease. This accessory or predisposing cause consists, probably, in the impure air of cities, by which the infantile system is rendered irritable, and peculiarly predisposed to suffer disturbances from the irritation of dentition. It seems to me highly probable that erethism of the brain, caused by the irri- tation of difficult dentition in the peculiarly irritable habit of body just mentioned, is frequently deeply concerned in the production of this malady. Throughout the whole course of the disease the head is always preternaturally warm; and in most instances the child is peculiarly restless and fretful for several days previous to the accession of the disease. The tendency of cerebral irritation to cause inordinate irritability of the stomach and bowels is well known. Diarrhoea is very common, and in general a salutary occurrence during the process of painful dentition. In the commencement of hydrocephalus, great gastric irritability and frequent vomiting are very rarely absent. In concussion of the brain, vomiting is often a very troublesome symptom: and sea-sickness, which is often so vio- lent as to resemble cholera, appears to depend entirely on the peculiar cerebral excitement occasioned by the swinging or rocking motion of a vessel at sea. The great tendency of cholera infantum, in its chronic form, to terminate in a state of cerebral oppression and coma, seems also to show that the brain is especially predisposed to inflammation, or to that peculiar morbid condition which consti- tutes what is usually called acute hydrocephalus. We may, therefore, presume that in the irritable condition of the system pro. CHOLERA. 649 duced by the influence of a very warm and contaminated atmosphere, dentition causes more or less cerebral irritation, which, being reflected on the stomach and bowels, renders them preternaturally irritable. If, in this state of the alimentary canal, the cutaneous exhalents are over excited and debilitated by high atmo- spheric temperature, the slightest reduction of temperature, a current of fresh air, or damp night air, will readily cause a sudden torpor of these emunctories. The blood will retreat from the surface to the internal organs, and give rise to engorge- ment of the vessels of the liver and mucous membrane of the bowels, by which the gastro-intestinal irritability will be still further increased, and the character- istic symptoms of the disease excited. According to the pathological researches of Professor Horner,* cholera infantum consists in an inflammation of the mucous glands or follicles of the alimentary canal, and not in a common vascular or erythemoid inflammation of the intestinal mucous membrane. In most instances he found the mucous follicles very dis- tinct to the naked eye, and their orifices enlarged and tumid. In the large intes- tines they were generally larger and more tumid, so as to present the appearance of small grains of white sand sprinkled over the mucous membrane. Sometimes enlarged muciparous glands were more or less ulcerated; and in a few instances he found the follicles " converted into small cysts, of the transparency and size of the itch vesicle, which, on being punctured with a needle, and pressed, readily gave out their transparent fluid." The mucous membrane of the stomach and small intestines was, generally, of a more or less deep sienna color—and, in some cases, portions of this membrane were so soft " that it could be very easily scraped off with the finger nail.' Treatment of Cholera. The principal indications in the treatment of the cholera of adults are, to allay as speedily as possible the irritability of the stomach and bowels ; to restore the action of the skin and liver; and to determine the circulation from the internal to the external parts. As the progress of this disease is always extremely rapid, the most prompt and energetic means should be at once resorted to, with the view of moderating its violence ; and for this purpose we possess no remedies so powerful and certain in their effects as opium, and the application of a large and active sinapism to the region of the stomach and liver. When the disease super- venes soon after having taken a full meal, or some indigestible and irritating arti- cles of food or drink, the patient should be directed to take copious draughts of chamomile or balm tea, or warm water, in order to procure the speedy evacua- tion of the irritating substances lodged in the alimentary canal. In all cases, in- deed, it will be proper, in the commencement of the disease, to allow the patient the free use of bland drinks, both with a view of washing out the contents of the intestinal canal, and of moderating the painful and exhausting effects of frequent ineffectual efforts of vomiting and purging when the stomach and bowels are empty. As soon, however, as the irritating contents of the stomach and bowels are evacuated, a large dose of opium should be administered, and the patient kept from taking any drinks for at least thirty minutes after the medicine is taken. From 80 to 100 drops of laudanum should be given at once; and" the same quan- tity, mixed with a small portion of warm water, thrown into the rectum. If vomiting occurs soon after the first dose is taken, the laudanum should be re- peated in doses of from 30 to 40 drops every fifteen minutes, until its influence on the system is fully obtained. At the same time a large sinapism must be laid over the right hypochondrium and epigastrium. Instead of sinapisms, we may resort with nearly equal advantage to active rubefacient embrocations. I have in several instances derived very prompt benefit from the application of the oil of monarda punctata to the abdomen, in conjunction with the internal use of large • American Journal of Medical Sciences. February 1829, 650 CHOLERA. doses of laudanum. This oil is one of the most active local irritants we possess. When applied in an undiluted state it inflames the skin in a few minutes, and causes exceedingly severe burning pain in the part. The spirit of turpentine may also be used for this purpose, but its effects are less prompt and powerful than those of the ol. monarda. Upon the prompt and free use of opium and external revulsive applications, our chief reliance must be placed. The practice of giving warm spiced brandy, and other powerfully exciting articles of this kind, is highly improper. Brandy may be allowed in the latter stage of the disease, when the prostration is extreme, and it is absolutely necessary to support the sinking powers of the system by potent diffusible stimulants ; but if it be given during the early period of the disease, with the view of moderating the excessive vomiting and purging, it will not only generally disappoint our expectations but often manifestly aggravate the symptoms of the complaint. The sedative powers of opium, however, are eminently calculated to allay the extreme irritability of the alimentary canal, and when promptly and efficiently given, will seldom fail to procure complete relief in the course of sixty or eighty minutes. In not a single instance in which I have resorted to this valuable remedy, did it fail to arrest the vomiting and purging within the period just mentioned ; and the only fatal case I ever saw, was treated chiefly with warm spiced brandy. If from six to eight grains of opium can be introduced into the stomach, and retained for fifteen or twenty minutes, we may calculate almost with certainty on the speedy subsidence of the disease. When the laudanum is immediately thrown up again, it should be repeated, again and again, until its effects are obtained. I have in the course of an hour given nearly an ounce of laudanum in this way, before the gastric irritability was allayed, without any injurious consequences from its ulti- mate narcotic operation. Where this medicine is immediately rejected by the stomach, we may obtain its effects by external application, with almost the same promptitude and certainty as if it were retained in the stomach. For this pur- pose the cuticle should be removed from the epigastrium, which may be speedily done by means of the nitric acid, as practised by Mr. Powell in the cholera of India. Two parts of this acid diluted with one part of water are to be applied by means of a sponge upon the whole region of the stomach; and as soon as the patient feels considerable pain from its impressions, the partis to be washed with a solution of the carbonate of potash. Tbe cuticle may now be easily detached, so as to leave the cutis exposed and raw. Upon this surface, from ten to twelve grains of morphia may be applied, either in tbe form of a plaster, or by sprink- ling the powder over it, and covering it with a piece of linen thinly spread with simple cerate. By this procedure we at once obtain the advantage of a power- ful counter-irritating application, and of the full influence of the opium. When the irritability of the stomach and bowels is in some degree allayed, it will be proper to employ calomel in small but frequent doses, with the view of stimulat- ing the action of the liver. Half a grain of this article may be administered every half hour, and continued until the alvine discharges become bilious, or the disease is subdued. Dr. Ayre speaks highly in favor of minute and frequent doses of this remedy in cholera, and there can be no question as to its entire adaptation to the treatment of this affection. Where the disease is very violent and rapid, however, we cdYinot depend on its operation without the conjoined influence of efficient doses of opium. It may be very advantageously given in union with powdered opium, in the proportion of two grains of each, every half hour, until the narcotic effects of the former are manifested, when the calomel should be continued alone in half grain doses. The warm bath may be used with occa- sional advantage in the commencement Of the disease ; and where the exhaustion is great, and the muscles of the extremities affected with severe cramps, much benefit will generally result from rubefacient frictions—particularly from frictions with a strong tincture of capsicum. When the pulse sinks and the extremities become cold, the patient should be wrapped in •flannels soaked with hot brandy, and recourse had to the internal administration of diffusible stimuli. One of the CHOLERA. 651 best articles of this kind, according to my own experience, is a solution of cam- phor in vitriolic ether. Of a solution of a drachm of camphor in an ounce of ether, a teaspoonful may be given every half hour until the reaction is considera- bly increased. In one instance, where the pulse was scarcely perceptible, and the extremities cold and clammy, this solution, given in the way just mentioned, produced the happiest effects. I have stated above, that drinks should be with- held for some time after administering the first dose of laudanum, in order, if possible, to prevent it from being thrown off before it can produce its impressions on the stomach ; with this exception, it will always be proper to allow mild mu- cilaginous fluids in a warm state—such as barley-water—as long as the vomiting and purging continue; for, as has already been stated, the exhaustion produced by the excessive vomiting and purging, is much less rapid when the stomach and bowels are freely supplied with fluids, than when they are nearly empty, and the evacuant efforts are ineffectual or attended with but small discharges. After ihe disease is subdued, the patient should take light and nourishing diet, such as animal broths. It will also be proper, during the period of convalescence, to wear a flannel roller round the abdomen; and to take a few grains of blue pill, with a grain of ipecacuanha, every evening on going to bed ; and when the digestive powers remain weak, a tablespoonful of the infusion of colomba, or gentian, or a wineglassful of chamomile tea, with a few grains of the carbonate of ammonia, may be taken three or four times daily. Treatment of Cholera Infantum. Although the morbid condition of the liver and alimentary canal, in cholera infantum, does not appear to differ from that of the cholera of adults, yet the treatment proper in the former, differs in several very essential points from that which is best calculated for the removal of the latter variety of the disease. Be- sides the indications already mentioned for the treatment of ordinary cholera, we have, in the present variety, the important one of obviating irritation and san- guineous congestion of the brain; and hence opium, which is decidedly the most valuable remedy in the cholera of adults, cannot be employed without great hazard of doing mischief in the cholera of infants. Some practitioners, under an idea that the stomach contains offending matter, which spontaneous vomiting is incapable of throwing off, commence the treatment with the exhibition of a gentle emetic; but this practice is not only founded on an erroneous view of the patho- logical condition of the alimentary canal, but what is still more to the purpose, is generally decidedly injurious. From what was said above, in relation to the pathology of this affection, it would appear that torpor of the liver and skin, in connection with cerebral irrita- tion, constitute the immediate cause of the excessive irritability of the stomach and bowels. Our principal object, therefore, must be, to restore these two func- tions; to obviate irritation and sanguineous congestion in the brain, and to deter- mine the blood from the engorged vessels of the liver and mucous membrane of the alimentary canal. To answer these purposes I generally commence the treatment with the application of from ten to twelve leeches to the temples, the exhibition of minute portions of calomel and ipecacuanha, and a large stimulating poultice over the abdomen. I am persuaded, by what I have repeatedly observed in my practice, that great benefit will in general result from local depletion from the head, as well as from the application of blisters behind the ears, or on the back of the neck, in this affection. Within the last four years, I have not treated an instance of this complaint, in which I did not at once apply blisters behind the ears, and in most instances with unequivocal advantage. This at least I may confidently affirm, that since I have adopted this practice, I have been much more successful in the management of this disease than previously. Where the pulse is irritated and the head very warm, leeching at the temples or behind the ears is particularly indicated, and will seldom fail to procure very manifest relief. 652 4 CHOLERA. In an extremely severe case which I lately attended in a child about eighteen months old, twelve leeches applied to the back of the ears, was almost imme- diately succeeded with great abatement of the violence of the symptoms. With the view of moderating the gastro-intestinal irritation, and of stimulating the action of the liver, minute portions of calomel and ipecacuanha constitute, I think, the most valuable internal remedy we possess for combating this disease. From one-sixth to a quarter of a grain of calomel in union with half a grain of ipecacu- anha, should be given every hour or two, and continued until the evacuations become mixed with bilious matter. Let it be borne in mind, that so long as the liver remains torpid, and the alvine discharges free from bilious matter, the dis- ease may be regarded as still possessing all its violence and dangerous tendency, whatever temporary abatement may occur in the severity of the vomiting and purging. The appearance of bile in the stools, whether green or dark, is always to be hailed as a very favorable sign, and the sooner the liver can be brought to resume its secretory action, the greater in general will be the probability of ulti- mate success in our attempts to subdue the disease. Ipecacuanha in small doses is a most excellent auxiliary to the calomel, in affections attended with morbid irritability and excessive peristaltic action of the alimentary canal. Its tendency to counteract inordinate action of the bowels, when given in small doses, is well known; and its tendency also to excite diaphoresis, still further enhances its applicability in this and other similar intestinal affections. Where, from a tumid and tense state of the abdomen, there is reason to presume that the bowels are loaded with fecal matter, the quantity of calomel at each dose should be larger, so as to procure its purgative operation. I have occasionally given a grain every two hours until its evacuant effects were procured, and afterwards continued it in doses of about one-sixth of a grain every hour. Dr. Edward Miller appears to have been the first physician who particularly recommended minute doses of calomel in cholera infantum; and under judicious management it is unquestion- ably a very valuable remedy in this affection. Except under the circumstances just mentioned—namely, a loaded state of the bowels, purgatives are not, in general, advisable in the commencement of the disease. Where the disease con- tinues, however, until the liver, under the exciting influence of the calomel, pours out a large quantity of bile, mild laxatives are highly useful. In a case which I attended during the present season, the vomiting and purging were in a great measure arrested on the third day of the disease. The infant, however, sunk into a state of stupor, from which it was very difficult to rouse it. As the eva- cuations from the bowels were very dark and small, and the vomiting had ceased, I prescribed a full dose of caslor oil. In about two hours after the oil was taken, copious evacuations of a pitch-like matter took place from the bowels; and the little patient was almost immediately freed from the alarming symptoms of cere- bral oppression under which it labored. Where the disease comes on gradually, and proceeds slowly, it may perhaps be better to commence at once with purga- tive doses of calomel, than with the minute alterative portions mentioned above. In cases of this kind, the bowels are, frequently, much loaded with fecal matter, which it is of much importance to evacuate, as speedily and completely as can be done without resorting to very active or irritating purgatives. At the same time that the means already indicated are employed, external revulsive applications to the abdomen, more especially to the epigastrium and right hypochondriac region, should be used. So far as my own experience en- ables me to judge, blistering the region of the stomach is decidedly the most efficient application of this kind in the present affection. Before the blister is applied, the part should be slightly bathed with spirits of turpentine, in order to procure vesication as speedily as possible. I have seldom, however, suffered the vesicatory to remain on the skin longer than four hours. As soon as the skin is uniformly inflamed, which in children occurs generally in about four hours, and sometimes much sooner, the cantharides should be removed, and an emollient poultice applied over the whole abdomen, including of course the in- CHOLERA. 653 flamed surface. This will, in a short time, excite the inflamed vessels to pour out a copious quantity of serum under the cuticle, and form a large blister, which should then be opened and dressed with fresh mercurial ointment, prepared without turpentine or other irritating substances. Where the general habit is phlogistic, and the pulse manifestly febrile, leeching both from the head and the region of the liver are important preliminaries to the employment of vesicatories. The warm bath, also, is an excellent auxiliary in the treatment of this disease ; and this measure is especially indicated, when the skin is very dry and harsh, and the pulse quick and tense. While the patient is immersed in warm water up to the neck, it will be proper to apply a napkin wet with cold water to the head. Various other external applications to the abdomen have been recom- mended, for the purpose of moderating the gastro-intestinal irritability in this affection. Rubefacient embrocations and cataplasms, made of stimulating herbs and spices, may be beneficially applied to the abdomen ; and where the disease is violent and rapid in its progress, recourse should be had to the most active articles of this kind—such as sinapisms, ol. monardae,* spirits of turpentine, and even diluted nitric acid, in the way mentioned for the treatment of the cholera of adults. I have already stated, as a general rule, that the use of opium is highly im- proper in this affection. The great tendency to congestion and irritation of the brain, in this species of cholera, renders all medicines of this kind decidedly prejudicial, when given in the early period of the disease, or where, in its ad- vanced stage, symptoms of cerebral oppression are manifestly present. Never- theless, where the disease assumes a chronic form, and the patient is very restless and wakeful, with a dry, harsh, and withered state of the skin, and there are no particular marks of cerebral congestion, small doses of Dover's powder, in union with minute portions of calomel, will sometimes produce very excellent effects. In a few instances of this kind, I have given half a grain of Dover's powder, with the sixth of a grain of calomel, and two grains of magnesia, every two hours, to a child under two years old, with unequivocal advantage. I must con- fess, however, that I have witnessed some instances of this kind, in which the employment of this narcotic was speedily followed by more or less stupor and cerebral oppression, without any beneficial effect on the intestinal disorder. With regard to the astringent and absorbent remedies, formerly so much em- ployed in this affection, we can scarcely pronounce too strong a sentence of condemnation against their use in the acute form or stage of this malady. I am entirely persuaded, that " much of the mortality of the disease has been pro- duced" by the injudicious employment of cretaceous juleps, astringent mixtures, aromatic draughts, and opiates. Where the disease becomes chronic, or con- tinues rather in the form of chronic diarrhoea than of cholera, the milder astrin- gents may occasionally do some good. Thus, I have, in a few cases, known a decoction of the root of the geranium maculatum in milk, procure considerable advantage; but I have much more frequently found it either to produce no mani- fest impression on the disease at all, or to do injury. The employment of un- irritating tonics, in the chronic form of the disease, attended with great debility and relaxation, is much more apt to afford relief, than the use of astringents and absorbents. I have frequently procured considerable benefit, in the advanced periods of the disease, from the employment of a solution of the tartrate of iron. Forty grains of this preparation may be dissolved in two ounces of water, to which half an ounce of the lemon syrup is to be added. Of this, from thirty to forty drops may be given to an infant, four or five times daily. Dr. Robert Jackson speaks very highly of finely powdered charcoal in diseases of the intes- tinal canal attended with diseased secretions; and Dr. Condie states, that he has used this article with very decided advantage, " in the latter stage of the disease, * R.—Ol. monarda?, ^i. Spirit camphora;, ^ss. 654 CHOLERA. when it had become in some degree chronic, and the discharges from the bowels were acrid, dark-colored and offensive." From my own experience, I can say nothing of this remedy, but I do not doubt its occasional usefulness under the circumstances just mentioned. From five to ten grains of the powdered char- coal, with four or five grains of rhubarb and a grain of ipecacuanha, may be given every three hours. (Condie.) When, from the violence and rapidity of the disease, or its long continuance, the exhaustion becomes very great, the extremities cold, and the pulse very small and feeble, internal, as well as external stimulants, become necessary. Under such circumstances, stimulating frictions, together with the internal use of wine- whey, milk-punch, or a weak solution of the carbonate of ammonia, are indis- pensable to support the sinking energies of the system. To relieve the colic pains which are apt to occur from flatulent distension of the bowels in the advanced periods of chronic cholera infantum, Dr. Condie strongly recommends a few drops of the spirits of turpentine; and my own ex- perience enables me to speak favorably of this remedy. I have, generally, how- ever, preferred the oil of juniper to the turpentine, and I am inclined to think it more certain in its effects in this respect, than the latter. No remedy has ap- peared to me so promptly to allay colic pain, and promote the expulsion of flatus from the bowels, as a weak solution of common soot sweetened with sugar. Particular attention must be paid to the proper regulation of the diet, through- out the whole course of the disease. If the child is weaned, nothing but the blandest liquid articles of food must be allowed. Boiled milk ; liquid prepara- tions of arrow-root, tapioca, sago, and rice; thin oatmeal gruel, barley decoction, or a solution of gum Arabic, are the best articles for food and drink in every stage of cholera. In some instances, of a chronic character, I have known beef-tea, or weak chicken broth, to produce a favorable change in the state of the stomach and bowels. In chronic cholera infantum, the appetite sometimes suddenly be- gins to crave urgently for certain strong and stimulating articles of food, such as salted herring or shad ; old bacon ; salted and smoked beef, &c, whilst the sto- mach loathes all the lighter and unirritating articles of nourishment enumerated above. When this occurs, it will be proper cautiously to gratify the newly awakened appetite, however opposed to the ordinary dietetic rules the indulgence may appear to be. " I have seen many children recover," says Dr. Rush, "from being gratified in an inclination to eat salted fish, and the different kinds of salted meat. In some instances they evince an appetite for butter, and the richest gra- vies of roasted meat, and eat them with obvious relief to all their symptoms." Without these strong instinctive calls of nature, however, it would be highly im- proper to allow such coarse articles of food; yet where the inclination for them is strongly expressed, it may, and ought to be gratified. Nothing contributes more to the removal of this disease, than the enjoyment of the pure air of the country. Whenever it is practicable, the little patient ought to be removed into the country; for this change is often sufficient to remove the disease, in a short time, without any other remedial applications. If the circum- stances do not admit of a removal from home to a suitable situation in the coun- try, some advantage may be gained, by carrying the patient about in the open air; and still more, by frequent rides into the country in an open carriage. As preventive measures, gestation, or residence in the pure air of the country ; the avoidance of cool night air after a very warm day; nourishment at the breast during the process of dentition, or where circumstances render this impracticable, a very light liquid diet—particularly milk, and a thin preparation of arrowroot, with beef-tea, or weak chicken broth, tepid bathing, and lancing the gums as soon as they become swollen by the protruding tooth, are the most important.* • [Daily scarifications of the gums in a still earlier stage of dentition after the manner pre- scribed by Dr. Marshall Hall, has become a popular method in this city.—Mc] COLIC. 655 Sect. IV.—Colic. Writers have divided colic into a great many varieties; but as most of these distinctions are mere nosological refinements, I shall notice those only which have a practical bearing. The most common variety of colic is that which is occasioned by irritating and indigestible articles of food, and which Dr. Gregory, from this circumstance, calls accidental colic; but which is more commonly designated by the term flatulent, from the prominent symptoms of indigestion and flatulency which always attend this painful affection. 1. Flatulent Colic. A weak and irritable state of the digestive organs predisposes, in an especial manner, to this variety of colic. In persons so predisposed even the ordinary articles of food will sometimes give rise to the disease; and when food of an indigestible character is taken more or less suffering from colic is almost inevita- ble. Salted meats—all kinds of pastry—crude vegetables, such as cucumbers, celery, and unripe fruit—sour fruit—fresh and warm bread, &c, are especially apt to excite the disease in persons laboring under weak digestive powers. When articles of this kind are received into the stomach no inconvenience is usually felt until an hour or two after they are swallowed. In some instances, where the stomach is weak and irritable, the food passes into the bowels in an imper- fectly digested state; in which case, the colic pains may not come on for several hours after eating, and usually occur most severely about the umbilical region. More commonly, however, the pain commences in the stomach or duodenum, before the offending substances have had time to pass lower down the alimentary canal. At first, the patient experiences a sense of distension and uneasiness in the pit of the stomach, or occasionally in the left iliac region. This is soon fol- lowed by a dull, peculiarly distressing, and sickening pain in these parts, accom- panied with a feeling of strong distension of the stomach and bowels. The pain now rapidly increases in violence, until it becomes extremely severe. In some cases, the pains continue, with but short remissions, for several hours. More commonly, however, they occur in severe paroxysms, with complete, though transient intervals of ease. During the exacerbations, the patient is apt to move to and fro, with the body bent forwards, and the hands firmly pressed against the abdomen. When the stomach is the principal suffering organ, large quantities of air are, from time to time, forced up, and this is generally immediately fol- lowed by some mitigation of the pain. When the colon is the part chiefly affected, the flatus sometimes passes off downwards ; but this seldom takes place to any considerable extent, until the disease is about terminating. The bowels are always torpid in this affection, and the tongue soon becomes covered with white fur. Diagnosis.—The diagnosis of this variety of colic is not attended with any difficulty. The relief obtained from firm abdominal pressure—the agitation and writhing motion of the patient; as well as the absence of fever, and the paroxys- mal character of the pains, and frequent eructations of flatus, distinguish it pro- minently from gastro-intestinal inflammation. From bilious colic it may be distinguished by the absence of bilious vomiting, as well as of the icterode appear- ance of the eyes, of the extreme obstinacy of the constipation, and of the head- ache and bitter taste in the mouth, which characterize the bilious variety of colic. From cholica pictonum it is readily distinguished by the hardness and retraction of the abdominal muscles, and the gradual accession of the colic produced by lead. Prognosis.—Flatulent colic is not attended with much danger, unless it ter- minates in inflammation of the gastro-intestinal mucous membrane—a termination which sometimes, though rarely occurs. In some instances where the flatulent 656 colic. distension is very great, it produces paralysis of a portion of the bowels, or de- stroys, to a degree, the power of contraction, giving rise to habitual costiveness, and an especial tendency to a recurrence of the complaint. It is not improbable, that paralysis of a portion of the intestinal canal, induced in this manner, may be the principal occasion, in some cases, of introsusception or invagination of the bowels. Where flatulent colic is produced by very indigestible and irritating ingesta, it may give rise to rapid inflammation and gangrene. Treatment.—The treatment of this variety of colic is seldom attended with much difficulty. In slight cases, where the flatulent pains are seated in the sto- mach, and there is no reason to presume the existence of chronic irritation in the mucous membrane of this organ, we may, in general, soon procure relief by ad- ministering some of the carminative and antispasmodic stimulants. Dry frictions with flannels or a flesh-brush, is an excellent means for removing flatulent pains of the stomach. By rapid frictions on the epigastrium, the flatus is generally discharged in copious torrents, and where there is no fixed irritating cause in the stomach that requires removal, we may often, in this way, put a termination to the gastric pains. From five to ten grains of camphor with about thirty drops of vitriolic ether, and the same quantity of laudanum, has frequently afforded prompt relief in my hands. The oil of juniper or the spirits of turpentine will also generally allay the pain in slight cases. Articles of this kind will, in general, give relief where there is no particular irritating cause lodged within the aliment- ary canal; but where the disease is the consequence of crude indigestible and irritating ingesta—or where it comes on within an hour or two after taking a full meal of stimulating mixed and indigestible food, carminatives and antispasmodics will not only be insufficient, but generally decidedly injurious, unless they are used in conjunction with proper evacuants. Where there is reason to believe that the offending matter is still in the stomach—which may be presumed to be the case when the disease comes on within an hour or two after taking a full meal, recourse should at once be had to an emetic dose of ipecacuanha. To moderate the excessive suffering of the patient as speedily as possible, we may administer some carminative along with the emetic. From twenty to twenty-five drops of the essence of peppermint may be advantageously given in such cases, with about thirty grains of ipecacuanha. When the pain is confined to the bowels occupying the colon, an active purgative in union with aromatics, or with some of the more volatile antispasmodics, ought to be given, and purgative ene- mata administered at short intervals until the bowels are freely moved. Castor oil with spirits of turpentine is an excellent purgative in colic from the irritation of acrid substances or imperfectly digested articles of food lodged in the bowels. I have often employed this mixture with prompt and complete success. In some instances, however, the sufferings of the patient are so extremely great, that we cannot wait for the operation of a cathartic to procure relief. In such cases, almost the only remedy upon which any reliance can be placed is opium, given in large doses. From two to three grains should be given at once, or what is better, an equivalent dose of laudanum. This will always procure relief in the course of forty or fifty minutes; and in many instances of this severe character, nothing but this remedy, in enormous doses, will allay the extreme agony of the patient. The opium, when given in large doses in this affection, does not mate- rially impede the subsequent operation of cathartics—and the administration of a purgative should never be neglected as soon as the violence of the disease is mo- derated.* When the disease occurs in robust and plethoric habits, venesection * For this purpose, we may use either castor oil and turpentine, in the proportion of six drachms of the former to two drachms of the latter—or the following pills: R.—Extract, colocynth. compos, gss. Calomel ^i- Tart, antimonii gr. i.—M. Divide into ten pills. Take two every hour until the bowels are freely moved.—Or. R.—Pulv. jalapa grs. xvi. Calomel grs. viii.—M. To be taken all at once. COLIC. 657 should be practised, in order to obviate the occurrence of inflammation, and to pro- mote the operation of the necessary purgatives. Little or no advantage usually results from the employment of external revulsive applications; yet when, after the subsidence of the colic pains, the epigastrium remains tender to pressure, and the tongue becomes furred in the middle, with a florid appearance of the edges leeching and blistering cannot be safely dispensed with. After the disease has been subdued, the patient should confine himself to the lightest and most digestible articles of food for several days. 2. Bilious Colic. There is another variety of colic, which, from the manifest derangement of the biliary organs, and symptoms indicative of a superabundant or vitiated secretion of bile, has with propriety been denominated bilious colic. This variety of the disease appears to depend on the same remote cause which gives rise to intermitting, remitting, and other forms of miasmatic fevers: and it accordingly most commonly occurs during the autumnal months—particularly after a long continuance of a very warm and humid state of the atmosphere. Before the more urgent and characteristic symptoms of the disease come on, the patient generally experiences headache, loss of appetite, a bitter taste in the mouth, thirst, nausea, and occasionally bilious vomiting. After these symptoms have continued for an indefinite period of time, acute pain in the stomach and bowels supervenes, moving at first from one part of the abdomen to another, though generally most severely felt about the umbilicus. This pain is often in- tensely severe during the exacerbations. In the early stages of the complaint, pressure on the bowels affords some degree of relief; but as the disease ad- vances, the abdomen becomes tender to the touch. Nausea and bilious vomiting occur more or less frequently from the commencement of the malady; and the patient always experiences a temporary abatement of his sufferings immediately after a spell of vomiting. Although the stomach is morbidly irritable, and ex- tremely apt to be excited to vomiting, yet the bowels are almost invariably extremely torpid, being generally in a state of obstinate constipation from the beginning of the disease. The pulse seldom deviates materially from its natural condition during the early period of the complaint; but in the advanced stage it becomes increased in fullness, force and frequency. In violent cases, the hands and feet are sometimes quite cold during the exacerbations of the pains. About the second or third day of the disease, ihe eyes and skin become more or less suffused with a yellow tinge; and in some cases, indeed, these manifestations of biliary disorder occur several days before the pain in the abdomen commences. In cases of great severity, the nervous system usually suffers considerable disturbance—the patient becoming despondent and affected with slight spasmodic twitches in the muscles of the extremities.* Dr. Staley, in the interesting paper on this disease just referred to, observes, that he has sometimes met with cases in which much numbness and tremor of the superior extremities occurred; and he saw one case in which the "arms were so completely paralyzed that all power of voluntary motion was destroyed." Paralysis of the wrists has, indeed, been frequently noticed as an occurrence in this affection, and this circumstance has been adduced as an argument in favor of the identity of this affection with the variety of colic produced by lead. Eructations of flatus are very common in bilious colic; and, as in the former variety of the disease, they are always fol- lowed by a temporary mitigation of the abdominal pain. Causes.—I have already said that bilious colic appears to depend on the same remote cause which gives rise to autumnal bilious fever. Dr. Rush includes this variety of colic among the usual forms of miasmatic fevers; and Dr. Staley ob- * An Inquiry relative to the Causes, Nature, and Treatment of Bilious Colic. By Dr. Henry btaley, of Maryland.—See Medical Recorder, vol. vi. p. 231. 42 658 COLIC. serves, that he has uniformly found "the cases of bilious colic most numerous after a summer remarkable for the prevalence of bilious remitting and intermitting fever." My own observations correspond fully with these statements. In the autumn of 1821, 2, and 3, when bilious remittents prevailed very extensively, I met with a greater number of cases of bilious colic than had previously come under my notice during a period of fifteen years. Although there can scarcely exist a reasonable doubt that koino-miasmata is intimately concerned in the pro- duction of this malady—more especially when it prevails, in a degree epidemic- ally; it must nevertheless be admitted, that other causes, of a sporadic character, occasionally give rise to this affection. I have met with cases of strongly- marked bilious colic under circumstances that precluded all ideas of the agency of miasmata. It is generally believed that the liver is morbidly active in this disease, and that a redundant secretion of bile is one of its most essential conditions. This idea is favored by the circumstance, that from the very commencement the fluid thrown from the stomach is always mixed with a considerable portion of bilious matter. There is much reason, however, to doubt the correctness of this opinion. Dr. Staley observes, with much plausibility, that if we reflect on the quantity of bile which is secreted in a healthy individual, and the obstruction which exists to its passage downwards, from the constipated state of the bowels in this disease, we can have no difficulty in accounting for the quanlity of bile discharged by the mouth, although there be a paucity in the secretion. It is not improbable, indeed, that so far from there being too copious a secretion of bile in this disease, there is, in fact, generally a deficiency of this fluid. The functions of the liver are unquestionably deranged, and the bile secreted is, without doubt, vitiated. That this is the case may be inferred from the analogy which bilious colic bears to cholera—an analogy which has been particularly noticed by many writers. Dr. Gregory observes, " that bilious colic is closely allied to bilious diarrhoea and cholera, occuring along with them, and apparently differing from them only in some unessential features." The opinion that the liver is in a state of torpor rather than of increased activity, is moreover strengthened by the fact, that so soon as the alvine discharges become bilious, an amendment of the dis- ease usually takes place ; and that however frequent the discharges may be, they seldom procure any particular relief when they are devoid of bilious matter. " When bilious stools are not brought away," says Dr. Gregory, " it is common to find chocolate colored motions passed, frequently in vast quantity, reducing the patient to a state of great weakness." Dr. Musgrave, in a valuable paper on this disease, states that he invariably found the liver in a highly congested state, and in the majority of instances there were strong marks of intestinal inflamma- tion and its consequences.* The etiology of bilious colic does not appear to differ materially from that which is common to cholera, dysentery, &c. The atmospheric heat and mias- mata act probably as predisposing causes; and sudden changes of atmospheric temperature, by which the cutaneous exhalents and secretory vessels of the liver are struck torpid, and the blood determined to the internal organs, constitute, perhaps, the principal exciting cause of the disease. Treatment.—The principal indications in the treatment of bilious colic are: to free the bowels of their irritating contents; to allay the morbid irritability of the stomach and intestinal tube, and to restore the healthy actions of the liver. Some writers speak very favorably of the employment of emetics in the begin- ning of the disease, and there can be no doubt of their usefulness where there is much nausea, without full vomiting in the commencement of the attack. Under such circumstances, the exhibition of an emetic should be among the first mea- sures resorted to for the removal of the disease. Much bilious matter, of a vitiated appearance, is usually thrown off, and considerable temporary relief * Med. Repository, Nov. 1825. COLIC. 659 almost invariably ensues. In cases attended with much spontaneous vomiting, it will not be necessary to resort to the use of emetics. In such instances, it will be sufficient to request the patient to take copious draughts of eupatorium or chamomile tea, or some other diluent, in order to facilitate the complete evacua- tion of the vitiated bile and other irritating matters lodged in the stomach. Where an emetic is indicated, the tartarized antimony will in general answer better than any other article of this kind, on account of its greater tendency to excite the action of the liver and of the alimentary canal. Many writers advise the exhibition of purgatives, as soon as the stomach has been well freed of its irritating contents. But in the majority of cases, the stomach is so extremely irritable, that medicines of this kind cannot be retained a sufficient length of time to enable them to act on the bowels. As the early evacuation of the intestinal canal, however, is all-important, measures should be immediately taken to allay the gastric irritability, so as to enable us to administer a cathartic with a prospect of advantage as early as possible. So far as my own experience enables me to decide, calomel is decidedly the best internal remedy we possess for preparing the stomach for the reception and retention of purgatives. Given in small and frequent doses, in conjunction with the application of sinapisms or epispastics to the epigastrium, this mercurial will seldom disappoint us in allaying the irrita- bility of the stomach sufficiently to enable us to administer with effect the neces- sary cathartics. What renders this remedy still more useful as an antecedent measure to the use of purgatives, is its well known powers to correct functional disorder of the liver, as well as its tendency to co-operate as an aperient with'the purgatives which are to follow. After the stomach bas been freed of its contents, either by spontaneous vomiting or the operation of an emetic, half a grain of calomel may be given every half hour, at the same time that a large epispastic is applied to the region of the stomach and liver, and continued until the gastric irritability is moderated. When this is accomplished, a full dose of some active purgative should be administered ; and for this purpose we may give from fifteen to twenty grains of calomel, followed in about three hours with an ounce and a half of castor oil, or a draught of a strong infusion of senna and manna. In some instances, however, none of the usual purgatives will be retained, notwith- standing the previous employment of small doses of calomel and counter-irritat- ing applications to the epigastrium. Where this is the case, it/is best to depend on calomel alone, with the view of procuring the evacuation of the bowels. " When the gastric irritability is very great, calomel," says Dr. Staley, " com- bined with gum Arabic, will be retained, when every other cathartic will be re- jected." This corresponds entirely with my own experience. I have, in several instances, ultimately procured free alvine evacuations by administering from five to six grains of this mercurial every three or four hours, until from twenty to thirty grains are taken, and then assisted by repeated purgative ene- mata. The employment of enemata should, indeed, always accompany the use of purgatives in this affection. An excellent injection for this purpose is the following mixture of castor oil and turpentine;* or we may use a strong infusion of senna and Glauber's salts. As soon as the bowels are freely evacuated, a full dose of opium ought to be administered. This valuable narcotic allays the irritation and spasmodic contraction of the intestines; and when given in com- bination with calomel, it does not impede the subsequent operation of cathartics, and tends, in no small degree, to equalize the circulation, and to excite the cutaneous and hepatic functions. When the obstinacy of the disease is very great, and the bowels resist the effects of purgatives, the calomel, with an occa- sional dose of opium, should be given with a view to its constitutional influence. * R— Ol. ricini ^iss. Spir. terebinth. Jss. Infus. sem. lini. Oj. Sapo Venet. gi.—M. 660 COLIC. In general, cathartics will operate freely as soon as the mercurial influence is manifested by the soreness of the gums. A general mercurial action has, in fact, a most beneficial influence upon the disease, whatever may be its grade of violence ; and in prescribing calomel in the commencement of the disease, with a view of its purgative effects, we must not lose sight of the more permanent and equally important influence, procured by its specific effects upon the system, and particularly upon the liver. Deranged hepatic function constitutes, probably, the foundation of the malady; and the removal of this morbid condition should be held a primary object in the treatment. After the bowels have once been freely evacuated, we must by all means endeavor to keep up regular alvine evacuations throughout the subsequent course of the disease. For this purpose, castor oil, or infusion of senna and manna, with an occasional dose of calomel, and the daily use of one or two purgative enemata, will in general answer very well. In robust and plethoric subjects, or where the pulse is vigorous and tense, and the tenderness to abdominal pressure considerable, blood-letting is a very import- ant auxiliary remedy in this affection. It not only tends to moderate the irrita- bility of the stomach, and to favor the regular operation of the necessary purga- tives, but what is still more important, it lessens the liability to inflammation, which, in plethoric and robust habits, is always very considerable in this affec- tion. When the pulse is vigorous, it will be best, at once, in the commencement of the disease, to draw the blood to the extent of making a decisive impression on the system ; and the operation may be advantageously repeated whenever the state of the pulse, and other symptoms, indicate its propriety, at every stage of the disease. Epispastics, sinapisms, and warm fomentations, also, are valuable auxiliaries to the remedies already mentioned. When the irritability of the stomach is very great, or when the epigastrium and abdomen are very tender to the touch, a large epispastic should be applied over the region of the stomach—having previously practiced an efficient blood-letting—and an emollient cataplasm laid over the lower part of the abdomen. These applications assist, in no inconsiderable degree, to allay the irritability of the stomach; and they are especially useful, also, to obviate intestinal inflammation—an occurrence which it must always be our principal aim to prevent. When, in the beginning, the fluid thrown from the stomach is of an acrid qua- lity, alkaline remedies should be administered. Calcined magnesia may be given either in union or in alternation with other purgative medicines; or from twenty to thirty grains of the bicarbonate of potash, dissolved in a draught of senna and manna. The warm bath occasionally affords considerable relief in violent cases of this affection; and warm fomentations to the abdomen may be very beneficially used. After the disease has been subdued, much care is necessary on the part of the patient, in relation both to diet and exposure. There are few diseases which are so apt to be re-excited by even slight errors in either of these respects, as the pre- sent one. For eight or ten days after an attack of this disease, the diet should be of the lightest and most digestible kind. Rice, sago, dry toast, beef tea, &c, should be used for three or four days, after which small quantities of the most digestible meats may be allowed. It is particularly important to avoid getting cold and damp feet. To lessen the liability to a relapse, it will be proper to wear a flannel roller round the abdomen for some time after the subsidence of the disease; and the patient must be particularly cautioned against drinking very cold water, during the first three or four days of convalescence. 3. Colica Pictonum. This variety of colic has been described under a diversity of names—as dry gripes; Devonshire colic; colica pictavensis; c. saturnina; c. damnoniensis; rachialgia raetallica; painters' colic, &c. It generally makes its approaches in a COLIC. 661 very gradual manner—commencing with symptoms of gastric derangement, such as irregular and weak appetite, foul eructations, languor, slight nausea, constipa- tion, with transient pains, and a feeling of weight and tightness in the abdomen, more or less drowsiness, and disinclination to mental and corporeal exertion. By degrees, the pain in the epigastrium and umbilical region becomes more and more severe and constant. The abdomen is hard, retracted, and somewhat tender to pressure, the bowels immovably torpid, and the stomach, in most instances, very irritable. The pain in the abdomen suffers occasional remissions, but except for a moment after vomiting, and in mild cases, no perfect intermissions take place, as in the other varieties of colic. The exacerbations of the colic pains are pro- tracted in duration, and exceedingly agonizing ; and during the first two or three days the retching and vomiting is generally very distressing, although a moment- ary mitigation is usually experienced immediately after the contents of the stomach are ejected. In violent and rapid cases, or what may be called the acute form of the disease, the pains extend from the umbilical region upwards to the chest and arms, and downwards to the pelvic viscera, giving rise to paroxysms of violent pain in the region of the bladder and rectum, with much difficulty of voiding urine, and a distressing sense of weight, constriction, and bearing down in the lower part of the abdomen. During the exacerbations, the anxiety and agitation are extreme—cold sweats break out on the extremities and face; the countenance is pale, contracted, and expressive of great suffering; and in some cases of very great violence, partial syncope, delirium, convulsions, paralysis of the wrists, and severe pains in the extremities occur. When remedial measures fail to make a favorable impression on the disease, the vital energies at last begin to sink; the abdominal pains abate; the stomach becomes extremely tender and puffy; the thirst unquenchable; vision imperfect; and finally, oedema of the feet, drow- siness, a pale, livid hue of the face, and occasionally suppression of urine, and more or less tenesmus, with great dyspnoea, ensue; and the patient dies under symptoms of apoplexy, or in a state of syncopic insensibility. Colica pictonum, if not subdued by an appropriate treatment, or if the remote cause continues to act on the system, or the patient has already suffered one or two attacks of the disease, is particularly apt to assume a chronic character, and to become associated with a variety of fixed and peculiarly distressing affections. The excretory and nutritive functions become impaired; the mental and physical energies torpid ; the capillary circulation extremely inactive, giving rise to a pale, sallow, and leaden hue, and a shriveled, dry, and harsh state of the surface of the body; the temper becomes irritable, desponding, taciturn, and gloomy; the coun- tenance lurid, and expressive of deep suffering; the body emaciates; the fore- arms become wasted and palsied; the abdomen exceedingly hard, painful to pressure, and tumid ; the legs cedematous, with pains in the joints, particularly in the ankles and toes, and great tenderness of the soles of the feet. The patient is extremely restless at night, his vision becomes weaker and weaker, the oedema extends up the legs, and the abdomen enlarges with dropsical accumulations. In some cases paraplegia, epilepsy, mania, or total imbecility of mind ensue ; and the patient is at last reduced to a state of complete exhaustion and emaciation, and dies under symptoms of apoplexy, or of dropsical effusion into the cavity of the thorax, pericardium, &c. On post-mortem examination, traces of inflammation, with patches of disor- ganization, almost always occur in the mucous membrane of the stomach and intestinal canal. Frequently, portions of the intestines are so contracted as scarcely to admit the passage of an ordinary sized quill; and occasionally the stomach, and whole track of the bowels, are in a state of preternatural contrac- tion. The vessels of the abdominal and thoracic viscera are generally very turgid with blood; but the muscular structure everywhere exhibits a pale and exsan- guinous appearance. The omentum is often marked with livid spots. M. Thomes, a late French writer, states that, in the dissection of eleven persons who had died of this disease, he fouad the meninges of the brain strongly injected, 662 COLIC. together with softening and other morbid appearances of the cerebral structure, with serous or sanguineous extravasations between the membranes. Causes and nature.—Lead, in whatever way and form it may be brought to act on the system, is almost the only well ascertained cause of this variety of colic. It would seem that the fumes of melted lead and the white oxide of this metal are most apt to act injuriously on the animal system, and to give rise to this extremely distressing affection. It has been said that the acetate of lead is incapable of producing this disease, and that no apprehensions need be enter- tained on this account in prescribing the internal use of this article. It must be admitted, indeed, that the acetates manifest a much less deleterious tendency in this way than any of the other forms under which this metal may exert its poi- sonous influence on the system. It would appear that the tendency of lead to produce colic is not confined to the human species. It has been distinctly noticed, that in the neighborhood of smelting furnaces and white lead manufac- tories, pigs, poultry, and other animals, occasionally become affected with a simi- lar disease. Plumbers, painters, glaziers, gilders, the workers in lead mines and in white lead manufactories, are most exposed to the influence of this poison, and of course almost peculiarly liable to this disease. Formerly it was the practice, in some parts of Europe, to put litharge into new made wine, for the purpose of rendering it palatable, or to convert acid into sweet wine. This gave rise to the extensive prevalence of this form of colic in some districts ; and it is from its endemic prevalence at Poitou, in France, from this cause, that the disease obtained the name of colica pictonum.* It has been contended, nevertheless, that other causes are capable of producing this variety of colic. Crude wine, fresh cider, and other drinks, acidulated with fresh vegetable juices, are mentioned as possessing a tendency, under otherwise favorable circumstances, to produce this disease; but the correctness of this opinion has, I think, with great propriety been doubted; for if the circumstances attending the occurrence of instances of this kind are accurately investigated, it will, perhaps, generally be found that in such cases these drinks had been tainted with lead employed in some part of the machinery or vessels made use of. Without doubt, such beverages may give rise to severe colic; but we have no satisfactory evidence that they are capable of producing the protracted 1rain of distressing symptoms which are known to arise from the poisonous influence of lead. Larrey, and some other late writers, assert that atmospheric vicissitudes, in conjunction with malaria, are a frequent source of this form of colic; but it is probable that, when produced by these causes, the disease does not differ from the preceding variety—namely, bilious colic. It has, indeed, been maintained that the affections called bilious and lead colic are essentially the same ; but, although the former often bears a very close resemblance, in its course and phe- nomena, to the latter, the more decided manifestations of biliary derangement in the former, and the great aptitude of the latter to pass into a chronic state, and to become complicated with various affections of a most distressing character, among other distinctive circumstances, seem to indicate a radical distinction between them. Of the nature or proximate cause of colica pictonum there is but little known of a satisfactory character. That the nervous system is prominently affected is very evident; but whether the ganglionic or the cerebral nerves are the seat of the primary irritation is by no means evident. M. Thomas, to whose dissections I have already referred, conceives that the primary location of this affection is in the brain; but the facts upon which he grounds this opinion— namely, the very obvious traces of high vascular congestion, and other organic affections of the brain which are frequently detected on post-mortem examina- * [A new pathognomonic sign has of late been much insisted on by foreign physicians, i. e., a lividity or blueness of the gums, or rather of that portion of the gums which is immediately adjacent to the teeth. If lead has been in any way introduced into me system il is supposed that it must always discolor the gums in this way.—Mc.J COLIC. 663 tion—are by no means satisfactory, since they may he, and I presume are, rather the ultimate effects than the causes of the malady. The disease may be compared to a tetanic spasm of the intestinal canal, the result, probably, of a primary mor- bid condition of the ganglionic nerves, gradually extending to the nerves of relation. Mr. Teale thinks that colica pictonum always depends on a primary irritation, or neuralgia of the spinal and sympathetic nerves. This corresponds nearly with the sentiments of Andral and Lobstein on this subject. The former of these pathologists observes that lead colic is a nervous disease, in which the spinal marrow and plexus of the great sympathetic appear to be particularly implicated. Treatment.—The indications for prescribing in this affection are: 1, to allay the pain and spasm of the bowels; 2, to evacuate the intestinal canal; 3, to correct and excite the hepatic and intestinal secretions; and 4, to obviate the occurrence of inflammation in the stomach and bowels. As the tendency to intestinal inflammation in this affection is always very con- siderable, it will be proper, in the first place, to reduce the momentum of the cir- culation, more especially in robust and plethoric subjects. If the pulse is hard and full, a vein should be immediately opened, and the blood suffered to flow until a manifest impression is made on the action of the heart and arteries. Blood-letting does not appear to exert any direct influence over the violence of the symptoms, but it is obviously proper as a means to lessen the chances of the supervention of inflammation, and it tends, in no inconsiderable degree, to render the operation of the other remedies more certain and beneficial. As soon as the action of the pulse has been moderated, we must prescribe with a view of allay- ing the pain and spasm of the intestinal canal; for unless this be effected, little or no advantage can be gained from the use of purgatives, on the free operation of which much of our ultimate success depends. For this purpose opium is de- cidedly the most valuable remedy we possess. When given in large doses, it not only allays the spasm and excruciating pain in the bowels, but by these effects it contributes also very greatly to the free operation of cathartics. In order to excite the action of the liver, and to obtain the general mercurial influence on the system as speedily as possible, as well as to predispose the bowels to be properly affected by the subsequent purgatives, the opium should be administered in union with calomel. Two grains of opium, with five or six grains of calomel, should be given every two hours until the abdominal pains are removed. After the pain has been thus allayed, the calomel should be continued, at the same intervals of time, in two or three grain doses, with half a grain of opium, until the gums begin to manifest the mercurial influence. As soon as this is perceived, recourse must be had to active purgatives, and it will scarcely be advisable to resort to them before the general mercurial action has been obtained; for, pre- vious to this the most active cathartics will almost universally fail; and what is still more unfavorable, they frequently give rise to severe vomiting and gastric distress, with but very small or no alvine evacuations, however vigorously urged. When, however, the mercury has affected the system, the skin generally becomes moist and of a natural temperature, and a full dose of an active purgative will rarely fail to procure free evacuations. I have repeatedly given opium and calo- mel for three or even four days before an attempt was made to evacuate the bowels; and I have had much reason to be satisfied with the result. Castor oil in union with the spirits of turpentine constitutes a very excellent purgative in cases of this kind. An ounce of the former with three drachms of the latter may be taken at once, and half this quantity repeated afterwards every hour until the bowels are freely moved. I have not, in a single instance, failed to procure free evacuations from the administration of this mixture, after the gums had become affected with the calomel. A strong infusion of senna and manna, with a portion of Epsom salts dissolved in it, will also, in general, answer well as a purgative in this affection ; but it is less certain, I think, than the oil and turpentine, 664 COLIC. and much more apt to produce very severe tormina during its operation. If the pain returns, after the operation of the purgatives, recourse should be again had to opium, and the mercurial impression must be maintained by the regular administration of a few grains of calomel every three or four hours. Where the torpor and spasm of the intestinal canal offer a very strong resistance to the operation of cathartics, purgative enemata are very useful auxiliaries. A strong infusion of senna, with an ounce of Glauber's salts dissolved in it; or an emulsion formed of two ounces of castor oil, with half an ounce of the spirits of turpen- tine, and a pint of warm flaxseed tea, should be repeatedly thrown into the rectum until the bowels begin to discharge themselves freely. After the use of large doses of opium and calomel, however—more especially when a general mercurial excitement has been established—the difficulty of moving the bowels is seldom considerable. External counter-irritating applications rarely contribute materially either to mitigate the symptoms or to shorten the duration of their progress. Nevertheless, where from the violence and obstinacy of the disease there is reason to appre- hend the supervention of gastro-intestinal inflammation, vesicatories, or pustulation with tartar emetic ointment, and leeching, ought by no means to be neglected. From some reports that have been published in the French journals, it would seem, indeed, that leeching is capable of doing much good in this affection. Recamier cured a case veay promptly by the application of fifty leeches to the abdomen, after the routine treatment pursued in the Hospital La Charite had been ineffectually employed.* Warm fomentations and the warm bath may also be used with occasional advantage in this variety of colic. Alum is much praised by Richter and other German writers as a remedy in this affection; and I have myself used it in some instances with remarkable suc- cess. Richter declares that it will sometimes procure relief where opium and all other remedies fail; and from a case which I treated lately, I am inclined to think that there is much foundation for this assertion. In this instance I em- ployed venesection, vesication to the epigastrium, and opium with calomel in * This method of treating colica pictonum—which is denominated " Traite'ment des Peres de la Charite," consists in the following course of management:—On the first day, a purgative enema, made by boiling half an ounce of senna in a pint of water, and adding four ounces of the sulphate of soda, and four ounces of antimonial wine, and during the day the patient takes occasional draughts of a drink made by dissolving an ounce of the sulphate of magnesia, and three grains of tartar emetic, in two pints of cinnamon water, with the addition of an ounce of the syrup of buckthorn. At five o'clock in the evening an enema is administered, consisting of eight ounces of the oil of walnuts, suspended in twelve ounces of port-wine. Three hours afterwards, a bolus, containing one grain of opium and a drachm of treacle, is given. On the second day, the "eau benite," an emetic potion, consisting of six grains of tartar emetic, dissolved in eight ounces of tepid water, is given; the half at first, and the remainder in half an hour. When the vomiting has subsided, draughts of a diaphoretic ptisan are given during the rest of the day, made by putting china root, lig. guaiac. and sarsaparilla, of each a drachm, into two pints of water, and boiling it down to one. An ounce of sassafras, and half an ounce of liquorice root are then added, and the mixture gently boiled and strained. At night, the above anodyne enema and bolus of opium are again administered. During the third day the patient drinks two pounds of the diaphoretic ptisan, to which, however, an ounce of senna is added—the whole being taken in four equal portions; and besides this, he continues the use of the ptisan without the senna. In the evening the above-mentioned purgative enema, composed of a decoction of senna, sulphate of soda, and antimonial wine; in two hours afterwards the anodyne enema, (walnut oil and port wine;) and in two hours more the anodyne bolus. The fourth day is commenced with a purgative potion, composed of two drachms of senna, boiled from eight down to six ounces, to which are added half an ounce of the sulphate of soda, a drachm of powdered jalap, and an ounce of the syrup of buckthorn; and the patient drinks the diaphoretic ptisan mentioned above, and in the evening, the oleaginous enema and the ano- dyne bolus are repeated. All the fifth day is occupied with the sodorific laxative ptisan used on the third day; with the purgative enema (used on the first day) at four in the afternoon; the anodyne (oil and port-wine) enema, at six o'clock, and at eight the opium bolus. The treatment is adopted by Ratier, and it is said that it accomplishes many cures. Dr. Lerminier also follows this practice rigidly, and with no inconsiderable success. Pinel calls this method "empirisime consacre par une tongue suite de sacces." COLIC. 665 very efficient doses. The pains and intestinal spasms were but moderate whilst the patient was under the influence of the opium, and on the evening of the third day very free evacuations were produced from the bowels by the castor oil and turpentine purge, assisted by enemata of senna infusion. On the following morn- ing, however, the patient's sufferings were as great as at first; and although they were again allayed by opium, and the gums were manifestly affectedly the calomel, it was^evident from the general distress and firmness of the abdominal parietes, that the disease was not subdued. Another pretty free action of the bowels was obtained by the oil and turpentine, with the assistance of purgative enemata; but the patient's sufferings were still extremely severe on the following day. I now resorted to the alum, giving twenty grains of it with a grain of opium, every three hours. On visiting my patient next morning, I found him almost entirely free from pain, and was informed that he had five or six very copious evacuations during the night. He recovered rapidly under the use of purgative enemata, and an occasional dose of castor oil, with small doses of calo- mel and opium. M. Kapeler has for many years been in the habit of employing alum in this affection, in the Hospital St. Antoine; and M. Montancaix has lately published nine cases, which furnish very striking evidence of the usefulness of this practice.* This remedy was first employed by Grashuis.t and it is highly praised by Lentin.J & J Since the third edition of this work was published, I have witnessed the good effects of alum in two very severe cases of this species of colic. In one case, ten grains of alum with half a grain of opium, were given every two hours. In about twelve hours, the patient was almost entirely relieved, and under the fur- ther use of the alum, without the opium, his health was completely restored. In the other case I gave fifteen grains of alum, singly, every three hours, with the same favorable result. Alum is, without doubt, a remedy of great efficacy in this obstinate and painful affection, though, I believe, but rarely employed for this purpose by the physicians of the United States. It is said that cold water dashed on the body and limbs of the patient has oc- casionally excited the action of the bowels after opium, calomel, the warm bath, and purgatives had been ineffectually used. For the removal of chronic colica pictonum, or the various distressing conse- quences of this affection, mercury is, without doubt, the best remedy we possess. It should be given to the extent of producing gentle ptyalism; and this should be regularly maintained for three or four weeks, during which the patient ouaht to go into the warm bath daily, and avoid with all possible care the influence'of cold or atmospheric vicissitudes. Dr. Clutterbuck and other writers of eminence have found salivation to be the most effectual means we have for the cure of the paralysis of the wrists, produced by the poisonous influence of lead. The nitrate of silver has also been used with success in paralysis from this cause. We may commence with half a grain three times daily, and gradually increase it to the extent of five or six grains in the twenty-four hours. When it causes purging, which it appears to be apt to do in this affection, it should be given in union with a small dose of opium.§ During the treatment of this variety of colic the patient should take freely of fat animal broths, or chicken water ; and it is particularly important that he should avoid drinking cold water or stimulating fluids. To prevent the recurrence of the disease, it is of course absolutely necessary to avoid the influence of its re- mote cause; and therefore to relinquish the employments which render the ex- posure to this cause unavoidable, such as painting, glazing, manufacturing white * Arch. Medic, Novembre 1828. t De colico pictonum tentamen. Amstel., 1752. Ejusd. Appendix decadem observationum sestens, 1755. t Memorab. circa Eerem, vitae genus, sanitat. et morbos, Clausthaliens, p. 115. § Dr. Roberts. Med. Transactions, vol. v. art. 5. 666 ILEUS. lead, &c. The utmost care is necessary not to take crude and acid articles of food and drink, and to avoid the influence of a humid and cold atmosphere for a considerable time after recovering from an attack of the disease. The free use of fat and oily articles of diet is said to counteract, to a very considerable extent, the poisonous influence of lead. Fat pork, and the daily use of two or three ounces of sweet oil in the morning on an empty stomach, will often protect the system a long time from the injurious effects of this poison; and those who are employed in lead mines, and in the manufacture of the preparations of this metal, are fully aware of the protecting influence of such articles of food, and generally use them very freely. Sect. V.—Ileus. Ileus very generally depends on the intussusception, invagination, or inversion of one portion of the intestinal tube into another. This unnatural position of parts induces irritation, which eventuates in spasmodic contraction of the muscu- lar coat of the intestine, thus constricting the calibre of the enclosed gut, and pre- venting the regular passage of the feces. The invagination commonly occurs at the termination of the small in the large intestines, the ileum and caecum being enveloped within the colon. It, however, frequently happens also in other parts of the intestinal tube, and it is by no means rare to see invaginations in several places in the same individual. Invaginations of the small intestines frequently take place in children, and occasion but slight and temporary inconvenience. Ileus is not, however, invariably dependent on intussusception or mechanical obstruction of the intestinal tube. M. Corbin has related a case in which there was copious stercoraceous vomiting with colic pains and constipation, which was finally relieved by the purgative operation of a large dose of scammony. Cases, attended with painful stercoraceous discharges from the stomach, have occurred, in which the fluids which were injected into the rectum were quickly vomited up, "showing that there was no permanent or organic obstruction in the bowels." An instance is mentioned in the Medico-Chir. Rev. (April 1831), in which "six or seven pints of warm water could be injected into the bowels, and soon after- wards it would be ejected by the mouth. No motion could be procured by the anus." Such cases may depend on an indomitable inversion of the peristaltic action of the bowels. Causes.—This disease may be produced by everything which may tend to excite irritation or spasmodic action in the stomach and bowels. Among these may be enumerated irritating and drastic cathartics, emetics, or indigestible sub- stances taken into the stomach—such as coins, glass, cherry or peach stones, and unripe fruit. Ileus is also occasionally produced by hernia, by wounds, or other injuries of the abdomen, by cold externally or internally applied,by intestinal cal- culi, by organic derangements of the alimentary canal, or by anything which either directly or indirectly tends to contract or close the intestinal lube. Symptoms.—The indications of an attack of ileus are in some instances very insidious, and the organic cause or affection may have continued months or per- haps years unsuspected. It usually, however, comes on suddenly and without any premonition, by violent spasmodic and paroxysmal pains in the abdomen, eructations of wind, jactitation, frequent and ineffectual attempts at stool, disten- sion of the abdomen, and all the symptoms of spasmodic colic. The bowels are constipated, although a discharge of the large intestines below the invaginated part may be accomplished by means of enemata or by nature. Tbe stools are often mixed with, or consist entirely of coagulated blood. Upon examination of the abdomen, a hard, irregular, convoluted tumor may often be discovered, show- ing the situation, and perhaps the extent of the invagination. To the symptoms detailed, succeed obstinate constipation, hiccup, vomiting at first of the contents ILEUS. 667 of the stomach, and ultimately of stercoraceous matter. The symptoms of in- flammation may supervene upon those of spasm, in which case the disease will become greatly aggravated, and the life of the patient put in imminent danger. Should the spasmodic constriction and inflammation of the intestines be sufficiently severe, and continued for any great length of time, gangrene and mortification of the bowel will be the result, which will be indicated and accompanied by cessa- tion of pain, prostration of strength, and all the distinguishing and alarming symptoms of mortification. The invaginated portion, however, becoming gan- grenous, sometimes sloughs off, and cases of recovery in this manner have been recorded. Twenty years ago I saw a case of this kind, in which, by the efforts of nature, adhesions formed, several inches of the bowel sloughed off and passed away by stool, producing immediate relief and a rapid recovery. Nature may / also accomplish a favorable termination of the disease by overcoming the con- striction, and procuring the disengagement of the enclosed intestine. Diagnosis.—The diagnosis of this disease is exceedingly difficult and uncer- tain. Attacking suddenly, with great violence, and without any premonitory symptoms, it is apt to be mistaken for spasmodic colic, colica pictonum, cholera morbus, or tympanitis. On the other hand, insidious as it frequently is, and ac- companied with symptoms uncertain, and common to some other complaints, its very existence is often unsuspected, and it may easily be mistaken for other dis- eases. So uncertain are the diagnostic symptoms, that John Hunter, who paid particular attention to this subject, has declared that its existence could never be satisfactorily ascertained during life. Violent and spasmodic pains occurring in paroxysms, however, with long-continued and obstinate constipation ; fecal vomit- ing; distension of the abdomen ; with a hard convoluted tumor about the arch of the colon, will indicate its presence with a considerable degree of certainty. Prognosis.—Ileus is always dangerous. Occurring in robust and plethoric habits, inflammation, followed by gangrene and mortification, is very apt to ensue. In delicate and irritable habits, the spasmodic constriction is carried to a great extent, and is productive of effects equally dangerous. The spasmodic or inflam- matory action may, however, in some instances, be overcome, and the disease relieved. The skill of the physician, however ably and scientifically directed, will generally fail, in which case nature sometimes comes to our aid, and brings about results as unexpected as they are salutary. Pathology.—It has been said that ileus is a spasmodic disease, and that in- flammation, gangrene and mortification are the consequences of the pre-existent spasm. In a late publication upon " the diseases of the stomach and bowels," Abercrombie has advanced a new theory upon this subject. Having observed in a great number of post-mortem examinations, that distension of the bowel above the invagination was a uniform occurrence, he conceives the distension to be a paralytic affection of the intestine, in consequence of which the fecal matter can- not be propelled onward through the canal. The intussusception has, according to this theory, nothing to do with the disease. Ingenious as this theory un- doubtedly is, facts are wanting to support its claims to our notice. A careful review of the disease will convince us that it is entirely inadequate to account for the origin, symptoms, causes, effects and treatment of this disease. The spas- modic nature of ileus can admit of but little doubt. We have seen that ileus is produced by all the causes which give rise to spasmodic diseases generally—that it is indicated by symptoms peculiar to this class of affections; and we shall soon observe that every plan of-treatment which has been pursued with any prospect of success, has been based upon the position of the spasmodic nature of ileus. The remedies which Abercrombie himself proposes, are such as are eminently calculated to allay spasmodic action, without any view to the paralytic affection of the bowel. Dissections exhibit very clearly the pathology of ileus. The disease appears to expand its whole force upon the intestines about the intussusception. This 668 ILEUS. intussusception is very satisfactorily presented to our view. One portion of the bowel is drawn within another, and is there firmly constricted—so much so, that in some instances considerable difficulty is experienced in extricating it. Sur- rounding this invagination, the marks of inflammation are everywhere apparent. In some parts, and particularly at the constricted point, gangrene and mortification will generally be detected. Above the intussusception the intestine will be found distended bv feces or flatus, which had been prevented from passing through the constricted portion of the tube. Below, the intestine is generally in a state of emptiness and contraction In some cases, several invaginations will be seen in different parts of the fecal tube—each one presenting to a greater or less degree the peculiarities just described. In the majority of cases, the invagination has been found'at the arch of the colon, or at the termination of ihe small into the large intestines. The invagination, in the great majority of cases, will be observed to take place from below upwards, although the opposite occasionally obtains. Treatment.—The leading indication in the treatment of ileus is to alleviate, and if possible overcome the spasmodic action of the muscular coat of the intes- tines, and thus prevent inflammation, relieve the intussusception, and open the bowels. At the very onset of the attack, we should endeavor, if possible, to ascertain the cause, and if hernia be detected, it should immediately be reduced. Cases of ileus have terminated fatally from a neglect of this precaution. Believing the disease to be spasmodic in its nature, and prone to become in- flammatory in its progress, we should keep our attention steadily directed to the pulse, remembering that in this case, as well as in all other diseases of the intes- tines, it very frequently betrays us into error. The least tendency to inflamma- tory action should be combated by the free use of the lancet. Keeping in mind the rapidity of the progress, and the extreme danger of this disease, we should, without hesitation or delay, abstract blood largely. This alone will in many instances have a decided effect in subduing spasm and preventing the occurrence of inflammation. Great advantage may also be derived from topical bleeding by means of cups or leeches applied to the abdomen. Blood-letting having been premised, we may have recourse to antispasmodics with the happiest effects. Of these, opium is decidedly the best. To obtain its most beneficial effects, the system should be put completely under its impression, by the administration of large and repeated doses. Under the influence of opium, spasm will be fre- quently allayed, the intussusception overcome, and the bowels evacuated. We may, at this period, with great prospects of success, interpose the use of purga- tives. In the employment of these remedies, we should select such as are mild in their operation and gentle in their effects. Calomel will be found to possess a superiority over every other cathartic. Given in doses of ten grains, alone or with one or two grains of opium, it will frequently be retained on the stomach when everything else would be rejected. Castor oil in small and repeated doses, will frequently be retained, and may prove a useful adjunct. Much reliance is to be placed in enemata. Acting directly upon the diseased intestine, they will often display effects highly salutary. A great variety of ene- mata have been recommended, all of which may, in particular instances, have had a beneficial influence. Copious injections of warm water will sometimes prove an important auxiliary, by relaxing the spasm, distending the bowels, and perhaps overcoming the constriction. Dr. Wiltbank related to me a case of ileus, in which the only remedy that had any influence in overcoming the dis- ease, was a large enema of warm water administered by means of a stomach- tube introduced its whole length per anum. This remedy is worthy of further trial. That the administration of enemata by means of the stomach-tube may exert a powerful action in overcoming an intussusception, appears very reasona- ble. Cold water administered in a similar manner may also have a salutary effect. Tobacco is a remedy of pervading influence upon the abdominal viscera, and evinces such decided relaxing properties upon the muscular system gene- CONSTIPATION. 669 rally, that the most happy effects may be anticipated from its employment.* Great caution is requisite in its use: beginning witb a weak infusion, the strength may be gradually increased, until the system is under its full impression. Of the terebinthinate enema, I know nothing from experience; but from the adapta- tion of turpentine to many of the diseases of the bowels, I am inclined to think favorably of its powers, more particularly in the sinking stages of the disease. These remedies failing, we should next have recourse to blisters. These are particularly efficacious in cases attended with inflammatory action. They should be sufficiently large to cover the whole abdomen. Cold affusions to the abdomen and legs have long been a favorite remedy, and we are led to believe may, in some instances, have proved serviceable. Crude mercury has been used in intussusceptions from time immemorial, and is still a favorite practice in England. Abercrombie recommends it in this disease, in doses of one or two pounds. Whether it has ever proved beneficial, is extremely doubtful. John Hunter's practice in ileus, consisted in the administration of purgatives, when the enveloped gut was drawn upwards, and of emetics when it was drawn downwards. But the difficulty of this plan of treatment lies in the impossibility of determining, during the life of the patient, whether the constricted gut is drawn within the upper or lower portion of the intestine. All our remedies will, however, frequently fail, and the system will sink under the combined effects of spasmodic and inflammatory action. In this case, stimu- lants are indispensable. In the administration of stimulants,'it is desirable to select such as possess a purgative property. The tincture of rhubarb, and the wine or tincture of aloes, will be found to possess these qualities in an eminent degree. Taking into consideration the difficulty experienced in affording relief, and the imminent danger attending an attack of ileus, surgeons have within a few years advised the Caesarean operation. This operation, however, has been performed but in one instance. Dr. Fuschstiust relates a case, in which, after every remedy had proved unavailing, this operation was performed, the invaginated intestine drawn out, and a perfect cure obtained. Further trials of its efficacy in the relief of this disease will be required, before we should be justified in recommending it as a general remedy. I have only to remark further, that we should resolutely persevere in the use of every remedy that our skill can devise, knowing that recovery is sometimes effected at a very late period, and when, to all appearance, no human effort could restore life. Sect. VI.—Constipation. Constipation is a term of relative import. For the due preservation of health and comfort, it may be laid down as a general rule, that a daily evacuation of the bowels is indispensably necessary. There are, however, exceptions to this rule. It is by no means rare to see individuals who have a natural stool but once or twice in a week; and cases have been reported, in which weeks, months, and, in one instance, seven years elapsed, without the appearance of a stool. These cases, however, are extraordinary, and should not affect the rule, that the bowels should be opened every day. Constipation of the bowels is generally referable to sluggishness of the peris- taltic action of the intestines, or to torpor of the liver. Good ascribes it, in some instances, to excessive action of the intestinal absorbents, by which the fluid portion of the feces is too rapidly removed, and they are left dry, scybalous, and difficult to be evacuated. * [I have relieved several desperate cases of ileus by the tobacco injection, after the pre- vious use of blood-letting, and of calomel and opium.— Mc ] t Hufeland's Journal der Heilkunde, Feb. 1820. 670 CONSTIPATION. The symptoms attending constipation of the bowels are highly disagreeable. The breath is offensive ; the mouth dry, and out of taste ; the tongue furred, more particularly in the morning, and at its root; there are loss of appetite, nausea, headache, flatulence, and distension of the abdomen. The continuance of this affection is apt to induce indigestion, varices in the lower limbs, and piles. Causes.—Costiveness may be produced by an astringent diet, want of fresh air, and active exercise, confinement to any particular posture of the body, neglect of the calls of nature, stricture of the bowels, and other organic disorders of the intestines and liver, and pressure of the uterus during pregnancy. Constipation is often a constitutional disease, or it may become habitual from the nature and continuance of the causes producing it. The studious, the seden- tary, the indolent, and all whose occupation confines them within doors, and especially those who are under the necessity of remaining long in any particular posture of the body, are peculiarly obnoxious to this affection. Females, from their want of active exercise in the open air, and during the period of pregnancy, from the pressure of the impregnated uterus upon the bowels, are particularly subject to constipation. Treatment.—In attempting the relief of constipation of the bowels, it should be borne in mind, that simple and dietetic means will, in many instances, be suf- ficient to accomplish a complete cure. Ripe fruits, such as apples, peaches, pears, prunes, figs, gooseberries, strawberries, possess aperient properties, suffi- cient, in many instances, to overcome the most obstinate habitual constipation. Boiled vegetables are also proper articles of diet. The brown bread made of unbolted flour is a favorite remedy in this disease, and rarely fails in procuring regular and natural stools. All stimulating and astringent articles, such as cinna- mon, nutmegs, &c, are injurious, and should be sedulously avoided. Meat should be eaten sparingly and under-done; beef, mutton, fowls, and the various kinds of game, are the most proper animal food. Exercise is also an important remedy in this affection. It should be regular, active, and in the open air: walking, or riding on horseback will, in general, prove most salutary. Above all, however, we should never lose sight of the necessity of a regular attempt at stool. This will frequently overcome attacks of this disease which have resisted every other means. An attempt at evacuations should be made daily at a certain hour, and although for a time we may be disappointed, yet per- severance will ultimately overcome the habit and relieve the disease. Should the treatment recommended fail, or the urgency of the case admit of no delay, we must, without loss of time, administer purgatives. In the selection of these remedies, such should be preferred as operate mildly and effectually. The liver being usually implicated in this disease, the use of mercury in some form cannot be dispensed with. Commencing with calomel alone, or in combination with rhubarb, aloes, jalap, or some other active cathartic, it should be continued until the bowels are freely evacuated. The operation of the cathartics may be greatly aided by the administration of an enema. Injections are, indeed, an important remedy in this disease, and have, in this country and in England, been too much neglected. They should be simple, emollient, and frequently repeated. The bowels having been evacuated, should be kept in a soluble state by the use of laxatives. The remedy I have found most effectual for this purpose is a combination of the blue pill, aloes, and tartarized antimony,* which may be re- peated as often as occasion requires. Inspissated ox bile, in pills of five grains each, has been highly extolled, and may, perhaps, in some instances, have proved * R.—Massa ex. hydrarg. J)ij. Pulv. aloes grs. xij. Antim. tart. gr. i.—M. ft. Massa in pilul. No. xij. divid., one of which is the dose. INTESTINAL WORMS. 671 serviceable. Powdered charcoal has of late years been much used in this dis- ease; care should be taken in its administration, as it, like magnesia, may form concretions in the bowels, and thus increase the disease it was intended to re- lieve. When it is employed, it should be in combination with some more active cathartic. Castor oil with a few drops of the oil of turpentine, will often display very happy effects. Good quotes two very obstinate cases of constipation, in which affusions of cold water over the legs and pubes produced an almost imme- diate evacuation of the bowels. Should these remedies fail, and the habit become confirmed, the blue pill should be given every night for two or three weeks, and purged off on each suc- ceeding morning by rhubarb. This will frequently succeed after everything else has failed. If it, however, prove inadequate to the relief of the disease, the mer- cury maybe pushed to moderate ptyalism. This being accomplished, the disease will, in general, immediately give way, and a rapid cure be effected. When the constipation is so great as to resist the operation of cathartics and purgative enemata, relief may, in general, be obtained by introducing a gum elas- tic tube (the stomach tube will answer) as high up the rectum as possible, with- out applying much force, and then throwing some purgative fluid, as infusion of senna, into the bowels. The quantity injected should be sufficiently large to cause considerable distension of the bowel.* Sect. VII.—Intestinal Worms. The origin of intestinal worms is enveloped in great obscurity. In whatever light this interesting subject is examined, insuperable difficulties present them- selves to the mind. There are but two possible modes in which worms may be produced in the alimentary canal. They are either developed from ovula re- ceived into the stomach and bowels, from without, along with the food and drink —or they are formed in the intestines, independently of seminal matter, or ova generated by similar animals, by new chemical combinations, or what is techni- cally called spontaneous generation. It does not comport with the design of this work to enter into a detail of the various arguments that have been advanced both for and against these views of the generation of intestinal worms; but it may be observed, that the supposition of their origin from ova received into the aliment- ary canal, necessarily presumes the existence of similar worms out of the body, by which these ova are generated. This, however, is not confirmed by accurate observation; for, although Linnaeus, Gmelin, and a few others, assert that both taeniae and ascarides have been found in stagnant waters and in marshes, the ablest helminthologists of the present day affirm that these worms differ very distinctly, both in structure and character, from those which are found in the intestines of animals. It must be observed, moreover, that earth worms of this kind are of exceedingly rare occurrence, and that they have been met with only in particular districts and localities—a circumstance which strongly discounte- nances the supposition, that they furnish the semina of intestinal worms, so com- mon in man and in the inferior animals in every country and situation. The fact, too, that all intestinal worms almost immediately die when removed out of the body and exposed to the air, or placed in water, militates against the doctrine that they are the offspring of worms, whose natural habitation is out of the ani- mal body ; and finally, it has been satisfactorily ascertained, that earth worms and such as live in water, do not change their forms or character when accident- ally received into the intestinal canal. Another circumstance directly opposed * [The influence of galvanism has been relied upon in many cases by practitioners in this city. One pole of a light battery is introduced into the mouth, and the opposite pole is attached to a metallic bougie in the rectum. Galvanic beads made of alternate balls of zinc and copper, strung on a piece of whalebone, have also been introduced up the rectum. I have never ob- served, however, that any permanent advantage has been derived from such measures.—Mc] 672 INTESTINAL WORMS. to the opinion that the seminal rudiments of intestinal worms are generated by worms out of the body, and conveyed, in some way or other, into the stomach and bowels of animals, is the fact that intestinal worms have been found in the bowels of new-born foetuses. Kerkringius asserts, that he discovered lumbrici in the stomach of a seven-month foetus; and in another instance he found a great number of small worms in the bowels of an infant soon after birth. Pallas states, that Brendel found a tape-worm in the bowels of a new-born foetus ; and Heim, according to the testimony of Bloch, met with a similar instance. Rudolphi mentions a case which occurred to the celebrated Blumenbach, in which taeniae were found in the intestines of a recently born pup.* If this view of the generation of intestinal worms be rejected, and to me it ap- pears to be altogether untenable, we are obliged either to confess our total igno- rance concerning this mysterious process, which would perhaps be the most prudent, or to resort to the doctrine of spontaneous generation to account for the origin of these parasitic animals. I cannot here enter into the arguments which may be adduced in support of this doctrine ; but it appears to me that an errone- ous" sentiment of religion has here repressed the spirit of genuine philosophy— in other words, the prejudice, founded on a narrow view of the wise and myste- rious scheme of Providence, has not permitted the majority of competent minds to view this interesting subject of research in its true light. The ancient dogma, omnia ex ova, may, I think, be rightfully questioned. When experience and sound reason lead us to a conclusion in philosophy, we may safely abide by it, although it may at first sight appear to run counter to the cherished sentiments drawn from the highest source of wisdom and goodness. Of the causes that favor the production of intestinal worms.—However un- certain our notions may be, in relation to the origin of intestinal worms, obser- vation has made us acquainted with the principal circumstances which favor their generation and increase. Among the remote causes that appear particularly to favor the production of intestinal worms, are,—a sedentary and inactive course of life; habitual exposure to a humid atmosphere; the abundant use of fat, and farinaceous articles of diet, and of fresh milk; the use of more food than the sto- mach can readily digest, or than is necessary to maintain the health and vigor of the system. Dr. Bremser asserts, that in general all articles of food which furnish a very abundant supply of nutrient elements, when habitually taken in larger portions than the ordinary wants of the system require, are particularly calculated to favor the generation of worms in the alimentary canal. Some writers have mentioned the free use of sugar among the causes particularly favor- able to the production of intestinal worms—but this has been denied by others, whose opportunities of forming a correct judgment on this point were considera- ble. From the occasional epidemic prevalence of verminous diseases, it would seem that there are peculiar atmospheric constitutions, or aerial causes, which favor the generation of intestinal worms. The occurrence of epidemics of this kind has, indeed, been denied and even ridiculed by some ; but if we are to place any reliance on the concurrent testimonies of some eminent writers, the fact of such epidemics having occurred must be admitted. Marie has given the history of a very remarkable instance of this kind, which occurred at Ravenna and the surrounding district. Bloch, too, has given an account of an epidemic worm- fever. That verminous affections are vastly more common in some countries or districts than in others, is unquestionable. It is said that in Savoy and Chambray intestinal worms in every class of society are remarkably common, (Daquin, Bremser,) and the same observation has been repeatedly made of Holland and Switzerland. Bremser thinks that the abundant use of milk and cheese in the latter country is probably the principal cause of the great prevalence of worm affections among its inhabitants. The occurrence of the tape-worm is particu- larly common both in Switzerland and in Holland; and it is especially remarka- * Dr. Bremser—iiber lebende Wiirmer in lebenden Menschen, p. 16. INTESTINAL WORMS. 673 ble, that in the former country, the bothriocephalus latus (taenia lata) is by far the most common : whilst in Germany, the greater part of France, in Italy, and even in the Tyrol, the taenia solium (t. cucurbitina) is almost the only species of tape-worm met with. Rudolphi asserts, that in Sweden the bothriocephalus latus occurs very rarely, whilst the taenia solium is by no means uncommon. Species of intestinal worms.—There are five distinct species of intestinal worms, viz : 1. The tricocephalus dispar—(trichuris—tricocephalus hominis — ascaris trichuria.) This worm, called by the English "the long thread-worm," is from an inch and a half to about two inches in length. About two-thirds of its length are almost as thin as a horse-hair, the remaining and posterior part being con- siderably thicker, terminating in a rounded or blunt extremity. The thin part is transversely striated ; and the alimentary canal may be seen, by means of a lens, running from its thinner extremity in a direct line through the centre, into the thick posterior portion, where it assumes a flat and spiral form. These worms are seldom numerous, and are principally found in the caecum. 2. Ascaris vermicularis.—(Oxynris vermicularis—fusaria vermicularis—maw or thread-worm.) This is a very small white worm—the male being not above two lines in length, with a rounded or blunt extremity anteriorly, tapering to a point posteriorly. The female is considerably larger, being from four to five lines in length, terminating in an extremely fine extremity posteriorly, resembling the point of the finest needle. These worms are found only in the large intestines, and principally in the lower part of the rectum, where they are often collected in almost countless numbers. 3. Ascaris lumbricoides.—(Furaria lumbricoides—lumbricus teres.)—These worms are from two or three to ten or twelve inches in length, round, of a yel- lowish-white or brownish-red color, of nearly a uniform thickness, except at the extremities, which taper to a blunt point. They are from two to three lines in thickness. The head may be distinguished by a circular depression within a line of one of the extremities, terminating in three small tuberosities or valves, which the worm has the power of opening and closing. When they are opened, a very minute patulous projection may be seen, which constitutes the mouth of the worm. A very small groove passes longitudinally from one extremity to the other, on both sides. The alimentary canal terminates in a transverse depression on the under surface near the posterior extremity. The male is smaller than the female, and may be distinguished by its shortly curved caudal extremity. In some instances the organs of generation are conspicuous—consisting of two small cylindrical projections in the curved part of the tail. These worms inhabit the small intestines, and occasionally ascend into the stomach. 4. Taenia lata.—(Bothriocephalus latus—taenia membranacea—t. vulgaris.)— This worm often acquires a very great length—from thirty to forty feet and more. It is from four to ten lines in breadth, flat, white, and composed of a series of concatenated joints, resembling a piece of white tape. The head is armed with two processes, by which the worm attaches itself to the intestines. It inhabits the upper portion of the bowels and the stomach. 5. Taenia solium.—(Taenia cucurbitina.—t. osculis marginalibus.)—This worm is rarely if ever voided whole. It is passed off in pieces of a greater or less number of joints, or in single joints bearing a considerable resemblance to the seeds of gourd. Pieces, however, upwards of twenty feet in length, have been discharged, although generally not more than three or four joints pass off together. The anterior part tapers off into a very fine thread-like extremity, the head being extremely small, and furnished at its sides with four small apertures (ascula). This is the most common species of tape-worm, and like the taenia lata, inhabits the stomach and small intestines. Symptoms.—The symptoms which usually arise from verminous irritation, and from the presence of which we may presume the existence of worms in the alimentary canal, are—countenance pale, lead-colored, with occasional transient 43 674 INTESTINAL WORMS. flushes; eyes dull; pupils dilated, with a bluish semicircle around the lower eye- lids ; tickling in the nose; tumid upper lip ; occasional headache, and humming in the ears; copious secretion of saliva; tongue slimy or furred ; breath foul; variable appetite—being sometimes voracious, at others wholly gone ; transient pains in the stomach; occasional nausea and vomiting; pains in the abdomen, particularly about the umbilical region; frequent slimy stools, or costiveness; urine turbid, yellowish, or milky ; abdomen tumid and hard, with emaciation of the other parts of the body ; lassitude ; irritability of temper. None of these symptoms, however, are certain indications of the existence of worms in the bowels—the only certain indication being the appearance of them in the evacu- ations from the bowels or stomach. The opinion which has been expressed by some writers, that worms are harm- less inmates of the intestinal canal, is most assuredly not founded on correct ob- servation. Without doubt, many of the affections usually ascribed to worms, arise from other causes; and it is quite probable that that peculiar condition of the alimentary canal which favors the production of worms, may be, fre- quently, mainly concerned in giving rise to the various general affections which attend the presence of worms in the stomach and bowels. That verminous irritation is, however, sometimes the direct and exclusive exciting cause of severe and dangerous affections, is unquestionable. Chorea, epilepsy, hydrocephalus, emaciation, convulsions, mania, paralysis, fevers, dropsy, and a vast variety of anomalous disorders, are sometimes the immediate consequences of irritation from worms in the bowels, and occasionally speedily disappear after the expulsion of the worms. Esquirol states, that he has known eleven persons cured of mania, by the expulsion of a large number of lumbrici with anthel- mintic remedies. Treatment.— In prescribing for the removal or destruction of intestinal worms, it is of considerable consequence to confine the patient to a spare and liquid diet, and to exhibit two or three mild purgatives a few days previous to the exhibition of the proper anthelmintic remedies. With these preparatory measures, the ordinary vermifuge remedies will not disappoint us so often as without them.— My own plan of management for the expulsion of the long round worm (lum- bricoid,) is to put the patient on a liquid diet, and to order him a small dose of Epsom salts every morning for three or four days. On the fourth morning I direct a decoction of the root of spigelia, in the proportion of an ounce of the root to a pint of water boiled down to half a pint. This being sweetened, is to be drunk in the course of three or four hours, by a child of from five to ten years old, commencing in the morning after having taken a little milk and water into the stomach. As soon as the whole of the decoction is taken, an active dose of calomel and jalap is to be administered, or a dose of castor oil and turpentine, in the proportion of half an ounce of the former to two drachms of the latter, given in doses corresponding to the age of the patient. I have rarely failed, by this plan, to procure the discharge of worms, where they existed in the bowels. A vast number of remedies and modes of treatment have been recommended for the expulsion of this species of intestinal worms. Bremser speaks very highly of the vermifuge powers of the following electuary.* A teaspoonful is to be given to a child every morning and evening for six or seven days. I have used this electuary in four or five cases with complete success. It should not be given to the extent of producing frequent and watery evacuations. I have found it to do most good when it procured three or four consistent stools daily. Rudolphi asserts, that the anthelmintic oil of Chabert (oleum empyreumaticum Chaberti) is decidedly the most efficacious vermifuge we possess, and both Bremser and * R.—Sem. santon. sive tanacet. rudet. contus.^ss. Pulv. rad. valerian gii. ---------jalapa gss— gii. Sulphat. potassae ^iss—Zii. Oxymel. scillit. q. s. ut fiat eleotuar.—M. INTESTINAL WORMS. 675 Brera have added their testimony in favor of its usefulness in this respect.* Fif- teen or twenty drops may be taken three or four times daily by children from two to seven years old. Small doses of calomel with the powdered roots of spigelia and valerian may also be resorted to with a prospect of advantage.— There is danger, however, of producing ptyalism from giving calomel in this way—more especially as it is generally necessary to continue its use for several days before its anthelmintic powers can be properly obtained. The most effica- cious vermifuge remedies for the expulsion or destruction of the round worms, besides the articles already mentioned, are—chenopodium anthelminticum ; sem. santonic; tin filings; garlic; conferva helminthocordon ; spirits of turpentine ; Geoffraea Surinamensis; the green rind of unripe walnuts; and camphor. To prevent the rapid reproduction of worms, after they have been expelled or destroyed by anthelmintics, recourse must be had to tonics—particularly chaly- beates, in conjunction with minute portions of aloes, and a plain and abstemious diet. A strong decoction of the helminthocordon has appeared to me not only very valuable as an anthelmintic, but particularly also to remove that debilitated and disordered state of the alimentary canal, which favors the production of worms. An ounce of this marine vegetable, with a drachm of valerian, should be boiled in a pint of water, down to one gill. Of this, a teaspoonful may be given every morning, noon and evening, with peculiar advantage, to children laboring under verminous affections. I have, in several instances, known the use of this decoction to restore perfect health to children who were supposed to labor under verminous irritation, without any appearance of worms in the evacua- tions. It has appeared to me particularly beneficial in cases attended with the usual symptoms of worms, connected with want of appetite and mucous diar- rhoea, arising from mere debility of the digestive organs, and vitiated secretions in the bowels. Ascarides.—These little worms are generally extremely annoying. During the day they seldom give rise to much inconvenience; but in the evening, and particularly soon after lying down, they usually occasion a very distressing, and indeed, an almost insupportable itching and titillation in the lower part of the rectum and the anus. So extremely distressing is the sensation which they cause in these parts, that nervous children are sometimes thrown into convulsions by it. In females, these worms sometimes pass into the vagina, and give rise to very great uneasiness. Dr. Bremser states, that he has known an instance in which symptoms of nymphomania were excited by the irritation of ascarides, which had made their way into the vagina. They are generally most trouble- some during damp weather. The removal of ascarides is often attended with great difficulty, for although the inconveniences which they create may be removed for a time, they almost always recur again and again, in those who are once infested with these worms. From the location of these worms, in the lower part of the rectum, little or no advantage can be obtained from the use of anthelmintics administered by the mouth; and even active purgatives seldom evacuate them sufficiently. Aloes, however, from its decided tendency to act on the lower portion of the bowels, will occasionally expel them in great quantities, particularly when assisted with proper enemata. My usual mode of proceeding for the expulsion of these trou- blesome worms, is to prescribe three or four aloetic purgatives every second day, together with two or three enemata composed of a mixture of lime-water and milk, in equal proportions daily. Injections of a solution of aloes, or of infusions of any of the above-named vegetable anthelmintics, will generally bring off an abundance of these annoying little worms. I have, in a few instances, brought them away in great quantities, by injections composed of spirits of turpentine * This oil is made by mixing one part of the fetid spirits of hartshorn with three parts of the spirits of turpentine, and suffering them to digest for four days. The mixture is then to be put into a glass retort, and distilled in a sand-bath unttt three-fourths of the whole have passed over into the receiver. This is to be kept for use in small and well-closed vials. 676 INTESTINAL WORMS. mixed with milk, in the proportion of a teaspoonful of the former to a gill of the latter. The introduction into the rectum of a bougie smeared over with mercu- rial ointment, has been employed with success for the destruction of ascarides; and Nil Rosen speaks very favorably of injections composed of a drachm of refined sugar dissolved in warm milk. When ascarides have passed into the vagina, injections of cold water with a small portion of vinegar, are, according to the experience of Dr. Bremser, the best remedy we possess. Dr. Van Vest asserts, that flowers of sulphur, taken in the morning on an empty stomach, are one of the most efficacious remedies for the destruction and expulsion of these worms. Tape-worm.—For the expulsion of the tape-worm, a very great variety of remedies and modes of treatment have been recommended. The anthelmintics that have been found most effectual against this species of intestinal worms, are —polypodium felix; spirits of turpentine; tin ; valerian; the bark of the pome- granate root; and the empyreumatic oil of Chabert. Whatever mode of treat- ment be adopted, it is always of much consequence to prepare the patient by proper diet and laxatives before the proper vermifuges are given. A spare and liquid diet, with the daily use of small doses of saline purgatives for four or five days, will greatly increase the chances of procuring the expulsion of the worm, by the use of anthelmintic or active cathartic remedies. The following is the substance of some of the most celebrated methods of treatment recommended for the removal or destruction of taenia. Alston's method.—On the first day the patient is actively purged with an in- fusion of senna and manna. On the following morning an ounce of pure tin filings, mixed with common syrup, is to be taken (by an adult): and on the se- cond and third mornings respectively half an ounce of tin filings is administered, which is followed on the fourth morning, by an active dose of senna and manna. Pallas speaks in very favorable terms of this mode of management, and assures us that he has several times succeeded completely in effecting the expulsion of taenia with it. Bremser also has employed it with success in a few cases. Desault's method consists in the employment of mercurial frictions on the abdomen, followed by drastic mercurial purges. Herrenschwand's method.—A drachm of the powdered male fern root is to be taken morning and evening on an empty stomach, for two days in succession. On the morning of the third day the following purgative must be taken.* Three hours after this dose is swallowed, the patient must take an ounce of castor oil, and this dose must be repeated in an hour; if in three hours, after the second dose of oil, the worm has not been expelled, a third dose of it is to be taken; and should all these fail in procuring the expulsion of the worm, an injection of three ounces of castor oil in warm milk and water, should be administered in the evening. Hufeland's method.—A cup of a decoction of garlic in milk is to be taken every morning on an empty stomach; and a tablespoonful of castor oil every morning, noon, and evening, with half an ounce of tin filings daily, and frictions on the abdomen, with petroleum twice every day. The patient is to eat salted food. This method must be pursued for several weeks, or until the head of the worm is expelled. Nouffer's method.—This mode of treatment was at one time in high esteem; and many very respectable names might be mentioned in testimony of its occa- sional efficacy for the expulsion of the tape-worm. In the evening the patient must take a bowl of panada for his supper; fifteen minutes afterwards a glass of light wine with a biscuit; and if the bowels were not moved during the day, an enema composed of an infusion of mallows and a little common salt, with a few ounces of sweet oil, is to be administered. Early on the following morning, * R.—P. gambogiae grs. xii. Subcarbonat. potassae grs. xxx. Sapo Venet. grs. ii. Misce.—To be taken at one dose INTESTINAL WORMS. 677 eight or nine hours after the panada was taken on the preceding evening, the fol- lowing powder is to be administered, while the patient is yet in bed.* Should this be rejected by the stomach, a second dose must be taken. Two hours after this powder is swallowed, the following purgative bolus must be administered ;t after which the patient should drink a few cups of green tea, and walk about in his chamber. As soon as the purge begins to operate, a cup of weak tea must be drank at short intervals, until the worm passes off. When this occurs, and not.sooner, he may take a moderate portion of animal broth. If this course of management do not succeed in bringing off the whole of the worm, it should be repeated in the same manner as has just been described. This method will fre- quently succeed in expelling the taenia bothriocephalus; but it does not appear that it is capable of effecting the expulsion of the t. solium. M. Odier recom- mends the use of three ounces of castor oil instead of the above purgative bolus: and it would appear from the observations of other writers, that this modification of Madame Nouffer's plan is advantageous. M. Rathier speaks highly of the following composition as a remedy for the expulsion of tape-worm.;[: Schmucker's method, which has been highly praised, consists in the employ- ment of the seeds of sabadilla. The pods with the seeds are to be finely pow- dered ; out of which boluses are to be made containing five grains of the powder. Having purged the patient well with rhubarb or Glauber's salts, on the following morning, half a drachm of the sabadilla powder, rubbed up with an equal quan- tity of sugar, is to be taken. This generally causes vomiting. In an hour after this powder is taken, some barley-water or oat-meal gruel should be swallowed. On the next morning another dose of the sabadilla powder must be administered, which will again excite vomiting. If no worms are discharged after this dose, the patient must take but fifteen grains of the powder on the following morning, but the same dose should be repeated in the evening; and the same doses are to be taken on the fourth day. On the fifth day, a purge, composed of thirty grains of powdered rhubarb with eight grains of rosin must be taken. On the morn- ing of the sixth day, three of the above-named boluses must be swallowed, and the same number on going to bed. In this way the treatment must be continued for twelve, fifteen, or even twenty days; and Schmueker asserts, that when pro- perly persevered in, it will seldom fail to effect the expulsion of the worm. Bremser's method.—Mr. Bremser assures us, that, by the following method of treatment, he has succeeded in more than five hundred instances, in procuring the expulsion of the taenia solium. The cure is commenced by taking three times daily a teaspoonful of the electuary already mentioned for the expulsion of the round worm. (Sem. cinae; rad. valerian.; p. jalap; and tart, vitriol.) When the whole of the portion ordered in the formula is thus used, two teaspoonfuls of Chabert's anthelmintic oil must be taken every morning and evening in a little water. If it occasions vertigo, as is sometimes the case, the dose should be di- minished. After the patient has taken this oil about ten or twelve days, he must take a purgative ;§ after which the use of the oil must be continued. In general it requires from four to five ounces of this oil before the cure is effected. * R.—P. rad. filicis mas ^ii-^iii.—To be taken in six ounces of common water. f R.—Submuriat hydrarg. P. scammon., aa grs. x. G. gambogiffi grs. vi.-vii.—M. ft. bolus. X R-—Pulv. herb, saben. grs. xx. Pulv. sem. ruth. grs. xv. Submuriat. hydrarg. grs. x. Ol. destil tanacet. grs. xi. Syrup, folior. persicor. q. s. Ft mass. ex. quo. form. bol. no. ii.—One of these boluses is to be taken in the morning and the other in the evening, § R.—Rad. jalap. Qi. P. fol. senn;e ^ss. P. sulph. potassae ^i.—M. Divide into three equal parts. Take one every hour. 678 INTESTINAL WORMS. The spirits of turpentine has of late years been highly recommended as a remedy for the expulsion of tape-worm. From two to three ounces of this arti- cle may be given at once, and followed in about two hours by a strong dose of castor oil. From the accounts which have been published, of the employment of this article as a vermifuge for taenia, there can be no doubt that it is well de- serving of attention as a remedy for this purpose. I have known it to be used with complete success in one instance. In a late number of Hufeland's Journal, the following formula is highly recommended as a remedy against tape-worm:— R.—Tereb. venet. §i. Sapon. jalapin. 5SS. Extract, hyoscyam. grs. iv. Calomel grs. viii.—M. Divid. in pil. pond. grs. ii. Take four every three hours—the patient taking nothing but very thin broth for his food. If the worm is not expelled the first day, the use of the pills must be con- tinued for three or four days. Dr. Wilde used this remedy with success in two cases; and an instance was successfully treated with it in the Polyclinic Insti- tute of Berlin.* The extract of the male fern has lately been employed for the cure of taenia with marked success. Dr. J. I. Ebers has given an account of eight cases, in which this extract was used with the happiest effects. He gave from eighteen to twenty-four grains of the extract divided into two doses. In general this quantity has been sufficient to cure the patient. In some instances, however, it was necessary to repeat the dose three or four times. On the day after the ex- tract was taken he administered an active cathartic, which generally brought away the worm. From his experience with this remedy, Dr. Ebers draws the following conclusions: 1. The extract of male fern root is one of the most cer- tain means that can be employed against the tape-worm; 2. It generally kills the worm speedily; 3. It acts as a specific ; 4. It does not expel the worm in a ball or mass as other anthelmintics usually do; 5. This medicine acts, usually, in a mild manner, and without producing any severe symptom : once only it produced some severe effects in a female, who had not the tape-worm; 6. It also expels ascarides, but does not kill them.t The root of the pomegranate also is a valuable remedy for the expulsion of the tape-worm. Dr. Ruggia, a physician of Naples, has employed it with great success; and Dr. Mile informs us that in his hands it has proved very effectual. I am informed by Dr. MeaSe, of this city, that he has used it in one instance with entire success ; and he has heard of other instances in which it effected a cure, in this country. It is somewhat singular that this valuable remedy should so long have been neglected by the profession ; for it is only within a few years past that we have heard anything concerning its active anthelmintic powers, although, among the ancients, it appears to have been a favorite and common remedy for this purpose. Celsus prescribed it for the expulsion of taenia ;X and it is strongly recommended by iEtius, as a most efficacious remedy for this purpose.§ Two ounces of the fresh root are to be sliced finely, and slowly simmered in a pint of water down to half a pint. Of this decoction, one-third must be * Hufeland's Journal. June 1826. X Amer. Journ. Med Sciences, vol. v. p. 214, quoted from the Journ. de Chimie Medicale. X Si lati sunt, aqua potui dari debet; in qua lupinum, aut cortex mori decoctus sit: aut cui adjectum sit contritum vel hyssopum vel piperis acetabulum, scammoniae paulum. Vel etiam pridie, cum multum alium ederit, vomat. Posteroque die mali punici tenues radiculas colligat, quantum manu comprehendet, casque contusas in aquas tribus sextariis de coquet, donee tertia pars su- perset; huic adjiciat nitri paulum et jejunvs bibat. Interpositis deinde tribus horis duas potiones sumat talis aquae vel inuriae dura; huic adjectae ; turn desideat, subjecta calida aqua in pelve.— Celsus, De re Med., lib. iv. cap. xvii.—I doubt whether any treatment proposed by modern phy- sicians, is better calculated to effect the expulsion of taenia than the one here recommended by Celsus § Tetral. iii., serm. i. c. 39, 40. HEMORRHOIDS. 679 taken early in the morning on an empty stomach, and another third every two hours. If this does not expel the worm, the same is to be repeated next day, and so on. The diet should be liquid, and an active purgative given after the third portion is taken.* Sect. VIII.—Hemorrhoids—Piles. Hemorrhoids having, of late years, been considered as more especially belong- ing to the province of the surgeon, we need not wonder that they are now much too exclusively regarded as mere painful tumors of a local character, the cure of which should never be delayed. Dr. Gregory observes that the hemorrhoidal flux was formerly "believed to be a salutary provision of nature for the advan- tage of the constitution. The sudden suppression of it, therefore, was highly dreaded. These notions have passed away, and piles are now regarded as a painful and disagreeable complaint, arising,, in most cases, from local causes, the cure of which should never be delayed." Upon this point, however, we may reasonably demur; for, without regarding this affection as "a special effort of the vis medicatrix naturae," observation and experience have, I think, amply demonstrated the fact that these tumors, and the consequent effusion of blood, are, in many cases, the consequence of plethora of the portal vessels generally, attended with a particular sanguineous determination to the vessels of the lower portion of the rectum, arising, perhaps, generally from constitutional causes analo- gous to the sanguineous afflux to the uterus during the menstrual periods in females. The premonitory symptoms which usually precede the appearance of the hemorrhoidal flux—the molimina hemorrhoidalia—generally indicate a preter- natural afflux to, and congestion in, the vessels of the lower part of the abdomen; and, I apprehend, the precept that the suppression of this hemorrhage should "never be delayed," would, if it were generally followed, afford no very gratify- ing illustration of the supposed advancement of our science in relation to this subject. Without doubt, hemorrhoidal tumors are sometimes the result, also, of mere local causes, and may be safely removed as soon as possible. But whether the original cause be local or general, we may well doubt the propriety of sup- pressing the discharge after it has become habitual. A deranged state of the circulation and plethora of the abdominal viscera, and especially of the lower portion of the intestinal canal, is never absent in this affection, unless the piles arise wholly from local causes, and consist rather of an indurated or thickened state of the mucous membrane than of vascular or varicose tumors. The veins of the rectum, in consequence of this state of the portal cir- culation, become dilated or varicose, or the blood is effused into the cellular mem- brane beneath the mucous membrane of the rectum, forming sanguineous tumors. "In consequence," says Montegre, "of various causes which are sometimes beyond our cognizance, sanguineous determinations occur, at certain periods, towards the lower part of the rectum. This, at first, gives rise only to a feeling of tension and weight in the pelvis and extremity of the rectum—which, as it is not attended with actual pain, is often scarcely noticed, and usually subsides in three or four days. After a longer or shorter lapse of time, these symptoms are renewed, which generally terminate in a discharge of florid blood, spread over but not mingled with the feces. This blood issues by a kind of exhalation from * [I once caused the expulsion of an entire tape-worm from a young lady, by active purging with croton oil. During my attendance on the Philadelphia Alms House Hospital, I allowed a veteran sufferer from the same evil, to cure himself by permitting him to subsist for three days upon brandy and spirits of turpentine. His name was George Williams, and he had been afflicted with the disease in its worst form for several years. He swallowed the turpentine in half pint draughts at a time, and brandy in still larger quantities, both of which he repeated several times without exciting either strangury or intoxication. At the end of three days he expelled many yards of a large t;enia. and was effectually cured. He remained well, under my occasional observation, for many years.—Mc.J 680 HEMORRHOIDS. the mucous membrane of the rectum, without any lesion or erosion of this tissue whatever. After these fluxionary movements have returned more or less fre- quently—sometimes after a few repetitions—tumors of a greater or less size, and more or less painful, begin to make their appearance."* As has already been intimated, there are two kinds of hemorrhoidal tumors, viz: the vascular or varicose swellings just mentioned ; and those firm, spongy tumors, more commonly called piles, which arise from a thickened and condensed state of submucous cellular tissue. These two forms of the disease may be readily distinguished from each other by the following characteristic circumstances. The former or varicose tumors are of a dark and bluish color, soft and elastic to the touch, broader at the base than at the apex, rounded or somewhat hemi- spherical, and considerably lessened by gradual pressure with the fingers, though quickly returning to their usual size when the pressure is removed. They gene- rally occur in regular clusters, and often extend high up along the rectum. The other variety of hemorrhoidal tumors appears like small fleshy tubercles of a pale-red or brownish color, situated a short distance above the margin of the anus, or descending like pendulous excrescences from the rectum. They have a somewhat firm and spongy feel, " and when cut into, present a more or less compact surface, from which the blood oozes, leaving the texture pale and re- laxed." When they are situated externally, they are paler and more elastic and transparent. These tumors frequently contain a small cavity in ihe centre, containing fluid or coagulated blood. More commonly, however, no such cavity exists, the whole substance of the tumor being infiltrated with blood, becoming at last coagulated and dark.t " The manner in which these hemorrhoidal excrescences are formed, is in general pretty uniform. The patient is at first made sensible of its development by a peculiar pricking, stinging sensation, generally within or around the margin of the anus, and on applying the finger to the part it is felt slightly elevated, as if some newly-formed substance were forcing its way to the surface. The in- crease of these tumors, when once they become permanent, does not take place in every direction ; they elongate rather than expand, the body being usually of a conical shape, and larger than the neck. Sometimes more or less blood is exhaled from their surface; on other occasions a serous fluid only is exhaled, or they remain nearly dry; but in either case they generally disappear in a short time, and return again at an uncertain or irregular period, increasing in size, and becoming firmer in texture with each repetition." (Calvert.) General symptoms and consequences of hemorrhoids.—The approach of an attack of hemorrhoids is frequently announced by various symptoms denoting a deranged state of the circulation. In most instances the patient experiences, for several days before any manifestations of the local hemorrhoidal affection occur, a sense of weight and pressure in the abdomen, with a peculiar feeling of un- easiness in the bowels, constipation, and a sensation of bearing down in the rec- tum or perineum, attended, frequently, with horripilation in the back and loins,| slight flatulent pains in the stomach and colon, scanty and high colored urine, pale countenance, an occasional confused sensation in the head, general lassitude and heaviness of the extremities, an irritable and discontented state of the mind, a hard and contracted pulse, and a sense of anxiety and fullness in the epigas- trium. In many cases an unusual desire for venereal enjoyment, with strong erections, and even nocturnal pollutions take place ;§ and the patient often expe- riences a troublesome itching in the glans penis, and occasionally slight swellings and tenderness of the prepuce and testicles, attended sometimes with a blennor- rhceal discharge from the urethra.|| * Dictionnaire des Sciences Medicales, art. Hemorrhois. | Practical Treatise on Hemorrhoids, &c, by George Calvert, p. 35. X Pinel, Nosograph. Philos., vol.ii. § Lentin, Bertraeg. zur Ausuebent Arzneiwiss, vol. ii. p. 365.. || Richter, Specieile Therapie, bd. iii. p. 350. HEMORRHOIDS. 681 These symptoms are not, in general, continuous. They are apt to remit, or to disappear entirely for a short time, and then return again, especially on com- mitting errors in diet, taking stimulating drinks, or making unusual corporeal or mental exertions. They generally continue, in a greater or less degree, until the tumors either burst and relieve the engorged vessels, by a free discharge of blood, or until they begin to decline and disappear. In some cases, however, these molimina hemorrhoidalia, after having continued for some time, disappear again, without the occurrence of the local hemorrhoidal affection. The local affections which attend hemorrhoidal tumors, are sometimes ex- tremely severe and distressing. In some instances the elongated fleshy tumors, at last, become inflamed and give rise to severe pain—particularly during the ex- pulsion of feces. When they are situated high up, they are often forced down past the sphincter, and from the irritable condition of the parts, and the enlarged and exquisitely tender state of the tumors, they cannot be again returned. In this situation they give rise to continued and extreme suffering, and the inflamma- tion occasionally runs so high as to cause suppuration and sloughing. When the inflammation extends to the surrounding mucous membrane, it gives rise to a blennorrhceal discharge from the tumors and lower portion of the rec- tum—consisting of a thin, acrid, and mucous secretion, which soils the patient's linen, and causes tenderness and excoriation about the anus. Sometimes the tumors break, leaving fissures, which, from the irritation caused by the mo- tion of the parts, and the passage of indurated feces, as well as the acrid secre- tions, are converted into very painful irritable ulcers. Montegre has classed the pains which attend hemorrhoids under four heads. 1. Those which arise from active inflammation, characterized by heat, tension and throbbing in the part, va- rying from a moderate degree of these sensations to the most excruciating suffer- ings. 2. Nervous pains, characterized by the intermissions and the very sudden increase and diminution to which they are subject, as well as the considerable relief which is generally obtained by pressure. These pains do not appear to depend either on fissure or strangulation of the tumor, and often take place with- out any evident inflammation. They sometimes supervene after the inflamma- tion has subsided, and may continue, with variations of intensity, for several months, and occasionally much longer. (Montegre.) The pain which usually attends fissures, or rhagades of the tumors or edge of the anus, are distinguished by the following circumstances. On going to stool the patient experiences a slight stinging pain in a certain part of the rectum or anus. After the feces are expelled, the pain increases more or less rapidly until it becomes excruciatingly severe—in which state it usually continues until "ex- hausted, the patient falls into a sound sleep, from which he awakes free from suffering." No further pains are experienced until the patient again goes to stool, when they are renewed in the same way as before. Contraction of the anus is no uncommon consequence of habitual hemorrhoids, and may arise—1. From a number of tumors formed around the internal sur- face of the rectum, a short distance above the anus, which, when pressed down on going to stool, approximate each other, and diminish the passage so as to create more or less difficulty in voiding the feces—more especially when they are hard. 2. From induration of the cellular tissue near the extremity of the rectum, giving rise to a progressive decrease of the size of the passage, being in general unaccompanied with pain, except when the patient goes to stool, and the feces are hard. 3 From spasmodic constriction of the anus.—This appears to occur almost exclusively in persons of a nervous and irritable temperament. When the patient goes to stool, the sphincter of the anus being irritated by the feces, contracts spasmodically, and with such force, that extreme difficulty and pain occur in voiding the contents of the rectum, and any attempt to introduce the finger, with the view of examining into the state of the affected parts, is at- tended with the same difficulty and severity of pain. It is often wholly uncon- 682 HEMORRHOIDS. nected with inflammation of fissure. Sometimes ulcers, abscesses, and fistulx are formed near the extremity of the rectum, terminating occasionally in fistula ani. Among the most common consequences of this affection is a kind of tenesmus, with protrusion of the inner tunic of the rectum, so as to form a prominent and extremely sensitive ring around the anus—particularly after each attempt to expel the feces. The tenesmus seems, in part, to be caused by the afflux of blood to the affected parts, and also by the impressions of the feces upon the irritable mucous membrane of the lower part of the rectum, by which a frequent desire to stool is created, which being repeatedly assisted by ineffectual efforts to eva- cuate the feces, gives rise to permanent induration, scirrhus, and even cancer of the rectum. (Montegre.) Causes.—The causes of hemorrhoids may be classed under two heads,— namely, general and local. Among the general causes some are evidently simply predisposing; whilst others are more immediately concerned in exciting the hemorrhoidal affection. There appears to be a peculiar physical temperament or abnormal condition of the body, which predisposes in an especial manner to the occurrence of this affection; and it would seem that this hemorrhoidal consti- tution is often manifestly hereditary. Richter supposes that this predisposition consists principally in an original inactivity of the circulation in the abdominal viscera, in consequence of which habitual congestion of the portal vessels is esta- blished. Be this as it may, it appears very evident that persons of a sanguino- tnlious, or as it has also been termed, sanguino-melancholic habit of body, are most prone to hemorrhoidal affections. Of the very great influence of age in favoring the occurrence of this disease, there can be no doubt. Hemorrhoids before the age of twenty-one years, is far from being common, and when the disease does occur at or before this period of life, it is almost always the consequence of local causes, or of other diseases giving rise to congestion in the portal vessels. From thirty to fifty years of age is the period to which the appearance of these tumors is in a great measure confined. Those who remain free from the disease until they attain the age of fifty, seldom afterwards become more than very tempo- rarily affected by it. Although pregnancy, and the final cessation of the menses, are well calculated to favor the occurrence of sanguineous congestion in the vessels of the abdominal viscera, and particularly of the rectum, yet, with the exception of the periods when these conditions are present, hemorrhoidal affections appear to be much more common in males than in females.* The influence of age in favoring the occurrence of this malady, may be ac- counted for from the natural tendency of the venous to predominate over the arte- rial system, as individuals advance in age—and especially, from the equally manifest tendency in middle and advanced age to a sluggish state of the circulation in, or perhaps an increased sanguineous determination to the abdominal viscera, in consequence, probably, of a natural disposition, aided by the many causes which, as life advances, intervene, and tend to the same effect—such as the de- pressing passions, a more inactive course of life, debility of the digestive organs, and consequent torpor of the liver and bowels. I have stated that the predispo- sition to hemorrhoids appears sometimes to be hereditary; but it is probably, also, in many instances, acquired during infancy from improper dietetic manage- ment, and the habitual use of purgative medicines, so common, and in its ultimate tendency, so injurious a practice with nurses and mothers. Habits of life tending to determine the blood to the abdominal viscera, or to cause congestion in the portal vessels, are by far the most common source of hemorrhoidal affections. A studious and sedentary habit; a superabundance of high-seasoned and stimulating food; the depressing passions; the intemperate use of spirituous drinks; and the very free use of strong coffee,t are among the most active general causes of this affection. It is probable that these causes operate towards the production of hemorrhoids chiefly by producing weakness * Jahn. Klinik. der Chron. Krank., bd. iii. 453. X Richter, Jahn, loc. cit. HEMORRHOIDS. 68,3 of the digestive organs, as well as torpor of the liver and intestinal canal—giving rise to habitual costiveness, and consequently to a sluggish and congested state of the portal circulation. When to these conditions is added the local irritation of the rectum and anus caused by the remora and passage of hardened feces, it is obvious that hemorrhoidal tumors must be especially apt to occur. Among the local causes of hemorrhoids, besides constipation, we may mention the abuse of active purgatives—particularly aloetic preparations; stimulating enemata; frequent excitation of the venereal organs; pregnancy; parturition; supposito- ries; clothes worn so tight as to compress the abdomen; ascarides; irritating applications to the anus after going to stool; indurations of the liver or spleen ; riding on a hard trotting horse; dysentery; the irritation of calculus in the bladder; enlargement of the prostate gland; lifting and carrying heavy burdens. Hemorrhoids have been divided into a great number of species; but although these classifications may be convenient for imparting a full view of the subject to learners, they do not appear to possess any particular practical value. It is suffi- cient to bear in mind, that there are two kinds of hemorrhoidal tumors—one con- sisting in a dilated or varicose state of the veins, which may inflame, burst, and give exit to copious discharges of blood; and another kind, more common— consisting in firmer, fleshy, somewhat spongy elongated tumors or excrescences —which may inflame, open into fissures, ulcerate or remain entire, and give rise to the various painful and distressing affections already described. When the former tumors burst and bleed, they are called hemorrhoides fluentes, or bleeding piles; when the tumors do not bleed, they are termed h. cascae, or blind piles. Treatment.—May we, with safety, attempt to remove or suppress these tumors; and more especially, is it prudent speedily to suppress the sanguineous discharges to which they give rise ? Upon this subject very discrepant opinions have been expressed. Cullen was of opinion that the disease is but very rarely of a constitutional character; and, consequently, that it ought, in all cases, to be removed as speedily as possible ; as no danger, he presumed, need be appre- hended from the immediate suppression of the hemorrhoidal discharge. Dr. Gre- gory appears to be of the same opinion. This view of the subject, however, would inevitably lead to very disastrous consequences were it generally adopted in practice : for, although hemorrhoids are, in many cases, of a purely local character, and in such instances may be removed as soon as convenient, without any detriment to the system, yet both experience and analogy present us with abundant testimony of the dangerous consequences which are liable to result from a hasty interference with the hemorrhoidal discharge, where the disease is founded, as it very often is, on a constitutional predisposition.* In cases that depend on a constitutional hemorrhoidal tendency, and that have become habitual from long continuance or frequent recurrence; or where the general health or some chronic affection has been improved by the supervention of hemorrhoidal discharge; and especially where the disease is preceded and accompanied in its progress by distinct manifestations of an hemorrhoidal effort in the system, very particular caution should be exercised in the application of remedies calculated to suppress the disease. Nevertheless, where the discharge is excessive, and endangers the life of the patient by the great depletion it causes, we need not hesitate to interfere with the progress of the disease, so far, at least, as to moderate the hemorrhage, and obviate the immediate and remote dangerous consequences from this source. The general indications to be kept in view in the remedial management of this affection are—to remove and counteract the tendency to plethora in the portal * [During the last 15 years, I have been in the habit of extirpating all troublesome hemor- rhoidal tumors, either by the knife or ligature, without any such troublesome consequences. Even after long-protracted hemorrhages which have resulted in complete anemias, I have suc- ceeded in restoring excellent health by my operations. I may quote the high authority of Dr. Chapman upon this point, who invariably recommends extirpation of the tumors, in all vexa- tious cases.—Mc] 684 HEMORRHOIDS. circulation; to obviate the predisposing and occasional causes; to moderate (he hemorrhage where excessive; and to prevent and remove local inflammation and its consequences. During what may be called the latent stage of the disease, when the various premonitory symptoms enumerated above, the molimina hemorrhoidalia, exist, a general treatment calculated to remove the plethora of the portal vessels, as well as all irritation and preternatural determination to the vessels of the rectum, should be pursued, with the view of obviating or moderating the approaching hemorrhoidal attack. For this purpose, the patient should be put on a light vegetable diet; and if the pulse be full and active, blood should be freely drawn. Particular attention, too, must be paid to the state of the bowels. If they cannot be kept in a soluble state by vegetable diet, some of the milder laxatives, particu- larly the flowers of sulphur and cream of tartar,* with an occasional dose of blue mass in the evening, should be given once or twice every day, in doses sufficient to keep the bowels loose, without producing actual purging. The patient must lie on a matress, rise early, take gentle exercise by walking, avoid severe mental or very active corporeal exertions, abstain from stimulating drinks, as well as from condiments, and according to the observations of Jahn and Richter, from the use of strong coffee. Treatment of the hemorrhoidal discharge.—When the tumors burst and pour out blood, the patient almost always soon feels considerably relieved. The con- fusion and uneasiness in the head, the irritability and depression of the mind, as well as the general lassitude, tension, and aching in the loins, pressure and weight in the perineum, and in general all those symptoms which have been mentioned as indicative of the hemorrhoidal effort, abate very materially, and in many instances almost entirely disappear. So long as the hemorrhage remains moderate, it may with propriety be regarded as a salutary discharge, in reference to the radical affection, or state of the circulation in the portal vessels. It should always be recollected, that the discharge of blood is only one of the ultimate consequences of hemorrhoids ; and that as its direct tendency is to lessen the engorgement of the vessels of the rectum, and consequently to reduce the vascular hemorrhoidal tumors, it is obviously most proper to leave the hemorrhage to itself, unless it becomes very profuse, or inordinately protracted. We cannot, however, decide from the mere copiousness of the discharge, whether it should be regarded and treated as a morbid excess or otherwise ; for some individuals will bear very large evacuations in this way, whilst others will be much debilitated and exhaust- ed by a smaller loss of blood. Whenever the pulse becomes weak, the counte- nance pale, and the prolabia exsanguious, with much debility, general relaxation, and spasmodic symptoms, means should be adopted to restrain or arrest the evacuation. Here it must be recollected, that this, as well as other varieties of hemorrhage, may be connected with a manifest phlogistic diathesis of the general system on the one hand, or a relaxed, prostrated, and sluggish state of the general and abdominal circulation; in other words, that there is an active and a passive state of the hemorrhoidal discharge. In the phlogistic or active form, the patient must be kept cool and quiet, in the horizontal position ; his drink must be bland, cool, and acidulated; and nitre dissolved in a mucilaginous fluid, should be ex- * R.—Flor. sulph. crem. tart., aa. ^ss.—M. Take a teaspoonful twice or thrice daily. When the intestinal canal is in a debilitated and very torpid condition, Richter recommends the following composition: R.—Tartar depurat. Magnes. carton. Flor sulph., aa. ^ii. P. camphorae grs. viii. Pulv. sem. foenicul. ^iii.—M. Divide into 14 equal parts. Take one every three hours. Hildebrandt speaks very highly of a mixture of sulph. sodae and tincture of rhubarb, as a laxative in such cases. Two drachms of the salt, dissolved in two drachms of water, to which the same quantity of the aqueous tincture of rhubarb is to be added. One half to be taken in the morn- ing, and the other in the evening. HEMORRHOIDS. 685 hibited internally.* If these measures do not adequately moderate the dis- charge, recourse may be had to dry cupping over the loins or hypochondriac region; or to sinapisms and blisters to the inner part of the thighs, or over the hypochondriac region; and in very obstinate cases we must have recourse to injections of cold water or water in which a small portion of the acetate of lead or alum is dissolved ; and occasionally it may become necessary to introduce a tampon into the rectum. Considerable benefit may sometimes be derived from the internal administration of one or two grains of the acetate of lead in such cases. It very rarely occurs, however, that any particular difficulty is expe- rienced in arresting the discharge where the general habit is not particularly relaxed. The most obstinate and protracted cases of hemorrhoidal discharge are those which are termed passive, in which the general system is sluggish, the countenance pale, and usually somewhat bloated; the pulse small, feeble, and languid; and the muscular powers debilitated. In such cases, the hemor- rhage will sometimes continue with but short intermission until the system becomes almost entirely exhausted, and anasarcous effusions take place in the extremities and face, with occasional paroxysms of violent palpitation of the heart, and a peculiarly pallid and bloodless appearance of the surface. In in- stances of this kind, the sulphuric acid with cinchona, tincture of cinnamon, chalybeate preparations, and particularly the acetate of lead with small portions of opium, will, in general, afford considerable relief. In such cases, the tincture of cinnamon, so generally recommended by the German writers in passive he- morrhages, will often produce very excellent effects. From thirty to fifty drops of it may be given every three or four hours in conjunction with from eight to ten grains of the prussiate of iron. I have witnessed the good effects of these two articles in a case of remarkable obstinacy. There is no remedy, however, which, in general, produces such speedy salutary effects in chronic cases, con- nected with great languor and relaxation, as aloes, in small doses. This article is highly recommended by Jahn in cases of this kind,t for although one of the most improper medicines in the active or ordinary forms of the complaint, ex- perience has shown that where the hemorrhage depends on debility or relaxation of the vessels, both in menorrhagia and in hemorrhoids, it is calculated to pro- duce much good, by its tendency to excite the action of these vessels. Under the head of menorrhagia, I have already spoken of my experience with small doses of aloes in the passive form of the disease, and in relation to the present affection, I can affirm that its effects in two instances were very prompt and most beneficial. Jahn prefers the watery extract of this article, but I have given it as we find it in the shops, in conjunction with small doses of ipecacuanha.^ The diet in such cases should be nourishing, but not stimulating, such as animal broths, jellies, soft-boiled eggs, &c. Benefit will also result from astringent injec- tions, particularly solutions of alum, sage tea, infusions of the root of geranium maculatum, of the blackberry root, &c. Treatment of hemorrhoidal tumors, or blind piles.—When these tumors are situated on the margin of the anus, they may, in general, be kept from causing any particular inconvenience, by always washing them with cold water after going to stool, and applying moderate pressure, by means of a soft linen com- press laid on them and secured by a T bandage. When they become irritated and painful, without much inflammation, washing them with cold water, and the use of mildly astringent and anodyne applications^ will usually afford consider- * R.—Pulv. nitrat potassae giss. Aq. fontanue ^ vi. P. g. Arab. ^lii.—M. S. Take a tablespoonful every two hours. t Klinik. der Chron. Krankh., bd. iii. p. 557. X R.—G. aloes Soc. grs. xx. Pulv. ipecac, grs. xxx.—M. Divide into forty pills. Take one every morning, noon and evening. § R-—Axungiae £i. Cerussae £'\. Pulv. opii J)ii.—M. ft. ungt. 686 HEMORRHOIDS. able relief; but the ordinary astringent ointments, particularly those made of powdered nutgalls, are often decidedly injurious; and where the inflammation is violent, they are almost always highly pernicious. The most soothing applica- tion I have ever used in cases of irritated and painful piles, is the, following oint- ment.* To keep the bowels in a soluble state, where there is much irritation, the lenitive electuary, in union with powdered nitre, is an excellent medicine.t It is necessary, however, to guard particularly against purging; and where there is much inflammation present, this observance is especially important. The feces should be kept soft, but not liquid; and one such evacuation daily will be sufficient. When the piles are inflamed, all astringent applications, with the exception of poultices made with lead water, should be avoided. The patient must remain in a recumbent posture; and as the inflammation is almost always the conse- quence of some degree of strangulation of the tumor, by the contraction of the sphincter ani, an attempt should be made to press them within the sphincter. In many cases, however, the pain caused by even the slightest pressure is so intense, and the tumors are so much swollen, that all attempts to return them are abortive. In this case we must previously endeavor to reduce the inflammation; and for this purpose, emollient fomentations and cataplasms—or cold lead water must be applied, and where the pulse is active, an efficient blood-letting from the arm should be practiced. I have also known much good derived from the above- named mixture of nitre and lenitive electuary, given in small doses, so as not to procure an evacuation for the first twenty-four hours. The patient should take nothing but toast water, and very thin farinaceous preparations for his food. Some writers have recommended the application of leeches to inflamed hemor- rhoids, but the advantage to be derived from this practice is seldom considerable. Montegre is decidedly opposed to local depletion in this way, and thinks that leeches applied to the inflamed hemorrhoids tend often to aggravate the symp- toms, by irritating and determining the blood to the parts. Scarifying the tumors, or making free incisions into them, will in general do more towards the reduction of the inflammation than any other applications. Dr. Hartshorne tells me, that he always pursues this practice in cases of inflamed piles; and he has never known any dangerous consequences to follow the operation, but almost invaria- bly unequivocal benefit. As soon as the inflammation is sufficiently reduced to enable us to press up the tumors within the sphincter, it should be done; and cold water, with a small portion of the acetate of lead dissolved in it, cautiously injected into the rectum. Nothing produces a more soothing effect than cold injections in moderately inflamed piles; more especially when they are situated in the sphincter. Montegre places great reliance on the use of such injections, where the inflammation is not very intense, and where, moreover, the piles do not bleed. To relieve the pain and irritation which arise from fissures and ulcers of the lower part of the rectum, some surgeons recommend the removal of the tumors by which the pain is usually kept up ; and there can be no doubt of the propriety of this practice, where other means fail to procure relief. The application of caustic, and gentle escharotic ointments or lotions, will in general be necessary, where the ulcers assume a chronic character, with elevated and indurated edges; but undoubtedly the most effectual measure is excision of the tumors, or of the ulcerated part, when they are accessible to the knife. The excruciating intermitting pains which occur after each alvine evacuation, and in many cases without fissure or much inflammation, apparently from an extreme sensitiveness of the nervous extremities of the affected parts ; and which * Take two ounces of lard and a drachm of flowers of sulphur ; mix and rub them together between two plates of lead, until they acquire a^black color. t R-—Elect, lenitivi %i. Pulv. nitrat. potass. gi.—Misce. Take a teaspoonful once or twice a day. JAUNDICE. 687 Montegre calls nervous hemorrhoidal pains, are more effectually relieved by cold ablutions and injections than by any other applications that have as yet been recommended. M. Montegre, who dwells particularly on this remedy, states, that he was led to resort to it from having observed, that " when patients affected with the complaint happened to discharge their feces while bathing in a river or the sea, they sometimes escape the torment which ensued when they used a common commode." I have known much relief obtained from the application of the following liniment to the protruded piles, after having washed them with cold water.* Having applied the liniment, the tumors must be pushed up within the sphincter. It is in cases of this kind that Ward's paste will occasionally procure very considerable relief.! I have used this electuary in a number of instances, and sometimes with great advantage. Dr. Gregory very justly observes, that although it may be very difficult to explain on what principle this stimulating mixture proves useful, experience has" fully demonstrated its powers. When, from a state of chronic irritation or inflammation of the mucous mem- brane of the rectum, there is a profuse or troublesome leucorrhoeal discharge from the anus, recourse may be had to the internal use of balsam copaiva, oil of tur- pentine, or the cubebs, and slightly astringent injections should be thrown into the rectum three or four times daily. For this purpose a weak solution of sul- phate of copper, (one grain to an ounce of water,) will in general answer very well. Where, however, the pain arises from hemorrhoidal tumors of a permanent character, located either on the margin of the anus, or high up, and brought to the view only by pressing down as in going to stool, the removal of them by ligature or the knife, may be considered as the only means for effecting a radical or effectual cure ; and this may always be safely done where the local inflamma- tion and general irritability of the system are not very great, or when no habitual hemorrhagic discharge has been established. Where alarming consequences, or symptoms of general ill health, follow the suppression of hemorrhoids, we should endeavor to re-establish the complaint. This may usually be done without much difficulty by aloetic purgatives, small doses of the extract of savin, stimulating enemata, particularly terebinthinate or aloetic injections, leeching about the anus, semicupia, and cupping in the neighbor- hood. Richter strongly recommends the following combination for this purpose.J Sect. IX.—Jaundice.—Icterus, aurigo, morbus regius, morbus arcuatus. Jaundice consists in a disordered state of the liver or of the biliary passages, characterized by yellowness of the eyes and skin ; clay-colored feces; a highly bilious urine ; and generally by a languid state of the circulation. In many instances the disease approaches very slowly and insidiously. It * R_Ol. amydalor. gi. Extract, stramonii £'\. Sulph. morphiae grs. vi.—M. ft. linimentum. f R.—Pulv. rad. enul. campan. Pulv. peper. nig., ii oviii. Pulv. sem. fcenicul. §xii. Mel. despumat. Sacch. albhaa. gxvi.—The first three are to be intimately mixed ; then melt the honey and sugar over a fire into a clear syrup; add the other ingredients and form an electuary. X R— G. aloes. G. assafcetid. Extract, hellebor. nig. Ferri sulphur. Croci orient. J^i. Mucilage g. Arab. q. s— Divide into grain pills. Take from five to eight every evening. 688 JAUNDICE. commences with a general feeling of languor, disinclination to bodily and mental exertion, an irritable and dejected temper, weakness of appetite, constipation, acid eructations, slow and painful digestion, slight flatulent pain in the bowels, a feel- ing of fullness and slight tension in the epigastrium ; anxiety in the praecordia, restlessness at night, a turbid urine usually depositing a copious pitchy sediment, slow and languid pulse, more or less nausea, and frequently transient creeping chills alternating with flushes of heat. After these symptoms have continued for a few days, a disagreeable itching over the whole body occurs ; the taste becomes bitter; the stools whitish or clay-colored; the urine of a deep saffron hue; and finally the white of the eyes, and ihe skin about the lips, neck and forehead assume a yellow color, which speedily extends itself, until the whole surface acquires a uniform yellow hue. When the disease has arrived at this stage, the general debility and sluggishness, as well as the uneasiness and tension in the epigastrium, increase, and although the pulse is generally slow, full and somewhat firm, slight febrile exacerbations almost always take place in the evening, with some augmentation of the temperature of the skin, and occasional transient sen- sations of chilliness, with much restlessness during the night. The skin is gene- rally dry and husky. If the disease continue a long time, the body begins to emaciate; the evening febrile exacerbations become more conspicuous ; night sweats ensue; and in many instances, dropsical effusions at last take place into the cavity of the abdomen; respiration becomes anxious and oppressed, and where it verges to a fatal termination, a soporose and torpid condition comes on towards the conclusion. In some instances, however, the disease comes on so insensibly that no parti- cular local or general manifestations of its approach are noticed until the eyes and skin begin to assume a yellow hue. When the disease makes its appearance in these two ways, it depends probably on a morbid viscidity of the bile, in conse- quence of which, its passage from the liver into the intestines is impeded or entirely prevented. Sometimes, instead of the gradual manner just mentioned, the disease com- mences at once with severe dull pain a little below and to the right of the pit of the stomach, increasing rapidly in violence, with excruciating exacerbations, spreading towards the left shoulder down to the loins, and throughout the whole epigastric region ; at the same time, the patient experiences almost incessant and extremely distressing nausea, attended with so great a degree of gastric irritability that everything swallowed is immediately thrown up again with the most violent and painful vomitive efforts. In such cases, the epigastrium is distended, and generally tender to the touch; but the pulse usually differs but little from its natural condition. When the disease comes on in this manner, it commonly depends on obstruction of the common duct by a biliary concretion. The intensity and brightness of the icteric color differ very considerably in different cases. In some instances, it is of a golden-yellow, in others of a trreen- ish-yellow, and in others again it acquires a dark and almost black shade.* The latter two varieties are, generally, connected with organic diseases of the liver, such as enlargement, induration, and tubercles. In protracted cases of jaundice, the yellow color is not confined to the skin, but pervades almost every part of the body. The adipose structure, particularly, acquires a bright saffron color ; and the internal membranous tissues are usually conspicuously marked with the same tinge. It is, however, extremely uncommon to find the brain and nerves pervaded with its color, and its appearance in the cartilages and bones is an almost equally rare occurrence. The fluids, too, become tinged with yellow. Mursinna gives an account of a fatal case of jaundice, in which he found the viscera of the breast and abdomen, as well as the meninges of the brain, of a deep yellow color, and the serum which he found in the pericardium and ventri- cles of the brain was of the same color and of a bitter taste.X * Cases of this kind are usually called black jaundice, (melasicterus.) X Journal fur die Chirurgie, bd. ii. s. 222. JAUNDICE. 689 It is from the tinge being communicated to the humors of the eyes, that to some jaundiced patients all objects appear of a yellow hue. Of the secretions, the urine is most conspicuously charged with the bilious coloring matter. It is so abundant in this fluid, that pieces of linen or paper dipped into it immediately acquire a yellow stain. In the milk of women affected with this disease, the color and the taste of bile are hardly ever detected. Heberden, indeed, asserts that the presence of bile in this secretion has never been noticed ; but in relation to the taste, I have myself observed an instance in which the milk was very per- ceptibly bitter. Dr. Good thinks that the cause of the very rare occurrence of yellowness in the milk of jaundiced females, arises " probably from its rapid pas- sage and elaboration from the fluids introduced into the stomach." I am inclined to think that this circumstance depends on the bile uniting with the oily portions of the lacteous secretion, and becoming thus suspended with it in the form of an emulsion. We know at least that in the duodenum, it is entirely owing to the union of the bile and the fatty portions of the chyme, that the chyle obtains its milky color;* and it is not improbable that the union of oily and bilious matter may, in part, destroy or precipitate the bitter principle of the latter. This, at all events, must be the case in the duodenum; for, notwithstanding the union of the chyme and bile, the fluid in the lacteals, resulting from the combination, and the thoracic duct, is wholly free from bitterness. The duration of an attack of jaundice is extremely various, and depends, of course, almost entirely upon the greater or less degree of permanency of the occasional cause. In some cases the icteric symptoms come on rapidly under symptoms of great violence, and in a short time disappear again. This is most apt to be the case when the disease arises from the passage of a biliary concre- tion through the common duct, or from spasmodic constriction of this part. Sometimes the disease is marked by manifest remissions, the yellowness of the skin and other symptoms increasing and abating at short but regular intervals for a long time. Not unfrequently this malady assumes a strictly chronic character, without any particular feelings of ill health except slight dyspeptic symptoms, costiveness, and a disposition to indulge in sleep. More commonly, however, * Mr. Brodie, from some experiments he performed, inferred that the principal purpose of the bile is to separate the chyle from the chyme; for he remarked, that, when the choledochus duct was secured by a ligature, and food then given, chymification went on in the stomach as usual, but no chyle could be found in the intestines or in the lacteals. The lacteals contained a trans- parent fluid, which he supposed to be lymph and the watery part of chyme. Herbert Mayo draws the same results from his experiments. These results are at variance, however, with the experiments of Leuret, Lassaigne, Tiedemann, and Gmelin. The former, after tying the duct and clearing out the bowels with castor oil, fed the animal, twelve hours after the opera- tion, with bread, milk, and sugar. Eight hours after this meal, the animal was killed. The food was found digested, and "the thoracic duct was distended with a yellowish-red transparent fluid, which coagulated on standing exposed to the air, and yielded the usual proportion of fibrin, albu- men, and saline matters." Brodie, Mayo, Leuret, Lassaigne, Tiedemann, and Gmelin, observed that chymification went on as perfectly after the common bile duct was tied as in a sound animal. In the experiments of Tiedemann and Gmelin, the thoracic duct always contained an abundance of fluid, which was generally of a yellowish color, (confirming in this respect the experiments of Leuret and Lassaigne, and partly also those of Brodie and Mayo.) This fluid coagulated like ordinary chyle; the crassamentum acquired the usual red color; in short, the only difference between it and the chyle seen in a sound animal, was, that after tying the com- mon duct it was never white or milky. The reason of this difference appears to be, that the white color is owing to fatty matter taken up from the food by means of the bile, which pos- sesses the power of dissolving fat, and probably, therefore, aids in effecting its solution in the chyle at the mouths of the lacteals. " Mr. Brodie appears to have been misled by the absence of the white color which the chyle usually possesses; but which it is well known equally to want in ordinary digestion, if the food does not contain fatty matter." Tiedemann and Gmelin confine the agency of the bile in chylification, simply to the accomplishing the solution of the fatty matter. These experimentalists believe that the biliary secretion, besides its agency in chylifi- cation, is supplementary to the function of the lungs in freeing the blood of its carbonaceous and other heterogeneous principles. 44 690 JAUNDICE. protracted instances of the disease ultimately cause great emaciation and dropsi- cal effusions, and often terminate in a state of apoplectic stupor. Causes.—The etiology of jaundice is, in many respects, still involved in much obscurity. In a general way, it may be said, that all the remote causes of this disease act either by obstructing or preventing the flow of bile from the liver into the intestines ; or by impeding, deteriorating, or suspending the secretory action of the liver. Of the former kind of causes are: 1. Biliary concretions plugging up the duct. 2. Spasm of the duct, which may be excited by acrid bile, duodenal irritation, and perhaps violent mental emotions. 3. Viscid mucus clogging up the orifice of the common duct. 4. Inflammation and thickening of the coats of the duct. 5. Enlargement and induration of a neighboring part, particularly of the pancreas, and perhaps of the mesenteric glands.* 6. Preter- natural viscidity of the bile, by which its flow along the duct is greatly impeded, or altogether prevented ; pregnancy, and impacted feces in the colon. When, by any of these causes, the bile is prevented from flowing into the irftestines, and thereby congested in the biliary passages, it is generally believed to gain ad- mission into the current of the circulation either by absorption or regurgitation, and to be afterwards secreted into the subcuticular tissues, giving rise to the yel- low tinge of the surface. It is quite certain, indeed, that the jaundice will gene- rally supervene speedily when an obstruction of this kind occurs in the common duct; and, from the manifest presence of bilious matter in some of the secre- tions, we can scarcely doubt that in relation to such cases, this view of the etiology of the disease is, in the main, correct. MM. Tiedemann and Gmelin, in their interesting account of a series of experiments on digestion, state, that on passing a ligature round the common duct of animals, they found that about the third day the eyes became yellow, and the urine strongly imbued with a coloring matter, which, by chemical tests, they ascertained to be bile.t To this doctrine it has been objected, that no bile has ever been detected in the blood of patients affected with jaundice, a circumstance which certainly does not countenance the opinion that bile enters the circulation by regurgitation. Against the opinion that the biliary secretion is absorbed into the circulation, it is alleged that it is not at all probable that a fluid so irritating as the bile is, would be received by the extremities of the absorbent vessels, and there is much plausibility in this observation. Nevertheless, when we find the bile making its appearance in the urine, and often in the other secretions, together with a uniform yellow tinge, not only of the surface of the body, but also on the internal organs, at the same time that the white or clay-colored feces show that there is no bilious matter poured into the intestines; and when, finally, dissection discovers to us a com- plete obliteration or obstruction of the common duct, we are forced to admit, that in consequence of the engorgement of the excretory ducts of the liver, from the exit of the bile through its natural passages being obstructed, it is in some way or other abundantly secreted by the kidneys, and its coloring matter at least co- piously deposited in the subcuticular and various other textures of the body. The admission of the bilious matter into the circulation is most likely by ab- sorption; but it is not probable that the bile is thus introduced into the blood- vessels in its state of complete combination. The serous and coloring matter alone may, perhaps, be taken up by the absorbents, while the most acrid and * An interesting case of jaundice, which terminated fatally, is related in the Journal de Pro- gres, and in which the following phenomena were discovered on post-mortem examination. " Two or three inches from the origin of the duodenum there was a tumor with elevated edges, rather larger than a crown piece, the surface of which was uneven, very hard to the touch, of a whitish-yellow color, and very vascular. The different coats of the intestines were involved in the disease, which included, at one of its edges, the openings of the biliary and pancreatic ducts, which were extremely contracted and almost annihilated. The gall-bladder was extremely distended, and, when strongly pressed, a few drops of bile issued forth into the duodenum/'— Med.-Chir. Rev., July 1828, p. 440. t Recherches Experimentales Physiologiques et Chymiques sur la Digestion, second partie, p. 47. JAUNDICE. 691 irritating portions are left in the liver. Both Deyeux* and Clarionf found in the blood of patients laboring under jaundice a considerable portion of a yellow mat- ter, which communicated a saffron stain to liver, just as the urine of such per- sons is known to do. Among the above-mentioned causes of obstructions to the flow of bile into the intestines, the most common undoubtedly are, biliary concretions, spasm of the duct, and preternatural viscidity of the bile. A very viscid state of the bile is probably much more frequently concerned in the production of this disease than seems to be generally supposed. Dr. Annesley, in his work on the diseases of India, states that he frequently found, upon post-mortem examination, "the gall- bladder loaded with a bile of a dark-green color and so thick and viscid that it could scarcely be forced through the ducts by squeezing the gall-bladder, although the blow-pipe or probe would pass readily along them, showing that the obstruc- tion was then owing to the viscidity alone." When the disease is preceded and accompanied by a constant aching and soreness, with occasional extremely severe paroxysms of pain in the right epigastrium, together with great irritability of the stomach, we may infer that it arises from the passage of a gall-stone through the common duct. The suffering, in cases of this kind, after a longer or shorter period, suddenly ceases; and this occurrence may be considered as announcing the entrance of the calculus into the duodenum. From some late pathological researches by Andral, it appears that irritation and inflammation of the mucous membrane of the duodenum sometimes produce jaundice where no obstruction can be detected in the biliary ducts; and it is perhaps in this way that the jaun- diced hue of the skin is produced in yellow and other severe forms of bilious fever. Dr. Marsh has also related some cases which render it probable that inflammation of the mucous membrane of the duodenum is sometimes extended to the lining membrane of the ducts, whereby a contraction of these passages is produced, either by spasmodic constriction or by a thickening of their coats. Dr. Marsh observes, that hysterical women, of a relaxed and gross habit of body, are subject to a form of jaundice which, though strongly resembling those cases that arise from the impaction of a gall-stone in the common duct, appear, nevertheless, to owe their origin to a less permanent cause. Some mental com- motion, and particularly an error in diet, seems, in most instances of this kind, to be the remote cause of the disease. These come on like a violent attack of bilious colic, or with symptoms resembling those which occur from the passage of a biliary concretion through the common duct. "A pain," says Sydenham, "not less severe than that of the iliac passion, is felt at the region of the stomach, or somewhat lower, which is succeeded by copious vomitings of matter, sometimes green, sometimes yellow. To these symptoms are added, a depression of mind and despair exceeding that in any other disease. // is accompanied sometimes with a remarkable jaundice, which spontaneously subsides in a day or two. The least commotion of mind, whether it be anger or fear, brings back the pain." When the pain subsides, large quantities of flatus pass off, either upward or downward; and the ejections from the stomach, during the continuance of the pain, are usually acid. I have attended an elderly lady in this city, who is prei cisely of the habit of body just mentioned, in five or six paroxysms of this kind. The disease always commences like a violent attack of bilious colic, attended with vomiting of a green and acrid bilious fluid. It seldom lasts longer than about forty-eight hours, by which time the surface of the body begins to become yellow, and soon acquires a deep jaundiced hue. In nearly all the attacks, I have been able to trace its origin to errors of diet or some mental commotion. Dr. Marsh says these cases may, in general, be readily recognized by the copious * Considerations Chymiques sur le Sang des Icteriques.—Journal de Medecine, Messidor an. xii. p. 288. t Considerations Chymiques et Medicinales sur le Sang des Icteriques, Presentees et Souten- nues a fecole de Med. 692 JAUNDICE. secretion of limpid urine which occurs in them. This, however, is only correct with regard to the appearance of this secretion in the very commencement, for commonly in the course of thirty-six hours from the beginning, the urine becomes bilious, as in other instances of jaundice. The leading proximate cause, in cases of this kind, is probably spasmodic constriction of the gall-ducts, or preternatural viscidity of the bile. Duodenal irritation, from flatus or acrid bile, and imper- fectly elaborated chyme appear to constitute the principal exciting causes of this variety of the disease. Leeches, fomentations, abstinence from food, purgatives, and full doses of opium, will always soon relieve the painful symptoms of the complaint. Jaundice, as has been already intimated, may be produced also by causes that act upon the liver through the medium of the general system. Some of these causes appear to produce torpor of this organ, and consequent suspension of the biliary secretion; others, perhaps, give rise to the secretion of acrid bile; which, stimulating the ducts, may occasion spasm and retention of the biliary matter in the hepatic ducts; and others, finally, gradually produce more or less disorgani- zation of the liver. Of this variety of causes, are—intemperance in the use of spirituous liquors; irritating substances in the primae viae; suppression of acute and chronic cutaneous eruptions; violent mental emotions, particularly grief;* constipation; suppressed perspiration; the slow influence of malaria; wounds of the scalp; metastasis of gout; and perhaps mercury .t That the cessation or great diminution of the biliary secretion, whether from mere functional torpor or structural alteration of the liver, is capable of giving rise to jaundice, admits of no reasonable doubt. Cases of fatal jaundice have been reported, in which, upon post-mortem examination, the ducts were found entirely unobstructed, and the small portion of the bile found in the gall-bladder and liver, of a natural consistence.^ When the elimination of the recrementi- tious matter which enters into the composition of the bile is not duly effected by the organ destined for this office, the blood will necessarily become surcharged with this matter, and by a natural tendency of the animal economy to cast off what may be injurious to its welfare, the kidneys, as well as the general capillary system, will in a manner perform the office of the liver, and free the blood of a portion of its superabundant biliary elements, by depositing them into the sub- cuticular textures, as well as into other tissues, and particularly also in the urinary secretion. Prognosis.—The prognosis of jaundice varies of course according to the nature of the occasional cause, and the general vigor of the system. When the disease does not depend on organic affection, or obstruction of the common duct by large biliary concretions, it may, in general, be removed without much diffi- culty. Cases arising from violent anger, spasm of the duct, mucus clogging the orifice of the duct, and on preternatural viscidity of the bile, are often speedily removed by an appropriate treatment. In many instances arising from biliary concretions, the obstructing calculus is not so large as to cause it to be very long in passing through the duct into the duodenum; and such cases, though often attended with extreme pain and gastric disturbance, usually disappear in the course of eight or ten days ; but where the disposition to form biliary concretions is strong, which is not uncommonly the case, the paroxysms of suffering and * Dr. Marsh gives an account of a case, where a young girl, in the Lock Hospital, who had got cold while under the influence of mercury, was suddenly informed of the death of her uncle, the only one of her relations who had treated her with kindness; she immediately became uni- versally jaundiced.—Dublin Hosp. Reports, vol. iii. art. 6. ■j- Dr. Colles communicated an instance to Dr. Marsh, where a young gentleman, after under- going an alterative course of mercury, suddenly became deeply jaundiced. In a few days after- wards he died, in a state of delirium and convulsions. On dissection, not the slightest change of structure was discovered. The internal as well as external parts were strongly tinged with bile. X Stoll, Ratio Medend., vol. iii. pp. 361-366. JAUNDICE. 693 jaundice are apt to recur again and again, at longer or shorter intervals. It is said, that jaundice occurring in consequence of injuries of the head, is, in gene- ral, particularly dangerous, and difficult to be removed.* The supervention of stupor, coma, or delirium, is always an extremely unfavorable sign. When the icteric tinge acquires a very dark appearance, approaching to a blackish hue, we may infer that the disease will be very obstinate, or probably altogether incur- able; for such cases are almost always dependent on incurable organic affection of the liver, or of the neighboring organs. If, in cases of this kind, copious hemorrhages occur from the nose or lungs ; or if violent colic pains and profuse colliquative diarrhoea come on, the prognosis may be regarded as extremely un- favorable/! When the perspiration is so copiously charged with the coloring matter of bile as to communicate a yellow tinge to the patient's linen, there is reason to apprehend a total and obstinate obstruction to the passage of the bile into the intestinal canal. (Jahn.) The occurrence of tympanitis, dropsical effu- sions, slow febrile irritation, emaciation, and great muscular debility, leaves us but little hope of an eventual recovery. Treatment.—From what has already been said concerning the etiology of jaundice, it is manifest that the treatment requires considerable modifications, according to the particular condition of the biliary organs, upon which the symp- toms of the disease depend; for it should be recollected, that the phenomena which we denominate jaundice, are mere manifestations of some local or sym- pathetic disorder of the biliary organs. When the disease commences with violent pain in the epigastrium, with constant nausea and frequent vomiting, we may ascribe it either to a spasmodic affection of the bile ducts, and perhaps of the duodenum, from some local or sympathetic irritation; or to the impaction of a biliary concretion in the common duct. In cases of this kind, our principal ob- ject, in the first place, must be, to relieve the extreme sufferings of the patient; and for this purpose, opium, the warm bath, leeching, frictions, and emollient applications to the epigastrium, are almost the only appropriate remedies. If the patient be robust and very plethoric, blood should be at once drawn to an extent sufficient to make a decisive impression on the system. I am inclined to think that blood-letting is too much neglected in cases of this character. I have, in several instances of jaundice, commencing in the way just mentioned, procured manifest advantage from an efficient abstraction of blood. Blood- letting may prove beneficial in various ways in this affection. By it we les- sen the tendency to inflammation in the irritated parts ; and it may favor the passage of biliary concretions through the duct, by its general relaxing powers. But it is also a very proper preliminary measure to the employment of opium, upon the liberal use of which our principal reliance must be placed for palliating the painful symptoms. During the first stage of cases of this violent character, emetics, and even purgatives, are out of the question—at least until the gastric irritability has been in a great measure allayed. After having drawn blood, where this evacuation is indicated by the pulse and general habit of the patient, a large dose of opium in union with calomel, should be immediately administered. Small doses of this narcotic will do no good—on the contrary, they often appear rather to add to the general distress of the patient. From four to five grains of opium, with ten or fifteen grains of calomel, should be given at once. When adminis- tered in such a dose, it rarely fails to allay the pain and gastric distress in a few- hours. But in some instances, even this quantity is not adequate to remove the extreme sufferings of the patient, and it becomes necessary to repeat it in smaller doses, until the desired effect is produced. It is not, however, simply as an ano- dyne, that this narcotic may be beneficially employed in painful cases of jaundice unconnected with febrile irritation. When the pain and obstruction to the flow of bile into the intestines are the result of spasm of the duct, we can resort to no * Jahn. Klinik. d. Chronisch. Krankheiten, b. ii. p. 395. f Richter's Specieile Therapie, b. iv. p. 315. 694 JAUNDICE. remedy more directly calculated to remove this condition than opium given in very efficient doses. At the same time that we have recourse to this powerful narcotic, the bowels should be emptied by purgative enemata, repeated until a free evacuation is procured. Much benefit may sometimes be obtained from the warm bath, and where its employment is practicable, it ought to be resorted to in conjunction with the measures just indicated. If by these means we succeed in allaying the violence of the symptoms, we may then have recourse to purgatives and emetics. The latter have been very generally recommended in cases where there is reason to apprehend the presence of a biliary concretion in the common duct. The relaxation and concussive agitation produced by the operation of an emetic, may contribute materially to expedite the passage of the concretion through the duct, an event which must be deemed essential to the removal of the disease. We are told by Dr. Darwin, that in two instances he saw upwards of thirty gall-stones voided by stools soon after the operation of an emetic. We must not, however, forget, that great pain in the epigastrium, with irritability of the stomach, and a universal jaundiced hue of the surface, may arise from high irritation, or inflam- mation of the mucous membrane of the duodenum, without any obstruction from biliary concretions ; and in such cases the exhibition of an emetic could not fail to prove injurious. These cases may be distinguished from calculous irritation of the ducts, by the very manifest presence of fever, or rather the small, quick, tense, and frequent pulse, and the warm and dry skin, which occur in duodenal inflam- mation ; and the slow, full, and rather active state of the pulse, and entire absence of the usual symptoms of fever, in cases depending on obstruction to the course of the bile from biliary calculi. Where there is reason to suspect high duo- denal irritation, or subacute inflammation, as lying at the foundation of the malady, recourse must be had to leeching, blistering, and fomenting cata- plasms to the epigastrium; a bland and liquid diet; laxative enemata; cool- ing acidulated drinks; small portions of opium and ipecacuanha in combina- tion ; and rest. The use of emetics and purgatives is out of the question. Various remedies were formerly recommended with the view of consuming or dissolving the biliary concretions lodged in the liver or its ducts; but the age of confidence in such remedies has passed by, and there is now but little, attention paid to articles of this kind, with a view to their resolvent powers, although some of them may do good by their tendency to excite and alter the action of the liver. The alkalies, soap, a solution of the yolks of eggs in vitriolic ether, Durande's mixture, composed of two parts of vitriolic ether and one of spirits of turpentine, the natural mineral waters containing carbonic acid gas in an un- combined state, and mercury, have been most generally employed for this pur- pose. With regard to the vitriolic ether and spirits of turpentine, Dr. Good very justly observes, that where there is a tendency to inflammation, they may do harm by their stimulant effects. In one case under my care, this mixture ap- peared to do much harm, for it manifestly increased the general irritation of the sanguiferous system, and gave rise to much epigastric tenderness. Where spasm of the duct may be presumed to be the primary affection, nauseating doses of antimony; hyoscyamus; assafoetida; infusion of chamomile; active purgatives; emollient cataplasms or fomentations; anodyne frictions, and enemata, are recom- mended by the older writers, but they are so greatly inferior to opium, the warm bath, and revulsive applications to the epigastrium, that they scarcely deserve any attention as remedies in this affection. In cases that come on gradually, with little or no pain in the region of the duodenum and duct, and where, of course, there is little or no probability of the existence of spasm or biliary concretions, the principal indication is to restore the regular functions of the liver, and alimentary canal. Unfortunately, we cannot determine, with any degree of certainty, whether such instances consist merely of functional torpor of this organ, or of a slow organic change of its structure, or of the gradual formation of an indurated enlargement of the pancreas, or of some other latent affection of the bile ducts, or duodenum near JAUNDICE. 695 the opening of this duct, or finally of a loaded state of the colon ; and our reme- dial measures must, therefore, often be applied under much uncertainty as to their fitness to the actual condition upon which the general icteric symptoms depend. The mere empirical prescription of remedies for the remote consequences, or symptoms of the primary hepatic disorder, or for jaundice, as is usually said, will not satisfy the scientific physician ; and yet, in many cases, the minutest attention to the circumstances and phenomena of the disease, will enable us to form only plausible conjectures as to its true nature. Where there is reason to presume that the primary morbid condition consists in functional inactivity of the liver, mercurials are the principal curative means. As this functional torpor is, however, itself, probably only a consequence of an irritation located elsewhere, particularly in the mucous membrane of the alimentary canal, it will always be especially proper to attend to the state of the bowels in all cases that come on slowly, and without any particular pains in the epigastrium. About two years ago, I had a striking example, illustrative of the propriety of this latter observa- tion. A young man, who had for several years labored under weak digestive powers, became gradually deeply jaundiced, with clay-colored feces and highly bil- ious urine. The liver was manifestly in a very inactive condition, and although no distinct pain was felt in the epigastrium, moderate pressure about the region of the umbilicus gave rise to great soreness and distress. He had already taken a great deal of medicine, under the direction of another physician, without the least perceptible advantage. I put him upon the lightest kinds of liquid farinaceous diet, and directed him to have fifty leeches applied to the epigastrium, and to use a laxative enema every morning soon after breakfast, and three grains of blue pill every night on going to bed. In less than a week after this treatment was com- menced, he began to mend, and in the course of four weeks his health was entirely restored. Jaundice has been known to recur in a strictly periodical manner, and cases of this kind are, perhaps, always intimately connected with intestinal irritation. Bang mentions an instance of periodical jaundice, which, after many other remedies had been ineffectually used, was speedily cured by the application of a large blister over the right hypochondrium. In cases of this kind, unattended with high irritation of the mucous membrane of the intestinal canal, some advantage may also be derived frrom the extract or infusion of taraxacum ; and some of the German physicians strongly recommend the infu- sion of saponaria officinalis, a common plant in this country. The taraxacum is supposed to possess considerable powers as a deobstruent; but its usefulness in affections of this kind, if it really possesses any, arises probably from its mild aperient and diuretic operation. Mercurial frictions on the right hypochondrium are highly proper in such cases. A most excellent remedy for exciting the action of the liver, and promoting a healthy secretion of bile, is the nitro-muriatic acid bath, employed in the way mentioned under the head of Chronic Hepatitis, at page 209 of this work. Many highly respectable testimonies might be cited in proof of the beneficial effects of this remedy in cases of chronic jaundice. I have myself used it with marked advantage. Mercury, in alterative doses, and the nitro-muriatic acid bath, appear to be equally well adapted to the treat- ment of this affection, whether it consists in mere functional torpor of the liver, or in vitiated biliary secretion ; and in general, wherever the disease is gradual in its approach, and unaccompanied with distant pain, these remedies deserve a full trial. When the disease continues a long time, and the icteric hue acquires a dark ap- pearance, there will be much reason for suspecting the existence of some organic affection of the liver. Cases of this kind are almost always entirely beyond the control of remedial measures; yet it will be proper, even under the most unfa- vorable circumstances, to make an effort to remove, or at least to arrest, the progress of the hepatic affection. External revulsive applications, low diet, and the use of mercury or the acid bath, just mentioned, are the only means upon which the least jeliance can be placed in cases of this character. Where 696 DIABETES MELLITUS. enlargement and induration of the spleen or pancreas exist, the tincture of iodine would, probably, be of service. Whatever be the precise nature of the hepatic derangement, a strict attention to proper dietetic regulations is of great consequence. The digestive powers are always weak in cases of jaundice, and an error in diet may not only cause great uneasiness and distress from the ordinary affections of dyspepsia, but what is more to be dreaded, may readily give rise to high irritation in the mucous membrane of the duodenum, as well as of the other portions of the alimentary canal, and thus tend, in no trifling degree, to increase the hepatic disease, or to develope inflammations. Where there is tenderness in the epigastrum, and, in general, in all recent cases commencing with violent symptoms, the diet should be of the lightest or least irritating kind. In instances that assume a chronic form, the food should be digestible and simple ; and where there is reason to suspect the presence of gastro-enteric irritation, it will not be prudent to allow solid food, even of the lightest and most digestible kind. There are few cases that have given so great a scope for empiricism as the one now under consideration. Articles of the most opposite, and in many instances of a decidedly pernicious character, have been extolled as specifics for the cure of this affection. The old and exceedingly absurd doctrine of " signa- tures" gave rise to the employment of the celandine,* and there are not wanting many highly respectable authorities in favor of its use in this malady. The agrimony, too, was formerly highly extolled for its efficacy in jaundice,! and of late years the sanguinaria has been brought forward as a valuable remedy in this affection. This remedy was much praised by the late Professor Smith, of New Haven. He gave the tincture in doses of from thirty to fifty drops three times daily. Hempseed boiled in milk, is another remedy which has been said to possess very useful powers for the cure of this affection. Sydenham strongly recommends rad. rub. tinctor.; and Baldinger relied much upon the use of small doses of ipecacuanha. It is not improbable that these, and many other remedies that have been mentioned, may, under peculiar circumstances, be occasionally serviceable ; but as we are wholly without any rational indications for their use, their employment is a kind of hap-hazard practice, which will be more likely to do mischief than good. CHAPTER VII. CHRONIC DISEASES OF THE URINARY ORGANS. Sect. I.—Diabetes Mellitus. Diabetes was known to the ancient Roman physicians, but it does not appear that they had any knowledge of the essential characteristic of the disease—namely, the saccharine character of the urine. They seem to have considered the disease * Jahn speaks very favorably of the following combination, where the disease depends on torpor of the liver, and a sluggish condition of the portal circulation : ]j.—Sulph. aurant. antimon. Qi- Gum. ammon. G. assafcetid. Fel. tauri, aa gii. Extract, chelidonii maj. q. s.—M. Divide the mass into two grain pills. Take from eight to twelve pills four times daily. f J. Hill. Method of Curing Jaundice and other Diseases of the Liver,.by the Herb Agrimony. London, 1709. DIABETES MELLITUS. 697 only as a rapid discharge, by the kidneys, of whatever drinks were taken into the stomach, without having undergone any changes by the digestive or assimi- lative functions. " Diabetes," says iEgineta, "est subitus potulentorum exitus, talibus per urinam redditis qualia pota fuerant"—"a sudden discharge of liquids drank, which are voided by the urine, such as they were taken in by the mouth." Celsus, too, says diabetes consists in a greater discharge of urine than there are fluids taken in by the mouth; and Aretaeus, who has given an accurate descrip- tion of the course and phenomena of this disease, defines it in the same way. The saccharine character of the urine in diabetes, was not known or pointed out, until Willis directed the attention of the profession to it; and although this morbid condition of the urine is unquestionably the essential characteristic of diabetes, it has frequently been wholly left out of view in the definitions which have been given of this disease. Cullen himself has fallen into this error in his definition of this malady. "It consists," he says, "in the voiding of a preternatural quan- tity of urine;"—and in thus neglecting to notice the characteristic quality of the urine, he confounds it with diseases which are radically distinct from it, and which resemble it only in the circumstance of an unusually large flow of urine. There are at least three varieties of urinary disease, which are accompanied with a preternatural flow of urine, but which are nevertheless essentially distinct, as well from each other, as from the disease now under consideration. By diabetes, then, is meant that form of urinary disease, in which the urine is sensibly impregnated with saccharine matter, Und voided in an unusually large quantity, being attended with great thirst, voracious appetite, and an obstinately dry and harsh skin. Diabetes usually makes its appearance in a very gradual manner, although in some instances it comes on suddenly, with slight chills and febrile commotions. When its invasion is gradual, it is generally attended from the first with various indications of a disordered state of the digestive organs—such as variable appe- tite, acid eructations, occasional nausea, and vomiting. The quantity of urine discharged in this affection, is almost always extremely great; and in some instances truly enormous. I have seen two cases in which from twelve to fifteen pints of urine were discharged in the course of twenty-four hours, for several weeks. That such a drain from the system must cause great and rapid exhaustion and wasting of the body may be readily conceived; and, indeed, the utmost degree of prostration and emaciation never fails to ensue as the disease advances in its course. The urine in this disease is generally of a pale straw color, approaching some- times to a shade of green.* Its smell is usually faint, resembling that of milk, or, according to some, that of fresh animal broths, and its taste is more or less sweet, from the sugar which it contains. Diabetic urine always contains very little or no urea, and in most instances it is entirely destitute of lithic acid. It enters very slowly into putrefactive decomposition, but passes readily into the acetous or vinous fermentation. In these circumstances it differs very essentially from the urine of other varieties of disease resembling diabetes—in which latter it always putrefies with great rapidity, and becomes exceedingly fetid. Symptoms.—The constitutional symptoms which attend this disease, are— very urgent thirst; craving appetite; dry skin ; a distressing sense of weight and uneasiness in the stomach after taking food; dry and parched mouth ; white, foul, sometimes clean and red tongue; wasting of the flesh; a feeling of languor and aversion to exercise; debility; pain and weakness in the loins; irregular action of the bowels, being most commonly costive; some degree of inflammation and pain about the prepuce and glans penis, and especially about the external orifice * Cases have been frequently observed, in which the inordinate secretion of urine has sud- denly ceased without any assignable cause. A distressing strangury has been known to super- vene" on the occurrence of such sudden cessations of the diabetic symptoms.—(Dr. Carter, Med. Repos. 1823.) 698 DIABETES MELLITUS. of the urethra; loss of virility; cold feet, with a tendency to oedema in the latter period of the disease; dull arid aching eyes; indistinct vision, with vertigo; head- ache; and difficulty of breathing. As the disease gains violence, and draws towards the fatal termination, the gums become spongy and the breath fetid or disagreeable, and the voice rough, or extremely weak and whispering. The emaciation and exhaustion proceed with great rapidity towards the conclusion, and the patient finally sinks into a state of somnolency or drowsiness, from which it is often extremely difficult to keep him roused even for a moment. In general, the pulse is but little or not at all accelerated in the early periods of the complaint; but in many instances it is even less frequent than in health. In the advanced stage of the disease, however, when the emaciation and exhaustion are very great, it is not uncommon to find the pulse very frequent and quick. In some instances the blood has been found sizy, or covered with a thick inflam- matory crust. Home states, that the blood of one of his diabetic patients mani- fested a highly inflammatory character, although the pulse was rather below the regular standard in frequency and strength. It is by no means unusual for this disease to terminate in apoplexy—a circumstance somewhat remarkable, when we consider the exhausted and worn down condition of the system in the last period of the disease. In a case which I attended some years ago, the patient became completely lethargic for about eighteen hours previous to death, and during this period the urinary secretion was almost entirely suspended. I sus- pect, indeed, from this case, as well as from others which have come under my notice, that in all instances where the disease terminates in a state of stupor or lethargy, the secretion of urine is greatly, if nqt almost entirely suspended. The disease, in such instances, seems to pass from the kidneys to the brain—an oc- currence which is not uncommon in ischuria renalis. The duration of diabetes is extremely various. In some instances, not more than four or five weeks intervene between the commencement and the fatal ter- mination of the disease, whilst the majority of cases are protracted to several months, and occasionally to as many years. In some instances considerable re- missions occur in the progress of the malady; and cases are mentioned, in which the diabetic symptoms recurred in a strictly periodical manner, with perfect in- termissions of longer or shorter duration. In some individuals there appears to exist a natural or constitutional predispo- sition to this disease; and there are many instances on record, which go to prove that this predisposition is sometimes hereditary. I attended a young man labor- ing under this disease a few years ago, in consultation with Dr. Parrish, who had lost his mother and a sister by the same complaint. Dr. Prout mentions several instances of this kind ; and similar cases are to be found in other works on this disease. Mr. Venables has recently directed the attention of the profession to the dia- betic affections of children. He thinks that many of the cases that are considered as instances of marasmus, rickets, &c, are intimately connected with morbid and excessive urinary secretions. Several cases of gradual wasting, attended with great thirst and voracious appetite, came under his notice, which he ulti- mately ascertained to be wholly dependent on diabetic affections. Infantile diabetes, says Mr. Venables, seldom appears till after the child has been weaned. The child, when the disease comes on, will lose its usual flow of spirits, and manifest an obvious state of general indisposition. After some time, it begins to waste in flesh—the skin becoming, by degrees, harsh, dry, and flabby, and very warm. " In the early state of the disease, the bowels are regular, and little or no deviation from the natural and healthy appearance of the alvine discharges is to be noticed. The tongue also, at the beginning, indicates no symptom of dis- ease." After the disease has made some progress, the bowels become disordered, and the alvine evacuations are unnatural—being sometimes greenish, at others dark, and mixed with bile. At a still more advanced stage the abdomen becomes dis- tended and tense, similar to what occurs in chronic enteritis or marasmus. The DIABETES MELLITUS. 699 pulse is Usually accelerated from the commencement, and soon becomes small, tense and wiry. "The most remarkable symptom, however, although it fre- quently escapes observation, is the inordinate discharge of urine. This discharge increases in quantity so gradually that it is not usually noticed. By the time it has become more remarkable, great thirst prevails." In the advanced stage of the complaint, the brain often becomes more or less affected. Headache, vertigo, and temporary delirium occasionally occur, and when it proves fatal, the patient dies comatose, or apoplectic. The skin is always extremely dry and harsh to the touch; and in general, considerable fever attends during the advanced periods ; and this fever is almost invariably of a remitting form. In cases that continue a long time, anasarca, and even general dropsy sometimes supervene. This is a condensed abstract of the phenomena of this affection, as given by Mr. Venables. That children may become affected with diabetes, cannot be doubted ; but there is reason for suspecting, that in the disease just described, the diabetic symptoms are symptomatic of gastro-intestinal irritation. In his post- mortem examination, Mr. V. confines himself to the phenomena presented by the urinary organs, a restriction which is much to be regretted.* Of the exciting causes of diabetes our knowledge is as yet but very limited and unsatisfactory. It would appear from the observation of some writers, that males are more subject to the disease than females. According to Rollo, those whose digestive organs are unusually active, and who indulge freely in the pleasures of the table, are most liable to this malady. The free and habitual use of condi- ments and of vegetable articles of diet, especially the farinaceous substances, is said to favor the occurrence of this disease in an especial manner. Protracted grief; despondency; deep sorrow; chagrin; and a sense of great affliction, when favored by an exclusive vegetable, or by weak and innutritious diet, have been known to give rise to diabetes. Sudden atmospheric vicissitudes, more especially when attended with protracted humidity, are supposed also to be capable of giv- ing rise to this disease.! That the habitual or frequent use of diuretic and spiritu- ous potations should have a tendency to produce diabetes in persons who are naturally predisposed to it, can scarcely be doubted. It is probable, also, that renal calculi have sometimes produced this complaint. Upon this subject, however, all our sentiments are, as yet, in a great measure conjectural; for the disease is frequently found to make its appearance without any assignable excit- ing cause whatever.*. Diabetes mellitus has been known to occur sympathetically from pregnancy. A very remarkable case of this kind is related in Dr. Osann's Clinical Reports. During five successive pregnancies, and throughout the whole of each period, the diabetic symptoms were very conspicuous. The quantity of urine discharged was exceedingly great, and on being analyzed, it was found to contain no inconsiderable portion of saccharine matter. The thirst was extremely urgent, but the appetite and digestive powers remained regular, and rather active.§ Pathology.—The opinions which have been expressed concerning the patho- logical character of diabetes, are very various and contradictory. According to the celebrated Mead, its primary seat is in the liver, and not in the kidneys. Some pathologists have ascribed it to spasm in the secretory organs, and placed it among the spasmodic diseases. Others attribute this disease to suppressed perspiration, in consequence of cold, or some other adequate cause. The most * A Practical Treatise on Diabetes; with Observations on the Tabes Diuretica, or Urinary Consumption, especially as it occurs in Children, &c. By R. Venables, M. B., &c. X iEtius asserts that diabetes has been known to occur in consequence of the bile of the colubar dipsas; and Frank mentions the same fact from his own observations. Excessive in- dulgence in venery has also been known to give rise to this disease. X Reil, Home, and others, assert that diabetes is sometimes infectious. This is exceedingly improbable. It is well ascertained, however, that in some districts it is vastly more common than in others. At Colombo, in India, it is so frequently met with, as almost to merit the title of endemic. § Jahresbericht des Poliklinischen Institutes zu Berlin 1823-4-5, p. 23. 700 DIABETES MELLITUS. prevalent opinion on this subject, however, is that which ascribes the disease to a laxity of the kidneys, and to a debility of the urinary organs in general. Sy- denham, Rollo, Cullen, and others, regarded this affection as depending primarily on a disordered state of the digestive organs, in conjunction with a defect in the assimilating functions. Home also entertained a similar idea concerning the pathology of this disease ; he considered it as arising from a defect of the assimi- lative process. Quite recently, Dr. Ayre has published some observations on this disease, from which it appears that he considers it as depending wholly on chronic inflammation of the kidneys. Dr. Barry maintains, that the grand source of diabetes is to be looked for in the fluids; whilst Dr. Johnson is of opinion that it is a disease of the general system, or at least that its pathology cannot be fixed on any one particular organ ; neither in the kidneys, the liver, the stomach, nor the lungs, exclusively. Whatever may be the essential nature of diabetes, or the primary seat of the disease, it appears quite certain, that the proper functions of the kidneys are greatly deranged or perverted in this disease. That this is the case can admit of no doubt, when we advert to the circumstance, that, according to the experi- ments of Nicholas, Granville, and Wollaston, the serum of diabetic blood does not contain a particle of sugar. Its presence in the urine can, therefore, arise only from a perverted secretory action of the kidneys ; and whatever may be the immediate causes of the functional derangement of these glands, its existence must be regarded as the proximate cause of all the characteristic phenomena of the disease. Another pathological condition, though less demonstrable than the former, is, as I conceive, a peculiar state of the blood, which may perhaps exist as the immediate cause of the perverted renal action. That the constituent ele- ments of the blood are not such as they are wont to be in health, is rendered probable by the effects which different articles of aliment have, both on the sac- charine quality, and on the quantity of the urine. If by an exclusive use of ani- mal diet, the secretion of urine becomes less copious, and its saccharine character disappears, the inference naturally is, that by this kind of food the elements of sugar are reduced in the blood, and consequently less abundantly combined by the perverted action of the kidneys. In health, there is always more or less urea secreted by the kidneys ; but in diabetes, this peculiarly urinary compound is rarely formed in any appreciable quantity, and very often none at all. When we take into view the close chemical analogy which exists between this sub- stance and sugar, it appears extremely probable that the urea, which is secreted in health, is, in diabetes, converted into sugar by the perverted action of the kid- neys. According to the analysis of Prout, for instance, urea and sugar are com- posed of the following constituent elements— Urea. Sugar. G.5 hydrogen. 6.5 hydrogen. 20.5 carbon. 40.0 carbon. 26.5 oxyyen. 54.0 oxygen. 46.5 azote. -— azote. Thus the absolute quantity of hydrogen in a given weight of sugar and of urea is precisely the same, while the qnantities of carbon and oxygen of sugar are just double those of urea. From all this it would appear probable, that diabetic blood is deficient in azote, in consequence of which the kidneys are not furnished with a sufficient quantity of this element to form urea, of which it constitutes a large constituent part; and therefore sugar, which contains no azote, is the result of the renal action. This idea, first started, I believe, by Wollaston, is rendered still more probable by the effects which an exclusive animal diet has in reducing the quantity of sugar in the urine, and increasing the formation of urea; for the large proportion of azote which animal food furnishes to the blood, supplies this element in sufficient proportion for the formation of urea by the kidneys, in con- sequence of which the secretion of sugar is either much diminished or wholly DIABETES MELLITUS. 701 arrested. From these observations it is probable, as I have already said, that the blood itself, in this disease, is defective in the regular proportions of its healthy constituent elements. But here we are necessarily led a step further in our in- quiries into the pathology of this malady. What is it, namely, that causes this defective or abnormal condition in the composition of the blood? We can think of but one cause, and that is, a defect of the digestive, but more especially of the assimilative functions of the system. Thus', then, it would appear that diabetes is a disease by no means local, or confined in its pathological state—but, on the contrary, one in which the digestive and assimilative functions, the state of the blood, and the particular functions of the kidneys, are all deeply and essentially implicated. After all, our views concerning the pathology of this mysterious disease, are as yet, in a great measure, conjectural. In this uncertain state of our knowledge, therefore, I may be allowed to throw out a conjecture on this subject, which must be left for future inquiries, either to refute or confirm. It is well ascer- tained that the bile contains a very considerable portion of a saccharine matter, called picromel. May not a morbid condition of the liver, by which this con- stituent of the bile is prevented from being formed, give rise to the vicarious secretion of a similar substance by the kidneys, and thus produce diabetes ? An accurate analysis of the bile of a diabetic patient would throw much light on this point; and until this is done it must remain wholly hypothetical. Post-mortem appearances.—It is a singular circumstance, that the lungs are almost universally found in a diseased condition, in those who die of diabetes. Dr. Johnson declares, that so far as his inquiries go, there is not a single instance on record, where, on dissection, pulmonic disease was not discovered in persons who had sunk under this disease.* The kidneys frequently exhibit an increased vascularity; and many writers state, that these organs are often enlarged, soft, flabby, and otherwise diseased. Some traces of disease are also sometimes discovered in the mesenteric glands, in the lacteals, and in the mucous membrane of the alimentary canal. The blad- der, also, sometimes exhibits a morbid condition, being considerably contracted, with its coats much thickened and indurated. The prognosis in this disease is always unfavorable ; few, comparatively speaking, recover from its attack ; and the cure, under the most favorable cir- cumstances, is always tedious and difficult. I have seen but one case of recovery out of six that have come under my care. Cullen and Currie state that they never knew a single instance of this disease having yielded to remedial treatment; and the celebrated Frank succeeded only in two out of ten cases which he treated. Many other physicians have, nevertheless, been much more fortunate in their treatment of the disease; and although it is certainly exceedingly difficult to cure this malady, it is not quite so intractable as Cullen was led to believe. Treatment.—The plans of treatment recommended in this disease by writers, are as various and discrepant as the notions which have been advanced concern- ing its pathology. A vast number of remedies have been mentioned, as having been used with success in this intractable malady; but, as they have been gene- rally introduced upon vague and hypothetical grounds, or adopted in a purely empirical manner, there are but few of them which appear now to deserve any attention. I have already slated that the blood drawn from diabetic patients exhibits, in * In a recent number of the Strasburg Hospital Reports, Mr. Suroth gives an account of a case of diabetes which proved fatal in a few months. On dissection, no apparent change was discovered in the kidneys, liver, spleen, or pancreas. But in the chest, the morbid phenomena far exceeded the symptoms during life. There were hydrothorax in the left side, hepatization of the left lung, and in its upper portion a large cavernous excavation; universal adhesion of the right lung to the side, but its structure was sound; hydro pericardium; aneurismal dilatation of the pulmonary artery, at least two inches in diameter. The blood was everywhere fluid in the vessels, and mixed with air. 702 DIABETES MELLITUS. many instances, a decidedly inflammatory appearance. From this circumstance, and from the firmness of the pulse observed in some cases of the disease, a direct antiphlogistic treatment has been proposed, and successfully practised by several eminent physicians. Mr. Watt, of Glasgow, who, I believe, first resorted energetically to the depletory plan of treatment in this disease, has adduced seve- ral very interesting examples of its efficacy in this affection. Since the publica- tion of his valuable work on this malady, venesection has been frequently re- sorted to, both in Europe, and in this country ; and cases have been reported in which its usefulness appears to be well attested. It is, indeed, pretty generally admitted, that the abstraction of blood-may, in some cases at least, be very ad- vantageously practised, although there are very few, I think, who would be will- ing to accord to it as much importance as is done by Mr. Watt. Dr. Prout observes, that in recent cases of a manifestly phlogistic character, blood-letting is often a very valuable remedy. In very protracted instances, however, occurring in old and infirm subjects, and, indeed, in all cases attended with great debility, it is scarcely necessary to observe, that this remedy can very seldom be required. In one of the cases which I treated some years ago, the pulse was such as in- duced me to think advantage might be obtained from the abstraction of a portion of blood. The patient was accordingly bled to the extent of fourteen ounces, but instead of the benefit which I anticipated, an obvious aggravation of the affec- tion was the consequence. It must be observed, however, that the only case which I have ever succeeded in curing was bled twice, and the pulse in this instance was by no means very active, or hard, nor did the blood drawn exhibit the inflammatory crust. It appears, indeed, that blood-letting is, in general, bet- ter borne by diabetic patients with a feeble state of the circulation, than in most other affections under the same state of arterial action. Mr. Watts relates a case of diabetes in which the pulse was slow, feeble, and irregular; there was also great prostration of strength, and the lower extremities were cold and aedema- tous. The blood was very dark, with a crassamentum as black as pitch, and wholly devoid of tenacity. Notwithstanding these appearances, the lancet was freely employed, and the result showed that it was proper and judicious. The bleeding was repeated six times, and it was not till the fourth repetition of it, that the appearance of the blood was changed, the crassamentum having now become dense and sizy on the top. On the fifth bleeding, the buffy coat was contracted to the size of a quarter of a dollar; after the sixth it was still firmer, and the serum exhibited a white milky appearance. The patient felt better after every bleeding, and he recovered without much difficulty. In a late number of Majendie's Journal, (1828,) M. Lefevre has related a case of this disease which was successfully treated by blood-letting, in conjunction with an exclusive ani- mal diet, the use of milk and lime-water, and the hot bath every evenino-. Dr. Venables agrees with Dr. Watt, in regarding blood-letting as a valuable curative means in this affection. " We should not be deterred," he says, " from repeat- ing the bleedings, merely because the blood does not exhibit the buffy coat. I have generally found that a dense milky appearance of the serum indicates in- flammatory action, and this independently of the appearances presented by the coagulable part. I have found the pulse rise under such circumstances after venesection, and a repetition of the operation required. He prefers repeated small bleedings to fewer larger ones. Upon the whole, I think it may be con- cluded that venesection is a remedy which deserves considerable attention in the treatment of this disease, although it is certainly by no means so generally salu- tary as was supposed not many years ago. Local bleeding by means of leeches and cups, has also been resorted to with excellent effect. Dr. Ayre, who considers this disease as depending on chronic inflammation, or inflammatory irritation of the kidneys, considers the application of leeches or cupping over the region of the kidneys" as the most effectual means we possess, for subduing this malady. It appears, however, that he has founded both his theory of the pathology of the disease, and his high opinion of the effi- DIABETES MELLITUS. 703 cacy of local depletion, on the fortunate result of but a single case; a foundation which, it must be confessed, is much too infirm to justify us in placing any great reliance on his experience in this respect. I should be inclined to prefer cupping to leeches, as the former, besides its evacuant effect, is decidedly the most pow- erful derivative measure. Opium.—There is no article which possesses so much reputation as a remedy in diabetes as opium. Since the time of Ferriar, there have, perhaps, been few cases of diabetes treated in England and in this country, in which this powerful narcotic has not been tried in some form or other. Without speaking in very extravagant terms of its efficacy in this disease, general experience justifies the declaration that it is one of our most useful remedies in this malady. Besides its tendency to diminish the inordinate secretion of urine, it is particularly useful in subduing that nervous irritability which, in most cases, becomes so distressing in this disease. Dr. Warren was one of the first who employed this narcotic extensively in this affection. (Lond. Med. Trans. College of Phys., vol. iv.) Dr. Ferriar also used it in nearly all the cases he relates ; he gave it in combina- tion with bark and uva ursi, in the proportion of a scruple of each of the latter to half a grain of the opium, three or four times daily. In conjunction with this combination, he directed the use of lime-water and an animal diet. Prout regards opium as decidedly the best remedy we possess for the cure of this affection ; and of all its preparations, he thinks Dover's powder is the best. It must not be forgotten, however, that where the pulse is strong and firm, blood-letting is an important, if not an essential, preliminary to the employment of this narcotic. " The first immediate effect of opium upon the urine," says Prout, " is to increase its specific gravity. This depends on the diminished secretion of water, while the sugar remains unaltered, in consequence of which the urine is rendered more concentrated, and consequently heavier. As the remedy is persevered in, the urine acquires its original specific gravity, and becomes even lighter. The quantity of sugar is diminished, and that of urea much increased, sometimes so much so as to become greater than natural. Lithic acid soon after makes its appearance in abundance, and the urine acquires altogether a more natural color and appearance," &c. Latham states that he has obtained much advantage from a combination of the carbonate of iron and opium, in cases of a chronic character, and attended with much debility and nervous irritation. Much of the benefit which results from the use of opium, depends, probably, on its tendency to ex- cite the exhalents of the surface. A diaphoresis, in whatever way it may be produced, rarely fails to check the excessive flow of urine, and this effect is always a considerable advantage, although the urine may remain saccharine. From five to eight grains of Dover's powder may be taken every four hours; or we may give a grain of opium, either by itself or in combination with uva ursi and lime water, two, three, or four times daily. It is of importance, when the patient is put on the use of this narcotic, to keep his system constantly and pretty equally under its influence. Opium may also be advantageously given with lime water. From thirty to forty drops of laudanum, in a gill of lime water, may be given three or four times daily. The Germans have been much in the habit of giving large doses of alum in this affection. Cases are related in which scruple doses of this article were given several times daily with very decided benefit. Dr. Venables speaks very favorably of the effects of the phosphate of iron in this affection. "I have been really struck," he says, " with the efficacy of the phosphate of iron in excessive discharges of urine. The quantity of this secre- tion is rapidly reduced under the use of this salt, and, indeed, its qualities sensibly altered. The bulimia, also, which attends diabetes, is reduced, and the powers of digestion invigorated and increased. The dose may be gradually increased from a few grains to half a drachm three or four times daily." Dr. Carter, in his interesting and valuable series of Hospital Reports, has re- lated a case of diabetes, where the disease resisted various modes of treatment, 704 DIABETES MELLITUS. " until hard work, aided by warm clothing, and a scruple of Dover's powder at night, entirely removed the disease." Dr. Johnson, in remarking on this case, observes, "it is evident that the skin, as an extensive outlet, sympathizing pow- erfully with almost all the glandular viscera, is an important agent in the removal of this disease. Its agency, therefore, should never be neglected in the treatment of this disease." Dr. Marsh, in his valuable memoir on this disease in the Dub- lin Hospital Reports, speaks in high terms of the usefulness of exciting the action of the skin in diabetes. For this purpose he directed the same measures which 1 have just mentioned, as having been successfully employed by Dr. Carter— namely, "hard work, warm clothing, and large doses of Dover's powder." In the case which terminated favorably in my own hands, I united the Dover's powder to uva ursi in doses of fifteen grains each, three times daily. This will generally excite emesis for the first two or three days; and the good effects of the remedy appeared to me to be considerably enhanced by the vomiting which it produced. There can exist no doubt that very active exercise or labor, by favor- ing free exhalation from the surface, will often assist very materially in subduing this disease. Some have recommended the warm bath with the same view, but this remedy has too strong a tendency to relax and debilitate the system, to ad- mit of very frequent application in this affection. Frictions with dry flannel, however, are not subject to the same objection, and they have been resorted to with manifest benefit. Magnesia has of late years been recommended in England as a remedy of considerable powers in diabetes. Dr. Trotter has published an account of five cases which were effectually treated with this article. He directed his patients to take from one drachm and a half to two drachms of the pure magnesia, in twenty-four hours. The relief obtained, he says, was generally prompt, and attended with no unpleasant consequences. In one instance out of three in which I have prescribed the magnesia, a manifest impression was made on the disease, but the relief obtained was only temporary. I have met with several accounts in the journals since the publication of Dr. Trotter's cases, in which the beneficial effects of this article are set forth in diabetes. I suspect, however, that its usefulness is chiefly confined to that form of urinary disease, in which the urine, though morbidly increased in quantity, is wholly free from any sac- charine matter. Emetics are recommended by Richter, in the treatment of this disease. He has given an account of several cases which were cured by the use of ipecacu- anha in doses sufficient to produce active emesis. In one case, he asserts that the disease was removed completely in the course of twenty-four hours. It would seem, however, that these cases were characterized only by an increased . discharge of urine, for he nowhere mentions a saccharine urine. Indeed, the custom which prevailed formerly, of including all the urinary affections which are attended with a preternaturally copious discharge of urine, under the head of diabetes, throws no small degree of ambiguity and uncertainty over the recorded experience of the practitioners of the preceding ages. Among the remedies which have been employed with success in this malady, the carbonate of ammonia deserves respectful mention. Dr. Neumen of Ber- lin, has given an account of a case which yielded to the use of this 'remedy continued for about four months. The dose was gradually increased from five grains thrice daily to fifty grains in the day. I have heard of two other instances in which benefit was obtained from this article, though both cases finally termi- nated fatally. Alkaline remedies have indeed been very frequently employed in the treatment of diabetes. Lime water, especially, was at one time much re- sorted to in this disease. Ferriar seems to have placed considerable reliance on it, since we find it mentioned in every case which he has reported. I have my- self used it in three or four cases, in conjunction with uva ursi, but I did not per- ceive that any advantage arose from its exhibition. Rollo thought very favorably of the powers of'the ammonium sulphuretum, DIABETES MELLITUS. 705 or hepatized ammonia, which he rarely failed giving, in conjunction with the more important measure of an exclusive animal diet. In some instances he ad- ministered the kali sulphuretum to the extent of from one to two drachms daily, for several weeks. The application of an epispastic over the sacrum, or the region of the kid- neys, has been thought a very useful auxiliary in the cure of this disease. Rollo, Frank, and Marryat, speak favorably of this practice ; and I am inclined to think that it deserves attention. In the case which terminated favorably under my care, two large epispastics were applied on the inside of the thighs ; as, how- ever, several other active means were used at the same time, it is impossible to say what share this, or indeed any of the other remedial measures, had in the production of the favorable result. Tonics were formerly much resorted to in the treatment of diabetes ; a prac- tice which was founded on the supposed flaccid and debilitated condition of the kidneys and digestive organs. Ferriar gave the cinchona with opium and uva ursi; but the earlier physicians more commonly employed the metallic tonics, more especially iron. Where the system is much relaxed and exhausted, I doubt not at all that the sulphate of quinine may be often very usefully given. If I am not mistaken, Prout advises the employment of this preparation in union with opium. I have heard of an instance in which the administration of three grains of quinine with a grain of alum and the same quantity of ipecacuanha, administered three times daily, produced very excellent effects. The mineral acids, also, are said to have been given with complete success in this affection. Gilby affirms, that out of four cases he cured three with the in- ternal use of the nitric acid; and Scott succeeded in one case with the same remedy. Brea, moreover, cured a case of this disease with the nitric acid given internally, together with mercurial frictions over the lumbar region. Besides the remedies already mentioned, a vast variety of other means are noticed by authors; all of which have been used with more or less advantage, if we are to place any credit in the statements that have been given. Among these may be mentioned the following, as perhaps most entitled to attention: viz., alum;* spir. turpentine; tinctura ferri muriatis; flor. zinci.; cuprum ammonia- cum;! mercury ;| digitalis ; the internal use of cantharides ;§ valerian; assafoetida; catechu ; kino ; camphor; myrrh ; phosphoric acid ; phosphate of soda; phos- phate of iron. I have hitherto said nothing concerning the dietetic means for treating this dis- ease, which, after all, are perhaps the most important and indispensable to suc- cess. Rollo was the first who adopted fully the plan of restricting diabetic pa- tients to on exclusive animal diet, with the view of keeping out of the circulation, as much as possible, the saccharine principles which vegetable substances alone afford. When we recur to what has been stated above concerning the close chemical analogy between urea and sugar; the former being little else than a duplication of the constituent parts of the latter, with the addition of a large proportion of azote; it would seem that in diabetes there is a great deficiency of azote in the blood, in consequence of which the kidneys cannot form urea; but, instead of it, secrete the saccharine matter which characterizes the disease. Now, as animal substances, especially the muscular parts, contain a large pro- portion of azote, whilst vegetables contain little or none of it, it appears probable that the benefits which result from the former kind of food, arise from the abund- ant azote which it furnishes to the system, by which the kidneys are enabled to secrete urea instead of saccharine matter. This accords with the gradual changes which occur in the urine in the progress of amendment; for in proportion as the quantity of sugar decreases, that of the urea increases. * Selle, Beitr. zur Natur. und Arzneiwiss., bd. i. X P. Frank, De Curand. Homin. Morb., p. 65. J. Frank, Ratio Instit. Clinic. Ticinem., p. 208. Brisbane, Select Cases, &c, Steelier, Hufeland's Journal, bd. vi. 45 706 DIABETES INSIPIDUS. Whatever may be thought of these speculative views, it is very generally ad- mitted, that an exclusive animal diet constitutes decidedly one of our most efficient means for curing this disease. It is true, that within a few years, Dr. Starky, physician of the Cork General Dispensary, has adduced some facts which would seem to show, that contrary to the common opinion, vegetable substances, or such as contain sugar, will sometimes prove more beneficial than animal food. He states that he has cured several cases of this disease with a vegetable diet, and a drachm of phosphate of soda three times daily. Dr. Johnson also seems inclined to place some reliance on the occasional usefulness of a vegetable diet in this affection. Were these cases attended with a saccharine urine ? I am much inclined to believe that this fact is not always inquired into; physicians being satisfied that they have a case of diabetes before them, when they find the patient suffering great thirst, ravenous appetite, and an enormous discharge of urine. All these symptoms may, however, exist, without the disease being diabetes—at least diabetes of the kind we are now considering. I shall presently have to describe a variety of this disease, in which there is an excess of urea, and in cases of this kind, a vegetable diet is decidedly indicated, and useful. It is this latter disease, perhaps, which Dr. Starky treated ; and if so, we need not wonder that a vegetable diet was found so useful. The observances to be attended to, in the regulation of the diet for a patient affected with this disease, may be summed up as follows : Fresh bread and potates should be avoided ; but the patient may use moderate portions of pilot bread and biscuit. It is of great importance that the quantity of food taken at each meal should not be more than the stomach can readily digest. Roasted or boiled beef, beet-steak, mutton, lamb, and game, should form the principal part of the food; and it is said that fat meats are, in general, more beneficial than the lean parts. For drink, the patient may use water, alum whey, weak brandy and water, milk and water, and beef or chicken. Sect. II.—Diabetes Insipidus. I proceed now to the consideration of those urinary diseases in which the inordinate secretion by the kidneys is attended with an excess of one or more of the regular ingredients of healthy urine. These affections bear so close a re- semblance to diabetes mellitus, that up to the time of Willis they were compre- hended, indiscriminately, under the single term diabetes. Collectively, they con- stitute the disease which has, since the time of this writer, been denominated diabetes insipidus; but as they are characterized by a very different condition of the urine, it is more consistent with scientific accuracy to treat of them, as Prout has done, under their several appropriate heads. In one variety of these urinary affections, the characteristic state of the urine consists in an excess of urea, with an augmentation of its quantity, often not inferior to that which occurs in saccharine matter in diabetes mellitus. Bostock has given a particular account of a case of this kind, in the third volume of the Medico-Chirurgical Transactions, with an analysis of the urine, from which it appears that the patient discharged, on an average, twenty pints daily, containing seven and a half ounces of urea, without a particle of sugar. But no writer has investigated this disease so minutely, and described its course and phenomena so accurately, as Dr. Prout, in his highly valuable work on the diseases of the urinary organs. In this affection, there is almost invariably a very frequent and distress- ing desire to pass urine, both by day and night. In some instances, though exceedingly seldom, the quantity of urine is not much increased. In a great majority of cases, copious diuresis is a prominent symptom. " The quantity of urine, (says Prout,) appears to be particularly liable to be increased by cold weather, and by all causes producing mental agitation. In some instances the patient experiences a considerable sense of uneasiness or aching pain in the loins, DIABETES INSIPIDUS. 707 and along the course of the ureters, and there is occasionally a good deal of irritation at the neck of the bladder, extending along the urethra." The skin generally retains its regular functions, being often moist, with general diaphoresis, even when the urinary affection is exceedingly aggravated. The desire for food and drink also, is not morbidly urgent, except in very violent cases ; nor are the stomach and bowels often particularly deranged—the tongue being generally clean, and the alvine discharges regular, both in time and appearance. It would appear from the observations of Prout and others, that persons of a thin and spare habit of body, " with a sort of hollow-eyed anxiety or expression in their countenance," are the most liable to this complaint. With respect to the causes of this form of urinary disease, little is known of a definite character. Prout observes that whatever debilitates the system, and particularly the urinary organs, may give rise to the complaint. There is another variety of urinary disease, in which the presence of a large portion of albuminous matter in the urine is the characteristic symptom.* This is the variety which has probably been most commonly described under the name of diabetes insipidus; for along with its albuminous principle, the urine is always greatly increased in quantity. There are two varieties of albuminous matter oc- curring in the urine—namely, the chylous and the serous. The first, according to the observations of Prout, occurs most frequently; "it may, however, be re- marked, (says this writer,) that strongly defined instances of either variety are not very common, and that by far the most frequent form which the disease as- sumes, seems to be of an intermediate character; that is to say, the albuminous matters partake in some degree of the properties of both those of chyle and se- rum; though generally more of those of the chyle." A morbidly copious discharge of chylous urine was known and described by the ancients as a variety of diabetes. Celsus divides too great a profusion of urine into thin and thick ; the former kind, he says, though most frequent, is less dangerous than the latter variety, in which a great quantity of urine is discharged, together with chyle or milk, and the body consequently rapidly deprived of its nutrient principles. Some writers deny that the chyle ever passes off with the urine, as has been stated. They assert, that where the urine has exhibited a milky color, it must have arisen from pus formed in the kidneys, and intimately mingled with the urine in its passage down the ureters to the bladder. That this is a mistaken opinion, is satisfactorily attested by some of the most observant physicians of both ancient and modern times. The appearance of chyle in the urine has been noticed even in apparently healthy subjects. Van Swieten, in his Commentaries, says, " that he has seen in himself some hours after a meal, and especially after hard walking, his urine turbid and milky at the moment that it was evacuated;" and he adds, that he had afterwards observed the same kind of urine in others. Galen also seems to have noticed this chylous state of the urine. (De Aliment. Facult., lib. i. c. 2.) But the authority of Prout is alone sufficient to establish the opinion that ihe milky appearance of the urine, in cases of this kind depends solely upon the presence of unchanged chyle. When, along with the chyle, there is a large portion of albuminous matter in the urine, this fluid undergoes a spontaneous coagulation, assuming the appearance nearly of blane mange. Mr. Elliotsoii, in his edition of Blumenbach's Physiology, re- lates a remarkable instance of chylous urine. This case occurred in a young * [This subject has been carefully investigated by Dr. Bright, of London, and so much im- portance has been attached to it in consequence as to induce the fabrication of a new term in nosology, viz., " morbus Brightii."—Of late the same condition has been denominated by the European journalists, " albuminuria." The only practical result which has been derived from these inquiries is, that when the urine exhibits coagulable matter under the influence of heat, just below the boiling point, an inflammatory condition of the kidneys may be suspected, which should be assailed by the appropriate antiphlogistic remedies. The granulated appearance of the kidney described by Dr. Bright, is by no means essential to the pathology of this affection.— Mc] 708 . DIABETES INSIPIDUS. married woman. In the morning, the coagulum of chyle in the urine was pale, with pink streaks ; in the evening it was white. After fasting for twenty-four hours, the coagulum " was extremely pale, with pink streaks." This kind of urine is extremely prone to decomposition, becoming speedily very offensive to the smell. In some instances, says Prout, the urine, on standing awhile, "throws up a sort of creamy matter upon its surface." The general symptoms which accompany this affection, after it has continued long, and is violent, do not differ materially from those that attend diabetes mellitus. In violent cases, the thirst becomes very tormenting, the appetite craving, and the skin dry and harsh, with progressive emaciation. In less aggravated cases, the constitutional symptoms are generally mild, and in some instances scarcely per- ceptible. The patient, however, generally complains of some degree of uneasy feeling in the praecordium, and a sensation of languor and feebleness in the mus- cles of the loins. I have seen two cases in relaxed, debilitated, and emaciated females, in which the urine seemed to consist almost wholly of albuminous mat- ter, mixed with a small portion of chyle. In both these cases, the urine changed to a jelly-like mass after standing an hour or two. Prout has given an account of a similar case. " The first specimen of urine, voided in the morning," he says, "consisted of a solid jelly-like mass or coagulum, of a pale amber color." The second specimen, voided after breakfast, resembled the first in its general charac- ter, but exhibited a whey or slightly milky color. The third specimen, voided in the evening, after an early dinner, was the most remarkable, and so closely re- sembled chyle in all respects, that it could scarcely be distinguished from this fluid. Causes.—No age, it seems, is wholly exempt from the formation of chylous urine, although it occurs most commonly after the middle period of life; and in persons of an irritable habit of body, and impaired digestive powers from a pre- vious course of free indulgence in the pleasures of the table, and in spirituous drinks. The exciting causes appear to be such, chiefly, as have a tendency to weaken and irritate the kidneys. Violent passions of the mind, and protracted courses of mercurial remedies, are also accounted among the ordinary exciting causes of this disease. Prognosis.—This complaint is not attended with much danger, and in its milder form may continue for many years without producing any very serious consequences. In the more aggravated cases of chylous urine, however, a great degree of languor and emaciation sooner or later ensues; and life is ultimately destroyed, either by the supervention of hectic, or a gradual and total exhaustion of the vital powers. One of the above named cases, that came under my notice, terminated in phthisis pulmonalis. The last variety of urinary disease I have to mention is that in which there occurs an excess of the earthy phosphates in the urine. This affection is by far more common and distressing in its consequences than either of the two pre- ceding urinary complaints. Prout is, I believe, the first writer who has given a definite and circumstantial account of the phenomena and character of the urinary affections, characterized by a deposition of earthy phosphates. A preternatural copiousness of urine forms, in general, a conspicuous circumstance in this variety of the disease. In some instances, indeed, the quantity discharged is not inferior to that which occurs in the most perfect cases of diabetes. The urine is inva- riably pale-colored; and in many instances, it is perfectly colorless and pellucid. When this is the case, the quantity discharged is always very profuse, and it de- posits no sediment on being left to cool. Occasionally it happens that the quan- tity of urine is not much greater than natural; and in ihis case, it is usually somewhat opaque, and deposits a very copious pale-colored sediment after stand- ing awhile. In none of the kindred affections, already considered, does the urine manifest so great a tendency to decomposition as in the present complaint. In a very few hours after being voided, it becomes alkaline, and emits an extremely pungent and disagreeable smell. Connected with these morbid conditions of the DIABETES INSIPIDUS. 709 urine, there always exists very great irritability of the general system, and an obvious derangement of the digestive functions. The patient is tormented with flatulency, nausea, costiveness, or diarrhoea; attended with a sense of weight and oppression after taking food; and variable and capricious appetite. " The stools are extremely unnatural, being either nearly black or clay-colored, or sometimes like yeast. These are always accompanied by more or less of a sensation of pain, uneasiness, or weakness in the back and loins. There is a sallow, haggard expression of the countenance ; and as the disease proceeds, symptoms some- what analogous to those of diabetes begin to appear—such as great languor, de- pression of spirits, coldness of the legs, complete anaphrodisia, and other symp- toms capable of extreme debility." (Prout.) Prout, to whom I am indebted for the foregoing description of this affection, asserts, that "a large portion of the cases which have come under his own obser- vation, were distinctly traced to some local injury of the back—such as a fall from a horse," &c. Among the general causes, he enumerates protracted depress- ing passions ; excessive fatigue. The most common local causes, besides the one already mentioned, are some irritation about the bladder, or urethra, espe- cially when of a chronic character—"such as a foreign substance introduced into the bladder, including all sorts of calculi; the retaining of a bougie or catheter in the urethra; strictures of the urethra in particular constitutions;" and disease of the prostate gland. When injury of the spine is the exciting cause of the disease, the prognosis may, in general, be regarded as unfavorable. Prout observes, that this affection " very rarely gives origin to calculus in the kidneys." Treatment for diuresis with excess of urea.—Experience has shown that tonics, in union with opium and alkalies, constitute the most useful remedies in this variety of the disease. From one to two grains of quinine, with from twenty to thirty grains of the bicarbonate of soda, may be given three times daily, and an opiate administered in the evening. Much advantage may also be obtained from alterative doses of mercury. Three or four grains of blue pill, with one or two grains of ipecacuanha, should be given every other evening, or smaller doses may be given every evening. Gentle purgatives, too, are useful in this variety of the complaint. A mixture of magnesia and rhubarb will, in general, answer better than any other aperient in cases of this kind. The diet should be simple, unirritating, and digestible; and all kinds of stimulating drinks must be avoided. Some benefit will occasionally result from the use of limewater and milk, in conjunction with the remedies just mentioned; but the principal object should be to establish the healthy action of the liver and digestive organs. In diuresis attended with an excess of phosphatic salts in the urine, opium, according to the experience of Dr. Prout, is decidedly the best remedy we pos- sess. The great object, in this variety of the disease, is to allay the general irritability which is so prominent a symptom in this affection. Where opium is objected to by the patient, we may resort to the use of hyoscyamus, in union with uva ursi, with considerable advantage. Two or three grains of the extract of hyoscyamus, with from twenty to thirty grains of pulverized uva ursi, should be given twice or three times daily, according to the urgency of the symptoms. I have, in several instances of this disease, employed the following pills with a most excellent effect.* Mr. Prout mentions a strong infusion of the alchemilla arvensis as a very useful remedy for t^e purpose of allaying the irritability of the bladder. When the irritability of the system is in some degree moderated by the narcotics just mentioned, tonics are more particularly proper—and of this class of remedies, the mineral acids, in conjunction with cinchona or quinine, are decidedly the most valuable in this affeclion. The nitric, or nitro-muriatic * J*..—Extract, hyoscyam. Pulv. camph , aa. ^ss. Mucilag. g. Arab. q. s.—M. Divide into thirty pills. S. Take one four times daily. 710 LITHIASIS. acid, diluted in water, should be freely administered, and continued until the character of the urinary deposit is changed. When the mineral acids are dis- agreeable to the stomach, the citric acid may be employed; but this latter is not, in general, equal to the nitric, or nitro-muriatic acids. From one to two drachms of these acids, diluted in a sufficient quantity of water, may be taken daily. The diluted acid should be sucked through a glass tube or quill, to prevent the teeth from being injured. Ten grains of the extract of hyoscyamus may be dissolved in a pint of water, to which a drachm of the nitric acid is to be added, and which may be used in divided doses during the day. At the same time that acids are employed, it will be proper to keep down the general and local irritability by the use of opium or hyoscyamus; and after the phosphatic condition of the urine has been, in a great measure, removed, by the use of the acids, quinine and iron, in full doses, constitute the principal remedies. Dr. Venables strongly recom- mends the use of the phosphate of iron in this affection. He asserts, that it seldom fails to lessen the quantity of urine discharged. Some benefit may also be obtained from local applications of a stimulating character to the loins—such as plasters of Burgundy pitch, galbanum, turpentine, or stimulating embrocations. Active purgatives are injurious. Prout states that he has known the most serious consequences brought on by a small dose of calomel, which, by inducing diarrhoea, and consequent debility, aggravated all the symptoms. Nevertheless, costiveness is almost equally injurious, and particular care should be taken to keep up a regular action of the bowels. This may, in general, be accomplished by the use of two or three Seidlitz powders, or small doses of castor oil, without the risk of inducing frequent and debilitating stools. Prout says, that mercury, in all its forms, is calculated to do much harm; and all alkaline remedies must be rigidly avoided. The diet should be mild and nutritious. In general, the lean parts of tender meats afford the best food for patients affected with this variety of urinary disease. In some instances, however, a diet of this kind, from the very irritable state of the general system, renders the patient very uncomfortable during the period of digestion. In such cases, farinaceous, and particularly acescent vegetable articles of food, will usually answer very well. Sect. III.—Lithiasis. There is no subject in pathology which has of late years been more patiently and minutely investigated, than the secretion of sabulous matter with the urine, and its formation into calculous concretions. The latest and best works on this subject, are those of Dr. Marcet, Mr. Brande, and Dr. Prout; and it is to the excellent treatise of the latter that I am chiefly indebted for the following facts and observations. Urinary deposits.—There are three forms of urinary depositions, namely: 1. Pulverulent sediments—appearing on the sides and bottom of the vessels in which the urine is left to cool, in the form of a very fine sedimentous powder. These pulverulent depositions are usually of a red color, inclining sometimes to a brown, and at others to a yellow hue. In a general way, they may be stated to consist of two classes of calculous maUer—namely, the lithates of soda, am- monia, and lime, constituting what are usually called lateritious or pink sedi- ments ; and the phosphates of lime, magnesia, and ammonia, constituting the white sediments. These sediments exist in a state of solution in the urine, and are deposited only when it cools, or an acid is added. 2. Crystallized sediments, called gravel or sand, consisting of minute, irregu- lar grains, suspended, not dissolved, in the urine; and of course sink to the bottom of the vessel almost as soon as the urine is voided. They consist of lithic acid nearly in a pure state j or of a triple combination of phosphoric acid, LITHIASIS. 711 magnesia, and ammonia; or finally, of oxalate of lime. The first are red the second white, and the third of a dark blackish-green color. These different va- rieties of gravel are never voided together in the same urine, though in the pul- verulent state the two former often occur in union with each other. 3. Solid concretions.—These result from the gradual agglomeration of the two former varieties—forming what are termed urinary calculi. Of these con- crete masses, Prout mentions thirteen varieties; but a description of these does not properly come within the scope of the present work, the general pathology and remedial management of the different lithic diatheses being the objects to which the attention of the physician is more particularly called. In relation to the comparative frequency of the different varieties of urinary deposits, it appears from the data collected by Dr. Prout, that the lithic acid predominates in more than one-third of the whole number of urinary calculi; and it has moreover, been ascertained, that lithic acid very generally constitutes the central nucleus, even in the other varieties of calculi. It would seem, therefore, that the deposition of lithic acid must be considered as the primary process in the formation of urinary calculi; and that the phosphate and oxalate formations are the result of a gradual transition from the lithic acid to the phosphatic or oxalic diathesis. In the progress of this transition, the lithic acid deposition is in the first place changed into the lithate of ammonia, with a loss of the tinge derived Jrom the coloring principle of the urine. After some time, this latter gives place to the deposition of sediment, composed chiefly of carbonate and phosphate of lime and this is finally succeeded by the phosphates of lime and magnesia, in combination with ammonia. It is a curious circumstance in the pathology of hthiasis, that although the deposition of lithic acids or its compounds is very frequently followed by the phosphatic and earthy deposits, " yet it may be laid down as a general law, that in urinary calculi, a decided deposition of the mixed phosphates is never followed by other depositions." Notwithstanding the various forms and appearances which urinary calculi present, they may be classed under four heads, according as one or the other of the following elementary substances predominates; namely, 1, the lithic acid and its compounds ; 2, the oxalate of lime; 3, the cystic oxide; and 4, the earthy phosphates. The abnormal conditions of the system which give rise to the secretion of these lithic substances, are with propriety distinguished as peculiar diatheses; and we accordingly have the lithic acid diathesis—the phosphatic diathesis—the cystic oxide diathesis—and the oxalate of lime diathesis, as the four cardinal points of attention in the pathology of lithiasis. 1. Lithic Acid Diathesis. The urinary sediments which belong to this diathesis, are either pulverulent or crystallized. When the former is the case, they consist of some combination of this acid with an alkaline basis, generally ammonia; but when the deposit is crystalline, it consists nearly of pure lithic acid. These amorphous sediments may be classed under three heads, corresponding to the color which they possess, namely, the yellow, the red or lateritious, and the pink sediments. The yellow depositions, varying from almost a white to a brown color, con- sist of the lithate of ammonia tinged by the coloring matter of the urine. These are the sediments which occur in the urine of healthy, or slightly dyspeptic individuals; but when they occur in abundance, they indicate a tendency to an excess of lithic acid and its consequence. Children are most subject to the yellow lithates in the urine. The red or lateritious, varying from nearly a white to a deep brick-red color, consists, like the former variety, of the lithate of ammonia, and sometimes of lithate of soda; deriving their red color partly from the purpurates of soda and ammonia, and the coloring matter of the urine. The presence of the red color 712 LITHIASIS. of these depositions, or rather of the purpurates upon which this color depends, may be regarded as a certain indication of a febrile or inflammatory condition of the system. To this, says Dr. Prout, " I have never seen a decided exception." In general, the deeper the color or redness of the sediment, the more decidedly phlogistic is the condition of the system. The pink sediments are much less comm»n than the other two amorphous sediments belonging to this diathesis. " Like the other two varieties, they con- sist essentially of the lithate of ammonia," but they derive their color exclusively from the purpurate of ammonia. The pink sediments are most apt to occur in chronic visceral inflammation, particularly hepatitis; and we frequently meet with it in dropsy, hectic fever, and in the more aggravated forms of dyspepsia. The sediments which occur in the sweating stage of remitting and intermitting fever, and during the favorable crisis of gout, rheumatism, and other febrile affec- tions, are of the lithic acid kind. Prout says, that in three instances he has seen a perfectly white lithate of soda deposited in the urine. Of the causes which favor the excessive secretion of lithic acid, or its com- pounds.—The circumstances which tend to produce a redundancy of lithic acid sediment in the urine, independently of general local inflammatory and febrile affections, are: a. Errors in diet.—The mere excess of wholesome food; heavy, indigestible, irritating, or unwholesome articles of diet; taking full meals at unusual hours; in short, whatever resists or deranges the digestive powers, will produce or in- crease the deposition of the lithate of ammonia. Prout says, that, according to his observations, the articles most apt to give rise to this urinary deposit, " are animal substances, and more especially heavy unfermented bread, or compact, hard-boiled fat dumplings or puddings." b. Excessive and unusual corporeal and mental exertions, or want of exer- cise, are accounted among the exciting causes of the lithic depositions in the urine. c. Debilitating circumstances.—Whatever is capable of diminishing the vital energies, has a peculiar tendency to give rise to urinary depositions of this kind. The depressing passions, want of nourishment, great fatigue of body or mind, &c, seldom fail to induce these sediments in the urine. d. I have already referred to the frequency of the lithic acid sediments, in the urine of persons laboring under fevers of an inflammatory character; and parti- cularly during the critical perspirations which occur in gout, rheumatism, inter- mitting and hectic fever, and in acute and chronic inflammation of the liver, as well as in various other affections attended with a phlogistic diathesis. In ag- gravated cases of dyspepsia, these urinary depositions are rarely wholly absent. With regard to the exciting causes of the crystallized depositions, or the excess of uncombined lithic acid in the urine, different opinions have been ex- pressed by the late writers on this subject. According to Magendie, the exces- sive secretion of this acid in the urine is very particularly favored by articles of food that contain an abundance of azote, and, therefore, especially by animal food. This opinion is predicated on the facts, that azote enters into the composition of lithic acid, and that animals confined to food destitute of azote, produce no lithic acid, whilst those which live almost exclusively on animal food (which contains an abundance of azote) secrete large quantities of pure lithic acid. Notwithstand- ing these plausible facts, later experiments and observations have afforded abund- ant evidence, that the formation of this urinary acid is independent of the quantity of azote introduced with the aliment, and that there are numerous other circum- stances which favor or oppose its secretion by the kidneys. From a series of experiments performed by Dr. Philip, with the view of elucidating this subject, he draws the following conclusions: " 1. That acid and acescent ingesta tend to increase the deposition of lithic acid from the urine, and to prevent that of the phosphates. LITHIASIS. 713 " 2. That a diet composed of a large proportion of animal food, tends to lessen the deposition of lithic acid, and to increase that of the phosphates. "3. That everything which promotes the action of the skin, tends to prevent the deposition of lithic acid, and to occasion that of the phosphates. " 4. That dyspepsia tends to increase the deposition of lithic acid, and to lessen that of the phosphates, both by producing acidity of the primae viae, and by ren- dering the skin inactive. " 5. That indolence has the same tendency, both by inducing dyspepsia, and by lessening the activity of the skin in proportion as it impairs the vigor of the circulation. " 6. That an acid passes off by insensible as well as sensible perspiration."* It appears from the observations of Dr. Prout, that certain unknown circum- stances, connected with the age of the patient, modify, in no inconsiderable degree, the influence of the ordinary causes of an excess of lithic acid in the urine, as well as the constitutional symptoms which attend the active state of this diathesis. Thus, children born of gouty and dyspeptic parents "are exceedingly liable to lithic acid deposits in the urine." Such children are very apt to manifest a fre- quent desire to pass urine, with very small discharges, and evident pain or unea- siness during and immediately after micturition. If, on examination, the urine is found to be charged with this sediment, immediate means should be used to counteract the diathesis, " as there is much greater risk at this period of life than at any other, of the formation of stone in the bladder." There seems to be less disposition to form lithic acid deposits between the ages of puberty and forty, than at any other period of life. There is less risk, too, says Prout, of the formation of urinary calculi between the ages just men- tioned, than at other periods ; for except in cases attended with an extremely copious secretion of this acid, it generally passes off" entirely with the urine, in the state of gravel. Between forty and forty-five years of age, the constitutional habit of body, in most individuals, undergoes a considerable change; and concomitantly with this change the lithic acid diathesis is frequently very strongly developed. Not only do we, in general, find persons who have passed this stage of life secrete much larger quantities of lithic acid, or its compounds, than previously, but there ap- pears to be a manifest disposition in the constitution at this period, "to separate the acid in a concrete state—thus giving origin to the formation of renal caculus," and the consequent train of various distressing secondary symptoms. The general symptoms which usually accompany an excessive secretion of lithic acid, are—pain and uneasiness in the region of the kidneys; a sensation of irritation and heat at the neck of the bladder, and in the urethra; a frequent de- sire to void urine, " which is passed in small quantities at a time, and without affording the usual relief, the sensation still continuing as if some urine were left behind in the bladder." Dyspeptic symptoms—particularly acidity and flatu- lency in the primae viae, are among the most common symptoms of the lithic acid diathesis. 2. Phosphatic Diathesis. The phosphatic deposits from the urine are generally amorphous, though occa- sionally lhey appear also in a crystallized form. The deposition of the phosphates rarely occurs as an original affection, being almost universally consequent "to the other forms of urinary deposition, and more especially the lithic acid and oxalate of lime. The crystallized phosphatic sediments consist almost universally of the triple phosphate of magnesia and ammonia. In connection with the appearance of this sediment in the urine, which is of a yellowish-white color, the patient generally * Medical Transact, of the College of Physicians of London, vol. vi. art. 9. 714 LITHIASIS. complains of dyspeptic symptoms, general nervous irritability, some pain and uneasiness in the loins, lassitude, and want of mental energy. The urine is generally copious and pale, and when suffered to stand awhile, becomes covered with an iridescent pellicle, consisting of minute crystals of the ammoniated phos- phate of magnesia. The urine is very apt to enter into the process of decom- position, and to become alkaline and putrescent. Sometimes this crystallized deposit is formed immediately after the urine is voided; but more commonly the crystals do not appear until the urine has become cool, or begins to putrefy. The amorphous phosphatic sediments are always composed of a mixture of phosphate of lime, and the triple phosphate of magnesia and ammonia—the former constituting by far the greater proportion. Some writers of eminence maintain that these sedimentous matters are not separated from the blood by the kidneys, but wholly and exclusively by the inner coat of the bladder, from a pe- culiarly morbid condition of this structure. Prout admits that the phosphate of lime is sometimes derived, in part, from the mucous membrane of the bladder— but he doubts "if any portion of the triple phosphate is ever derived from this source," the kidneys being, according to his observations, the only source from which it proceeds. The general symptoms which accompany an habitual and copious deposition of the amorphous phosphates from the urine, are often peculiarly distressing. The general system, both physical and mental, is almost extremely irritable; and great derangement of the digestive organs, manifested by flatulency, nausea, con- stipation, or exhausting diarrhoea; extremely variable and unnatural stools—being black, or whitish, and sometimes resembling yeast—accompanied with a dull aching pain, and a peculiar feeling of weakness in the loins. The countenance, in aggravated cases, becomes sallow and haggard, " and as the disease proceeds, symptoms somewhat analogous to those of diabetes ensue, such as great languor and depression of spirits, coldness of the legs, complete anaphrodisia, and other symptoms of extreme debility." The urine is pale and often very copious. With regard to the causes of the urinary sediments, composed of phosphates, writers have expressed some difference of opinion. Dr. Marcet and M. Brande maintain that the use of alkaline remedies, when continued for some time, has an especial tendency to give rise to the phosphatic depositions, and this opinion has been particularly acted on in the remedial treatment of urinary disorders of this kind. Dr. Prout, on the contrary, considers this tendency of alkaline remedies as very trifling, and scarcely worth attention, either in an etiological or therapeutic point of view. The occasional causes of the present variety of urinary deposits, are either of a local or general character. Injury of the back, as a blow or a fall, says Dr. Prout, is a very common source of this affection ; and its occurrence is also particularly promoted by excessive fatigue, and the protracted influence of debilitating mental emotions. Irritations about the neck of the bladder or urethra, from whatever source they may proceed, particularly when operating for a consi- derable length of time, have an especial tendency to give rise to the secretion of phosphatic sediments, and hence the presence of a small uric calculus in the blad- der very frequently becomes surrounded by a mass of urinary phosphates—so as to present the character of a phosphatic calculus externally, whilst its central portion, or nucleus, consists of lithic acid, or of the lithate of ammonia. Treatment. Treatment for the lithic acid diathesis.—To counteract the excessive secretion or formation of lithic acid depositions from the urine, our principal aim must be to establish the healthy action of the digestive organs. For this purpose, we must, in the first place, adopt proper dietetic regulations ; for without an especial attention to this point, little or no benefit will be derived from any remedial mea- sures. The patient must be put on a plain, digestible, and nourishing diet, and be particularly cautioned against taking very full meals. " An error in quantity is LITHIASIS. 715 infinitely more important," says Dr. Prout, " than an error in quality of the diet." Indigestible, mixed, and irritating articles of food, particularly fresh and unfer- mented bread, solid farinaceous preparations, salted and dried meats, and all kinds of acid drinks and acescent aliment must be carefully avoided. At the same time that attention is paid to the diet, it will be proper to use means for correcting the secretion of the liver and alimentary canal, and for keep- ing up a regular action of the bowels. With this view, mild aperients, followed by alkaline medicines, in union with weak infusions of some of the usual bitter vegetable tonics, are particularly beneficial. One of the following pills may be taken every second or third evening, until the hepatic and intestinal functions are restored to a healthy condition.* If they do not procure one or two full evacua- tions on the following morning, a small dose of magnesia, or one or two Seidlitz powders, may be taken to promote their operation. The regular use of alkaline remedies is an important measure in the remedial management of this diathesis. From fifteen to twenty grains of magnesia, taken in a glass of soda water, will often answer this purpose very well. The sal aeratus, (potassae aerata,) too, is an excellent alkaline in such cases.t From one to two drachms, dissolved in a few ounces of a very weak infusion of colomba or gentian root, may be taken once or twice daily. Twenty or thirty drops of the liquor potassae may also be employed. It appears from the experiments and observations of Dr. Philip, that the regu- lar action of the cutaneous exhalents tends very considerably to lessen the depo- sition of lithic acid from the urine: and he observes, that tbe lithic acid is much more effectually thrown off by the cutaneous exhalents, when merely the insen- sible exhalation is augmented, than when the sensible perspiration is increased. The action of the skin should therefore be duly supported by regular exercise, the occasional use of the warm bath, small doses of the pulvis antimonialis or tartar emetic, and the wearing of flannel next the skin.f Prout says, that warm sea-bathing is sometimes " particularly beneficial, though occasionally the gravelly deposit seems to be increased under its use;" which latter circumstance he ascribes " to the use of the hard waters that generally prevail along the coast;" for the use of such water is especially injurious in the lithic acid diathesis. In cases accompanied with a general irritable state of the system, or with much irritation in the urinary organs, narcotics should be used—particularly opium and hyoscyamus. Although a regular action, and even a moderate degree of loose- ness of the bowels, are very desirable in the management of this affection, yet care should be taken not to employ very active purgatives. About the age of forty, a particular tendency is apt to occur to rid the system of the cause of con- stitutional irritation in this diathesis, in consequence of which the kidneys secrete an unusual quantity of lithic acid, "and by this process gives great relief to the system at large." It is thus that diuretics are often highly serviceable at this period of life; which, favoring the secretion of large quantities of lithic acid, * R.—Mass. pil. hydrarg. £i. G. aloet. Soc. gr. xvi. Tart, antimon. gr. iss.—M. Divide into 16 pills.—Or, R.—Calomel gr. iv. Pulv. antimonialis gr. vi. Extract, colocynth. compos, gr. vi. . Extract, hyoscyam. gr. iii.—Divide into 4 pills. Take one at bedtime, twice or thrice a week- and followed the next morning by an active dose of the sulphate of magnesia. t This preparation is made by dissolving half a pound of the subcarbonate of potass in ten ounces of water, adding two ounces of subcarbonate of ammonia: after it has effervesced, it is crystallized. t Dr Philip observes, that "the effects of Dover's powder on the urine are transitory, appa- rently ceasing as soon as the sweat ceases to flow. But those of the tartrate of antimony may generally be perceived for several days after it is taken, during which it still seems to lessen the tendency of the urine to deposit lithic acid. I have also repeatedly observed, that the de- position of lithic acid was not so effectually prevented by tartrate of antimony when it produced nausea, as when no sensible effect was experienced from it.'-—Loc. cit., p. 202. 716 LITHIASIS. and thus causing a kind of artificial crisis—frequently give great relief to the conslitution. Prout says, that muriatic acid, in union with opium, will often answer very well for this purpose; and Dr. Henry has known a combination of turpentine and laudanum to " bring away several ounces of lithic acid in the course of a day or two." For this purpose we may also have recourse to various vegetable diuretics with occasional benefit;—particularly the infusion of monarda punctata; of erigeron heterophyllum ; alchemilla arvensis; sem. daucus carota, and of galium aparine. When the kidneys are in a state of high irritation or inflammatory excitement, these diuretics must be employed with great caution ; it would seem, also, lhat they are "not adapted to any other species of deposit than crystalized lithic—nor even to this form of the disease, when it occurs in very young or very old subjects." In what is usually called a fit of the gravel—an affection which " consists in the secretion of a large portion of lithic acid by the kidneys," preceded, as well as accompanied, usually, by general conctitutional irritation and febrile move- ments—the treatment does not differ materially from that which has already been described, "except that it must be more active." Thus venesection, cupping, or leeching from the region of the kidneys, and active mercurial purges with antimonial powder, ought to be efficiently employed before diuretic remedies are prescribed. The warm bath, or warm fomentations applied to the loins, in con- junction with the less stimulating diuretics just mentioned, with the addition of colchicum, will seldom fail to procure considerable relief. A strict antiphlogistic regimen is indispensable, and after the attack is over, the patient should adhere strictly to the dietetic rules mentioned for counteracting the lithic diathesis. Treatment proper in the phosphatic diathesis.—It was before stated, that a peculiarly irritable state of the system is one of the most constant, and in general the most distressing circumstance attending the completely developed form of ihe phosphatic diathesis. An important indication, therefore, is to diminish this unnatural irritability, and to restore the general health of the system, at the same time that measures are adopted to correct the morbid condition of the urinary organs. Opium, according to the experience of Dr. Prout, is the only beneficial remedy for allaying the morbid irritability of the constitution; and it should be given in large and repeated doses—from one to five grains three limes daily, ac- cording to the urgency of the symptoms. After the irritable state of the system has been, in some degree, reduced by the use of this narcotic, recourse should be had to tonics—particularly to the mineral acids, cinchona, the ferruginous prepa- rations, uva ursi, &c. The acids are not only beneficial by their general tonic influence, but they tend, also, in a direct manner, to lessen the alkaline character of the urine.* Where the mineral acids disagree with the stomach, the citric acid should be used. Local applications to the region of the kidneys—such as a large pitch, soap, or galbanum plaster; and in very severe cases, setons or issues in the back, will often assist considerably in mitigating the violence of the symptoms. Active purgatives are apt to prove injurious : and those saline purgatives that contain a vegetable acid, are said to be particularly improper in this affection. "Mercury in all its forms, especially when pushed so far as to produce its specific effects on the constitution, seems capable of doing a great deal of mischief." If small alterative doses of this medicine are indicated, they should be given in union with opium. All alkaline remedies must be strictly avoided, and diuretics of every kind are almost equally improper in the phosphatic diathesis. Hard waters, used as drink, " are literally poison in this form of the disease." The drink should be distilled, or the softest water that can be procured. In moderate cases, where the irritation is chiefly confined to the urinary organs, hyoscyamus, in union with uva ursi, with an occasional small dose of opium, * [Of these, the nitric acid, or the nitro-muriatic acid, is to be preferred in all respects. From 20 to oO drops may be given three times a day largely diluted in gum water.__Mc] ISCHURIA RENALIS. 717 should be administered. In cases of this kind, I have known much benefit de- rived from taking from half a pint to a pint of a weak infusion of the monarda punctata during the day. Prout speaks very favorably, in the slighter cases of ihis affection, of the employment of the infusion of alchemilla arvensis. The diet should be digestible, mild, and nourishing—such as the lean parts of the most tender kinds of meat. Some writers direct the use of an acescent vege- table food, but Dr. Prout is inclined to prefer an animal diet. Much, of course, will depend on the state of the stomach in relation to the propriety or impro- priety of these different kinds of food. When the irritation of the mucous mem- brane is great, animal food will be found too stimulating; and, on the other hand, the greater digestibility of this kind of diet renders it decidedly proper where the digestive powers are weak, with an absence of mucous irritation of the stomach. A tranquil state of the mind has a most important curative influence. " The influence of mental anxiety," says Dr. Prout, "is really astonishing in this dis- ease ; and absence from care, the exhilarating air of the country, and such exer- cises as are consistent with the patient's condition, will, perhaps, more than anything else, contribute to the cure, particularly in the slighter cases, and when the cause is not local injury." Sect. IV.—Ischuria Renalis. Suppression of urine is always a very formidable affection, whether it occurs as an idiopathic malady or secondarily in the course of other diseases. This affection must not be confounded with mere retention of the urine. In ischuria, the functions of the kidneys are more or less suspended or destroyed, the secre- tion of urine being either morbidly diminished, or entirely suppressed. In reten- tion of the urine, on the other hand, the urine is regularly secreted by the kid- neys, and conveyed to the bladder; but from some cause or other, an inability to evacuate it occurs, and being thus retained, it gradually accumulates, until, in some instances, the most distressing, and even fatal consequences occur. Ischuria renalis may be partial or complete. In the former case, very small portions of urine are, from time to time, discharged from the bladder, under symp- toms often extremely distressing. The patient is harassed with a very frequent desire to pass off the urine, accompanied with more or less uneasiness or pain, and a sense of dull, heavy weight in the iliac region, and in some cases much pain and tenderness throughout the whole lower part of the abdomen, together with great anxiety of feeling, nausea, or vomiting, and occasionally hiccup. In almost all instances of urinary suppression, febrile symptoms are conspicuously present. The thirst is usually urgent, and where the suppression is complete, and continues for some time, patients often experience a distinct urinous taste in the mouth ; and the whole surface of the body, in instances of an obstinate cha- racter, exhales a very perceptible urinous smell. In cases attended with the foregoing symptoms, the suppression is, probably, always the consequence of high irritation or inflammatory action in the kidneys. Suppression of urine is not, however, always attended with the painful symptoms just mentioned. In some cases the patient experiences neither pain, nor weight, nor any particular uneasi- ness in the region of the kidneys and bladder. Sir Henry Halford has related five instances of this kind.* Cases of this kind would seem to depend on total paralysis of the kidneys. Whatever may be the immediate cause of the sup- pression, or with whatever phenomena it may be accompanied in its early stage, symptoms of cerebral oppression never fail to ensue, if the disease continues for two or three days, and often in the course of thirty hours, if the urinary secre- tion is not in some degree restored. Indeed, one of the most singular circum- * On the Necessity of Caution in the Estimation of Symptoms in the last Stage of some Dis- eases. 718 ISCHURIA RENALIS. stances attending this disease, is the inevitable tendency to coma and effusion in the brain. In complete suppression, depending on paralysis of the kidneys, where little or no uneasiness is experienced in the abdomen or urinary organ, the patient, in the course of the second or beginning of the third day, begins gradually to sink into coma, and finally dies in a state of complete stupefaction. Mr. Abercrombie, in an interesting paper on this affection, has related five cases, all of which terminated in this way.* Where inflammatory action of the kidneys is the proximate cause of the suppression, the coma is frequently preceded by de- lirium, and convulsions sometimes finally ensue. I have already adverted to the strong urinous smell of the perspiration which occurs in the latter periods of this complaint,! and it appears, from various cases that have been published, that a vicarious secretion of urine sometimes, though indeed very rarely, takes place from particular organs or parts—more especially from the umbilicus. Dr. Hastings has related a most interesting case of ischuria renalis, in which, many days after the commencement of the disease, considera- ble quantities of urine were discharged from,the umbilicus, for three days in suc- cession.}. Dr. Hastings refers to some of the older writers for accounts of simi- lar cases. Schenck relates two instances of this kind ;§ and a case is recorded by Sennertus, as having occurred under the observation of the celebrated Platerus, in which, in consequence of a total inactivity of the kidneys, an urinous fluid was copiously discharged from the right ear.|| Instances of this complaint are on record, also, in which a fluid resembling urine was copiously discharged by vomiting, and hy stool. Valisneri has given an account of a case of ischuria, in which copious discharges of a urinous fluid occurred from the stomach. Water is always found more or less abundantly effused into the cavities of the brain, and has, in general, a very perceptible urinous smell.^[ Causes.—The immediate cause of suppression of urine may be either inflam- mation, or paralysis of the kidneys, or mechanical obstruction. Nephritis is always attended with a greater or less suppression of the urinary secretion; but as both kidneys are very rarely inflamed at the same time, there is, in general, a sufficient quantity of this excrementitious fluid separated from the blood, by the sound kidney, to obviate any particular danger from this source. Of course, whatever is capable of causing much irritation, or inflammation of the renal organs, may become the remote cause of this affection. Schenck relates a fatal case, which was caused by a blow on the loins ; and on post-mortem examina- tion, a considerable abscess was discovered between the muscles contiguous to the kidneys. Laelius a Fonte has recorded a case, in which the left kidney was gangrenous ; and in several cases related by Hildanus and Bonetus, the kidneys * Edinb. Med. and Surg. Journal, April 1821. t Dr. Yeates (Med. and Phys. Journ., No. 29) relates instances of ischuria, in which the secretion of a urinous fluid by the skin was noticed; and Sauvages mentions a case in which this phenomenon was distinctly observed. X Midland Medical Reporter, No. 4. § One of these cases was in a female. " Cum suppressa per multas dies fuisset urina tandem per umbilicum urinam profluit."—06s., lib. iii. de Urina, p. 489, as quoted by Hastings. || Puelhe cuidam annos natae tredecim cum aliquando copiose minxisset, urinam°subito sup- pressam esse atque tunc aquam serosam ex aura dextra adeo affatim ccepisset effluere, ut una vice duae ssepe emanarint idque dies aliquot.—Sennerti, Opera, lib. iii. p. viii. s. ii. cap. ix.__ Hastings. 1T Several very extraordinary instances of long-continued suppression of urine have recently been reported. In Hufeland's Journal for August 18:27, there is a case related of a lady, who made no water for seven weeks. There was no vicarious secretion of urine. "In another German Journal there is a case reported, in which the secretion of urine by the kidneys was wholly suspended for six months. The patient, a boy, became extremely emaciated and the bowels were obstinately constipated. He was also affected with occasional pains in the loins, which were sometimes so severe as to throw him into convulsions. The abdomen was greatly distended,.but not apparently with fluid, as it emitted a hollow sound when struck.'— Amer. Journ. Med. Sciences, vol. iii. p. 198. ISCHURIA RENALIS. 719 and neighboring parts were extensively inflamed.* The suppression of hemor- rhoids and of the menses has been known to give rise to this affection; and its occurrence from gouty irritation has been frequently noticed. Dr. Prout ob- serves, that when there are no signs of renal inflammation present, "and the patient has been subject to gout, or if a female, to hysteria, the ischuria may be supposed to depend, in part at least, on spasm." The healing up of old ulcers has also given rise to total suppression of the urine. A very remarkable case of this kind is related by M. Dupont, physician to the Hospice de Gournay, in which a lady had an ulcer on one of her legs of twenty-five years' continuance, which was rapidly healed by an ointment. Soon after the ulcer was cicatrized, she was seized with pains in the abdomen, attended with nausea, some fever, red and dry tongue, and abdominal distension. Almost total suppression of urine speedily ensued. After a few days' continuance and ineffectual treatment, a blister was applied over the cicatrix of the ulcer, which had the effect of speedily freeing the patient of her disease. The sudden application of cold to the body, particularly during the flow of the menses, has occasionally given rise to fatal ischuria. The case related by Hastings, mentioned above, was produced in this way; and one of the cases of suppression from renal paralysis mentioned by Sir H. Halford, was excited by the influence of cold, while the patient was under the operation of mercury. It would seem, that ischuria from paralysis of the kidneys, sometimes depends on a disordered state of the brain or of the nerves, without any immediate connection or dependence on inflammation.t " The presence of a mechanical cause may be suspected," says Dr. Prout," when the per- son has been previously subject to calculous affections. Generally, however, in this latter case, the effects cannot be ascribed altogether to the simple operation of the mechanical cause, but in part also to the inflammation or spasm, or both, which it is liable to produce, and the affection thus assumes a mixed character. A fatal case of this disease is related by Dr. Teeling, which occurred in a very gouty individual. On post-mortem examination, the right kidney was found diminished in size, and the cavity of its pelvis filled with gray-colored, rough calculi, about the size of small peas, and the whole internal surface of the kidney was " firmly coated over with a fine gravel resembling pulverized free-stone." In the upper part of the ureter, belonging to this kidney, a calculus was found as large as a small almond, " which blocked up its cavity." Some calculi were also found in the pelvis of the left kidney. Prognosis.—The prognosis, in ischuria, is always extremely unfavorable. So long as the suppression is not complete, a reasonable hope maybe entertained of an eventual recovery; for even a small secretion of urine by tbe kidneys will, in general, keep off the more alarming symptoms of cerebral oppression for a con- siderable time, and give greater opportunities for subduing the renal affection. When the suppression is complete, the disease almost always terminates fatally in the course of four or five days, and often as early as the third day. Sir Henry Halford, in the paper already quoted, states, as the result of his observations, that a complete suppression of the secretion of urine cannot continue beyond three days without terminating fatally. This, however, is incorrect. Dr. Laing has related an instance where the secretion of urine was suspended for nine days, and nevertheless terminated favorably;+. and Dr. Brown mentions one case in which the secretion was suspended for six days and six hours, and in another the suppression continued eleven days, and yet both patients recovered.§ A very extraordinary instance of this complaint is described in Hufeland's Journal for August 1827, in which the action of the kidneys was wholly suspended for * See Dr. Abercombie's Memoir, already referred to. t [Sympathetic irritation resulting from the influence of severe wounds and surgical opera- tions, occasionally produces a total suppression of urine. I have had this alarming condition continue for three days after an extirpation of a scirrhous parotid.—Mc] Ecliub. Med. and Surg. Journ., vol. x. Essays, &c. on Medical Subjects. See Med.-Chir. Rev., Dec. 1828. 720 RETENTION OF URINE. seven weeks, without any particular inconvenience, although no urinous fluid was secreted vicariously. Treatment.—The treatment in this affection must be modified according to the particular morbid condition of the kidneys, as well as according to the nature of the remote cause. When symptoms of renal inflammation exist, the treatment already pointed out for the cure of nephritis should be energetically pursued. Venesection, cupping, leeching, ihe warm bath, purgatives, emollient enemata, sinapisms, and even blistering over the region of the kidneys, constitute the prin- cipal remedial measures. In cases attended with no decided manifestations of inflammatory action in the kidneys, diuretics are the means upon which our chief reliance must be placed. In general, stimulating articles of this kind have been found most beneficial—more especially where the disease appears to depend wholly on a torpor or paralysis of the kidneys. Spirits of turpentine, both in the form of injections, and internally in doses of from twenty to thirty drops every two hours, have been employed with a very good effect. When the bowels are constipated or inactive, the turpentine should be given in union with castor oil, in doses sufficient to procure pretty free purging. The remarkable case mentioned above, from Hufeland's Journal, was cured by a mixture of oil of amber, Venice turpentine, and balsam copaivae, after a great variety of other medicines had been ineffectually used. I have seen two cases of incomplete sup- pression, attended with a somnolent condition, in nervous females, which were removed by a mixture of juniper oil, sweet spirits of nitre, and laudanum.* Mer- cury has been recommended for the use of this affection, and some interesting cases have been reported, illustrative of its beneficial influence. In the case already referred to, related by Dr. Brown, mercury was freely given; and he states that, very soon after the mercurial fetor of the breath was noticed, a pretty copious discharge of urine ensued, and the patient recovered. Valisneri, also, gives an account of a case which was cured by mercury. In Dr. Laing's case, which, however, was manifestly attended with both local and general inflamma- tory action, the remedies employed were blood-letting, repeated three times daily, saline diuretics, and the warm bath. Mr. Raymond strongly recommends the application of a large blister across the region of the kidneys. He has related several cases in which the flow of urine soon followed vesication over the loins, after a variety of remedies had been ineffectually employed.! Lieutaud recom- mends emetics for the cure of ischuria renalis.}: Sect. V.—Retention of Urine. Retention of urine is by no means an uncommon affection ; and though not, in general, so dangerous and difficult of being cured as ischuria, it is often met with under circumstances which render it a most alarming malady. The immediate cause of retention of urine consists either, 1, in a loss of the expulsive power of the bladder and of its detrusor muscles; or 2,in mechanical obstruction of the urethra, qjr neck of the bladder. 1. Paralysis, or loss of the expulsive power of the bladder, generally arises from over-distention of this viscus. After the middle period of life, the sensi- bility of the bladder, in some individuals, gradually diminishes as age advances; and this insensibility occasionally becomes so considerable, that the urine fails more and more to impart the due degree of stimulus to the bladder; in conse- quence of which it is often suffered to accumulate inordinately, before the desire * R.—Ol. juniper, ^ss. Spir. nit. dulc. !Ji. Tinct. opii Ji.—M. Take a teaspoonful every two hours. t Med. Obs. and Inquir., vol. vi. Appendix. X Nonnullos enim decumbentes et cum morte colluctantes hocce prsesidiis tempestive adhibito ex orci faucibus ereptos vidi.—Synop. Prox. Med., torn. i. p. 269. RETENTION OF URINE. 721 to evacuate it is experienced. The bladder, then, from its torpid and relaxed condition, is incapable of completely expelling its contents, and the action of the abdominal muscles is called into aid to effect this purpose. From this deficiency of the expulsive powers, the bladder is not entirely emptied ; and more urine is daily left in the bladder, until at last, only a small portion of its contents is evac- uated, at each attempt to urinate. Finally, from the occurrence of slight general indisposition from cold, or from some adventitious local affection, as diarrhoea, suppressed hemorrhoids, riding on horseback, fatigue from exercise, &c, a total inability in the bladder, even with the aid of the abdominal muscles, to overcome the ordinary pov«er of the sphincter, ensues, and complete retention of the urine is the consequence. Retention from paralysis is not, however, entirely confined to old people, and may arise from difficult parturition; blows or falls on the back; injury of the spine; excessive onanism; and from paraplegia; and it sometimes occurs in the latter stage of typhus, and other forms of low fever. This variety of the disease is readily distinguished by the facility with which the catheter may be introduced, and by the general course and progress of the complaint. No symptoms indicative of mechanical obstruction of the urethra, or of inflammation, precede or accompany the disease. The approach or tend- ency to the complaint is indicated by the stream of urine, though sufficiently large, becoming weaker and weaker. The patient is obliged to stand a long time, and to make considerable effort with the abdominal muscles, before the urine begins to flow; and the quantity discharged gradually becomes smaller and smaller, whilst the desire to urinate becomes more frequent and urgent. Retention from paralysis of the bladder, is much less alarming and dangerous in its consequences, than when the retention occurs from inflammation or ob- struction; but it often continues for many months. I have known several in- stances, apparently of spontaneous occurrence, in which the daily use of the catheter was necessary for three months before the bladder regained sufficient expulsive power to discharge its contents. This form of the disease is not in general attended with much distress, unless the urine be suffered to accumulate until the bladder becomes very greatly distended. Indeed, cases sometimes oc- cur, in which the patient is not even aware that a retention of the urine exists ; for the bladder may gradually become enormously distended, and give rise to uneasiness, although more or less urine is gradually discharged at each attempt to urinate. Instances of this kind have even been mistaken for abdominal drop- sy ; for when the discharge of urine, though in diminished quantities, continues, the abdominal distension and uneasiness may, on a superficial examination, be readily ascribed to dropsical effusion. A case is mentioned as having occurred in St. George's Hospital, where the patient was thought to be laboring under ascites. Paracentesis abdominis was in contemplation, " when the house-surgeon happened to introduce a catheter, and drew off many quarts of water, with immediate reduction of the abdominal swelling."* Similar instances are mentioned in the article on this affection in the Diet, des Sciences Medicales. A woman was ^supposed to be affected with ascites, and tapping was determined on, at the same time that diuretics were diligently employed: finally, in consequence of the sudden occurrence of com- plete retention of the urine, the catheter was introduced, and a large quantity of water was unexpectedly drawn off. The abdominal swelling soon disappeared. Another case is related, in which retention of the urine was mistaken for dropsy, which, after various measures had been employed ineffectually, was speedily cured by the use of the catheter; and an instance is mentioned in the same work, where ihe patient died from rupture of the bladder—the patient having been treated for ascites. Dr. Felici, of Milan, has related the case of a woman who considered herself pregnant. She labored under oedema of the feet; enormous • Med.-Chir. Rev., April 1825, p. 525. 46 722 RETENTION OF URINE. swelling of the abdomen; violent and painful efforts to void urine, which passed off in small quantities; pains in the thigh; dyspnoea; palpitations; a sense of suffocation from the slightest motion; puffiness of the face; frequent pulse; and a dry cough. Under these symptoms she had labored a considerable time before Dr. F. saw her. He suspected retention of urine. The catheter was introduced, and nearly fourteen pints of water drawn off. 2. Retention of the urine from inflammation.—Inflammation of the urethra and bladder is one of the most common causes of retention of, the urine, and may be produced by a great variety of causes—such as irritation from calculus; irri- tating diuretics, particularly terebinthinate remedies and cantharides; gonorrhoea; stimulating injections into the urethra; the incautious introduction of the catheter or bougie; the spread of inflammation from neighboring parts; an acrid or irri- tating state of the urine ; the sudden suppression of perspiration by cold; cold and damp feet; the suppression of hemorrhoids and the catamenial discharge; excessive venery and onanism; mechanical injuries received on the pubic region or upon the perineum; general fever and constitutional irritation; metastasis of gout and rheumatism, &c. When the neck of the bladder or urethra is inflamed, the penis is usually somewhat enlarged and tender to the touch, and when the exciting cause consists of calculous irritation, considerable pain is generally ex- perienced in the glans penis. Cases depending on inflammation are attended with severe burning pain in the neck of the bladder, with tenderness to pressure of the perineum and the parts immediately above the pubis. The desire to void urine is very frequent, and extremely urgent and painful. Fever is an early attendant and the patient is apt to experience nausea and occasional vomiting. All attempts to introduce a cathe- ter or bougie give excruciating pain. It must, nevertheless, be observed, that the inflammation upon which the suppression depends, is not always seated in the bladder or urethra, but sometimes in the parts contiguous to the viscus. Thus, retention of urine may arise from inflammation of the rectum, by causing high irritation and vascular engorgement of the mucous membrane of the bladder and urethra, or spasmodic constriction of the urinary passage; or finally, the inflam- mation may spread to the detrusor muscles, and destroy their powers of regular action. Chronic inflammation of the mucous membrane of the bladder is very frequently attended with dysury, strangury, and sometimes with retention of urine. Retention from this cause is most commonly met with in old people; and in such as have labored under protracted and badly managed gonorrhoea; or in individuals affected with vesical calculi. It may also arise from metastasis of gout and rheumatism; from hemorrhoidal irritation, and repelled chronic diseases of the skin. The diagnosis of retention from chronic inflammation and vascular engorge- ment or tumefaction of the mucous membrane of the bladder, is often attended with considerable difficulty. In general, a sense of tickling and uneasiness is at first experienced in the bladder, extending some distance into the urethra. After some time an almost constant gnawing pain is felt in these parts, with more or less difficulty of voiding the urine; and in some instances temporary incontinence of urine alternates with dysury. The urine discharged contains a large quantity of very viscid mucus mixed sometimes with considerable portions of purulent matter. In this state, the disease may continue for a long time, with occasional attacks of more or less obstinate and painful retention of the urine. In such instances, the whole bladder is usually found, on dissection, contracted, so as not to contain more than half a pint of water, with its coats thickened and indurated, and the internal surface varicose, or covered in parts with concretions of the urinary phosphates. Sometimes ulcers of various sizes, warty excrescences, or a pustular eruption, occurs on the mucous membrane. Retention of urine, from causes of this kind, may be distinguished from enlargement or disease of the prostate or stricture near this gland, by the very gradual progress and increase of the difficulty of passing the urine; and particularly by the slight difficulty which RETENTION OF URINE. 723 is in general encountered in introducing the catheter; and, finally, the occasion- ally temporary incontinence of urine, which, in many instances, occurs. Soem- mering states that chronic inflammation, and the consequences just mentioned are almost invariably attended with a very peculiar uneasiness and numbness of the thighs, amounting, in some instances, to a state of incomplete paralysis. The prognosis in such cases is always very unfavorable, more especially when there is reason to suspect structural lesion of the bladder. 3. Spasmodic retention of urine.—-In cases of this kind, the retention occurs suddenly. The patient is seized with extremely painful and urgent efforts to void urine; but only a few drops pass off under great suffering. The pain in the bladder is cutting, and attended with a sense of constriction and pressing down, which by females is often compared to labor pains. The urethra is sen- sible, sometimes painful throughout, and the patient is often harassed with very distressing erections. The pain is not increased during the flow of the small quantity of water that occasionally passes off, but immediately after the last drops are expelled, it becomes very severe, attended with a sensible spasmodic contrac- tion in the perineum. In this way it may continue for a longer or shorter time, until at last the pain and urgency to urinate pass off by a considerable flow of urine. The pain in this variety is not constant, nor is it increased by pressure on the perineum or pubic region. There is no fever, but the pulse is small and contracted. The catheter is usually passed with great difficulty, and often cannot be introduced into the bladder at all. Spasmodic retention does not, however, occur often as a purely spasmodic affection. In many instances slight inflammation of the bladder, or of some neighboring part renders the neck and upper portion of the urethra so extremely irritable, that the stimulus of the urine causes the sphincter to contract spasmo- dically. The spasm may also be excited by mechanical irritants. This variety of the disease is most apt to occur in irritable and nervous individuals, and in such as are predisposed to colicky affections. It is sometimes suddenly excited by mental emotions, particularly terror and grief. Gouty and rheumatic irrita- tion; irritation of the rectum from ascarides and other causes; cold and humidity, particularly when applied to the feet; irritating diuretics ; hemorrhoidal irritation; gonorrhoea; stimulating injections, by heightening the irritability of the bladder and sphincter muscles, may give rise to spasmodic retention of the urine. This variety of the disease is not, in general, attended with any particular danger or obstinacy. By frequent recurrence, it is, however, liable to terminate in in- flammation, and thus ultimately to give rise to very serious consequences.* 4. Retention from mechanical obstruction of the urethra or neck of the blad- der.—Obstruction to the discharge of the urine may depend on calculus lodged in the bladder, or impacted in the urethra; stricture, more or less permanent of the urethra; enlargement and induration of the prostate gland; thickening and indu- ration of the mucous membrane of the urethra; pressure from tumors in the neighboring parts, or from the gravid uterus ; retroverted, or prolapsed uterus ; foreign bodies accidentally introduced into the bladder; polypi and fungoid tu- mors in the bladder; very viscid mucus and coagula of blood clogging up the urethra; hernia; and a varicose state of the vessels of the neck of the bladder. Of all these causes, however, stricture, and calculi lodged in the urethra, are in- comparably the most common causes of obstruction. Retention of the urine, whatever may be its cause, becomes highly alarming, if it continues beyond twenty-four hours, without being in some degree relieved. In general, complete retention of urine proves fatal in four or five days ; and I have known an instance which terminated in gangrene and effusion of the urine as early as the end of the third day. It is generally supposed, that when the bladder at last gives way, and pours out its contents into the cavity of the abdo- men, it is ruptured or lacerated by the violent distension. This, however, is * Richter, Spec. Therap., b. iv. p. 392. 724 RETENTION OF URINE. rarely the case ; for in nearly all instances that prove fatal, the urine finally gains exit through an opening, formed by ulceration of some portion of the vesical parietes, or by the occurrence of gangrene and softening, through which the water bursts from the distended bladder. In some instances the lower portion of the bladder forms adhesions with the surrounding parts, and then ulcerates—the urine being infiltrated into the cellular structure about the rectum, scrotum, and perineum. In such cases, extensive mortification and sloughing usually take place in these parts, before the disease terminates in death. Instances have oc- curred, in which adhesion took place between the bladder and rectum, and the urine was discharged by the anus, with an eventual recovery of the patient. (Richter.) Ulceration and effusion of the urine into the vagina sometimes occur in females. The anterior and superior part of the bladder has been known to ulcerate, so as to give exit to the urine into the cellular tissue of the abdominal muscles, giving rise to extensive oedema of the anterior part of the body and thighs; with gangrene and fistulous ulcerations. Instances have occurred, in which the urine was evacuated by the umbilicus. (Richter.) Most commonly, however, the bladder ulcerates directly into the cavity of the abdomen, and occa- sions fatal peritonitis. When the bladder gives way, the tumefaction and tension of the abdomen suddenly subside, and the abdominal parietes become soft and relaxed, until peritonitis ensues, when the usual tenderness and tension of this affection occur. Retention of urine does not, however, always terminate fatally by ulceration or rupture of the bladder, and consequent extravasation. Occasion- ally, death ensues before the bladder gives way, under symptoms resembling those which have been mentioned as occurring in the last stage of fatal ischuria renalis. In such cases, the distension is not confined to the bladder, but occu- pies the whole course of the ureters, which have been found enormously enlarged; and the pelvis of the kidneys, even, is sometimes considerably dilated by the accumulated urine. When these conditions occur, the secretion of urine is ulti- mately arrested, the patient becomes comatose, or is seized with convulsions or spasmodic respiration, his perspiration acquires a urinous smell, and he finally dies in a state of apoplectic stupor. On dissection, water of a distinctly urinous smell is generally found effused between the meninges, and into the cavity of the brain. There is another variety of retention of urine—renal retention—which arises from an obstruction of the ureters, either by inflammation and obliteration of their cavity, or by being plugged up with calculi, coagula of blood, or compressed by a tumor in some contiguous part. In such cases, the ureter, above the obstruc- tion, becomes more and more dilated, until it acquires, in some instances, a very great size, and the kidney itself ultimately becomes greatly distended. Callisen has seen the pelvis of the kidneys so dilated as to contain nearly a quart of urine; and the ureters have been found dilated to the size of the colon. (Desgranges.) Walter states, that he saw the kidneys so enlarged as to resemble the bladder, with its parietes attenuated almost into a membrane.* Such cases usually ter- minate fatally under symptoms of cerebral oppression. The diagnosis of renal retention is, however, so extremely difficult and uncer- tain, that its presence can never be inferred with sufficient probability of correct- ness, to found on it any practical indications; and it is here mentioned, rather as a pathological phenomenon, than as a subject for therapeutic observations. Treatment.—From the foregoing observations, it is obviously of the utmost importance, in the treatment of this affection, to be particularly acquainted with the various immediate causes of urinary retention ; and never to proceed to the employment of remedial measures, until strict inquiry has been made into the nature of the existing obstacle to the urinary evacuation. From ignorance or inattention to this important rule, diuretics are often given, where the cause con- sists in permanent stricture; or persevering, rude, and ruinous attempts made to • Einige Krankh. der Nieren und Harnblase, &c. Berlin, 1802. S. 5-16, tab. ii. iii. and iv. RETENTION OF URINE. 725 introduce the catheter, in the same condition of the urethra. There is another point which should be strongly impressed on the attention of the practitioner— namely, never to tamper too long with warm baths, tobacco injections, and various similar remedies, where the obstructing cause resists proper measures for per- haps forty-eight hours—more especially if it consists of stricture or impacted calculus. I have seen two instances which were thus tampered with for five days, and sacrificed to the timidity or want of decision of the practitioner; although the lives of both could, in all probability, have been saved, if tapping had been seasonably performed. In one case where the obstruction was mani- festly of a character which precluded all reasonable hopes of being removed sufficiently early to save the life of the patient, tapping was proposed and urged by a surgeon, but postponed by the other two medical attendants until next morning. On the following morning the operation was again put off until the afternoon, to try the effects of a tobacco enema. In the afternoon the bladder gave way, and the patient died. In retention of urine from paralysis, the ca- theter is the only proper means for evacuating the contents of the bladder; and where the disease is unattended with enlargement of the prostate, its introduction may in general be effected with the greatest ease.* The object here, both in a palliative and curative point of view, is to obviate undue distension of the bladder; and as the loss of its expulsive power is very rarely transient, and the urine re- accumulates with more or less rapidity, it becomes necessary, in such cases, to draw off the urine every six or eight hours. I have known cases, in which this operation was required four times daily for several months, before the bladder recovered its powers. When the distension of the bladder is very great, the urine generally flows off very slowly through the catheter, and unless pretty firm pressure is made with the hands on the external vesical region, the greater por- tion of the urine will remain in the bladder. Some surgeons recommend the introduction of a flexible catheter, and leaving it in the bladder. When this is done, the external orifice of the catheter must be closed with a small plug, which the patient may from time to time remove, and give exit to the accumulated water. In some cases attended with an irritable state of the urethra and neck of the bladder, this practice may answer very well—more especially when the patient is remote from his surgeon, and cannot be conveniently visited at regular hours. With many patients, however, it causes much irritation, and cannot be borne without great inconvenience. Whilst proper attention is paid to the regular discharge of the urine, by means of the catheter, remedies should be employed with the view of restoring the lost tone of the bladder. For this purpose, cantharides, used both internally and externally, have been generally esteemed a very useful remedy. From twenty to thirty drops of the tincture may be taken two or three times daily, and con- tinued until slight symptoms of strangury ensue. Richter speaks very favorably of a union of cantharides and camphor, in the proportion of a fourth of a grain of the former to one grain of the latter, given four times daily. Frictions with the tinctura lytlse, and terebinthinate embrocations over the hypogastric region, will assist in restoring the contractile power of the bladder. I have known une- quivocal benefit obtained from a blister applied over the pubic region ; and Richter recommends the application of a fresh onion, beat up into a pulp, to the peri- neum. The internal use of the spirits of turpentine, of juniper oil, of the animal oil of Dipple, Peruvian balsam, and according to Jahn. the infusion of solidago virga aurea, may all be used with more or less advantage in cases of this kind. Cold water dashed upon the lower part of the abdomen and perineum, or injected into the rectum, has been found very beneficial in this affection.t Richter states, * When the prostate is much enlarged,.the difficulty of introducing the catheter is sometimes very great. In such cases, this operation is, in general, much facilitated by the previous appli- cation of a poultice made of stramonium leaves, to the perineum.—See Dr. W. M. Eahnestock's observations on this subject, in the Amer. Journ. Med. Sciences, vol. v. p. 251. X Richter, Spec. Therapie.,, bd.. iv.. p. 377. 726 RETENTION OF URINE. that in some cases of retention from vesical paralysis, almost immediate and very considerable relief was obtained by pouring water from the spout of a pitcher, in a stream descending several yards, upon the hypogastrium. Old people often find a great deal of difficulty in voiding the urine—they are obliged to stand a long time before the urine begins to flow, and at last it passes off in a very weak stream, though with little or no uneasiness in the bladder. Persons who are thus affected, may sometimes derive considerable benefit from the use of the phosphoric acid, as recommended by Dr. Valentin.* One drachm of this acid is to be dissolved in two drachms of distilled water, of which ten drops should be taken every two or three hours in a little water. Retention of urine from inflammation requires, of course, the usual efficient local and general antiphlogistic measures. Unless the symptoms of vesical dis- tension be very urgent, it will be most prudent to endeavor to reduce the inflam- matory condition of the parts, before an attempt is made to draw off the water with the catheter. A very efficient blood-letting—ad syncopen—in robust and full habits, together with the free application of leeches to the perineum, cupping on the iliac and pubic regions, emollient clysters, fomentations, mild purgatives, and the internal use of antimony, constitute the means upon which our main re- liance must be placed for removing the malady. Having used local and general depletion, and emptied the rectum by enemata, an anodyne clyster should be given an hour previous to the introduction of the catheter. The catheter will be much more easily introduced into the bladder, and with much less suffering to the patient, after these measures have been efficiently employed. The warm bath, especially the hip-bath, is a valuable auxiliary in such cases. It should be repeated every two or three hours, where conveniences are at hand for its proper employment. The patient may drink moderately of the blandest diluents, and emollient enemata ought to be frequently administered during the day. After efficient general depletion, calomel and opium usually procure more advantage than any other internal remedy. Where the disease is the consequence of an ineffectual hemorrhoidal effort, or of suppressed hemorrhoids, leeching around the anus is especially proper. Whatever other measures be employed, local depletion in this way is one of the most important of our curative means in every variety of inflammatory retention of the urine. For the treatment of spasmodic retention of urine, a great variety of remedies have been recommended. The warm bath often causes the urine to flow almost as soon as the patient is immersed ; but in some instances it fails entirely in pro- curing relief. Various local applications by frictions have been advised, and may be employed with occasional benefit. A liniment composed of two drachms of spirits of turpentine, the yolk of an egg, with six ounces of peppermint water, is particularly recommended by Kieser.t Richter applied bruised onions to the perineum and pubis, with evident good effects. The application of decoctions of stramonium, conium, and of poppy heads, may also be tried with some pros- pect of benefit in cases of this kind. Anodyne enemata are particularly indicated, and occasionally afford very prompt relief. I have known an instance which had resisted the warm bath, and various other remedies, for five or six hours, speedily relieved by an injection of two drachms of laudanum in about a gill of warm milk, into the rectum. Bingham and others strongly recommend tobacco injections; and they sometimes procure very speedy relief; although occasion- ally, they cause great and even dangerous prostration and distress, without any advantage. Internally, opium, in purely spasmodic cases of the disease, some- times does much good; but in order to obtain any decided advantage from this narcotic, it should be given in large doses, so as to bring the system fully under its influence. Richter states, that he has known the following pills to relax the * Archiv. fur Pharmacie, bd i. st. iii. 332. X Hufeland s Journal, an. 1820? st. iii. p. 92. RETENTION OF URINE. 727 urethral spasm in a very short time.* Of late years the muriated tincture of iron has been a good deal employed in spasmodic retention of the urine. From twenty to thirty drops should be given every ten minutes until nausea is pro- duced. The late Mr. Cline, of London, speaks in the highest terms of this article as a remedy in this variety of the disease. I have known it to be suc- cessfully employed in several instances of this kind. It should be particularly observed, however, that it is only where the retention depends on spasm of the urethra or sphincter of the bladder that any benefit can be obtained from this medicine. There is much reason for believing that it is often given in retention from stricture, and even from inflammation ; and that it has thus unjustly lost credit as a remedy in the spasmodic form of the disease. From the decided and speedy relief it procured in the few cases to which I have just alluded, I am well satisfied that it deserves particular attention as a means for removing spasmodic retention. Most writers, in referring to Mr. Cline's experience with this remedy, state that he gave but six or seven drops at a dose; but Dr. Johnson asserts, and no doubt correctly, that this is a mistake, and that Mr. Cline gave it in doses of from twenty to thirty drops every ten minutes, until nausea was produced. The attempt to introduce the catheter, so long as the spasm of the urethra continues, is almost invariably abortive; and it is, indeed, highly improper to persist in the efforts to pass it into the bladder, where the spasmodic contractions are powerful, and resist the first few moderate attempts. It is surprising with what force the urethra sometimes contracts on the catheter, after it has been introduced to a considerable distance during a temporary relaxation of the spasm. So firmly is the instrument grasped, at times, that it is with difficulty drawn out again. Even where the urethral spasm is so far allayed, by the means just men- tioned, as to enable the patient to force out small and interrupted jets of urine, the catheter can seldom be introduced into the bladder without a great deal of difficulty; for the urethra, in such cases, is so extremely irritable, that the irritation produced by the catheter generally excites immediate and insur- mountable spasmodic contractions. If we succeed in introducing the instrument too near the bladder, its progress is almost invariably arrested by the contraction of the sphincter and upper portion of the urethra. By holding it awhile in one hand, and gently rubbing the perineum with the fingers of the other, we may sometimes succeed in slipping it in with little or no difficulty. Retention from stricture, and other mechanical obstructions, is by far the most alarming form of the disease. The means to be employed when the retention de- pends on stricture in the urethra, are local and gentral bleeding—particularly by leeches applied to the anus and perineum, and cupping on the lumbar regions. After the action of the pulse has been reduced by these depletory measures, the patient should be put into a warm bath, more especially the hip-bath, and large injections of warm water and oil thrown into the rectum. When the bowels have been thus evacuated, great relief will in general result from an opiate enema composed of barley decoction and fifty to eighty drops of laudanum ; and inter- nally five or six grains of Dover's powder every two or three hours, together with a repetition of the warm bath, and the tepid diluent drinks, should be used until the skin becomes uniformly moist. Should all these means fail in procuring adequate relief, it will be proper to introduce with due caution a small bougie, "not to draw off the urine, but with the view of restoring the natural action of the muscles of the parts." Mr. Bell, from whose excellent work the foregoing mode of management is chiefly drawn, gives the following directions for intro- ducing the bougie in such cases : " The patient should be standing or resting, on » R.—G. assafcstid. gss. P. rad ipecac. i— opii, aa gr. iv. 01. menth. pip. gtt. iv.—M. ft.—Divide into two grain pills. Take ten pills, three or four times daily. 728 DYSURY. his knees if he is in bed. Take a wax bougie, oil it, soften it, give it the proper curve to pass the turn of the urethra, introduce it into the bladder; now make gentle pressure above the lubes; make the patient exert himself to discharge the urine ; sprinkle cold water on his thighs; withdraw the bougie while he continues the effort; and when he has the sensation as if he could pass the urine, withdraw the bougie altogether, and the urine will probably flow." Even where we fail to reach the bladder with the bougie, the patient may oflen be relieved by pressing a small bougie gently forward, till the point of it has wedged itself into the stricture, when the hypogastrium is to be gently pressed, and the patient directed to exert himself to pass the urine; and at the same time his hands should be put in cold water, or some of it sprinkled on his thighs. (Bell.). If these efforts fail, an attempt may be made with a very small catheter; and where, after all, the stricture is insurmountable, recourse to the operation of puncturing the bladder is the only means left us for preserving the life of the patient. As to the employ- ment of caustic, or of metallic bougies for breaking through the stricture, nothing useful can be expected from them, unless the stricture be very narrow, and not situated too high up; which, however, is but very rarely the case. When the symptoms become urgent, and the general and local means already indicated have been ineffectually employed, it would be unnecessarily placing the patient's life in great jeopardy, by relying on the slow, and, after all, uncertain process, of working through the stricture with caustic. With regard to the mode of ope- rating either for puncturing the bladder or laying open the urethra in perinseo, above the stricture, and introducing a flexible tube through the artificial opening into the bladder, the reader must consult the writings of surgeons—particularly the valuable treatise on the urethra, &c, by Charles Bell, edited by Mr. Shaw. It may be observed, however, that in retention from urethral stricture, it is not often necessary to puncture the bladder, since an incision into the membranous portion of the urethra above the obstruction, will in general answer every purpose that can be obtained from an operation of this kind. It would seem, that, at present, the majority of surgeons prefer the suprapubian operation, where punc- ture of the bladder is determined on. When retention from pregnancy cannot be relieved by pushing up the bladder, or by change of position during the efforts to pass water, such as lying down on the back with the hips raised, the catheter is the only proper means for relief. If tbe pressure of the uterus against the urethra opposes the introduction of the catheter, the patient must be placed on her back, with the hips elevated, and the womb pushed up with the finger of one hand, whilst with the other the catheter is introduced. When the suppression is con- nected with retroverted uteres, the bladder is usually raised so high above its proper location, that it becomes necessary in general to use the male catheter, in order to reach the cavity of the bladder. Sect. VI.—Dysury. Difficulty and Pain in voiding Urine—Strangury. Difficulty and pain in making water, without any particular tendency to reten- tion of the urine, is a very common complaint. In general, whatever is capable of increasing the irritability of the bladder, or of giving rise to the secretion of an acrid urine, will cause more or less pain and difficulty in voiding the urine It is particularly apt to occur where there is an excess of uric acid secreted with the urine; and where the urine is charged with the earthy phosphates, it is seldom absent—although in this latter case the urine is generally more copious than natural, ami does not properly come under the designation of disury, which implies difficulty in passing the urine, as well as pain. The usual sensations of disury are—uneasiness in the neck of the bladder; frequent, painful and slow micturition, with a sense of tenesmus or straining in perinseo—particularly at DYSURY. 729 the moment the last drops are voided ; and a cutting or burning sensation in the posterior part of the urethra. It may be produced by a great variety of causes, such as excess in eating, and in drinking spirituous liquors; the free use of condiments; irritating diuretics; onanism; excessive venery; acid ingesta; in- flamed hemorrhoids; ascarides; suppressed catamenia; the irritation of vesical calculi; astringent injections; redundancy of lithic acid, or of the phosphatic sediments in the urine; leucorrhoea; repelled cutaneous affections; rheumatism ' and gout. It occurs in inflammatory fevers, particularly in hepatitis, jaundice, scurvy, and from verminous irritation and dentition in children. Strangury is an extremely distressing affection. There is a continued urgency to void urine, which passes off in small quantities, or drop by drop, with the most severe burning and cutting pains in the neck of the bladder. Cantharides are pe- culiarly apt to give rise to this affection ; and some individuals are so very suscep- tible in this respect, that they cannot have a blister applied to any part of the body, without suffering more or less from strangury. The spirits of turpentine, also, is very apt to occasion this painful irritation of the neck of the bladder. Treatment.—Where there is reason to suppose that the disease depends on simple irritation of the neck of the bladder from some accidental cause—as in- jections, gonorrhoea, &c.—it will, in general, suffice to empty the bowels by mild laxatives, and to order copious draughts of bland diluent drinks, such as barley water, flaxseed tea, or a solution of gum Arabic, and perhaps an anodyne enema, and rest. When the disease is dependent on an excess of the lithic or phosphatic sedi- ments, the measures already mentioned under the head of lithiasis, for counter- acting these secretions, must be resorted to. " When the urine is perfectly natural both in quantity and quality, and contains no mucous, purulent, or bloody deposit, there is reason to infer that the cause of the irritation is not connected with the urinary system, and must be sought for elsewhere, as in the rectum, or uterine system in females." (Prout.) Should it depend on a hemorrhoidal effort, recourse must be had to the means mentioned in the chapter on hemor- rhoids, for counteracting it. Nervous and hysterical females are liable to ex- tremely violent pains in the neck of the bladder and urethra, and which are generally most intensely felt immediately after discharging urine. Opium and camphor is the only remedy that I have found decidedly useful in cases of this kind. Four or five grains of Dover's powder, with three grains of camphor, taken three times daily, will seldom fail to remove the complaint. Infants, as has been already said, are subject to violent pains of this kind in passing urine during the process of dentition. The existence of the complaint is recognized by the violent shrieks which they utter on voiding the urine. The proper treatment in such cases is to open the bowels freely with castor oil, or rhubarb, and to exhibit twice daily one-sixth of a grain of calomel, with a fourth of a grain of ipecacuanha. In the evening, a drop or two of laudanum should be administered. I have never failed of speedily removing the affection by these remedies. When ihe cases are attended with a copious secretion of the phos- phate of ammonia (an occurrence by no means uncommon), magnesia, which is so frequently administered to infants, is decidedly prejudicial. In old people, this affection is generally attended with a diseased condition of the internal coat of the bladder, or calculous irritation, or disease of the prostate. The careful physician will, of course, endeavor to ascertain the cause; and for this purpose it is particularly important to examine the urine, and the state of the prostate, by examining through the rectum. Females subject to leucorrhoea are apt to suffer the most excruciating pains on voiding urine, from an extremely irritable and tender state of the orifice of the urethra. So sensible is this part in some cases of this kind, that the slightest touch with the finger gives rise to extreme pain. I have found no remedy so effectual, in cases of this kind, as a weak solution of lunar caustic. Two grains to an ounce of water, to which a watery solution of opium is to be added, should 730 ENURESIS. be used two or three times daily as a lotion to the part; and a little lard applied with the finger after each application of the wash. A strong solution of borax will also sometimes give relief; and I have used the cilron ointment, mixed with an equal quantity of oil of almonds, with much benefit. At the same time, however, that these applications are used, it will be necessary to use frequent i injections of a weak tepid solution of sulphate of zinc, or of alum, into the vagina, and to employ other means for counteracting the leucorrhoeal affection. For the relief of strangury, caused by cantharides, &c, and which consists of a slight degree of inflammation of the neck of the bladder, copious draughts of mucilaginous diluents, opiates, fomentations, and, where it is extremely severe, leeching at the perineum should be used. An anodyne enema will, in general, procure very considerable relief. The Germans are in the habit of administer- ing camphor for the removal of strangury ; but although I have used it repeatedly, I have never known it to afford any unequivocal advantage. The free use of flax- seed tea, or of barley water in conjunction with the spirit, ether, nitrici, and an opiate enema, will rarely fail to allay the suffering very materially. Dr. John Davy asserts that the introduction of a catheter almost invariably procures im- mediate relief in strangury from cantharides. " It should be introduced with delicacy and caution, just slipped into the neck of the bladder, and kept in only a few seconds. The process is seldom very painful, and the relief is almost immediate."* Sect. VII.—Enuresis—Incontinence of Urine. This, though not in general a painful affection, is always a very troublesome and distressing complaint. The urine passes off involuntarily ; sometimes con- stantly, in drops, as it is secreted and conveyed into the bladder; at others, only after a considerable portion has been accumulated in the bladder, the impulse coming on so suddenly and irresistibly, that the utmost efforts of volition are not able to restrain its immediate flow. In some instances the involuntary discharge occurs by day and night, whether the patient be awake or sleeping; in other cases, by far the most common, it takes place only at night, during sleep. This affection may, therefore, be divided into three varieties. 1. Enuresis paralytica.—In incontinence of urine from paralysis of the sphincter of the bladder, the urine passes off continually, as it is secreted by the kidneys, without pain, and even without the least sensation of its occurrence. In such cases the diagnosis is not, in general, attended with difficulty. In very old peo- ple it is, nevertheless, not uncommon to find the urine to dribble off involuntarily, without any particular paralytic affection of the sphincter. These cases occur in the slighter instances of partial retention of the urine, from a weakened state of the expulsive powers of the bladder; for, when the urine accumulates in the bladder to a certain degree of distension, the resistance to a further dilatation of the bladder, in conjunction with the pressure of the abdominal muscles, slowly forces the urine into the urethra, and causes it to pass off guttatim. This variety of incontinence often occurs as a symptom of some general dis- ease. Thus, it is frequently met with in the latter stages of low fever—in paraplegia and hemiplegia; and it is occasionally the consequence of concussion of the brain and spinal injuries. Richter observes, that an inability to retain the urine has arisen from plunging into very cold water. Among tbe local causes of this affection the most common are: difficult parturition; injuries done to the neck of the bladder by the unskillful employment of obstetrical instruments; a large calculus located in the neck of the bladder; lythotomic operations ; great dilatation of the neck of the bladder in the extraction of a calculus. The prognosis in this variety of the disease is generally unfavorable, and when * Edinb. Med. and Surg. Journ., 1828. ENURESIS. 731 it occurs as a symptom in febrile affections, it is always one of the most danger- ous indications. Mere local paralysis of the sphincter of the bladder is, indeed, not dangerous, so far as the life of the patient is concerned, but it is an exceed- ingly annoying complaint, and by the urine constantly dripping off, very painful and distressing excoriations on the inner part of the thighs, scrotum, and peri- neum, almost always occur. 2. Enuresis from mechanical causes, independent of paralysis of the sphinc- ter of the bladder, is not unfrequently met with. Most of the mechanical or organic causes mentioned under the head'of ischuria, may, under certain cir- cumstances, give rise to incontinence of urine. Tumors pressing on the bladder —as the gravid uterus; dropsical or scirrhous enlargement of the ovaria; tumors of the mesenteric glands of the rectum, and of the neck of the uterus—have been known to give rise to this affection. It may also be produced by prolapsus uteri; hernia, or prolapsus of the bladder; by the irritation of vesical calculus ; tumors and excrescences from the internal surface of the bladder, &c. These causes seem to operate in the production of incontinence of urine by the pressure which many of them make on the bladder, and by the almost constant nisus to evacuate the urine by which the sphincter may at last become so debilitated and relaxed, as to suffer the urine to pass off slowly and involuntarily; and cases have occurred, which arose from ulcerative destruction of a part of the sphincter. 3. There is a variety of incontinence of urine, described by Riehter, under the name of enuresis spastica, which sometimes occurs in very nervous or hys- terical individuals, and which may, therefore, with more propriety, be called nervous enuresis. The inability to retain the urine occurs in sudden and irre- gular attacks. The patient suddenly feels a most urgent desire to void the urine, and the impulse is so irresistible, that, in spite of the utmost efforts of volition, the urine immediately passes off without allowing time to withdraw, or even to reach for a vessel. This variety of the affection occurs also occasionally in very young children. Its most common exciting causes appear to be—ascarides; hemorrhoidal affections; suppressed catamenia; gouty irritation; and leucor- rhoea. Frequently, however, no obvious causes of this kind are present, and the disease apparently arises from a morbid irritability of the urinary passages, in connection usually with a very excitable or nervous state of the general system. 4. Enuresis nocturna.—This is a very common complaint among children, and occurs also occasionally in adults. When awake, the individual subject to this affection experiences no inconvenience whatever in this respect; but at night, while sleeping, and lying on the back, the urine is apt to pass off, either invo- luntarily, and without the least consciousness of its occurrence, or voluntarily, under the influence of a dream. In children this variety of incontinence of urine is often "associated with some tendency to urinary disease, and very frequently a disposition to gravel; or sometimes, as in young females, with constitutional irritability and weakness; and in advanced life this affection is almost always associated with some organic or other affection of the neck of the bladder or prostate gland." In those cases where the discharge occurs in consequence of a voluntary effort during a lively dream, the urine, on examination, will almost invariably exhibit "some unnatural property, and most generally a strong dis- position to, or actual deposit of gravel. Hence," says Dr. Prout, " 1 have been led to infer that in this species of urinary incontinence, the acrid proper- ties of the urine are chiefly in fault, and that these, favored, perhaps, by the position of the body, and, probably, also, by the morbid sensibility of the blad- der, excite so vivid an impression on the imagination, as actually to lead to a voluntary discharge of the urine." That urinary incontinence may occasionally occur in this way cannot be doubted; but it may justly be questioned whether the causes here assigned are so commonly concerned in the production of the affection as is supposed by the author just quoted. It is certain that we may sometimes prevent the recurrence of the evacuation by exhibiting remedies cal- culated and intended to produce an irritation or tenderness in the neck of the 732 ENURESIS. bladder; as, for instance, cantharides—a circumstance that does not seem to favor the idea that the affection depends on the irritation of acrid urine. Habit, no doubt, oflen has a principal agency in keeping up this affection. When children neglect to pass off the urine on going to bed, the bladder is apt to become dis- tended in the course of the night. This stimulus excites the brain, and awakens a lively dream, occupied with a desire to urinate, and the sphincter yields to the instinctive effort to void the urine. In cases where the urine passes off involuntarily, and without the person being conscious of it during sleep, Dr. Prout thinks that there probably always exists " some morbid condition of the urinary organs," which it is in general extremely difficult to overcome, and continues often, long after the age of puberty. Treatment.—From the foregoing remarks on the various and very distinct character of the causes and pathological conditions of urinary incontinence, it is obvious, that the modes of treatment proper for its removal must be equally va- rious and diverse in different cases. When the incontinence depends on gene- ral palsy, recourse must be had to the treatment mentioned under the heads of paralysis. In instances of urinary incontinence from mere local paralysis of the sphincter vesicae, without any manifest spinal affection, or organic cause, we must endeavor by tonics and local stimulants to re-excite the activity of the sphinc- ter. Among the means that have been proposed for this purpose, the following are the most important. Alum, in doses of twenty grains every four hours, with mucilage of gum Arabic. This, according to Selle, has occasionally removed cases of long continuance. The tincture of cantharides will sometimes produce a very good effect. It should be given in gradually increased doses three or four times daily, until a feeling of ardor urinae or strangury ensues. Dr. Otto, of this city, has recently published an account of three cases of incontinence of urine, which yielded under the employment of uva ursi and the muriated tincture of iron. One of the cases was congenital, and the remaining instances were inve- terate. During the present summer, I prescribed these remedies in a long-stand- ing case, and the result was entirely satisfactory.* Externally, cold bathing or cold water poured from a height on the pubis, and dashed upon the perineum, will sometimes do good. Richter recommends cold injections into the bladder; and in females, cold water may be beneficially injected into the vagina. Elec- tricity and galvanism have also been employed with success in cases of this kind.t Stimulating frictions, of various kinds, will occasionally assist in restor- ing activity to the sphincter. M. Lair, in a memoir of this affection, refers most cases of incontinence of urine to a want of equilibrium in power between the body of the bladder and its neck, the latter being in an atonic or relaxed condi- tion. This view of the subject led him to seek for a mode of stimulating the neck of the bladder, without affecting its body. With this intention, he intro- duced, by means of a catheter, the tincture of cantharides, so as to touch the urethra in a prostatic part, as well as the neck of the bladder; and he affirms that by this mode of management he cured three cases of this malady.^ Dry cupping the perineum and blisters applied to the sacrum are also very useful measures in cases of this kind. M. Canin has lately related two cases before the French Academy of Medicine, which were cured by these applications. In one of them, in a lad about fourteen years of age, the disease had already con- tinued two years. It required eighteen applications of the cups in the course of a month, before the cure was effected. In the other case, also in a young per- son, the cups were applied twenty times, and a blister laid over the sacrum be- fore the cure was completed. In both instances, various means had been tried without any apparent advantage. In urinal incontinence from mechanical causes, we can seldom do more than * North American Med. Journ., Oct. 1830. X Loders Journ. der Chirurgie, b. iv. hft i, X Med.-Chir. Rev., January 1827, p. 244. ENURESIS. 733 palliate the disorder, or procure temporary relief. When it occurs from the pressure of the gravid uterus, nothing but the delivery of the child will in general remove the complaint; yet in some instances, incontinence of the urine occurs about the third and fourth month of pregnancy, and after having continued for a time, goes off spontaneously, before the termination of the regular period of gestation. In nervous or spastic urinary incontinence, anodyne enemata, together with uva ursi in union with Dover's powder, or with the extract of stramonium, and the employment of tonics—particularly iron, quinine, and the oxyde of zinc —with a nourishing and digestible diet, regular exercise in the open air, early rising, and, in general, whatever is calculated to invigorate and to allay the mor- bid irritability of the system, constitute the appropriate means in cases of this kind. Wendt speaks very favorably of the expressed juice of the mesembryan- themum crystallinum, in the incontinence of urine which occurs in very nervous individuals. When the patient is affected with leucorrhoea, or ascarides, or with an irritated state of the rectum from hemorrhoids, particular attention should, of course, be directed to the removal or mitigation of these affections. For the removal of enuresis nocturna, a great variety of means have been proposed, but they have not been very often applied with much success. The disease generally disappears, as cnildren approach the age of puberty, and often at a much earlier period; and this occurs apparently from the powerful influence of a sense of shame, and a determination, during the waking state, to resist the desire to micturate, which occurs in dreams during sleep. Mr. Prout observes, " that when the incontinence in children is associated with gravel, it is of the utmost consequence that this circumstance be attended to; and that the remedies appropriate for counteracting the formation of these urinary deposits, should be employed before any other means are used to restrain the urinary incontinence," for without this almost all other remedies will be in vain. The urine should there- fore be carefully inspected, both in its recent state and after it has stood awhile; and if a sediment either of the lithic acid or phosphatic variety be deposited, recourse should be immediately had to the remedial measures mentioned under the head of lithiasis, in a preceding section of this work. After this object has been ac- complished, we may proceed to the employment of tonics and some one of the various remedies or modes of management which experience has shown to be capable of doing good. Among these, there is no article which has been more generally prescribed than the tincture of cantharides, with the view of producing a slight degree of strangury, or considerable ardor urinae; so that the pain excited by the first efforts to micturate, may excite and awaken the patient, and thus interrupt the habit which always ultimately contributes chiefly to the recurrence of the discharge. This article may be beneficial also, by increasing ihe sensi- bility and activity of the sphincter, and thereby enabling this muscle to make greater resistance to the expulsive efforts of the bladder. The same effect may sometimes be derived from the application of a blister to the sacrum. I have known an instance of long standing, removed by the use of the spirits of turpen- tine, in doses of from fifteen to twenty drops three times daily, until a consider- able degree of ardor urinae was produced. Where these remedies do not afford relief, and there is reason to believe that the incontinence depends on a morbid irritability of ihe neck of the bladder, which is often the casein adults, an opiate administered on going to bed, will sometimes have the effect of preventing the evacuation during the night. Children should always be required to empty the bladder just before going to bed, and when they awaken at night, they ought to be taught to rise and pass off the urine. By this, we may often prevent the occurrence of the disorder, and even occasionally obviate it after it has occurred. Mr. Charles Bell makes the following observations in relation to this subject, and which are worthy of particular attention in the management of ibis complaint. "Incontinence of urine," he says, "never takes place but when the boy is asleep upon his back; and the cure is a simple one. He is to accustom himself to bleep upon his face or side ; the urine is not passed, nor is he excited to dream 734 HYDROPS. of making urine, while he keeps this position. The circumstance is unaccount- able, until we reflect on the position of this master-spring of the muscles of the bladder—the sensible spot, a little behind and below the orifice of the bladder. When a person lies upon his belly, the urine gravitates towards the fundus; but when he lies on the back, it presses upon this sensible spot, and distends that part of the bladder, which is towards the rectum." CHAPTER VIII. CHRONIC DISEASES OF THE SEROUS EXHALANT VESSELS. Hydrops—Dropsy. Dropsy, or rather the effused and accumulated fluid which constitutes the most conspicuous external character of this disease, must be regarded only as an effect of a primary morbid condition of the solids. This morbid condition of the solids constitutes the essential malady, to which the physician's attention must be directed in order to obtain rational views concerning its nature and remedial management. The cure of this disease does not depend merely on the removal or evacuation of the aqueous accumulation, but principally, if indeed not entirely, on the removal of that disordered state of the vascular system, upon which the dropsical collection depends. Here, then, the fundamental question meets us: In what does this morbid condition of the solids consist, and in what particular structure is it chiefly located ? According to the late Dr. Rush, the morbid action which gives rise to dropsical accumulations, is seated in the arte- rial system, and is, in its nature, closely allied to inflammation. Dropsical accu- mulations, agreeably to his views, are the result of an increased action of the exhalent vessels, attended with a general pyrexial condition of the system. The correctness of this doctrine is now very generally, we might perhaps say, uni- versally admitted. Indeed, the removal of dropsy from the cachexia to the py- rexia, is justly regarded as one of the most important of modern improvements in pathology. That the increased secretion or effusion of serum, which occurs in dropsy, depends on a condition which, if not identical, is at least closely allied to inflammation, receives the greatest degree of probability from the following circumstances: Every one who has observed the progress of inflammation, knows that at the period when the inflammation is passing off, or changing to the subacute or chronic state, an effusion of serum is apt to occur into the surrounding cellular tissue or contiguous cavities. Thus, rheumatic inflammation, gout, and sprains, frequently pass off by an effusion of serum into the circumjacent cellular struc- ture. It is well known, too, that hydrothorax is by no means an uncommon sequel of pleuritis; and hydrocephalus of arachnitis. Indeed, the pathological fact, that all inflammations of the serous membranes, if not very violent, or speed- ily terminated in resolution, end in effusion, is directly corroborative of the cor- rectness of this view of the pathology of dropsy. It is therefore highly probable, that the morbid action which exists in the tissues from which the dropsical effusions occur, partakes more or less of the nature of inflammatory excitement; but it seems likely, that it is always of the lowest grade of phlogosis, amounting, in some instances, probably, only to an irritation bordering on actual inflamma- tion. It would appear, indeed, that a considerable degree of inflammation is incompatible with serous exhalation—and that this effect can occur to any ma- terial extent, only where the vascular irritation is somewhat below the grade of actual inflammation. HYDROPS. 735 To this doctrine of the nature of dropsy, objections of much plausibility have been urged. When duly estimated, however, they do not appear to possess any solid value. It has been stated, for instance, that dropsy is not unfrequently the consequence of profuse hemorrhage and of other exhausting causes, and that in such cases at least, neither the general symptoms, nor the nature of the causes, justifies us in considering the disease as one of an inflammatory character. Against this, however, it may be observed, that local irritative or inflammatory action, and great debility and exhaustion, are by no means incompatible. Sub- inflammation may exist in one structure or organ, whilst the general system ex- hibits all the char.acteristic traits of debility and cachexy. The post-mortem phenomena which occur in the human subject, and in animals who have died from hemorrhage, would seem to show, indeed, that even in dropsies from hemorrhage, there exists a morbid state allied to inflammation in the membranous structures from which the effusion occurs. The experiments of Mr. Seeds and of Kellie show that in animals bled to death, the meninges of the brain, and other membranous tissues, almost invariably exhibit a highly injected and congested stale, similar, in all respects, to what occurs in actual inflammation. In many instances of this kind, a considerable quantity of watery effusion was found within the head ; and in some instances, high and tumultuous action of the heart and arteries occurred shortly before the animals expired. I have met with seve- ral cases, in which internal inflammation occurred, apparently in consequence of excessive losses of blood. I attended a gentleman, a few years ago, who was reduced to the utmost degree of exhaustion compatible with life, in consequence of a long-continued and almost uninterrupted loss of blood from the rectum, and who finally became anasarcous over the whole body, while at the same time his eyes were very considerably and obstinately inflamed. The phlogistic character of dropsy is sometimes strikingly illustrated by the conversion of inflammatory dis- eases into dropsy, and vice versa. In a late number of the Medico-Chirurgical Journal, there is a case related, in which rheumatism was successively converted into dysentery, erysipelas, peritonitis, and finally, dropsy.* Although it must be admitted, that increased exhalation of serum constitutes the chief immediate cause of dropsical accumulations, yet it is probable that there always exists a simultaneous diminution of absorption in the surface from which the effusion takes place. In the first place, it may be observed, that vascular irrita- tive excitement or inflammation in a part is necessarily attended with a preterna- tural afflux, and consequently, sanguineous congestion in such part. This being the case, it follows, that the capillaries of the structures from which dropsical effusion occurs, must be in a state of repletion or sanguineous congestion. Now, it is a truth, I believe well established, that the function of absorption from the cavities and cellular tissue, is chiefly, if not entirely, performed by the venous extremities. The experiments of Magendie, or Meckel, of Tiedemann and Gmelin, have placed this physiological fact beyond all reasonable doubt. It ap- pears, moreover, to be equally well established, that the process of absorption is accelerated or diminished, according as the capillaries contain a less or greater quantity of blood. WThen they are full and congested, and the current of blood moves along sluggishly, absorption is comparatively slow, and vice versa. This fact was long ago noticed by Home in his Essay on Croup. "The less blood," he says, "there is in the veins, the more rapidly will absorption be effected." When it is considered, therefore, that the tissues from which the dropsical effusions oc- cur, are, as is believed, in a state of sub-inflammatory action, or at least of vascu- lar irritation, and that the capillaries of these tissues must consequently be in a state of fullness or congestion, it would seem to follow, that the process of ab- sorption must be correspondingly diminished. Hence, in every case of dropsy, there are, probably, two simultaneous morbid conditions present, namely, in- creased exhalation, and decreased absorption. * Med.-Chir. Rev., vol. vi. p. 197. 736 HYDROPS. Etiology.—The principal occasional causes of dropsy are mechanical obstruc- tions to the free return of blood to the heart; the influence of cold; excessive hemorrhages; disease and inactivity of the kidneys; repelled cutaneous erup- tions; suppressed habitual discharges; chronic diseases which tend to exhaust the system ; arsenic ; and some of the acute exanthematous affections, particularly scarlatina and measles. Dr. Ayre, in his treatise on this disease, denies that me- chanical obstruction ever has any, direct agency in the production of hydropic effusions. When dropsy supervenes on scirrhus of the liver, he considers it the consequence of the slow inflammation of the indurated viscus, extending to its peritoneal covering, and thence along the abdominal peritoneum. It is not im- probable that the disease may, in some instances, be developed in this way; but it seems much more likely, that the congestion which necessarily occurs in the portal system in such cases, produces, by degrees, that irritated condition of the peritoneal capillaries which gives rise to the effusion. It is a well established fact, that habitual sanguineous congestion in a part, tends ultimately to excite a low degree of inflammation. We may reasonably presume, also, from the above observations on the influence of vascular turgescence in diminishing absorptions, that this process is in such cases morbidly diminished, even before capillary irri- tation and consequent preternatural exhalation have commenced. The influence of obstructions to the return of blood to the heart, in producing serous extravasa- tions, is sufficiently illustrated by the oedema which occurs when ligatures are passed round an extremity. Cold rarely produces hydropic affections, unless there exists a predisposition to the disease. Of all the causes which predispose to the occurrence of dropsy from the influence of cold, the most powerful are scarlatina, measles, and the mercurial excitement. Neither these two exanthematous affections, nor mercury, are apt to give rise to dropsy, unless they co-operate with cold, or vicissitudes of atmospheric temperature. They leave the surface of the body in a highly sensi- ble and irritable condition, and the cutaneous exhalation is usually carried on freely during the period of convalescence. When the body, in this condition, is exposed to the influence of cold, the cuticular exhalants are particularly liable to become torpid; and congestion in the capillaries of the subjacent cellular tissue almost necessarily ensues. This tissue being already predisposed to morbid ex- citement from the previous exanthematous affection, passes readily, under the combined influence of these circumstances, into a state of irritation or sub-inflam- matory action, whence dropsical effusions proceed. It is not improbable, how- ever, that in some instances of dropsy from scarlatina or measles, the disease may be the immediate consequence of the extension of the inflammation or irritation from the skin to the subjacent cellular texture. The fact, however, that dropsy from these affections occurs but very rarely when the patient is carefully protected from cold, would seem to show, that the disease is not apt to arise from an exten- sion of the inflammation to the cellular tissue. Dropsies from cold are frequently attended with slight catarrhal symptoms, and are always manifestly of a phlogistic character. When blood is drawn, it is generally found sizy ; and the pulse is tense, quick, and frequent—more espe- cially in those cases which occur as the sequela of scarlatina or measles. The effusion generally takes place very rapidly. The variety of dropsy which most commonly proceeds from cold, is anasarca, although some degree of abdominal effusion is not uncommon. In relation to dropsies from excessive hemorrhage or other profuse and long- continued discharges, we have two observations to make, in elucidation of their etiology. In the first place, it would seem to be well established, that excessive losses of blood are almost invariably attended or immediately followed by irre- gular determinations, or foci of congestion, in one or more of the serous mem- branes. It is thus that the red and injected appearance of the arachnoid and other membranous structures occurs in animals, when killed by bleeding. The struc- tures which may have thus become the foci of determination, gradually pass into HYDROPS. 737 a state of irritated action, which ultimately, in most instances, gives rise to drop- sical effusions. There is, however, another circumstance connected with the production of dropsy by excessive losses of blood, which, though little estimated by pathologists, has, I am convinced, an important concern in the causation of the disease. I have already observed above, that immediately after a profuse loss of blood, absorption goes on with unusual activity. The blood-vessels are rapidly replenished with crude fluids; for, the absorbents being extremely active, nearly all the aqueous fluids received into the stomach are speedily absorbed into the circulation; and this is especially favored by the very great thirst which almost always occurs after excessive sanguineous losses. The blood being thus inordi- nately supplied with a crude and watery fluid, becomes more irritating to the heart and capillaries, and diluted to such a degree as to pass off more readily by the exhalants. That this is not a hypothetical view of the subject, is shown by the experiments of Harles and Schulze, both of whom rendered animals hydropic by drenching them copiously with water, after they had abstracted from them large quantities of blood. Haller a|so bears testimony to the fact, that copious hemor- rhages produce an increase of serous fluid in the blood. Dropsy from hemorrhage is generally of the anasarcous kind. The blood, in these cases, always contains a very great over-proportion of serum, the crassa- mentum being very small, usually cupped, and often covered with a buffy coat. The pulse is frequently full and active, though not hard or tense. Dropsical effusions from hemorrhage, rarely supervene immediately after the loss of the blood. Several weeks usually intervene between the hemorrhage and the occur- rence of the dropsical swellings. Disease or torpor of the kidneys is another, though not a very common cause of dropsy. Dr. Bright* has recently published some interesting cases of this kind. In nearly all these instances, the kidneys were found in a state of dis- organization. In dropsies depending on deficient urinary secretion from renal torpor or organic disease, the urine invariably contains a portion of albuminous matter. Among the causes of dropsical effusions, we may also mention amenorrhoea, diabetes, chronic gout, the intemperate and habitual use of spirituous liquors, and in short, almost every chronic affection or cause which is capable of exhausting the constitution, or causing important functional lesions. General symptoms.—A dry and harsh skin is almost universally present. The appetite is usually impaired—but when the disease is the consequence of hemor- rhage, the appetite for food is sometimes particularly strong. The thirst is generally considerable, and sometimes very urgent. The bowels are commonly inactive, though readily moved by laxatives. The pulse is irritated, and usually indicative of a pyrexial state of the system; for however small and febrile, it is almost always quick and frequent. The urine is scanty and generally of a deep red color; sometimes jumentose—and occasionally, though rarely, whey-like or chylous. In a diagnostic point of view, much attention has of late years been paid to the appearance and character of the urine. Dr. Blackall has investigated this subject with minute attention; and the observations of Ayre and Wells have thrown further light on it. The circumstance which has particularly occupied the attention of these physicians, in relation to this subject, is the absence or presence of coagulable matter or serum in the urine of hydropic patients. In many instances of this disease, a greater or less proportion of coagulable serum exists in the urine, whilst in others this excretion is wholly devoid of coagulable matter. Observation would seem to show, that this occurrence is intimately connected with the general state of the system ; for it would appear that in those cases of dropsy which are attended with an obvious phlogistic diathesis, and especially such as arise from the influence of general causes, the urine, with * See his Reports of Medical Cases. London, 1827. 47 738 ASCITES. scarcely an exception, contains a large quantity of coagulable serum. The quantity of serum mixed with the urine, may therefore be regarded as a pretty correct index of the degree of general inflammatory excitement attending the disease. Serous urine may be considered as a kind of pyrexometer in hydropic affections, which, though not universally to be relied on, is yet sufficiently con- stant to entitle it to the attention of the practitioner. I am satisfied, from con- siderable attention to this subject, that in almost every instance where there is coagulable serum in the urine of dropsical patients, the general condition of the system will be found manifestly phlogistic. In the dropsies which occur after scarlatina, the urine generally contains a large portion of ihe serum; whilst in local dropsies, and in which the general vascular system does not participate, little or no serum is detected in the urine. (Ayre.) When the urine is high colored, scanty, and, on cooling, deposits a red sediment, or remains muddy, the liver, probably, is in a state of organic disease. (Cruikshank.) After all, it is highly probable, from what is said above, that every case of dropsy is essentially phlogistic, so far at least as relates to the immediate local excitement which gives rise to the effusion. The general system, however, does not always participate in the local affection—the heart and arteries receiving no sympathetic impulse from the local, irritated, or sub-inflammatory action. In such cases, the general circulation is languid, and debility and relaxation charac- terize the disease. Where the heart and arteries do sympathize with the local hydropic affection, and this is by far most commonly the case, the pulse will manifest more or less of a pyrexial state, being sometimes full, hard and active, or small, tense, quick and frequent. 1. Ascites—Dropsy in the Cavity of the Abdomen. Ascites, or abdominal dropsy, is very generally dependent on visceral indura- tion, more especially on scirrhus of the liver or spleen. Whatever, therefore, has a tendency to produce induration of these viscera, may become the remote cause of this form of dropsy. Among the most common and powerful of these causes, may be ranked the habitual and intemperate use of alcoholic liquors ; protracted agues ; hepatitis ; and inveterate dyspepsia. Whatever may be the remote cause of ascites, however, chronic inflammation of the peritoneum con- stitutes, no doubt, the immediate and essential cause of the abdominal effusion. Subacute inflammation of this membrane, in whatever way it may be produced, terminates perhaps always in effusion; although in some instances this may not be so copious as to constitute dropsy. In the majority of fatal cases of ascites, the peritoneum exhibits a highly injected state; and, in many instances, the traces of previous inflammation are still more conspicuous and unequivocal, its structure being either thickened or otherwise altered, or covered with an infini- tude of miliary tubercles. Occasionally, indeed, no marks of pre-existing inflamma- tion whatever are to be seen; but the investigations of modern pathologists have rendered it abundantly manifest, that where no disorganization or structural change has been effected, the mere redness, or injected state of the inflamed parts may, and does often disappear in articulo mortis, or even post-mortem. Besides the causes I have just mentioned, it will be sufficient to observe, that everything which is capable of producing slow inflammation of the peritoneal lining of the abdominal cavity, may give rise to this variety'of dropsy : such as cold ; parturition; blows on the stomach ; enteritis; metastasis of cutaneous eruptions; gout, or rheumatism ; suppressed habitual discharges; and infarcted bowels. Diagnosis.—The only condition which is likely to be mistaken for ascites is pregnancy. From this state it may be distinguished by the fluctuation; the uni- formity of the tumor; the lateral pressure and distension of the abdomen on lying on the back; the oppression of breathing on lying down, so as to raise the pelvis and abdomen higher than the chest; the thirst; the paucity of the urine; HYDROTHORAX. 739 the dryness of the skin ; which characterize effusion into the abdomen. And, on the other hand, the absence of the peculiar symptoms of pregnancy assists us in forming a correct diagnosis. When the dropsical accumulation becomes very great, much uneasiness and general disturbance in the system arise from the mechanical irritation which it causes by its pressure on the organs and parietes of the abdomen. Respiration becomes short and anxious ; the stomach will admit of but small quantities of drink or food ; the fibres of the abdominal muscles yield, and the whole ab- domen becomes sore .and tender to the touch, and a dry and short cough gene- rally comes on in the advanced stage of the disease. Ascites is very rarely wholly unconnected with anasarcous swellings. Ultimately, oedema of the feet and legs, if not more diffused cellular effusion, ensues. The urine is much more apt to be very high colored and sedimentous in ascites than in the other forms of dropsy. The bowels, too, are more torpid, especially in aggravated cases. 2. Hydrothorax—Dropsy of the Chest. Hydrothorax generally supervenes gradually, without causing, in its initial period, any particular inconvenience or disturbance calculated to excite much attention or suspicion of the true nature of the malady. At length, however, the patient begins to experience a sense of oppression and tightness at the lower part of the sternum, with slight difficulty of breathing when at rest and in an erect posture. He now finds that, on lying down, or using active bodily exer- tion, especially on ascending an acclivity or stairs, the dyspnoea and sense of suffocation are greatly increased. When recumbent in bed, he raises his head and shoulders high by means of pillows, which, by diminishing the pressure of the effused fluid on the lungs, generally enables him to obtain some sleep. His sleep is, however, frequently interrupted by sudden and violent starts, and feel- ings of alarm and terror. The pulse is irregular and commonly very hard; the thirst urgent; the urine scanty, high-colored, and sedimentous. As the disease advances, the feet become cedematous ; the countenance is expressive of anxiety and alarm, and of a mixed pallid and livid aspect. There is generally a dry and short cough attending the disease, more especially when the patient lies down, or uses bodily exertion. All the foregoing symptoms increase, if the disease continues unchecked in its course, until the quantity of fluid in the chest is so great as to prevent the patient from lying down even for a moment, and obliges him to take his short and disturbed periods of sleep in a sitting or leaning pos- ture. The extremities are generally cold, and more or less benumbed. Of all the foregoing symptoms, the sudden starting during sleep is, according to Baglivi, the most certain pathognomonic symptom of this disease. Laennec, however, asserts that this symptom is sometimes absent; yet, when it does occur, it may be viewed as a very strong evidence of the existence of thoracic effusion. Hydrothorax may occur either as an idiopathic affection, or as one symptom- atic of organic disease of some viscus of the chest or abdomen. The former variety of the disease is very rare. (Laennec.) By far the greater number of cases are of the latter kind. Organic cardiac disease is the most common source of symptomatic hydrothorax. Structural disorder of the liver and spleen may also give rise to the disease, and cases are recorded which appeared to have arisen from organic disease of the stomach. Chronic inflammation of the pleura, occurring as the sequel of acute pleuritis, is always attended with hydropic or sero-puruloid effusion into the chest. A tuberculous state of this membrane, and aneurismal dilatations and ossifications of the large vessels within the cavity of the chest, sometimes give rise to this malady. Besides these peculiar causes, hy- drothorax may be produced by any of tbe general and particular causes mentioned above. Dr. Ayre observes, that a plethoric state of the system predisposes es- 740 ANASARCA. pecially to serous effusion into the cavity of the chest; more particularly in persons who have passed the middle period of life, and who have indulged freely in the pleasures of the table. The correctness of this observation will be acknowledged by every one who has paid due attention to this subject. When this disease arises from some general cause, the effusion almost invariably occurs only in one side of the chest; but in those cases which come on in consequence of organic or structural disorder, the dropsical effusion, almost without exception, takes place at once in both sides of the thorax. (Laennec.) Prognosis.—Idiopathic hydrothorax is not often a dangerous or unmanageable affection. Laennec says, that he considers the instances of death from the idio- pathic variety of the disease, as rare as one in two thousand, when under the control of judicious remedial management. Indeed, even in the symptomatic variety of the disease, we may frequently succeed in removing the effused serum ; but this seldom affords permanent relief, since we can but very rarely thus re- move the organic disorder upon which the effusion depends, and which conse- quently still continues to take place, and give rise to further accumulation. Dr. Ayre asserts, what indeed I am well inclined to admit, that " the means which are sometimes used for the removal of the water in symptomatic hydrothorax, have now and then the effect, at the same time, of removing the organic disorder which gives rise to the effusion." Sir Henry Halford affirms, that he has ascer- tained from much experience, that if " the swelling in the feet or legs disappears without an increased discharge of urine, the patient generally dies very soon, and most frequently suddenly."* I have myself remarked this circumstance in seve- ral cases. Diagnosis.—Ability to lie down only on the side affected, if the effusion has taken place only in one side. Percussion produces a very obscure and dull sound. The percussion should be made while the patient is in a sitting posture. General agitation, cough, and a sense of suffocation when firm pressure is made on the abdomen just below the ribs, so as to push up the viscera against the dia- phragm. Inability to rest and sleep in a recumbent posture. If with these symp- toms there are habitual cough ; starting during sleep; tension and irregularity of the pulse; slight oedema of the feet, and of the integuments of the chest; great dyspnoea on ascending an acclivity or stairs, with a disposition to syncope, we may pronounce on the existence of an effused fluid in the cavity of the thorax with confidence. (Roux's edition of Desault's Surgery.) 3. Anasarca—Cellular Dropsy. This form of dropsy consists in a morbid collection of serous fluid in the sub- cutaneous cellular tissue, and this accumulation may be either generally diffused throughout the whole body, or confined to a part of greater or less extent. The ordinary and most unequivocal sign, by which effusion into the cellular tissue is detected, is the pitting from firm pressure with the fingers. Anasarcous effusion commonly commences in the feet and legs, and thence rises up over the body with more or less rapidity. This, of all the forms of hydropic disease, is the most frequently connected with a sluggish and languid state of the system ; and it is this form of the disease especially, which is apt to supervene on excessive losses of blood, and other exhausting or debilitating causes. The skin is exsan- guious, and of a peculiar sallow or pallid cast; and the patient frequently mani- fests a great disposition to drowsiness, with a depressed or sluggish state of the intellect. Anasarca is often attended with some degree of abdominal effusion ; and the latter, when it forms the primary affection, is rarely wholly free from anasarca. When anasarca arises from general causes, however, it is rarely con- nected with ascites. In nearly all instances in which these two forms of dropsy co-exist, the effusions into the internal cavities precede those into the cellular * Transact. College of Phys. of London, 1820. DROPSY. 741 membrane. (Ayre.) Local anasarca may be produced by whatever impedes the free return of the blood by the veins. Hence, the gravid uterus, tight bandages, and the pressure of indurated glands in the groins, often give rise to oedema of the feet and legs by compressing, in some degree, the iliac veins. Mere debility, too, especially when aided by a long-continued erect posture, will have the same effect; and hence the frequency of oedema during the debility of convalescence from fevers. In nearly all organic diseases of the heart, oedema ultimately occurs in the feet and legs—more particularly in cases attended with ossification of the valves. Anasarca, from suppressed perspiration in consequence of the influence of cold, generally comes on and proceeds to its acme rapidly. Prognosis.—This form of dropsy is not often attended with much danger when it occurs as an idiopathic affection—that is, without organic disease, and in eon- sequence of some general remote cause, such as cold, arsenic, scarlatina, hemor- rhage, &o. When unattended with abdominal or thoracic effusion, it is, upon the whole, much more frequently removed by remedial treatment than the other forms of dropsy. The more rapidly the disease supervenes, the more easy in general is its removal. Causes.—Hemorrhages ; suppressed perspiration from cold, particularly after scarlatina, or when the system is under the influence of mercury; the long-con- tinued internal use of arsenic ; intestinal irritation ; great debility and exhaustion; repelled cutaneous eruptions; chronic gout; excessive and long-continued diar- rhoea ; indurations; organic disease of the kidneys, &c, are the most common causes of this variety of dropsy. Treatment of Dropsy. If the pathology which is laid down in the commencement of this chapter be correct, the principal indications to be pursued in the treatment of dropsy are, 1, to subdue the local sub-inflammatory or irritated action of the structures from which the dropsical exhalation takes place ; and, 2, to promote the absorption and removal of the effused fluid. The first of these general indications is to be fulfilled—1, by diminishing the general momentum of the circulation where it is preternaturally great; and, 2, to drive the blood, as much as possible, from the capillaries immediately implicated in the morbid effusion, and to equalize the cir- culation. The second general indication is to be fulfilled—1, by promoting the activity of the various serous emunctories; 2, by diminishing the quantity of blood circulating in the venous extremities of the structure from which the drop- sical fluid is poured; and, 3, by stimulating the activity of the absorbent system. One of the first and most important measures to be adopted in establishing an adequate derivation of blood from a part, is to diminish the general impetus of the circulation. In vain will we endeavor to diminish the preternatural afflux of blood to an irritated or inflamed part, if the vis-d-tergo of the circulation, or its general momentum, be suffered to remain undiminished. Whenever, therefore, the pulse is active, or tense and frequent, in dropsy, blood-letting is an all-import- ant measure. By reducing the mass of the circulating fluid in such cases, we not only predispose the veins to absorb more rapidly, but we contribute, more- over, in a direct way, to the reduction of the process of effusion. I have known one or two efficient bleedings to cause an immediate and conspicuous amend- ment in the disease.* Muscular debility does not constitute any objection to blood-letting, provided the pulse be active, tense, or hard and frequent. The arterial system may be irritated to vigorous action, whilst the muscular system manifests a state of languor and debility. Of course, where the pulse is feeble and languid, venesection is uncalled for and improper. Having moderated the * Dr. Hohnbaum has recorded a case of ascites, which, after paracentesis had been repeatedly performed, was removed by spontaneous epistaxis.—Analen der Medizin., vol. iv. p. 226 of the Sequel. 742 DROPSY. momentum of the general circulation, where it was too great, considerable advan- tage may, in general, be obtained from local bleeding, by cups, or leeches, applied to the chest or abdomen, according as the effusion may have taken place in one or the other of these cavities. Blisters, also, often assist materially in the successful treatment of ascites and hydrothorax. They tend in a direct way to derive the circulation from the irri- tated or congested serous membranes, from which the effusion occurs, and con- sequently to lessen the effusion, and promote the absorption of the dropsical fluid. In anasarca, or in any other forms of disease attended with anasarcous effusion, neither leeching, nor cupping, nor blisters, can be applied without some risk of gangrene, or mortification. Little or no peculiar advantage can, indeed, be expected from local abstractions of blood in anasarca, and the same observa- tion applies to blistering. Dr. Ayre speaks very favorably of the effects of a seton fixed in the integuments of the chest in hydrothorax. In one instance of this form of dropsy, which came under my observation, much benefit appeared to result from this measure. I should prefer, however, resorting to blistering and cupping, as being decidedly more derivative and prompt in their influence than setons or issues. In ascites, leeching, followed by blistering or cupping, ought never to be neglected unless the anasarcous state of the surface be such as to render these measures hazardous. Cathartics.—Drastic purgatives have, from the earliest periods of medicine, held a high rank among the remedial means employed in dropsy. They consti- tute, in facl, a very important class of remedies in this affection. Very active purgation not only often carries off the effused fluid, but in some instances has the effect of removing that morbid slate of the peritoneal capillaries upon which abdominal dropsy depends. The efficacy of hydragogues is generally more con- spicuous in abdominal dropsy than in the other varieties of this disease. Their influence upon the morbid condition of the peritoneum is much more direct and powerful, from its contiguity to the mucous membrane of the intestinal tube, than upon the more remote structures concerned in the other forms of dropsy. Though, in general, less beneficial in anasarca and in hydrothorax, cathartics are nevertheless frequently of considerable service even in these forms of dropsy ; nay, in some instances, the effects of active purgation in removing dropsical fluids from the chest, are surprisingly prompt and complete.* Physicians have varied, and still differ in opinion as to the particular articles of this class of remedies best calculated to procure the desired advantages. It is, indeed, agreed, that those purgatives which are most apt to cause copious watery stools, or, as they are called, hydragogues, are decidedly the most efficient in diminishing dropsical accumulations; but there exists some diversity of sentiment in relation to the relative value of this variety of cathartics. Cremor tartar may be placed at the head of this class of articles, in reference to hydropic affections. It is mild,ibooling, and potent in its operation as a hy- dragogue, and possesses the additional and peculiar advantage of exciting, at the same time, considerable diuresis. Dr. Ferriar's statements afford strong testi- mony of its usefulness in abdominal and anasarcous dropsy. Out of forty-three cases treated chiefly with this remedy, thirty-three were cured—a result, which, however, has been but rarely obtained by other practitioners. In my own prac- tice I have had unequivocal examples of the efficacy of a course of purgation with this article. I have for ten years past been in the habit of prescribing it according to the following formula, and as it appeared to me, generally with peculiar efficacy: R.—P. crem. tart. ^iss. — sulphat. potassa? ^ss. — scillEe maritim. gri. Tart, antimonii gr. ii.—M. S. A teaspoonful of this mixture is to be taken four or five times daily. * Pring's Principles of Pathology, p. 262. DROPSY. 743 Given in this way, it has never failed, in my hands, to produce copious watery stools, together with a considerable flow of urine, and frequently diaphoresis.* Elaterium is another valuable hydragogue in the treatment of dropsy. Dr. Ferriar asserts, that it surpasses all other articles of this kind, in the removal of dropsical accumulations ; and it continues to be a favorite hydragogue with many of the most eminent practitioners of the present day. Dr. Clutterbuck, especially, attaches great value to this article, as a remedy in dropsy. I have employed it in a considerable number of cases of this disease, but it has not, in my hands, produced advantages equal to those I have derived from cremor tartar. Indeed, I have met with instances in which it did manifest harm, by the violent irritation it caused in the mucous membrane of the bowels. It must be constantly borne in mind, that although an excitation of the serous emunctories of the intes- tinal tube will in general afford advantage, yet when the effects of purgatives on the mucous membrane transcend this grade of excitement, and establish an irri- tation, bordering or actually passing into subacute inflammation, mischief must inevitably be the consequence. In prescribing such active purgatives, therefore, great care must be taken, lest in our anxiety to produce copious aqueous evacu- ations, we establish a morbid and permanent irritation in the mucous membrane of the bowels, and thus create a new and highly injurious focus of morbid sym- pathies in the system. Whenever such articles cease to produce copious watery stools, when given in ordinary doses, and leave a general sensation of soreness or tenderness in the abdomen, we are admonished to desist from their further employment. Active cathartics will generally bring off* copious watery stools for the first two or three times that they are administered; but by being again and again repeated, they will at last cease to excite the desired evacuations. A larger dose is then, perhaps, resorted to, but the stools will be still more incomplete and painful. -"" Determined to overcome the supposed torpor of the bowels, the physician now prescribed a still more powerful dose, but instead of procuring free and watery evacuations, the patient will probably be harassed by small mucous stools, at- tended with great tormina or tenesmus. Thus mucous inflammation will be established in the intestinal tube, and a disease which, under a more judicious treatment, might perhaps have been removed, is rendered incurable. Gamboge is also a favorite hydragogue with some practitioners; and I have myself employed it with much advantage. I have, however, always given it in union with cremor tartar, in the proportion of from two to four grains to a drachm of the latter article. It has appeared to me less apt to excite permanent irritation in the bowels than elaterium. Gamboge is the hydragogue which Dr. Ayre prefers. He gives it, as Dr. Ferriar did, to the amount of four or five grains at a dose, triturated with a few crystals of super-tartrate of potash. The gamboge rarely fails to cause copious watery stools. With regard to the frequency with which hydragogue remedies ought to be administered in the treatment of dropsy, we must be governed by the general strength of the system, and the particular effects resulting from their operation. When the strength of the patient will admit, the purgatives may be repeated every two or three days, provided they do not produce great tormina and soreness, and provided also that they cause free evacuations. I cannot but think, however, that the use of these remedies is fre- quently carried to an injurious extent in the present disease. Employed occa- sionally, and interchangeably with diuretics, they generally contribute materially to the reduction of hydropic affections, more especially of ascites and anasarca. But to exhibit them daily for a week and longer, must put the system to a severe * This formula was first published by a German writer of the name of Langhans. I have known it to remove dropsical accumulations very speedily, after a great variety of diuretics and hydragogues had been used without much advantage. Dr. Charles Hildreth,of Marietta, (Ohio,) recommends the following hydragogue mixture: R.—Crem. tart, £ij; Pulv. jalap gi; Nitrat. potassa? 7,1; P. gambogiae grs. vi.—M. Dose, one or two teaspoonluls daily.—Amer. Journ. of the Med. Sciences. 744 DROPSY. trial, and even if the water be removed, frequently lay ihe foundation of much future suffering and infirmity. Much praise has lately been given to the Caincae root, (chiococca racemosa,) as a remedy in dropsy. It is said to operate powerfully as a hydragogue and diu- retic, and some remarkable instances of its efficacy in dropsy have recently been published in the medical journals of Europe. This root has lately been im- ported into this country, and may be had in this city. The mode of employing it is as follows : R.—Rad. chiococcas racemos. f, ii. Aq. bullient. Biss.—M. To be boiled down to jfviii. Of this a tablespoonful is to-be taken three or four times daily. Diuretics, of all our remedial means, are the most universally employed and re- lied on, in the treatment of dropsy. The kidneys appear to be the most direct and manageable outlet for dropsical effusions, and an important part of the treatment of this disease consists in exciting these emunctories to increased action. Obser- vation has shown, that a full and phlogistic habit of body is much opposed to the free operation of diuretic remedies; and hence bleeding and purging in such a state of the system, are indispensable preliminary measures to the employment of remedies intended to promote the renal secretions. Equally difficult is it in general to procure the operation of diuretics in cases where the dropsical effusion is very extensive, and where the blood-vessels are drained of the serous portion of their contents. To obviate the difficulty which arises from this source, it will often be sufficient to allow the patient copious draughts of water, or of some other bland fluids. Dr. Cullen states that dropsies have been cured by the free use of diluent drinks, without any other remedies. I have known an instance of extensive anasarca cured, after a course of ineffectual treatment, solely by the free indulgence in eating water-melons. Much dispute has existed as to the propriety of allowing patients the free use of aqueous potations. It has been strenuously asserted by some, especially the older writers, that the plentiful use of drinks in this disease is decidedly prejudicial. Others, on the contrary, have maintained that this grateful indulgence is not only harmless, but often manifestly beneficial. Upon this subject, however, no universal rule can be laid down; for the fact ap- pears to be, that in some instances, a liberal indulgence in the use of drinks is followed by unfavorable consequences; whilst in other cases, manifest benefit results from it. In all those instances of hydropic effusion which are the result of excessive hemorrhage, copious draughts of diluent drinks are, according to my own observations and views, decidedly detrimental. When the blood-vessels are suddenly deprived of a large portion of their contents by hemorrhage, their venous extremities absorb with great rapidity whatever aqueous fluid may be taken into the system. The blood-vessels will therefore soon be replenished, if much fluid be taken into the stomach ; and as this circumstance, from the large proportion of crude watery fluid in the blood-vessels, must favor the dropsical effusion, as explained in the beginning of this chapter, injury can scarcely fail to result from the free use of diluents in such cases. The blood, in dropsies from hemorrhage, consists almost wholly of serum, the crassamentum being always exceedingly small; and the more drink there is taken in such cases, the longer will the morbid disproportion between these two constituents of the blood continue. Upon this point, Dr. Parry makes the following observations, which go directly to strengthen the above sentiments. " When dropsy is associated with large hemorrhages, it does not usually accompany them, but comes on after they have ceased ; and I have concluded, that it is the effect of the fluids taken into the stomach being ab- sorbed too suddenly for the relative state of the vessels, which therefore strive, if I may be allowed the expression, to get rid of it by every outlet." It appears to me manifest, therefore, that in such cases of dropsy, it will be advantageous to abstain as much from the use of drinks as the urgent thirst will admit. In instances arising from other causes, however, and in w,hich the general diathesis DROPSY. 745 is manifesly phlogistic, a moderate indulgence in the use of mild beverages may be allowed with advantage. When, indeed, the thirst is great, and the blood sizy, diluent drinks may be regarded as decidedly remedial, and should be very freely taken. Among the diuretics recommended in the treatment of dropsy, the following are the most important, viz., squill, digitalis, acetate of potash, nitrate of potash, cantharides, juniper berries, colchicum, spirit of turpentine, erigeron heterophyl- lum, and parsley. Among these articles, the squill is the most frequently employed, and is, upon the whole, the most useful diuretic in the treatment of hydropic affections. It does not, however, appear to be equally beneficial in all the varieties of this dis- ease ; for where there exists much febrile reaction, and the general diathesis is decidedly phlogistic, its effects are rarely conspicuously salutary. In instances of dropsy, on the contrary, where the urine is scanty, high-colored, and sedi- mentous, with no very decided phlogistic habit of body, its powers are in gene- ral peculiarly beneficial. Almost all writers agree that squills are, generally, the best diuretic we possess in hydrothorax. Blackall, M'Lean, Ayre, and many other respectable writers on this subject, recommend this article as particularly calculated to do good in this variety of dropsy; and my own experience has fur- nished me with abundant evidence of the propriety of this recommendation. The squill is commonly prescribed in union with other articles, and it would appear that its diuretic powers are frequently considerably enhanced by such combinations. Home thought that its diuretic effects were often much increased, by uniting with it some article calculated to promote its emetic powers; but Cul- len strenuously opposed this opinion, and pointed out its erroneousness. Perhaps the best adjunct to squills is calomel—especially in the treatment of hydrothorax. I have been most satisfied with the triple compound of squills, nitrate of potash, and calomel, according to this formula: R.—Pulv. scilla? Qi. P. nitrat. potassa? gii. Calomel gr. v.—M. Divide into ten equal parts. S. Give one every four hours. The only objection which exists against this combination, is its tendency, in some instances, to produce gastric disorder; such as pain in the stomach, nausea, or vomiting. When effects of this kind occur, and the arterial system is not too much excited, one-fourth of a grain of opium should be added to this mixture. The addition of calomel to the squill, it may be again observed, is peculiarly valuable in hydrothorax; for, although this mercurial will frequently do much good in the other forms of dropsy, its tendency to increase diuresis, when given in this combination, is generally much more conspicuously displayed in the for- mer variety of the disease. Dr. Blackall asserts, that squills act much more powerfully on the kidneys when given in as large doses as the stomach will bear without nausea, than when given in small portions. Dr. Ayre, on the other hand, recommends the exhibition of this article in small but frequent doses; and Richter is in favor of this mode of administering it. I prefer giving the squill, in doses of from one to two grains, every three or four hours, whether singly or in combination. The squill is also frequently given in combination with digitalis; and many add to this combination small doses of calomel. In anasarca from scarlatina or cold, digitalis may in general be very advantageously given in this manner. The most serious objection to the employment of squill, is its aptitude to irri- tate and derange the digestive organs. Its tendency in this way is so considera- ble in some individuals, that it cannot be used at all. Indeed, some persons ap- pear to have an idiosyncrasy against the influence of this article—rendering even small doses injurious. Besides the formula given above, I will add another one, which, in some instances, has, in my hands, produced copious discharges of urine. 746 DROPSY. R.—Pulv. rad. scill. gr viii. ----- pip. nigr. gr. x. P. nit. potass, gr. xviii. Submuriat. hydr. gr. iv. Pulv. opii gr. ii. This (altered from Fordyce) is to be given once daily. I have found this com- bination particularly efficacious in cases attended with much languor and relaxa- tion of the system. Richter mentions it as peculiarly useful in cases of this kind. Digitalis is another valuable diuretic for the treatment of dropsy. The most opposite opinions, however, are expressed in relation to its powers in this disease. By many it is highly extolled; whilst some speak of it as of little or no essential value. The weight of good testimony is, nevertheless, decided in favor of its usefulness ; although, generally, it is undoubtedly inferior to the squill, as a diu- retic in hydropic affections. According to the observations of Withering and others, digitalis seldom does much good in persons of a robust habit and tense fibre. Its beneficial powers are most apt to be manifested in subjects of a relaxed and irritable habit of body. Dr. M'Lean entirely confirms this observation of Withering. He asserts, that he has seldom derived any particular advantage from this article, from persons of a corpulent habit and an irritable fibre; but in such as were of "a weak, delicate, irritable constitution, with a thin, smooth, and soft skin," he has generally succeeded well with this remedy. So far as my own experience enables me to judge, I am inclined to think, that there are good grounds for these observations. Dr. Blackall observes, that digitalis is our best remedy in those cases of dropsy which occur after scarlatina and measles ; an observation which I believe to be well founded. I have known the diuretic effects of this article, in such cases, promptly efficient in removing the dropsical accumulation. Digitalis would appear to be especially useful in those cases of dropsy that are attended with a very scanty secretion of urine, becoming turbid when cold, and coagulating when exposed to the heat of a lamp, and depositing a red sedi- ment after standing for some hours. (Blackall.) When the urine of hydropic patients, though loaded with serum, is pale and crude, and rather abundant, digi- talis, according to this writer, very seldom does any good. In such cases, he says, the squill is the best diuretic we possess. These observations deserve particular attention, in the selection of an appropriate diuretic: for, although they may not be universally, or perhaps even very generally, applicable, there is suffi- cient correctness in them, as a general guide, to afford considerable assistance in the adoption of our remedial means. Digitalis is not often employed singly. The most common mode of prescrib- ing it is in combination with squills. In cases attended with considerable febrile excitement, it may be very advantageously given in union with nitre. In very febrile habits, where there are much restlessness, spasmodic dyspnoea, and fre- quent and distressing urgency to void urine, I have known a combination of opium with digitalis to afford much relief. The addition of opium to this, or to whatever other diuretic may be used, is especially called for in cases attended with frequent and ineffectual efforts to evacuate the bowels, a condition which is sometimes superinduced by the inordinate use of drastic purgatives. Digitalis ought to be administered in substance; it has appeared to me to do most good, when given in small but frequent doses—that is from one-sixth to one-fourth of a grain, every hour or two, until its peculiar influence on the system is percep- tible. In general this article is more effectual in removing anasarca than ascites, and ascites than hydrothorax. Many physicians are in the habit of prescribing it, in union with calomel; and there can be no doubt, that, under certain circum- stances, this combination will act with peculiar advantage. Drs. Blackall and Paris, however, decidedly condemn this practice. Conceiving thai the curative powers of digitalis, in dropsy, are dependent on its sedative effects, they main- DROPSY. 747 tain that calomel, being a stimulant of no inconsiderable powers, is incompatible, as a therapeutic agent, with the digitalis, and that it must necessarily tend rather to counteract than to promote the salutary influence of the latter. This objection appears lo me hypothetical; and it certainly is frequently contradicted by expe- rience. There is no good ground for believing that the diuretic effects of this article depend on its sedative powers; for the former effect is generally most conspicuously evinced when the action of the heart and arteries is least reduced ; and, on the contrary, diuresis is sometimes entirely wanting, when the sedative influence of digitalis is the most conspicuous. In general, the more phlogistic the diathesis, the more appropriate will this article be. In such cases, we may employ it with the twofold intention of ex- citing an increased flow of urine, and of moderating the general vascular irritation. Cantharides have been employed with no inconsiderable degree of success in the treatment of dropsy.* Where the general habit is weak and sluggish, and especially, where the disease is connected with an original torpor of the kidneys, this article sometimes excites copious diuresis. Hufeland recommends this for- mula for administering the cantharides in dropsy : R.—Pulv. canthar. ^ii. Amyg. dulc. 5;i. Sacch. alb. §iss.—M. Rub them together in a mortar, and make an emulsion, by adding gradually ten ounces of warm water. Of this a tablespoonful is to be taken every two or three hours, until symptoms of strangury supervene. I have known this mix- ture to reduce anasarca from suppressed menses, very speedily. It appears to be particularly adapted to cases arising from suppressed cutaneous affections.— (Richter.) Colchicum autumnale has not, hitherto, been much employed in the treatment of dropsy; its powers, however, deserve more attention in this respect than it appears as yet to have obtained. I have derived great benefit from this medicine in a case of anasarca, apparently the consequence of a gouty habit; and I am disposed to place considerable reliance on it in all cases attended with a rheu- matic or gouty diathesis. I have found it most efficacious as a diuretic, when given in union with the sulphate of potash. In the case just alluded to, I gave forty drops of the vinous tincture, with a scruple of the powdered sulphate of potash, every six hours. The nitrate of potash has been much employed, and occasionally with the happiest effects, in hydropic diseases. It is usually given in combination with other articles—particularly squills and digitalis. I have employed it by itself, with much benefit, in a few cases of ascites. It will rarely do any good in hydrothorax. From its known antiphlogistic powers, it is manifestly only in cases characterized by a phlogistic habit of body, that any particular advantages can be looked for. When the pulse is small, corded, and irritated, nitre and opium in combination, frequently do much good. From fifteen to twenty grains of the former, with one-fourth to half a grain of the latter, may be given every three hours. I have known this combination to render the pulse soft and ex- panded, the skin moist, and the urine copious. There are a number of other diuretic remedies, all of which have been used with more or less of success in the treatment of dropsies. It is by no means uncommon to succeed in removing dropsical accumulations through the renal emunctories, by some simple diuretic article, after the more powerful and esteemed remedies of this kind have been tried without success. I have known the in- fusion of the erigeron heterophyllum to bring on copious diuresis, and to reduce dropsical swellings speedily, after the remedies already mentioned had been given unsuccessfully. This is, indeed, an article which merits no small degree of * Prispane's Select Cases. Chalmers on the Diseases of South Carolina. Robertson's Treatise on the Power of Cantharides used internally. Edinb., 1836. 748 DROPSY. attention as a diuretic, in this disease. It may be conveniently employed as a ptisan, along with the squill, digitalis, or some other more powerful article. The infusion of the seed of daucus carota, too, is an excellent diuretic, and has been a good deal employed by the practitioners of this country. Of a similar character are juniper berries, lactuca virosa, galium aparine, horseradish, and a number of other diuretic vegetables employed as domestic remedies, and occasionally also in regular practice. Of the usefulness of the galium, I can speak from expe- rience. I knew an instance, where a strong infusion of this vegetable removed a long-standing case of abdominal dropsy in a very short time. Whatever reme- dies may be prescribed, the concomitant use of some one of these ptisans will generally contribute, more or less, to the success of the treatment. When the stomach will bear it, the erigeron will, in general, answer better than any of the other articles just mentioned. This was a favorite medicine with the late Dr. Wistar. It is well to have a variety of diuretics at hand, in the treatment of dropsy; for, in some instances, a number of the most active medicines of this kind will be used without the least perceptible action on the kidneys, and yet, at last, there will be some one found which will speedily produce copious diuresis. It is a good rule to vary the prescription, if, after a reasonable time, and proper auxiliary measures, the desired effect does not ensue.* Diaphoretics are mentioned by Celsus as among our best means for the cure of dropsy. We can very rarely procure the full operation of diuretics, so long as the skin remains uniformly dry and harsh. The union, therefore, of antimo- nials with diuretics, will, in instances of a decidedly phlogistic character, often assist materially in removing dropsical accumulations. Sydenham appears to have placed very considerable reliance on the employment of antimony in this affection, although his principal object in prescribing it was the production of active vomiting—an effect which sometimes procures the speedy absorption and removal of dropsical accumulations from the abdomen and cellular tissue. I have never myself employed antimony with this view: but as a diaphoretic, I have known it to produce very happy effects. In those cases of anasarca and ascites, which occur in consequence of suppressed perspiration from cold when the sys- tem is under the influence of mercury, or after an acute cutaneous disease, I know of no remedy which will more certainly procure relief than antimony, given in minute and frequently repeated doses. I have also known it speedily successful in a case of anasarca from a protracted intermittent. In general, wherever the exciting cause of the disease is cold, or connected immediately with torpor of the cutaneous exhalents, antimony ought not to be neglected as a means of relief. I have always given it dissolved in a large proportion of some diaphoretic beverage —such as infusions of juniper-berries, wild carrot seed, parsley, or erigeron. One grain may be dissolved in a pint of any of these ptisans, and drank ad libi- tum, during the day, so that at least one, and, if convenient, two pints may be taken in this space of time. Munro speaks favorably of a combination of anti- mony and opium: when the disease is attended with a rheumatic habit, this mixture is often especially beneficial. It must not be forgotten, however, that very profuse perspiration and diuresis are incompatible; all that is requisite, in * Dropsy is a disease by no means so uniform in its character as is generally supposed. It arises from a great variety of remote causes—in the most opposite states of the system, with regard to vascular action and repletion—it is dependent on various organic affections; appears as a consequence of diflerent acute and chronic affections, and is attended with divers and dis- tinct characters of the urinary secretion. These circumstances point out much diversity in the general character of the disease itself, and it is not reasonable to suppose that anyone particular diuretic is equally applicable to the disease under all these diversities of general character, When, moreover, we take into view the diversities of constitutional habit—of idiosyncrasy— and the ever-varying state of the organic functions—we can readily conceive, that out of a great number of diuretics, there might not be more than one which is calculated, in a particular in- stance, to excite the action of the kidneys. It is, therefore, a good rule to vary the prescription, if, after a reasonable time, and proper adjuvant measures, the desired effect does not follow. DROPSY. 749 relation to the action of the skin, when we continue to act on the kidneys, is to render it soft, relaxed, and moderately moist. In those cases of anasarca in which the skin is cold and very dry, with a sluggish action of the pulse, the black sulphuret of iron is a medicine of excel- lent powers. Dr. Archer, of Norfolk, has reported an interesting case which was speedily cured by this remedy. It is also mentioned by Alibert* as an ex- cellent medicine in anasarca attended with great relaxation and weakness. I have had occasion to prescribe it in two instances of this kind—both the consequence of immoderate lochia, and great previous debility ; and the results were highly gratifying. This article generally excites a glow of warmth throughout the whole body, attended with a peculiar tingling sensation in the extremities ; and, in most instances, a profuse perspiration ensues a few hours after it is taken. Besides its diaphoretic effects, it is also peculiarly calculated to do good in such cases by its tendency to invigorate the assimilating functions. I am not aware that any advantages are to be obtained from this article in any other cases than such as proceed from excessive hemorrhages, or other exhausting and relaxing causes. Diaphoretics are in general decidedly useful only in anasarcous dropsy. Among the ancient Romans, it was customary to excite sweating in this disease, by burying the body up to the neck in warm sand ;t and I may here also men- tion the use of oiled silk, which, when closely applied over the surface of the body, generally excites a considerable perspiration. This application is particu- larly useful in local dropsical effusions into the cellular tissue.X Emetics have by some been highly extolled for their power of removing drop- sical accumulations. I have already mentioned Sydenham as an advocate for their employment in this disease; and I may add the authority of Richter, Len- tin, Cruikshank, and Pinot in their favor. I knew an instance of ascites which was removed by spontaneous and protracted vomiting; but I have never yet prescribed remedies with a view to their emetic operation in this disease. Mercury is a favorite remedy with many of the American physicians in the treat- ment of dropsy; and there can be no question as to its utility in certain modifica- tions of the disease. In cases depending on hepatic and splenic disorder, it consti- tutes our main stay; and in the treatment of hydrothorax it is generally highly beneficial. In instances which occur in consequence of excessive hemorrhage, or other exhausting causes, and in subjects of a scorbutic or depraved habit of body, mercury cannot be employed with propriety. Some degree of firmness of the general habit may be regarded as the most favorable for the exhibition of mercury, with a view to its constitutional influence. (Blackall, M'Lean.) A decidedly inflammatory condition of the system, however, is opposed to the bene- ficial influence of mercury in this disease; and where such a diathesis is con- spicuous, antiphlogistic measures must precede its employment. Calomel is the preparation usually prescribed in dropsy. As a general rule, mercurialization should not be carried beyond the extent of producing only a slight soreness of the gums; profuse ptyalism being not only unnecessary to procure the peculiar advantages of this remedy, but sometimes, perhaps generally, injurious in its consequences, more especially in anasarca. This article, as has already been stated, is almost always given in combination with some diuretic, particularly squills and digitalis. In ascites, much benefit may sometimes be derived from mercurial frictions on the abdomen. From some cases which have been recently published, it appears that subacute inflammation of the peritoneum often yields to mercurial frictions, without scarcely any aid from other means. Laennec has cured cases of effu- sion into the abdomen by this application after a variety of other remedies, usually relied on, had been employed without benefit.§ Tonics were, at one time, much employed in dropsy. The disease was sup- * Elemens de Therapeutique, torn. i. p. 180. X Celsus, De Medicina, lib. iii. cap. xxx. X Richter, Specieile Therapie, vol. iii. p. 59. § Revue Medicale, Mai 1824. 750 DROPSY. posed to depend chiefly on debility and relaxation, and every effort was, accord- ingly, made to invigorate the system. In general, this class of remedies is not only useless but injurious. Occasionally instances are met with, in which tonic remedies produce very good effects. Where the general debility and languor are very great, and the pulse feeble and sluggish, bark, iron, particularly the muriated tincture, and the vegetable bitters, may perhaps be used with advantage. Gum kino, in large doses, cured a case, after various other remedies had been used without benefit.* The sulphate of copper has been frequently given with com- plete success in cases of dropsy attended with great vascular debility. Gardane, Chalmers, and Wright mention successful instances of this kind. This remedy has been generally given in combination with opium, in doses of a grain of each three times daily. Several German physicians have recently employed the muriate of gold in ascites and anasarca with peculiar success. Dr. Wendt states that he prescribed it in eight cases, in the hospital at Breslau, seven of which yielded entirely to its influence.! This article often manifests decided diuretic powers ; and, as it is also an excellent alterative, resembling in this respect mercury, it may probably be particularly suitable in cases connected with a depraved habit of body from the abuse of mercury, syphilitic taint, or an arthritic diathesis. It were, indeed, almost an endless task to give an account of all the remedies which, under peculiar circumstances, have removed dropsical accumulations. The following are the principal articles of this kind. Ipecacuanha, Dover's powder, helleborus niger, pilulae hydragogae janini, radix sambuci, the fixed al- kalies,}, millepedes, lactuca virosa, garlic, scandix cerefolium, apium graveolens, onions, iris palustris, sorbus acuparia, balsam copaiva, turpentine, olive oil, opium,§ apocynum cannabinum, pipsissewa, trifolium fibrinum, camphor, and asparagus. Dr. Laurie has published cases which tend to show that the internal use of nitric acid is often very efficacious in those forms of dropsy which suc- ceed to acute febrile diseases.|| The external application of diuretic agents has of late years been employed with considerable success in this disease, by some of the French physicians. It would appear from the accounts which have been published, that the kidneys may often be as actively excited by diuretics applied in frictions to the surface of the body as when taken internally. Where the stomach is weak and irritable, a condition so peculiarly opposed to the regular operation of diuretics, the external mode of using them, if, in truth, their remedial influence may be thus fully ob- tained, would be decidedly preferable. I have seen but one instance of this disease, in which the production of diuresis was attempted in this way, and this case afforded me sufficient evidence that some advantage, at least, may be obtained from frictions on the abdomen, with diuretic remedies. In a recent number of the Revue Medicale,^ there are four cases of thoracic and abdominal dropsy recorded, which were successfully treated upon the iatraleptic plan. The author, • Medico-Chirurg. Review, July 1827. f Rust's Magazine, b. xxv. X ThS alkalies are sometimes decidedly beneficial. Monro, Pringle, Mead, and Fallot, speak of them in terms of encomium, as remedies in dropsy. They are said to be particularly appli- cable incases attended with great atony. They have been generally given in union with vege- table bitters. I attended an old lady, during the present year (182b). affected with ascites and anasarca of the inferior extremities, in whom I found no remedy so useful as the salt of tartar in union with the expressed juice of tansy. She took ten grains of the alkali with a tablespoon- ful of the juice, thrice daily. The celebrated Frank thought highly of the powers of the alka- lies in dropsy. His formula is— R.—Kali, carbon. Ibj. Herbe absinth, ^i. Infunde c. vin. rhen. ftj. Digere per xxiv. horas cola. Dose, one ounce every four hours. § I have prescribed opium in a case attended with a rheumatic habit with unequivocal benefit. U Analen der Medizin, vol. iv. p. 266. H Septembre 1828, p. 349. DROPSY. 751 Dr. Guibert, directed frictions on the chest, or the abdomen, or the thighs, ac- cording to the form of dropsy present, with the following fluid: R.—Tinctura scilla. --------digitalis. --------sem. colchic, aa. ^ss. Ol. camphorat. ^iss.—M. The frictions to be made with flannel three or four times daily, and continued from five to twenty minutes. Concomitantly with this external application he ordered a diuretic mixture to be taken internally, composed of squills, digitalis, and nitrate of potash in equal quantities, and a somewhat larger portion of thridace, in doses of two grains and a half of the mixture twice daily. " The iatraleplic method of treating dropsy," says Dr. G., " has appeared to me par- ticularly efficacious in abdominal dropsy; and it is chiefly to the external employ- ment of the above diuretic liniment, that I think myself warranted to ascribe the success which attended my efforts in the above cases. The internal remedies which I employed at ihe-same time, seemed to me very useful auxiliary measures, but they could not, I am persuaded, have by themselves produced the very copious urinary discharges, resembling almost complete diabetes, which occurred in these cases under this treatment. In all these cases, and I might adduce others equally remarkable, the dropsical swellings were reduced with surprising rapidity. The iatraleptic mode of treating this disease is attended with little or no inconvenience to the patient. It should not, however, be adopted until the phlogistic state of the system is reduced by appropriate antiphlogistic means. In idiopathic ascites and anasarca, this mode of treatment will succeed almost without exception. Dr. Thomas Short,* of Edinburgh, has recently employed the marchantia hemispherica, as an external application in the form of cataplasm, with marked success in hydropic affections. Applied in this way, it often acts strongly as a diuretic. "In many cases," says Dr Short, "it ha's been astonishingly success- ful, but it has, like other diuretics, failed. I cannot say that I have ever known the slightest benefit derived from its internal use, although I have fre- quently administered it in the form of decoctions. Employed externally in the form of poultice, however, 1 consider it as a remedy of great value. The poul- tice is prepared by carefully picking and washing about two large handfuls of the leaves ; these are thrown into a pot containing about a quart of boiling water, and simmered by the side of a fire for twelve hours, adding fresh water if required. It is then beat into a pulp, and as much linseed meal stirred in as to bring it to the consistence of a poultice, which is spread on flannel and applied to the abdomen (in ascites), and fastened with a pretty tight bandage—or it may be applied to the legs, if anasarca of the extremities alone exists. The poultice should be renewed every twelve hours. This poultice produces, in general, copious perspiration, and, at the same time, acts powerfully on the kidneys. In some constitutions it occasions feelings of great sinking and exhaustion, but I have never known it to do harm. A few small doses of the spirit, aether, nitros. will, in general, soon remove this unpleasant sensation. The effects of this application are increased by the patient's drinking plentifully of warm fluids, and I have always preferred weak beef-tea or chicken-broth with the view of keeping up the strength. Opi- ates of all kinds I have found hurtful; but I employ warm clothing, and keep the patient in bed, during the whole period in which the poultice is applied."t Among the external means which may be resorted to with occasional advan- tage in ascites, a tight flannel bandage worn around the abdomen will frequently prove decidedly beneficial. This application was much extolled by the late Dr. * Edinb. Med. and Surg. Journ., vol. xxxix. p. 129. t The marchantia hemispherica, commonly called liverwort, grows abundantly in certain locali- ties of the eastern and middle states of this country. It is a lichen, consisting of membranous expansions, cut into rounded lobes, with entire edges, of a bright green color on the upper sur- face, and a slightly purplish hue on the under side. It is usually found in. moist and «hady places, on the banks of rivers, and on rocks, and is to be met with at all seasons of the year, but is sup- posed to be in the greatest vigor about the end of August. 752 DROPSY. Monro, in the treatment of abdominal dropsy. I have repeatedly found such a bandage of advantage, particularly after the dropsical swellings had been in part removed, but continued stationary for some period. The effects of the bandage will be increased, if previously soaked in a strong solution of salt, and dried again before it is applied. Would not the powers of such a bandage be still more enhanced, by imbuing it with a strong infusion of squills, or of some other active diuretic ? After all, our efforts to prevent or remove dropsical effusions are but too fre- quently foiled; and it becomes necessary, in order to prolong the life of the pa- tient, and to gain more time for remedial applications, to evacuate the collected fluid by means of a puncture into the cavity which confines it.* It is usual to delay this operation until every other measure for the removal of the fluid has been found unavailing, and the distension from the effused water has become so great as to threaten immediate danger. This is one of those errors in medical practice, which, though readily and generally acknowledged by practitioners, it is extremely difficult to correct, on account of the great dread which all surgical operations, and especially such as penetrate into the large cavities, are so apt to excite in patients. Being, moreover, universally viewed as the last resource, and only for a temporary procrastination of the fatal conclusion, few are willing to submit to the operation until all other means for removing the water have been tried. Without doubt, however, tapping is by far the most direct and certain means for removing dropsical accumulations, and it is as safe in its consequences as any of the other measures that may be adopted for this purpose. Were tap- ping more early resorted to in ascites than it always is, there can be but little doubt, that its permanent usefulness would be greatly enhanced. The mere me- chanical irritation of the effused fluid, when the distension is very great, must tend to keep up that morbid condition in the peritoneum which gives rise to the effusion. The earlier this over-distension is taken off, the greater, one may reasonably presume, must be the chance of effecting a radical cure, by some of the means already mentioned—more especially by local bleeding, blistering, mer- cury, and frictions. Indeed, the operation is by no means simply palliative in its consequences. There are many cases on record which were perfectly cured, solely by removing the water by an operation. Frank, Lentin, Richter, Desault, Fothergill, and others, relate cases of this kind; and there is reason to presume, that if tapping were not so commonly delayed until the disease has assumed an inveterate character, such fortunate terminations would be much more frequent than they are under the present plan of procrastinating it.t * It is truly surprising what large quantities of water are sometimes drawn in the aggregate, in cases of abdominal dropsy. M. Lecourt de Cantilly has related an instance in which the operation of tapping was performed one hundred and thirty-five times in the course of six years, and by which the aggregate amount of two thousand seven hundred pounds of water was drawn off. Mead mentions a case (monita) in which tapping was performed seventy times in five years and seven months, which yielded one thousand nine hundred pounds of water. M. Louyer Villermay relates an instance where tapping was undergone five hundred times, the patient having finally tapped himself.—Revue Medicale, Juillet 1828. f M. Lhomme, in January 1827, communicated to the French Royal Academy of Medicine an inveterate case of ascites, which, after hydragogues, diuretics, and tapping, had been fully but unavailingly employed, was speedily cured by the injection of the vapor of wine into the cavity of the abdomen through an orifice made with a trochar. He was led to the employment of this anceps remedium, by having read in the Annates de la Medecine Physiologique, an account of two cases of abdominal dropsy which were cured by the same means. The vapor of wine was injected sixteen times without causing any pain or particular uneasiness in the abdomen, with the exception of some slight colic pains which required no remedial attention. At the time of reporting the case, two years had already elapsed from the period at which the injection was made and the malady arrested. M. Lhomme tried the same means in another case, but with- out success. No unpleasant consequences, however, resulted from the operation. It is not difficult to conceive how such a measure might put a stop to dropsical effusion, if a state of chronic inflammation of the peritoneum be its cause. It is well known that stimulating appli- cations are generally the only means effectual in removing inflammations of a low or languid grade of excitement. We thus remove gleet, chronic ophthalmia, and chronic bronchitis, by stimulating injections, collyria, and inhalations of the vapor of tar.—Revue Medicale, vol. i.p. 343. SCROFULA. 753 CHAPTER IX. CHRONIC AFFECTIONS OF THE LYMPHATIC SYSTEM. Sect. I.—Scrofula. Scrofula appears in a great variety of forms and grades of violence—varying from the slightest habitual deviations from health, to the most distressing, rapid, and fatal forms of local and general disease. In a general way, scrofula may be divided into two distinct forms; namely, its latent and its active states. The former constitutes what is usually called the scrofulous habit or diathesis; and the latter, the state of full development and activity of the disease. The scrofulous habit, or predisposition to the active forms of the malady, is characterized by the following phenomena: a peculiar delicacy and languor of the countenance, with a soft, rosy tint of the prolabia and cheeks;* or a pale, soft, flaccid, and apparently tumid aspect of the countenance, with a dull lead- colored circle round the mouth, and a swollen appearance of the upper lip. The hair is generally fair, and the eyes blue or black. The head, particularly the posterior part, is usually large, and the temples flattened, or somewhat depressed. There is, in general, a great proneness to slight catarrhal affections, during which the wings of the nose and upper lip are apt to become swollen. The edges of the eyelids are much disposed to become inflamed, and where the scrofulous tendency is strongly developed, the tarsi are almost constantly red and tender. The digestive powers are usually weak and irregular, and the bowels are apt to be either constipated, or affected with painful mucous diarrhoea. The appetite, also, is very variable—being sometimes entirely depressed, and at others very urgent. The urine commonly deposits a whitish sediment, and becomes turbid some time after it is passed. A disposition to transient swellings of particular parts, as of the face and scrotum, is mentioned by some writers as belonging to this habit. In female children, a leucorrhoeal discharge is apt to occur from time to time; and in very young children, excoriations behind the ears, scabby erup- tions about the head and lips, obstinate ophthalmia, logether with a fretful and irritable temper, are among the most common phenomena attending the scrofu- lous diathesis. The growth of the body usually proceeds slowly : but the mental powers are generally precociously developed, and often astonishingly active. This dormant or inactive state of the disease may continue for many years, and at last pass off without terminating in any particular local affections. More commonly, however, the scrofulous habit gradually requires strength, and at last, under the influence of the usual exciting causes, shows itself in its more obvious and active form. The lymphatic glands along the neck and other parts become enlarged and firm to the touch, in which condition they may remain for years, without either receding or going on to a more active form of disease. In general, however, they pass by degrees into slow inflammation, which at last terminates in suppuration or scirrhus. When they suppurate, which is by far the most common mode of termination, they form chronic indolent ulcers, from which a thin, milky, and somewhat viscid fluid is copiously discharged, and which are always extremely * This appearance of the countenance is particularly met with in those instances of a scro- fulous habit, in which a particular tendency to phthisis pulmonalis exists. Mr. Lloyd, however, asserts that there are no just grounds for regarding the white and rosy cheek, the flaxen hair, and azure eyes, as marks indicative of the scrofulous habit 48 754 SCROFULA. slow in cicatrizing. The cicatrices left by these ulcerations, are, in general, easily distinguished from those left by other ulcers. They are peculiarly uneven, irregular, and conspicuous. In connection with these tumors, or ulcerations about the neck, the eyelids and conjunctiva are very apt to become affected with obstinate inflammation; and, in some instances, much irritation occurs in the mucous membrane of the nose and bronchia. In a more advanced state of the disease, the salivary and thyroid glands, as well as the pancreas and other inter- nal glandular parts, become enlarged and indurated. Scabby eruptions appear on different parts of the surface; the extremities of the long bones enlarge; ulcerations occur in the cartilaginous structures; some of the bones become cari- ous ; the large joints inflame and suppurate; in some instances the vertebrae be- come diseased ; and occasionally the bones and soft parts of the nose, palate, and fauces, are more or less rapidly destroyed by ulceration. There is, in short, scarcely any part of the body which is not sometimes the seat of the frightful ravages of this affection. The most common forms of scrofula, however, are tubercular phthisis pul- monalis ; white swelling, or disease of the hip and knee joints, and ophthalmia. The general progress and duration of scrofula are exceedingly various. In some cases it is developed in infancy, whilst in others the constitutional tendency to the disease remains dormant until the age of puberty, or until a period much later, before it manifests itself in an, active state. Some individuals are more or less affected with scrofulous disease of the lymphatic glands during the greater period of a long life, without experiencing any particular sufferings from this source. Much more commonly, however, some one or more of the distressing and fatal consequences already mentioned, ensue before the age of manhood. Although scrofula is vastly more common during childhood than at any other period of life, yet the occurrence of decided scrofulous affections in new-born infants is an exceedingly rare phenomenon. Mr. Lloyd, nevertheless, states, that he found the lungs of an eight months foetus tuberculous—the mother hav- ing died of phthisis pulmonalis; and a few similar instances may be collected from writers on this subject. The manifestations of the scrofulous habit seldom make their appearance before dentition commences. Causes.—Scrofula, or rather an especial predisposition to this disease, is one of those constitutional habits or tendencies, which often occur in children as an hereditary diathesis. This, however, is by no means the only source of the scrofulous habit; for that it may be generated in individuals originally of sound constitutions, and born of parents perfectly healthy in this respect, by various external influences, admits of no doubt. The causes which are acknowledged to be most frequently and actively concerned in the production of a predisposition to this disease, are— 1, Climate and atmospheric influences. It would appear that the influence of hot climates, in infancy and early youth, has a considerable tendency to pre- dispose the system to the occurrence of the scrofulous diathesis, from the subse- quent influence of a cold and variable, and damp atmosphere. Scrofula is a very uncommon disease in the East and West Indies; but when the children of Eu- ropeans, born in these climates, or even the natives, are brought to reside in the variable climates of Europe and this country, they are in general particularly liable to suffer more or less from scrofulous affections. " We know at least," says Dr. Alison, " that a great majority of the inhabitants of the West and East Indies, both negroes and Hindoos, are unusually prone to scrofula when they come to temperate climates."* A cold, humid, and variable atmosphere, more especially when aided by deficient and unwholesome nourishment, appears to have a strong tendency to favor the development of the scrofulous habit. It is from this cause, probably, that in the deep and narrow valleys of Switzerland and Savoy, in which the atmosphere is very variable and humid, certain forms * Observations on the Pathology of Scrofulous Diseases, &c, p. 397. SCROFULA. 755 of scrofula are so very common. In Holland, and in some of the marshy districts of England, this disease is said to be peculiarly prevalent. 2. The impure and confined air of populous cities also seems particularly capa- ble of promoting the occurrence of scrofulous diseases. It is certain, at least, that in the same amount of population, this malady is vastly more common in large and crowded cities than in the salubrious districts of the country. " It is notorious," says Dr. Gregory, "that the population of our large manufacturing towns—Manchester, for instance—pent up during the day in cotton mills, are of all others most affected with it." 3. Deficient and unwholesome food, with the usual attendants, squalidness and mental depression, may contribute to the production of the scrofulous diathesis. Without doubt, however, coarse, indigestible, and irritating articles of diet, when habitually and freely used by young children, have a much more decided tend- ency to produce this affection, than mere deficient or innutritious aliment. An improper dietetic management of very young children, in relation both to quantity and quality, is probably one of the most common sources of scrofulous affections. By over-distension of the stomach, or the use of heavy, irritating or indigestible food, dyspepsia and high irritation of the gastro-intestinal mucous membrane will seldom fail to supervene; and as this condition of the stomach and bowels is usually attended with a morbid appetite, more food is habitually taken into the stomach than can be digested, and the gastro-intestinal irritation is thus kept up, until the chylopoietic and assimilating functions, and indeed the whole system, become intimately deranged. Nothing is more common than to meet in children, who have been mismanaged in this way, and who are almost constantly eating from morning till night, glandular swellings along the neck, and scabby eruptions on the head and face, with tense and tumid abdomens, and other symptoms of gastro-intestinal disorder, where, from the health of the parents, no hereditary taint can be presumed to exist. Chronic inflammation or habitual irritation of the mucous membrane of the stomach and bowels, is probably much more fre- quently concerned in the formation of the scrofulous habit, than seems to be generally supposed. There are few children long affected with what is usually called marasmus, who do not subsequently manifest a predisposition to scrofu- lous affections. 4. Various diseases possess a tendency to give rise to the scrofulous diathesis. This is especially the case with measles, scarlatina, and whooping-cough; but it would seem that it is rather by the influence of cold, and errors of diet, during the stage of convalescence from these diseases, that the scrofulous habit is generated, than by any direct tendency in these affections to develop this diathesis. Without specifying any more causes of this kind, however, we may observe, in a general way, that whatever tends permanently to derange the digestive poivers, and to debilitate the general system during infancy and childhood, is calculated to en- gender a predisposition to scrofula. My own observations, though limited in relation to this disease, have led me to the conviction, that disorder of the digestive organs, from whatever cause it may arise, often constitutes the principal source of scrofulous symptoms. Upon this point, the observations of Dr. Carmichael appear to me to possess much interest and value. "I have adduced," he says, "incontrovertible facts, which demonstrate that disorder of the chylopoietic viscera precedes and accompanies the symptoms of scrofula, and that there are the strongest grounds for be- lieving that such disorder is, in a very great majority of cases, the immediate cause of the disease. A defective digestion, continued for any length of time, must as certainly produce chyle or blood of a vitiated quality, and unfit to reple- nish the waste of the body, as the constant use of unwholesome food. A disor- dered state of the system first ensues, and is followed by various local complaints. It is highly probable, however, the gastro-intestinal irritation, which always attends, in a greater or less degree, where the digestive functions continue long in a disordered condition, contributes as much, and perhaps much more, to the produc- 756 SCROFULA. tion of the scrofulous symptoms in such cases, than the vitiated chyle which is prepared by the stomach."* It need scarcely be observed, that where there exists an hereditary or natu- ral predisposition to scrofula, the foregoing causes have an especial tendency to excite it into a state of activity; for it is sufficiently obvious, that whatever is capable of originating the peculiar diathesis in question, will be still more apt to call it into action where it already exists. Scrofula cannot be communicated by inoculation, or in the manner of a con- tagion. Hufeland inoculated healthy children with matter taken from mild scrofulous ulcers, without the least perceptible consequences on the health of the inoculated individuals.t Mere local ulcers or scabby affections have, indeed, been known to occur from the frequent application of the matter discharged by ulcerations of this kind. Thus, healthy children who sleep with persons affected with scrofulous scabby eruptions about the head, will sometimes become affected with similar disorders. But these do not possess the character of true scrofula. Pathologists have expressed a variety of opinions in relation to the essential nature of the scrofulous diathesis; but the most plausible doctrine upon this point is, that the scrofulous habit consists in constitutional or acquired excess of irritability in the lymphatic system, in connection with a weak condition of the assimilative powers. Prognosis.—Where the predisposition is hereditary, the chance of subduing scrofula, after it has manifested itself in an active form, is always extremely small. Nevertheless, it is a fact well established, that even where the diathesis is manifestly congenital, moderate cases of the disease not unfrequently disap- pear entirely about the age of puberty, or after the corporeal development is completed, and the age of manhood has arrived. It must be observed, however, that these epochs in the physical development of the system are much more fre- quently attended with results of a very contrary character; for it is precisely at these stages of life that the scrofulous habit is most apt to pass from a latent to an active state. Similar observations apply to the effects of acute general diseases. Severe febrile affections have been known to remove incipient scrofula, in habits obviously predisposed to the disease, but, as has been already stated, it is vastly more common to find the disease more or less rapidly developed by violent febrile affections—more especially measles, scarlatina and small-pox. In some instances, the disease slowly continues to develop itself, until the stage of puberty or man- hood has arrived, when it remains stationary during the subsequent period of life. In forming a prognosis as to the probability of effecting a cure, or of a spontaneous subsidence of scrofula, particular regard must be had to the following circumstances. 1. The nature of the predisposing and exciting causes. Where a number of causes of this kind co-operate in the production of the disease, and especially where the situation and circumstances of the patient are such as to render an entire removal of them impracticable, the chances of advantage from remedial management must, of course, be exceedingly limited. Among the poor and squalid, who can neither procure proper nourishment, nor protect themselves against the injurious influences of cold, it is next to impossible to effect a cure, when the disease shows itself in an active form. I have already stated the greater difficulty of removing hereditary scrofula than those cases which arise from external influences. 2. The age of the patient and the duration of the malady. The younger the patient is, the more easy, in general, will it be to remove, or effectually counteract, the progress of the disease. When the disease makes its first active appearance after the age of puberty or of manhood, the chances of being able to suspend its progress are but small, and still less to remove the symptoms altogether. 3. The degree of violence of the disease. So long as * Carmichael on the Venereal Disease, p. 351. X Ueber die natur, kendniss, und heilart der scrophel krankhert, p. 105. scrofula. 757 the disease remains in a latent state, and is manifested only by the symptoms which characterize the scrofulous diathesis, a reasonable prospect of success may be entertained from proper remedial management. Even so long as the disease shows itself only in the usual form of glandular swellings about the neck, without any indications of tubercular formations in the lungs, a judicious treat- ment will sometimes arrest the further progress of the disease, and occasionally gradually effect a removal of the scrofulous symptoms. When these tumors become irregular, uneven, immovable, painful, and inflamed, the difficulty of ar- resting their progress, and still more of effecting their entire reduction, may be regarded as nearly insuperable; and the prognosis will be the more unfavorable in proportion as these tumors are numerous. Suppurated scrofulous tumors, when they are situated externally, and not attended with strong constitutional tend- ency to the disease, are not, in general, to be regarded either as more dangerous or difficult of management, than mere inflamed tumors, although they are always extremely tedious in their progress, and cicatrize very slowly. Indeed, the sup- puration of external glandular swellings is sometimes attended with a manifest melioration of the general scrofulous symptoms;* and when suppurations of this kind occur in individuals laboring under slight incipient symptoms of pulmonary tubercles, they should be encouraged, rather than suppressed or cicatrized, unless, indeed, they begin to assume very unfavorable or dangerous appearances.— When febrile symptoms, cough, and emaciation supervene, all hopes of successful treatment may be abandoned. 4. The seat of the local scrofulous affections forms, also, an important consideration in estimating the probable issue of cases of this disease. So long as the disease appears to be concentrated upon the ex- ternal glandular structures, some prospect of an effectual removal of the malady may, with reason, be entertained; but when the ravages of the disease occur in deep-seated structures, or internal organs, particularly in the lungs and mesen- teric glands, all ideas of ultimate recovery may be abandoned as entirely hopeless. Treatment.—The first, and decidedly the most important part of the manage- ment of scrofulous affections, is a constant and careful avoidance of the various exciting causes enumerated above. Without an especial attention to proper ob- servances in relation to this point, nothing, or at best but very little, can be effected by remedial treatment. The enjoyment of a pure, dry, and equable air; an attention to proper clothing, so as to obviate, as much as possible, the injurious influence of atmospheric vicissitudes; a wholesome, abstemious, but nourishing diet; regular exercise in the open air; and cleanliness, constitute the means upon which our hopes of successful opposition to the progress of the malady must chiefly be placed. So long as the disease shows itself only by a gene- ral scrofulous habit, without any important local affections, the diet should be sim- ple, nourishing and digestible; and it is of great importance that the meals be taken at regular intervals, and no more food taken into the stomach at once than can be easily and completely digested. All kinds of stimulating irritating articles of food must be carefully avoided ; and the same observation applies to every spe- cies of stimulating drink. The lean parts of lender and digestible meats may be moderately taken at noon ; and for children, light animal broths, liquid, mu- cilaginous, or farinaceous preparations, barley, rice, boiled apples, turnips and milk, constitute proper articles of nourishment. With regard to the clothing of individuals laboring under a strongly developed scrofulous habit, it should be so regulated as to preserve as equable a temperature of the body as pos- sible. Flannel should be worn next the skin, except in very warm weather, when it may be substituted by cotton. The influence of a pure and dry air, and if possible of an equable climate, is all-important to the successful manage- ment of this malady. It would appear, from the observations of some writers, that the air along the sea-coast is often peculiarly beneficial in scrofulous affec- * Bordeu, Recueil des pieces qui on tremporte le prix de l'Acad. Royale de Chirurg., vol. iii. p. 69, as quoted by Richter. 758 SCROFULA. tions ; but these are advantages which can seldom be enjoyed but by the wealthy, and the majority of scrofulous subjects in large towns cannot even obtain the benefits of a pure country air, so desirable in the treatment of this affection.— Inactivity and indolence are to be shunned as decidedly favorable to the progress of the malady. Walking, gestation in an open carriage, or, when the patient is old enough, riding on horseback, should be regularly practiced when the weather is favorable. The patient should rise early from bed, and retire seasonably in the evening, and particularly avoid the damp and chilling night air. With regard to the medicinal treatment, whether for latent or active scrofula, the prominent indications are—to restore or maintain the integrity of the digest- ive, perspiratory, hepatic, and intestinal functions, and to support the general ener- gies of the system. Of these indications, the regular maintenance of the action of the bowels and of the liver may be regarded as of primary importance. For this pur- pose recourse must be had to calomel or blue mass, in conjunction or alternation with proper aperients. Some diversity of opinion is expressed by writers as to the best mode of administering mercurials in this affection ; and some even condemn them almost entirely as remedial means in scrofula, but most assuredly without just grounds. Undoubtedly, much caution is required in the employment of mercury in this disease, or where the scrofulous diathesis exists; for it cannot be questioned, that much mischief is apt to result from the constitutional or sali- vant influence of this article. Nevertheless, when it is given in small doses at proper intervals, followed by a mild laxative, or even in occasional purgative doses, its effects are often unequivocally beneficial, in every variety of scrofulous disease. When the bowels are in a loaded condition, and torpid, the treatment should be commenced by pretty active doses of some purgative, and this should be repeated every third or fourth day, until there is reason to believe that the fecal accumulations have been removed. For this purpose from two to six grains of calomel, according to the age of the patient, should be given late in the even- ing, and followed, next morning, by a dose of rhubarb, castor oil, or Epsom salts. When the intestinal canal has been adequately evacuated in this way, it will, in general, be better to depend on the exhibition of from two to three grains of blue pill every night, with a pretty smart purgative every fourth or fifth day. From such a course of management, in conjunction with proper dietetic regula- tions, I have in several instances obtained the most decided benefit. Mr. Lloyd gives five grains of blue pill every night, with half a pint of the compound decoc- tion of sarsaparilla twice a day; and if the bowels are not moved during the fore- noon, he administers some laxative, so as to procure moderate evacuations. This plan he pursues until the action of the bowels becomes regular, and then goes on exhibiting the compound calomel pill, in five grain doses, every second night, for an indefinite time.* The pills I havealreadj' frequently mentioned in the course of this work, appear to me peculiarly well adapted as an alterative in scrofulous affections. I have repeatedly prescribed them in cases of this kind with ex- cellent effeet.t The employment of mercurial aperients should be persisted in as long as the alvine evacuations continue to exhibit an unnatural appearance. Mr. Farr recommends mercurial frictions, as preferable, in his estimation, to the internal administration of this medicine, more especially in children. He directs five grains of the unguentum hydrargyri fortius to be rubbed in upon the arm or leg of children from four to eight years old; eight grains in children from eight to twelve years of age, and twelve grains for subjects of from twelve to fif- teen years old. "The frictions are to be continued until no portion of the oint- ment can be observed to stain a clean finger when applied to the part."}. Mr. * A Treatise on the Nature and Treatment,of Scrofula, &c. t R-—Massse pil. hydrarg. ^ss. G. aloes Socot. grs. x. Tart, antimon. gr. i.—M. Divide into .twelve pills. S- Take one every night, or second night, according to the state of the bowels. X A Treatise on the Nature of Scrofula, &c„ pp. 47-^48. SCROFULA. 759 Lloyd makes the following judicious observations in relation to the remedial treat- ment of scrofula in children. "Every one must have observed that the same medicine may act very differently on children even of the same age; and that what purges one violently, will have no effect on another. We should, too, be very care- ful not to exhibit violent purges; and we should particularly avoid large purgative doses of calomel, as, I am convinced, they often produce more general irritation than the evacuation they occasion from the bowels is able to relieve; and that they often so much weaken the stomach that it is a very long time before it is able to recover its natural powers." To keep up a regular action of the bowels, " any of the mild purgatives may be employed ; and if one does not appear to have the proper effect, we should desist from its use and substitute another." Although purgative doses of calomel are apt to prove injurious, " we may derive the greatest assistance from exhibiting alterative doses of this article." The dose should be varied from a half to one grain, according to the age of the child, and repeated twice or thrice a week. After the action of the liver and bowels has been in some degree brought to a regular state, benefit will in general result from the employment of the tonic vegetable bitters; and where the digestive functions are much impaired, it will be proper to resort to the moderate use of tonics, in conjunction with the alterative and aperient treatment, as soon as the fecal accumulations have been evacuated by a few brisk purges, in the beginning of the treatment. Tonics are, indeed, generally recommended as peculiarly advantageous in counteracting the scrofulous diathesis; but I am inclined to think, that, except where the digestive powers are very feeble, and the mucous membrane of the stomach free from irritation, the active employment of remedies of this kind is seldom attended with advantage. Most assuredly, they are decidedly indicated where the general system is languid and debilitated; but in children, high mucous irritation of the alimentary canal is so frequently present in scrofulous affections, and the general habit is often so irritable and prone to inflammatory excitement, that the indiscriminate use of tonics must be frequently productive of mischief. When the alvine and hepatic functions are restored by alteratives, aperients, and proper dietetic regulations, "the symptoms of debility and relaxation almost always soon disappear, under the use of a nourishing and digestible diet, regular exercise, warm clothing, and the enjoyment of pure air." Mo'st writers speak favorably of sea-bathing as a means of invigorating the system and counteracting the scrofulous disposition. When the disease manifests itself in the form of a general scrofulous habit, with- out the presence of local affections, in a state of active progress, benefit may, no doubt, be obtained from this measure; but it does not appear to possess any peculiar powers, as many formerly supposed, in promoting either the discussion of scrofulous tumors, or the healing of the ulcers which proceed from them. (Lloyd.) It is also decidedly objectionable, where the scrofulous habit tends strongly to the formation of tubercles in the lungs, or where tubercular matter has already been deposited in the pulmonary tissue; and the same observation applies to the employment of the usual internal tonics. The tonics most gene- rally prescribed are cinchona, gentian, steel, the mineral acids, and the quinine. Of these articles, the quinine appears to be particularly useful in certain states of scrofulous affections. Mr. Rennie, in a very excellent paper on the treatment of this disease, states that he found this preparation more effectual in allaying irritability, and that febrile diathesis which depends on atony of the stomach, than any other tonic he has ever used.* In the preceding part of this work, (p. 321,) I have already referred to Dr. Mackenzie's observations on the valuable powers of the sulphate of quinine in scrofulous ophthalmia; and in one instance of well- marked scrofula in an infant, which lately came under my notice, one grain of quinine given three times daily, after proper evacuants, afforded unequivocal advantage. • London Medical Repository, 1825. 760 SCROFULA. Where, along with the symptoms of gastric debility, much acidity prevails in the primae viae, alkaline remedies should be given, either by themselves, or, what is usually more advantageous, in union with weak infusions of the tonic vegetable bitters. The alkalies have indeed long been regarded as peculiarly beneficial in the management of scrofulous affections. Mr. Farr strongly recommends Bran- dish's liquor potassae as a remedy for indurated, inflamed, and suppurated scrofulous tumors about the neck, as well as "in the thickening of the ligaments and periosteum, with caries of the bones." He asserts that he has found this medicine " pre-eminently successful both in arresting the further progress, and effectually eradicating a disease so destructive to human life." He employs it in connection with the mercurial frictions mentioned above. A drachm of this preparation is to be given twice a day to a child from four to six years old; to a patient of from six to eight years old, one drachm and a half; and to one over eight years old, two drachms are to be given in any agreeable drink. Its opera- tion is slow, and must be long-continued.* What has been said applies particularly to the constitutional treatment of scrofula. When the disease appears in an active form, the same general manage- ment may still be proper, to a greater or less extent, with additional remedies adapted to the local affections, and varied according to circumstances. M. Dupuytren adopts a treatment in scrofula, differing materially from the methods of treatment generally followed. During the early period of the disease, he endeavors to fortify the constitution by the usual means resorted to in affec- tions of this kind. When the complaint has advanced to what he calls its second stage—which is characterized by febrile irritation, local pains, swelling and in- flammations, he rigidly avoids all remedies of an exciting character, and treats the disease as an inflammatory affection, by bleeding, leeching, low diet, &c.; and he asserts that by this mode of management he has often arrested the pro- gress of the disease, and prevented caries of the bones, gibbosities, spontaneous luxations, suppurations, and destruction of the organs. The authority of M. Dupuytren is not to be lightly rejected; and yet I apprehend that, although decidedly proper in certain phlogistic cases, the antiphlogistic method he recom- mends cannot be so generally applied with benefit, as his observations would appear to indicate.! Glandular swellings.—So long as the glandular tumors remain in an indolent state, all active local applications should be avoided; for as discussive means they are wholly useless, where these enlargements depend on a scrofulous dia- thesis; and by their tendency to irritate and inflame, may greatly hasten the progress of the disease. Nevertheless, with the view of preventing the surround- ing parts becoming irritated by the pressure of the enlarged gland, it may be proper to bathe the tumors "with salt water, or some other cooling lotion." (Lloyd.) When the tumors become inflamed and painful, however, local anti- phlogistic applications are in general decidedly indicated. Leeching, saturnine lotions, and cold applications should be resorted to where the skin over the painful tumor is as yet free from tension and inflammation; but "where several glands have coalesced, forming a large tumor, and the superincumbent skin is tense and discolored, the best applications are warm emollient poultices." The leeches should not be applied to the inflamed or discolored skin of the tumors, but to the sound skin immediately surrounding the swellings. "It often happens, that when the swellings have arrived at this height, an abscess forms ; but it also happens, that they become indolent, and the pain and tension both subside. The tumor, however, remaining undiminished, will, upon examination, be found to contain in its upper surface a small quantity of fluid. In this case the applica- tion of a blister, to be kept open for a few days, and repeated according to * The formula for preparing Brandish's liquor potassa is given in the Edinburgh Dispensa- tory, edited by Dr. Dyckman, p. 459. f Ratier on the Practice, &c, of the Parisian Hospitals. SCROFULA. 761 circumstances, will often promote rapid dispersion of the fluid, and indeed some- times of the whole tumor." In general, however, the application of blisters and other stimuli to glandular swellings, in an indiscriminate way, is calculated to do much mischief. The foregoing observations on the local management of scrofu- lous tumors are drawn from Mr. Lloyd's excellent treatise on this subject, a work to which the reader is referred for much valuable information in relation to the management of this alarming malady. Scrofulous ulcers.*—The successful management of scrofulous ulcerations is always attended with great difficulty. A great variety of local remedies have been recommended for the cure of ulcers of this kind; but without a judicious constitutional treatment, they are rarely capable of procuring more than tempo- rary benefit, and when applied without great discrimination, may readily do much mischief. Mr. Rennie, who has paid particular attention to the effects of topical applications in scrofulous ulcerations, states that he has found the follow- ing compositions highly beneficial in foul and indolent sores of this kind.t When the thickened purple edges of the ulcers overlap the surface, and prevent cicatri- zation, they should be destroyed with some escharotic, and for this purpose the kali parum, or the nitrate of silver, should be employed. Mr. Lloyd recommends the former, in preference to any other applications of this kind. Slightly astring- ent ointments or lotions generally agree better with scrofulous sores than such as are more stimulating. A weak solution of the sulphate of copper, in the pro- portion of four grains to an ounce of water, or of lunar caustic, or the nitrate of mercury, will usually answer all the purposes that may be expected from such applications. Mr. Lloyd considers the diluted citron ointment as the best local remedy for promoting the healthy granulation and cicatrization of scrofulous sores. Whatever topical remedies may be employed, and whether the local affection consists merely in enlargement of the lymphatic glands, or in ulcerations, it must not be forgotten that our main reliance should be placed on an appropriate constitutional treatment. Besides the general remedial measures already men- tioned, and which may be deemed indispensable in all instances of scrofula, there are a vast variety of remedies which have been strongly recommended for the cure of this affection ; and there can be no doubt, that some of them, at least, may, under certain circumstances or modifications of the malady, occasionally prove serviceable. The iodine has of late years been a good deal used in scrofulous affections; and in certain forms of the disease, it is, without doubt, deserving of much atten- tion. In mere local lymphatic tumors, its powers are unquestionable; but it does not appear to possess any decided remedial powers over glandular enlarge- ments and ulcerations, depending on a scrofulous habit of body. In scrofulous inflammation of the eyes, it is said by some writers to be very useful—a state- ment which I have not, however, found verified in my own practice, although I have used it a long time, and in efficient doses, in five cases of this kind. For * The only signs by which the scrofulous ulcer may be distinguished from one of a different character, are: " its occurring after a suppurated scrofulous tumor—the peculiar dull red, or purple color of its edges—its remaining indolent for a great length of time, neither increasing nor diminishing in size, and its being attended with that particular state of health which inva- riably prevails in the scrofulous constitution."—Lloyd. X R.—Picis nigra? fbi. -----liquidae Rjiss. -----resinae Bbii—M. ft. emplast.—Or, R.—Picis liquid, ffiss. -----niger. fti. -----resinse fti.—M. ft. emplast.—Or, R.—Picis liquid, ftiii. -----resinae fbiv.—M. ft. emplast. To be heated and spread at the time of applica- tion, not, however, too thinly. The best thickness seems to be from one to two lines.—Loc. citat., p. 194. 762 SCROFULA. the removal of insulated strumous tumors about the neck, it is decidedly the most effectual remedy we possess. The only three instances of this kind in which I have employed it, disappeared under the use of frictions with the ointment of the hydriodate of potash.* It should be observed, however, that a preternatural sensibility or irritability of the system ; a tendency to irregular determinations, and the presence of internal local congestions; prominent gastric and intestinal derangement; febrile symptoms, general plethora, diarrhoea, a disposition to hemorrhages, arid an inflamed or sensible state of the tumors, are decided con- tra-indications to the employment of this article, whether used externally or internally. Mercury.—This article, as has already been slated, is of unquestionable uti- lity, under cautious management, in scrofulous affections, by its tendency to correct the hepatic and alvine functions, and thereby contributing essentially to the restoration of the general health and vigor of the constitution. It has been supposed, however, to possess direct and specific powers over the scrofulous action, by its constitutional influence; but for this opinion there does not appear to exist any good foundation. It is, nevertheless, true, that in old and obstinate ulcerations of a scrofulous character, minute doses of corrosive sublimate, in union with some alterative ptisan, such as the compound decoction of sarsapa- rilla, will sometimes prove surprisingly beneficial. I have succeeded in curing several remarkably severe and obstinate cases of this kind, unequivocally of a scrofulous nature, by the continued employment of a tenth of a grain of this mer- curial, thrice daily, in conjunction with the free use of sarsaparilla decoction; and there are, perhaps, few practitioners who have not witnessed its occasional good effects in similar instances of the disease. Except so far as it tends to correct the actions of the liver and bowels, this article does not appear to possess any direct power of dispersing scrofulous tumors; but, on the contrary, when its in- fluence is carried to the extent of producing a manifest general mercurial action in the system, it not unfrequently accelerates the progress of these enlargements, and deteriorates the general habit of the body. Narcotics.—Most of the officinal narcotic extracts were formerly much ex- tolled as remedies in every variety of scrofulous affections. The confidence of the profession in their powers has, however, long since, in a great measure, passed away; and although some relief may occasionally be obtained from the employment of these articles, their effects on the disease rarely amount to more than a mere palliation of its symptoms, or a temporary suspension of its progress. The most celebrated of these articles are—conium, belladonna, hyoscyamus, and solanum dulcamara; but there are a great variety of other vegetable remedies of a similar character, that have been particularly praised for iheir occasional good effects in scrofula. Thus, tussilago farfara is much extolled by Hoffman : and Meza strongly recommends digitalis in small doses.t The expressed juice offumaria; chaereofolium; becccthunga; sonchus; lactuca; marubrium album and taraxacum, have all had their advocates as remedies in this disease. Of all these articles, however, conium is decidedly the best; and which, in combination with small doses of muriate of mercury, I have known to do much good in scrofulous ulcerations. The muriate of baryfes was much in vogue as a remedy for scrofula some thirty years ago. It was introduced to the particular notice of the profession by Dr. Crawford ;J and Hufeland, soon afterwards, published a small treatise, with cases illustrative of its remedial powers in this disease.§ Many other writers * R —Hydriod. potassae j^ii. Axungias ^ iss. Liq. potassae caust. gtt. v.—M. ft. ungt. Of this ointment, a portion about the size of a small nutmeg should be rubbed in upon the tumor twice daily. f De digital, purpur ejnsque usu in scrofulus medico. Jena?, 179. X Duncan's Medical Comment., vol. iv. Deo. ii. p. 433. § Volstind. Darstell. d. Urafte u. anwendung d. salzsaur. schwererde, &c. SCROFULA. 763 have published statements favorable to the employment of this article; but general experience did not confirm these accounts ; and it has long sunk almost into total, though, as I have some reason to think, not entirely merited, neglect. I have employed it in several cases of scrofulous ophthalmia, with unequivocal advan- tage; and I am persuaded that in some instances, at least, its powers might be very beneficially called into aid in the management of this intractable malady. It is slow in its effects, and must be used for a considerable time before any obvious amendment occurs in the disease. For the mode of employing it, the reader is referred to page 321 of this work. Of a similar character is the muriate of lime—an article which, at one time, had considerable reputation as a remedy in scrofulous complaints. Thirty drops of a solution of one drachm of this salt to two ounces of water, are to be taken every three hours, and the dose gradually increased until it begins to affect the stomach. Fourcroy, Beddoes and Hufeland speak very favorably of its powers. Twenty years ago, I saw it employed in a case attended with several very large scrofulous tumors on the neck, and an ulcer in the left axilla, and although it did not accomplish a complete removal of the external affections, its beneficial in- fluence was very manifest. In the early period of my practice, I employed this article in a considerate number of instances of scrofulous ophthalmia, and erup- tions about the head in young children, and, as it appeared to me, with some advantage in several cases. General experience, however, has not established its usefulness, and it is now entirely neglected as a remedy in this affection. Antimony, by its tendency to counteract inflammatory action, and to keep up the regular cutaneous exhalation, is a highly useful medicine under proper manage- ment, in certain varieties and stages of scrofulous affections. Under the head of Phthisis Pulmonalis, I have already spoken of its usefulness in counteracting the progress of tubercles in the lungs. This article is particularly useful when the glandular swellings manifest a tendency to pass into a state of inflammation; and in minute doses, it will co-operate very advantageously with warm clothing, to prevent the general scrofulous diathesis from passing into the active forms of the disease. That it possesses any direct or specific influence over the scrofulous action, cannot, indeed, be admitted ; but by its general operation in promoting the secretions, and opposing an inflammatory tendency in the system, it is calcu- lated to do much good in affections of this kind. Weikard and Richter recom- mend the following combination in scrofulous cutaneous eruptions.* Some of the German writers speak very favorably of the effects of large and frequent doses of assafcetida, in scrofulous caries of the bones. Schmucker, in particular, has published a very favorable account of its powers in affections of this kind. Where the general circulation and habit are languid, benefit may be obtained from this remedy; but its beneficial influence, in cases of this kind, appears to depend solely on the general excitement and invigoration it imparts to the system. Richter recommends the following formula.! Of the importance of tonics, in conjunction with aperients, and the cautious employment of mercu- rials, for counteracting the scrofulous diathesis, I have already spoken, and I need here only repeat, that although unquestionably of primary consequence where the system is languid, and the digestive powers feeble, they are not only useless, but often prejudicial, where the general habit is phlogistic, and the alimentary canal * R.—Antimon. crude, alcoholis £vi. G. guaiaci ,^ss. Extract, aconit. gi. Sacchar. albi ^x. Mucilag. g. Arab, q s.—M. To be made into boluses of xv grains each. One of these is to be taken four times daily by an adult. j- R.—Antimon. sulphuret. nigr. gii. G. assafcetid. 3hi. Extract, cicutae £ss. ------- aconit gr. xv.—M. Divide into four grain pills. S. Take from four to five pills twice or thrice daily. 764 BRONCHOCELE. in a high state of irritation. During the active progress of glandular swellings, that is, whilst they are in a state of inflammation and suppuration, tonics cata rarely be given without mischief. After the active state of the inflammation has terminated in foul and languid ulcerations, they may, in general, be used with propriety and advantage. In old scrofulous ulcerations, attended with general de- bility and relaxation, the employment of large doses of cinchona, quinine, or steel, is sometimes an indispensable auxiliary to the local applications and general alterative remedies that may be deemed proper. The following combination forms an excellent tonic in old scrofulous ulcerations, or in general where tonics are indicated in this affection, at any period of its course.* The aromatic tonics, says Richter, deserve much attention in scrofulous affec- tions attended with general relaxation and debility, and where the ulcers are foul and indolent. Of course, where there is a disposition to inflammation, they are decidedly objectionable. Weikard particularly recommends calamus; Richter speaks favorably of cloves ; and Hufeland mentions a decoction of rad. helenii; cort. winteranus; cort. et lig. sassafras; and where the general habit is very torpid, Tilenius advises the use of the essential oil of sassafras, as being often peculiarly beneficial. Sect. II.—Bronchocele—Goitre. This very remarkable disease consists of a chronic enlargement of the thyroid gland. It commences with a small tumor on one or both sides of the larynx and trachea, which gradually increases in size, until, in the course of years, it acquires, in many instances, an enormous bulk, occupying the whole anterior part of the throat, from ear to ear, and projecting considerably beyond the chin, and occasionally even extending down to near the middle of the chest.t In the early period of the disease the tumor is always soft, elastic, and spongy to the touch; the color of the skin natural and movable over the enlarged gland. In the progress of its enlargement, however, the tumor becomes more and more firm, until, at last, in severe cases, it acquires great density and firmness in cer- tain parts, whilst small portions retain their original soft and spongy state. Although indolent, or free from pain or tenderness, during the early period of its progress, and in many cases of moderate size always so, yet in the majority of instances, where the tumor becomes large and indurated, transient pains are at times felt darting through the enlarged gland, at the same time that the skin assumes a slightly red or copper color, and the veins of the neck become large and turgid. JNo inconvenience whatever is experienced from the disease while the tumor remains soft and of a moderate volume; but when it acquires a large size, it generally gives rise to more or less difficulty of respiration, and a slight change or loss of clearness of the voice. In some cases the enlargement ex- tends inwardly, so as to cause considerable pressure on the oesophagus and large blood-vessels in the neck, occasioning difficulty of swallowing, and, at times, great anxiety and palpitations of the heart, throbbing of the carotids, and danger- ous and even fatal congestions in the brain. The progress of the enlargement is sometimes very irregular. The tumor in some instances remains stationary for a considerable time, then rapidly increases in size for a short period, and again * R.—Ferri limatur. vel pulver. ^iii. P. rhaei ^ ii. G. ammonine !Jii. Tart antimon. grs. iii.—M. Divide into three grain pills. S. Take four pills three times daily—Or, R.—Ferri limatur. 3ii. G. assafoetid. gi. G. aloes soc. grs. x.—M. Divide into sixiy pills. S. Take two four times daily. X Albert, Fodere, Larrey, Keate, and Sir Robert Wilson, have all related instances of this kind. BRONCHOCELE. 765 continues nearly in the same state, or decreases until it again rapidly augments in volume. More generally, however, the progress of the tumor is very gradual and regular. In many localities, where bronchocele prevails endemically, particularly in the deep valleys of the Alps, the disease is very frequently attended with a stunted and deformed development of the body, and a corresponding deterioration of the intellectual faculties. It is thus, that amidst these magnificent and beautiful scenes of nature, man alone is doomed to dwindle—to sink, under the inevitable influences that surround him, from his noblest prerogatives to the lowest state of corporeal and intellectual deterioration. The unfortunate beings who are affected in this manner—and, in some situations, the majority of the native inhabitants are more or less affected—are stunted in growth, with enormous heads, tumid necks, and a manifest degree of mental hebetude which, in aggravated instances, amounts to absolute idiotism. This combination of affliction is called cretinism, and the unfortunates themselves, cretins. Bronchocele has, however, no neces- sary connection with the general debasement of the moral and physical constitu- tion of man ; for, in many parts where the goitre is exceedingly prevalent, the development of mind and body is not impeded by the disease, or the endemic cause upon which it depends. Nevertheless, from the almost inseparable con- nection of these affections, where cretinism prevails, we can scarcely doubt of their dependence on some peculiar modification of a common cause. The internal structure or substance of a goitrous tumor varies according to its age, or stage of progress. Recent enlargements of this kind consist generally of a gelatinous mass, or a cellular structure containing a glutinous fluid. Some- times they exhibit a soft and spongy texture, with large cavities or cysts dis- persed throughout their structure, containing a serous fluid. Old tumors some- times contain masses of ossified or cartilaginous substances, imbedded in a soft, friable, or adipose-like matter,* and in some cases the goitrous tumor is filled with dark blood. Morgagni found tumors of this kind composed almost entirely of a number of cysts filled with a viscid transparent fluid ; and occa- sionally the whole gland resembles amellicerous or steatomatous tumor. Some- times the goitrous enlargement consists almost wholly of a congeries of varicose veins.t Bronchocele very rarely enters into suppuration ; and the occurrence of ac- tive inflammation and ulceration is equally uncommon, and hardly ever takes place spontaneously, or without some external injury or irritating applications. Nevertheless, instances of spontaneous suppuration have occurred; and this has, in some cases, eventuated in a complete cure of the affection. Petit has men- tioned examples of this kind. Alibert has recorded a case, where an enormous strumous enlargement of the thyroid entered into suppuration, and disappeared after ihe discharge of about five pounds of purulent matter, (loc. cit., p. 467.) Suppuration does not, however, always, or even generally, terminate thus favor- ably. Sometimes the abscess ulcerates into the trachea, and causes suffocation. Instances of this kind are related by Morgagni, Valsalva, Lieutaud, Baillie, and Portal. Diagnosis.—Although generally sufficiently distinctive in its external charac- ter, goitre, when not very large, and situated only in one of the lobes of the gland, may, on superficial examination, be mistaken for aneurism of the carotid arterv, and still more readily for sarcoma of the trachea or neighboring glands; and, perhaps, for dilatation of the internal jugular vein. When the tumor ac- companies the motions of the larynx and trachea in the act of swallowing, and is movable, wholly insensible, soft and spongy to the touch, and free from pul- sation, we may conclude that it is of a strumous or goitrous character. When, however, the tumor is situated on one side of the neck, directly over the carotid, a pulsatory motion will be communicated to it by this artery, and in this case, * Morgagni, Benetis, Baillie, Richter. t Fodere, Essai sur le goitre et le cretinage. § fe. 766 BRONCHOCELE. much difficulty may occur in the diagnosis. An instance is mentioned in the Diction, des Sciences Med., where a tumor in the neck was pronounced to be aneurismal, by several eminent surgeons, which was afterwards found by Boyer to consist entirely of an enlarged lymphatic gland in the neck. An interesting example of this kind occurred in this city. A tumor on the neck was regarded as aneurism of the carotid by Drs. Griffitts, Chapman and Dorsey, which, upon dissection by Dr. Parrish, was subsequently ascertained to be composed wholly of an enlargement of a portion of the thyroid gland.* From scrofulous enlargements of the glands of the neck, goitre may, in gene- ral, be distinguished by the position of the tumor—and the firmness and greater proneness to inflammation and suppuration of the former than the latter form of glandular disease. Mere dilatation of the internal jugular vein is also liable to be mistaken for bronchocele ; but the former may, in general, be distinguished from the latter, by its situation, which is usually just above the sternum; and by its softness and compressibility, its undulating or pulsatory motion, and the gene- ral turgescence of the vein, and the sudden return of the tumor when pressure is removed. Etiology.—One of the most singular circumstances in the history of this affection, is its permanent and extensive prevalence in certain localities, often of limited extent, whilst the inhabitants of the vicinal districts are almost wholly exempt from the malady. In no part of the world is the disease so prevalent, and so distressing in its character, as in some of the valleys of the Alps and Apennines. In certain districts of Switzerland and Savoy, almost ihe whole of the indigenous population are more or less affected with goitrous enlargements. In the valley of the Rhone, at Martigny, St. Maurice, Aigle, Villeneuve, Bourg, Lucerne, and at Dresden, and in the valleys of Piedmont, this disease is ex- tremely common. Goitre occurs also extensively in various parts of Asia—par- ticularly in Chinese Tartary and in Hindostan; and in certain districts in Africa, it is said to be very common. In England the disease occurs very frequently in certain mountainous districts of the counties of Derbyshire, Buckinghamshire, Surrey, and Norfolk. In our own country, also, there are localities in which goitre is of frequent occurrence. At Bennington, Chittenden, Camden, Sand- gate, Windsor, and Chester, in Vermont, bronchocele is very common. In the State of New York it is frequenly met with at Oneida, the German Flats, in the Onondaga valley, in the township of Manlius, at Brothertown, in the neighbor- hood of Angelica in Allegheny county, and in various other localities in the north- western districts of the state. In Pennsylvania it occurs not unfrequently at Pittsburgh, at Cannonsburgh, Brownsville, and along the Allegheny, Sandusky, and Monongahela rivers. It is met with in Virginia at Morgantown, and on the banks of the Cheat river. Where the disease prevails endemically, it occurs at all periods of life from infancy to old age. Saussure, indeed, asserts that those who remain wholly free from the disease until they have passed the tenth year, very rarely, if ever, af- terwards, become affected with it; and Kortum states, that it never occurs in infants, and in adults of the male sex. These assertions are, however, wholly unfounded, and have been abundantly contradicted by later observations. Hacquet, for instance, states that he has met with goitre in infants; and he has known the disease to come on after the fiftieth year of age.t It is even asserted that infants have been born with goitrous tumors. Fodere,| Consbruch§ and Sterndalel] have related instances of this kind. Iphofen, however, contends that * See an essay on Goitre, by Dr. W. Gihson, in the first number of the Philadelphia Journal of Med. and Phys. Sciences. X Neii Physic. Politische Reise, durchdie Dacischenund Sarmatischen oder nord. Karpathen., p. 129, as quoted by Richter. X Traite du Goitre et du Cretinisme, p. 18. § Klin. Tasclienbuch., t. ii. p. 281. || Lond. Med. Repository, vol. x. p. 200. BRONCHOCELE. 767 true congenital bronchocele never does take place, and that the cases which have been recorded as such, were, in all probability, lymphatic tumors of a different character,* or simply an unusually developed state of the thyroid gland. In gene- ral when the disease occurs in females after marriage, it is during the state of pregnancy that the tumor first makes its appearance. (Fodere.) It would appear that cold weather has a tendency to retard the increase, or even to diminish goi- trous tumors ; for it is by no means uncommon to find the enlarged gland percep- tibly smaller during the winter than in the warm months of summer. Goitre occurs also in the inferior orders of animals—particularly in sheep, horses, and horned cattle.t In relation to the remote causes of goitre, a great variety of opinions have been advanced ; but our knowledge upon this interesting subject amounts, as yet, to little more than to some very general facts and a few plausible conjectures. It has been supposed that the habitual use of water impregnated with limestone or other calcareous substances, is the principal cause of this affection, (Coxe, de Luc;) and this appears to be the general opinion in Switzerland and Savoy. This, however, is satisfactorily contradicted by the fact that goitre prevails in districts where not the smallest portion of calcareous matter occurs in the water used by the inhabitants; and in many localities, where the water is highly charged with limestone, this affection is wholly unknown. (Barton, Iphofen.) Another opinion still entertained by many is, that the use of snow water, abounding in mountainous districts, is the cause of this malady, (Darwin, Selle, Percival, Des- genettes;) but there are many facts which conclusively contradict this view of the causation of the disease. Thus, in the valley of Chamouni, " where the water is nothing else than the droppings of snow water from Mount Blanc," bronchocele is but very rarely seen; while on the other side of the Col de Balme, in the val- ley of the Rhone, we hardly see anything else than goitre and cretinism. Again, in Lapland, where snow water is constantly used, goitre is a very uncommon affection; and on the contrary, the disease is known to prevail extensively in some parts of Africa, and in other warm climates, where snow and ice scarcely ever occur—as in the island of Sumatra.*. The following observations made by Dr. Richardson, who accompanied Captain Franklin in his voyage to the polar sea, is decisive on this point. " Bronchocele is a common disease at Edmonston. The disorder attacks those only who drink the water of the river. It is, indeed, in its worst form, confined almost entirely to the half-breed women and children who reside constantly at the Fort, and make use of river water, drawn in winter, through a hole in the ice. The men, from being often from home on journeys through the plain, where their drink is melted snow, are less affected; and if any of them exhibit, during winter, some incipient symptoms of the disease, the an- nual summer voyage to the sea coast generally effects a cure. The natives who confine themselves to snow water in winter, and drink of the small rivulets which flow through the plain in summer, are exempt from the attacks of this disease." Iphofen (loc. cit., p. 50) maintains that bronchocele is produced by the use of water entirely devoid of carbonic acid gas, but this, like the other opinions mentioned, is not sufficiently supported by facts to entitle it to any par- ticular attention. Many writers have attributed this disease to the use of particular articles of food. Thus, Dr. Drug, who saw a great deal of goitre in Derbyshire, conceives that goitrous affections are very generally produced in that district, by the use of sour oatcake, and other innutritious aliment, more especially inferior potatoes, &c. Magneti and Roncalli also have ascribed the disease to the abundant use of heavy and indigestible articles of food, particularly to fat and oily substances and chest- * Der Cretinismus Philosoph und Med. Untersucht., Dressten. 1817, p. 4. X Barton's Memoir on Goitre. Dr. Alexander Coventry—in the New York Medical and Physical Journal. X Marden's Geschichte und Beschreibung von Sumatra, 64. 768 BRONCHOCELE. nuts, which, in some parts of Switzerland, constitute a large proportion of the ordinary nourishment of the peasantry. Its dependence, however, on causes of this kind, is decidedly contradicted by a variety of facts bearing directly on this point. Thus of different contiguous localities, we find the disease extremely prevalent in some, whilst in others it occurs but seldom, although the general diet and mode of living are the same. Besides the foregoing causes, various others have been mentioned as the probable source of this affection ; such as the inordi- nate use of vinous liquors; the repulsion of cutaneous diseases ; mechanical inju- ries of the thyroid gland by carrying heavy burdens on the head, &c. The opinion that the disease depends on certain atmospheric causes, has re- ceived many advocates ; and there are various circumstances, indeed, which favor this view of its origin. It is supposed by some, that a dense, stagnant, and hu- mid atmosphere is the ordinary source of the disease; and this idea is counte- nanced by the circumstance that goitre is known to prevail extensively in many situations where the atmosphere is constantly loaded with moisture, as in the deep and shady valleys of the Alpine countries. (Fodere, Saussure, Chavassein, D'Aubert.) Fodere asserts that the frequency of the disease is found in many localities to bear a pretty close relation to the hygrometrical states of the atmo- sphere. In many deep, damp, and woody valleys, goitre is extremely prevalent; but in proportion as we ascend towards the more elevated and dry situations on the sides and tops of the adjacent mountains, the disease becomes less and less frequent. It is well known, moreover, that when young persons affected with goitre, remove from the valley in which the disease was contracted, to high and dry situations, the tumor almost always becomes considerably diminished in size, and in many instances disappears altogether.* It is even asserted, that in some foundling hospitals, where the air was suffered to become damp and malarious, goitre has been known to occur endemically—and that it disappeared again, after the air was rendered purer and dryer.t These facts certainly appear very strongly to countenance the opinion that the disease depends on atmospheric causes; but they may be used with equal propriety as arguments in favor of the dependence of the disease on some peculiar impregnations of the water used in the localities where it prevails. It must be observed, too, that bronchocele is known to prevail extensively in some elevated situations, where the air circulates freely, and is not charged either with humidity or paludal exhalations. Thus, at Annaberg, or Marienberg, and in several other localities pointed out by Ipho- fen, (loc. cit., p. 42,) the air appears to be pure and dry, and yet goitre is a very common affection. Again, it is unquestionable that there are a vast number of deep valleys in every country, in which the air is stagnant, and particularly loaded with moisture and terrestrial exhalations, but in which goitre is neverthe- less entirely unknown. Humboldt advanced the opinion, lhat a deficiency of electricity in the atmo- sphere is intimately concerned in the production of endemic bronchocele;J and the same doctrine is strenuously advocated by Iphofen. It would appear from the experiments and facts adduced by the latter writer, that in all the situations where goitre prevails endemically, there is a constant deficiency of the electric fluid in the atmosphere; and he asserts, that when goitrous tumors are lessened or removed by a change of residence, from the low and humid situations in which they were produced, to elevated and dry districts, it is chiefly by the abundance of electricity which the atmosphere contains in the latter situations, that the salutary effect on the disease is produced. Notwithstanding the plausible facts that may be adduced in evidence of the aerial character of the remote causes of goitre, it appears to me much more probable that it is not in the atmosphere, but in the water of goitrous districts, * Edinburgh Med. and Surg. Journal, vol. v. p. 53. t Richter, Chirurg. Biblioth., bd. viii. p. 500. X Ueber d. gereizte Muskel. und Nervenfassern, b. ii. p. 208.—Richter. BRONCHOCELE. 769 ha we must look for the cause of this malady. It cannot, indeed, be maintained triat it is either snow water, or calcareous matter contained in the common water that gives rise to the disease; but there are many facts which appear to me very clearly to show that the origin of the disease is connected with some peculiar condition of the water habitually used in those districts of country where the disease prevails The account given of a goitrous family near Fort Schuyler, in the State of New York, by Dr. Coventry, demonstrates very conclusively the correctness of this view of the etiology of goitre. This family resided on the banks of a small stream, running through a bed of schist and slaty gravel It consisted of seven members, all of whom, with but one exception, were affected with bronchocele. They were in the habit of using the water of the brook for all culinary and other purposes. In the spring of 1798, Dr. Coventry settled within three quarters of a mile of this family. "There being no well, and prepossessed with the idea of the hereditary nature of the disease/' says Dr C my family also used the brook-water; when towards the approach of winter' to my no small mortification and vexation, I perceived an evident thickening in the necks of my daughters. Then I first began to suspect the water of Regel's creek. The next summer I sunk a well, and since we commenced the use of it none of my family has been subject to goitre." The goitrous family removed to Onondaga, and became entirely freed from the disease.* Dr. Johnson, in relation to the etiology of goitre, observes that "the upper Rhone, where it falls into the lake of Geneva, is turbid, even to whiteness, with the attntus which its tributary Alpine streams carry along; but its waters, while nearly quiescent in the lake, become clear, and pass through the city of Geneva like translucent streams of bluish crystal. Among those who inhabit the banks, and drink the waters of the upper or turbid Rhone, there are twenty cretins and goitres for one that can be seen on the banks of the lower or filtered Rhone."t Dr. Coventry seems to think it probable that the substance with which the waters that give rise to this disease is impregnated, consists in aluminous particles. In dry seasons the surface of the schist, after having been acted on by the air, " be- comes^coyered with a white efflorescence, which, on examination, is found to be alum." The material which furnishes the alum manufactured near Glasgow, in Scotland, is found "in the schist rock which forms the sides, bottom, and roof, of an exhausted coal-pit." This observation receives support, by the fact, that in certain districts in Europe, where alum is extensively manufactured, although elevated and dry, bronchocele is extremely common. (Iphofen.) Whatever may be the remote cause of goitre, Dr. Gibson thinks, that " the disease arises immediately from an obstruction of the tracheo-thyroideal passages of Borden—of the openings communicating with the sacculus laryngeus and the thyroid, and of other passages with which we are unacquainted." " I am in- clined," he says, " to draw this conclusion from the circumstance of a watery fluid being found to occupy naturally the cells of the thyroid gland—from this fluid being increased in quantity in almost every goitrous tumor—and from the passages of Borden being much smaller in the first dissection I made of broncho- cele than they are usually met with in subjects without such disease. This is a mere conjecture; neither is it original—but was advanced by one of the older writers on surgery." (Loc. cit., p. 65.) * Dr. Coventry adds the following highly interesting facts. "A few years after this, I leased a small house, standing near the brook, to a Mr. Walworth, who had a son about twelve years old. This lad, in the course of a few months, exhibited appearances of bronchocele; he was sent from home, and his neck returned to its natural size; but in the succeeding season began to enlarge, and the family moved away." "About the autumn of 1802, I put a small flock of sheep into a pasture, through which the stream ran; next spring one lamb proved goitrous; the succeeding season every lamb had a swelled neck, and seven out of eight died. My next neigh- bor had sheep in an adjoining pasture, which was watered by a spring; his sheep had no dis- temper."—New York Med. and Phys. Journ., June 1824. t Med.-Chir. Rev., April 1825, p. 443. 49 770 BRONCHOCELE. Treatment.—Since the discovery of the extraordinary remedial powers of iodine in bronchocele, it is scarcely necessary to pay any attention to the various other means that were formerly resorted to for the cure of this affection; for it can hardly be presumed, that where the judicious employment of iodine fails, there can be any particular advantage obtained from any other remedies at pre- sent known. Although but a few years have elapsed since this remedy has become generally known to the profession, a very great number of instances of its successful employment in this affection have been reported. Dr. Manson has given a tabular statement of 116 cases of bronchocele treated by this article; and of this number, seventy-seven were completely cured, eleven much relieved, and but two not relieved; the remainder were discharged for non-attendance, or remained, improving under the treatment.* Dr. Manson used the iodine both internally, and externally in the form of a liniment,! rubbed into the tumor. In individuals of a very irritable or plethoric habit of body, or where the stomach and bowels are in a deranged condition, the free and protracted internal employ- ment of iodine will sometimes give rise to various unpleasant symptoms, such as " headache, giddiness, sickness at the stomach, with some degree of nausea, lan- guor and inaptitude for exertion." By suspending the use of the medicine for three or four days, these affections, in general, soon disappear. Where the in- conveniences occasioned by the iodine are moderate, it will be sufficient to exhibit it in diminished doses. It is evident, however, from the experience of Dr. Manson and others, that the tendency of this article to produce unpleasant effects, has been much exaggerated by some writers. Dr. M. states that no in- convenience resulted from the internal use of this article, in any of the cases in which he employed it; but on the contrary, it generally appeared to produce a cordial and tonic effect, unless it was given in too large a dose. " Patients generally found themselves in better health and spirits after a course of treatment with the iodine, than they had previously been for years; and this observation applies not only to those who labored under bronchocele, but also to those who labored under other diseases in which iodine was exhibited." I have used this medicine in perhaps twenty cases of different diseases, both internally and ex- ternally in full doses, continued in some instances for six or eight weeks, without having ever observed any unpleasant consequences to result from its operation. It cannot be doubted, however, that in certain habits of body, it may give rise to unpleasant and even injurious effects; but this may be said, with equal justice, of every important article of the materia medica. Dr. Kolley, in a very interest- ing memoir on the medicinal powers of iodine, observes, as the result of his experience, that iodine is incomparably the most powerful remedy in goitre which has yet been discovered; but in order to employ it successfully, it is necessary : 1, that the disease be confined to the thyroid gland ; 2, that the tumor be devoid of a scirrhous or sarcomatous character; 3, that the disease be not inveterate, or of very long standing; 4, that the general health be not particularly deranged or impaired; and 5, that the goitrous tumor be free from inflammation. Where these conditions are not present, the iodine will almost invariably effect a cure. It would appear, that in general this remedy is most apt to give rise to unfavorable effects, where there is a tendency to congestions of the head and of other internal organs; and Dr. Kolly observes, that individuals of a robust, mus- cular, and what is usually termed atrabilious habit, do not, in general, bear the action of iodine without more or less inconvenience—particularly when unac- companied by the use of laxatives. " In such constitutions, the tendency to local congestion increases; the head becomes confused, and cephalalgia often rises to such an extent as to threaten delirium." A deranged state of the di- * Medical Researches on the Effects of Iodine in Bronchocele. t R-—Liniment, sapon. ^i. Tinct. iodii ^i.—Misce. This was rubbed into the tumor once, and in some cases twice daily. BRONCHOCELE. 771 gestive organs, all local inflammatory affections, diarrhoea, and phthisis pulmona- lis, are unfavorable to the beneficial operation of this remedy.* In general, the external application of the iodine in the form of an ointment, or liniment, will procure all the benefit that can be derived from this remedy in goitre. Mr. Coindet has entirely left off its internal employment, and recom- mends frictions on the tumor with the following ointmentt Internally, ten drops of a tincture made by dissolving forty-eight grains of the iodine in an ounce of alcohol may be given twice daily. Of the various other remedies that have been particularly recommended for the cure of bronchocele, it will be sufficient merely to mention the following: Burned sponge; this article, no doubt, owes its remedial powers, in this affec- tion, to the small portion of iodine it contains. It is given in doses of from a scruple to a drachm daily, and will occasionally remove goitrous tumors. Cal- cined egg shells; the external application of sea water, (Lieutaud ;) hepar sul- phuris, (Selle, Fodere;) the vinegar of squills; kermes mineral; belladonna; and especially, conium maculatum; digitalis; burned boletus suaveolens, in union with small portions of muriate of soda and lime; the muriate of barytes; and the different preparations of mercury and antimony. Externally, repeated blistering; frictions with stimulating liniments; mercurial ointment; various stimulating plasters ; cataplasms, or bags of emollient herbs, applied over the tumor; and compression; have all been recommended, and occasionally used with advantage in this affection. In some cases, however, the disease bids defiance to the powers of medicine, and the tumor goes on increasing until it becomes so large as to endanger suffo- cation, or some other fatal consequences. In instances of this obstinate and dan- gerous character, the passage of a seton through the tumor appears to promise more success than any other mode of treatment. Dr. Quadri has published an interesting memoir on the treatment of this affection by setons;+. and Mr. Cope- land Hutchinson has adopted this practice with complete success.§ " He passed a long and narrow seton needle, armed with half a skein of silk thread, obliquely through the substance of the gland from the left lobe upwards, leaving a space of nearly two inches from the entrance and escape of the instrument." Mr. Hutch- inson refers, also, to a case successfully treated in this way by Mr. Thompson, and to another one by Mr. James, of Exeter and Devon Hospital. An instance of the successful use of the seton by Mr. Lyford, is related in the Med.-Chir. Rev. for July 1827.11 Extirpation has also been resorted to, and, it is said, in a few instances with success. Fodere refers to some cases where tumors of this kind were removed * Reflexions et Observations sur l'Emploie de l'lode en Medecine. Par le Docteur Kolley. f R.—Hydriod. potassae ^ii. Axungise ^iss. Liq. potassae caust. grs. iv. Ft. ungt. 1 Medico-Chirurg. Transnct, vol. x. § Medico Chir. Rev., March 1822. || [The seton sometimes produces excessive inflammation of the tumor, and has been followed by fatal results. It is chiefly in cases of hydro-bronchocele, or hydrocele of the neck, that setons and stimulating injections have proved serviceable. I have met with more decided success, however, from free incisions and the subsequent introduction of lunar caustic into the cavity of these cysts so as to excite discharges of pus and the growth of granulations. I have repeatedly extirpated large tumors, both encysted and sarcomatous, from the thyroid with success. In one case I removed the entire enlarged gland and saved the patient from suffocation thereby. When the gland is merely hypertrophied, we may reasonably expect to disperse the swelling by judi- cious treatment perseveringly employed. But surgical remedies will be required when any actual disorganization has taken place. The diagnosis is always sufficiently easy. The expe- rienced practitioner will not confound the hard, irregular lobulated masses which are the result of degenerations of the thyroid gland, with the smooth and uniform rounded tumors, unaccom- panied with any change in the color of the skin, and in which mere fleshy hypertrophia is perceptible.—Mc] 772 SCURVY. by excision; and Dr. Harris has given an account of two instances of the suc- cessful extirpation of bronchocele. It must be observed, however, that this ope- ration is always attended with much danger; and many cases might be collected from writers, in which the attempt to extirpate bronchocele was followed by fatal hemorrhage, or some other disastrous consequences. There is another operation which has been performed with more or less advan- tage by several surgeons—the tying up the thyroid arteries. The operation was first performed by Mr. Blizard, of London. The tumor, in the instance he re- lates, diminished one-third in size, in the course of a week after the operation; but an attack of hospital gangrene, followed by repeated secondary hemorrhages, finally destroyed the patient's life. Dr. Jameson, of Baltimore, also took up the superior left thyroid artery in an inveterate case of goitre, with the effect of considerably diminishing the size of the tumor; and other instances of this ope- ration, attended with still more decided success, have been recorded. CHAPTER X. CHRONIC DISORDERS OF THE ASSIMILATIVE FUNCTIONS. Sect. I.—Scorbutus—Scurvy. Scurvy does not appear to have been much observed until about the middle of the sixteenth century. Soon after that period, however, it became an object of particular attention, and in conformity with the prevailing notions concerning the agency of morbid humors in the production of diseases, almost all chronic af- fections—gout, rheumatism, hypochondriasis, and particularly cutaneous affec- tions, were ascribed to a scorbutic disposition and acrimony of the blood. Masked scurvy was supposed to be present in almost every variety of acute and chronic disease; and there has perhaps never been an opinion in pathology which has been carried to so injurious an extent as the doctrine of a latent scorbutic hu- moral diathesis.* At present, however, the term is properly restricted to a peculiar form of the disease, which is undoubtedly connected with a morbid condition of the blood, arising from a want of proper nourishment, or other causes tending to derange the assimilating functions. This affection seldom occurs in its more aggravated form, except among seamen; although slight, and occasionally even very severe, cases are met with in individuals, deprived of wholesome nourishment and a pure air, who have always resided on shore. Symptoms.—The disease commences with an unusual degree of lassitude and want of muscular energy; a feeling of stiffness of the knees and feet is experi- enced, attended with depressed spirits, and a great disinclination to corporeal exertions. The muscular weakness gradually increases, and the respiration becomes short and panting on the slightest bodily exertions. The countenance exhibits a pale and sallow, or lead-colored and bloated appearance; the skin is dry, and sometimes peculiarly tense and shining, and separates in small scales on different parts of the body. Sooner or later, brown or livid spots make their appearance on the surface, generally first on the legs, then on the thighs, and last on the arms and abdomen, but they very rarely appear on the face. In con- nection with the appearance of these maculae, cedematous swellings of the feet and legs occur; and, in hot climates, extensive anasarcous effusions sometimes * Richter, Specieile Therapie, bd. p. 795. scurvy. 773 ensue, without any of the ordinary scorbutic blotches. Simultaneously with the occurrence of the spots on the skin, and in many instances at an earlier period, the breath becomes fetid, and the gums tender and spongy, and extremely apt to bleed on being even lightly touched. The patient complains of a putrid taste, and usually expresses a strong desire for fresh vegetable food and acids. The urine is turbid and dark-colored, the vision becomes more or less impaired, and the muscular powers so prostrated that the patient can scarcely maintain the erect position. The blood is thick, dissolved, and very dark ; the pulse weak and soft. As the disease advances, stiffness of the joints and indurations in the mus- cles occur, accompanied with severe pains in the thighs, back, and loins, particu- larly in the knees ; and the patient, at times, experiences violent spasmodic or flatulent pains in the bowels, attended with retraction of the umbilicus, and con- stipation. The respiration is constantly more or less oppressed; subcuticular extravasations of blood appear on the extremities, and occasionally on other parts of the body; and passive hemorrhages occur from the gums, nose, rectum, blad- der, &c, at the same time that ulcers are formed on the calves of the legs and thighs, exhibiting an oedematous and flabby appearance, with irregular and bloody edges, and discharging a red ichorous fluid. The gums separate from the teeth and slough, and the teeth become loose in their sockets, and often drop out; old and cicatrized wounds re-open ; the bones become brittle, and syncope occurs on slight corporeal exertions. If the disease continues unchecked in its progress, extreme prostration at last ensues; respiration becomes exceedingly anxious, fatiguing, and oppressed ; syncope, even while the patient is at rest, or merely by turning himself in bed, occurs frequently; a cadaverous or fetid effluvium exhales from the body; emaciation goes on rapidly, and in some instances para- lysis of one or more extremities ensues, or extensive dropsical effusions, jaun- dice, diarrhoea, or dysenteric discharges, and finally a rapidly exhausting irritative fever, or coma and convulsions, close the scene. The duration of scurvy is, in general, protracted ; but there nevertheless occurs a very considerable diversity in this respect. In violent instances of the disease, where its progress is favored by previous habits of living, or, perhaps, by a peculiar constitutional predisposition, the disease sometimes acquires great severity in the course of a few weeks. This, however, is rarely the case with land scurvy—the most rapid and fatal instances usually occurring on board of ships while at sea. Land scurvy very rarely appears in the violent form described above. In many instances it continues for a long while, with no other symptoms than languor, a fetid breath, spongy and hemorrhagic gums, and brownish spots on the legs, with slight oedema of the feet, and a pale and puffy countenance—the patient being all the while able to be up and about. Sometimes it shows itself chiefly by blotches of extravasated blood on the inferior extremities, and foul and bleeding'ulcers on different parts of the body, with spongy and tender gums. Post-mortem phenomena.—The different cavities of the body generally con- tain an abundance of serous fluid, mixed, in many instances, with more or less blood. The mucous membrane and surfaee of the viscera commonly exhibit dark and apparently gangrenous spots; and blood is found extravasated in differ- ent parts of the cellular tissue, under the membranes, and sometimes into the alimentary canal, the lungs, and even into the abdomen. The heart is flaccid and pale; the spleen soft, and turgid with dissolved blood; the muscles livid, and often so soft that they may be easily broken down between the fingers. The bones are usually very brittle, or preternaturally soft—particularly the epiphyses, which may sometimes be separated from the bones with great ease. The blood is universally found in a dissolved state, and very black. Causes.—Persons of a debilitated and phlegmatic habit of body, with a dispo- sition to obesity, are said to be most subject to this disease. The exciting causes are : the habitual use of innutritious, unwholesome, or an exclusive salt animal or vegetable diet, more especially when conjoined with much fatiguing labor, and exposure to a dump aad impure .atmosphere. Anxiety of mind, with a sedentary 774 scurvy. mode of life, and the habitual intemperate use of spirituous liquors, contribute also very considerably to the production of scurvy. Damp and impure air, how- ever, in conjunction with a vitiated or exclusive salt animal diet, is by far the most common source of this malady, whether it originate on land or on sea. In relation to the essential nature or proximate cause of scurvy, pathologists have expressed a variety of opinions. That the blood exhibits a morbid condi- tion, is unquestionable; but whether this state of the humors is primary or se- condary, in reference to the occurrence of the disease, has been a subject of much controversy. Lind, Milman, Sprengel, and Dreysig contend that scurvy consists essentially in a weakened and relaxed state of the solids, of which the changes which occur in the blood are mere consequences. On the other hand, Hoffman, Trotter, Jackson, Cullen, and some later writers, consider a putrescent or morbid state of the blood as the primary and essential condition upon which the debility and relaxation of the solids and the other characteristic phenomena of scorbutic affections, more or less directly depend. From a view of the nature of the most common and powerful remote causes of this disease—namely, unwholesome, in- nutritious, and especially an exclusive salt animal diet, the idea of its depend- ence on a deranged or vitiated state of the blood appears very plausible ; and the more so, as we know that the chyle, and, we may presume, the blood, also, are manifestly modified, according to the nature of the aliment used. The circum- stance, too, that a scurvy which occurs while the individual is confined to a par- ticular kind of diet, almost invariably soon begins to disappear when the aliment is changed, argues directly and strongly in favor of its humoral origin. It is nevertheless most probable, that the fundamental affection consists in a deranged condition of the chylopoietic functions and of the process of sanguification; for it can scarcely be admitted, that any considerable change could occur in the com- position of the blood, without a previous derangement of the functions that are more immediately concerned in the elaboration of this fluid. That the morbid condition of the blood, resulting from a disordered action of the functions just named, has a direct, and perhaps a principal share in the production and support of the characteristic phenomena of the disease, cannot, I think, be doubted; for an intimate depravation of the general mass of the blood, from whatever cause it may arise, must, one may suppose, necessarily give rise to a universal morbid condition of the organization—more especially to the reproductive or vegetative functions of the system. Prognosis.—In general, the prognosis in scurvy is not very unfavorable ; and in the ordinary cases of the disease, manifestly the result of some peculiar and exclusive aliment, it very rarely resists an appropriate change of regimen. In- deed, it is surprising how rapidly even very aggravated instances contracted at sea, will often disappear as soon as the patient is put on shore, or is allowed a fresh vegetable and acescent diet. In severe cases, however, the influence of the land air is occasionally, though indeed very rarely, manifestly injurious, and greatly hastens the progress of the malady. (Richter.) After the disease has continued until symptoms of extreme prostration and universal depravation of the solids and fluids are induced, such as great difficulty of respiration, frequent syn- cope, and sloughing of the gums, with extensive oedema, or dropsical effusions, there is but little advantage to be expected from any mode of management. When the disease occurs in persons of a gouty habit of body, or is complicated with syphilis, the prognosis is always to be regarded as unfavorable; and a broken-down constitution, by the frequent use of mercury, is also particularly calculated to enhance the obstinacy and dangerous consequences of the malady. Treatment.—The first and most important part of the remedial management of scurvy is the removal of the causes which produced the disease. When it is the result of impure diet, and a vitiated and damp air, more wholesome food and a purer atmosphere are indispensable. The scurvy which occurs at sea, is almost universally the consequence of the exclusive and long-continued use of salt animal food, and of bad and impure water; and hence cases of this kind almost always scurvy. 775 disappear very speedily, as soon as the patient is put upon the use of fresh vege- table and animal food, and vegetable acid drinks—such as lemon juice and good vinegar. The employment of acids of this kind, particularly the lemon juice, is one of the most effectual means for preventing or arresting the progress of this affection, when it arises from the use of old and salted meats. It appears, how- ever, that vegetable acids are not so universally beneficial in this affection as has been supposed. An interesting account of the total failure of lemon-juice in arresting the progress of scurvy on board of the British ship Leander, is given in the Med.-Chir. Rev. for June 1824.* After this acid had been fully tried, with- out the least benefit, the disease was quickly vanquished by the free use of fresh animal food, in conjunction with vegetables. Dr. Bampfield, also, in his work on tropical dysentery, speaks of the great benefit which may sometimes be de- rived from fresh animal food, in sea scurvy. In general, however, a mixed diet, composed of fresh animal and vegetable articles of food, is the most salutary in scurvy arising from the exclusive use of old and salted meats, or of unwholesome, coarse, and oily aliment. There are certain vegetables, which experience has shown to be especially beneficial in this affection; and they should undoubtedly be used whenever they can be had. The principal of these are—horseradish, scurvy-grass, garden-cresses, water-cresses, garlic, onions, the fruit of cloud-ber- ries, iettuce, celery, endive, spinage, carrots, cabbage, oranges, mustard, and all kinds of acid fruits. Of all these vegetable substances, however, cabbage in the form of sour-krout is decidedly the most valuable, both as a preventive and curative means. Fermented liquors, buttermilk, fresh milk, vinegar and water, but especially water acidulated with lime juice and a decoction of malt, taken freely as common drink, are highly proper beverages in scorbutic affections. Medicinal articles are seldom of very material service in the treatment of scurvy; and without the proper changes in diet already mentioned, they are always wholly ineffectual, and may even prove injurious under the most careful management. Mr. Patterson, however, speaks very favorably of the effects of a solution of nitre in vinegar, in the proportion of four ounces of the former to a quart of the latter—given in doses offrom half an ounce to two ounces twice or thrice daily. Mr. Charles Cameron, a naval surgeon to the British Naval Me- dical Board, has lately published a statement confirming Mr. Patterson's favor- able account of the effects of nitre in this affection. This disease broke out among the convicts on board the Ferguson transport, on her passage from Ireland to New South Wales; and threatened, by its violence, to exterminate the crew. After employing the usual means with but little success, Mr. Cameron had re- course to nitre and vinegar; and the effects, he says, were highly and promptly beneficial. " The oppression and sinking at the pit of the stomach," which were so distressing to the majority of patients, yielded almost without exception to a few doses of this mixture. "Eight ounces of nitre were dissolved in so much vinegar as would make the solution amount to sixty-four ounces." One ounce of this solution was given at a dose from three to eight times daily.t During * "In the year 1822, his majesty's ship Leander sailed from Trincomalee for the Cape of Good Hope, taking on board the mechanics of the dock-yard establishment then reduced on the island. There were also embarked twenty-six invalids, and all the sick that could be removed from the hospital. These invalids and sick were principally affected with chronic hepatitis, dysentery, and phthisis pulmonalis, all of which (even some who were expectorating large quantities of purulent matter), recovered on the passage to the Cape. This good fortune was counterbalanced by scurvy, which broke out among the crew, and, in spite of large quantities of lemon juice plentifully administered in conjunction with every other antiscorbutic which the ship could produce, spread to an alarming extent, and in one case proved fatal. Had they not reached the Cape at the time they did, the Leander would have presented as deplorable a spectacle as the Anson at Juan Fernandez, notwithstanding the supposed specific lemon juice, which in no instance on board the Leander had the slightest effect in even checking the ravages of scurvy. Immediately the ship reached the Cape, and the crew got plenty of fresh animal food, in con- junction with vegetables, they rapidly recovered. Specimens of the lemon juice were trans- mitted to the Victualing Board, and carefully analyzed in London. It was found perfectly good." f Medico-Chir. Rev., Feb. 1830, p. 484. 776 CHLOROSIS. the stage of convalescence, some advantage may be derived from tonics, particu- larly iron, cinchona, calamus aromaticus, cort. aurantior., cort. winteranus, cas- carilla, and the mineral acids. Richter mentions the following infusion as often very useful in the treatment of land-scurvy.* An infusion of calamus and Peru- vian bark, with the addition of elixir vitriol, is particularly praised by Jahn. Kotrum asserts that he has derived considerable advantage from the use of savin in this affection ; and the bark of the betula alba is said to have been very bene- ficially employed in this affection. As a local application to scorbutic ulcers, whether situated in the mouth or elsewhere, a strong solution of the muriate of lime will in general answer a very good purpose. Water acidulated with muri- atic acid, and sweetened with honey, forms an excellent lotion for the gums. A weak solution of the sulphate of copper, or of lunar caustic, may also be bene- ficially employed for this purpose. Sect. II.—Chlorosis.X This disease occurs principally in young, unmarried females, and occasionally also in married women, at various periods of life. It is not, however, exclusively confined to the female sex, for its occurrence in males, during the period of adolescence, and even at mature age, is sometimes, though indeed but rarely, noticed. Symptoms.—In the commencement of chlorosis, the countenance exhibits a peculiarly pallid appearance, and the lips especially appear to be bloodless, with a puffiness of the upper and lower eyelids, and a slight appearance of tumidity of the face. The lower eyelids are often encircled with a streak of a dark or leaden hue, and in some instances the eyelids exhibit a greenish sallow tinge. As the disease slowly proceeds in its course, the whole surface of the body be- comes very pale, more especially the hands, fingers, and nails, and presents a white, puffy and flabby state, with more or less oedema of the ankles and legs, and an evident tendency to emaciation. The tongue is pale, and covered with a transparent mucus, and exhibits a swollen or bloated appearance, with numerous and enlarged papulae, and the edges indented by the pressure of the teeth. The gums and internal surface of the cheeks also become tumid, and paler than natural, and the breath is generally foul. From the commencement of the dis- ease, much general languor and listlessness prevail, with great indisposition to corporeal or mental exertion. Headache, ringing or noise in the ears, and vertigo are common symptoms, and the energies of the mind are subdued, accompanied, in many instances, with a drowsy, peevish, and spiritless condition. In the more acute cases of chlorosis, considerable pain is apt to be experienced in the hypo- chondriac regions; and, in some instances, cough, oppressed respiration, parox- ysms of palpitation of the heart, or partial syncope, "and almost universally a sense of fluttering about the praecordia," are experienced by the patient. The appetite is usually weak; but in many instances there is a distressing morbid craving for particular articles, particularly for acids and absorbent earths, as mag- nesia, chalk, or even clay. The bowels are generally torpid, with occasional transient attacks of diarrhoea and griping—the feces usually presenting a very unnatural appearance, with thick and sedimentous urine. The catamenial func- tion always becomes early deranged, and in many cases the menses are suppressed before the occurence of the chlorotic symptoms. * R.—Rasur. raphan. rustic. §iii. Ferri. pulverat. ^i. P. rad. rha?i _^ss. Rad. zingiberis ^ii. Vin. alb. generos. Ibii.—M. Stent in infus. per xii. horas, cola. Take a teacupful three times daily. X See Dr. Marshall Hall's excellent little work "On the Disorders of the Digestive Organs," &c &c. CHLOROSIS. 777 When the disease continues until it becomes confirmed, the countenance ac- quires a still more pallid, bloodless, and puffy appearance; the prolabia assumes a pale lilac hue, and the skin becomes smooth, dry, puffy, and of a singularly pale yellowish color. By degrees the tongue acquires a clean and smooth sur- face, and exhibits a peculiar, semitransparent, exsanguious, and pale lilac ap- pearance. The general languor and debility increase, and the occasional attacks of pain in the head and side become more severe. In this confirmed stage of the complaint, the morbid cravings of the stomach are often peculiarly strong and singular. The patient experiences an indomitable desire for certain indigest- ible substances, such as chalk, cinders, sand, coffee-grounds, tea-leaves, flour, clay, &c. The catamenia, if they have not previously ceased, are attended with pain, and become pale, smaller in quantity, and usually terminate in more or less profuse leucorrhoea, where this affection does not precede or accompany the chlorotic disease in its course from its commencement. In inveterate cases of chlorosis, emaciation goes on slowly but progressively. The muscular debility is extreme; the oedema increases, and acquires the form of anasarca; the pulse is very small, frequent, and in many instances quick and corded; the confusion and pains in the head are more permanent; the mind ex- tremely excitable, or unusually torpid and sluggish ; and the attacks of dyspnoea and palpitation of the heart become more frequent and distressing. Sometimes diarrhoea ensues—the matter discharged exhibiting a dark, or even black appear- ance, resembling in all respects the evacuations of melaena. In cases of a more chronic character, " there is a continued though variable state of sallowness, of yellowness, or icterode hue, of darkness, or of a wan, squalid, or sordid paleness of complexion, or a ring of darkness surrounding the eyes, and extending a little perhaps towards the temples and cheeks, and some- times encircling the mouth, without tumidity as well as without the pallidness of the prolabia already mentioned." In the severer cases of chronic chlorosis, the nails are apt to become deformed in a peculiar manner, sinking down in the mid- dle, and breaking off in brittle laminae on the anterior margin. The tongue, in such instances, (chronic chlorosis,) exhibits various appearances. In general it is clean, moist, often of a bright red, and sometimes of a light green or pale lilac color, with a smooth, shining, or a granulated raw appearance of the surface, sometimes divided into lobules by deep creases, and at others bloated and indented along the margin by the pressure of the teeth. The blood in chlorosis is usually attenuated, the relative proportion of the crassamentum, or red part, being in- variably less than natural. (Hall.) Chlorosis is peculiarly liable to frequent changes and exacerbations of its symptoms. Dr. Hall observes that he has often observed "an eruption of urti- caria, in very large, elevated wheals, sometimes solitary, and at others in con- siderable numbers, in chlorotic patients." Diagnosis.—Chlorosis is liable to be confounded with certain forms of insidi- ous organic disease. From disorders of this kind, however, we may in general distinguish chlorotic affections, without much difficulty, by the following circum- stances. The pallid countenance of organic diseases is usually attended, at times, with a slight flush of the cheeks; and the prolabia are free from that pe- culiar bloodless and semitransparent pallidness or lilac hue, which is so charac- teristic of chlorosis. The countenance, too, is generally expressive of pain and suffering in organic diseases, which is seldom met with in chlorosis, except in the latter periods of aggravated cases ; and the whole surface of the body remains either nearly in a natural state, or becomes slightly icterode, whilst emaciation usually commences early and proceeds rapidly. From chronic disease of the liver, with which chlorosis is most apt to be confounded, we may distinguish it, by the icteric appearance of the conjunctiva, and of the surface generally, as well as the clay-colored feces, the bilious urine, and the usual tenderness and fullness of the right hypochondrium, which occur in organic hepatic affections. Causes.—A sedentary and confined habit of life, more especially when assisted 778 CHLOROSIS. by impure and stagnant air, is a common and powerful cause of chlorosis. " The mimosis decolor," (chlorosis,) says Dr. Hall, "is the prevailing affection of those females who, in manufacturing towns, are doomed to sit from morning till even- ing at the lace-frame, or the tambour, or engaged in mending, seaming, cheyening, &c. Unwholesome and indigestible diet, particularly when accompanied with indolence, .want of cleanliness, and want of exercise in the open air, is especially calculated to produce this disease. Too long lactation ; frequent hemorrhages ; protracted or long-continued menorrhagia; leucorrhoea; the depressing mental affections; long-continued and exhausting labor; and unsatisfied sexual desires; are not unfrequently the source of chlorotic affections. There are few circum- stances, probably, more frequently concerned in the production of this disease, than chronic intestinal irritation ; and consequent derangement of the digestive functions. A torpid and loaded state of the bowels, in young females, when co- operating with one or more of the above-named causes, rarely fails to give rise to more or less of a chlorotic condition. Chlorosis sometimes occurs apparently in consequence of the tardy, or non-appearance of the menses, after the sexual organization is fully developed, and the same occasionally results from suppressed menstruation in females of a delicate and leucophlegmatic habit of body. Occa- sionally, however, the disease comes on gradually, while the menses are regular, without any obvious exciting cause ; but in instances of this kind, the bowels will generally be found, on inquiry, to be torpid, and the appetite variable and disor- dered. Treatment.—Little or no benefit can be derived from remedial treatment, so long as the exciting causes continue to act on the patient. These, therefore, must be obviated as early and effectually as possible. If the disease be contracted under the influence of a sedentary habit, and an impure or confined air, regular exercise in the open air will be indispensable to the removal of the malady. If deficient and unwholesome nutriment has contributed to the production of the disease, the use of a more pure and nourishing diet is necessary. Where grief and despondency have exercised an injurious influence in this respect, efforts must be made to dissipate the mental depression, by proper society, travel, and conversation. In the majority of cases, conspicuous symptoms of a loaded or otherwise disordered state of the alimentary canal are present; and to these symptoms of intestinal derangement it is particularly important to pay immediate and especial attention. Dr. Hamilton has laid great stress on the value of purgatives in the cure of chlorosis, and although his estimate of their usefulness is undoubtedly too favorable, it must be admitted, that under judicious management, they are generally decidedly beneficial, and in many cases perhaps absolutely indispensa- ble to successful treatment. Where the abdomen is tumid and tense, and the bowels torpid, laxatives must be employed until the accumulated feculent matter has been thoroughly evacuated. It is to be particularly observed, however, that active cathartics, or such as excite copious liquid stools, are calculated to do much mischief. Two or three consistent or soft alvine evacuations in the course of twentv-four hours, will be sufficient to procure all the advantages that can be derived from aperients, without the risk of doing injury by increasing the de- bility, or exciting permanent intestinal irritation. Moderate doses of aloetic ape- rients are, I think, decidedly the best remedies for this purpose. From three to four grains of rhubarb, in union with one or two grains of aloes, taken in the evening, will in general procure one or more full and consistent evacuations on the following morning; and this dose may be given every third or fourth evening, until there is reason to believe that the bowels have been freed of their vitiated and accumulated contents. As the liver almost invariably partakes of the mor- bid excitement of the alimentary canal, it will be proper from time to lime to exhibit small doses of blue pill or calomel. Dr. Hall recommends the adminis- tration of five grains of the latter article once every week, or every ten or four- teen days, according to the degree of hepatic derangement indicated by the symp- CHLOROSIS. 779 toms ; whilst " on the intermediate days, a sufficient, consistent alvine evacuation must be procured, by pills of aloes and rhubarb, or by infusion of senna, with sulphate of magnesia." In the use of mercury, the utmost caution is necessary to prevent a general mercurial impression on the system, the object in employing it being solely to correct the hepatic and intestinal secretions. Where the dis- ease continues until diarrhoea, with small, unnatural and fetid discharges occur, small doses of blue pill, in union with ipecacuanha and the extract of hyoscyamus, will in general afford much benefit. A grain of the blue mass, with two grains of ipecacuanha and one grain of the hyoscyamus, may be given every night on going to bed. I have known this combination to produce the happiest effects in an instance attended with such symptoms. Dr. Hall has obtained very good effects from the conjoined employment of opium and blue pill, in cases attended with diarrhoea. If opiates are indicated, Dover's powder will in general do more good than any other preparation of this narcotic. In conjunction with the use of remedies calculated to correct the hepatic and intestinal functions, it is particularly important to regulate the diet of the patient. The aliment should be simple, nourishing, and of the most digestible kind. In the commencement, before the bowels have been adequately evacuated, the more nourishing kinds of farinaceous fluids and light broths should be used, such as preparations of barley, rice, arrowroot, oatmeal, &c.; but after the accumulated feces have been removed, and the hepatic and intestinal secretions in some degree corrected, solid animal food, particularly the lean parts of mutton, lamb, venison, and very tender beefsteak, and boiled fowl, with stale bread or biscuit, should form the principal articles of the aliment; in short, the patient should observe all the dietetic rules laid down for the management of the first stage of indigestion. The enjoyment of a pure country air, and regular exercise by gestation, are powerful auxiliaries in the treatment of this affection ; and along with an appro- priate diet and gentle aperients, are generally adequate, without any other means, to restore the health of the patient. After the system has regained some degree of vigor, advantage may be obtained from sea-bathing; but this will seldom be admissible until convalescence has already considerably advanced. At an earlier period, however, " sponging the body with cold water, or with vinegar and wa- ter," or the tepid shower-bath in summer, will often do much good ; but even these applications cannot be freely used with propriety, where the powers of vital resistance are greatly reduced. Dr. Marshall Hall does not seem to entertain a favorable opinion of tonics administered internally, with the exception of iron, which, he thinks, may be used with some advantage. After due alvine evacuations, and an amendment of the intestinal and hepatic secretions have been effected, by the cautious use of ape- rients and mercury, I am disposed to ascribe very considerable importance to the internal employment of tonics. When early employed, and in large doses, pre- vious to the preparations just mentioned, they are, no doubt, well calculated to do mischief, and at all events, can rarely prove in any degree beneficial. Iron is the best tonic we possess in chlorotic affections. No preparation of iron has appeared to me so useful in diseases of this kind as the black sulphuret of this metal. From eight to ten grains may be given three times daily. Its peculiar usefulness would seem to depend on the tendency which it generally manifests to excite a moderate diaphoresis, in conjunction with the ordinary tonic powers of the ferruginous remedies. The tartrate of iron, too, is a valuable tonic, on account of its tendency to keep up a regular action of the bowels—so contrary to all the other preparations of this metal. From a scruple to two of the tartrate may be given twice or thrice daily, dissolved in some sweetened water. The phosphate and carbonate are so apt to give rise to constipation, that they are, in general, objectionable on this account, unless diarrhoea be present, when they may be appropriately used. Richter observes, that after the exciting cause has been obviated, and the alimentary canal sufficiently evacuated, the following 780 GONORRHOEA. combination " cannot be too highly recommended."* When the digestive powers are much debilitated, we may administer the iron in union with some of the tonic vegetable bitters, with peculiar advantage.t Among the Germans, Wieckart's pills*, have been highly recommended in obstinate cases of chlorosis. Kopp declares that he has employed them with great success in this affection. The chalybeate mineral waters are especially beneficial in chlorotic cases. The use of the ferruginous remedies should be continued until the health of the patient is completely restored. The clothing should be sufficiently warm to favor the regular action of the skin ; and the influence of damp and inclement weather must be carefully avoided. Dr. Bland says : " The real cause of chlorosis, under all its Protean forms, is a vicious and imperfect sanguification; the blood being defective in crassamentum and coloring matter, and in consequence becoming less capable of imparting functional energy to the body. In some cases severe gastrodynia attends, not to be relieved by ordinary remedies. Occasionally fre- quent attacks of asthma ; sometimes excruciating headaches, murmuring noise in the head, and symptoms of diseased heart." Dr. Bland considers iron as among the very best remedies. He thinks that it is not, generally, given in sufficient doses to derive the benefit which it is capable of affording. His favorite formula is thus : R.—Ferri sulphat, Potassae subcarb., aa ^ss.—M. In pil. forty eight dividend. The dose, at first, is one pill night and morning, to be increased gradually in a fortnight to four pills morning, noon and night.—(Revue Medicale.) CHAPTER XI. CHRONIC DISEASES OF THE SEXUAL ORGANS. Sect. I.— Gonorrhoea. A running or discharge of purulent matter from the urethra, has been noticed as a loathsome affection " by successive authors, from the earliest periods in which we have any medical records," but it was not considered as having any essential connection with syphilis, until upwards of half a century after the introduction of this latter disease into Europe. Since that period, the relation subsisting between these two affections has been a subject of much controversy ; but the general opinion at present is, that they are radically distinct, each depend- ing on its own specific virus, although some eminent physicians still contend for their identity. The experiments of John Hunter, which appeared to prove that * R.—P. lig. quassias, Sacch. alb., aa "^i. Flor. martialis grs. x.—M. Divide into twenty-four equal parts. S. Take one every four hours. This mixture, he says, possesses the advantage of not being liable to cause consti- pation. j- R.—Ferri phosphat. gi. Pulv. cort. aurant. giii.—M. Divide into ten equal parts. Give one three times daily. X R.—G. aloes Soc. 3;i. Ferri. pulver. J^h- Sulph. antimon. aurant. ^ss. Submur. hydr. ^i. Ol. sabin. xx. Syrup, cort. aurant. q. s. Ut fiant pil. grs. iii. Take two every evening. GONORRHOEA. 781 gonorrhoeal matter is capable of forming chancre, and, on the contrary, that matter taken from a chancre, when brought in contact with the urethra, will form gonor- rhoea, have been contradicted by various experimenters—more especially by Mr. Benjamin Bell; and the very frequent occurrence of gonorrhoea, where of course the virus is largely and constantly applied to the glans penis, without the appear- ance of chancre, is strongly opposed to the opinion of their specific identity. It must, indeed, be admitted, that chancre and gonorrhoea frequently appear together, but where this is the case, there can exist but little doubt that the two poisons were communicated either at the same impure venereal intercourse, or at distinct connections. I have lately seen an instance illustrative of this fact. The patient labored under gonorrhoea of about six weeks' standing: before it was cured he had connection with a woman ; and in six days afterwards a genuine excavated syphilitic chancre made its appearance. Gonorrhoea generally comes on in three or four days after an impure connec- tion ; but in some instances it appears within the first forty-eight hours, and occasionally not until the expiration of eight or ten days after the application of the virus. At first, a disagreeable itching or pricking sensation is felt in the point of the urethra, passing a short distance up from the orifice, which on examination will be found slightly reddened and somewhat tender. After this sensation has continued for ten or twelve hours, the mouth of the urethra becomes sensibly inflamed and swollen, and a limpid or yellowish matter begins to ooze from it. The stinging and itching increase, and the emission of urine occasions a severe smarting and burning pain in the anterior portion of the urethra. The pain now extends more or less speedily inwards along the urethra; the glans penis becomes swollen, dark red, and tender to the touch, and the discharge acquires a yellow- greenish color, resembling diluted pus. Frequent and very painful erections harass the patient—more especially after he has been some time in bed ; and on passing water, the pain, in some instances, is exceedingly smarting. In many cases the inflammation extends from the mucous membrane of the urethra to the corpus spongiosum, giving rise to much tenderness and hardness of this part, and particularly to a most painful affection called chordee, which consists in strong and protracted erections, whilst, from the inflamed and unyielding state of the corpus spongiosum, the penis is thrown into a curved form, with the fraenum drawn down and the body forced upwards. At this stage small portions of blood are often mixed with the gonorrhoeal discharge; and the prepuce sometimes become much inflamed, tumid, and slightly excoriated at the edges and in spots on its internal surface. In some instances, one or more of the inguinal glands become inflamed and swollen, and a knotted cord of inflamed lymphatic vessels is felt along the dorsum of the penis. Many patients experience a constant aching pain in the glans and body of the penis; and occasionally one or both testicles become tender, inflamed and much swollen, attended with pain along the whole course of the spermatic cord. Considerable symptomatic fever always attends, when the inflammation becomes thus extended from the urethra to the neighboring structures. Not un- frequently the whole track of the urethra becomes inflamed, giving rise to harass- ing sensations of burning and titillation in the neck of the bladder and anus, and very severe cutting pains in the perineum on making water. The patient, under these circumstances, feels a continual urgency to make water, but from the great tenderness of the neck of the bladder and urethra, only a few scalding drops are voided at a time. When the testicles become inflamed, the gonorrhoeal discharge is always sensibly diminished, and in many cases entirely suppressed. Some- times some of the engorged capillaries of the mucous membrane burst, and more or less of pure blood passes off. After an uncertain period, these inflammatory sy m ptoms begin to subside. The scalding pain in making water gradually ceases; the erections become less frequent and painful; and the gonorrhoeal matter ac- quires a oreater consistence and becomes white and ropy. The specific inflammation of gonorrhoea is primarily seated in the mucous 782 GONORRHOEA. membrane of the urethra, a short distance above its orifice in the fossa navicu- laris, and chiefly affects the lacunas mucosae of Morgagni, and their excretory ducts. From this point, however, it often extends higher up the urethra, to the membranous portion, the veru montanum, and neck of the bladder. Sometimes the gonorrhoeal matter, in the first instance, does not penetrate the urethra, during impure venereal connection ; but being applied to the glans penis, it gives rise to irritation and a discharge of thin purulent matter from the sebace- ous glands situated around the corona glandis. Much more commonly, however, the matter discharged from the urethra comes in contact with the internal surface of the prepuce and the glans, and causes excoriations of these parts, from which a thin whitish or whey-like fluid is discharged. These excoriations usually ap- pear in the form of irregular patches, leaving interstices of sound skin between them. It would seem, too, that the virus of gonorrhoea, when brought to act on the glans and internal aspect of the prepuce, often produces a peculiar variety of venereal ulcer, of a mild character, exhibiting a smooth, level, and nearly circular surface, slightly raised above the surrounding skin, having a healthy color, but without granulations and induration, and exhibiting somewhat of a fungous ap- pearance. (Carmichael.) These ulcerations are most commonly seated on the anterior and posterior verge of the prepuce, or beside the fraenum, and generally connected with more or less phimosis. In some instances, gonorrhoeal discharge from the urethra is accompanied both by excoriations and ulcers of the kind just mentioned ; but more frequently the disease is attended with simple excoriations of the prepuce and glans. Gonorrhoea is sometimes succeeded by constitutional symptoms—and this is most apt to be the case in those instances of the disease that are attended with the primary excoriations or ulcers just mentioned. Mr. Travers asserts, that so long as the mucous surface remains sound, or unbroken by excoriation, gonorrhoea is not capable of producing secondary symptoms.* He contends that the absorption of the virus or matter is indispensable to the production of constitutional symptoms, and that "the inflammatory secretions of sound surfaces are not absorbed into the system." Experience, it must be admitted, supports the assertion, that secondary constitutional symptoms very rarely occur, except in cases that are attended with primary gonorrhoeal excoria- tions or lesions of the mucous surface from which the discharge occurs; but it admits of much doubt whether such lesions are indispensable to the production of secondary symptoms; and still more, whether the assertion that absorption cannot take place from an inflamed mucous surface, be strictly correct. In some instances, the secondary symptoms of gonorrhoeal sores are almost as strongly marked as those of lues ; sometimes the glands of the groin become much enlarged and indurated. The inflammation in the fauces is usually diffuse and superficial, the surface of the velum palati and uvula being often "roughened with innumerable small tufts of white lymph, or pitted with small shallow indent- ations where ulceration has taken place." Sharp, deep and clean fissures of the tonsils sometimes succeed gonorrhoeal ulcers on the genitals. The cutaneous affection is always mild, consisting of minute papular eruptions, varying from a pale red to a deep crimson color, which are ushered in by pyrexia and redness, pain and swelling of the joints. These papulae do not come out together, but follow each other in succession. Some of them are simply pimples, while others are almost advanced to the pustular form. These are most numerous, and in some instances almost altogether confined to the parts about the shoulders, arms, and back. The febrile symptoms are transient, and the papular affection usually disappears without difficulty under the use of purgatives, a simple and unirritating diet, antimonials, and an equable and dry air. In women, gonorrhoea is very rarely attended with the painful symptoms that accompany the disease in men. Indeed, in many instances there is so little un- easiness and pain experienced by females from this disease, that the discharge is • Observations on the Pathology of Venereal Gonorrhoea. GONORRHOEA. 783 often regarded as simple fluor albus. It is very remarkable, that gonorrhoeal in- flammation in females is exceedingly seldom, if ever, extended to the urethra. Swediaur asserts that he has "never seen a woman in whom the disease was seated in the urethra." The orifice of this canal, however, is generally more or less irritated, and in some instances it becomes so very sensible, that the urine in passing off gives rise to extremely severe pains. The seat of the disease is usually either in the clitoris, round the orifice of the urethra, and on the nymphae in the cavity of the vagina, or at the inferior commissure of the labia and rapha. (Swediaur.) Women affected with gonorrhoea, generally experience a disagreeable itching and titillation about the orifice of the vagina, and at the rapha. In severe cases, the labia, nymphae and clitoris become swollen and extremely tender; and there is generally a severe burning and stinging pain felt in voiding the urine. In vio- lent instances of the disease, there is a constant aching pain, experienced in the bladder, womb, groins and back; and the upper and inner surface of the thighs often becomes inflamed, excoriated, or covered with an inflamed pustular erup- tion, from the irritation occasioned by the gonorrhoeal discharge. In general, the mucous surface from which the gonorrhoeal matter proceeds, is entirely free from ulceration or excoriation. But this does not appear to be always the case, as was formerly asserted by writers; for, according to the ob- servations of Whately, irregular patches of excoriation, similar to those which appear on the prepuce and glans, sometimes occur on the lining membrance of the urethra. It must be observed, however, that excoriations or ulcers of the mucous membrane of the urethra in this affection, are by no means essential con- ditions of the disease. It should not be forgotten, that a purulent discharge from the urethra in men, and vagina in women, resembling in all respects genuine venereal gonorrhoea, may occur without any impure connection or infection, by a specific gonorrhoeal virus. A knowledge of this fact will sometimes enable the physician to allay the most painful suspicions, and to establish peace and confidence in families divided and distressed by the occurrence of such affections. Mr. Travers has made some very judicious observations on this subject.* An inflammatory action of the mucous membrane of the vagina, in whatever way it may be produced, will convert the vaginal mucus into a purulent or puriform fluid; and it seems to be well ascertained, that such a morbid vaginal secretion is capable at times, "of communicating the inflammatory irritation to other mucous surfaces either of the same or another individual." "It is well known," says Mr. Travers, " that a woman affected with inflammatory leucorrhcea sometimes communicates a discharge to her husband;" and the origin of purulent ophthalmia, in infants, from the same source, is equally well ascertained. Treatment.—Gonorrhea appears to have a natural tendency, if left to itself, to terminate spontaneously. At first, as has already been stated, the matter is thin, and communicates a greenish stain to the linen ; but as the inflammation gradually subsides, the discharge becomes thicker, cream-like, and less abundant; and if the general habit is not phlogistic or irritable, and the patient avoids the influence of stimulating causes, the secretion of the gonorrhoeal fluid often gradu- ally diminishes, until, in the course of six or eight weeks, it ceases entirely. There are few individuals, however, who are willing to delay the use of the remedial measures, or who are sufficiently prudent to abstain from stimulating ingesta and other causes calculated to keep'up the phlogistic habit of the system, to obtain such a favorable result; and in most instances, either from injudicious attempts to arrest the discharge, or from a general inflammatory and irritable diathesis, favored by stimulating diet and drink, the disease, if it is not subdued by an appropriate treatment, degenerates into a chronic urethral discharge, con- sisting of a milky fluid, usually called gleet. • Loc. citat. 784 GONORRHOEA. During the inflammatory stage of the complaint, it should be treated strictly as a local inflammatory affection, without any regard to the peculiar nature of the inflammation, or the attending muco-purulent discharge. In plethoric habits, particularly where the pulse is hard and active, blood should be freely drawn ; and the inflammatory state of the system must be reduced by the use of internal antiphlogistic remedies. For this purpose, the saline purgatives, nitre, and tartar- ized antimony, are the most useful remedies we possess. Dr. Carmichael is particularly partial to the use of the tartarized antimony, dissolved in a solution of sulphate of Magnesia ; and when given so as to keep up a slight degree of nausea, and procure four or five alvine evacuations during the day, this combi- nation is, in fact, a highly efficient remedy during the inflammatory period of this complaint.* Nitre and antimony dissolved in a large proportion of some mucilaginous fluid, such as a solution of gum Arabic, barley-water, or flax-seed tea, is in general very serviceable, as a means for lessening both the scalding of the urine, and the general and local inflammatory action.! In conjunction with these remedies, the patient should drink freely of some bland, mucilaginous fluid. For the relief of the painful erections and chordee, which usually harass the patient, particularly at night in bed, cold applications may be tried; but although occasionally beneficial, they frequently procure but very little relief.— Warm fomentations, or emollient cataplasms, are more frequently serviceable, in this respect, than cold applications to the part. Opium, given in full doses, is in general a very useful remedy for this purpose ; and its good effects are often considerably enhanced by giving it in union with camphor. From one to two grains of the former to eight or ten grains of camphor, taken an hour before going to bed, will generally prevent the occurrence of these painful affections during the night. Mr. B. Bell strongly recommends the use of camphor and hyoscyamus, as a means for alleviating the sufferings occasioned by chordee.—* These articles, he says, should be given in large doses. In general, half a drachm of the former, with a scruple of the latter, given in the course of twenty-four hours, will be found sufficient to allay this affection ; but in some instances, he gave it to twice this extent in the same period of time.J If bleeding takes place from the urethra, it ought not to be arrested, unless it becomes too copious, which very rarely happens. When it is desired to stop the hemorrhage, pressure made upon the urethra with the hand for twenty or twenty-five minutes, will almost always suffice to arrest it. Rest and a mild unirritating diet always contribute very materially to the reduction of the inflammatory symptoms. Much advan- tage may also be obtained from the application of warm fomentations to the penis, during the inflammatory stage of the complaint. Nothing is more common than the employment of astringent injections, almost as soon as the disease commences ; and although the discharge may sometimes be speedily arrested in this way, the consequences are often extremely injurious. " This practice," says Mr. Carmichael, " is attended with such risk of exciting inflammation of the entire urethra and bladder, and all the immediate, as well as the secondary train of evils attendant upon this calamity, that I have no hesitation in saying, that it is a practice that cannot be too strongly deprecated." As soon as the general and local inflammatory symptoms are in some degree reduced, and the discharge has become thick and more purulent, balsam copaiva, cubebs, or what are called the terebinthinate remedies, must be resorted to. Almost all writers agree in giving a preference to the balsam copaiva, as a re- medy in this affection; and when given in large doses, it will in fact, more frequently * R.—Sulphat. magnesias ^ii. Tart, antimonii grs. ii.—M. Take a tablespoonful every two or three hours. f R — G. Arab. giss. Nitrat. potassaa gi. Tart, antimonii gr. i. Infus. sem. lini. Jxvi. Of this a wineglassful may be taken every hour. X Edinb. Journal of Medical Science, No. 1, January 1826. GONORRHOEA. 785 put a stop to the disease than any other article we possess. To obtain the full advantages which it is capable of affording, it should be given in as large doses as the stomach will bear. The following is an excellent formula for administering this article.* Balsam copaiva may be safely and beneficially administered in this affection where the general habit is not very irritable or phlogistic, even though the local inflammation may still remain in an active state. I have often given it in the beginning of the disease, as soon as the bowels were freely evacuated by a saline cathartic, with complete success. Indeed, many eminent practitioners do not hesitate to administer it in large doses, soon after the commencement of the disease; and where the inflammation is not particularly violent, and the general arterial system does not sympathize with the local affection, it may be employed with advantage. Dr. Johnson ob- serves, that according to his experience, this article "may be safely administered in drachm doses, during the inflammatory stage of the disease, and with palpable success. Under such a treatment, incipient gonorrhoea has ceased in two or three days." Cubebs, also, are an excellent remedy in gonorrhoea. They are, however, much more stimulating than the preceding article, and must be given with more caution during the inflammatory stage of the disease. Mr. Jeffries states, that where cubebs are serviceable, they usually begin to manifest their beneficial in- fluence within forty-eight hours after the first dose ; and where no material re- lief is obtained in the course of five or six days, their further use will rarely be attended with advantage.! This remedy appears to be most apt to do good in relaxed and leucophlegmatic habits ; and in order to derive the full advantage which it is capable of affording, it should be given in large doses. From six to eight drachms of the powdered cubebs may be given in the course of twenty-four hours, where the inflammatory action of the affected parts has been previously considerably reduced. The tincture is an excellent mode of administering the cubebs. I usually direct a large teaspoonful of it every four hours. Much more commonly, however, I have given it in combination with balsam copaiva, accord- ing to the following formula.*. In cases entirely free from general irritation, and inclining to a chronic charac- ter, I have often united the balsam copaiva, cubebs, and spirits of turpentine, with peculiar advantage ; and in gleet, I know of no remedy which so frequently suc- ceeds in making a decidedly favorable impression on the disease as the tincture of cubebs in union with the spirits of turpentine, in the proportion of two parts of the former to one of the latter, given in teaspoonful doses, three or four times daily.§ * R.—Bals. copaiv. gi. Spir. nit. dulc. 33s. Tinct. opii, Spirit, camphorse, aa £i.—M. Of this a teaspoonful should be taken four times daily. f Practical Observations on the Use of Cubebs in the Cure of Gonorrhoea, p. 18. X R.—Bals. copaiv. Tinct. cubeba?, aa. ^i. Spir. nit. dulc. ^ss. Tinct. opii. %i. Sacch. alb. %\. P. g. Arab. gi. Aq. fontanie 3 vTiii.—M. Take a tablespoonful three or four times daily. § My friend Dr. Dodil, of the United States navy, has informed me that he has employed the extract of cicuta with great success in gonorrhoea. He avers that in the very considerable num- ber of instances in which he prescribed this article, it generally removed the disease completely in three or four days, and not unfrequently sooner; but "under very unfavorable circumstances, the cure was not effected under eight or ten days." He employs it as follows: R.—Extract cicutaa £i; G. opii grs. x.—M. Divid. in pil. No. xv. Two of which are to be taken every two hours, and continued until vertigo and a disagreeable sense of fullness in the head are experi- 50 786 GONORRHOEA. It is proper to observe, that the use of medicines of this kind ought always to be continued for four or five days after the discharge has been arrested by them ; for when they are discontinued as soon as the running ceases, it very frequently returns in the course of five or six days; and when this happens, we rarely find the medicine to produce the same beneficial effect as it did in the first instances. Many of the obstinate cases I have met with were relapses of this kind, after the discharge had been suspended by the use of terebinthinate remedies. When, notwithstanding the free employment of the medicines of this kind, the discharge continues, recourse should be had to astringent injections. Under judicious management, and after the inflammatory stage has passed off, local astringent applications may be used without the least risk of injury, and very generally with speedy success. A great variety of articles have been recom- mended for this purpose; but in general the sulphate of zinc will prove more promptly beneficial than any other astringent we possess. The injection should at first be weak—not above a grain and a half of this article to an ounce of water—but in proportion as the disease assumes a chronic character, the quantity of the zinc should be increased to eight and even ten grains to the ounce. It is a very common practice to unite the sulphate of zinc and acetate of lead in injec- tions for this complaint; but it has never appeared to me that any peculiar advan- tages are to be derived from such a combination. It must, nevertheless, be ob- served, that there occurs much diversity in different cases, with regard to the utility of different astringent injections. We sometimes find a variety of injec- tions wholly ineffectual in this complaint, when at last some particular combination or article will speedily put a stop to the discharge. This, no doubt, generally depends on the peculiar grade of the irritation of the mucous membrane of the urethra. In the atonic stage of the disease, I have often employed the diluted sulphuric acid with success, after the zinc and other articles of a similar character had failed to arrest the disease. A drop or a drop and a half of the oil of vitriol to an ounce of water, forms an injection of the proper strength. The sulphate of copper, too, may be advantageously used for this purpose. Two grains of this article to an ounce of water form an injection of the medium strength; but it will, in general, be better to commence with a grain to the ounce, and to in- crease it to three or four grains afterwards, according as the disease assumes a chronic character. In some instances the nitrate of silver, in the proportion of two grains to an ounce of water, will succeed very speedily; and in gleet or atonic gonorrhoea, the proportion of the silver may be increased to three or four grains to the ounce.* I have in a few instances of very obstinate gonorrhoea, succeeded with an injection prepared from the balsam copaiva in the following manner. Two drachms of the balsam are to be triturated in a mortar with a drachm of carbonate of magnesia. After they have been rubbed together, eight ounces of warm water must be added, and well mixed with the magnesia and enced. His object is to put the system under the narcotic influence of the cicuta, and to sustain this influence until the discharge ceases, which seldom requires more than two or three days. Dr. Edward Graffe, of Berlin, has employed the chloride of lime with much success in gonor- rhoea. When there is much burning in the urethra and chordee, he directs a tablespoonful every two hours of a solution of one drachm of the nitrate of potass in eight ounces of almond emulsion. When by this remedy the burning and chordee are considerably allayed, he orders a tablespoonful of the following mixture every three hours: R.—Chloride of lime gi; Almond emulsion gviii; Mucilage g. Arab. 3L In general, after three or four doses of this'mixture are taken, the patient experiences painful erections, burning in the course of the urethra, and pain in voiding urine. All these symptoms, however, usually abate in the course of two or three days; and by the time that they are entirely removed, the gonorrhceal discharge also ceases. The cure is thus generally effected in the course of five or six days.—Journal fur Chirurgie und Augenheilkunde, bd. xiv. s. 9.—Amer. Journ. Med. Sciences, vol. viii. p. 240. * [The alterative plan of treatment is now frequently adopted by surgeons. It consists in applying the solid caustic by means of the porte caustique; or in throwing up a strong solution by means of a glass syringe. This is a mere revival of Hunter's plan of cure by exciting a new action or counter-irritation. It is also accomplished by giving large quantities of cubebs in table- spoonful doses three or four times a-day.—Mc] GONORRHOEA. 787 • i 1 tv i--- ".jv^«wii mi guiiunnuja, auer wie innammation has sided. Dissolve some sulphate of copper in a sufficient quantity of water • p cipitate the solution with lixivium of tartar; suffer it to separate, then pour off the clear liquor. Wash the precipitate until the water becomes insipid; then make a saturated solution of carbonate of ammonia in water, and mix as much of the precipitate with the filtered solution of the ammonia as will dissolve, which reserve for use. Six drops of this ammoniated copper to an ounce of water, form an injection of the proper strength. Six or eight years ago, I used this injection in various instances, and generally with benefit. In obstinate cases of gleet, the long-continued use of the tincture of cantharides, in conjunction with astringent injections, particularly a solution of the nitrate of silver, will sometimes succeed better than any other remedy. The cantharides should be given in gradually increasing doses, commencing with about thirty drops three times daily, until symptoms of strangury ensue, when it must be dis- continued, and resumed after the ardor urinae has disappeared. I have often succeeded with the internal use of the spirits of turpentine, in conjunction with injections ; but this article is much more offensive to the stomach than the can- tharides, and patients will seldom continue it a sufficient length of time to obtain the full advantages which it is capable of affording. The direct application of astringent and exciting applications by means of a bougie, will sometimes succeed, after all other remedies have failed. I have in several instances removed the disease by introducing a bougie, upon which some citrine ointment was smeared; and in one very obstinate and protracted case, I lately succeeded in effecting a cure, by applying in this manner the lunar caustic rubbed up with lard. Twenty grains of the caustic may be triturated with half an ounce of lard, as an applica- tion for this purpose. A gleety discharge is, however, very frequently dependent on the irritation of stricture of the urethra ; and when this is the case, nothing but the removal of the stricture by the judicious employment of bougies will effect a cure. Whenever a thin milky discharge continues obstinately after the use of the foregoing means, we may suspect the existence of stricture; and on being consulted for aid in a long-standing case of this kind, it is always proper, before any remedial measures are adopted, to make the proper examination, in order to ascertain the state of the urethra in this respect. It may be proper again to say, that where there is much irritability or active inflammation of the urethra present, all astringent or irritating injections are highly improper. When used under circumstances of this kind, they are apt to give rise to various distressing affections—particularly to obstinate chordee, inflamma- tion of the body of the penis, of the neck of the bladder, and of the testes, and to strictures in the urethra. In relation to the formation of strictures, however, Mr. Carmichael makes the following observations, which are entirely accordant with my own views. "Strictures," he says, "are more generally attributed to the use of injections than any other attendant of gonorrhoea; but I have so often witnessed their occurrence where injections have never been used, that I am more inclined to ascribe these affections to the irritation of gonorrhoea than to any other cause. The sooner such irritation is removed, the more likely is the patient to avoid those unpleasant visitations which are far more to be dreaded than the original disease. I have, therefore, no hesitation in putting as speedy a stop to the discharge as I can, by the use of astringent injections, if the internal remedies mentioned disappoint my expectations." The observations made above in relation to the propriety of continuing the internal terebinthinate remedies for several days after the disappearance of gonor- rhoeal discharge, are entirely applicable also to the employment of injections. In using injections care should be taken to prevent the passage of the fluid into the neck of the bladder, which may be readily done by making pressure over the 788 SYPHILIS. posterior part of the urethra, near the margin of the anus, at the time of using the syringe. The secondary symptoms of gonorrhoea do not, in general, require any very active treatment.* An attention to cleanliness, with the use of the ordinary dia- phoretic alterative ptisans, such as infusion of sarsaparilla, in conjunction with a mild mercurial course, the occasional use of the warm bath, and proper dietetic regulations, rarely fail to remove all these secondary affections. In relation to the employment of mercury, however, much discrepancy of opinion has been expressed by writers on this subject. My own experience is decidedly in favor of gentle mercurialization in these affections. It is, indeed, not at all improbable, that all the secondary consequences of gonorrhoea may be cured without this po- tent medicine ; but many of the most experienced physicians of the present day believe that the gentle action of mercury very considerably expedites the radical removal of these affections. Mr. Travers, among other late writers, speaks de- cidedly in favor of mercurial remedies in cases of this kind. " The disadvantage," he says, "of slowness in the cure, and a continual tendency of the disease to relapse, or reappear in a new form, long since compelled me to abandon, as a general principle, that of treating these cases without mercury." The sarsapa- rilla should always be employed conjointly with the mercurials. In mild cases, Mr. Travers gives the compound decoction of sarsaparilla, " with free doses of the diluted nitric acid, with or without an equal portion of the tincture of hen- bane," and omits the mercurial remedies. Small doses of blue pill, with mode- rate doses of Dover's powder, form an excellent combination where there is much irritability present. I have, more generally, however, resorted to minute doses of corrosive sublimate, in union with the extract of conium, or opium, as recom- mended by Mr. Travers. This combination seems to be particularly useful where there is much disease in the fauces. In cases attended with much constitutional debility, Mr. Travers uses the hydrarg. cum creta with a small portion of rhu- barb, or of Dover's powder. Sect. II.—Syphilis. The origin of syphilitic diseases is still involved in much obscurity. The general opinion of its having been introduced into Europe from South America, by the sailors who accompanied Columbus, admits of a great deal of doubt. Dr. Thomson, who has investigated this subject with much learning and discrimina- tion, observes, that it " is extremely improbable that sailors, after a long and suc- cessful voyage, landing on the northern coast of Spain, objects of curiosity, ready to embark again to reap the fruits of their discoveries, and the wealth the new countries were supposed to abound with, should have been sent off to act as soldiers at the siege of Naples, laboring under a new and horrid disease, which must have been of some months' duration, and have incapacitated them for every kind of exertion. That neither Columbus himself, nor his brother, who left such accurate narratives of his voyage, should make the least mention of such disease being discovered among the natives, or prevailing among the crews of their ves- sels, is certainly still more difficult to be reconciled with reason, and affords strong presumption of error."t He thinks it probable that the disease has existed more * [Authors have differed in their opinions respecting the occurrence of secondary symptoms after gonorrhoea. Many have spoken of the cotemporaneous and subsequent occurrence of a troublesome species of rheumatism which is called " gonorrhceal rheumatism," and most appear to believe in the papular form of venereal disease of Carmichael, which he ascribes as a se- condary consequence to gonorrhoea. But the great authority of Ricord is decisively against the possibility of any secondary constitutional form of this disease. He attributes the supposed secondary eruptions, in all cases of gonorrhoea, to internal or concealed chancres, " chancres lar- vees."—Mc] f Medico-Chirurg. Review, December 1821, p. 617, SYPHILIS. 789 or less, and under different grades of severity in all ages, and that "it has been thousands of times generated de novo by impure sexual intercourse." The cir- cumstance which especially attracted the attention of physicians to the disease, about the period of its supposed importation into Europe, was probably its hav- ing assumed, at that time, an extraordinary degree of violence; for it is very evident, from the records of medicine, that the disease has varied very much since the first accounts that were given of its phenomena and character; and it is certainly very far from possessing the terrible severity now which it manifested during a long period after it was particularly noticed. It is not improbable, too, that the connection between primary ulcers on the genitals, and what we now call the secondary constitutional symptoms, was overlooked by the ancients: for as the former would very generally heal before the latter could make their ap- pearance, and more especially as these constitutional affections were free from the power of infecting the healthy, they might very readily have been regarded as distinct diseases, wholly independent of primary sores on the organs of gene- ration. Besides, although ulcers were abundantly noticed and described on these parts, their origin from impure venereal intercourse may have escaped detection. It is certain, at least, that Celsus describes various species of ulcers on the geni- tals; and it appears to me difficult to read his sections De cancro qui in cole nascitur; De phagedena in cole nascente; and De carbunculo qui in cole nas- citur, without being impressed with the conviction, that he had reference to the various species of sores now known under the name of syphilitic cancer. The opinion that syphilis is an ancient disease, but that it has been subject to various modifications from the influence of some occult cause in different ages, is strongly illustrated by the following account of the " new syphilitic disease which has lately appeared in Canada," in the last edition of Swediaur's valuable work on syphilis. " A new disease," says the writer, " broke out some time ago in Canada, especially in St. Paul's Bay. This disease has made rapid progress within these few years among the inhabitants of Canada. The parents transmit it to their children. It is communicated by eating, drinking, &c. If it once enters a family, rarely any one escapes catching it. Some habits seem to absorb the virus, and then sometimes it remains concealed or dormant for years, and then breaks out, at last, with all the symptoms of the third stage. The patients, often dragging out a miserable existence to old age, lose, by degrees, eyes, nose, cheeks, velum pendulum, and the whole basis of the skull, &c. They call it mal Anglois, (the English disease,) because they think the English brought it first among them." This accords with the violent and exceedingly contagious character which syphilis is said to have had during the first century of its ravages in Europe. It was communicated " by lying in the same bed, by the clothes, gloves, or money of the patient;" and even the breath was thought to be sufficient to communicate the disease ; for it is stated that Cardinal Wolsey was indicted " for whispering in the king's ear while supposed to be laboring under the venereal disease." (Thomson, loc. cit.) Finally, it must be observed, that some of the earliest writers did not consider this affection in Europe as of trans- atlantic origin. Fracastorius ascribed it " to the different constitutions of heaven and stars, which but seldom happen, but may effect great matters when they do coincide ;"* and he, as well as others, believed that it was one of those diseases which rise, cease, and again return, at long intervals of ages.t But although inquiries into the origin of the disease are highly interesting, and not altogether useless, the immediate scope of this work does not admit of an ex- * Aphrodisiac, p. 202, as quoted by Van Swieten. •j- Quam tamen (reternum quoniam dilabitur sevum), Non semel in terris visam, sed scppe fuisse, Ducendam est: quanquam nobis nee nomine nota Hactenus ilia fuit: quoniam longaeva vestustas Cuncta situ involvens et res, et nomina delet; Nee monumenta patrum seri videre nepotes. 790 SYPHILIS. tended discussion on this point, and I proceed, therefore, to the more practical details of the phenomena and modes of remedial management of this malady. Syphilis, when suffered to proceed in its course, passes through two distinct stages or series of the phenomena; the first, or primary, which is altogether local;—and the second, or constitutional, in which the system generally becomes implicated in the disease. Primary ulcers, or chancres.—At an uncertain period, varying from a few days to several weeks after an impure venereal intercourse, one or more small pimples, excoriations, or ulcers, preceded, usually, with an itching in the part, appear on some part of the genital organs, most commonly on the internal surface of the prepuce, the corona glandis, the glans, or on the fraenum, and occasionally on the external surface of the prepuce, skin of the penis, scrotum or thighs in men ; and in females, on the internal or external surface of the labia pudendi, on the clitoris, the nymphae, in the vagina, or on the thighs. Authors have of late years distinguished with great minuteness the primary venereal ulcers; and some have arranged them under distinct heads, ascribing to them specific differences, with the view, principally, of establishing certain indications in relation to the propriety of administering or withholding mercurial remedies for the prevention and cure of the secondary constitutional symptoms which may ensue. That there are divers local affections of this kind, is unques- tionable. The observations of Hunter have long ago established this fact very conclusively ; but it may be greatly doubted, whether the classifications and hair- splitting distinctions which have been announced as absolute and essential dif- ferences in the various ulcers of this kind, are entitled to our confidence, at least to the full extent to which they have been carried by some writers. Carmichael asserts, that there is but one of the four classes of the primary ulcers he describes —namely, the indurated and excavated chancre of Hunter—that is capable of giving rise to the true secondary symptoms of lues. This assertion, however, is by no means established on incontrovertible observations ; for it may be affirmed, on the authority of competent testimony, that constitutional symptoms, differing in no material point from those which are regarded as truly syphilitic, may arise from various primary venereal sores, distinct from the excavated and indurated chancre. One thing, at least, is certain, that it is often extremely difficult, and sometimes impossible, to determine, from the appearance of the chancre, to which of the species usually described, it may belong; for in their external characters they sometimes pass into each other so insensibly—and the varieties of appear- ance met with in practice are so multifarious, that it will often baffle all our at- tempts to form a satisfactory diagnosis on this point. Even the unquestionable syphilitic chancre, so accurately described by Hunter, is liable to be confounded with other venereal sores, from these latter occasionally assuming the appearance of the excavated and indolent chancre.* Dr. Hennen, whose opportunities for carefully observing these affections were very extensive, confesses his inability to point out " any invariable characteristic symptoms, by which to discriminate the real nature of the primary sore." " It would," he observes, " be by no means difficult to show, that the high round edge, the excavated sore, the preceding pimple, the loss of substance, the hardened base and edge, whether circumscribed or diffused, and the tenaciously adhesive discharge of a very fetid odor, are all observable in certain states and varieties of sores unconnected with venereal * [The experiments of Ricord, in Paris, have done more in the way of elucidating this sub- ject than all former experience. He inoculates his hospital patients with the matter of all sus- pected sores, and produces a small pimple from the re^l virus, which can always be cured without any danger of being followed by secondary symptoms during the first eight days, by the application of solid caustic followed by a dressing of lint, dipped in aromatic wine. After eight days, the pustule or ulcer begins to show an indurated base or edge, and then there is danger of the occurrence of secondary symptoms. If allowed to progress, it afterwards assumes the cha- racteristic appearance of true chancre, according to Hunter. After the period of induration, Ricord employs mercurials both topically and internally.—Mc] SYPHILIS. 791 origin. The hardened edge and base, particularly, can be produced artificially, by the application of escharotics to the glans penis of a sound person ; and if any ulceration or warty excrescence previously exists on these parts, this effect is still more easily produced."* Indeed, when we take into consideration the variety of textures which compose the parts upon which these primary sores occur, the diversity which exists in individual constitutions, and the various influences which are continually modifying the general habit of the body, we can readily conceive that sores, even from the same virus, must be liable to very dif- ferent aspects in different individuals. In making these remarks, I would by no means wish to be understood as re- garding all distinctions of this kind as unfounded or nugatory; but to attempt to classify these primary venereal sores as fixed and essential diversities, merely from their external characters, and to propose them as indications for the em- ployment or rejection of particular remedies, appears to me obnoxious to very serious objections.! In relation to the diversities which occur in the primary as well as the second- ary venereal affections, it must, in the first place, be observed that there are two distinct classes of these maladies, namely: 1. Genuine lues or syphilis, for the cure of which mercury is indispensable; and 2. Venereal affections, oflen closely resembling, though differing essentially from the former, and which may, in general, be cured without mercury. I. The true syphilitic chancre is thus described by Mr. Hunter:—" The sore is somewhat of a circular form, excavated, without granulations, with matter ad- hering to the surface, and with a thickened edge and base. This hardness and thickening is very circumscribed ; not diffusing itself gradually and imperceptibly into the surrounding parts, but terminating rather abruptly." When examined, by pressing the chancre between the fingers, it will be found that the whole ex- cavated surface of the ulcer is surrounded by a hard or indurated basis. In some instances, a small indolent ulcer is seated, as it were, in an indurated knob on the glands ; and occasionally indurated tubercles passing deep beneath the surface, with scarcely any visible ulceration, will be followed by constitutional symptoms of syphilis—but in cases of this kind, " we will probably learn, a small ulcer existed at first on the callous part, which healed under the use of some local ap- plication." (Carmichael.) When the syphilitic chancre is situated on the body of the penis, it presents a dark livid color, without being scooped out or excavated, and the surrounding parts are less indurated than when it occurs on the glans penis. True syphilitic chancre is always of an indolent character—very slow in its progress. The excavated and circumscribed state of the ulcer, its indurated edges and base, and its slow progress, constitute the characteristic marks of the syphilitic chancre : but it must not be forgotten, that almost any sore situated on the glans penis is apt to acquire a more or less indurated condition from being frequently irritated by improper applications; and hence, in forming a diagnosis, we should always take into consideration the previous management of the ulcer." (Carmichael.) The constitutional symptoms which proceed from the true syphilitic chancre, appear first upon the skin, the throat and mouth ; and finally upon the periosteum, bones, and deep-seated parts. The true syphilitic eruptions appear in distinct circular patches, from a few lines to half an inch in diameter. They are slightly raised, and covered with thin, whitish, hard scales, easily separated, leaving smooth, shining, copper-colored spots, somewhat elevated above the surrounding skin. In some instances a small white band encircles the base of each disk; and occasionally several of the spots unite, forming large irregular copper-colored * Principles of Military Surgery, &c, p. 517. t " It is not," says Swediaur, " by the external characters alone that we can discover the nature, and distinguish the different kinds of ulcers alluded to; to inspection and practical knowledge, we must join a profound acquaintance with the diseases, an attentive examination into the actual state of the patient, his constitution, and the remedies and regimen which he has adopted." 792 SYPHILIS. patches, with portions of scales adhering to them. These scaly copper-colored spots are sometimes in a great measure confined to the forehead, neck, breast, forearms, legs, and anterior part of the abdomen. Syphilitic eruptions occasion- ally appear in the palms of the hands and soles of the feet, presenting a very peculiar aspect—namely, masses of dry friable scales, very easily removed, and exposing spots of a livid color, with an indurated state of the skin and subjacent structure. When the syphilitic patches are situated on parts opposed by another skin— as between the nates, under the arms, between the thighs and scrotum, &c, they do not present a dry and scaly appearance ; but an elevated, soft, moist, and flat surface, discharging a thin whitish matter. Sometimes the upper part of the extremities of the fingers and toes become affected, and the nails are gradually separated. If the disease is not opposed by the employment of mercury, "every succeed- ing scurf which is formed becomes thicker than the preceding, till at length it forms a crust, under which matter collects, and it becomes a true ulcer." These ulcerations spread very slowly. After the eruption has made more or less progress, the throat also becomes ulcerated, generally about the tonsils and soft palate. These ulcerations are not preceded by much inflammation or swelling, and the tonsils exhibit ulcerated cavi- ties with well-defined edges, similar to the primary syphilitic ulcers on the glans penis. As the disease proceeds, the periosteum, the fasciae, ligaments and bones become affected ; and of the bones those nearest the surface, as the cranium, cla- vicle and sternum, are most liable to become the seat of its destructive ravages. " The true syphilitic node is a solid enlargement of the bone," unaccompanied, during the earlier periods of its progress, by any discoloration of the skin, nor is there much pain, until it has arrived at a considerably advanced state. II. Of the non-syphilitic venereal sores, and in which mercurial remedies are, in general, unnecessary, and often injurious, the following are the principal va- rieties:— 1. Vcnerola vulgaris*—or the simple primary venereal ulcer of Carmichael. This is by far the most common variety of venereal ulcerations. The simple venereal ulcer commences from three to seven or eight days after the impure sexual connection, by an itching or redness, which is speedily succeeded by a small pustule surrounded with a red margin. In a few days the pustule becomes converted into a thin crust, under which more or less matter collects, and gives rise to considerable pain. The scab gradually enlarges, and acquires a triangular or circular shape, varying in color from yellow to dark brown. This scab soon separates, and exposes an excavated, round, or oval ulcer, with a glossy reddish or dirty yellow color, surrounded by a narrow red areola. The bottom of the sore now begins to fill up; it rises above the level of the surrounding parts, and exhibits a smooth surface, seated on a fungoid basis, without granulations, and of the color of a healthy sore, the base and edge being usually a darker red than the disk of the sore. Between the fourteenth and fifteenth days, the ulcer generally has risen to its greatest height; but the process of ulceration, as well as the sur- rounding efflorescence, generally ceases as soon as the fungoid stage commences. In some instances, the top of the elevated sore extends beyond its base over the surrounding sound skin, giving it the appearance as if a ligature were tied about it beneath the surface. In this state the sore remains stationary for some time, and then' gradually and usually slowly declines and heals, the average period of the commencement to the termination of the ulcer occupying from four to six weeks. " Wherever may be the seat of these ulcers, on the inner part of the prepuce, their characters are seldom doubtful after the ninth day ; for by draw- ing the skin well back, and making allowance for the form of the parts, the raised * Pathological and Practical Remarks on Ulcerations of the Genital Organs. By James Evans, Surgeon, &c. &c. SYPHILIS. 793 edge and surface cannot escape discovery; for although these may not be plainly discernible all around, they will be so on some one side." (Evans.) These ulcers are particularly apt to excite phimosis, and are frequently accompanied with patchy excoriations on the glans and prepuce, and occasionally with a profuse gonorrhceal discharge. The causes of venerola vulgaris consist of gonorrhoeal matter and of other morbid vaginal secretions communicated by the sexual intercourse. With this variety of venereal ulcerations we may place the "patchy excoriations" already mentioned, for they proceed from the same cause, and may exist either conjointly or separately. Secondary or constitutional symptoms sometimes succeed or attend this va- riety of primary venereal ulcers ; but these are always mild, and readily disap- pear under mild aperient and diaphoretic treatment. These symptoms consist in slight febrile excitement, attended with headache, and aching pains in the joints, and occasionally also in the chest, succeeded by a papular eruption on the fore- head, chest, and back, and scattered more thinly over the extremities. Fresh crops of these papulae appear, at the same time that the slight febrile irritation and nocturnal pains in some of the joints continue. "The papulae vary from a pale red to a deep crimson color," some of them preserving the character of pimples, whilst others are more of a pustular form. They may appear from five weeks to three or four months after the infection. When they are about declin- ing, they become paler, and often assume a copper tint, " while the exfoliation of the cuticle gives them an appearance of scaliness"—a state in which they may be confounded with the scaly eruption of true syphilis. "But they may be readily distinguished from each other; for when the papular eruption is on the decline, and has assumed a pale-red or copper color, on examining the patient we shall find other spots in their papular or pustular form, which will at once point out the character of the eruption." (Carmichael.) The fauces generally become affected, but not with excavated or spreading ulcers. The patient complains of soreness on swallowing; and on looking into the fauces, the entire cavity exhibits a red and cedematous appearance, with swollen tonsils. 2. Venerola superflcialis of Mr. Evans, or the primary ulcer of the pustular syphilitic eruptions of Carmichael.—This variety begins with a small pustule, which soon breaks, and forms a crust, under which the cuticle ulcerates in a cir- cular or oval form. When the crust separates, it exposes an ulcer of a reddish- brown surface, on a level with, or somewhat elevated above, the surrounding skin, with raised and well defined edges. It is free from marginal or sur- rounding induration, of a granulated appearance, and seldom attended with con- siderable pain. It varies from the size of a pea to that of a shilling; but when neglected or improperly managed, it sometimes increases to a much greater extent. It occurs most frequently on the external surface of the prepuce and body of the penis, and is sometimes met with on the anterior aspect of the scrotum. In some instances this variety of ulcer surrounds the orifice of the prepuce, and occa- sions, when the ulcer heals, a permanent phimosis. It is generally tedious in its progress, and does not manifest any tendency to spread. This ulcer has not the smooth fungous appearance of the former variety, and is strictly defined in its circumference. Venerola superficialis, when left to itself, is almost invariably followed by constitutional symptoms. These consist usually of a pustular eruption coming out in succession, and terminating speedily in scabs and super- ficial sores, so that " at the same time, on the same individual, there will appear some new formed pustules, and others in their scabbing stage, with an inter- mixture of small ulcers, whose crusts have fallen off, and of discolored patches of the skin, where they have healed." Considerable inflammation and ulcera- tion of the tonsils and pharynx, attended with pains resembling acute rheuma- tism, are particularly apt to follow this variety of primary ulcer. Mr. Evans asserts that he never met with an instance that was not followed by secondary 794 SYPHILIS. symptoms. Mr. Carmichael thinks that this variety of venereal disease forms " the natural link between the simple ulcer and its consequences, and the pha- gedenic venereal disease." 3. Venerola indurata, or the indurated sloughing primary ulcer.—This variety of venereal ulcer is characterized by great derangement of the general health, much inflammation of the part, local pain, a strong tendency to sloughing or destruction of the parts, and by a cartilaginous induration of the base, unless seated on the glans. The situation of this sore is frequently at the duplication of the prepuce behind the corona glandis, in which case the ulcer generally bur- rows deep between the skin and the body of the penis. When it is situated on the internal surface of the prepuce, which is very common, the peculiar hardness of the base is very remarkable; and the surface of the sore, whether seated on the prepuce or glans, presents a dark liver-colored slough, " which falls off, and is succeeded rapidly by other sloughs, destroying the parts rather in depth than in breadth." (Bacot.)* When the general and local inflammatory action is very severe, mortification to a greater or less extent is by no means uncommon. Mr. Evans says, that he has "known gangrene to take place as early as twenty-four hours after the appearance of the disease, and in less than seventy-two hours after the venereal connection. When these sores heal, they are apt to leave in- durated spots, which are peculiarly disposed to ulcerate again from irritation, or want of cleanliness." (Evans.) This variety of sloughing ulcer is distinguished from the phagedenic ulcer by the presence of the indurated base. The constitu- tional symptoms commonly show themselves at a very early period, even before the active progress of the ulcer is completely arrested, and do not differ material- ly from those which succeed the next variety—namely: 4. The phagedenic primary ulcer of Carmichael.—This ulcer exhibits an irregular, corroded appearance, without granulations and surrounding indurations. It sometimes spreads rapidly, and causes extensive destruction of the parts in a few days. Sometimes it "creeps on slowly, healing in one part and making progress in another." The internal use of mercury very generally renders its course more rapid and destructive. It is usually seated on the glans near the pre- puce, which " it often entirely consumes, and continuing its depredations on the corona and glans, at last effects their total destruction. When this event takes place, the ulceration usually receives a sudden and permanent check; but in some instances, profuse hemorrhage occurs before the glans is entirely destroyed, in which case a favorable change usually takes place in the ulcer. Occasion- ally, though indeed rarely, the disease slowly proceeds until the whole penis is destroyed." (Carmichael.) It is highly probable, as Dr. Emerson observes,t that the last two varieties of venereal ulcer owe their characteristic phenomena " more to circumstances of climate, constitution, and habits of the patient, than to a peculiar or distinct specific virus." Of this, indeed, I do not in the least doubt. " A southern climate predisposes most to these forms of primary syphilis, which are compa- ratively rare in the more northern and temperate latitudes. In the south of Europe, the predisposing causes seem to be far more active, and particularly so in their operation upon northern visitors. The crews of our men-of-war "and merchantmen have occasionally suffered very much from this form of syphilis in the Mediterranean, especially on their visits to the Italian and Spanish ports." Persons of a scorbutic and irritable habit—and especially those whose constitu- tions have been impaired by breathing an unwholesome atmosphere, or by a spare and unwholesome diet, or finally, by long residences in hot climates, are most liable to the sloughing and phagedenic varieties of venereal ulcerations. (Evans, loc. cit., 109.) * Observations on Syphilis, principally with reference to the use of Mercury in that Disease. By John Bacot, Member of the Royal College of Surgeons, &c. f See his edition of Carmichael's work on Venereal Diseases. Philadelphia, 1825, p. 164. SYPHILIS. 795 According to Carmichael, the secondary constitutional symptoms of the last two varieties of primary ulcer are: tubercles, pustules, or spots of a pustular tendency—degenerating quickly into ulcers, with thick scabs, healing usually from the centre, while the ulceration spreads along the circumference. Strong fever often ushers in this eruption; but in many cases a general feeling of indis- position, of listlessness, pallid countenance, languid eye, and broken rest, precede for several days the appearance of the eruption, unaccompanied by distinct febrile movements. In other instances, "nocturnal headaches, tenderness of the scalp, slight dyspnoea, with soreness of the sternum and of the breast, generally occur previous to the appearance of the constitutional symptoms." Phagedenic ulcera- tions in the throat, tending to destroy the pharynx; the spongy bones of the nose; soft palate and tonsils; severe and obstinate pains in the joints—particu- larly of the knees and wrists ; and obstinate enlargement of the testes, are among the most common constitutional affections from primary ulcers of this kind. When the ulcers in the throat extend into the larynx, which is not very uncom- mon, " there is but little chance of saving the patient's life." This occurrence is announced by "a whispering, stridulous voice, constant cough, and copious expectoration of viscid matter; restlessness, great anxiety of countenance, ema- ciation, night sweats, rapid pulse, and all the concomitants of phthisis." Treatment.—In perusing the various writers of acknowledged authority on this subject, it would seem almost impossible to come to any satisfactory con- clusion as to the proper mode of treating both the local and general symptoms of this malady. All indeed agree, that in genuine syphilis, mercury is indispensable to the removal of the disease; but this forms but a small portion of the great number of venereal cases met with in practice, and it is moreover admitted, and very justly, too, that it is frequently almost impossible to determine, from the external character of the disease, whether it be true lues, or only one of the various venereal affections which have been described. Some writers condemn the use of mercury, without exception, in the various non-syphilitic venereal affections; others admit its utility in certain varieties and under certain conditions, but they disagree among each other as to the particular varieties and circumstances which call for its employment. Others, again, less scrupulous in the use of mercury, affirm that, with very few exceptions, and under cautious management, it may be used not only safely but very beneficially, in almost every variety of primary and secondary venereal affections. The result of all this disparity of opinion would seem to be that there is " a proper medium," in relation to the employment of mercury in affections of this kind ; and that the entire rejection of its aid is just as apt to lead to disastrous consequences, as its indiscriminate and universal employment. Mr. Bacot ob- serves, that " with the exception of the sloughing and phagedenic venereal sores, the exhibition of mercury, in the majority of primary ulcers, is so safe and so generally beneficial, that where a sore of this kind continues for a certain time to pursue its course, and to resist all those mild methods of cure, both external and internal, which influence the progress of sores in other parts, I should not hesi- tate to have recourse to its exhibition." In reference to the late discussions concerning the non-mercurial treatment of venereal affections, this experienced writer makes the following observations, to the correctness of which I am entirely disposed to subscribe. " It is assumed, therefore, as an established fact, that all ulcers upon the parts of generation are curable without the use of mercury; but I cannot concede that, generally speaking, they are cured with equal celerity: they require more strict confinement; more attention to the state of the general health and to regimen, than is found necessary under a mercurial treatment care- fully conducted ; and in some instances, the length of time requisite for their complete cicatrization is alone a serious evil. It may also be added, that under the non-mercurial treatment, they frequently heal with hardened and elevated cicatrices." It must be admitted, moreover, that a much greater proportion of cases are followed by constitutional symptoms, when the primary stage is treated 796 SYPHILIS. without mercury, than where a cautious exhibition of this mineral is resorted to. "From these circumstances, therefore," says Mr. Bacot, "I would advocate the moderate and gentle use of mercury in all those cases of primary sore, where a mild mode of local and general treatment is productive of no beneficial change in the course of a reasonable period; at the same time being perfectly prepared to do without it in all those cases and in those constitutions where its employment appears to be pernicious, being convinced that it is both much wiser and more safe to postpone the exhibition of this remedy where the habit is irritable, and it appears to operate upon the system as a poison only, calling into action that peculiar and anomalous class of symptoms usually called cachexia syphiloida." (Loc. cit., p. 35.) Mr. Hennen observes: "In every primary ulcer, I would give up the idea of using mercury at first, treating it as if it were a simple ulceration, by cleanliness, rest, and abstinence, and applying to it the most simple and mildest dressings. If the sore did not put on a healing appearance in a reasonable time, the extent of which must depend on the circumstances of the patient, I should make use of more active dressings. But if beyond all calculation it remained open, I should certainly sacrifice every dislike to mercury, knowing how many persons have been seriously benefited by a judicious and mild administration of that remedy." These sentiments appear to me unexceptionable, as general precepts, and I have for five or six years uniformly treated the cases that have come under my care in conformity with them. It will be proper, however, to give a more particular detail of the management of the various primary ulcers. The simple venereal ulcer—venerola vulgaris, usually runs its course in spite of remedial applica- tions; and where the irritation is not,considerable, nothing but the lightest emol- lient dressings are necessary, so long as the scab has not separated and exposed the fungoid and raised surface of the ulcer. Warm emollient poultices should be applied until the crust comes away, when the ulcer is on the external part of the penis ; when the ulcer is seated on the inner surface of the prepuce, a piece of linen kept constantly moist with a weak solution of lead should be laid over the part; and when phimosis attends, the same liquid should be frequently injected with a syringe between the prepuce and glans. When the scab separates and exposes a raised and fungous ulcerated surface, nothing in general answers better than the application of a weak solution of the sulphate of copper, (in the propor- tion of about four grains to an ounce of water,) two or three times daily; and in the advanced stage of the complaint, the same may be injected under the prepuce, if phimosis attends. I have derived much benefit in the fungoid state of this variety of venereal sores, from the application of citrine ointment softened down with an equal proportion of lard. The aqua phagedenica—made by dissolving eight grains of corrosive sublimate in four ounces of lime water, or a' very weak solution of lunar caustic, may also be usefully employed. All such applications, however, should be weak; for the object is not to destroy the raised surface of the ulcer by an escharotic, but simply to stimulate it. Mr. Carmichael recom- mends the zinc ointment, either alone or mixed with a third or fourth part of the citrine ointment. During the early stage the patient should use a light, unirri- tating diet, remain quiet, lake mild aperients; and where the constitutional irri- tation is considerable, venesection and perfect quietude in bed are proper. When phimosis attends, emollient poultices, efficient blood-letting and nau- seating doses of antimony should be resorted to. Sometimes the attendant in- flammation terminates in the formation of matter under the ligament of the penis. In this case the tension and pain are excessive and obstinate—the skin becomes discolored, but, from the extreme tension of the part, no fluctuation can be felt. The excessive pain, induration, tension, and obstinacy of the affection, are the only circumstances by which the formation of pus under the ligament can be in- ferred with sufficient confidence. If the matter is not evacuated by a free incision into the dorsum penis, it usually makes its way up the dorsum, and escapes by an ulcer near the pubis. SYPHILIS. 797 Venerola superficialis, or the primary superficial ulcers with elevated and per- fectly defined edges, are seldom benefited by stimulating and caustic applications ; but often rendered much worse. Moderately astringent and soothing applications are in general beneficial—such as weak solutions of sulphate of zinc, sugar of lead, althea or tutty ointment. When the constitutional irritation is very con- siderable, the lancet, purgatives, antimonials, nitre, and other refrigerant diapho- retics, with local, emollient, and sedative applications, will be necessary. The internal use of mercury generally renders the progress of primary ulcers with elevated edges, extremely obstinate. " I have frequently," says Mr. Carmichael, " seen mercury, exhibited in full doses, maintaining a strong mercurial action in the system for several months, without inducing ulcers of this kind to heal." In the indurated sloughing ulcer, where there is much surrounding hardness, and the surface of the sore covered with a dark liver-colored slough, from which a thin dark-colored ichorous fluid issues, mercury, according to the experience of Mr. Bacot, is decidedly beneficial, until the hardness of the surrounding parts disappears. It does not appear, however, that the most careful administration of this medicine is capable of protecting the constitution from the secondary symp- toms ; but when the copper-colored eruption has once made its appearance, " it is as much under the influence of mercury as the primary sore"—disappearing in general without difficulty under the moderate employment of this remedy. When the constitutional irritation is high, attended with an evident disposition to gan- grene, great anxiety, heat and dryness of the skin, furred tongue, and much pain and swelling of the prepuce, vigorous antiphlogistic measures must be adopted. The lancet, cathartics, antimonials in nauseating doses, cold applications, and a rigorous antiphlogistic treatment, are indispensable in such cases, and the patient should remain in bed. When the local and general inflammatory action is mo- derated, and the system is much debilitated, recourse should be had to tonics— particularly quinine and opium; and the separation of the sloughs may be pro- moted by warm and emollient poultices. Mercury can only be safely employed where the surrounding inflammation and pain are moderate. The sores must be dressed with mild applications—such as weak solutions of acetate of lead, or a solution of sulphate of copper, in the proportion of two grains of the sulphate to an ounce of water, or the black lotion (calomel 9i, lime water |vi). The phagedenic, soft, sloughing primary ulcer, free from very conspicuous surrounding hardness, is often especially unmanageable. The most prompt and vigorous antiphlogistic measures are necessary to arrest the progress of the ulcer- ation ; but the employment of mercury in this variety of primary ulcer is almost invariably pernicious, " and often productive of the worst consequences." (Bacot.) The measures to be confided in, during the inflammatory stage, are: rest in a recumbent posture; venesection; nauseating antimonials ; warm foment- ations injected under the prepuce, or applied by stuping; warm emollient poul- tices ; together with the internal use of opium, hyoscyamus and cicuta. When the violence of the inflammation and the active progress of the ulceration have been moderated, and the ulcer " creeps slowly along," healing in one place while it advances in another, a weak solution of the nitrate of silver, (one, two, or three grains to an ounce of water,) " or the black or yellow mercurial washes, do well in some cases; but in some cases no applications seem to be capable of checking the progress of the ulceration." (Carmichael.) If spontaneous hemor- rhage ensues in obstinate cases of this kind, an immediate check to the progress of the disease is usually the result. Mr. Carmichael states, that he has in some instances derived decided advantage from "paring off the irregular and jagged superficies of the ulcer, and encouraging the bleeding afterwards by immersing the part in warm water." When a band or strip of integument connects one portion of the ulcer with another, or the ulcer has penetrated through the fraenum, leaving its anterior part attached to the glans, and the disease has assumed a chronic state, it will be proper to divide it by an incision. In sloughing ulcers, without indurated bases, we may often derive much benefit 798 SYPHILIS. from stimulating applications. Carmichael particularly recommends Venice tur- pentine, or balsam copaiva, mixed with one or two parts of olive oil. I have known very prompt advantage derived in sloughing ulcers of this kind, from the application 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 excision or destruc- tion of the chancre with caustic, will frequently arrest the further progress of the local affection, and prevent the occurrence of the secondary constitutional symp- toms. This practice is, however, 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 irri- table and depraved constitutions, too, the irritation produced by the caustic is apt to give rise to very injurious consequences. Swediaur asserts, that he has seen " the most dreadful 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 controlling 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 con- junction 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 conditions to the employment of this remedy exist, measures must be 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 ab- lution 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 con- trary 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 abstained from them until the system was put under a moderate mercurial influence. My usual mode of proceeding is to destroy the chancre with lunar caustic, when I am consulted during the first five or six days after its appearance; but when the chancre has already made considerable pro- gress, I 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 caus- tic, and direct the sore to be dressed with red precipitate ointment; or to be touched frequently, during the day, with a solution of the sulphate 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 unirri- SYPHILIS. 799 fating diet, and abstain wholly from the use of stimulating 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 afield of much contention—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 calculated, under certain cir- cumstances, 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 practised. 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 conse- quences which have occurred from its administration, 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 deprave the general constitutional habit—all of which circumstances are certainly very well calculated to interfere with the salutary operation of this remedy, and to convert it often into a decidedly deleterious agent. It must be admitted that the various forms of constitutional venereal 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 secondary 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 influence, 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 perma- nent advantage, will readily yield to a full salivation. About four years ago, I 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 long-continued mercurial courses with only very temporary benefit, and during the eight months immediately before I saw him, he daily took the sarsaparilla decoction and syrup—of the latter of which he had already taken above forty bottles. His nose and the internal fauces were much ulcerated, and various painful swell- ings on the ulnae, tibiae, and cranium, had reduced him to a most distressing con- dition. I put him immediately upon the use of large and repeated doses of calo- mel, 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 disappear under the use of antimonials and sarsaparilla, with a mild and unirritating regimen, aperi- ents, the warm bath, and the avoidance of a variable, damp, and cold atmosphere. Nevertheless, where this eruption continues .obstinately, and the patient's strength declines, 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, forearms, back, and hairy scalp, and which at last become converted into irregular crusts, leaving ragged, ill-looking ulcers, of a glassy, shining, and level surface when 800 SYPHILIS. they separate, are in general much improved by a mild mercurial course, em- ployed after the general phlogistic symptoms, which usually usher in the" erup- tion, have been reduced by venesections, antimonials, aperients, diluent drinks, &c. Carmichael recommends the free use of the decoction of sarsaparilla 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 compound decoction of sarsaparilla, is often highly bene- ficial. The internal use of 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 vene- real affections, he " does not wish to be understood as wishing to exclude the use of mercury altogether, for the cure of this most formidable of venereal com- plaints." 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 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 em- ployment of mercury." Without, however, extending these observations as to the particular circum- stances 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, tbe compound decoctions of the woods, antimo- nials, rest, an equable temperature, and simple and unirritating diet, recourse 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 indicated. 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 this local inflammatory condition has been moderated by general antiphlogistics, emollient gargles, the inhalation of aqueous vapor, perfect rest, low diet, and nauseating antimonials. In instances attended with an irritable habit of body, much advantage will usually result from the employment of opium or hyoscyamus in conjunction with mercurials. This combination is more especially necessary in cases at- tended with much pain in the extremities or bones, and where the mercury seems to augment the general 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 circumstance 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 atmosphere. 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 stimulating drink must be especially interdicted. It has already been stated, that in the commencement of the constitutional symptoms, it often becomes necessary to employ measures for the reduction of the general phlogistic habit, before mercurial remedies can be with propriety re- sorted 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* SYPHILIS. 801 continued for three or four weeks, are often decidedly useful preliminary mea- sures 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 affec- tions. 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 symp- toms or circumstances exist which seem to contra-indicate its vigorous employ- ment. Some difference of opinion prevails as to the preparation of mercury most eligible for the treatment of venereal affections. In recent cases, the blue pill, with or without ipecacuanha, is generally preferred. In chronic syphilitic affec- tions of every form, I have scarcely ever employed any other mercurial than the corrosive sublimate, 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. He makes one hundred and twenty pills out of twelve grains of corrosive 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 intervening days, until they are all taken, by which time the cure is completed. During the treat- ment, 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 com- pound decoction of sarsaparilla, and the last three months he was under an alter- ative course of mercury, without deriving any particular benefit from all I pre- scribed. He was then admitted into the Pennsylvania Hospital, and underwent two full mercurial courses, but he came away without being in the least relieved. My friend, Dr. Moering, 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 pre- scribed the corrosive sublimate in the above way, and in five weeks the patient was relieved of all 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 recommended as a remedy in syphilitic affections. M. Biett prescribes 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 affections ; and in conjunction with antimonials, a simple diet, warm bathing, and aperients, will often remove the milder forms of the disease without the aid of mercury. Although I should » JJ.—Proto-ioduret of mercury 3L Powder of marshmallows gi.—M. Divide into 72 pills.—Or, J£—Proto ioduret of mercury Qii. Thridace ^ss. Extract of guaiac, 'Z'\.—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. 51 802 SYPHILIS. not be disposed to depend solely on these means, yet the sarsaparilla infusions in common use can hardly be omitted with propriety, in conjunction with mer- curials, 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 solution in a ptisan of this kind. As a local application to the chronic and foul ulcers which occur in some in- stances on different parts of the body, as well as to those which are sealed in the fauces, the black or yellow mercurial washes, or a weak solution of blue vitriol, 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 mu- riate of gold in ten or twelve cases of constitutional syphilis, and in several in- stances 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 gra- dually 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 un- pleasant 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 effects in diseases of this kind. He asserts, that by the following combination, he has almost uniformly succeeded in remov- ing even the most inveterate syphilitic affections.t This article was formerly *R.—Rad. sarsaparil. ^ii. Flor. borag. ofhcin. Petal, ros. gall. Fol. senna?, Sem. anis., aa ^ii. Sacch. communis, Mel. despumat., aa Ibii.—Boil in a sufficient quantity of water to extract 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 Strop de Cuissinier. R.—Rad. sarsaparilla?, Lign. guaiac. offic, aa. Ibi. Fol. senn. G.Arab., aa %i. Rad. zingiberis §ss. Aq. fontanae ffix.—Boil the first two ingredients in water for one hour ; strain, and add to the residuum tbe same quantity of water as before, then boil it for two hours, and towards the end of the boiling add the other ingredients : strain, and to both decoctions add Sacch. communis, Mel. opt., aa Biii.—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: ]J.—Rad. sarsaparillae ^iii. Fol. cbimaphyllse umbel. §ii. Sulphuret. antimonii, enclosed in a linen cloth Si. Aq. bullient. Biii.—Boil it down to three half pints; then add— Mel. despumat. ^viii.—Dose, a wineglassful four times daily. ■j" B.—iErugo aeris grs. ii. Solve in aceti concent. Qii. Camphorse grs. iv. Opii gTS. ii. Micce panis, q. s. ut fiant pilul. No. 40.—Take from five to ten three times daily. BUBOES. 803 much employed 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 I attended about a year ago, twenty grains of the carbon- ate 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 peculiarly 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 repeat- edly 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 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, maybe 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 irritable and scor- butic 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 irritation, 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 in the internal surface of the prepuce and glans penis. Sympathetic buboes often dis- appear as soon as the primary local irritation upon which they depend is re- moved. Sometimes, however, they become indolent, and remain stationary for a long time. In instances of this kind, mercurial frictions, blistering, or simple emollient poultices, will either dispose them to disperse or to proceed to suppu- ration, after which they readily heal. I have lately used frictions with the hydriodate ointment, in a case of indolent sympathetic bubo, with marked benefit. Professor Alban G. Smith has been in the habit of employing an ointment composed of one ounce of strong mercurial ointment, intimately mixed with two or three drachms of the extract of belladonna. 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 answered his inten- tions. I have, in several instances of enlargement and induration of the mammae, used this remedy with the most satisfactory results. Swediaur divides buboes into the tonic and atonic; a distinction which is fre- quently 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 con- • See Eberle's Mat. Med., vol. i. p. 304, 3d ed. 804 BUBOES. stant. The atonic bubo is accompanied with the reverse conditions—the symp- toms indicating general debility. So long as the inflammation is not very high, or signs of commencing suppu- ration 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 con- sequences, under the idea that the venereal poison may be retained in the system, and give rise to subsequent unpleasant affections. For this apprehension, how- ever, there is not the least foundation. Many practitioners are in the habit of depending chiefly on mercurial 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 phlogistic, 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 fric- tions on the inner surface of the thighs. When the general irritation or phlo- gistic 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 anything will avert suppura- tion, except very efficient 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 am- monia. 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 glandu- lar indurations about the neck. In atonic buboes, advancing slowly, and remaining for weeks in nearly a sta- tionary condition, without manifesting a tendency either to suppuration or to resolution, the application of blisters to the tumor will often succeed in dispers- ing it, or at all events expedite its termination in suppuration. Both Mr. Car- michael 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 prac- tice 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 integuments. 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 the base of the tumor. Mr. Swediaur and some other writers, however, think it much better to suffer suppu- rated 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 judicious use of the lancet; for it is not improbable than 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 AMENORRHEA. 805 after this has been brought about, it is difficult to conceive any advantage from suffering 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 ulcer- ative process continues ; or the abscess acquires an indolent and unfavorable character, which prevents it from healing. In syphilitic bubo, mercury is indis- pensable; but where there is a scrofulous or a scorbutic habit, and in" instances where the general system is enfeebled and irritable, the worst consequences 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 grs. x, lime water oviii) into the cavity, and apply stimulating cataplasms—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 solutions of corrosive sublimate, &c. The solu- tion of sulphate of copper, or the black mercurial wash, will often answer well in such cases. Sometimes the ulcers formed by suppurated buboes become surrounded 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 upon the extensive and undermined edges of the buboes, that I 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. Full 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 moistened 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 materially 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.—Amenorrhea. This is one of ihe 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 distress- ing and dangerous consequences. The exciting causes of amenorrhoea are exceedingly various. Everything which is capable of deranging the general health, has a tendency to excite irregu- larities or suppression of the catamenial discharge. Organic and inflammatory visceral affections—more especially pulmonary consumption—chronic hepatitis, 806 AMENORRHEA. and gastro-intestinal phlogosis or irritation, are rarely unaccompanied by men- strual irregularities, and often by a total and obstinate suppression of this evacu- ation. Mental emotions, particularly protracted grief and despondency, and sudden terror or violent anger, have a powerful tendency to arrest the catamenial discharge. Metastasis of rheumatism—of erysipelas—and of chronic cutaneous affections; habitual hemorrhoidal discharges, as well as other varieties of he- morrhage, leucorrhcea, 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 interval 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 spontaneously at the succeeding period. Occasionally, how- ever, considerable 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 suppression of this evacuation without any materially unfavorable consequences during the first six or eight weeks, more or less derangement of the general health invariably ensues, if the menses fail to make their appearance after the second or third period. The usual symp- toms which ultimately arise from this affection are: languor and debility; a pale and sickly expression of the countenance; swellings of the ankles; various ner- vous affections, such as paroxysms of palpitation of the heart, and dyspnoea ; flatulent and spasmodic pains in the bowels ; loss of appetite ; and in relaxed and leucophlegmatic habits, leucorrhcea. 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 ihe menses are suddenly suppressed, whilst they are flowing; or when the remote cause of the obstruction is applied immediately before the impending appearance of the evacuation, the consequences are much more violent and sud- den. 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 occasionally with severe retching. In other instances, strong determinations of blood take place to the brain, giving rise to raving delirium, hysteric mania, convulsions, or a tem- porary loss of sensation and voluntary 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 mentioned suc- ceed the sudden suppression of the menses, the first object must be to allay the alarming and painful symptoms, without any immediate attention to the restora- tion of the evacuation. The attempt, 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 symptoms, will occa- sionally 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 AMENORRHEA. 807 than any other remedies we possess. Active cathartics and purgative enemata, sinapisms to the inferior extremeties, warm pediluvia, 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 pediluvia, 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 answer so well, where the pain in the stomach or lower part of the abdomen is severe, "as an injection composed of a gill of thin starch, a teaspoonful of laudanum, and thirty grains of finely powdered 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 cephalic congestion is strong, or in full, young, and vigor- ous 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 purpose of restor- ing 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 advantages 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 resortino- 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 restor- ing this secretion, has been, and no doubt will continue to be, the source of va- rious and irremediable mischief. Amenorrhoea in young subjects is at first almost invariably accompanied by a manifest phlogistic habit of body. In instances of this kind, moderate abstrac- tions of blood, aided by a simple and unirritating diet, laxatives, and regular ex- ercise in the open air, are all-important remedial measures. Where the disease has developed local inflammations, or sustains irregular determinations to internal organs, especial means should be used, in conjunction with the general 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 prac- tice, 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 days in succession, at the expected menstrual period. Some days previous to the employment of the leeches, he orders dry cupping on the upper 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 sys- * Rev. Med., January 1828. 808 AMENORRHEA. lem, and to improve the digestive and alvine functions. Iron,* 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 ex- citing 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 remarkable instance of this kind. The patient, a laboring woman, about twenty-five years of age, had suffered a long time under amenorrhoea, and the usual attending nervous symp- toms. 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 institutions, for the purpose of " bring- ing on her courses." On examination, I found her abdomen tumid and hard, the tongue like a piece of raw flesh along the edges and point, and the appetite vo- racious—in short, with all the symptoms of high irritation of the mucous mem- brane of the stomach and bowels. I ordered her a few doses of castor oil, and put her on the exclusive use of rye-mush aud milk for her diet, with which she faithfully complied. In four weeks the tension and fullness 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 pre- scribed 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-sup- pressed catamenia. By thus pursuing a general treatment adapted to the particular circumstances of the case, we may often restore the menstrual evacuation ; and should we even fail in effecting this purpose, we shall, nevertheless, gain some advantage, by placing the system in a condition favorable to the operation of the remedies more directly calculated to act upon the uterine system.§ * R-—Ferri phosphat. 'Zx. Pulv. zingiberis gii. ----aloes Soc. grs. v.—M. Divide into ten equal parts. S. Take one twice or thrice daily.—Or, R.—Extract, gentian, ^i. Sulphas, ferri grs. iv. G. aloes Soc. grs. v.—M. Divide into twenty pills. S. Take one every morning, noon and evening. t R.—Pulv. rhsei ^iv. G. aloes ^i. Pulv. capsici 5Ji. Muc. g. Arab. q. s.—M. Divide into twenty pills. Take two at night on going to bed. X R-—Sulphat. ferri grs. v. G. myrrh, G. aloes, u.1 grs. x.—M. Divide into twenty pills. S. Take one every morning, noon and evening. § 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 AMENORRHEA. 809 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 those of long standing, without its having failed in any cases 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 maybe mentioned as a singular circumstance, that although I have employed it in no small number of cases of ihis 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, I have, as yet, met with none who has been even moderately successful with it. Dr. Dewees himself notices this fact. " I have learned," he observes, " that some of my brother practitioners have not been equally successful with it—but I think I can readily account for their failure ; first, from their not placing the system in a proper situation for its use; and secondly, by not properly perse- vering in the remedy." The medicine in which I have hitherto most confided as an emmenagogue, 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 fol- lowing 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 melauipodium, too, has occasion- ally succeeded well in my hands ; and within the last few years I have employed the spirits of turpentine with success in several cases. Where hysterical symp- toms attend, peculiar advantage may sometimes be obtained from the following pills.t The tincture of cantharides, too, has been highly recommended as a remedy in this affection. Dr. Joseph Klapp, of this city, has published an account of his experience with this article, from which it would appear that, under judi- cious management, it will often operate very beneficially.^ It should be given in gradually increased doses, beginning with twenty or twenty-five drops three times daily, until a slight degree of strangury is produced, when it must be omit- ted, and resumed when the urinary affection has subsided. This article is cer- tainly worthy of particular attention as an emmenagogue, 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 car- ried 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 particu- larly important to reduce the local inflammatory 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; but, so far are present, all medicines of this kind are highly improper. When, for instance, a puruloid leucorrhceal discharge attends, with other signs of vaginal irritation, purgatives, low diet, rest, emollient injections into the vagina, and, perhaps, local bleeding, are indispensable preliminary measures. * R.—G. aloes Soc. grs. xv. Extract, sabin. ^ii. Pulv. ipecac. 9 i. . Mucilag. g. Arab. q. s.—M. Divide into forty pills. Take two pills three times daily. f R-—G. aloes ^ii. — assafietid. 5Jii. — myrrh gss. Sulph. ferri £ss.—M. Divide into three grain pills. Take two twice daily. X Med. Recorder, vol. i. 810 DYSMENORRHEA. as my experience enables me to judge, they are all much more apt to fail than to succeed in restoring the suppressed catamenial 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 employment of the ammonia in this way. Ten or twelve drops of the aqua ammoniae 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 quantity must be diminished. Dr. Hosack diluted a drachm of the ammonia 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 employ- ment 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 amenor- rhoea, 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.—Dysmenorrhcea.—Painful and Imperfect Menstruation. Dysmenorrhoea is a common, and generally an extremely harassing affection. It may occur at every period during the menstruating stage of life; but it appears to be the most common between the twentieth and thirtieth years of age, and in subjects of an irritable and sanguineous temperament. In many instances, severe pains are experienced in the back, loins, and lower part of the abdomen, for five or six hours previous to the appearance of the menstruous evacuation. This, however, soon ceases, and an immediate aggravation of the torturing pain follows. Sometimes the catamenia 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, accompanied throughout with extremely severe pains in the pelvis and lower portion of the abdomen ; and in some rare instances, the cata- menial evacuation, although attended with great suffering, is sufficiently copious and prolonged in its course, and may even exceed the regular duration and quan- tity 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 headache 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 appearance to the decidua. Females laboring under painful menstruation generally experience two distinct kinds of pain; namely, the intermitting 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 appearance of the evacuation. Dr. Dewees observes that there are two distinct states of this affection, which, * New York Med. and Phys. Journ. DYSMENORRHEA. 811 in a prognostic point of view, are worthy of attention. Thus, in some cases, the mammae sympathize 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-membranous sub- stance upon the internal surface of the uterus is always present in this affection, and constitutes, in all instances, the immediate cause of the difficult and painful menstruation. This, however, does not appear to be founded on correct obser- vation. I have known females to suffer very painful and incomplete menstrua- tion for two, three, or four periods in succession, and afterwards menstruate regularly without any particular difficulty, where no membranous matter what- ever was at any time discharged. It must, moreover, be observed, that painful menstruation is not universally attended with a scanty flow of the catamenial fluid. I have met with several instances where, in point of quantity and dura- tion, 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 membranous 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 in very many cases, such membranous 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 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-membranous matter. I cannot accord with Dr. Dewees in his notions concerning the etiology of this affection, or rather " of the membranous productions so often yielded in dysmenorrhoea." " Before I attempt an explanation of the formation of this membrane," 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 sup- pose 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 sub- dued, 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 elaboration, be thrown into the cavity of the uterus, without being dispossessed of the power of separation and of coagulation. It is poured into the uterus in a very gradual manner : and from this circumstance may tarry there sufficiently long to sepa- rate into its constituent 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 assume, as is usual with it when in contact with living parts, the appearance of a membrane."* These sentiments appear to me not only contrary to well-established patholo- gical principles, but most unquestionably, also, to the phenomena of dysmenor- rhoea. That the menstrual action of the uterus is morbid or deranged is, indeed, * A Treatise on the Diseases of Females, second edition, p. 91. 812 DYSMENORRHEA. 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 fullness, 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 excite- ment and sanguineous congestion in the uterine system. Lymph is never thrown out in such a state as to form membranous matter, except from inflamed, or at least highly irritated surfaces. The formation of such concretions is, indeed, one of the most certain evidences of previous inflam- matory action in a part. Most assuredly Dr. Dewees will not contend that the decidua, which strongly resembles the membranous masses thrown off in dys- menorrhoea, 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 incrusta- tions of lymph arise from the gradual separation of blood retaining its coagula- bility, in consequence of impaired or deficient action of the uterine vessels, we should, no doubt, frequently meet with these pseudo-membranous 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 affec- tion, 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 membranous structures, or devoid of such concretions, the uterus is in a state of much sanguineous congestion, attended with an irritable 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, instead of the catamenial fluid, lymph is often secreted by the irritated vessels, which concretes on the internal surface into the form of a membranous substance. This opinion of the pathology of dysmenorrhoea 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 dependent on a rheumatic affection of the uterus. In a case which I attended some time ago, the connec- tion of rheumatism and this affection 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 whenever she felt the pain in the joint at the menstrual periods, she menstruated with little or no difficulty; but when the period returned while the ankle was free from pain, she inva- riably suffered excruciatingly during the very sparing and transient flow of the menses. Dr. Mackintosh thinks, that in no inconsiderable number of instances, dysme- norrhoea 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 different 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 that such a condition of the mouth of the uterus would be apt to give rise to the symptoms of dysmenorrhoea. The menstrual discharge 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 recurrence of this uterine irritation will sooner or DYSMENORRHEA. 813 later give rise to inflammation in the lining membrane of the uterus, which will account for the formation of the decidua," which is, in many instances, discharged. Impressed with these opinions, Dr. M. resolved to attempt 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 catamenial 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 small- est silver probe. An artificial opening was made; and some time after he com- menced dilating this orifice, by daily increasing the size of the instrument. On the next menstrual period she menstruated regularly, and has done so since, with- out pain or difficulty. " I have since," says Dr. M., " dilated os uteri in six cases of dysmenorrhoea, 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 intervals of the attacks. I have already observed, that all emmenagogue remedies, or such as are calculated to determine the circulation of 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 Dover'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 decline. 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 perfoliatum tea. Opium, given in full doses, with small portions of ipecacuanha, so as to excite nausea, but not vomit- ing, is, perhaps, upon the whole, the best palliative, where the patient is capable of taking this narcotic without the disagreeable effects which, in some habits, it is apt to produce. It may be advantageously given in combination with camphor, 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 dysmenorrhcea. It would seem to have been an instance of menorrhagia, accompanied by frequent severe pains, occasioned by the contractions of the womb to expel the coagula. The warm bath will occasionally afford consider- able relief in dysmenorrhoea, more especially 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 symptoms, 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 dysmenorrhoea, par- ticular 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 important 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 treatment, before recourse is had to remedies more immediately directed to the uterine system. An occasional dose 814 LEUCORRHEA. 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 asserts, that the occasional employment of an ipecacuanha emetic will sometimes afford very considerable advantage 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 aperients, are obviously proper. When the disease is accohipanied with a rheumatic or arthritic diathesis, the warm bath, gentle diaphoretics, 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 particularly cal- culated to prevent the recurrence of the affection, the tincture of guaiacum is at present most particularly relied on by the practitioners of this city. Dr. Dewees, who introduced this article to the notice of the profession as a remedy in dysme- norrhcea, 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 obtained. Dr. D. observes that it is not uncom- mon to find the first return of the menstrual period, after commencing the use of this remedy, attended with unusually severe symptoms; and he considers this as a favorable symptom. I have employed it occasionally, 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 (Clutterbuck'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 way, that we possess no other article which can at all be compared to it as a remedy in this affection. Immediately previous to commencing 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 con- firmed 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 mercu- rial purge, removed the complaint effectually. What would the tincture of col- chicum 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 mucous, 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, whatever is capable of relaxing the system, as a luxurious, indolent, and sedentary manner of living ; habitual exposure to a humid atmosphere; and want of pure air and wholesome nourishment, are especially calculated to predispose to the occurence 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 LEUCORRHEA. 815 robust, muscular structure, are, comparatively, rarely affected with this disease. Everything 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 con- stitutional predisposition to this affection; for in many healthy, robust, and active females, scarcely any vaginal irritation, from accidental causes, will produce more than a temporary increase of the mucous secretion. In individuals, on the con- trary, 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 following 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 leucorrhceal character. 2. Difficult parturition, or the irritation caused by the employment of obstetrical 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 discharge. 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 keeping up a constant irritation in the rectum and neighboring parts, or by passing into the vagina, are no unfrequent exciting cause of leucorrhoea in young girls and children. 6. The abuse of emmena- gogueSy particularly when unseasonably employed for bringing on what is often injuriously supposed and treated as tardy menstruation about the age of puberty, often gives rise to obstinate leucorrhoea. 7. A loaded and torpid state of the bowels, is a common cause of this complaint in young females. 8. Tight lacing or dressing 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 leucorrhoea among young females than at any other former period, when the abdomen was a litttle 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 uncommon to find females, affected with leucorrhoea, to complain of more or less pain in the joints, and I 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. Atmo- spheric influences, particularly vicissitudes 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 hemor- rhoids ; diseases of the uterus; tumors pressing upon the vagina; mechanical injuries ; the intemperate use of spirituous liquors, &c, may all give rise lo 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 remainder of the menstrual intervals. Symptoms.—In some instances, the discharge has the appearance of the com- mon vaginal mucus. In others it is white, resembling pulverized starch mixed 816 LEUCORRHEA. with a mucilaginous fluid. Sometimes it presents the appearance of pus, pos- sessing an acrid and corroding quality. These differences in the appearance of the discharge indicate 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 inconvenience, 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 especially the os tincae, very tender to the touch. When the disease is suffered to continue, it seldom fails at last to make an in- jurious impression upon the whole system. The countenance 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 digestive functions deranged, attended with acrid eructations, gastralgia, pains in the back, loins and lower ex- tremities; 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 puru- lent; the relaxation and languor of the muscular system increase, whilst the pulse becomes more frequent and irritated. At length, in aggravated cases, the slight- est 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 exceed- ingly 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 se- vere, though sufficiently annoying and debilitating to become a source of much uneasiness and anxiety. Women who are habitually affected with leucorrhoea, very rarely become preg- nant; 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 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 leucorrhoea 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 sub-inflammation, in an exclusive sense. That the mucous mem- brane 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 effi- cient 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 subdued. In relation to the gene- ral 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, gene- ral weakness, and relaxation, as well as the feeble and sluggish pulse, so fre- LEUCORRHEA. 817 quently noticed in profuse leucorrhoea, are sufficient evidence of the correctness of this observation. I am by no means disposed to advocate the old doctrine, that the discharge is owing to a mere relaxation or passive state of the vessels from which it occurs. The increased flow of mucus is unquestionably the result of a morbid action of these vessels; and the immediate cause of this morbid action consists in that pe- culiar deranged condition of the vital properties, designated by the term irritation. 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 irri- tated vessels are, in the instance 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 acci- dental supervention of new exciting causes, both of a general and local character. Treatment.—The cure of leucorrhoea is almost always attended with great difficulty ; and protracted and severe cases often continue, in spite of the most judicious and persevering course of remedial management. Although, properly speaking, a local disease, leucorrhcea seldom fails ultimately to derange other organs, and to establish by degrees a general state of ill health. This, however, occurs only in protracted and severe cases, or in very delicate and irritable habits. In some instances the general health is impaired before the leucorrhoeal discharge commences. Whether primary or consequent, however, the general state of health ought always to be especially attended to, as an important preliminary step in the remedial management of this affection. General or constitutional indis- position is always a most serious obstacle to the restoration of particular func- tions, 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 antimonials, should be resorted to in cases of this kind. It will rarely be necessary, however, to practice more than one or two moderate blood-lettings, even under the most obvious indications of its usefulness. Purgatives and low diet will, in general, be quite adequate to reduce the phlogis- tic 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, particular 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 irritation. 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 all in- stances, however, whether the circulation be active or languid, it will be proper in the commencement 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 calculated to moderate the vaginal irritation. For this purpose, it will be useful to direct the patient to in- ject 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 solu- 52 818 LEUCORRHEA. tion of sugar of lead after each injection of warm water. By pursuing this management, in conjunction with a simple vegetable diet, laxatives, rest, and, if indicated, blood-letting, the local and general irritation will usually yield suffi- ciently, in six or seven days, to enable 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 everything, 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 leucor- rhoea, the tincture of cantharides holds the first rank. This article was, I be- lieve, 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 I have been often successful with its employment; but in a few very severe and protracted cases, I have used it with entire success. It may be commenced with, in doses of from twenty to thirty drops three times daily, and gradually increase until it causes a slight degree of strangury. When this symptom occurs, it must be omitted until the ardor urinae 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 in- stances 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 three or four weeks. Where it can be thus freely administered, it will rarely fail to make a very decided impression on the disease, and in con- junction with proper local means, often put a permanent stop to the discharge. From forty to sixty drops should be given three times daily, and when the sto- mach will bear it, the dose may be increased considerably 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 and water, in the form of an emulsion. When it acts too freely on the bowels, a few drops of laudanum should be added to each dose. The tincture 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 tur- pentine may be used wilh material advantage in some instances. I have lately succeeded in curing a case of this kind with the use of this remedy and astrin- gent injections ; but in the majority of instances, it is much too irritating to admit of being employed with propriety. When the general habit is languid and relaxed, some advantage may occasion- ally be obtained from the internal use of tonic and astringent remedies. The infusion or extract of the root of rhatany, has been particularly recommended by some European writers; and in a few instances in which I prescribed it, con- siderable benefit appeared to result from its use. Dr. Dewees states, that he LEUCORRHEA. 819 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 combination 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 injections, in conjunction with the use of the tincture of cantharides, or the terebinthinate remedies, or alurn pow- ders just mentioned. The sulphate of zinc forms an excellent astringent injec- tion 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 afterwards be gra- dually 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 decoction 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 ; pulverized 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 va- gina, its strength should be increased. Dr. Jewel places great reliance on the use of the nitrate of silver in this affection. He is of opinion that a very com- mon 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 inflammation 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 employing 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 sufficient 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 suc- ceed in arresting the discharge until the womb is replaced to its proper position; and this can be done only by the use of a pessary. 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.t * An Essay on Disorders of the Digestive Organs, &c. &c, p. 169. f TDuring the last five or six years, pessaries have been almost laid aside by the practitioners of this city, and there has been substituted for them either some species of abdominal truss, under the name of " utero-abdominal supporter," or a modification of the Russian belt, manufac- tured by Airs. Betts and several of her imitators.—Mc] 820 LEUCORRHEA. When the disease is attended with a rheumatic diathesis, or with rheumatic affections, the tincture of guaiacum, and probably colchicum, may be very ap- propriately 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. 821 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 Hindostan. Thence it extended its ravages along the principal rivers and great roads, with a pretty uniform pro- gress, 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 September 1823, and, nearly at the same time, broke out at Tripoli, on the eastern coast of the Mediterranean. In 1830, it again made its appearance 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, m England; and in the following spring it commenced its ravages in our own country. ,„,.,. • i i ,u Symptoms.—In many instances the approach of this disease is attended with giddiness, a slight degree of languor, and mental depression—a feeling of unea- siness 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 feelino-of inability to move the limbs. These symptoms are generally followed by moderate diarrhoea, the discharges being usually natural, and seldom attended with much griping. The duration of this stage is very various.* In some in- stances the diarrhoea continues for several days, before the characteristic symp- toms 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 extremely copious evacuation, the patient feeling as if the whole contents of the intestines were passing off at once. Sometimes, although seldom, the disease commences by nausea and vomiting alone, without any diarrhoea. The first alarming symptoms are commonly a sudden feeling of faintness, gid- « rThi= which wa« called the premonitory stage of cholera, affected the majority of our citi- zens during the prevalence of the epidemic in 1832; and was easily cured by the management recommended by our author. In several instances, however, I witnessed sudden attacks of the .eve eform of the disease without any premonitory symptoms whatever. The gallant Col. ^fft was seized in this manner after las prodigious and philanthropic exertions m relieving the Llferers in the Arch Street Prison. His symptoms have been exactly described by Eugene Sue n his delineation of Rodin's <:,sc in the llth No of the Wandenng Jew^ Large doses ot n omnium and camphor, follow.-,! by calomel and external simulation, speedily relieved! him from the most alarming condition, and he lives to deserve the gratitude ol his lellow-citizens. -Mc] 822 CHOLERA ASPHYXIA. diness, ringing in the ears, dimness of sight, uneasiness "amounting sometimes to great anxiety, or feelings of horror." The bowels begin to rumble; a burn- ing pain is usually felt at the pit of the stomach, and violent purging and vomit- ing ensue, followed by a feeling of great prostration. " If tbe 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 stomach, and as a sense of weight or constriction round the waist. This is followed by a prickling sensation in the arms and legs, extend- ing sometimes to the fingers and toes; the hands and feet become cold, and be- dewed 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 immedi- ately 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 solution 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 super- vene. The flexors of the fingers and toes are first affected with spasm ; the gastrocnemii and muscles of the thighs are next attacked ; and in some cases, the whole muscular 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 restlessness 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- fuse, clammy sweat. The thirst is, generally, extremely urgent; the pulse at the wrist and arms is imperceptible, and the respiration is commonly slow, some- what oppressed, and irregular. In old persons, 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 extreme coldness of the surface, there is often so great a sensibility to the im- pression 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 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 monosyllables only ; while his hands are cold and bloodless, he yet retains the sense of touch, and even feels with increased sensibility, some- times 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, * Observations on the Pestilential Cholera, as it appeared at Sunderland, &c. By W. Ains- worth. Esq , p. 53. f Cholera, as it has recently appeared in the Towns of Newcastle, &c. By T. M. Greenhow —page 4. CHOLERA ASPHYXIA. 823 doubtless, in a morbid or imperfect manner. When the febrile reaction is mode- rate, the patient usually soon convalesces. More frequently, however, 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 observation of some writers on this subject, the stage of re- action occasionally assumes the character of a malignant fever, of a congestive 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 symptoms are commonly terminated in delirium and death." (Ainsworth.) The second or cold stage sometimes terminates in coma, with no other mani- festations of increased arterial action than a slight throbbing of the carotids, and warmth of the chest. From this comatose stupor the patient can at first, gene- rally, 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 pre- ceded by sudden furious delirium ; the patient raves wildly, "but the struggle 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 purging and vomiting, great diversity occurs in different cases. In some instances, not more than two or three alvine evacu- ations 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 discbarge took place, although the patient speedily sunk into a fatal collapse. The evacuations sometimes 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 rectum 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. Ken- nedy states, that in certain epidemics of this disease, " scarcely an individual case has manifested this symptom. 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 simi- lar to that which occurs in rumination. The animal functions also are disor- dered 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 circula- tion 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 im- paired, and in some instances great prostration of strength occurs as the disease is developed. Spasm has been regarded as an essential phenomenon of this malady. Ob- servation, however, does not confirm this opinion; for cases have been noticed in which all the other symptoms characteristic of this malady were present, with- out 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 dangerous 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 fre- quent than in epilepsy or convulsion, and seldom durable as in tetanus." In some instances spasmodic twitchings of the muscles have been noticed a consider- able time after death. 824 CHOLERA ASPHYXIA. 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 de- prive 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 more freely, and if it con- tinues, the color gradually improves. When this is the case a singular appear- ance is occasionally observed :—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 characterize 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 recognized, 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 with- out 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 recognized. The phenomena which characterize this stage of the malady, are; 1, frequent discharges from the stomach and bowels of a serous or watery fluid, resembling rice or barley water; 2, complete sup- pression 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 cor- rugated 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 proceeding 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 undis- turbed state of the mental faculties and sensorial powers. It is manifest from this assemblage of symptoms, that the diagnosis 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 con- founded, is the ordinary cholera—the cholera biliosa. " Where the evacuations are tinged of a yellowish or greenish hue, where the matter vomited is bitter to the taste, while the skin remains warm and the pulse good, the disease 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—when no urine is voided, when the surface becomes cold, the features collapsed, the spirits depressed, and the pulse flags, the case may almost 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 shriveled, corrugated 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 subjects who have sunk under this disease do not differ materially from those which the body pre- sents 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 sunken, and have a dark ring around the orbits; the flexor mus- cles are rigidly contracted, the tendons standing out prominent on the extremities; CHOLERA ASPHYXIA. 825 the hands are firmly clenched, requiring an effort to open them. The uvula, tonsils, and pharynx are covered with granulations, 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 oesophagus is cor- rugated ; 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 inflammatory action. The stomach and intestines are generally filled with a turbid liquid like rice water, with little flocculi of a white membranous substance floating in it. The glands of Peyer 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 pep- per-corns, and have black points at their centre. The valvulae conniventes of the duodenum are flaccid, thickened, and swollen, covered with the little vesicles just mentioned, and occasionally they are ulcerated. The peritoneum is dry, and has a shining opaline lustre. The bile ducts are often thickened 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 pulmonary 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 en- gorged with blood, and almost always crepitate well; the veins of the kidneys are turgid with dark uncoagulated 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, 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 extraordinary malady, very little is known that can be deemed satisfactory. It seems, indeed, very pro- bable that the cause of the disease, whatever 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 symp- toms, clearly indicating a morbidly irritable condition of the stomach and intes- tines. 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 recognized, show very conclu- sively, that the first obvious morbid effects of the cause of cholera is derangement of the gastric and intestinal functions. This primary 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 * Dr. C. T. Jackson—Medical Magazine, No. 4, 1831. See Amer. Journ. of the Med. Sciences, vol. xi. p. 266. 826 CHOLERA ASPHYXIA. arrested—in short, the whole machinery of organic life is tending rapidly to a state of total inaction, 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 tbe blood, depends on the rapid and almost total loss of its serum, by the relaxed exhalants of the alimentary canal and skin, and partly also, on the retention of the recrementitious carbonaceous 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 explanation 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 shriveling, first of the remoter tissues, capillaries and ves- sels, ensue; the blood no longer filling the calibre of the arteries, the pulset 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 ex- planation 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 condi- tion 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 in- stances, 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 dis- charges 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 implicated 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 in- fluence. The natural or constitutional predisposition to disease consists, proba- bly, 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 occa- sion, 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 de- pressing 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 multiplying their victims. The broken down in consti- tution, hahitually intemperate, and the dissolute have everywhere been the first and most certain sufferers. Exposure to a cold and humid atmosphere, particu- larly at night; excessive fatigue of ihe body; inordinate mental excitement— the abuse of spirituous liquors—and crude, indigestible, and irritating articles of CHOLERA ASPHYXIA. 827 food, are particularly calculated to favor the developmont 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. Everything, 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. Excess 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 vicissitudes, by good lodging and warm com- fortable clothing—cleanliness, fresh air, the avoidance of excess in diet and drink —a cheerful, 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 deleterious influence of the epidemic causes. 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, generated 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 affluvium, engen- dered deep beneath the surface of the earth, by a slow process of decomposition or chemical change in some mineral strata, or by central volcanic action. There is certainly something very analogous 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 opposition to the regular currents of the wind, seems to accord well with what one might suppose would be the pro- gress of an epidemic if it depended on a subterranean cause of this kind. There are some who are disposed to believe, that the cause depends upon some occult modification in the constitution of the atmosphere itself. But this opinion is met by the objection, that, if such were its origin, it could hardly have advanced in a direction contrary to the prevailing current of the air, or winds—a circumstance which has frequently been observed. A few writers contend, that the disease depends on a deficiency of the electric fluid in the atmosphere, whereby the animal system is deprived of its most subtle and pervading stimulus, and the organic functions 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 Hahnemann, with a few other writers, has adopted the Linnean doctrine, of animalcular origin. It is maintained by the advocates of this hypo- thesis, that cholera arises from an infinite number of animalculae, too small to be perceived by the most powerful microscope, which, floating in the atmosphere, enter into the lungs, and alimentary 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 in- volved in these opinions. It may be sufficient to observe that they are all, as vet wholly conjectural; and that the experience and observation of the profes- sion though intently directed to this object, have, hitherto, failed in establishing anything 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 lo act on 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 828 CHOLERA ASPHYXIA. manner of a contagion? This is an important question. The fatality and cala- mitous consequences of epidemics, are always greatly augmented, by the con- viction among the people that the reigning disease is contagious. Besides the unhappy effects on the minds of the people, the vexatious, and often ruinous sanatary restrictions and quarantines, to which the existence, or supposed exist- ence, 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 wit- nessed 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, ninety-nine out of one hundred physicians believe that cholera is not con- tagious ; and in every country and district that has been invaded by this disease, a great majority of the most experienced and enlightened of the profession enter- tain the same conviction. In many populous cities and districts, as at Moscow, Orenburg, and Paris, the majority of medical men, as well as of citizens, did not doubt the contagious character of the disease while they contemplated it at a distance; but after it had made its appearance amongst them, and they were furnished with an opportunity of observing for themselves, the belief in its con- tagiousness was almost universally abandoned. The quarantine regulations and sanatary 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 contagion. 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 prevalence, during a period of more than seventeen years, the contagious character of the disease would not have been incontestably 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 inspec- tion 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, (Cin- cinnati,) 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 period, and fre- quently 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 alongside of dead bodies—had bathed in the same water where very bad cholera patients had been bathed just before, and that, notwith- standing, 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 atten- CHOLERA ASPHYXIA. 829 tion to the different stages of the disease; for the remedies and mode of manage- ment best adapted to one stage, would be wholly inefficient, or even injurious, at another period of the complaint. "A misapplication of the remedial measures," says Dr. Kennedy, "has been the source of extraordinary confusion and contra- dictory testimony. Several remedies, on which the strongest dependence 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 irregular appetite, disordered digestion, a sense of fullness, or uncomfortable feeling in the epigas- trium, unusual heat in the abdomen, noise and commotion in the bowels, diar- rhoea, 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 correct 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 accomplish these purposes a simple, unirritating and digestible diet must be en- joined, such as stale wheat bread, water and soda crackers, rice, hommony, grits, barley or oatmeal gruel, chicken or mutton broth, beef tea, black tea, or weak coffee with cream; and for common drink, toast-water, barley or rice-water, or weak cold chamomile 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 symp- toms. R.—Submuriat. hydrarg. 9i; g. opii grs. ii; pulv. camph. grs. 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, I have found nothing so effectual in giving relief as small doses of a solution 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 addition of small doses of lauda- num, is particularly beneficial where the incipient stages are attended with symp- toms 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. lavand. compos.; tinct. camphorae, aa 3iv; liq. Hoff. anod., tinct. opii, aa 3ij.—M. ft. mist. From ten to twenty drops of the above are to be administered at appropriate intervals. By the preceding mode of management, the premonitory or incipient symptoms of the disease have, in a large majority of instances, been speedily and effectually subdued, and 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 pur- pose 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 symptoms, and, indeed, for a considerable period after their disappearance, the patient ought to use a mild, digestible and nutritious diet, and especially, to avoid over-distending 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 seri- ous character__that is, if the evacuations begin to assume, or have assumed, the appearance of rice-water, and the patient experiences cramps in the extremities— then the primary objects are, to allay the cramps, vomiting, and purging, and to * Dr. Samuel Jackson, Amer. Journ. of Med. Sciences, vol. xi. p. 324. 830 CHOLERA ASPHYXIA. 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 expe- rience has fully convinced me, that all the benefits which this remedy can afford may be obtained from the doses I have just mentioned.* To allay the nausea and vomiting, the ethereal solution of camphor, already mentioned, is an ex- cellent 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. potassae 3iv; acetat. opii gtt. xv; aquae camphorae |iv.— 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 employ- ment 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 serious injury. In the "India Reports of Cholera" many instances are men- tioned " 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 alco- holic vapor bath. This application may be made without disturbance or fatigue to the patient; and 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 reprobated 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 respectable 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 affected with general tre- mors, 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 circumstances, almost uniformly produced the most decided salu- tary 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 impos- sible to procure the discharge of blood, which merely trickles forth in drops, and often fails entirely to issue from the orifice. Dr. Kennedy, in his excellent trea- tise on this disease, declares that " every patient from whom blood could be freely obtained was almost sure of recovery;" and this declaration is supported by the majority of his medical brethren in India. In our own country, 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 * 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 un- questionable 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. 831 to open an artery; this exhausts the patient, but does not relieve the venous con- gestion. 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 prostration than would attend the opening of a vein. In the early period 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 sur- prising to witness how prompt, often, is the alleviation and abatement of the symptoms, following the application of from thirty to sixty leeches to the epi- gastric or iliac regions. In no instance did I find it necessary, in the patients I treated, in the first stages, to repeat the local depletion. One application was sufficient to procure a favorable result. In several instances general depletion made but little impression, whilst 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 injury, and generally with decided advantage. But besides the general abstraction of blood, and consequent relief of the internal venous congestion, 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 irritable 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 quantities. When the thirst is attended with a sense of heat and 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 sina- pisms to the abdomen and extremities, are best adapted to answer this intention. It will also be proper to administer stimulants internally ; such as small portions of brandy and water, ammonia, turpentine, ether, &c. To check the excessive serous discharges from the stomach and bowels some practitioners have advised the internal employment of the sugar of lead; and from what I have seen of its effects in this disease, I am inclined to think that much advantage may often be derived 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, dis- 832 CHOLERA ASPHYXIA. solved 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 ap- peared to me, with a very manifest effect in diminishing the quantity and fre- quency 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, opium may do serious injury, either by blunting the sensibility of the system, already too torpid, or by promoting a dan- gerous determination 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 car- bonate 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 stomach, 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 ex- perience, however, has not furnished me with any evidence of the usefulness of this practice in the stage of collapse; but I have derived very manifest advan- tage from this emetic at an early period of the disease.* The tendency of forci- ble vomiting to excite the action of the heart and arteries and to impel the blood from ihe central vessels to the circumference, is indeed well known ; and it does not appear improbable, therefore, that 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 consists in a de- ficiency 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 phy- sicians, both in this country and in Europe, and several statements have been published strongly in favor of its usefulness. Mr. Wakefield, an English physi- cian of great respectabilily, 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 half a tumbler of tepid water, or occa- sionally, in a little thin, clear beef tea. R.—Supercarbonate of soda 3ss; mu- riate of soda 3i; chlorate of potass grs. vii. This was repeated every hour, and continued until the patients were recovering from the state of collapse ; after which it was diminished in frequency in proportion as the reaction increased."t * The mustard emetic is thus prepared. Dissolve a teaspoonful of common salt in a gill of warm water, and then mix with it a teaspoonful of finely powdered mustard. This is to be taken at one draught. "I" London Med. Gazette. Amer. Journ. of Med. Science, vol. x. p. 51. CHOLERA ASPHYXIA. 833 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, dissolved 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 recom- mended by Mr. Wakefield, and all but one, speedily and completely recovered." In accordance with the sentiments of Dr. Stevens, 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 perma- nency of its beneficial eflects. In New York and Philadelphia, this remedy was repeatedly tried, and a few cases have been mentioned in which it proved successful. Both this and the preceding mode of employing 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 influence. 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 re- vulsives ; but our success was small; no permanent reaction could be produced. At length I concluded that there was no absorption from the mucous membrane; 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 indications 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 ifci; powdered camphor ftss; powdered Cayenne pepper 3iv. Mix well together, and have the patient rubbed all over for half an hour at a time, and repeat the operation, ac- cordingly, till the mouth is affected. The success of this plan was perfectly astonishing. 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 indica- tions in cholera; but it is extremely doubtful whether this, or any other remedy, can avail aught in the state of " perfect collapse." When the disease has pro- ceeded to this extent, all remedial efforts are probably wholly unavailing; and if recovery from perfect collapse does 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 spasmodic and more advanced periods of the disease. Sinapisms, tartar emetic ointment, and turpentine, have been employed for this purpose. 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 decided 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 indication to fulfill, in the treatment of cholera, " is to keep up 53 834 CHOLERA ASPHYXIA. a constant impression upon the spinal marrow." With this view, he applies " over the whole tract of the spine, a strip of flannel, wet with a liniment com- posed 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 pro- duces 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 extremi- ties, with a decoction of mustard, to which some aqua ammonia is added, must be diligently made. If reaction takes place, there is generally much danger of excessive determina- tion of blood to the head; and many cases have terminated fatally, from sudden oppression of the brain, producing violent delirium or coma, or even convulsions, in the stage of reaction. During the first five or six hours after reaction com- mences, the case ought to be carefully watched, and the febrile action moderated, if it tends to become violent, by blood-letting. Very often, indeed, delirium 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 previously applied leeches or cups to the temples. During convalescence from cholera, the diet should be mild, digestible, 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 con- valescence 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. Amaurosis, Symptoms, Diagnosis, Prognosis, Causes, Treatment, Amenorrhcea, Causes, Treatment, Anasarca, Angina Pectoris, Pathology, - Treatment, Aorta, aneurism of, Apoplexy, Perfect or strong, Hydrocephalica, Diagnosis, - Prognosis, - Causes—predisposing, exciting, - Pathology, - Treatment, Arachnitis, Symptoms, Diagnosis, - Pathology, - Causes, Treatment, - Ascites, - - - Asphyxia, from drowning, Treatment, from irrespirable gases, Treatment, from electricity, Treatment, from cold, Treatment, Asthma, Symptoms, - Causes, Pathology, - Prognosis, - Treatment, Atmospheric heat, its relations with animal system, PAGE 570 572 ib. 573 ib. 574 805 80G ib. 740 621 622 624 615 433 434 435 ib. 436 437 438 440 443 216 217 219 220 221 221 738 596 ib. 598 601 ib. 602 603 ib. ib. 577 ib. 578 580 582 582 B. PAGE Bilious pleurisy, - - - 231 Treatment, - - - 235 rheumatism, - - - 291 fever, - - - - 101 colic, .... 657 Bladder, inflammation of, acute, - 277 chronic, - 279 Brain, inflammation of, - - 212,225 Bronchitis, acute ... 252 Diagnosis, - - - - 253 Post-mortem appearances, - - ib. Prognosis, - - - - 254 Treatment, ... ib. Bronchitis, chronic, - - - 256 Diagnosis, - 257 Post-mortem appearances, - - 258 Causes, .... ib. Treatment, - - - 259 Bronchocele, .... 764 Diagnosis, - - - - 765 Etiology, .--- 766 Treatment, ... 770 Bubo,.....803 the 40 Catalepsy, Diagnosis, - Causes, Prognosis, - Treatment, Catarrhal consumption, ophthalmia, Causes of fever in general, Their general character and sources Cerebritis, or softening of the brain Symptoms, Treatment, Chancre, Syphilitic, - Pseudo-syphilitic Chicken-pox, Chlorosis, Symptoms, - Causes, Treatment, 477 479 480 481 ib. 256 313 36 38 225 226 228 790 791 ib. 343 776 777 ib. 778 836 INDEX. PAGE Cholera Asphyxia, spasmodic, - - 821 Phenomena, ... ib. Cholera, diagnosis, ... 824 Post-mortem appearances, - - 824 Pathology, - - - - 825 Causes, - - - - 826 Not contagious, ... 828 Treatment, - - - 828 Cholera, of adults, - - - 645 Pathology, - ib. of infants, - - - 647 Treatment, ... 649 Treatment of cholera infantum, - 651 Chorea, - - - - - 4S2 Causes, - - - - 485 Pathology, - - - - 486 Prognosis, - ib. Treatment. ... 487 Clap, - - - - - 780 Cold, its effects on the animal system, - 40 Colica pictonum, ... gQO Causes, - - - - 662 Pathology, - ib. Treatment, - - - 663 Colic, flatulent, .... 655 Treatment, - - - 656 bilious, .... 657 Treatment, ... 658 Constipation, .... 669 Causes, .... 670 Remedies, - - - • ib. Consumption, pulmonary, - - 263 bronchial, - - 256 catarrhal, - - ib. Contagion, - - - - 55 fixed, solid, - - - ib. volatile, effluvium, - 56 Modes of disinfecting, - - 57 Continued fever, ... 120 Convulsions, of children, - - 491 Prognosis, .... 493 Carpo-pedal, - - . 494 Treatment, - - - 497 puerperal, - 510 Treatment, - - - 512 Cow-pox, - - . - 334 Its origin, .... fa Appearances, - 336 Prophylactic powers, - - 338 Causes of deterioration, - - ib. Effects upon diseases, - . 339 Croup, - 242 Symptoms, - ib. Causes, - - 243 Prognosis - - - - 246 Diagnosis, .... n Treatment, ... 247 Cynanche laryngea, ... 239 Symptoms, - - - 240 Treatment, ... i0 Cynanche trachealis, ... 242 Pathology, - - - - 243 Diagnosis, .... 246 Treatment, ... 247 Cystitis, • - . - 277 Symptoms, - . . ib. Cystitis, Suppuration, Causes, Treatment, Cystitis, chronic, Symptoms, Treatment, Cynanche tonsillaris, Symptoms, Causes, Treatment, D. Delirium tremens, Symptoms, Pathology, ... Prognosis, ... Treatment, Dementia, ... Diabetes insipidus, Symptoms, Causes, ... Treatment, Diabetes mellitus, Symptoms, Causes, ... Pathology, ... Post-mortem appearances, - Prognosis, ... Treatment, Diagnosis, general, Order of inquiry, - by the countenance, attitude and motions, nervous system, - alimentary canal, blood vessels, respiratory organs, cuticular surface, lymphatic system, secretions, Diarrhcea, - - . Causes, Prognosis, - Treatment, Dropsy, ... of the abdomen, of tbe brain, of the chest, of the cellular membranes, Treatment, Drowning, suffocation from. Dysentery, (mucous enteritis,) - Symptoms, Causes, Pathology, Prognosis, Treatment, Dysmenorrhoea, - Symptoms, - Pathology, - Treatment, - Dysury, - Causes, Treatment, - INDEX. 837 E. Eczema, Simplex, Rubrum, Impetiginodes, Chronic, Causes, Diagnosis, - Treatment, - Enteritis, acute peritoneal, Symptoms, - Diagnosis, Post-mortem appearances, Causes, Prognosis, - Treatment, - Enteritis, chronic, Causes, Post-mortem appearances, Treatment, - Enteritis, mucous, Causes, Prognosis, Treatment, - Enuresis, Epilepsy, Causes, Pathology, - Diagnosis, - Prognosis, - Treatment, - Epistaxis, Causes, Prognosis, - Treatment, - Erysipelas, phlegmonodes, oedematodes, - biliosum, neonatorum, - gangrenosum, Causes, Pathology, - Treatment, - Erythema, Causes, Diagnosis, - Treatment, - Exanthemata, minor, Fever, general pathology, Broussais's doctrine, general etiology, - general course and type, various stages, definition of type, Fever, intermitting, stages of, inflammatory variety, congestive, gastric, jnalignant, anomalous intermittents, ■ PAGE 397 ib. ib. ib. ib. 398 ib. ib. 171 ib. 172 173 ib. ib. ib. 187 188 ib. 189 176 178 180 ib. 730 460 463 465 466 ib. 4G7 411 ib. 412 ib. 370 371 372 ib. ib. ib. 374 375 ib. 400 401 ib. ib. 324 360 PAGE Fever, Prognosis, - - - - 87 Causes, - - - - 88 Treatment, - - - - 89 of inflammatory, - 92 of congestive, - - 93 of gastric, - . ib. of malignant, - - 94 Fever, remitting, - - - 101 Symptoms, - - - ib. gastric remittents, - - 103 hepatic remittents, - - 104 Causes, .... 106 Prognosis, - - - ib. Treatment, - - - ib. Fever, yellow, - - - -114 Symptoms, - ib. Etiology and origin, - - 115 Black vomit, what, - - ib. Post-mortem appearances, - - 116 Treatment, - - - 117 Fever, synocha, - - - 121 synochus, - - - ib. typhus, .... 122 Fever, inflammatory, ... 123 Symptoms, ... ib. Causes, .... 124 Treatment, - - - 130 Fever, common continued synochus, - 126 different forms of, - - ib. Causes, .... ib. Diagnosis, - - - -127 Prognosis, - - - - 130 Treatment, - - - - ib. Fever, typhus, .... 137 Symptoms, - - - 138 Causes and origin, - - - 140 Prognosis, - - - - 143 Treatment, - 144 Fever, scarlet, - - - - 354 varieties of, - - 355 sequela, ... 357 Diagnosis, - - - ib. Treatment, - - - - 358 Fluor Albus, - - - - 814 Causes, - - - - ib. Symptoms, - - - - 815 Treatment, - - - - 817 G. Gastralgia, . - 560 nature of, - - 560 Treatment, - - - 561 - 17 Gastritis, acute, - - - 163 - 20 Diagnosis, - - - 164 - 36 Causes, - - ib. - 58 Prognosis, - - ■ ib. - 59 Post-mortem appearances, - - ib. - 60 Treatment, - - - 165 - 83 Gastritis, chronic, - - 16Q - ib. Symptoms, - - - ib. - 85 Causes, - - 167 - ib. Diagnosis, - - - 168 ■ ib. Postmortem appearances, - - 169 - ib. Treatment, - - - 170 - 86 Glossitis, - - 158 838 INDEX. Glossitis, Treatment, - Goitre, - where found, Causes, - . . Treatment, - Gonorrhceal rheumatism, Gonorrhoea, - Symptoms, - in woman, Secondary symptoms, Excoriations, Treatment, - . . Gout, regular, ... irregular chronic, - Diagnosis, ... Causes, ... proximate, - Treatment, - H. Haematemesis, - Causes, Prognosis, - Treatment, ... Haematuria, ... Causes, - . . Treatment, - Haemoptysis, ... Predisposition, Causes, - . . Prognosis, - Treatment, ... Hemorrhages, ... Pathology, - Effects on the system, Causes, - Prognosis, - - . Treatment, - Hemorrhoids, - Molimina and consequences, Local affections, Causes, - Treatment of local affections, Treatment of hemorrhage, - Treatment of tumours, Heart, chronic diseases of, hypertrophy of, - dilatation of, sympathetic disturbance of, Treatment, - Heat, atmospheric, Hemiplegia, Treatment, - Hepatitis, acute, Terminations, Diagnosis, - Causes, - Treatment, - - . Hepatitis, chronic, Post-mortem appearances, - Treatment, - Herpes phlyctenodes, Diagnosis, zona zoster, Treatment, PAGE PAGE Herpes circinnatus, - 383 - 158 Treatment, - 384 - 764 labialis, ... ■ ib. - 765 preputialis, - ib. - 766 Treatment, ■ 385 - 770 Hydrocephalus acutus, - - 216 - 291 Symptoms, - - 217 - 780 Diagnosis, ... ■ 219 - 781 Pathology, ... ■ 220 - 782 Post-mortem appearances, - • ib. - ib. Causes, ... • 221 - 783 Treatment, ... ■ ib. - ti. Hydrophobia, ... ■ 524 . 303 Symptoms, - - . 527 - 304 Post-mortem appearances, - 529 - 306 Treatment, ... 530 - ib. Hydrops, .... 734 - 307 General symptoms, 737 - 308 Hydrothorax, .... 739 Hysteria, convulsive, 499 chronic, ... 500 Hysteric torpor, ib. - 413 Pathology, - 501 - 414 Causes, .... 502 - ib. Diagnosis, - 503 - 415 Treatment, - 504 - 416 Hysteritis, acute, 281 - ib. Treatment, - - . . 282 - 417 Hysteritis, chronic, ... 284 - 418 Phenomena, ... 285 - 419 Treatment, - - . . ib. - ib. - ib. - 420 I. - 406 - 407 Icterus, - 687 - 408 Causes, - 690 - 409 Pathology, - 691 - 410 Prognosis, - 692 - 411 Treatment, - 693 - 679 Idio-miasmata, - 49 - ib. Effects on the human system, 50 - 681 Effects in conjunction with koino- - 682 miasmata, ... 51 - 683 Idiotism, '. 545 - 684 Ileus, - 666 - 685 Pathology, .... 667 - 607 Treatment, - 668 - 613 Indigestion, - 626 - 614 Causes, - 627 - 619 Symptoms, - 630 - 616 Treatment, - 631 - 40 Inflammation in general, 153 - 448 Phenomena, ... ib. - 455 Pathology, - . . . 154 - 200 Terminations, ... 155 - 201 Inflammation of the brain, - 212 & 225 - 202 of the meninges, - 221 - 203 of the stomach, acute, 171 - 204 of the stomach, chronic, - 166 - 207 of the peritoneum, acute, - 190 ib. of the peritoneum, chronic, 196 • 208 of the bowels, peritoneal, 162 - 380 of the bowels, acute, mu- - 381 cous, 163 ib. of the bowels, chronic, rr.u- - 3S2 cous, 176 INDEX. 839 Inflammation, of the liver, acute, chronic, of the spleen, acute, chronic, of the kidneys, acute, of the bladder, acute, of the bladder, chronic, of the trachea, of the bronchia, mucous, of the bronchia, chronic, of the pleura, acute, of the lungs, of the larynx, of the tonsils, of the tongue, of the eyes, catarrhal, of the eyes, rheumatic, of the eyes, gonorrhasal, of the eyes, purulent, of the eyes, scrofulous, of the iris, of the parotid gland, of the pericardium, of the womb, acute, chronic, Intermitting fever, Intestinal worms, Causes which favor their production Their origin, Tricocephalus dispar, Ascaris vermicularis, Ascaris lumbricoides, Taenia lata, Taenia solium, Symptoms, - Treatment of ascarides, of lumbrici, of taenia, Alston's method, Desault's method, - Herrenschwand's method, - Hufeland's method - Nouffer's method, - Schmucker's method, Bremser's method, - Iritis, Treatment, - Ischuria renalis, - Causes, - Prognosis, - Treatment, - J. Jaundice, Causes, Pathology, Treatment, PAGE 200 207 210 212 274 277 279 242 252 256 228 230 239 159 158 313 ib. 315 316 315 319 377 161 2S6 281 284 83 671 672 ib. 673 ib. ib. ib. ib. ib. 675 ib. 676 ib. ib. ib. ib. ib. 679 ib. 322 323 707 718 719 720 Koino-m iasmata, Effects on the animal system, Union of koino and idio-miasmata, L. 687 690 692 693 K. Koino-miasmata, • How generated, Physical characters, 44 ib. 45 Laryngitis, Symptoms, - Prognosis, - Treatment, - Leucorrhoea, Causes, Symptoms, - Pathology, - Treatment, - Lichen simplex, agrius, - Causes, Diagnosis, • Treatment, - Lithiasis, Urinary deposits, Pulverulent deposits, - Crystallized do. Solid concretions, Lithic acid diathesis, Amorphous lithic sediments, Yellow deposits, - - - Red or lateritious sediments, Pink sediments, - - - Causes of the lithic acid sediments, Causes of crystallized deposits, Phosphatic diathesis, Treatment, - - - - Treatment of lithic acid diathesis, - of phosphatic diathesis, Liver, inflammation of, acute, - chronic, M. Malaria, (marsh,) Mania, - - - - - Mania-apotu, - - - - Cause, - Symptoms, - - - - Treatment, - Measles, - inflammatory, - congestive, - typhous or malignant, - gastric, Sequela?, - - - - Diagnosis, - Prognosis, - - - ■ Treatment, - Menorrhagia, - chronic, - : Effects on the system, Causes, Treatment, - Mental derangement, Causes, - Prognosis, - - - • Post-mortem appearances, - Treatment, - 50 53 239 240 ib. 241 814 ib. 815 816 817 394 395 ib. ib. 396 710 ib. ib. ib. 711 ib. ib. ib. ib. 712 ib. ib. 713 714 ib. 716 200 207 43 542 551 552 553 554 346 349 ib. ib. ib. 350 ib. ib. 351 422 ib. 423 424 ib. 534 535 539 541 545 840 INDEX. Miasmata, idio, ... Miasmata, koino, Infection, what, Physical character, - Morbific influence, - Union of koino and idio-miasmata, Miliary fever, Causes, ... Nature, Treatment, ... Modified small-pox, Monomania, ... Morbilli, (measles,) Mumps, (parotitis,) N. Nephritis, Diagnosis, - Causes, Treatment, - Nervous affections, chronic, Nettle-rash (urticaria), - Treatment, - Neuralgia, Symptoms, - Causes, Pathology, - Diagnosis, - Treatment, - 0. Ophthalmia, catarrhal, - Treatment, rheumatic, - Treatment, gonorrhceal, purulent, - Treatment, scrofulous, - Treatment, syphilitic, - PAGE 49 44 ib. 40 48 53 392 393 ib. 394 340 543 346 161 274 ib. 276 ib. 430 390 392 557 55S 562 ib. 503 564 313 ib. ib. 315 ib. 316 315 317 319 320 322 Painter's colic, - . . 660 Palsy, - - . 447 Pathology, - - - 448 Hemiplegia, - - 449 Paraplegia, - - - 450 Partial paralysis > - 451 of the face, . 454 of the wrist, - ib. Causes, - - 452 Treatment, - . - 455 Parotitis, . - 161 Character, - - - 102 Treatment, - - - 103 Peritonitis, acute, ■ - 190 Symptoms,- - 191 Causes, - - 192 Terminations, - ib. Post-mortem appearances. - ib. Peritonitis, acute, Treatment, - - 193 chronic, - - - 196 Causes, - - - 197 Post-mortem appearances, - ib. Terminations, - - ib. Treatment, - - 198 Pemphigus, acute, - - - 385 chronic, (pompholix.) - 387 Causes, ... - 388 Diagnosis, - ib. Prognosis, ... - 389 Treatment, - ib. Pericarditis, .... 236 Diagnosis, .... 287 Causes, - - - - 288 Chronic, - - - - 289 Treatment, - • - - ib. Peripneumonia, - 230 Peripneumonia notha, - - - 252 Diagnosis, .... 253 Postmortem appearances, - - ib. Treatment, - - - - 254 Phlegmasia dolens, - - - 426 Pathology, - - - - 427 Treatment, - - - - 429 Phrenitis. (phrensy,) - - - 213 Character, - - - ib. Causes, - - - - ib. Prognosis, - - - - ib. Pathology, . - - - 214 Treatment, .... ib. Phthisis pulmonalis, ... 263 Phthisis, tubercular, ... 266 Nature, - - - 268 Prognosis, - - 269 Treatment, - - 270 tracheal, ... 264 Symptoms, • ib. Causes, - - ib. Prognosis, - - ib. Treatment, - - ib. imposthumous, - - 265 melanotic, - - - 265 cancerous, - - -265 granular, - - - 266 pleuritic, ... 264 bronchial, ... 256 Diagnosis, - • 258 Treatment, - - 259 Piles, (hemorrhoids,) ... 679 Pneumonia, (pleurisy,) acute, - - 228 Causes, - . . 229 Post-mortem appearances, • - ib. Prognosis, - - - - 230 Treatment, ... fa. Pneumonia, (lungs,) - - - 230 Symptoms, ... 231 Terminations, ... ib. Pneumonia biliosa, - - . 231 Post-mortem appearances, - - 231 Engorgement, ... 232 Red hepatization, ... ib. Gray hepatization, ... fa. Gangrene, .... fa Diagnosis, .... 233 Prognosis, - - - - 234 INDEX. 841 Pneumonia biliosa, Treatment, - Pneumothorax, - Symptoms, Diagnosis, - Treatment, Puerperal convulsions, Phenomena, Varieties, Treatment, - Purulent ophthalmia, gonorrhceal, Egyptian, infantile, Purpura, simple, hemorrhagica, Pathology, - Treatment, Quinsy, (tonsillitis,) Causes, Treatment, R. Remitting fever, Retention of urine, Causes, ... from paralysis of the bladder, inflammation, spasm of urethra, - mechanical obstruction, Renal retention of urine, Treatment, Rheumatic ophthalmia, - Rheumatism, acute, bilious, Prognosis, - Causes, ... Metastasis, Diagnosis, - Treatment, Rheumatism, chronic, Causes, ... Treatment, Rheumatism, gonorrhceal, Ringworm, (herpes circinnatus,) Remedies, Roseola, Diagnosis, - - - Prognosis, - Treatment, Rubeola. (See Measles,) Symptoms, Modifications, Diagnosis, - - - Prognosis, - Treatment, Scarlatina, PAGE 235 004 ib. 005 ib. 510 ib. 511 512 • 315 • 316 ■ ib. ■ ib. ■ 402 . ib. ■ 403 • 404 ■ 405 159 160 ib. 101 720 ib. ib. 722 723 ib. 724 ib. 315 290 291 ib. 292 293 294 294 298 299 300 291 383 384 401 401 ib. ib. 340 347 349 350 ib. 350 354 Scarlatina, simplex, anginosa, maligna, Sequela, ... Diagnosis, - Prognosis, ... Treatment, general, local, Scorbutus, (scurvy,) Symptoms and general progress, Causes, ... Post-mortem phenomena, - Prognosis, - Treatment, Scrofula, ... Causes, ... Treatment, Scurvy, ... Scrofulous ophthalmia, Shingles, Small-pox, Small-pox, confluent, Small-pox, modified, Phenomena, Softening of the brain, - Splenitis, ... terminations, - Treatment, St. Anthony's fire, Stomach, acute inflammation, chronic, Strangury, Strumous iritis, Suspended animation, - Suffocation from drowning, from irrespirable gases, Syphilitic iritis, Syphilis, - - origin, primary ulcers, venerola vulgaris, indurated sloughing ulcer, phagedenic ulcer, syphilitic chancre, constitutional syphilis, treatment of primary ulcers, treatment of constitutional dis ease, T. Tetanus, Idiopathic, - Traumatic, Causes, Pathology, - Prognosis, - Treatment, Tic douloureux, (neuralgia,) Tongue, inflammation of, Tonsils, inflammation of, Causes, Treatment, Tubercular consumption, Causes, Prognosis, - PAGE ib. 355 356 357 ib. 358 300 367 772 772 773 ib. 774 ib. 753 756 757 772 319 381 324 327 340 ib. 227 210 ib. 212 370 171 187 729 322 596 ib. 101 322 728 ib. 790 792 794 794 798 ib. 795 . 799 513 ib. ib. 514 510 517 518 557 158 159 160 ib. 266 208 269 842 INDEX. Tubercular consumption, Treatment, Typhus, U. V. Variola, distinct, confluent, crystalline, suppuration, consequences, - Post-mortem appearances, 270 137 Urticaria, - 390 febrilis, - ib. evanida, - ib. tuberosa, - 391 subcutanea, Causes, - ib. - ib. Prognosis, -Treatment, Urine, retention of, - ib. - 392 - 720 incontinence of, - - 730 Uterus, inflammation of, - 281 chronic, - 284 hemorrhage from, - 422 324 325 327 328 ib. 329 ib. Variola, Treatment, - - 331 Vaccina, - - 334 phenomena and progress, - 335 origin, - - ■ ib. Diagnosis, - - - 337 Varioloid affections, - - 340 Varicella, . . 343 Character, ■ • 344 Symptoms, - - 345 Vitus's, St., dance, (Chorea,) - - 482 w. Whooping cough, Phenomena, Pathology, - Treatment, Worms, intestinal, Yellow fever, - Zona, 586 587 589 592 671 114 381 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 urinae, a scalding urine. Arthritis, rheumatic pains of the joints. Asphyxia, apparent death, suspended animation. Asthenia, diminished vital energy. Axungia, hog's lard. B. Belladonna, deadly nightshade. Blennorrhea, a morbid secretion of mucus. Bronchia, the air tubes in the lungs. Bronchotomy, an incision into the windpipe. 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. Carclia, the upper orifice of the stomach. Cardiac region, the pit of the stomach. Carotids, the arteries that convey the blood to the head. 844 GLOSSARY. Catamenia, the monthly discharge of females. Cataplasm, a poultice. Catheter, a hollow tube for drawing off the urine. Cephalalgia, headache. 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 process of digestion in the stomach, and has passed into the bowels. Colliquative stools, profuse watery discharges from the bowels. Collyrium, 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 co- agulable lymph. D. Dejections, alvine, evacuations by the bowels. Deliquium, fainting. Demulcents, soothing, mucilaginous fluids, as flaxseed tea. Dentition, teething. Derivatives, remedial 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. Emesis, vomiting. Emetic, a medicine that causes vomiting. Emulsion, a milk-like fluid, formed by mixing oily or resinous substances, 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 localities or dis- tricts. 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. GLOSSARY. 845 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. Exsanguious, 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 inter- mitting fever; as bark. Febrile, feverish. Fistula, a deep tube-like ulcer. Foramen, an opening, or hole. Fracnum, 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. Gangrene, mortification. Gastralgia, pains in the stomach without fever. Gastric, relating to the stomach. Gastritis, inflammation of the stomach. 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 drops. * H. Haematemesis, vomiting of blood. Haematuria, voiding bloody urine. Haemoptysis, bleeding from the lungs. Haustus, a draught of liquid medicine. Hectic, a slow habitual fever, with sweats and emaciation. Hemicrania, pain on one side of the head. Hemiplegia, palsy on one side. Hemorrhage, bleeding from any part of the body. Hemorrhoids, piles. Hepatization, 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. 846 GLOSSARY. Hydragogue, a purge that produces watery stools. Hydrocephalus, dropsy in the head. Hydropic, dropsical. Hyper catharsis, excessive purging. I. latraleptic, 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 ring-worm. Integuments, the skin. Irritability, the capacity of being excited into action. Ischuria, difficulty or stoppage of urine. L. Lactation, the act of suckling. Laedentia, medicines, or other agents that cause injury. Lateritious, like brick-dust, brick-colored. Leucophlegmatic, a pale, relaxed, debilitated, and torpid state of the body. Leucorrhcea, the whites. Liniment, a very thin ointment. 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 putrefying substances. 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. v 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. O. GZdema, swelling from a dropsical collection in the cellular membrane. Oesophagus, the gullet. Olfactory, relating to the sense of smelling. Ophthalmia, inflammation of the eyes. Opiate, a medicine whose prominent ingredient is opium. GLOSSARY. 847 Organic affection, a disease in which more or less of the substance of a part is changed, or disordered. Orthopnosa, 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 appearances 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. 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 forward their contents. Pharmaceutic, relating to the compounding, &c, of medicines. Pharynx, the top of the gullet. Phlegmasia, inflammation. Phlegmonous, inflammatory. Phlogosis, superficial inflammation. Phimosis, contraction of the foreskin, so as to prevent it being drawn back. Plethora, fullness 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 th^at returns daily. R. Rachialgia, colic, with costiveness and vomiting. Rachitis, rickets. RamoUissement, 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. 848 GLOSSARY. 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, degenerate 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 substance from the blood. 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. Synocha, 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. Tormina, griping pain. Tubercles, small, hard tumors, resembling cheese in their internal structure. Type, the peculiar form assumed by a fever as to the period intervening between its paroxysms or exacerbations. Typhoid, resembling typhus fever. U. Ureters, the tubes which convey the urine from the kidneys to the bladder. Urethra, the canal of the penis, through which the urine is discharged. Utero-gestalion, the term of pregnancy. Uterus, the womb. V0 Vaccina, cow-pox. Vesication, blistering. To all Physicians and Medical Students. NEW AND VALUABLE MEDICAL BOOKS, JUST PUBLISHED BY GKIGG, ELLIOT & CO., No. 14 North Fourth St., PHILADELPHIA. And For Sale by Booksellers generally in the United States, DR. WOOD'S PRACTICE. A TREATISE ON THE PRACTICE OP MEDICINE. IN TWO VOLS. OCTAVO. SECOND EDITION, IMPROVED. BY GEORGE B. WOOD, M.D., Author of the " Dispensatory of the U. S.," &c. &c. We pronounce the Treatise of Dr. Wood to be one of the most valuable works that has come from the American press, and exceedingly creditable to the zeal and abilities of the accomplished author.— Philadelphia Medical Examiner. 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