M ARMY MEDICAL LIBRARY WASHINGTON Founded. 1836 Section. Number 13J.£CJa) Fobm 113c, W. D.. S. G. O. 3__10543 (Revised June 13, 1936) /. ,'^-T, AMERICAN CYCLOPEDIA OF PRACTICAL MEDICINE AND SURGERY CONTRIBUTORS TO THIS VOLUME. E^l^^B^^M.^Pjtoofl^^^ AceticAcid. Acids; Acupunc. Chemistry in the Philadelphia College of ^ turg ^^ AMM AlkaUeg £um Ua?y ^'.^ . r!01^. . . C?! "."J Alumim; Am^> Ammonia; &c. N. CHAPMAN, M. D., Professor of the In-"! stitutes and Practice of Physic and Clinical > Angina Pectoris. Practice in the University of Pennsylvania. J REYNELL COATES M D I Abdomen (Surgical Pathology of); Adhe. ' .............^ sion. D F CONDIE M D \ Acrodynia; Ages; Amnesia; Anasarca; W. P. DEBTEES, M. D., Adjunct Professor 1 of Midwifery in the University of Penn- \ Abortion; After-Pains; Amenorrhea. sylvania.............................J GOUVERNEUR EMERSON, M. D...... Achor; Acne; Affusion; Alopecia. E. GEDDINGS, M. D., Professor of Ana-\^men (Anat. of); Acephalus ■ Acervulus tomy in the University of Maryland .... \ C.ere^n; A.dlP°se ^$ue' Amputation ; J J J J Anatomy; Anencephalous. Abortion (Med. Leg.); Absorbents; Acaly- pha ; Acclimatement; Acer ; Achillea ; Aetata; Adiantum; Adipocere; ASsculus; Agave; Ages (Med. Leg.); Agrimonia ; Alcornoque; Alexipharmic ; Alisma; AU pinia; Althaa ; Ambergris; Amomum; Anagallis; Analeptics ; Anaphrodisia ; Anda ; Andira ; Anemone, SfC R. E. GRIFFITH, M. D., Editor of the Jour- nal of the Philadelphia College of Pharmacy. THOMAS HARRIS, M. D., Surgeon in theT United States' Navy, and one of the Sur- > Abscess. geons to the Pennsylvania Hospital......J H. L. HODGE, M. D., one of the Physi- cians to the Pennsylvania Hospital...... Aneurism. WM. E. HORNER, M. D., Professor of ) , , , . Anatomy in the University of Pennsylvania. \ Amlmlance S At SAMUEL JACKSON, M. D., Assistant to^) the Professor of the Institutes and Practice | of Medicine in the University of Pennsyl- V Absorption; Alteratives ; Anemia. vania, and one of the Physicians to the J Pennsylvania Alms House Infirmary .... J J. C. WARREN, M. D., Professor of Ana-"J tomy and Surgery in Harvard University, V Air, its action when admitted into the veins. Abies; Acacia; Aconite; Aconitum; Aco- rus ; Agathosma; Aletris ; Alkanet; Al. Hum; Almonds; Alnus; Aloe; Moes; Ammonia; Ammoniac; Amygdalus; Amy- ris; Anacardium ; Anchusa; Anethum ; Angelica. Abdomen (Physiology, Symptomatology and Pathology of); Abstinence; Action ; Ady- namia ; Mgilops; Agony; Air (action upon the tissues of); Albino ; Aleze ; Amaurosis; Anchylops; Anchyloblepha- ron ; Angeial; &c. &c. Boston GEORGE B. WOOD, Professor of Mat. Med. and Pharmacy in the Philadelphia College of Pharmacy................. ISAAC HAYS, M. D., one of the Surgeons to Wills' Hospital, &c................. " J XilBRARY OF THE MEDICAL SCIENCES. THE AMERICAN CYCLOPEDIA OF PRACTICAL MEDICINE AND SURGERY; A DIGEST OF MEDICAL LITERATURE.- edited BY ISAAC HIAYS, M. D. SURGEON TO WILLS' HOSPITAL; PHYSICIAN TO THE PHILADELPHIA ORPHAN ASYLUM; MEMBER OF THE AMERICAN PHILOSOPHICAL SOCIETY, &c. &c. &c. VOL. I. /3/*t> ^hflatJclphfa: CAREY, LEA, & BLANCHARD. 1834. v-t Entered according to the act of congress, in the year 1834, by Carey, Lea, & Blanchard, in the clerk's office of the district court of the eastern district of Pennsylvania. THE CYCLOPEDIA PRACTICAL MEDICINE AND SURGERY. A. In composition. This letter, the a privative in Greek, and a, particle, in Latin, signifies a negation—the absence, want, or privation of a thing: thus, aphonia, without voice, from a priv. and $eponderance in the male greater than it is in reality. But what- ever may be its characters, it is always occasioned by an arrest of development taking place in the two lateral halves of the inferior portion of the anterior abdom- inal parietes, before they are united with each other upon the median line; and a defect of the structures of this region, va- rying in magnitude, according to the pe- riod at which the interruption takes place, is the necessary consequence ;—a defect, which not only involves the integuments and muscles, but in many instances even implicates the symphisis pubis, and the whole extent of the anterior wall of the bladder. We shall not speak particularly in this place of those congenital defects of the di- aphragm which sometimes allow one or more of the organs of the abdomen to pass into the cavity of the thorax. This con- stitutes a genuine diaphragmatic hernia, for the characters of which see Hernia. It will be sufficient, on the present occa- sion, to state that the characters exhibited by the organic deviation which takes place at this point, will differ according to the extent of the defect of the diaphragm, the presence or absence of the peritonaeum upon the surface of the protruded organs, and the nature of the part which has pro- truded. The most usual seat of the de- fective development of the diaphragm is ABDOMEN. {Anat.) 35 immediately behind the sternum, or at the several points at which that muscle is traversed by the aorta, the oesophagus, or the vena cava. Whenever the resistance of any one of these points is too weak for the impulse communicated to the viscera by the walls of the abdomen, the organs may be forced upwards into the cavity of the thorax, and thus give rise to a dia- phragmatic hernia. Meckel has figured the case of a hemi-cephalic foetus, which was also affected with spina bifida, in which the stomach, the principal part of the small intestines, and the spleen, passed through an opening in the diaphragm into the left side of the thorax, and compressed the corresponding lung. {Tabula Anato- mico-Pathologica. Fasc. 4. Plate 32. p. 15. Fol. Lipsiae, 1826.) In a second case figured byjhe same distinguished anatom- ist in another work, {Descriptio Monstro- ru?n Nonntdlorum. 4to. Tab. III. Fig. 1. p. 26. Lipsiae. 1826.) the left lobe of the liver, the stomach, and spleen, protruded through an opening in the left side of the diaphragm, of an inch and a half in diam- eter, and filled nearly the whole extent of the left cavity of the thorax. Other ex- amples of a similar vice of conformation, observed in children at birth, have been re- ported by Zwanzio, {in Meckel. Tab. Anat. Path. Sup. Cit. Tab. 32. Fig. 2.) .Macaulay, {Med. Observations and In- quir. Vol. I. No. 4.) Campbell, {Edin- burgh Med. and Surg. Journal. XVII. 513,) &c. In one case described by Macaulay, the stomach and greater part of the intestines, with the spleen and part of the pancreas, were found in the left cavity of the thorax; and in a second case, the small intestines and part of the liver had protruded into the right cavity of the thorax. In an instance observed by Zwan- zig, the stomach, spleen, and the small and large intestines, protruded through a large opening in the costal portion of the dia- phragm of the left side, and entered the corresponding side of the thorax. Camp- bell has also reported a case, in which nearly the whole of the stomach, the small and the whole of the large intestines, ex- cept the descending portion, the spleen, and pancreas, occupied the left thoracic cavity; and in the New-York Med. Re- pos., N. S. IV. 178, a drawing and notice of a case is given by Dr. Ramsay, in which the stomach and great intestines were transferred into the left thoracic cavity. Examples of this kind might be consider- ably multiplied, especially if we were to quote those cases in which the displace- ment in question has taken place rather as an acquired than as a primitive vice of conformation. But as those instances can be more appropriately brought in under the head of Hernia, we shall pass them over in this place. It may be stated, how- ever, in conclusion, that when a consider- able portion of the abdominal organs passes through the diaphragm into the thorax, their encroachment upon the organs of the latter cavity will tend to interrupt their development, or if they have been previ- ously formed, to impede their functions, and occasion an atrophy of their substance. 2. Deviations of Form dependent upon a preternatural adivity of the formative powers. {Vices of excess.) As it is not our intention, in the course of the present article, to consider the vices of conformation of the individual organs, in which the influence of the preternatural energy of the formative powers is partic- ularly manifested, in the multiplication of accessory organs or portions of organs, there will be little necessary to be said upon the few deviations of this character which implicate the parietes of the abdo- men. These consist, for the most part, of the multiplication of the muscles and ves- sels; the inordinate prolongation of the ensiform cartilage of the sternum; the de- velopment of a second foetus or some por- tion of a fcetus, in connexion with the ab- domen of the first, &c. , The most simple deviation of the latter kind, is the attachment of a rudiment of an upper or lower extremity of a second foetus upon the abdomen of one more per- fectly formed. A case of this kind was observed by Plancus. {De Monst. Venet 1748. p. 10. Meckel.) A lower extrem- ity was engrafted upon the anterior face of the pubis, from whence it ascended he- fore the abdomen, but was much less per- fectly developed than the normal extrem- ity of the individual. More frequently, however, the multiplication is much more considerable, the supernumerary parts con- sisting of a considerable proportion of the trunk or extremities of a second individ- ual, or even of an entire fcetus perfectly formed, connected with the first, either by the anterior or lateral face of the abdo- men. A great number of cases of this kind exist on record, but for an account of them we must refer to the works of those who have treated on the subject of mon- strosities, and especially to those of Hal- ler, {Opera Minora. Lib. III.) Van Dosv- erin, {Observat. Anat.) Ruysch, {The- saurus Anatomica.) Meckel, {De dupli- citata Monstrosa. Fol. Lips. 1826., also Handbuch der Pathologischen Anato- mie.) Otto, {Seltene Beobachtungcn.) Geoffroy St. Hilaire, {Philosoph. An- 36 atomique. 1822. Elbin, {De monst.corde carent.) Isidore Geoffroy St. Hilaire, {Anomalies de V Organization.) Serres, {Anatomie Transcendante.) &c. 3. Deviations of the situations and re- lations of the organs contained within the cavity of the Abdomen. The organs which occupy the cavity of the abdomen are subject to a great variety of displacements and transpositions. These may take place in a single organ, or may involve the whole of those which are in- cluded within the cavity; the displace- ment of one generally giving rise to a similar condition of some other; and when the preternatural situation of the different j)arts is owing to a congenital perversion of the laws which preside over their de- velopment we sometimes find all the or- gans of the abdomen and thorax completely transposed, those which should occupy the left side of the body being placed on the right and vice versa. Those parts which are most moveable are generally most li- able to accidental displacements. Thus, the transverse arch of the colon, being merely confined by a thin duplicature. of the peritonaeum, is frequently found drawn from its natural situation, and in some cases even descending as low as the pubis, or into the cavity of the pelvis. Under these circumstances, it generally tends to carry the lower extremity of the stomach with it in its displacement; the upper ex- tremity being fixed firmly to the diaphragm will of course resist the dragging force of the colon. The caecum, as well as the ascending and descending portions of the colon, may also be displaced by the de- velopment of large abdominal tumours, and the agency of other causes, which by sub- mitting the peritonaeum to an inordinate degree of distension, expose the organs to a kind of traction by which they may have their situation and relations entirely chang- ed. Many of these modifications in the position of the intestines are important in relation to the diseases to which they are liable; for it not unfrequently happens, that some mal-position of the colon, or even of the small intestines, occasions such an obstacle to the passage of the contents of the organ, as to submit the individual to violent and repeated colics, severe intes- tinal inflammation, and, in some cases, to strangulation and mortification. We have seen death occasioned by a constriction of the sigmoid flexure of the colon, in an in- dividual in whom that intestine was so pretematurally long as to form numerous convolutions, in one of the folds of which a portion of it became constricted so as to ABDOMEN. (Anat.) occasion a complete obstruction to the course of the feces. This accident is gen- erally facilitated by the development of adhesive inflammation upon the peritonaeal surface of the intestine, by which its con- volutions are frequently agglutinated, or numerous shreds or bands of an adventi- tious character are formed which may be- come a means of constricting the gut. The liver, spleen, pancreas, and kidneys, are also frequently removed to a considerable distance from their natural situation, either in consequence of an inordinate augmenta- tion of their volume, or the influence ex- ercised upon them by some neighbouring part In some cases the right lobe of the liver has been found reposing upon the brim of the pelvis, and the right kidney low down in the iliac region, while the corresponding portion of the .colon, the cardiac orifice of the stomach, and the duodenum, have also been drawn down- wards considerably below the level of their proper position. The spleen and left kid- ney may be displaced by the same causes that influence the organs just mentioned, and have accordingly been often found lodged in the left iliac fossa, or even de- scending into the upper portion of the cavity of the pelvis. In all these cases, as the situation and relations of the organs are changed, corresponding modifications must be developed in their pathological manifestations. But as we cannot under ordinary circumstances, be certainly ap- prized, during the life of the patient that any displacement of the abdominal viscera has taken place, we should be exceedingly liable, in exploring the abdomen for the purposes of diagnosis, to form erroneous conclusions. Mistakes of this kind have been frequently made, and are very often unavoidable. But the most remarkable examples of a mal-position of the abdominal organs, are those which consist of a complete transpo- sition of a part or the whole of them. Thin deviation is seldom confined to the abdo- men, but generally implicates the organs of the thorax at the same time, as well as the great vessels which arise from the arch of the aorta. The most simple devi- ations of the kind consist of a simple mul- tiplication of the parts of an organ upon the one or the other side of the body. This is manifested in the division of the left lung into three instead of two lobes; a preternatural division of the right or left lobe of the liver; the development of the pyloric valve of the stomach in the cardiac orifice of that organ, while the usual ar- rangement of the pyloric orifice is deficient. ABDOMEN. {Anat.) 37 This disposition of the parts would seem, at first sight to prove that a complete transposition of the organs had taken place; for when the left lung presents three lobes, the right presents merely two, and where a valve is developed in the cardiac orifice of the stomach, that of the pylorus is usu- ally deficient In the heart, moreover, we sometimes observe that the two ventricles seem to exchange characters, even though the arteries pass off as usual, the left ven- tricle being inordinately attenuated, while the right is thick and strong, and presents all the characters which generally apper- tain to the left. These phenomena are not the result of an absolute transposition, but arise from the influence of a law of the living organism which has been illus- trated by Geoffroy St. Hilaire, {Philo- sophic Anatomique, p. 244.) and which he has denominated the law of equilibrium, {principe du balancement des organs.) According to this law, whenever one or- gan, or set of organs, acquires an aug- mentation of volume or development, such increase is made at the expense of some other. If then we make an application of this principle to the cases under consider- ation, we shall find, as already stated, that whenever the organ on the one side or the other has undergone a multiplication of parts, or an increase of volume, it has been at the expense of that of the other. Thus in the lung, which has been mentioned as an example, that on the right side usually presents only two lobes, where those on the left have been multiplied to three; and in the heart, the preponderance of develop- ment in the right ventricle is attended with a corresponding defect of the growth of the left. The same thing is observed in those cases in which the pyloric valve is formed in the cardiac instead of the pyloric orifice of the stomach. (Meckel, Handbuch der Pathologischen Anatomie, Band II. p. 183.) These facts demonstrate a gradual transition from the normal type of the or- ganization to'a state in which some por- tions of it assume an important deviation from that condition; and tracing out the different degrees in the scale, we 6hall find a variety of intermediate stadia, between a slight deviation in the situation of the organs concerned, and a complete transpo- sition of those which occupy the left, to the right side of the body, and vice versa. In those cases in which the deviation is more considerable, the transposition may involve the whole of the organs of both the abdomen and thorax, or it may be con- fined to one or more of them, the others occupying their natural situation. Thus VOL. I. 4 in a case reported by Mentel, (Voigtel, Pathologischen Anatomie, Band II. p. 314.) the liver was situated in the left hypochondriac region, and the spleen in the right: the heart was also inclined to the right side of the thorax. Sandifort {Obs. Anat. Fasc. 1.) and Ludwig {Obs. de Situ praternat. vise. inf. Vent. Meck- el, Loc. Cit.) found the caecum in the left side of the abdomen; and Sampson {Phi- losophical Transactions, IX. 746.) reports a case in which the liver occupied the left; the spleen the right hypochondriac region. The first flexure of the jejunum, and the sigmoid flexure of the colon, were situated in the right side of the abdo- men. The aorta descended in front of the vertebral column, but the vena cava was placed on the left side, where it passed through the fissure of the liver as usual. In a case reported by Heuermann, {Phil. Bemurkungen, Band I. p. 18. Meckel,) all the organs of the abdomen were trans- posed, while those of the thorax occupied their normal situation; and in a case ob- served by Abernethy, {Phil. Transact. 1793, p. 59,) a condition nearly the reverse of this existed: all the thoracic organs were transposed, while the liver occupied the median line of the abdomen, and had its lobes extending equally into the right and left hypochondria. The portal vein opened directly into the inferior cava without enter- ing the liver, and the hepatic vein passed through the left side of the diaphragm. The records of the science also furnish numerous examples of a complete transpo- sition of all the organs of both the abdo- men and thorax. We met with a case of this kind a few years ago in the body of a male subject, who lived to an advanced age; and Professor Smith, of the Univer- sity of Maryland, has reported to us the particulars of a similar case, which occur- red in a female. Other examples of the same nature have been communicated by Mery, {Mem. de VAcad. des Sciences, 1743, p. 519,) Sue, {Memoires et Prix, Tom. I. p. 292,) Morand, {Hist, de VAcad. des Sciences, 1688, p. 44,) Hoffman, {Car- dianaster, Lips. 1671,) Morenheim, {Bei- trage, Band II. p. 305,) Bertrand, {Cal- tieri, XVIf.) Baillie, {Lond. Med. Jour. 1789, Vol. X.) Gauberton, {Mem. de Montpellier, Tom. I. Hist. p. 110,) Lar- rey, {Mem. de Chirurg. Militaire, Tom. I.) Bichat, {Treatise on Life and Death,) Meckel, {Handbuch der Pathologischen Anatomie, Band II. p. 187,) Post, {New- York Medical Magazine, I. 166,) Hufe- land's Journal, (Band XXII. p. 110,) and others which are referred to by Hallek 38 ABDOMEN. {Physiol.) {Op. Minora, Tom. III. p. 15,) Voigtel, {Handbuch der Path. Anatomie, Band II. p. 316,) Otto, {Lehrbuch der Pathologis- chen Anatomie, Band I. p. 27,) &c. Many of the deviations of form which have been enumerated, especially those in which the organs are exposed, constricted, or protruded, may give rise to serious con- sequences, by embarrassing or interrupting the functions. A simple transposition, how- ever, seldom interferes with the regular acts of the organs, and we accordingly find that many individuals in whom such an arrangement has existed, have attained a good old age without experiencing any inconvenience from the abnormal situation of their organs. The abdomen is subject to several other deviations of form, but as they are mostly of an accidental or acquired character, they will be considered under their appro- priate heads. Bibliography.—0&serotf..A7ia*.Amstelaedami. 4to. 1737. RUYSCH. Haller. Opera Minora, Tom. Ill- 4to. Lau- sanna, 1768. Troschel. De Morb. ex alieno situ part ab- dom. Francfort, 1754. Ludwig. Progr. de situ prattemat. Vise, infimi ventr. Lipsiae, 1759. Metzger. Progr. de iranslocat. Vise. 1779. Fried. De failu intestinis plane nudis extra ab- domen propend. nolo, &c. Argent 1760. Voigtel. Handbuch der Pathologischen Anato- mie, Band in. Halle, 1804. Band II. p. 313. Sandifort. Observat. Anat. Path. Lib. I. p. 39. Lib. IV. p. 59, 60. Eschenbach. Obs. qucedam Anat Chir. Med. rarior, Rost. 1769. Bartholin. Acta Med. Hafn. Part I. Obs. 110. Lachmund, in MiscelL Nat. Curios. Dec. 1. Ann. HI. Obs. 103. Schrock. Ibid. Ann. VI. Obs. 232. Herold, in Stark's Archives fur die Geburts- hulfe,Band I. p. 1. f. 36. New-London Medical Journal, 1792. Vol. I. Hist, de VAcadimie Royale des Sciences, 1688, p. 44. by Morand. Sampson. Philosoph. Trans. Vol. IX. p. 746. Baillie. Lond. Med. Journal, 1789, Vol. X. Mery, Petit, Littre, Mim. de VAcad. Roy des Sciences, 1716,1709. Calder. Edinburgh Med. Essays, I. 166. Dietrichs. Comm. Noricum, 1735, p. 67. Preuss, Merklin, Bachmann, Schulze, Al- BRECHT, RlTTER, HaSENEST, BOUCHARD, FRANK. Epli. Nat. Curios. Cent 7. p. 118. Ibid dec 1. p. 74. 314. Ibid. dec. 2. Obs. 45, p. 54. Act. Nat. Curios. Tom. I. p. 502. Tom. II. p. 283. Tom. VI. p. 44. p. 33. Ephemerid. Nat. Cur. dec. 1. p. 17. Act. Nat. Cunos. Tom. VTII. p. 320. Eph. Nat. Curios. dec. 2. p. 454. Meckel. Handbuch der Pathologischen Anato- mie, Band I. Leipzig, 1812, p. 117. Ibid. Tab. Anat. Pathological, Fol. Fasc. IV. Lips. 1826. Ibid. Dis- crip. Mons. Nonnullor,Ato. Lips. 1826. De Dupli- citat Monst. fol. Lips. 1826. Ibid. Anatomische Physiologische Beobachtungen, &c. Halle, 1822. Consbruch. Handbuch der Pathologisch. Anat. Leipzig, 1820. Osiander. Handbuch der Enlbindungskunst Band I. Tubingen, 1829. Geoffroy St. Hilaire. Philosoph. Anato- mique, Paris, 1822. Serres. Recherches d' Anatomie Transcendante, 4to. with Atlas, Paris, 1832. Montgomery, (W. F.) Description of a very remarkable FoUus, in which nearly all the abdomi- nal Viscera and the intestinal Canal were external to the Body. Dublin Medical Transactions, Vol. I. N.S. Dublin, 1830. Bryan, (D.) Case where the thoracic and ab- dominal Viscera were misplaced. Trans, of the College of Phys. in Ireland. IV. 123. Dublin, 1824. Ramsay. New-York Medical Repository, N. S. Vol. IV. Post. New-York Medical Magazine, No. I. Jan. 1814. Duncan. Edinburgh Med. if Surg. Journal, 1805. Macaulay. Med. Obs. & Inquiries, Vol. I. Campbell. Edinburgh Med. & Surg. Journal, Vol. XVII. Otto. Seltene Beobachtungen. Elbin. De Monst Corde Carentibus, Berol. 1821, 4to. Tab iEnei. 24. Beclard. Sur les Fetus Acephales, Paris, 1818. Tiedemann. Anatomie der Kopjlossen Missge- burten Landshut, 1814. Fol. 4. Kupfert. Klein, in Meckel's Deuiches Archiv. fur die Physiolog.m. 391. Chaussier. Bull, de la Facult. de Med. IV. Howell. Lond. Med. & Phys. Jour. XLV. 199. Yeatman. Ibid. UI. 367.1824. Duchateau. Journ. Compldmentaire, 1821. Pendleton. Observations on Monstrosities, m Philadelphia Journ. Med. ty Phys. Sc. XIII. 289. Dictionnaire de Med. Tom. I. 2me. edit. Hayward. Boston Medical Magazine, I. 92. Tyler. American Med. Recorder, IV. 150. Moore. American Journal Med. Sciences, V. 252. Philadelphia, 1829. Warren. Ibid. V. 253. Martin. Ibid. V. 549. Horner. Ibid. VIII. 349. Philadelphia, 1831 Robinson. Ibid. XI. 346. " 1833. E. Geddings. Art. II. Abdomen. {Physiological con- siderations relative to.) Functions of the highest importance are performed within the abdomen. Chymification, chylification, the secretion of bile and of the pancreatic fluid, the excretion of urine, impregnation and the development of the foetus, are all executed there. It is consequently the seat of the principal functions for the nu- trition of the individual and the propaga- tion of the species. These will be treated of under their proper heads. The abdominal parietes, physiologically considered, present three points of view: 1st As protecting the viscera they inclose; 2d. As exercising an energetic and con- stant pressure upon those viscera; and 3d. As performing certain movements by means of the muscles which enter into their composition. We shall briefly ex- amine them in each of these aspects. ABDOMEN. {Physiol.) 39 1st The conformation of the abdominal parietes, like that of every other part of the organism, presents the most perfect relation between their structure and uses. If, then, we find that these parts do not pos- sess in an eminent degree the power of protecting the viscera they envelope from external injury, this power has been sacri- ficed to a more immediate necessity, that of not impeding the functions of those im- portant organs. The extensive changes which take place in the size of the abdo- minal viscera, either from the introduction of food and drink, the disengagement of gas, or the development of the impreg- nated uterus, exact a corresponding capa- city for change in their envelope, a con- dition perfectly fulfilled by the soft and extensible parietes of the abdomen. The organs they inclose are not, however, en- tirely deprived of protection from exter- nal injury. The liver and spleen, whose parenchyma is easily ruptured, are shel- tered under the base of the chest; whilst posteriorly, the vertebral column and the fleshy masses on each side of it, protect the two important vessels which pass in front of the spine, as also a part of the intestines. The iliac fossae and the basin of the pelvis fulfil the same office for the viscera they contain. Finally, even where the parietes possess no hard parts, they are remarkably strengthened by the mode of superposition and the arrangement of the muscular and aponeurotic layers of which they are composed. 2d. The abdominal viscera are subjected, by their elastic and contractable envelope, to a constant and energetic pressure, which favours the performance of many of then- functions. The food and drinks are pro- pelled through a muscular canal, the pa- rietes of which must remain contracted to prevent the regurgitation of its contents; and hence we also find fasciculi of fleshy fibres performing the office of sphincters to the orifices of the reservoirs of the ab- domen. If these sphincters become par- alyzed, pressure on the abdomen occasions the involuntary discharge of the contents of these reservoirs. It has been already observed that the abdomen is always filled by its organs; consequently, when its walls are opened, the air does not rush into it as happens when the thorax is penetrated, (see Chest;) on the contrary, there is often an expulsion of some of its viscera, and this is especially the case when the intestines contain gas; for these organs, when de- prived of the support of the abdominal muscles, are no longer able to resist the expansive force of their aeriform contents, and are consequently greatly distended, and a portion of them frequently forced through the wound. These considerations explain various phenomena of punctured wounds of the abdomen, and of hemor- rhages and effusions within its cavity. Some of the functions performed within the abdomen being influenced by the structure of the chest, it is necessary here to remark, that the latter, in a healthy condition, is never entirely filled by the viscera it in- closes, and consequently it exercises no pressure upon them; whilst, then, the for- mer cavity is, if we may use the expres- sion, too full; in the latter there is a ten- dency to a vacuum, or, to speak more philosophically, the exterior surface of its viscera are subject to a pressure less than that of the ordinary weight of the atmo- sphere. The muscular partition, the dia- phragm, which separates these two cavi- ties, is naturally pressed up towards the chest, and the passage of the fluids, through the vessels of the abdomen which empty into the chest, is facilitated by the condition of the cavities to which we have alluded. The influence exercised by the abdominal pressure upon the course of the blood in the vena porta, and the stasis which some- times follows the relaxation of the abdomi- nal parietes after the operation of para- centesis, were long since noticed; this pressure equally favours the passage of the fluids through the thoracic duct and as- cending cava. Finally, the alternate con- tractions of the abdominal muscles, and diaphragm, promote the passage of the urine from the kidneys to the bladder, as also the flow of the bile and pancreatic fluid in the excretory apparatus of the glands which secrete these fluids. 3d. The motions performed by the ab- dominal muscles, are the flexion of the chest on the pelvis, or of the latter on the former; the rotation of one of these parts on the other, and their lateral inclination; and finally, various actions in which the movements of the abdomen are associated with those of the chest, as in straining and its different varieties, vomiting, the dis- charge of feces, of urine, and of the ovum. Flexion is performed by the contraction of the oblique and recti muscles. When the pelvis is the fixed point those muscles, in contracting, draw down the chest to- wards the former part; when the chest is the fixed point the reverse takes place; and when the individual lies on his back so that neither of these points is fixed, they bend the body so as to approximate the anterior parts of the chest and pelvis. When the oblique muscles of each side 40 ABDOMEN. act with equal power, their effect is to pro- duce direct flexion, and their action is then in perfect accordance with that of the recti muscles. Rotation is performed by the external oblique of one side and the internal ob- lique of the opposite, contracting in con- cert ; thus the simultaneous contraction of the right external and left internal oblique rotates the chest to the left, and vice versa. The contraction of the two oblique mus- cles of the same side produces lateral flexion without rotation. The abdominal muscles are nearly or wholly inactive in ordinary respiration, but in forcible or sudden expiration and the ac- tions which depend upon it, as coughing, sneezing, &c, they contract forcibly. The transversalis here acts in concert with the oblique and recti muscles, and their con- tractions alternate with those of the dia- phragm. There are other cases in which all these muscles act simultaneously; as in certain efforts in which it is necessary that the trunk should offer a solid point of support to the muscles inserted into it; and in the evacuation of some of the ab- dominal viscera, to effect which it is re- quired that the capacity of the abdomen should be diminished, as in the discharge of feces, urine, and in parturition. In these cases the action of the transversalis predominates over that of the other ab- dominal muscles; it represents, as observed by M. Berard, {Did. de Med. 2d Ed. I. 141.) a kind of contractile band, the action of which is not limited to the soft parts of the abdominal parietes, but also extends to the base of the chest which is strongly compressed by this muscle. If it be re- membered that the circumference of the diaphragm is almost everywhere united to the transversalis, that the former muscle occupies not only the superior but a great portion of the posterior walls of the abdo- men, and that the latter fills the vast space between the chest and pelvis anteriorly, we shall have little difficulty in figuring to ourselves the abdomen as a large con- tractile sac, the contraction of which will occasion the evacuation of the smaller sacs contained within it. The contraction of the diaphragm pushes the viscera down- wards and forwards; but the latter of these actions being counteracted by the abdom- inal muscles which press them backwards, the result of the combined actions is to push the viscera towards the perimeum, where the reservoirs which are to be evacuated arc situated. The expulsive contraction of the ab- dominal muscles is subjected to the will, {Symptomat.) but bometimes it is entirely involuntary, we observe in vomiting, in parturition, & Bibliography.—Berard. Diet- de Mtdecii Art. IV. Abdomen. {Symptomatology.) The great number and importance of the or- gans contained within the abdomen, and the frequency and diversity of their disorders, render that cavity, in disease, a fruitful source of symptoms, and these are often of a complex and multifarious character and consequently difficult of diagnosis. The means by which these symptoms are inves- tigated will be hereafter described; (See Exploration.) in the present article we shall offer a sketch of only the jesults ob- tained by the several modes of exploration. The changes in the abdomen observed in disease are in—1st its temperature; 2d, its form, size, and appearance ; 3d, its de- gree of tension and firmness; and 4th, its sensibility. 1st. The temperature of the abdominal surface furnishes important information in disease. It is generally increased in acute inflammation of the viscera of this cavity, as is particularly observed in enteritis and peritonitis; and this increase of heat cor- responds with the situation of the inflamed organ. There is often no increase of tem- perature in chronic inflammations of the abdominal viscera; and after blows on the epigastrium, in anaemia, chlorosis, &c, there is sometimes a diminution of temperature. In many fevers and inflammations of the abdominal organs, the increased heat of the abdominal surface is accompanied with a peculiar acrid pungency to the sensation of the examiner; a phenomenon indicative of the utmost risk of rapidly supervening disorganization. 2. The form and size of the abdomen are susceptible of great changes, in conse- quence of the elasticity of its parietes and the various states of its viscera as to pleni- tude or emptiness. Among the most striking of these changes is that exhibited in asci- tes, in which disease the abdomen is en- larged in all directions, the epigastric hol- low and iliac depressions disappear, and the umbilicus sometimes becomes promi- nent. In simple oedema of the abdominal parietes, the enlargement is neither so great nor so regular, and the change of form is principally observed at the sides, the abdomen enlarging without projecting anteriorly. In encysted dropsy and all other accidental tumours, the enlargement is local, at least at first, and is moreover very variable. In tympanitis, the enlarge- ment, although more general, often allows ABDOMEN. {Symptomat.) 41 the undulating and semicylindrical projec- tion of some portion of the intestine dis- tended by gas, and especially the arch of the colon, to be distinguished. In perito- nitis the abdomen is tumefied both by effu- sion into its cavity and a collection of gas in the intestines, thus combining the tu- mefaction of ascites and tympanitis. In some chronic diseases, the abdomen pre- sents a condition the very reverse of the preceding, becoming concave, the osseous and cartilaginous parts which form its boundaries being prominent. There are few peculiarities to be no- ticed in the appearance of the skin of the abdomen, except the red and lenticular spots which it commonly exhibits in ty- phus, (Dance, Did. de Med. 2d Ed. I. 143.) its shining and polished aspect occa- sioned by its distension in ascites; its nu- merous wrinkles after a fluid has been evacuated, or any other abundant deple- tion ; and the great enlargement of its subcutaneous veins in some cases, an en- largement resulting, as would appear from the investigations of Dr. Reynaud, from the obliteration of some large internal vein, and indicating a supplementary cir- culation. We may add, that after partu- rition, wrinkles or folds of the skin form on the inferior and lateral portions of the abdomen, which are most conspicuous in those who have had the greatest number of children; a brownish line may be ob- served extending from the umbilicus to- wards the pubis, and there is a widening and thinning of the linea alba, principally in the umbilical region. 3d. The increased tension and hardness of the abdomen may be limited to its pari- etes or to the organs contained in its cav- ity. Apprehension of pain from pressure, the mere coldness of the hand, or even the simple touch, often occasions the contrac- tion of the abdominal muscles; but in such cases these muscles generally relax after a time, especially if the patient's attention be diverted from our proceedings; but in inflammation of the intestinal mucous membrane it is often impossible to obtain their relaxation, the patient instinctively keeping these muscles in a state of tension in order to ward off the pressure from the morbidly sensible parts beneath. When the increase of sensibility is re- stricted to a portion of the abdomen, the tension of the muscles usually corresponds to this limitation. The muscles in this state have been mistaken for deep-seated tumours, and the prominent bellies of the recti muscles supposed to be the inferior border of an enlarged liver, or a scirrhus 4* pylorus; and they have given rise to va- rious other errors in diagnosis. The increased firmness is sometimes general, but much more frequently partial. In the last stage of tabes mesenterica and chronic peritonitis it is general, which has caused these two affections to be confound- ed with one another; but in the former, on pressure, isolated tumours, the enlarged mesenteric glands, may be distinguished, whilst in the latter the hardness is uni- form. A partial increase of firmness oc- curs in many cases of engorgement or of tumours in the abdomen: thus tumours are found in the epigastrium from scirrhua or cancer of the stomach; in the right or left hypochondrium from engorgement of the liver or spleen; in the umbilical re- gion from induration of the omentum ; in the hypogastrium from distended urinary bladder, intumescence of the uterus or the presence of fibrous bodies in its substance; more to the exterior are those occasioned by exeysted dropsy, and finally in the iliac fossae those produced by an accumulation of feces or by phlegmonous tumours in the same regions. (Dance, Loc. Cit.) We shall treat elsewhere of the method of de- termining the seat and nature of these tumours. 4th. Many morbid sensations are expe- rienced in the abdomen, which are all con- founded together under the single epithet pain; but as each variety may have a pe- culiar signification, the symptomatologist should carefully distinguish them. Pain in the abdomen appears to occasion more anguish than in any other part of the body; it produces a remarkable alteration in the expression of the face, the countenance indicating not only suffering, but prostra- tion and despair. From their seat and peculiar charac- ters M. Dance {Loc. Cit.) indicates the following varieties of abdominal pain : 1st. peritonaeal, 2d. gastric or cardiac, 3d. in- testinal or colic, 4th. hepatic, 5th. ne- phritic, 6th. vesical, and 7th. uterine. Peritonaal pain is acute, severe, super- ficial, and aggravated by the slightest pressure. Gastric or cardiac, the prin- cipal seat of which is in the epigastri- um, is attended, notwithstanding its nu- merous grades, with more anxiety, sad- ness, and even despair, than any other pain. The intestinal or colic are charac- terized by being cutting, not constant, and accompanied with a sensation in the intes- tines of the movement of gas or fecal mat- ters ; they are also felt in the various parts of the abdomen when they affect the small intestines, and in the course of the colon 42 ABDOMEN. when they are seated in the large intes- tine ; in the rectum when the pain is at- tended with a freguent and often ineffec- tual inclination to go to stool, as is observed in dysentery, it is termed tormina and tenesmus. Hepatic pam has a greater tendency than any other to be converted into a sensation of weight or heaviness, generally imperfectly described by the pa- tient Nepltritic pain is principally seated in the renal region, but it often extends to the bladder, testicles, or groin, following the course of the ureters, and it is some- times intensely severe, as when a calculus is in the ureter.' Vesical pains extend over the hypogastric region and also to the perinaeum, and are aggravated by the dis- charge of urine which frequently occa- sions a burning sensation. One of the pe- culiar characters of uterine pains is that they occasion, during and after parturition, the cutting and intermitting pains corre- sponding to the contractions of the uterus. Besides these pains which are for the most part attendant on inflammations, there are others which have a different signification; they are sometimes more severe than the preceding; as, for instance, that produced by lead colic, a pain which comes on in paroxysms and is commonly lessened by pressure. Various other morbid sensations are ex- perienced in the abdomen, but thjeir char- acters are too indeterminate for them to furnish any assistance in diagnosis; M. Dance {loc. cit.) excepts from these, the epigastric uneasiness experienced by chlo- rotic females or those affected with pro- fuse leucorrhcea; the lumbar and hypogas- tric pains which come on at the approach of menstruation, and the sensation of a ball rising up through the abdomen felt by hysteric persons; to these we may add the pain in one of the sides, especially the left, immediately under the margin of the false ribs and extending to the spine of the ilium of the same side, pointed out by De- wees {Diseases of Females, 1st Ed. 213.) as indicating a prolapsus of the womb. Finally, we may remark that the absence of pain and the insensibility of the abdo- men to pressure offer no conclusive evi- dence of the non-existence of inflamma- tion of the viscera of this cavity. Of this, numerous cases might be quoted, some of which will be hereafter adduced. Bibliography.—Dance. Art. Abdomen. Did. de Med. Paris, 1832. Forbes. Art. Exploration of Abdomen. Cy. clopcedia of Pract Med. London, 1832. Copland. Ibid. Did. of Pract. Med. Lon- don, 1832. I. H\Y8.« {Pathology.) Art. IV. Abdomen. {Pathology.) The abdomen is the seat of numerous anec- tions, and these may implicate its parietes, its membranes, its cavity or the several organs included within it Among these disorders there are some which although they might be treated of in the general articles on those affections, ofter peculiari- ties so dependent upon their seat m the abdomen, and embrace at the same time so many parts, that we could not consider them in any other than the present article, without involving repetitions and render- ing it difficult to find the place in which these affections are discussed, the more so as some of the disorders of which we are about speaking, have not received any name which would lead the inquirer to seek for them under any other head than that of Abdomen. We shall therefore treat in succession, of what is peculiar to each of the fol- lowing diseases:—1st Of physical lesions of the abdominal parietes and viscera (wounds, contusions, and ruptures); 2d. Of the lesions of the same parts resulting from other affections (effusions of various kinds in the abdomen, morbid adhesions of the viscera, fistula? of the abdominal pari- etes) ; 3d. Of foreign bodies and acci- dental productions contained in that cav- ity, whether introduced from without or found within it; such as free concretions on the peritonaeal sac; 4th. Tumours of various kinds, lipomatous, cancerous, or purulent included in the abdomen but foreign to the viscera it contains; 5th. Tu- mours peculiar to the abdominal parietes or to the subjacent cellular tissue, among which are fatty tumours, encysted dropsy of these parietes, phlegmons and abscesses developed in the same situation, in the right iliac fossa, or in the inferior region after parturition : those purulent collec- tions which sometimes form in the lumbar regions will, however, be treated of under the words Psoas Abscess, Nephritis, and Abscess by Congestion ; Stercorary and Urinary abscesses will be discussed un- der those heads: although carbuncle and anthrax when seated • in the abdominal parietes are more painful than in any other part of the body, they do not require par- ticular attention here; 6th. Finally, we shall conclude this article with some ob- servations upon the abnormal pulsations sometimes observed in the abdomen. , I. Hats. $ I. Wounds of the Abdomen. These wounds are naturally divided into two elassee; those which involve the parietes ABDOMEN. {Wounds of.) 43 only, and those which penetrate the cavity of the abdomen. According to the nature of the instruments by which they are pro- duced, they are styled punctured, incised, lacerated, or contused wounds. 1st Punctured wounds of the abdomen which do not extend beyond the parietes, frequently give rise to but little difficulty, or complication, and heal with considerable readiness; but in patients of an irritable constitution, in those who are excessively alarmed by the injury, and in cases where the instrument has produced contusion or partial division of a nerve, symptoms so seri- ous and severe are frequently encountered, that we are at first inclined to believe that the wound has penetrated into the cavity of the abdomen. These symptoms gene- rally pass away with the nervous agitation which produces them, or yield without dif- ficulty to the local application of emollients and narcotics, to warm bathing, and the internal exhibition of opiates and anti- spasmodics. When severe pain continues notwithstanding the employment of these measures, and previously to the develop- ment of inflammation, it can only be ac- counted for on the supposition that a nerve has been punctured. Under such circum- stances, it may be proper to infuse into the wound a watery solution of opium, the oil of hyosciamus, or some other powerful narcotic, of not too irritant a character. The free application of leeches around the wound, followed by long-continued emol- lient bathing, and large poultices impreg- nated with laudanum or prepared with the leaves of hyosciamus, belladonna, or stra- monium, should then be employed. The infusion of these narcotics into the wound is, however, admissible only when its ex- tent and direction are certainly ascertain- ed ; but it is not always possible to arrive at this certainty, as will be seen hereafter. If there exists the slightest chance of inju- ry to the peritonaeum, such infusion may prove highly dangerous. If these remedies fail, and the patient still labours under acute suffering, there remains no alterna- tive but to euiarge the wound, in doing which, due care should be exercised to avoid the division of arteries, or the punc- ture of the peritonaeum. Wounds of this character, when they pass for considerable distances through the substance of the oblique or transverse mus- cles of the abdomen, into the sheath of the recti, or along the crista or costa of the ilium with injury to the periosteum, not unfrequently occasion inflammations more or less deeply seated and extensive. These inflammations are marked by acute pain coming on some days after the accident, by heat and tension, and sometimes a red- ness around the orifice of the puncture. The local symptoms are attended with traumatic fever of greater or less violence. This inflammation may be extended to the cellular tissue exterior to the peritonaeum, or it may even involve that membrane itself. It sometimes terminates by resolu- tion, at others by suppuration, and the pus secreted may make its escape along the track of the wound, or becoming confined, may give rise to abscesses, which in some cases are sufficiently obvious, but in others are detected with difficulty. In the treatment of this inflammation, the usual remedies, such as general and local bleeding, a strict diet, mild drinks, emollient bathing or poultices, &c. should be steadily employed. When the pus is obstructed in its escape from the wound, the orifice, and if necessary, the canal also, should be enlarged. When an abscess is formed in the neighbourhood, it should be laid open as soon as its existence is dis- covered. In enlarging the wounds, and in opening the abscesses, the incisions, if made in muscular parts, should be carried as much as possible in the direction of the fibres, and care should be taken to avoid the larger arterial trunks, such as the epigastric, the branches of the internal mammary, the circumflex artery of the ilium, the vessels of the spermatic cord, and the lumbar ar- teries. When, in wounds of the description under consideration, the trunk, or a large branch of either of the arteries just men- tioned is opened, attention should be im- mediately given to the consequent hemor- rhage. The blood at first escapes freely from the external orifice, but in most cases it speedily becomes infiltrated into the cel- lular tissue, giving rise to extravasations sometimes extending to a great distance round the seat of injury, occasionally reach- ing even to the inguinal region and the scrotum. In addition to venesection and absolute repose, M. Marjolin recommends, for the purpose of arresting these hemor- rhages, the employment of graduated com- presses in the form of inverted pyramids, thoroughly imbued with cooling fluids, or a solution of alum, directing pressure to be effected by means of a tight body-bandage, supported by scapularies and strips of roller around the perinaeum. Methodical pres- sure thus applied will often repress the hemorrhage, but it will be more successful in proportion to the small extent of infil- tration which has taken place previously. If) however, a 6oft swelling, unattended by the usual signs of inflammation, appears 44 ABDOMEN. around the injured part and goes on in- creasing after the adjustment of the proper compresses, it is reasonable to infer that the hemorrhage still continues, and it be- comes absolutely necessary to enlarge the wound, and to search out and to tie the injured vessel, or compression must be im- mediately employed if the ligature be im- practicable. {Diet, de Med. 2d Ed. Art. Plaies de VAbdomen.) Simple punctured wounds of the abdomi- nal parietes, require a simple treatment consisting of rest, a low diet mild drinks, and, if the patient is not in danger of pul- monary disease, cold applications. As soon as this first danger has received proper at- tention, the wound should be lightly dressed with a pledgit of lint spread with simple cerate, and this course should be pursued until the period at which inflammation may be expected, has elapsed. When, after ex- tensive extravasation, the blood is not ab- sorbed, it is recommended by Marjolin to open the cavity and evacuate its contents as soon as it begins to inflame. Consider- able care should be exercised in following this advice, lest by interposing too soon we should increase the difficulty : vast collec- tions of blood are frequently absorbed, and much time is occupied in the process: we distinctly recollect a patient who was ad- mitted into the Pennsylvania Hospital some years ago, with fracture of the wing of the ilium, whose case was beautifully illustra- tive of this truth. The parts over the dorsum ilii, the groin, and scrotum, were distended by a mass of extravasated blood, so large that the peculiar emphysematous crepita- tion which has been frequently noticed in similar cases, and which is probably due to the escape into the cellular tissue of the gas eliminated during the act of coagulation, was perceptible over this whole surface; yet the patient recovered without the ne- cessity of incision or the formation of ab- scess. Those who have examined, after death, the condition of fractures of four or five weeks' standing, well know how long coagulse may remain in the midst of the common cellular tissue without proving a source of irritation. When the extrava- sation is superficial, it is safe to leave the case to nature; when deep-seated, we can hardly recommend any interference until the general symptoms warn us of the formation of an abscess. As the front of the abdomen is almost covered with tendinous expansions, punc- tured wounds of its parietes are very fre- quently attended with symptoms much more severe than those which accompany similar injuries of other parts; and when {Wounds of.) inflammation takes place beneath those expansions, the system suffers violent dis- turbance, and suppuration is a very general consequence. When the inflammation is seated in the superficial cellular tissue, it requires no peculiar treatment; and should abscess result, its detection is easy and its proper management obvious. But when the inflammation is more deeply seated, it becomes necessary to employ the various means of combating it with unusual vigor and decision, for there is always a danger that the inflammation may be extended to the peritonaeum, which accident produces a most serious complication of the case. Absolute rest should be insisted on, and the body and lower extremities placed and preserved in such a position as to relax the abdominal muscles, and more especially those which are wounded. Venesection, and the abstraction of blood by leeches, should be carried to an extent proportioned to the violence of the traumatic fever and the local symptoms; the diet should be rendered as strict as possible; cold appli- cations, poultices, and mild laxatives, are also proper in most cases. If, m defiance of our exertions, deep-seated abscess is formed, it is wrong to trust to the unaided efforts of nature for its evacuation; for though the well-known tendency of pus to make its way to the surface, is sufficiently obvious in these cases, yet the tendinous covering external to the cavity is so un- yielding, and the division between the bot- tom of the abscess and the abdominal cavity so thin, consisting, in many cases, of the peritonaeum alone, that a pointing internal- ly and the inevitable death of the patient, may result from improper delay. When the pus is deposited within the sheaths of the recti muscles, or between the inter- nal and external oblique muscles, it be- comes diffused to a very great extent before it can approach the surface; and if it is at length evacuated externally, it flows in enormous quantity, leaving a cavity of great dimensions, which in itself consti- tutes a dangerous affection even when un- connected with inflammation or rupture of the peritonaeum. When, as is frequently the case, punc- tured wounds, of the abdominal parietes take such a direction as to enfeeble the resistance which these parietes oppose to the escape of the viscera, proper support, by means of bandage and compress, should be invariably given to the injured part and this support should be continued for some time after the apparent completion of the cure. When it becomes necessary to dilate the wound in consequence of any ABDOMEN. {Wounds of.) 45 of the accidents enumerated above, it is of course converted into an incised wound, and the precaution just mentioned becomes doubly necessary; for it is long before the new bond of union, when effected in mus- cular or tendinous parts, obtains sufficient strength to oppose the dilating or extending force of the intestines, acted on by the tonic pressure of the abdominal muscles. Trou- blesome or incurable hernia may result from a neglect of this precaution. Incised wounds of the abdomen not in- volving the peritonaum or viscera, are dangerous, or not so, according to their extent and direction; but their treatment is simple. Their depth is more easily as- certained than that of punctured wounds; they are less frequently attended with symptoms simulating those of penetrating wounds; and by exploration with the finger, the integrity of the peritonaeum can be as- certained in almost all cases. They are more frequently attended by free hemor- rhage, and are less liable to ecchymoses. The danger of the consecutive formation of a hernial sac, is greater in proportion to their extent; and when muscular parts are traversed, this danger, and the diffi- culty of treatment, are increased if the incision divides the fibres obliquely. If hemorrhage is produced, the bleeding ves- sels are easily detected and secured by ligature. This done, and the coagula be- ing removed from the wound, it should be accurately closed, and union by the first intention effected as speedily as possible. In a very large majority of cases, the co- aptation of the edges is readily secured by adhesive strips, which should be of a length proportionate to the extent of the incision; but when the wound is situated in the course of one of the transverse duplicatures of the integuments, more especially if the patient is corpulent, a disposition to roll inward is displayed by the edges, and it may be impossible to bring them into ac- curate contact without the assistance of a few stitches of the interrupted suture. In aid of the adhesive strips, it is sometimes advisable to apply graduated compresses near the sides of the wound, and to act upon them by means of a broad bandage round the body, so as to assist in approxi- mating and supporting the edges. This is most useful when the direction of the in- cision corresponds pretty nearly with that of the axis of the body. The wound itself should be dressed with a narrow piece of patent lint spread with simple cerate, over the adhesive strips. The position of the patient is of great importance; it should be such as to relax the muscles of the abdomen in general, and those which are injured in particular. Most writers direct the horizontal position; but when the wound is situated over or near the recti muscles, the knees should be considerably raised, and the shoulders and pelvis slightly elevated. When the lateral portions of the parietes of the abdo- men are the seat of the injury, in addition to the former precautions, the shoulders and pelvis should be carried toward the affected side. When the incision is deep and extensive, this position should be care- fully preserved until the completion of the cure; and the importance of this direction is obviously greater in transverse than in longitudinal wounds. To prevent the dan- ger of consecutive hernia, the patient should continue to wear a belt, and should carefully avoid all violent exertion, par- ticularly in lifting. Proper attention to the bowels during the treatment is highly im- portant. Contused and lacerated wounds of the abdominal parietes are, cateris paribus, more dangerous than incised wounds, be- cause there is much less certainty of effect- ing their union by the first intention; and when inflammation and suppuration super- vene, the violence of the traumatic fever, the frequent occurrence of peritonitis, pain, nervous agitation, visceral disturbance, ex- tensive ecchymoses, exhaustion from puru- lent discharge, and, in certain epidemic conditions of the atmosphere, erysipelas, are so many complications of greater or less importance, one or more of which will frequently occur in the progress of severe cases. The general plan of treatment is the same as that already laid down for punctured and incised wounds; and in or- der to avoid repetitions, we shall speak only of some additional precautions of more special application. The immediate hemorrhage in contused and lacerated wounds is seldom severe, and ligatures are not required so commonly as in incised wounds; but after the careful removal of all foreign bodies, we should search for and take up any vessels of con- siderable dimensions which cross the direc- tion of the wound. In lacerations, we should not place too much confidence in the temporary absence of bleeding, when there is reason to suspect a rupture of the epigastric, or other large artery, lest sec- ondary hemorrhage should compel us to reopen the wound, a peculiarly unfortunate necessity in extensive injuries of the ab- dominal parietes. It should not be forgot- ten, however, that by too much handling and protracted examination for minute 46 ABDOMEN. ramifications, the chance of union by the first intention is considerably diminished. Upon little niceties, much of the difference in degrees of success depends, and this is a fine field for the exercise of tact. It is seldom necessary to dilate wounds such as we are now treating upon, unless they involve the sheath of the recti mus- cles ; but in this case the opening may be enlarged with great advantage in many instances. If the muscles are severely con- tused at the same time that their sheath is torn, this precaution should be very gene- rally resorted to, in order to prevent the excessive pressure of the tendinous en- velope upon its contents during the subse- quent inflammatory swelling. Every ex- ertion should be used to effect union by the first intention; and if this end is only partially obtained, still the partial success is highly important Adhesive strips should always be employed when the coaptation of the wound can be accomplished by such means; and when the nature of the injury permits us to employ graduated compres- sion, so as to act at a mechanical advantage in aid of the strips, it should be effected by means of suitable compresses, and a many-headed bandage. The roller is ob- jectionable in all cases. Absolute repose, and strict attention to position, are of the utmost moment. M. Marjolin {Did. de Med. I.) states, that in the hospital to which he is attached, when patients with con- tused wounds are not liable to be affected with cough, cold water, or vegeto-mineral water combined with a small portion of laudanum, is found to be the best topical means of preventing inflammation. If this complication supervenes, it may be neces- sary to renounce the adhesive strips, more especially when the skin is erysipelatous, and the treatment must be restricted to dressing the wound with fine lint, over which is to be applied mild fomentations, or emollient poultices, the general anti- phlogistic treatment being continued. We have had frequent occasion to notice the strong tendency to erysipelas produced by the continued application of adhesive plas- ter, during those periods when there exists an epidemic predisposition to this disease: and have even observed sloughs of the subcutaneous cellular tissue to follow the use of this, in cases unattended by any wound. Sir A. Cooper {Lectures by Tyr- rell, III.) condemns its application to the edges of wounds, on the same ground. When Delpech so happily succeeded in arresting the progress of hospital gan- grene among the wounded of the Spanish army, received at I'Hdpital Saint Eloi, at {Wounds of.) Montpellier, he was compelled to discard adhesive strips, and depend upon the suture. Phlegmonous erysipelas often immediately checks the progress of union, and not unfre- quently destroys it when recently formed. It is also extremely apt to extend itself very widely, endangering, in wounds of the abdomen, the occurrence of peritonitis, one of the varieties of which, the puerperal fe- ver, prevails epidemically as a congener of this disease. The question may be started, therefore, whether, in lacerated wounds of the abdomen, when occurring during the prevalence of these epidemics, it may not be advisable to resort more frequently to the suture, than is customary in this coun- try. The opinions of John Hunter in Eng- land, and Pibrac in France, have brought the suture under reproach, perhaps too generally applied. The school of Mont- pellier errs widely, we think, on the other hand; but we refer the reader to the work of Serre, Sur la Reunion Immediate, for a candid and full defence of the suture. When suppuration is completely estab- lished, and the traumatic fever has abated, it is unnecessary to pursue the antiphlo- gistic treatment "with such absolute rigor; and when the inflammatory swelling and hardness have subsided, it is often injuri- ous to continue too long the application of poultices, which tend to promote an undue secretion of pus. Much good may be done in many cases, and the progress of cure may be accelerated, by the judicious appli- cation of a bandage and compresses, so as gradually to contract the extent of the suppurating cavities. The proper dressing for the wound after the omission of poultices, is patent lint spread with simple cerate, unless peculiar circumstances render other applications advisable. The treatment of erysipela- tous inflammation and abscess from these wounds, should be conducted upon general principles, which will be discussed under the appropriate head. The continued use of a belt, and the avoidance of great exertion, are still more necessary after lacerated wounds of the abdominal parietes, than after 'those which are produced by cutting instruments. Gun-shot wounds of the parietes of the abdomen, require but little further notice. Those produced by splinters, or large frag- ments of various substances, being refer- able to the former sections, there remain to be considered those produced by small shot and balls. Small shot when lodged in the thickness of the skin should be re- moved, and if the number is considerable, a simple emollient poultice should be ap- ABDOMEN. {Wounds of.) 47 plied over the injured surface. When, however, they have penetrated to a greater depth, it is rarely necessary to trace them out for very little inconvenience ordinarily results from their presence. Fatal cases have indeed occurred, but in these the shot are lodged far beyond our reach. The nature of the wound produced by a ball is such, that union by the first in- tention is of course impossible; and as the surrounding parts are always either contused or have their vitality destroyed, but little immediate hemorrhage generally results; nevertheless, considerable ecchy- moses occasionally take place. The dan- ger from inflammation is greater in these than in other wounds, because the perito- naeum, or even the viscera, may be seri- ously injured, although the ball may not have been in contact with them. Extreme care is necessary in all examinations for foreign bodies, particularly in deep wounds, lest the probe, the finger, or the foreign body itself, may irritate or puncture the peritonaeum. The wound should seldom be enlarged, except when the ball has penetrated the sheath of the recti muscles, or when substances are lodged within it which cannot be extracted through the original orifice. The early symptoms are frequently such as to induce a suspicion that the abdomen has been penetrated, when this is not the fact. But great caution must be exercised in searching to assure our- selves by means of instruments that may verify our fears by their own action. In all doubtful cases, it is safe and proper to pur- sue the treatment best adapted to wounds which do not penetrate the cavity or the viscera. 2d. Penetrating wounds of the Abdo- men.—It is customary to class under this head only such injuries as produce an open- ing into the serous cavity of the perito- naeum ; and although a part of certain ab- dominal and pelvic viscera, such as the kidneys, the great intestine, the uterus, and the bladder, may be^wounded without injury to that membrane, yet the difference between these two kinds of accident is so important that it is perhaps be6t to pre- serve the distinction. Great attention has been given to the signs of penetrating wounds of the abdo- men, because of the extreme gravity of the consequences which often supervene upon even slight injuries of this nature. The facility with which trivial and local irrita- tions of the serous tissues give rise to severe and general inflammations, is well known. Even when the peritonaeum alone is wound- ed, without any lesion of the viscera, and, as John Bell remarks, " although the in- jury be almost too small to be visible on the outside, and scarcely within," fatal in- flammation of the whole surface of the membrane may result in an astonishingly short time. Daily experience proves, however, that such consequences do not very frequently follow slight punctures when the integrity of the viscera is preserved, and when no unusual peculiarity in the instrument or in the condition of the patient, gives rise to additional danger. Thus, after the opera- tion for paracentesis, we do not anticipate the occurrence of peritonitis; after that for strangulated hernia, when it is necessary to enlarge the mouth of the sac, it is not very frequent; and the occasional success of the caesarian operation, and that for the removal of the diseased ovaries, in which the wound has been closed by ligatures passed through the peritonaeum, prove beyond a doubt that even very large openings into the cavity of the abdomen are not necessarily followed by dangerous symptoms. The diagnosis of penetrating wounds of the abdomen, is very easy, provided the opening is large. The eye or the finger can at once determine the nature of the case. The view obtained of a portion of the stomach, an intestine, or the omentum located at the bottom of the wound or pro- truding from it is the best possible evi- dence ; but we may be deceived for a mo- ment, as Boyer has observed, by mistaking a projection of the subcutaneous fatty tissue for the epiploon. When the eye cannot aid us, the finger recognizes with facility the external surface of the viscera and the smooth internal side of the peritonaeum. Here again, however, some attention is necessary to avoid being led astray by the surfaces of aponeuroses, over which the finger may glide to a considerable extent in corpulent subjects. The opening of the cavity being ascertained, there still remains great uncertainty as to the number and extent of the injuries inflicted upon its contents, which are generally better under- stood from the course of consecutive symp- toms, than from any examination which is admissible at the time of the accident When the wound is too narrow to admit the finger, it has been recommended by some surgeons to explore it by the probe. This plan is liable to several objections. The passage of the instrument is frequent- ly rendered very difficult in consequence of the sliding of the various planes tra- versed by the weapon or body producing the wound; so that the apertures in the integuments, aponeuroses, muscles, cellu- 48 ABDOMEN. far tissue, &c. do not coincide. It may also_ induce hemorrhage by disturbing the coagula formed upon the mouths of divid- ed vessels; or it may irritate, detach, or tear the peritonaeum. In fact the know- ledge obtained by the use of the probe sel- dom compensates for the pain inflicted by its introduction; and it is no longer con- sidered correct surgical practice to employ it with the simple intention of ascertaining the depth of the puncture. Mr. Samuel Cooper says, that " it may be set down as an axiom in surgery, that in general, whenever the probing of a wound is not rendered absolutely necessary by some particular object in view, it may be judi- ciously omitted." {Did. of Surgery, Art. Wounds.) When, however, it becomes in- dispensably necessary to search for foreign bodies carried into the wound, we should use the utmost caution, the sound or probe employed should be blunt and flexible, and the patient should be carefully placed in as nearly as possible the same attitude as that in which he was when he received the injury. A surmise as to the extent and direction of the wound may sometimes be grounded upon a comparison between the dimensions of the orifice and those of the weapon by which it is inflicted; but when the latter is furnished with a cutting edge, we may be deceived by the enlarge- ment of the incision in the act of retracting it. All wounds of the abdomen should be treated as superficial, unless the accidents and symptoms of the case render it obvious that it is of a graver character; for simple puncture of the peritonaeum, or even of an intestine, when unattended by alarming complications, does not require any modi- fication of the treatment; and great injury may be done by the endeavour to ascertain a fact which, when known, is often of little importance. The symptoms, both local and gene- ral, attendant on penetrating wounds of the abdomen, when the peritonaeum alone is involved, or when the injury to the viscera is slight are frequently as mild as those of the most simple wounds of the parietes; but in many other cases they are widely different They may be ranged in two series; firstly, the rational signs, and secondly, the certain signs of penetrating wounds. Among the former, are classed a deep-seated pain felt by the patient at the moment of the accident, and continuing afterwards; paleness of the countenance; a jaundiced hue; excessive thirst; nausea, vomiting, and hiccough; spasmodic tension of the abdominal muscles; tympanitis; a small, frequent and concentrated pulse; ( Wounds of.) coldness of the extremities; faintness; spasm of the muscular system generally, &c. All these phenomena are occasionally seen, singly or combined, in simple wounds of the abdominal parietes; they are also ab- sent in manv cases of penetrating wounds. The rational signs are, therefore, insuffi- cient to establish a certain knowledge of the nature of the accident; by their aid, how- ever, we may estimate the probability of injury to the cavity or its contents, which is of course greater in proportion to the number, violence, and obstinacy of these disturbances combined in the case. The certain signs of penetrating wounds of the abdomen are few in number. The possibility of introducing the finger into the cavity, and that of the issue of a por- tion of intestine or omentum, exist only in wounds of certain dimensions; but the escape of intestinal gases, chyme, feces, bile, urine, or blood from the liver or spleen, may take place from the narrowest punc- tures, and remove every doubt of their na- ture. Marjolin says that he has seen a considerable emphysema occasioned by a penetrating wound involving the superior part of the descending colon. In many cases we meet with bloody ejections and stools, or the evacuation by the urethra of blood, either pure or mixed with urine; and we are also certain that the abdomen is opened when those symptoms supervene which mark the effusion into the perito- naeum of any of the intestinal contents or secretions. {Op. Cit.) It is difficult in many cases to determine precisely what particular organs are in- jured by penetrating wounds of the abdo- men, and to what extent they have suf- fered. An accurate inquiry into the attitude of the patient at the moment of the acci- dent the nature of the instrument or wea- pon producing it, and the probable depth to which it has entered, together with a careful examination of the discharges, if any occur, furnish us with our most cer- tain lights. Such wounds occasionally in- terest not only the cavity of the abdomen, but that of the thorax also, with its pari- etes and contents; the symptoms already enumerated are then complicated with others characteristic of wounds of the chest, under which head they will be de- scribed. The diagnosis of such cases is extremely difficult, unless the track of the weapon is rendered obvious by its having completely transfixed the body, producing two orifices in the integuments. In judging the nature of wounds of the abdomen by the discharges, it sliould not be forgotten that urine may escape from ABDOMEN. {Wounds of) 49 the bladder or the kidney, or feces from the great intestine, through a puncture which has no connexion with the perito- naeum ; for a considerable portion of each of these organs is left uncovered by that membrane. We have said that punctured wounds penetrating the abdomen, when unattended by any complication, are frequently cured without the intervention of any serious symptoms; but it would be highly crimi- nal to neglect the means necessary to pre- vent the occurrence of peritonaeal inflam- mation in any case where there is the least reason to suspect an injury of this nature. The wound should be closed with the greatest care, and strict repose enjoined. The anodyne and emollient applications recommended in the previous section, are equally useful here; and the antiphlogistic treatment should be pushed with a degree of vigor in accordance with the violence of the consecutive symptoms and the strength of the patient The diet should be entirely fluid, and when necessary the mildest laxatives may be given. Castor oil is preferable to any other cathartic, but whenever it is possible to keep the bowels sufficiently open by means of enemata, no other measures should be employed, and cathartics should never be administered during the first few days, unless under very peculiar circumstances. At the same time that cautious attention and a decisive practice are recommended in the simplest cases, it should be borne in mind that in the most severe, there is no necessity for despair; our exertions should not be relaxed because the extent of the mischief induces an unfavourable prog- nosis. The annals of surgery are rich in proofs of the wonderful powers of nature in effecting a cure under circumstances ap- parently desperate. A small-sword is not unfrequently passed completely through the abdomen, and yet the patient recovers without difficulty ; and Hennen, in his Treatise on Military Surgery, relates the case of a soldier whose abdomen was pierced by a ramrod, the end of which was so fixed in the spine that considerable force was re- quired for its removal; the result was nevertheless favourable. It was formerly supposed that the weapon, in injuries of this character, pushed aside the intestines and passed through the cavity without wound- ing them; but since we have become fa- miliar with the rapidity with which the sur- faces of the serous membranes may contract adhesions to each other, and the extent to which false membranes are often formed within their cavities, the subject has been VOL. I. 5 much better understood, " for we now know," says John Bell, " that in a thrust across the abdomen, six turns of intestine may be wounded, each wound may adhere; adhesion, we know, is begun in a few hours and perfected in a few days; and when it is perfect, all danger of inflamma- tion is over; and when the danger of in- flammation is over, the patient may wralk about" The cure is effected by the ag- glutination of the corresponding edges of the different wounds in the intestines and the peritonaeum, and not by a speedy closure of the openings; for a passage from one viscus to another may still exist after all communication with the cavity of the peritonaeum is in this manner foreclosed. It is necessary, however, to the safety of the patient that the adhesion should be formed before any effusion can take place. By many writers the introduction of at- mospheric air is supposed to be one of the principal causes of the serious inflamma- tions which follow these wounds. John Bell has very fully exposed the fallacy of this idea, in criticizing the opinions of A. Monro in his work on the bursae mucosae. There being, as already stated, no void space in the peritoneal cavity for the ad- mission of air, if there be any irritation occasioned by this agent it must be con- fined entirely to the surface of the intes- tines exposed at the orifice. This ex- posure is seldom or never so long contin- ued as to produce the more serious danger of exsiccation. Even when the wound is large enough to permit of the protrusion of the bowels, the muscles contract upon the remaining contents, and the results of the extensive incisions and the handling of the viscera in caesarian and ovarian operations, put at rest for ever the terror of the influence of air as a cause of mate- rial difficulty. (See Air.) Peritonitis, more especially general per- itonitis, is most frequently occasioned by the effusion of acrid substances, such as chyme, fecal matters, bile, or urine. It appears almost immediately upon the effu- sion, is extremely severe, and almost al- ways speedily mortal. Local peritonitis, or that which is confined to a particular portion of the membrane, commonly de- pends upon less irritating causes, such as the direct effect of the wound, or the effu- sion of blood: it comes on more tardily, and is susceptible of cure. Patients with traumatic peritonitis often succumb after languishing for some months; or, if they survive, they remain for a long time subject to pains in the ab- domen and great disorder of the digestive 60 ABDOMEN. functions. Violent peritonitis sometimes terminates by gangrene. (Marjolin, Op. CiL) The proper treatment of traumatic per- itonitis consists in the most vigorous em- ployment of the antiphlogistic remedies. Bleeding, both general and local, should be carried to the greatest extent which the patient's strength will permit and long-continued warm emollient baths are recommended when they can be endured. By these means, the local and the milder cases of general peritonitis may be con- quered. All the organs contained in the abdo- men are liable to be involved in wounds of this character, but the pelvic viscera are so protected that they are seldom injured unless when in a state of plenitude. The gravid uterus and the distended bladder enjoy no immunity. Wounds of the liver and spleen are very serious, though not necessarily fatal. In consequence of the great vascularity of these organs, the internal hemorrhage is generally very profuse, amd too frequently speedily mortal. These viscera being fixed, when we know the depth to which a weapon has penetrated and the direction of its track, it is perfectly easy to determine how far they are implicated; but when these points cannot be ascertained, we are sometimes left in doubt Wounds of the liver are for the most part attended by a more or less general jaundice, with discoloration of the skin, dejections, and urine, and accord- ing to Hennen, a great and distressing itching of the skin. {Military Surgery, 3d Ed. 434.) The pus from the wound is sometimes yellow and viscous from admix- ture with biliary matter. A tender and contracted abdomen, continued vomiting, hiccough, and irregular chills, are gene- rally present, but cannot be considered completely diagnostic. The difficulty and pain in respiration may lead to a stronger presumption of injury to the liver—par- ticularly if it is 6trongly marked before the occurrence of inflammation. Boyer states that, in injuries of the convex or diaphragmatic surface, the pain is of that dull heavy kind so familiarly met with in chronic hepatitis, extending to the shoulder and larynx; while in wounds of the con- cave surface, it is sharp, and is referred to the neighbourhood of the ensiform carti- lage. The charftoter 0f the effused blood may show that it fpws from the portal ves- sels, and if the hemorrhage is very pro- fuse, the probability of a wound of the liver is increased. In the treatment of these accidents, the {Wounds of.) first object is to arrest the bleeding. Vene- section carried to a sufficient extent with a bold hand—cold applications and cold acidulous beverages, with pressure upon the part when it can be endured, are the obvious means of accomplishing our pur- pose. The after-treatment is conducted on general principles—the antiphlogistic mea- sures being pursued as strictly as possible. Gentle laxatives should be employed when- ever the bowels are not freely open, and toward the conclusion of the case, when the liver is the part affected, small doses of calomel are frequently advisable. Wounds of the gall bladder have always been considered necessarily fatal, until very recently. There are two cases of recov- ery mentioned, one by Paroisse, {Opus- cules de Chirurg. p. 255.) in which a bul- let remained two years in this vesicle; the other by Fryer, of Stamford. {Med. Chir. Trans. V. 330.) The latter case was a rupture, without external wound, produced by a violent blow from the shaft of a cart, on the region of the liver. The injury was followed by pain, frequent bilious vomit- ing, great sinking, coldness of the extrem- ities, and a weak, small, and fluttering pulse. Inflammation supervened on the third day, and ran very high, but was in some measure relieved by active treat- ment. About a week afterwards he had an exacerbation and was completely jaun- diced ; his stools were white, but the pain and tension soon abated. In two days from this time fluctuation was perceived in the abdomen, which, in another week became considerably distended with fluid. The swelling was then punctured, and thirteen pints of what appeared to be pure bile were obtained. Fifteen pints were drawn off, at a second operation twelve days after; in nine days more a new puncture gave exit to thirteen pints, and in a fort- night, six pints more were obtained in the same manner. From this time the patient began to recover. Marjolin does not ad- mit that this fact affords proof that there was a wound of the gall bladder, but that a violent contusion of the liver had oc- curred, occasioning the exhalation into the cavity of the peritonaeum, of a large quan- tity of serosity, which in consequence of its yellow colour was mistaken for bile. A similar serosity is often found in the crani- um, the pericardium, the peritonaeum, and in the synovial membranes of persons who die jaundiced. Sabatier considered this accident cer- tainly fatal. {Mid. Op. I. 34.) One case observed by himself terminated on the third day, a few hours after a puncture ABDOMEN. {Wounds of.) 51 had been made at the lower part of the ab- domen, and a dark green, inodorous fluid drawn off A post mortem examination exhibited the gall bladder perforated and empty, and the bile effused in front of the intestinal convolutions, which were glued together by a thick coating of lymph. (See Abdomen, Effusions into the.) Wounds of the spleen have no peculiar rational signs by which they are distin- guished from those of other solid organs, except the nature and the amount of the hemorrhage, almost always internal, and the location of the pain. They are fully as dangerous as those of tho liver. A re- markable case of wound of the spleen, fol- lowed by recovery, is related by Dr. Pow- ell, in the Am. J. Med. Sc. I. 481. Punctured wounds of the stomach are not uncommon, and though very danger- ous they are not always mortal. The ac- cident most to be dreaded is an effusion into the peritonaeal cavity, but if this is prevented by rapid adhesion, the patient may recover. There may remain, how- ever, a fistulous opening which cannot be healed, and the contents of the stomach may find an exit through this passage. Such a state of things is not invariably productive of great danger or inconveni- ence. (See Fistula of the Abdomen.) In addition to the rational signs common to all penetrating wounds of the abdomen, we observe in these cases, vomiting of matter more or less tinged with blood, sometimes of almost pure blood; similar discharges per rectum, excessive thirst and frequently, the escape of a portion of the contents or natural secretions of the stomach, by the wound. Continued vomiting is productive of great inconvenience from the agitation which it produces, and from the inverted peristaltic action returning the contents of the duodenum into the stomach, on which account bile is sometimes found among the effusions or mingled with the substances escaping from the wound. In addition to the employment of venesection, warm emollient and anodyne applications to the whole abdomen, &c, we should be careful not to suffer anything to enter the stomach until time has been given for the forma- tion of adhesions: this is generally effected in twenty-four or thirty-six hours. To re- lieve the excessive thirst during the first day the mouth should be frequently moist- ened with cool water either pure or acidu- lated, and bathing the whole body with warm water will aid in alleviating this troublesome symptom: emollient injections are also recommended. When the adhe- sions are formed, mild and mucilaginous drinks may be given. When the hematemesis is alarming in amount and the pulse becomes extremely feeble, it is then improper to draw blood from a vein; and when the hemorrhage cannot be commanded by the application of ice or other local measures, Boyer re- commends the administration by the mouth. of a solution of alum, in the proportion of a drachm to four ounces of water. Punctured wounds of the intestines are attended by nearly the same train of symp- toms which characterize similar injuries of the stomach, though by the depth and direction of the wound when known, and sometimes by the nature of the discharge, we can form a tolerable surmise as to what part of the canal is injured. More danger is incurred by a puncture of a small intes- tine, than by that of the colon, because the process of nutrition is more embarrassed and there is greater probability of effusion. The treatment of punctured wounds of the intestines unattended by effusion resem- bles that already recommended in wounds of the stomach. When they take place shortly after a meal, M. Marjolin advises that vomiting should be induced, by tickling the fauces with a feather, in order to lessen the danger of effusion. All other means of producing emesis are obviously improper. It sometimes happens that a fold of in- testine is forced out through an exceed- ingly narrow wound, and becomes so tightly embraced that it cannot be re- turned. This is the only case in which it is proper to enlarge the peritonaeal orifice, such a step being altogether inadmissible, for the purpose of ascertaining the extent or nature of the injury. We may find it necessary to cut down upon, and take up, a wounded artery in the parietes of the abdomen, but our incision is then super- ficial. Care should be taken, when dilata- tion is absolutely necessary, to divide the parts as much as possible in the direction of the fibres, and to avoid not only the larger arteries, but also the suspensory ligament of the liver, for the umbilical vein sometimes continues open, and fatal hemorrhage may result from a division of this vessel. Sometimes when the reduction appears impossible, without dilating the wound, we succeed by withdrawing, an additional por- tion of the intestine^fid by "very gently urging its contents into the abdomen. Effusion, the most dangerous of all com- plications with wounds of the intestines, does not occur very frequently in punc- 52 ABDOMEN. {Wounds of.) tured wounds ; but the explanation of this fact and the symptoms, results, and treat- ment, of effusions, will be found under a distinct head. (See Abdomen, Effusions into the.) Passing over wounds of the omentum and mesentery, which differ in no respect from those of the peritonaeum, of which they are duplicatures—we come next to those of the kidneys and ureters. These parts may be wounded either through the abdominal cavity or from behind, so that the peritonaeum may be involved or not, according to the nature of the accident; but such injuries are uncommon, owing to the small dimensions and well-protected location of the organs—those of the ure- ters, in particular, are of course exceed- ingly rare. As in contusions and inflammations of the kidney, so in these injuries, very se- vere pain is felt. It is not confined to the wound, but generally extends throughout the track of the ureter to the neck of the bladder, and along the spermatic chord to the testicle, which is often strongly re- tracted. The sharp pain, referred by the patient to the spine, and the intolerance of the slightest movement of the vertebral column, are strongly diagnostic. Fre- quent and irregular chills, often moment- ary in their duration, are more remark- able in these than in most other wounds of the abdominal viscera. " Nausea, vom- iting, hiccough, and a generad anguish, are produced by these wounds, in some cases, and may even occasion a sympa- thetic jaundice." (Marjolin, Op. Cit.) The discharge of bloody urine is the most certain of all the signs of such injuries. The terrible inflammation induced by urinary effusions into the peritonaeum will be spoken of under the proper head; but it is necessary to remark in this place, that whether the peritonaeum escapes or is pen- etrated, the urine may be diffused into the cellular tissue external to that membrane, producing extensive destruction. When this is the case, there is observed, in a few days after the accident, an obscure fluctu- ation, generally accompanied by more or less emphysematous crackling, produced by the gases eliminated from the gan- grenous parts. The collection of urine may approach the surface in any part of the lumbar region, and if the original wound cannot be so enlarged as to give ready egress to the effused fluid and the sloughs which it occasions, free counter- openings should be made in a suitable situation: their direction should be such as not to endanger the lumbar arteries. We have seen two cases of extensive urinary effusion into the scrotal cellular tissue, consequent upon the rupture of the urethra, in which an early counter-incision prevented the formation of sloughs; but such instances must be extremely rare, and probably depend upon peculiar idio- syncracies. The treatment of wounds of the kid- neys and ureters, requires little additional notice. All the antiphlogistic measures should be carried very far; and as we are scarcely ever sure that the intestines have escaped injury in such cases, the precau- tions with regard to food and drinks, laid down under that head, should be strictly observed. The evacuation of the great in- testine by means of frequent but mdd clysters, is of the utmost importance; for an accumulation of feces is productive of much distress in all cases of" irritation in the kidney. Punctured wounds of the bladder are generally recognized by the flow of urine through the wound. Blood, either fluid or coagulated, is evacuated by the urethra, or, as sometimes happens, retention of urine is occasioned by the coagula clogging the orifice of that canal. Pain and a sense of tightness over the hypogastric region, pain along the urethra, and at the anus, are common symptoms, and these are sometimes combined with sickness, hic- cough, and, more rarely, with actual vom- iting. Too often, the signs of urinary effu- sion into the peritonaeum or into the neigh- bouring cellular tissue, supervene in the course of a few hours. Wounds of the bladder, like those of the kidney and ure- ters, may or may not be complicated with puncture of the peritonaeum. In the for- mer case, death is almost always the con- sequence. In the latter, though the peri- tonaeum is not interested primarily, it may become involved in a secondary manner, from the effusion of urine into surrounding parts, and the consequent extension of the inflammation to the abdominal cavity. Though very serious, these cases are not necessarily fatal. Safety mainly depends upon the ready egress of the urine, either by the natural passage or by the wound itself. When the puncture is made into the upper part of the bladder while that viscus is in a state of distension, the con- traction which takes place upon the evac- uation of its contents gradually lessens the orifice, and diminishes or removes the danger of subsequent infiltration: such wounds are therefore most serious when the bladder is empty at the moment of the accident. Wounds by the bayonet lance, ABDOMEN. {Wounds of.) 53 small-sword, &c. may enter the anterior surface of the bladder above the pubis, and after passing completely through it make an exit near its neck, and perhaps involve the rectum, without injuring the perito- naeum, and the patient may recover, unless the internal hemorrhage is too extensive. When the bladder is opened on its anterior part above the pubis, after the first jet the urine does not flow steadily, but by fits, as the bladder becomes distended again and again. When the orifice is situated lower down, the percolation is more constant. In the former case, if all accumulation of urine in the bladder is prevented by surgical means, the wound may remain closed from the first and it then heals without diffi- culty, provided there has been no previous effusion into the abdomen, nor diffused in- filtration into the cellular tissue. In the treatment of wounds of the blad- der, the first indication is to give a ready passage to the urine through the natural canal. A catheter as large as possible should be immediately introduced, and al- lowed to remain in the urethra. Difficulty is sometimes experienced from the coagu- lation of blood in the bladder, which may prevent the egress of the urine; and it has been recommended to attempt the re- moval of the blood by means of an exhaust- ing syringe adapted to a catheter or other tube. The supernatant urine may be drawn off by pushing the catheter through the coagulum; and when these means fail, it has been advised that we should throw in a stream of warm water through a sound with a double current in order to dilute and wash it away. (Marjolin, Op. Cit.) JLarrey, indeed, asserts, that blood rarely coagulates in the bladder, because of its ad- mixture with urine. {Chirurg. Milit. Tom. IV. p. 295.) Even when it does coagulate, its presence is not always productive of very serious symptoms, when unattended with rupture of the urethra, or any other barrier to the introduction of the catheter; for the urine will dissolve the coagula, as is shown by a curious case narrated by Dr. Condie in the N. A. Med. and Surg. Journ. v. IV. p. 259. The catheter should never be omitted until the completion of the cure, but it requires changing every few days, for it rapidly becomes covered with incrus- tations, which may render its withdrawal very painful and difficult if this precaution is neglected. The proper position for the patient is that in which the wound is dependent and the abdominal muscles in a state of relax- ation. For the rest the treatment should be conducted on general principles. When 5* collections of effused urine take place either in the perinaeum, the scrotum, or above the pubis, early and free incision is necessary for their evacuation. Wounds of the unimpregnated uterus, are extremely rare; but when gravid, this organ is more frequently subject to them. Serious or fatal hemorrhage, or the effusion of the liquor amnii and blood into the perito- naeal cavity, are a common consequence of such injuries, and a consequent abortion must follow when the wound extends be- yond the mere parietes of the organ. The most active antiphlogistic treatment is re- quired in every case. Wounds of the diaphragm are almost always complicated with injuries to other parts contained in the abdomen or thorax. Their signs are variable, and often obscure. Among them are noticed, difficult and pain- ful respiration, performed with but partial expansion of the chest; pains extending to the shoulders and neck; a contracted or shrunken countenance; and above all, the risus sardonicus. In addition to the anti- phlogistic treatment it is proper, in wounds of the diaphragm, to administer gentle nar- cotics, to apply opiates externally, and to prevent too great movement of the ribs in respiration by giving firm support with a bandage to the lower part of the thorax. The head should be supported upon high pillows, aind the shoulders should also be elevated. (Marjolin, Op. Cit.) Wounds of the great abdominal blood-vessels are generally followed by a very speedy death. They require no especial notice here, as they are beyond the reach of surgical aid; and the few recoveries that occur are due to the unaided powers of nature, or to ac- cidental circumstances beyond our control. (Vide Abdomen, Effusions into the.) Punctured wounds of the abdomen may be complicated with the presence of foreign substances. Large bodies which have been taken into the stomach, others which have entered and been lost in the cavity of the abdomen, and even parts of foetuses after extra-uterine gestation or rupture of the uterus, may make their way to the surface and be discharged by abscess, or ulceration, or, penetrating the intestinal canal, may be evacuated per anum by a similar process. In cases of this nature, these bodies are in- closed within a sac composed of false mem- branes and adhesions, in such a manner as to be entirely separated from the gene- ral cavity of the peritonaeum. Instances are on record of the escape by the rectum of arrow-heads, poignard-blades, musket- balls, &c. which had been deposited within the peritonaeum. Knives, and other hard 54 ABDOMEN. irregular bodies, after being swallowed have occasioned inflammation and adhe- sion between the viscus in which they were arrested and the parietes of the abdo- men, and have been discharged through fistulous orifices externally. Nature being thus fertile in resources, it would be exceedingly improper to en- large a punctured wound with the inten- tion of searching for foreign bodies known to have entered the abdomen; for we can never be certain into what part of the peri- tonaeal cavity they may have subsided, nor what viscera they may have penetrated. When, however, the extremity of the body is discoverable in, or immediately beneath the wound of the parietes, it should be carefully withdrawn. In penetrating wounds of the abdomen made by cutting instruments, there is no difficulty in ascertaining the fact of the peritonaeum being opened; for the finger may be introduced through the orifice, and the smooth internal surface of that mem- brane can, with ordinary discrimination, be distinguished. The question is often de- cided on simple inspection, by the protru- sion of a portion of mesentery, omentum, or intestine. These wounds may be simple, or com- plicated with a protrusion or with a lesion of some of the abdominal viscera. When simple, our first care should be to arrest the hemorrhage, if any divided superficial vessels are detected. The patient is then to be placed in that attitude which most completely relaxes the abdominal muscles, and the wound closed as speedily and ac- curately as possible. This can be gene- rally effected by adhesive strips alone; and indeed the cases are rare which require the additional aid of the suture. Even in- cisions of several inches in length, com- plicated with protrusions, are constantly cured by these means, and when stitches have been employed after great operations on the abdomen, it has sometimes happened that hiccough, sickness, and other alarm- ing symptoms have supervened, and could be alleviated only by removing this cause of irritation. Still it is well known that the presence of stitches passed through the peritonaeum and abdominal parietes, do not always occasion material inconvenience. There are cases in which the suture must be used, and there are some epidemic states of the atmosphere, during the prevalence of which, its employment may be prefer- able, for reasons already mentioned. The objection urged by Mr. S. Cooper against the suture, that the stitches not unfre- quently cut their way out by ulceration {Wounds of.) before they have accomplished their office, appears to us to be not a very valid one; for when no other evil consequence fol- lows their introduction, this little addi- tional extension of the wound is unimport- ant; the parts through which they make their escape generally heal behind as rapidly as they give way before them; and previ- ous to their removal, sufficient adhesions are formed between the edges of the wound to prevent their retraction, and the purpose of the suture is in great degree accom- plished. Still, the needle should never be resorted to, except under pressing emer- gency ; and the necessity for its use wdl be less frequent in proportion to the man- ual dexterity of the surgeon in managing the adhesive strips and other dressings. The edges of the wound being brought into accurate coaptation, the next step re- quired is the application of a suitable band- age and compress, to give general support to the abdomen, to assist the action of the strips or suture, and to resist the tendency of the viscera to escape at the orifice. To accomplish these objects, it is generally directed that a flat compress should be ap- plied over the simple pledget spread with cerate, which is laid upon the previous dressings. This compress is to be acted on by means of a bandage enveloping the whole abdomen. The roller is here liable to obvious ob- jection, as its application is difficult or im- possible without inducing improper exer- tion, or change of position, on the part of the patient. Nor is the many-tailed bandage, as ordinarily prepared and em- ployed in these cases, entirely free from inconveniences. The best apparatus for producing pressure on the abdomen, is a bandage of strips, so arranged as to overlap each other in two-thirds of their width, and stitched together by a seam along the middle of their length, which should cor- respond with the spinal column. When a portion of omentum or intestine protrudes through the wound, it should be returned as speedily as possible, care being exercised to handle these parts as littlo and as gently as may be. If, as sometimes happens in extensive incisions, the pro- truding parts have dirt or any foreign mat- ter adhering to their surface, this should be carefully removed by a stream of water gently warmed, or by the light touch of a soft sponge, if the wound is narrow, the surgeon should assure himself of the per- fect reduction of the viscera by passing his finger within the peritonaeum, and gently making it perforin there a circular movement, so that the smooth internal sur ABDOMEN. {Wounds of.) 55 face of the membrane may be felt around the whole circumference of the incision; for it is possible that a portion of intestine may be lodged between the fasciae of the abdomen, and thus remain without the pe- ritonaeum, while it is apparently returned into the cavity. In straight incisions, it is rarely difficult to retain the viscera within the abdomen without the use of sutures; but when ir- regular or angular wounds take place, they are sometimes indispensable. In England and this country, the interrupted suture is generally employed; but in France, they prefer the qudled suture, and we think with reason. This suture is applied by means of two curved needles, threaded by a flat ligature, formed of several waxed threads, doubled upon themselves, so as to make a loop at one extremity. With each of these needles the abdominal pari- etes are punctured from within outward, at two opposite points, distant about six or eight lines from the edge of the wound. When a sufficient number of these liga- tures have been passed, an assistant pushes together the divided edges, already relaxed by the position of the patient; the surgeon introduces a small cylinder of wood, linen, or waxed cloth into the loop presented by each ligature at one of its extremities to- ward the lower side of the wound, and after parting the threads of the other ex- tremity of the ribbon, he ties them in a bo;/-knot over a similar cylinder on the opposite side of the wound. These liga- tures are allowed to remain four or five days, unless some accident in the case requires their being removed sooner. (Mar- jolin, Op. Cit.) A simple ligature of waxed silk, of suitable thickness, is per- haps preferable, upon account of the small space which it occupies, and the readi- ness with which it can be procured at all times. When a portion of intestine is protruded, together with a part of the omentum, it is laid down as a standing rule, that the for- mer should be reduced before the latter, or, in general terms, that the part which protrudes last should be reduced first; and the propriety of this advice is obvious. This object is generally accomplished without much difficulty by acting upon the intes- tine with the two index fingers laid in the wound, either by a steady pressure exer- cised by both at once, or by the alternate action of each finger separately. Difficulty may occur in our attempts at reduction, from several causes. In small wounds the protruded intestine may be so surcharged with its ordinary contents, or with air, as to make its return by simple pressure impossible; it may be strangu- lated, or in a state of inflammation, or it may have formed adhesions to the edges of the wound. In larger incisions, a spas- modic contraction of the muscles may di- minish the cavity of the abdomen, and dilate the wound, so that the former can scarce contain the whole bulk of the visce- ra, and the edges of the latter cannot be properly approximated; there may also ex- ist a general dilatation of the intestines by gas, which may render it difficult to inclose them within the parietes of the abdomen, even when free from spasm, as was ob- served by Dr. J. R. Barton in the case of the unfortunate girl murdered by Gross; and also in that of a patient upon whom he operated for the reduction of a strangulated inguinal hernia, several years ago. In the former instance, the bowels were returned without puncture; but in the latter, this was impossible, and Dr. B. made a valvu- lar opening into the protruded intestine, which he effected with a bistoury. The air being evacuated, the hernia was re- duced with ease. The external wound was closed by suture and compress; but on the succeeding day the gaseous secre- tion had again accumulated, and repro- duced the protrusion. Finally, in defiance of all opposition, the intestine forced its way through the intervals between the sutures, and the patient died. No effusion had taken place in consequence of the puncture. The embarrassments from inflammation, strangulation, and adhesion, occur also when the omentum alone protrudes. We wdl notice each of these causes of diffi- culty in succession. When the protruded intestine is neither inflamed nor adherent but refuses to return in consequence of the bulk of its contents, whether solid, fluid, or gaseous, it is some- times recommended to withdraw an addi- tional portion of intestine, in order to dis- tribute the contents of the fold over a larger space, so that it may be more readily urged forward through the constricted orifice into the abdomen: the intestine, thus emptied of its contents, is generally returned with ease. In pursuing this plan, it should not be forgotten, that an increased amount of mesentery is involved in the wound, so that if too much intestine is withdrawn, the additional bulk may increase instead of diminishing the difficulty of evacuating the protruded part. When the distension is occasioned by air, we cannot perceive 56 ABDOMEN. {Wounds of.) the advantage of the step just recommend- ed; for if the protruded part is already so tightly grasped as to prevent the passage of so rare a fluid, it is hardly likely that anything short of the enlargement of the wound can facilitate the reduction. Pare occasionally punctured the inflated intestine, in such cases, with a small needle; and Rousset, Garengeot, Sharpe, and Van Sweiten, recommend the practice; but when the puncture is made with a fine needle, the mucous coat closes the aper- ture almost immediately, and thus destroys its usefulness. Chopart and Dessault therefore recommended the employment of a large round needle; the use of such an instrument is perhaps still more objec- tionable, for the orifice may still be closed by the projection of the mucous coat while the danger of inflammation is considerably increased. Boyer, Richerand, and Mar- jolin, limit the puncture for the evacuation of air to cases in which the enlargement of the wound is rendered inadmissible by some peculiarity in the circumstances; and when compelled to resort to this measure, they employ a fine triangular trochar, by means of which they are sure of accom- plishing their object. A very delicate instru- ment would be best adapted to this operation; it should be flattened like that employed in paracentesis abdominis, and should be in- serted with its edge in the direction of the length of the intestine; for the experi- ments of M. Travers show us, that trans- verse wounds of these parts are more seri- ous than those which are longitudinal. Most of those who recommend puncturing in these cases, advise that a fine ligature should be passed round the intestine and through the mesentery at the point oppo- site the puncture, so that by drawing the ends of this ligature out at the external wound, we may keep the little opening in the viscus in contact with its edges, after the reduction has been effected: this is done in order to lessen the danger of ex- travasation ; but the precaution is now generally held unnecessary. Marjolin thinks that if any fear of effusion is enter- tained, it would be better to seize the sides of the puncture with a dissecting forceps, and apply a delicate ligature, cutting off both the extremities close to the knot, as was successfully practised by Sir A. Cooper for a'perforation of an intestine in a case of hernia. {Op. Cit.) La Faye, Blancard, Sabatier, S. Coop- er, &c. discard the plan entirely; and al- though we think that the dangers of so slight an operation have been exaggerated by some, it is difficult to conceive what circumstances can require the measure in question, except when a large portion of protruded intestine becomes dilated to such a degree that the parietes cannot be closed over it. Certainly it should never be prac- tised when the reduction can be accom- plished by the enlargement of the wound. When the protruded portion of intestine is strangulated or inflamed, no time should be lost in enlarging the wound and re- ducing it. Venesection, both before and after the operation, is decidedly proper, when the inflammatory action is consider- able. We must not hesitate to return the inflamed intestine, whatever may be the violence of the inflammation or the pecu- liarity of its colour, unless it is unquestion- ably in a state of gangrene: it may be dark red or almost black, yet if it retains its firmness, it should be returned; but if it be in a state of mortification, other modes of proceeding become necessary, which will be noticed under the heads of wounds of the intestines and artificial anus. In enlarging a wound of the abdomen, it is generally recommended that the incision should be carried upward, as the danger of hernia is considered greater when the in- jury is seated near the lower part of the cavity. The instruments commonly em- ployed are the probe-pointed curved bis- toury, with or without the aid of a grooved director. While operating, the patient should be placed in the posture best cal- culated to relax the part, and the surgeon holding the intestine toward the lower part of the wound, with one hand uses the index finger as a guide to the bistoury or the director. If the latter can be intro- duced to the bottom of the wound without difficulty, the operation may often be per- formed at a single effort; but if this can- not be accomplished with facility, the apo- neuroses, muscles, and skin may be first divided by successive retractions of the knife, the incisions being carried from within outwards, and as nearly as possible in the direction of the fibres. Care must be exercised to avoid the track of any con- siderable arterial branch, and that of the suspensory ligament of the liver, for reasons already mentioned. When, in consequence of neglect or unavoidable delay, adhesions have been formed between the protruded parts and the edges of the wound, these should be divided, if possible, to permit the reduction to be accomplished. Great care is required in effecting this division, for we are com- pelled to carry the incisions in various directions. The probe-pointed bistoury is ABDOMEN. {Wounds of.) 57 generally considered as the best instru- ment in these cases; but it would be dif- ficult to lay down very strict rules where the circumstances of the accident may vary so widely. If the adhesions are so firm that the intestine cannot be reduced, the case is still by no means desperate when the wound is large enough to pre- vent the danger of strangulation; for as Callisen has observed, the protruded vis- cus sometimes becomes covered by granu- lations, and a cicatrix is formed over it When the spasmodic action of the ab- dominal muscles opposes a barrier to the reduction of the protruded bowel, or pre- vents the closure of the wound, we must have recourse to the free abstraction of blood by venesection, and the internal ex- hibition of opiate remedies, until the spasm is conquered. In very extensive wounds of the abdo- men, enormous quantities of intestine may escape. One of the most singular cases of this nature is that related by Mr. Hague, surgeon at Ripon. The patient, a lad of twelve years of age, received a wound about four inches in length, on the left side of the body, commencing about two inches below the scrobiculus cordis. " The great arch of the stomach, and the whole of the intestinal canal, (duodenum excepted) contained within the abdomen," protruded. The stomach had been evacuated by vom- iting. Mr. Hague proceeded to reduce first the stomach, and then the intestine, following the course of the canal. Some difficulty was experienced in prevent- ing the exit of the reduced viscera, from the pressure of the diaphragm in breath- ing, that function being performed with much labour. Five sutures were em- ployed, and supported by adhesive strips. The patient recovered. {Ed. Med. and Surg. Journ. V. 129.) In cases of this description, general inflation of the bow- els may render reduction very difficult; but if due care is taken to contract the wound as the intestines are returned, and to preserve the edges in contact at one extremity, by the aid of an assistant, the object can be accomplished in almost every instance. As a last resort if all other means fail, we may then puncture the bow- el with the trochar mentioned above, in- troducing the instrument obliquely through the several coats, and allowing the gas to escape through the canula. The instru- ment should be so small as not to require the closure of the puncture by ligature to prevent effusion, of which the danger is fortunately less considerable than many surgeons have represented. The intestines themselves may be im- plicated in the original wound; but this is not the proper place to treat of these very serious complications: they will be dis- cussed under the head of Wounds of the Intestines. It is also unnecessary to re- peat the proper consecutive treatment of wounds of the abdomen, that subject hav- ing been already enlarged upon in the pre- ceding section on punctured wounds. It has been stated that the omentum may be strangulated, inflamed, or adherent to the edges of the wound, when it pro- trudes without being followed by intestine. If no great difficulty opposes its reduction, it should be returned immediately; but if adhesions have taken place, there are two modes of proceeding recommended under different circumstances. If the protruded portion is small, and no unpleasant symp- toms are present, we may cut it off to the level of the integuments, and leave the re- mainder to cicatrize with the wound: this is supposed to lessen the danger of subse- quent hernia. When the protruded por- tion is larger, or when there exists a sense of dragging about the stomach, nausea, vomiting, or other symptoms of strangula- tion, the wound should be enlarged imme- diately and the reduction accomplished. To avoid the danger of lacerating the deli- cate omentum, it is best to dilate the wound from the lower angle when we have occasion to use the grooved director as a guide to the bistoury. The omentum, when protruded from the abdomen, is sometimes attacked by gan- grene. This condition is recognized by the clammy softness of the mortified part, by its colour, generally gray, but some- times dead white, by its fetid odour, and by the discharge of a greasy fluid from its cells. In other cases, when this part is on the point of becoming gangrenous, it is hard, and of a deep-red livid colour; yet it does not bleed when cut. It was for- merly advised that the gangrenous omen- tum should be included in a ligature placed above the dead portion; that the mortified part should be cut off, and the rest return- ed into the abdomen, the ends of the liga- ture being secured externally. This dan- gerous plan is now discarded; its grave inconveniences have been demonstrated by an observation of Poiteau, and by the experience of Louis and Pipelet. The proper mode of treatment in such cases is as follows: if the gangrenous portion is small, we leave it to nature; if it is vo- luminous, we examine it in order to assure ourselves that no fold of intestine is in- closed within it. The greater part of the 58 ABDOMEN. dead matter should then be cut off, with the scissors, in order to relieve the patient from the disagreeable odour, and the rest enveloped with a strip of linen, spread with cerate, or moistened with weakened liquid chloride of soda. The remainder of the eschar is detached in the course of a few days, and the healthy portion lying in the bottom of the wound, closes it and contracts strong adhesions there. The wound may also be enlarged, and after having displayed the epiploon, we may remove the gangrenous portion, by cutting through the sound parts. The reduction should then be attempted, after tying, or applying tortion to the divided arteries. This last method has the advantage of preventing the dragging produced by the adhesion of the omentum to the wound; but it greatly enhances the danger of trau- matic peritonitis and consecutive hernia. (Marjolin, Op. Cit.) Gun-shot wounds penetrating the ab- domen, when not complicated with similar injury to the organs contained within the cavity, seldom require any other treatment than the free use of local and general an- tiphlogistic measures. They are rarely followed by protrusion of the intestines; but the ball is not unfrequently lodged within the cavity or its parietes. Little aid can be afforded by the surgeon in cases of this character. The ball may subside, by its weight toward the lower part of the abdomen, or into the pelvis; it may re- main suspended among the convolutions of the intestines, surrounded by false mem- branes ; or it may be lodged in the spine or muscles of the back or pelvis. In some cases the presence of the foreign body gives rise to no considerable inconveni- ence ; but in other instances it excites vio- lent inflammation, with purulent secretion into the cavity of the peritonaeum; or pro- duces a limited abscess which may be dis- charged either into the same cavity, or, as sometimes happens, into the alimentary canal. In the latter case, the patient may survive. M. Marjolin relates an instance in which one of these abscesses resulting from a contusion, opened at the same time into the small intestine and the bladder; a great quantity of pus, mingled with mat- ter from the intestine, being evacuated by the urethra: this fistulous communication had continued many years when the pa- tient consulted him. The majority of cases in which gun-shot wounds involve the organs within the per- itonaeum, terminate in the death of the patients from effusion and the consequent inflammation, during the first few days {Wounds of.) after the accident. Even when this imme- diate danger is past, the effusion may still take place at a later period, on the sepa- ration of the sloughs: this last occurrence, however, is very rare, as it can only hap- pen when the peritonaeum has failed to form adhesions around the eschar. The number of recoveries, notwithstand- ing the formidable dangers which surround these injuries, is very considerable; but for the details of cases and treatment, we must refer the reader to the articles headed Intestines, Bladder, Stomach, &c, where the diagnosis and surgical management of particular accidents will be discussed more fully than would be proper in this general sketch. Reynell Coates. Bibliography.—VVepfer. (J. J.) Abdominis vulnus penetrans sine la-sione ventriculi et intes- tinorum. Miscell. Acad. Nat. Curios. Dec II. an. X. 1661, p. 334. Littre. Obs. sur des plates de ventre. Acad. des Sc. de Paris, 1705. Mem., p. 32. Gahrliep. De horrendo et inaudito hactenvs vulnere, &c. Acad. Nat Curios. Dec. III. an. IX et X. p. 62. Bilguer. Vulnus abdominis cum vulnere he- patis et vasorum biliariorum conjunctum, feliciter curatum. Nov. Act. Acad. Nat. Curios. Froumantin. Coup cTipie au bas-ventre, avec Usion de Vintestin. Acad. Roy. de Chirurg. I. Moscati, Louis, Vacossain, Pipelet, Ge- rard, Rey, &c. Cases in the Mem. de l'Acad. Roy de Chirurg. Richerand. Observation sur Vobscurite du di- agnostic dans les plaies ptnitrantes de Vabdomen. Mem. de la Soc. Med. d'emulat an. V. p. 443. Baudelocque. (J. L.) Rapport sur une obs. de plaie aux parois de Vabdomen. Journ. Gen. de Med. Tom. IX. Berthe. Plaies pinctrantes, fyc. Ibid. XVH. Sevestre. 06s. d'une plaie pinitrante de Vabdomen. Ibid. XLVI. Guillon. Obs. d'une portion sortie par une plaie a Vabdomen. Ibid. XLIV. Burdin aine. Obs. Ibid. LXIV. Hague. Remarkable Recovery from a very extensive wound in the abdomen. Edinburgh Med. and Surg. Journal. V. 129. Marjolin. Diet, de Med. 2d Edit. Paris, 1832. Art. Abdomen, plaies de V. Heister. A General System of Surgery. Book I. Wiseman. Chirurgical Treatises. London, 1676. S. Cooper. Surgical Dictionary. Art Wounds. See also the Theses published in Paris by the following:—Tombeur, 1806, No. 5.—Roubaud, 1808, No. 136.—Gaultier, 1810, No. 46.—Ac- briet, 1815, No. 90.—Candy, 1824, No. 137; and Girardin, Theses de Strasbourg. 1829. Hennen. Principles of Military Surgery. 2d Ed. Chap. XIX. Gibson. Inst.it. and Pract. of Surgery. 2d Ed. Philad. 1831. Sect. XI. Vol.1. Dorsky. Elements of Surgery. 2d Ed. Philad 1818. Vol. I. Chap. XV. * For the completion of this Bibliography the reader is referred to the articles on wounds of the several organs contained in the abdomen. I.H. ABDOMEN. {Contusions of.) 59 { 2. Contusions of the Abdomen.— Those contusions which affect the parietes of the abdomen without involving the vis- cera, are termed simple; but when the injury is extended to any of the organs contained within the cavity, the contusion is said to be complicated. 1st Simple contusions of the abdomen. These are not very frequently dangerous, except when they take place in the lum- bar region, or about the brim of the pelvis. The abdominal parietes are everywhere else so yielding and mobile, that the force of a blow is generally felt by the more delicate parts beneath, almost as strongly as by the integuments themselves; and the mischief which results, if it is very obvi- ous externally, is almost always compli- cated. The position of the spinal column and the muscles attached thereto, renders the lumbar region so firm and resisting, that simple contusions upon this part may be attended with all the consequences of similar injuries in other situations; and parts in the neighbourhood of the brim of the pelvis are liable to suffer in like man- ner, because of the immediate proximity of the fixed attachments of the muscles and tendons, and the perfect facility with which the intestines beneath may escape by their mobility. Contusions about the lower ribs are scarcely ever simple, if at all severe ; for the viscera in this region are more fixed, while the parietes, includ- ing the lower ribs themselves, are easily depressed by moderate forces. When, however, the abdominal muscles are in a state of strong contraction, their power of resistance is astonishingly great and they are then capable of protecting the bowels against the effects of blows and weights which under other circumstances would be highly dangerous or fatal. We have seen a man who, by simply contracting the recti muscles, could endure, without being moved from his position, the most violent blows of the fist upon the abdomen just below the umbilicus. Some of the feats of the Ravelle family, lately exhibited in Philadelphia, and those of a man who for- merly obtained great notoriety in London by lying down in the street and allowing carriages to be driven over his abdomen, are still stronger instances of this fact When thus contracted, the muscles, or their tendinous expansions, may suffer very severe contusions without permitting the viscera to participate in the injury; and thus we may account for the many record- ed cases of rupture, by external violence, of one or more tendinous expansions on the anterior part of the abdomen, of the recti, and of other muscles, unattended by solution of continuity either in the skin or peritonaeum. The treatment of simple contusions of the abdomen, when unattended with the rupture of any important fibres or vessels, should be conducted upon general princi- ples, (see Contusion,) and it is needless to discuss it here. When considerable ec- chymoses take place, they are generally found confined to a small surface when seated in the superficial cellular or adipose tissue, and much more widely diffused when located beneath the fascia superfici- alis : in the latter case, however, they spread less freely in the neighbourhood of the umbilicus, linea alba, and os coccygis, than in other directions. When the ex- travasation is seated between the perito- naeum and the muscular walls of the cav- ity, it extends with great facility, not be- ing arrested or confined by the edge of the pelvis, nor, entirely, by the linea alba. M. Velpeau {Did. de Med.) states, that in three cases of death from external vio- lence, he was able to ascertain that it be- comes more and more evident as it recedes from the umbilicus and the linea alba, in the middle two thirds of its length; and he refers to Pelletan, {Clin. Ch. Tom. II. p. 117.) for the case of a bricklayer, in whom the extravasation extended from the right lumbar region into the pelvis, and over the whole base of the left thigh. When blood is effused in this last situa- tion, it generally lies concealed from ob- servation ; and the dull pain felt by the pa- tient when attempting to rise, or to per- form any movement whatever, with the sense of pressure and weight in the abdo- men, are the only symptoms which pre- sent themselves. These, though they may lead to a suspicion of the nature of the case, do not furnish sufficient foundation for an accurate diagnosis, for they are equadly characteristic of effusions within the abdomen, and may be present in inju- ries of a different character. The aid of art is hardly ever demanded for the evacuation of these extravasations; they are for the most part absorbed with great rapidity, but they may remain for a very long time without occasioning serious inconvenience. It is only when they give rise to abscess, and when the symptoms of this change are unequivocal, that the ques- tion can arise whether they should be opened by the lancet When the ecchy- moses are very extensive; after the in- flammatory symptoms have subsided un- der the usual treatment, the absorption may be sometimes accelerated by the 60 ABDOMEN. {Contusions of.) proper application of moderate pressure with a bandage, skilfully applied. When severe—simple contusions of the abdomen are attended with danger of peri- tonaeal inflammation, from the same causes which produce that complication in wounds of the abdominal parietes, {q. v.); and the same cautions recommended under that head are equally necessary here. The an- tiphlogistic treatment should be carried as far as the circumstances of the case will permit, whenever such danger threatens. Although the parietes of the abdomen yield so readily to impinging bodies, that the viscera almost always participate in the injury inflicted by them, yet it is pos- sible for rupture to take place in any of the muscles, tendons, or fascia, or even in the peritonaeum itself, while the contu- sion still retains the character of strict simplicity, the skin remaining undivided and the bowels free from all lesions. One of the most frequent causes of such rup- tures is the kick of a horse received upon the abdomen : J. L. Petit and Boyer each mention a case of the rupture of a hernial sac in this manner, without any material injury either to the integuments or the intestine; and Velpeau refers to another, in the thesis of M. Darbefeuille. Desault has witnessed the complete divi- sion of the peritonaeum and other parietes, giving rise to a consecutive hernia which was covered by nothing but the integu- ments ; and we have noticed a fact similar in all respects, except in the integrity of the peritonaeum, and in the rupture being situated a little above the right internal ab- dominal ring. The patient was a seaman on board the Factor, of Philadelphia: he received a slight kick from a horse on the Course at Calcutta, which did not disable him from pursuing his usual occupations: after a short time, however, a small hernia made its appearance; and once, on the homeward-bound passage, the intestine was near being strangulated, a very unu- sual danger in injuries of this character. M. Thomas, in his thesis, mentions a rup- ture of the rectus muscle, not extending to the peritonaeum or the aponeurosis; and Larrey has seen all the broad muscles thus divided near their insertion into the crista ilii. It has been supposed that in these ruptures, and severe simple contu- sions, the extent of the external injury and the safety of the viscera may some- times result from there being no internal organ placed between the impinging body and the projection of the spinal column at the moment of the accident To this idea we cannot subscribe; for if a blow be in- flicted by a body small enough to depress the parietes to so great an extent, while it could thrust aside, without bruising, the convolutions of the intestines, it must necessarily act like a cutting instrument, and the integrity of the integuments could not be preserved; unless, indeed, in an extremely emaciated patient. We are in- clined to think that in all severe simple contusions of the abdomen, the contraction of the muscles at the moment, prevents the depression of the parietes; and that ruptures, when they occur in the muscular parts, are owing as much to spasmodic contraction, as to the direct action of the external force. (See Ruptures of the Ab- domen from Internal Causes.) These cases of simple contusion attend- ed by ruptures, like those of incised and lacerated wounds, are often liable to con- secutive hernia, which should be prevent- ed, if possible, by the use of a belt so con- trived as to produce firm support over the injured part This should be applied as soon as the inflammatory symptoms have subsided, and continued until some time after the union of the divided parts is com- plete, or until the new bond of union has had time to contract and condense itself 2d. Complicated Contusions of the Ab- domen.—These may involve a great vari- ety of injuries to the abdominal or pelvic viscera, in which, any one, and often, sev- eral, of the organs may be implicated. One of the most frequent complications results from the general pressure upon the nerves and other contents of the cavity, produced by the contusing force ; and this subject has not elicited a degree of atten- tion commensurate with its importance. It is by no means uncommon to observe, in patients who have been bruised by the ac- tion of large and heavy bodies, and partic- ularly in workmen who have been par- tially buried in making excavations, a state of general depression, or collapse, alto- gether disproportioned to the severity of the injury inflicted upon any particular part or organ, and which cannot be ex- plained upon any other supposition than that the splanchnic nerves have had their functions more or less completely suspend- ed by the compression to which they have been subjected. In such cases, costiveness and retention of urine are generally ob- served ; the former being attributed to the loss of tone in the abdominal muscles, which no doubt contributes in some degree to its production ; but the latter symptom has been singularly neglected by surgical writers. When the compression has not been violent or long continued, the organs ABDOMEN. {Contxisions of.) 61 soon regain their natural powers, moderate reaction speedily ensues, and the case may terminate favourably in a very short time; but when the reverse of this happens, the loss of tone continues for a considerable time; and if the bladder is not evacuated by artificial means, the urine accumulates continually, and the viscus becomes com- pletely paralyzed by distension, giving rise to a very serious, and perhaps fatal, com- plication. This retention of urine is not accompanied by any considerable pain; and the uneasiness is generally referred, both by the patient and surgeon, to the contusion of the organs contained within the abdomen. We have seen, on several occasions, the bladder distended almost to bursting, when no such state of things had been suspected until the long-continued absence of the discharge induced the sur- geon to examine the hypogastric region. It is highly important then, to attend to the condition of the bladder in all cases of contusion or strong compression of the ab- domen. Dr. Parrish of this city has for many years called the attention of his class to this subject in the course of clinical re- marks at the Pennsylvania Hospital. The same species of paralysis in contu- sions of the abdomen sometimes occurs in falls, from considerable heights, upon the lumbar region, and is then due to concus- sion of the spinal marrow, or the origins of the spinal nerves. This effect may be evanescent or it may last for several days. We give one mild case in illustration. W. T., a lad on board the Factor India- man, when at sea, in November, 1823, slipped and fell backward down the booby- hatch, striking the upper part of the lum- bar region strongly upon the edge of his sea-chest. He was at first unable to rise, but in a few minutes succeeded in reach- ing his berth. His lower extremities were somewhat enfeebled; but in the afternoon, he was able to walk without much diffi- culty. The bladder was somewhat dis- tended, and he wa^ directed to endeavour to urinate. He discharged a few drops with great difficulty, and apparently by strong effort with the abdominal muscles. As the other symptoms were rapidly de- clining, it was supposed that the bladder would soon regain its power of contraction. On the following morning the distension was so great that the fundus of the bladder rose nearly to the umbilicus; but as the boy was on deck, and apparently well, with the exception of weakness, no particular inquiry was matde until near the middle of of the day; and it was not until he com- vol. i. 6 plained of an involuntary discharge of urine, guttatim, that this distension wais discovered, and the catheter introduced. The bladder was found to be so completely paralyzed by the enlargement, that its con- tents were not entirely evacuated without the aid of pressure. In a few hours, the catheter was withdrawn, and the bladder was found to have regained its power. The patient complained of no considerable in- convenience except from the presence of the instrument The ordinary measures for relieving retention of urine are here obviously inapplicable, the difficulty de- pending not upon an irritation, but upon a suspension of the nervous power. Our sole trust is in the catheter, which should be introduced, repeatedly if necessary, until the proper tone of the organ is re- gained. Contusions of the abdomen, complicated with peritonaeal inflammation, injury of the kidneys, rupture of the ureters or urethra, or fractures of the pelvis, are also attended with retention of urine, or the arrest of the secretion of that fluid; each of which ac- cidents will be considered in its proper place. But although most of these causes are followed by more severe nausea, vom- iting, and rigors, than attend upon simple compression or concussion, they may all act consentaneously with the latter; and it should therefore be considered as a stand- ing rule, that the condition of the bladder must be examined in every case of these contusions, unless the patient discharges urine freely, within a reasonable time after the accident. One of the most dan- gerous consequences of contusions of the abdomen, is the traumatic peritonitis, which, when general or severe, frequently termi- nates in death before the expiration of forty-eight hours from the time of the ac- cident. It is needless to repeat in this place the directions given for preventing or combating that most formidable com- plication ; but it may be well to remark, that peritonitis may exist in full violence, producing universal adhesions among the bowels, and the secretion of pus; it may run its career, and terminate mortally, while the countenance continues shrunk and pale or livid, the muscular system re- laxed, the pulse nearly or quite impercepti- ble at the wrist and everything indicating a profound collapse. It is not even neces- sary that the viscera themselves should be seriously injured, in order that this in- flammation should be produced. Velpeau quotes a case from the thesis of M. Penasse, in which the abdominal muscles were the 62 ABDOMEN. seat of extensive extravasation, and the patient died of peritonitis. {Did. de Med. Art Contusions de V Abdomen.) The vigorous antiphlogistic treatment, so imperiously demanded in this complica- tion, would prove highly dangerous, or fatal, in simple concussion, or loss of power from pressure; and the stimuli resorted to, in severe cases of the latter, by many practi- tioners, a practice which, under all ordina- ry circumstances, should be followed with great caution, would be equally dangerous in the former. The diagnosis, in these ac- cidents, is often difficult; but the collapsed condition is generally attended with little absolute pain; and although vomiting, or nausea, commonly occurs immediately af- ter the infliction of the injury, it is seldom continued or repeated. The pulse, when perceptible, is neither very rapid nor con- tracted. The reverse of this is true in the majority of cases of traumatic peritonitis; and the countenance, which is languid hut calm in simple concussion, wears a painful expression in the inflammatory affection. The abdominal Viscera are liable to con- tusions in all respects similar, and quite as variotfs, as those which are met with in the parietes. Thus, extravasations of blood, precisely resembling those already de- scribed, take place beneath the peritonaeal covering of those organs, or within their substance. Velpeau has met with them on the convex surfaces of the liver and spleen, and in the thickness of the coats of the stomach and intestines; Morgagni has collected numerous cases of the kind in his 44th Epistle; and Jobert cites a case of a man whose intestines were cover- ed with ecchymoses. Partial ruptures by external violence, not interesting the whole thickness of the organ, have also been ob- served. M. Penasse has seen the rupture confined to some of the coats of an intes- tine without involving others. (Velpeau, Op. Cit.) Though every abdominal organ may be the seat of contusion, those are most likely to suffer which are most solid, fixed. and superficial; and first in rank in this class, is the liver. This organ must ne- cessarily suffer compression and injury in all severe blows on the right hypochon- drium, and inflammation is frequently the consequence, even in slighter cases, (see Hepatitis); but from its friability, it is often torn or ruptured by blows, falls, or pressure, and an internal hemorrhage results, which is beyond the reach of surgery, and too frequently terminates fatally. A diseased condition, or enlarge- {Contusions of.) ment of the liver, may increase the danger of this accident. The rupture may occur at a distance from the spot upon which the blow is struck, owing to the doubling or bending of the liver under the pressure of the force applied, or it may result from the momentum acquired by the viscus in falls from a considerable height; the extensibility of the abdominal parietes al- lowing the suspended liver to double or fold upon itself, or to break in part from its attachments. M. Penasse saw an instance at the Hotel-Dieu, in which the rupture took place on the concave surface; M. Forget met with two instances, in one of which, the liver of a patient with inter- mittent fever was torn in many places on the convex surface, in consequence of striking the abdomen forcibly against a bench; in the other, a triple rupture was occasioned by a blow of the fist. We have examined two cases of similar injury upon the concave surface, and one of fissure near the coronary ligament all consequent upon falls from great heights, and unattended with injury to the parietes. In the two former, the hemorrhage was not very great nor the lacerations deep, but the patients died of peritonitis; in the other, there was a fracture of the base of the skull, and the death was nearly instantaneous. Numerous instances are on record of rupture of the gall bladder by similar causes; an accident of the most hopeless character. The spleen, though smaller than the liver, is liable to similar changes from dis- ease; it is subject to contusion and rup- ture from like causes, and these acci- dents are attended with the same dangers of inflammation and effusion. In common with those of the liver, the ruptures of this organ are generally fatal; but when slight recovery may take place without our being assured of their existence. Cases of this accident are recorded by Morgagni, {Epist. 54, in which numerous cases are also quo- ted from the older writers,) Chisholm, {Edinburgh Med. <$■ Surg. Jour. VIII. 257,) Hennen, {Military Surg.) &c. Two cases are also quoted in the Am. Jour. Med. Sc. VII. 549, and VIII. 223. The kidney, although so much smaller and so deeply seated, is liable to contusions and lacerations of the same nature, as the annals of surgery amply testify. When a rupture of the kidney communicates with the peritonaeal cavity, the patient is some- times, though rarely, subject to all the dangers of effusions of blood or urine in that situation; but when the peritonaeum ABDOMEN. {Contusions of.) 63 retains its integrity, and the effusion occu- pies the cellular tissue, the case is much less grave in character. Rupture of the urinary bladder from contusions of the abdomen, though some- what rare, have been observed and nar- rated by several authors. Bonetus in the Sepulchretum relates a case; another is given by Dr. Fix, of Berne, {Bull, de Fe- russac, II. 167.); three by M. Delarue, {Journal Hebdomadaire, 1830); one by M. Hourmann, {Clin, des Hdpit. Tom. I. No. 14); one by J. Cloquet, {Ibid. Tom. II. No. 22); two by Dr. Cusack, {Dub. Hosp. Rep. II. 312); and four others were re- ported to M. Velpeau, from the wards of the Hotel-Dieu under Dupuytren. {Did. de Med. Art. Abdomen, Contusions de F.) This accident is regarded as necessarily fa- tal, when the laceration includes the peri- tonaeum. It is considered necessary that the bladder should be in a state of disten- sion at the moment of the injury ; and al- though one of Dr. Cusack's patients as- sured him that he had evacuated his urine a short time before the laceration took place, his account was not credited. The uterus, like the bladder, when emp- ty, is not liable to participate in the contu- sions of the abdomen; but when enlarged in gestation, it enjoys no farther immunity than that which results from the caution of the female and her friends in guarding her against accidents during that period. Ruptures of the uterus from external vio- lence are comparatively rare, but they have been observed in many cases: they are not always fatal, notwithstanding the dangers of terrible hemorrhage, and of the escape of the liquor amnii, or the foetus itself, into the cavity of the peritonaeum. The whole length of the alimentary ca- nal, from the stomach to the colon, is liable in every part to contusions from external injuries, which may occasion extravasa- tions within the proper coats, violent local inflammation, gangrene, or rupture, against which the mobility of the intestines does not appear to protect them. £ Such ruptures of the stomach are not common. One such case fell under the observation of Portal, {Anat. Med. V. 202.) and another was witnessed by M. Roques, {Jour, de Sedil- lot, Tom. 65.) Portal's case resulted from a fall in a drunken fit; the patient struck his abdomen on the ground, and died in four hours. No ecchymosis was observed, nor was there any external contusion. Ruptures of the intestines, both small and great have been very frequently noticed, even without any visible signs of injury externally; they have been sometimes com- pletely divided by a blow from a stick, a kick from a horse, and other similar causes, without the integrity of the skin being impaired. Numerous cases of this char- acter will be found in the writings of Hal- ler, Fabricius Hildanus, Bonetus, and Morgagni, and in other more recent an- nals. References to the 54th Epistle of the latter, to the cases of Tov, {Dull. Hosp. Rep. I.) Speer, {Ibid. IV. 349,) Drake, {West. Med. <£ Phys. Jour. Jan. 1828,) will present a view of most varieties of this accident The danger of severe contusion or rupture is of course greater in proportion to the quantity and solidity of their con- tents at the time of the accident. Contusions of the abdomen may be com- plicated, even with rupture of the great vessels, without abrasion of the skin. In these cases, the intestines are so thrust aside by the impinging body, that the yield- ing and flexible parietes may be brought nearly into contact with the spine, so as to permit these vessels to be torn. The vena portarum, vena cava, and aorta, have all been ruptured in this manner. Bonetus, {Sepulc.) S. Grass, and Preussius, {Eph. N. C. Dec. 3. Art. 2,5 & 6.) M. Breschet, {Did. de Sc. Med. Art Dechirement,) and M. Richerand, {Nosog. Ch.) have all described accidents of this nature. These terrible and fatal complications result from heavy blows, the pressure of great weights, or the passage of wheeled carriages over the abdomen, and can scarcely be produced by slighter causes, such as may be sufficient to produce rupture or severe contusion of the viscera. When contusions of the abdomen extend to the viscera without producing rupture of any organ, the most immediate consd- quence which calls for the attention of the surgeon, is the inflammation of the injured part; but as the symptoms and treatment vary with the situation of the lesion, we refer the reader to the articles treating of each particular organ for all details. The necessity of employing with vigor the measures best calculated to lessen the danger of peritonaeal inflammation, such as absolute repose, the abstraction of blood, low diet warm bathing, and emollient ap- plications, is not less pressing in this spe- cies of accident than in penetrating wounds of the same parts. One disposition is com- monly observed in all contusions of the ab- dominal viscera unattended by rupture; namely, the tendency to adhesion between the injured surfaces and the neighbouring portion of the parietes. When the occur- rence of general peritonitis is prevented, even for a short time, these adhesions sur- 64 ABDOMEN. round the site of the contusion, and remove the danger of that complication. When the vitality of a portion of the intestinal canal is destroyed by the blow or force applied, a slough separates, and the con- tents of the intestine may be poured out into a sac or chamber formed by false membranes, or they may be evacuated by fistulous openings into another viscus, or through the parietes of the abdomen; but if the surrounding adhesions are completely formed, the cavity of the peritonaeum is almost always safe from the effusion. (See Effusions into the Abdomen.) Reynell Coates. Bibliography.—Morgagni. De Sedibus et Causis Morb. Epist. 54. Pelletin. Clinique Chirurgicale, tyc. Paris, 1810. Tom. II. Boyer. Traiii des Malad. Chirurg. tyc. Paris, 1810, 4me. Ed. Tom. VIII. Larrky. Clinique Chirurg. Paris, 1830. Tom. n. Sabatier. Midecine Opiratoire. Paris, 1824. Tom. II. Hennen. Principles of Military Surgery, 3d Ed. London, 1829, & Philadelphia, 1831. Parroisse. Opuscules de Chirurgie. Paris, 1806. Cooper's Lectures. By Tyrrell. Wiseman. Chirurgical Treatises. London, 1676. Velpeau. Diet, de Med. Paris, 1832. Tom. I. Art. Abdomen, Contusion de V. Cooper. Surgical Dictionary, Art Wounds. J 3. Ruptures of the various parts constituting the Abdomen, from inter- nal causes.—Every part of the abdomen is occasionally the seat of rupture from in- ternal causes; thus, the intestinal canal, in all its parts, may be torn by its own con- tents, when surcharged, or weakened by disease. The rupture may be complete or partial, involving all the coats, or either of them separately, perhaps with the exception of the mucous coat, which is everywhere redundant. (Vide Stomach, Intestines, &c.) Rostan has frequently observed the peritonaeal coat torn, in wo- men advanced in life and affected with constipation. Marjolin has seen the same effect produced by strictures, either per- manent or spasmodic, and Velpeau has observed both the peritonaeal and muscular coats divided, in this manner. The gall bladder, the urinary bladder, and the uterus, are liable to similar acci- dents from like causes; and all the ab- dominal vessels, whether arterial or venous, are also subject to being burst in aneu- rismal or other enlargements. The abdominal muscles are all liable to spontaneous rupture, but the recti are more frequently broken than any other of the {Ruptures of.) large muscles. The efforts exerted during parturition have occasioned this accident several times; an instance of this has been published, by Chaussier. {Proces-verbaux de la maternite, anne 1809.) Efforts in vomiting during gestation have also given rise to the same disaster. It takes place, likewise, with great facility, in patients affected with dothinenteritis or with ty- phoid fevers. At the hospital at Tours in 1819, it occurred in the case of a soldier who died on the thirty-seventh day of the attack. (Velpeau, Dict.de Med. 1. p. 166.) The fragility of the muscles in the latter stage of putrid fevers, and the general diminution of the cohesion in muscular parts, in women of advanced age who are disposed to obesity, are causes which, ac- cording to the author just quoted, increase the frequency of such ruptures under these circumstances. The recti generally give way below the umbilicus, because they are there smaller and have fewer aponeurotic intersections. The great distension resulting from the enlargement of the uterus during preg- nancy, and the accumulation of water in ascites, abdominal tumours, &c. frequently produce a widening of the areolae of the aponeurotic expansions, accompanied with the rupture of some of the tendinous fibres, and may occasion consecutive hernia when the rupture is unusually large. Those injuries which are comniuiiy termed sprains of the back, and which are so often caused by violent efforts in lifting, or by sudden twisting of the spine, not unfrequently result from the rupture of some fibres of the great muscles connected with the lumbar vertebrae. The nature of the accident is sometimes rendered ob- vious by the position of the ecchymoses, or by a depression of the integuments at the spot corresponding with the fissure. Ruptures of the abdominal muscles pro- duce a disturbance of those functions which depend, in part, upon their action, such as the alvine or urinary evacuations, respira- tion, &c.; andlwhen neglected, they may give rise to more or less extensive ventral hernia. The proper treatment for these acci dents consists in regulating the position of the patient, so as to relax the injured muscle as completely as possible; the ob- servance of strict repose; warm emollient applications; general, and more especially local, bleeding, preceded, when the pain is very severe before inflammation or fever supervenes, by local bathing with opiates, and perhaps the exhibition of laudanum internally; and followed, after the subsi ABDOMEN. {Effusions into the.) 65 dence of those symptoms, by resolvents, and the use of a belt to prevent the occur- rence of hernia. When the rupture is deep- ly seated in the lumbar region, and when pain and weakness indicative of long-con- tinued chronic irritation are present it is sometimes proper to employ blisters, or even issues. When the torn ends of the muscle are preserved nearly in contact they unite; and the gradual contraction of the fibrous bond of union restores their functions in nearly their original perfection. Even the skin itself, and the whole thickness of the abdominal parietes, have been known to give way under the disten- sion produced by ascites—but these very rare and fatal cases are not essentially dif- ferent from lacerated wounds, and need not be considered in this place. Reynell Coates. } 4. Effusions into the Abdomen.— In consequence of various diseases and ac- cidents, a great variety of fluid or even gaseous matters may be effused into the cavity of the peritonaeum. In addition to the contents of any of the viscera, such as the stomach, intestines, bladder, &c, and that of the blood-vesseis, whether of the general or portal system, the sero puru- lent secretion of peritonitis, the serous or gelatinous fluids of ascites and hydatids, the matter of various tubercles, and the aeriform secretion of tympanitis, &c, are all found in the same situation. In this article we shall confine ourselves strictly to the consideration of those effu- sions which result from wounds and con- tusions, referring to the appropriate gene- ral heads, and to the articles on particular organs, for information on those which re- sult from diseased actions which are be- yond the jurisdiction of the surgeon. 1st. Effusions of Blood into the Peri- tonaal Cavity. These may take place from a great variety of causes, such as penetrating wounds, severe contusions, ruptures of the omentum, liver, spleen, in- testine, or any other abdominal viscus; and the blood may be derived from any vessel, either located within the abdomen, or dis- tributed to its parietes; for it is not unu- sual to observe a vessel opened by a punc- tured wound, discharging its contents in- ternally when the external wound is nar- row and obstructed. These effusions also occur from aneurismal or varicose enlarge- ment of the arteries or veins within the abdomen : the annals of pathological an- atomy are rich in such cases. The exit of blood from the injured ves- sels, in these accidents, does not occur with as much facility as external heraor- 6* rhage; for the abdomen, as already observ- ed, though called a cavity, is really a ple- num : no considerable quantity of blood can therefore be effused into it without producing a compression of the viscera, or a distension of the parietes, which press upon the intestines by the tonic action of the abdominal muscles. J. L. Petit, who was the first to attach much import- ance to this fact, thought that the resist- ance thus occasioned prevented the effused blood from subsiding to the lower part of the abdomen or pelvis, and occasioned it to remain, as indeed it generally does, imme- diately behind the external wound or con- tusion, the first portions which escape be- ing thrust aside, and spread in a circle around the divided vessel, by those which succeed. Garengeot, on the contrary, contends that notwithstanding the resist- ance opposed by the parietes, which re- tards the flow, the blood, when once ex- travasated, yields to the influence of grav- itation, and subsides toward the most de- pendent part of the abdomen, while the action of the intestines rejects it from among the convolutions, and drives it to- ward the surface. Petit attributes the dispersion of the effusion so frequently noticed in examinations after death, to the effect of accidental blows, and the handling and incisions necessarily em- ployed in opening the body. Mr. John Bell, {Discourses on Wounds.) whose admirable labours often lose a portion of their value, in consequence of his fondness for general laws and his neglect of the exceptions, coincides to the fullest extent with Petit, and the majority of modern surgeons agree with him. Sabatier, on the contrary, {Med. Op. Tom. I. p. 28.) seems to lean to the opinion of Garengeot ; and Velpeau declares, that " neither of these explana- tions is absolutely true, nor absolutely false. Their common fault is, that they mutually exclude each other." {Diet, de Med. I. 183.) That the effused blood generally re- mains coagulated in the immediate neigh- bourhood of the ruptured vessel, and ex- ternal to the intestinal convolutions, is suf ficiently proved by the testimony of Petit, John Bell, &c. : that it yields frequently to the laws of gravity, collecting in a mass about the hypogastric region, or in the pel- vis, is clearly shown by some of the cases cited by Sabatier, Pelletan, &c. : and that it occasionally becomes diffused, even in a direction contrary to its gravity, and between the intestinal convolutions, is dis- tinctly proved by several authentic records, 66 ABDOMEN. {Effusions into the.) among which, one of the most remarkable is the second case narrated by Pelletan, {Clin. Ch. II. 106.) in which the effusion took place from an aneurism or varicose condition of the ovary, and yet all parts of the peritonaeum were found studded with the partially absorbed and condensed remains of old coagula, produced by a long-continued, but slow, exudation from the diseased organ. Those who desire to see more numerous proofs of the excep- tions to the general law established by Petit, and so warmly defended by J. Bell, may consult, in addition to the works al- ready quoted, Ravaton, {Plaies, es are then found in the viscera of the three cavities. (Dezeimeris. Diet, de Med. I 100.) Ribes. (F.) Exposi de quelques recherches ana- tomiques, physiologiques, et pathologiques. Mem. de la Soc. d'Emulation. VIII. 622. Velpeau. These sur quelques propositions de Medecine. Paris, 1823. Ibid. Recherches et ob- servatioris sur Valteration du sang dans les mala- dies. Rev. Med. 1826. II. 440—559; III. 68— 85. Ibid. Deuxieme mimoire sur les abces tu- berculeux chez les sujets qui succombtni aux grandes opirations chirurgicales, ou bien a la ABSCISS.—ABSORPT. 113 suite d'une suppuration plus ou moins abondante. Rev. Med. 1826. IV. 392. See also same Jour- nal for May, 1827, and for June, 1829. Blandin. Recherches sur quelques points d'anat, de physiol., et de pathologic These. Paris, 1824. No. 216. Dance. De la phlebite utirine et de la phUbite enginiral, cemsideries principalement sons le rap- port de leurs causes et de leurs complications. Archives Gen. 1828,1829. XVIII. & XIX. Marechal. (J. F. A.) Recherches sur certaines altirations qui se diveloppent au sein des princi- paux visceres a la suite des blessures ou des opira- tions. These. Paris, 1828. Cruveilhier. Anat. Patholog. du corps hu- main. Fascic. No. 11. Rose. Observations on depositions of pus and lymph occurring in the lungs and other viscera, after injuries of different parts of the body. Med. Chirurg. Trans. XIV. London, 1828. Arnott. (J. M.) A pathological inquiry into the secondary effects of inflammation of the veins. Med. Chirurg. Trans. XV. London, 1829. Danvin. (Ad.) Observations et propositions sur quelques accidens tris commun^A la suite des suppurations aigues. These. PMs, 1831. 4to. 9 Nichet. Considiralions sur les causes et le traitement des accidens qui suivent^ les grandes opirations chirurgicales. Gazette MedicaTe, 1831. Nos. 6,13, 23, 36, 47, 52. Dance. Did. de Mid., I. 86. Paris, 1832. I. H. ABSCISSION. (From abscidere, to cut off.) The cutting away of a part, more especially of a soft part. This is the only signification in which it is at present employed, though formerly used in several others. I. H. ABSORBENTS. {Mat. Med.) This term has been applied indiscriminately to two distinct classes of remedial substances. The first are articles which, when inter- nally administered, have the property of chemically combining with, and thus de- stroying or neutralizing those acid secre- tions, which are produced in certain mor- bid conditions of the digestive canal. As, however, most recent writers on Materia Medica have considered these remedies under the appropriate name of Antacids, they will be treated of under that head. The second class includes all those ex- ternal applications which are made use of in ulcers, gangrene, (q.v.) &c, not only to arrest the progress of the disease, but also to prevent the patient or his attendants from suffering from the fetid discharges. Bibliography.—F. Ratier. Traiti Ele'men- taire de Mat. Med. Paris, 1829. 2 vols. 8vo. A. T. Thompson. Elements of Mat. Med. and Therapeutics. London, 1832. 2 vols- 8vo. R. E. Griffith. ABSORBENT VESSELS. (See Lac- \ teals and Lymphatics.) \ ABSORPTION. Absorptio, Lat. (From absorbere, literally, to drink up, to swallow, to absorb.) Absorption is an organic phe- 10* nomenon, usually classed with the func- tions. If we view this process, however, as a property attached to every particle of organized structure, and not as the office of an especial organ or apparatus, it can- not be regarded as a functional action, but as a vital and organic phenomenon. A state of vital activity is one of inces- sant change. Organic structure in the acts of vitality is undergoing constant re- novation, and sometimes modifications. In this respect, organic, for the most part contrast strongly wTith inorganic bodies. These last preserve their forms and com- position only when in a state of absolute quiescence: action destroys both form and composition. Organic bodies, on the other hand, maintain their existence by action. When motion or action terminates in them, they cease to exist as organized bodies. Their form and structure are lost The vital reaction of living bodies ex- hibits two well-characterized phenomena. 1. Attraction of new materials derived from exterior elements, and their appro- priation to the composition of organic tis- sues. 2. Rejection and elimination of the old materials, whose aptitude for vital ac- tivity is destroyed, and of those substances accidentally introduced, inapposite to vital structure. In this manner is accomplished a renewal or reconstruction of the tissues, or organic elements, the object of the vital actions. They are consequently always formative, and must be dependent on an- other phenomenon for the introduction of the exterior elements, and the removal of the rejected matters. This phenomenon is absorption, a term that has less applica- bility to this view of it, than when it is regarded in the light of a function. Absorption is a physiological phenome- non, too obvious to have escaped even su- perficial observation. Its existence has been recognized from the earliest periods. Hippocrates speaks of the inhalation of vapours and fluids not only from the ex- ternal, but from all the internal surfaces. Galen adopted his views, and entered into a fuller explanation. It was received by subsequent writers as a fixed principle, and formed a conspicuous portion of most sys- tems of pathology and therapeutics, and es- pecially in specific and contagious diseases. The intimate association and depend- ence of the nutrition of organized struc- ture on absorption, renders this process common to every living being. None, in active existence, can be developed or maintained, except from exterior matters whose molecules are seized on and con- 114 ABSORPTION. veyed into them by absorption. This pro- cess is not, then, exclusive, attached to any one class of beings; it is common to all, vegetable and animal; and belongs equally to the first rudiments of the em- bryon, and the being in its most perfect state of development. Neither is it the exclusive property of any one tissue; it is a property common to all, has its seat on all the surfaces, external and internal, and in the interior of the parenchymas. Extensive and diversified in its seat, it must consequently, present some diversi- ties in its phenomena, without however, varying in its essential nature. In all its modifications, absorption is nearly, if not entirely, an identical process. Various divisions have been made of this process, but it must not be understood that they are indicative of any essential distinction. It has been separated under the heads of ex- ternal absorption, as occurring from the ex- ternal skin and internal skin, or mucous membranes, lining the cavities in relation with external agents; and internal ab- sorption, or as exercised on the materials of the parenchymas, and internal structure of the tissues. It has been named nutri- tive absorption and incidental, as concur- ring in the aid of nutrition, or as displayed on foreign matters incidentally presented to the surfaces. It has been treated as venous absorption, or executed by the veins; and lymphatic absorption, or as performed by the lymphatics. The view we shall take of this phe- nomenon will be more satisfactorily eluci- dated by considering it under the follow- ing arrangement. 1. The seat or location of absorption. 2. The mechanism of ab- sorption. 3. Its physiological, therapeu- tic, and pathological relations. § I. The seat or location of absorp- tion. This process is manifested in all the membranes constituting so considera- ble a portion of the economy, and execut- ing some of the principal of the organic functions. These are, 1, the external der- moid membrane, or skin forming the exte- rior superficies; 2, the internal dermoid membrane, or mucous membranes, lining the interior surfaces, or cavities communi- cating with the exterior; 3, the genera- tive tissue, or cellular membrane, forming so extensive an element of all the organs, and spread throughout the whole econo- my, being the web or origin of every other tissue; 4, the serous membranes, a condensation merely of the preceding, lining the splanchnic cavities, and furnish- ing a covering to their contained organs; 5, the vascular tissue, or coats of arteries and veins; and, lastly, 6, the interstitial, intimate, and parenchymatous structure. A few observations may be required to explain more fully the phenomena of ab- sorption, as exhibited in these various sit- uations. 1. Absorption as manifested in the external dermoid membrane or skin. From the earliest periods cutaneous ab- sorption was received as an unquestioned fact. Applications of remedies were made to the skin, intended to operate on various organs. This practice was a favourite method of acting on the economy with the Arabian practitioners. They applied to the skin medicines intended to exert their influence on the bowels as purga- tives, on the lungs as expectorants, and on the kidneys as diuretics. This therapeu- tic method, although much neglected, was not entirel^forgotten, and, in our time, has been revived and advocated by Brera, a Alibert, and especially by Chrestien, in a work rich in observations and experi- ments, written expressly on the "Iatra- leptic Method," or administration of reme- dies by cutaneous absorption. The generally received doctrine of cu- taneous absorption, was first impugned by Seguin, and nearly at the same time was controverted by Rousseau in his inaugural thesis published in 1800. Dr. J. Klapp, of Philadelphia, in 1>>05, resumed and extend- ed the investigation in his thesis, and the same subject was treated by Dr. Dan- gerfield. The result of these various publications was to throw, for a period, very strong doubts on the existence of this phenomenon; and they have certainly shown that it is not as universal as it was previously supposed to be. Many of the facts that were regarded as evidences of cutaneous absorption, they have proved to depend on pulmonary absorption, from the introduction of vapours into the lungs. In denying, however, in toto, cutaneous ab- sorption, and attributing solely to pulmo- nary absorption all the effects on the gene- ral economy following the application of substances to the skin, they have arrived at a conclusion that cannot be justified by the facts. That the skin is endowed with active absorbing faculties, no one, at the present day, will deny; and the only question to be resolved in this controversy is, whether the cuticle intended as a general protec- tion to the skin, acts so completely as a defence, as to oppose, under all circum- stances, the introduction by absorption, of all substances in contact with it. This certainly cannot be positively affirmed. ABSORPTION. 115 No fact is better substantiated, than that various medicinal substances applied by friction to the skin, will display their pe- culiar effects on the whole economy, or particular organs. The mercurial fric- tions are too noted almost to be adduced in illustration. It is vain to assert, that the development of the mercurial action is always the result of absorption from the lungs, the metal being vapourized. Entan- gled in fatty matters this is not likely to occur. Besides, were this the fact, patients occupying the same ward, and the adjoin- ing bed, and the nurses who make the frictions, should be salivated as well as the one on whom the frictions are made. Yet such occurrences are very rare, if the pre- caution is taken to protect the hand by a glove, of the person applying the friction. Neither are the labourers employed by the druggists in the preparation of mercurial ointment and blue mass, who are often oc- cupied in rubbing up the metal in mortars for days and even weeks, ever affected, as they would be, were salivation induced by frictions caused by the vaporization, in these instances, of the metal, and its in- halation into the lungs. The cuticle is not in every part equally dense: around the genital organs, or the insides of the thigh, beneath the axilla, on the mamma? and the lips, the cuticle is of a more delicate organization, and when ap- plied to these parts, repeated experiments have established that medicinal substances produce most certainly their proper opera- tion. In a series of experiments by Dr. Mussey, of Massachusetts7?the absorption of the colouring matter of rhubarb, was clearly shown to take place from the skin. On a review of the whole controversy on cutaneous absorption, it may be conclud- ed, that while the epidermis diminishes very materially the absorbing activity of the external surface, and entirely abolishes it for some substances, that still it is mani- fested under certain circumstances, is fa- voured by frictions and bathing which soften the cuticle, and that it does occur with great constancy in particular parts and for other substances. When the epidermis is removed, and the skin is denuded, the mechanical ob- struction it opposes to the acts of absorp- tion being destroyed, this process is, then, displayed with decided energy. A great variety of matters are then introduced into the economy, either affecting it with dis- ease, if they possess morbific properties, or which may operate a therapeutic action, when of a medicinal character. This therapeutic method of bringing into play the remedial agencies of medicines, was introduced, a few years since, by Dr Lembert, and has now settled down into a received practice, under the name of endermic medication. It offers a most val- uable resource to the practitioner in a great variety of cases. In animals whose skin is moist, and which possesses a very delicate cuticle, cu- taneous absorption is a constant and im- portant function. Such are frogs, sala- manders, and similar animals. The ex- periments of Edwards have established the skin in them to be entirely absorbing, and instrumental in their support It is the opinion of Fohmann, that while the fcetus is in utero, cutaneous absorption from the liquor amnios, by which it is surrounded, is one of the means of its nutrition. 2. Absorption as manifested in the in- ternal dermoid membrane, or the mucous membranes. a. Of pulmonary or bronchial absorp- tion. The bronchial mucous membrane presents all the conditions of an absorbing surface in the highest degree, and is one of the most active of those executing this office. The physiological or normal ab- sorption of this surface, for which it is specifically provided, is that of the atmo- spheric air, in the function of respiration. This fact was long considered doubtful. In the theory of Crawford, and those of which it was the basis, no absorption of the air was supposed to exist. The changes it underwent were attributed to actions exterior to the mucous membrane, in the area of the lungs. The carbon of the blood eliminated into the lungs, there united with the oxygen of the atmospheric air that had penetrated into their cavity. From the later researches of Davy, Ed- wards, and others, it is now the received doctrine, that the oxygen, if not all the components of the atmosphere, is absorbed by the mucous membrane, and thus enter- ing the blood, unites with it In this doc- trine the absorption of the bronchial mu- cous membrane is no unimportant opera- tion in the function of respiration, and whatever condition of this structure inter- feres with or prevents the exercise of its absorbing powers, immediately affects the whole function of respiration. Absorption of the bronchial mucous membrane is not confined to atmospheric air exclusively. Numerous other sub- stances presented to it in the form of va- pour or gas, are likewise absorbed, intro- duced into the circulation, and, by this route, distributed throughout the economy. The vapour of spirits of turpentine has been proved, by the experiments of Bichat, Rousseau, and Klapp, to be absorbed by 116 ABSOR the pulmonary surface. The vapour of sulphuric ether, and nitrous oxide gas in- haled, very promptly exhibit their ex- citing and intoxicating effects on the brain, through the medium of the circulation. The vapours of ardent spirits, when breath- ed, have also been known to induce intoxi- cation. Mercurial fumigations are resort- ed to for bringing the economy under the influence of that remedy; and, in the memorable instance of the crew of the British ship of war, salivated, and other- wise affected by mercurial vapours pro- ceeding from a quantity of that metal loose in the hold, we have a strong evi- dence of the absorption of that metal by the bronchial mucous membrane. Mr. Achard, in the Journal de Physique, Oct. 1782, relates, that he was salivated by the vapours of mercury arising from a quanti- ty contained in a dish he had left over a furnace, daily heated, the temperature 72° F. {Bibliotheque Universelle, Jan- vier, 1818,) Meyer, in his experiments, in- jected small quantities of the solutions of different salts into the bronchial tubes, which he proved to have been absorbed by detecting them in the blood. These, and other strong instances that might be adduc- ed, attest sufficiently the active absorbing powers of the bronchial mucous mem- brane. b. Of alimentary absorption. The mu- cous membrane of the alimentary canal, takes precedence of all the surfaces in re- lation with the exterior, in the acts of ab- sorption. In structure, it possesses all the requisites for the exercise of this process. It is the seat of the nutritive absorption, destined for the reparation of the animal tissues, and is, consequently, the great portal giving entrance into the interior of the economy. All portions of the extended surface of this continuous tube, from the lips to the anal termination, are absorbing; but the stomach, small and large intestines, from admitting the prolonged contact of the matters they receive, are the most conspi- cuous for their absorbing energy. In the stomach, the solid food does not present the conditions adapted for absorp- tion, and is retained to bring it into that state, which is its molecular disintegration. This is the principal, if not exclusive end of digestion. But the drinks and other liquids, many colouring bodies, medicinal and other substances, whose materials are capable of penetrating the gastric mu- cous membrane, are rapidly absorbed, and carried into the interior of the or- ganism. Those of them endowed with active properties, display their influence on the organs with which they possess relations; others appear in the secre- tions eliminated by secerning organs from the economy. The rapidity with which fluids and colouring substances pass from the stomach to the bladder, is such as to have puzzled physiologists not a little to account for the phenomenon. Darwin resorted to the hypothesis of a retroverted action of the absorbents. Sir Everard Home suggested a direct communication by means of vessels between the stomach and bladder, which Lippi pretends, but we believe with Fohmann, incorrectly, to have discovered passing from the digestive or- gans to the pelves of the kidneys; and Magendie was directed by it to his ex- periments, which eventuated in the reno- vation of the exploded doctrine of venous absorption. In the experiments of Home and Magendie, repeated and confirmed in Philadelphia by Lawrence, and Coates, various substances placed in the stomach, were detected in the urine in the space of from four to six minutes. The absorbing faculty of the small in- testines is not less active than that of the stomach. The aliment reduced by the processes of digestion to its molecular state, is rendered capable of penetrating their mucous membranes. It is freely taken up. The lacteals, which appear to be the organs of chylosis, or the apparatus for the preparation of the chyle from the nutritive molecules, are to be seen, at this time, filled with that fluid; and, in a short pe- riod, the whole nutritive product of diges- tion is removed from the alimentary canal. The absorbing power of the small intes- tines, is not restricted to the imbibing of chyle only. Experiments have demon- strated, that it shows an equal activity for numerous active principles when they are applied to that surface. In the large intestines occurs the last of the series of digestions, or processes through which the alimentary matters pass for the complete evolution of the nutritive ele- ments they contain. The result is feca- tion, and the entire separation of all the nutritive principles from the innutritive matters. The first are absorbed, the last rejected. Besides normal or physiologi- cal absorption, in regular activity, when- ever foreign matters are addressed to this surface, many of them are immediately absorbed and carried into the economy. Tonics, narcotics, stimulants, diuretics, and other medicinal substances, when thrown into the rectum, will act on the organs they specifically affect, with nearly as much certainty and promptness as when addressed to the stomach. ABSORPTION. 117 Other mucous surfaces, as the genito- urinary, are also absorbing surfaces, though it is rarely possible that foreign matters, with the exception of some specific virus, are, or should be, introduced into the or- ganism by this route. 3. Absorption in cellular tissue. The ab- sorbing powers of the generative or cellu- lar tissue, are of unquestioned activity. Fluids of various kinds so often effused into this tissue, are rapidly taken up, and eliminated by the kidneys, or skin, or bow- els. Tumours of different kinds, nearly all of which arise in the cellular tissue, and are formed by its degeneration, and the secretion into its meshes of various fluids and matters, disappear very frequent- ly, even when they have acquired a consid- erable bulk. This must have been accom- plished by absorption. Blood, which is often effused into the cellular tissue; and air, that has escaped into it, forming em- physema, disappear by the process of ab- sorption. Various active medicinal prin- ciples, when they are placed in the cellu- lar tissue in the groin, thigh, or other parts of animals, will exhibit their specific actions in distinct organs. A solution of emetin injected, by Magendie, in the cellular tissue of the thigh of a dog, ex- cited vomiting in nearly as short a time as when introduced into the stomach. A so- lution of strychnine placed in the cellular membrane, in any portion of the body, in a few minutes, produces tetanic spasms, by its action on the spinal marrow, which is influenced by the poison in consequence of its absorption. The absorption of the cel- lular tissue is fully established. 4. Absorption in serous tissue. The serous membranes, a condensed modifica- tion of the generative or cellular tissue, lining all cavities, and coating all viscera and organs liable to movements, are en- dowed with powers of absorption in an ac- tive degree. These membranes are lubri- cated by a viscous serosity exhaled on their surface, admirably adapting them to easy motion by preventing all friction, and this exhalation is constantly renewed. Absorption is equally active, or its accu- mulation would be inevitable. In a patho- logical state, serous and other effusions are often products from these membranes, constituting the dropsical affections. Yet, these effusions, when they even exist to a great extent, are frequently removed in a short period. The water of ascites, and of hydrothorax, after great accumulation, and it is not an uncommon occurrence, is rap- idly absorbed, and the effusion, at least for a time, removed. Absorption in the serous tissues is not confined solely to the fluids they exhale. Various substances, when applied to them, are carried rapidly into the general econo- my, and display their peculiar mode of activity. Solution of emetin introduced into the peritoneum, or pleurae, excites vomiting as speedily as when taken into the stomach. Strynine applied to these surfaces a few minutes, is productive of tetanic spasms. Dr. J. K. Mitchell, of Philadelphia, injected into one of the pleu- rae of a rabbit, a solution of sulphate of iron, and into the peritoneum a solution of prussiate of potassa. The veins spread on the diaphragm, were of a beautiful blue, from the Prussian blue, formed by the re- ciprocal action of these substances, ab- sorbed from the serous tissues, and carried into the circulating vessels of the part. A b- sorption is thus demonstrated as a process equally active, and as general in the se- rous as in the cellular tissue and dermoid membranes. 5. Absorption in the vascular tissue. The phenomenon of absorption belongs also to the vascular structure. This was to be expected, as the vessels are compos- ed of serous tissue, (the inner coat,) fibrous tissue, (the middle,) and cellular tissue, (the external); the two first being also mere modifications of the last The fact is proved by the application of the solution of strychnine to a denuded vein or artery. The specific action of the medicine is very soon brought into operation. I have proved the same fact for colouring substances. 6. Nutritive absorption. In the nutri- tion of the tissues by which they are re- newed, a simultaneous process of compo- sition and of decomposition is going on. The animal organic molecules that have composed the tissues disappear, to be re- placed by new ones furnished by the ali- ment. The original ones pass into the gen- eral circulation, and are eliminated in the form of the excretions. This removal of the constituent molecules is the work of absorption, which thus enters into the se- ries of acts that compose nutrition. Ab- sorption consequently is not confined to the surfaces of the organism, but occurs in every portion of the organization, in the profound and intimate structure. Intersti- tial absorption is at work in the hardest as in the softest of the organs, in bones and cartilages as in mucous membranes and nervous medulla. By this process, the bones of the cranium are adapted to the changing form of the brain. Bones are re- moved entirely, when the growth or en- largement of the soft parts produces pres- sure, as in tumours and aneurisms; and they vary in their form, consistency, and 118 ABSORPTION. colour, in different epochs of life, and from dis- eases, food, and other circumstances. The 6ame effects are to be noted in the mus- cles that diminish in size, and in the nerves that are atrophied under particular conditions. The same circumstances are to be observed in the glandular parenchy- ma, in the adipose tissue, and, in fact, in every structure, and can have no other explanation than the incessant action of absorption exerted on the separate mole- cules of each distinct tissue and organ. Interstitial absorption is but rarely mani- fested, except in the physiological order. Coagula of blood, effused into the medul- lary portion of the brain, in apoplexy, are, however, sometimes removed by absorp- tion. The fact has been established by Serres; and, in the bites of venomous animals, and the wounds of poisoned weap- ons, the deleterious agent deposited be- neath the skin and in the muscles, is taken up by interstitial absorption, conveyed into the blood, infects that fluid, destroying its capacity for the maintenance of vital ac- tivity. The numerous, varied, and well- devised experiments of Fontana have cleared all doubts on this point. § IL Mechanism of Absorption. Ab- sorption was attributed, by Hippocrates, to the veins. The same doctrine was adopted by Galen, and was received with implicit belief in the subsequent eras of the science. The first to call in question this generally adopted opinion, was Dr. William Hunter, whose brother, John Hunter, was supposed to have overthrown it in the most signal manner, by experi- ments. For venous absorption, which was denied in toto, they substituted absorption by the lymphatics, which then received the name of absorbing vessels. Cruik- shank, a pupil of Dr. Hunter, in his fine work on the absorbents, embraced the doc- trine of his preceptor, and warmly sup- ported it. The views of the Hunters were the acknowledged principles of the age, con- tested by none. Venous absorption was looked on as an exploded error of the schools, and the lymphatics, or as they were more frequently and emphatically termed, absorbents, were considered as the exclusive agents in the performance of this office. Such was the doctrine of absorp- tion until the actual period. Lymphatic absorption, bolstered, as it was supposed, by irrefutable facts and ar- guments, was subjected to a new scrutiny. Magendie instituted a series of experi- ments, the results of which led him, not only to assert the existence of venous ab- sorption, but he denied the same function to the lymphatics. Segalas followed in the same track, and confirmed the accu- racy of Magendie's observations; and, re- investigated in this city, by Doctors Law- rance, Coates, and Harlan, the facts demonstrative of venous absorption were indubitably established. The American experimenters further exhibited the source of delusion which probably misled John Hunter, in one of his most important ex- periments. It was not long before it was perceived that the ground occupied by Magendie was too narrow, and did not include all the phenomena of absorption. He was himself amongst the first to enlarge his views on the subject, and he established by new ob- servations that absorption was not confined exclusively to the veins, but that the lym- phatics partook of it, along with every spe- cies of structure; and finally he has settled in the conviction that it does not essentially differ from imbibition. Absorption is still regarded by some phy- siologists as a function of the lymphatics, and it is attempted to sustain this doctrine on anatomical considerations. Lippi pre- tends, as has been already remarked, to have discovered absorbent vessels passing directly from the digestive organs to the pelves of the kidneys, and other lymphatics communicating with venous trunks. By these routes matters taken up by the lymph- atics are directly conducted into the veins, and the facts regarded as illustrative of venous absorption may be thus explained. The alleged discoveries of Lippi, although they received the approbation of the Acade- my of Sciences of Paris in 1829, are denied so positively by the superior authorities of Fohmann and Lauth that they cannot be admitted. But while Fohmann refutes Lippi, he is himself an advocate of lymphatic absorp- tion, and he accounts for the phenomena supposed to result from venous absorption by an anatomical arrangement totally dif- ferent. From his indefatigable investiga- tions he has discovered lymphatics in tis- sues and organs where they were before unknown; in the transparent cornea, con- junctiva, serous membranes, inner coats of vessels, and placenta. The lymphatics thus abound in every part of the body. The two Meckels (grandfather and father) had re- cognized in a few lymphatic glands a di- rect communication with the veins. Vro- lik had made the same observation on the mesentery in the body of a woman; and Abernethy had demonstrated the phenome- non in examining the large mesaraiic gland ABSORPTION. 119 of a whale. These facts Fohmann fully confirmed in repeated investigations, al- though he differed as to the mode of com- munication. He deduced in consequence this proposition, that in man and in the mamiferse the communications between the lymphatics of the veins, except in the clavicular regions, are limited exclusively to the absorbent glands. By this imme- diate communication existing in the lymph- atic glands, between the lymphatics and veins, Fohmann conceives may be explain- ed the facts that show the introduction of substances into the circulation, that could not have passed by the thoracic duct By the anatomical structure of the lymph- atic glands a direct communication between the lymphatics and veins must be admitted to exist. The authority in support of the fact is too respectable to be rejected. In this manner many substances, probably not re- quiring it may be introduced into the econ- omy without previous elaboration, while others must be previously subjected to the actions of the glands and lymphatics. Yet it does not follow because this arrangement may exist, that absorption is restricted en- tirely to the lymphatics, and no substances can enter the circulation except introduced through the medium of the lymphatics. In the experiments of Magendie a circumvo- lution of intestine was isolated from the remainder of the alimentary canal, and a portion of the extract of nux vomica intro- duced into it All the connecting parts, ex- cept a single artery and vein, were also re- moved, yet in the usual period, six to ten minutes, the convulsive movements that substance excites by its introduction in the circulation ensued. The communication between the lymphatics and veins through the glands was here cut off, and yet the poi- son had been absorbed and carried into the blood. This experiment having been re- peatedly verified, cannot be questioned, and the absorption of the poison consequently must have been independent of lymphatic absorption in the'manner advocated by Foh- mann. In order to test the correctness of Foh- mann's doctrine, assisted by Dr. Mutter I made the following experiment. The external jugular vein of a full-grown ram was laid bare, and completely isolated from the surrounding structure. A pledget of muslin was passed under it and a ligature applied to its lower portion. The ex- ternal coat of the vein was then touched with a solution of prussiate of potash, and a ligature distant two inches from the first was passed round the other extremity. The portion of vein between the two ligatures was then removed. The blood contained in it was emptied into a glazed cup. The internal membrane of the vein, touched with a solution of sulphate of iron, imme- diately became blue. After standing half an hour, the serum which had separated from the blood was also tested with the sulphate of iron, and the blue precipitate instantly took place. The prussiate of potash had therefore passed immediately through the coats of the vein, and had been mingled with the blood. The mode of in- troduction, asserted by Fohmann as that by which alone substances can enter the circulation, did not exist in this instance. This is the last effort to sustain exclusive lymphatic absorption; a doctrine which, it appears to us, must be abandoned. Physical, chemical, and vital phenomena, though apparently widely separated, are probably more nearly associated than they are now supposed to be. Advanced as is our knowledge of the physical and chemi- cal phenomena of the universe, infinitely more remains to be known, and when de- veloped, the wide space that now separates them from the phenomena of organized bodies, classed as vital, may, it is probable, be reduced to a mere artificial division. Most of the phenomena of organized bodies, or vital phenomena, as connected with their organization, with the exception, possibly, of the first or ultimate phenomenon, are no more than physical and chemical phenome- na occurring under new relations. They should be considered as such, and their ex- planation be always made on physical and chemical principles. Organic bodies are composed of the same physical and chemi- cal matters as compose inorganic bodies. The fact of their arrangement as organic matter does not divest them of their prop- erties or character as the subjects of the universal operations of physical and chemi- cal laws, and which they must obey in their organized state. Physical and chem- ical phenomena are in their most perfect state and exalted condition in organized beings, especially in the organisms of the most elevated beings. Metaphysicians, by a mental abstraction, have made solidity and impenetrability prop- erties of matter. This is, however, mere scholastic subtlety So far as matter can be brought to our positive knowledge by the senses, porosity and penetrability are its constant properties. We have what may be regarded as almost the demonstra- tion of the fact in the experiments of Gra- ham and Dalton, but more especially in the very ingenious experiments of our in- telligent collaborator Dr. J. K. Mitchell, 120 ABSORPTION. of this city, exhibiting the penetrativeness of the gases; and in the experiments of Dutrochet on the endosmose and exos- mose of fluids through animal and vegeta- ble tissues. It may be inferred from these experi- ments, that whatever may be the properties of matter in its ultimate atoms, of which we know nothing, that bodies, whether in- organic or organic, are porous and pene- trable by some other substances or matters. This property is not a mere passive one, but is active and incessantly in action, al- though exercised with different ratios in respect to different bodies. All bodies are consequently absorptive, actively imbibing or respiring in ratios definite for each sub- stance. Organic bodies exhibit this general phy- sical phenomenon, in its most perfect and active condition. The organic element of every tissue, vegetable or animal, is, as far as our means of investigation carry us, a spherical vesicle, with imperforated walls, imbibing or aspiring with a species of se- lection the exterior matters with which it is in relation, elaborating in its interior such as are of its own nature, expiring or ejecting others. Such is the result of the demonstrative experiments and observations of Raspail, in his admirable work " Chi- mie Organiquey The properties of a tissue are no more than the aggregate of the properties of each of its constituent mole- cules, and absorption is consequently a property of every organized tissue. It is now seen why, in the beginning of this ar- ticle, absorption was asserted to be an or- ganic and not a functional phenomenon. In the simpler forms of animals, the prin- cipal vital phenomena consist m imbibition or aspiration, and expiration. In the ani- mals of more complex structure, the phe- nomena cease to be simple. Several are combined, so as to constitute apparently but a single phenomenon, and can be prop- erly appreciated only when reduced to the expression of their simple state. Such it- absorption in the mammalia. It is a com- pound phenomenon, composed of imbibition or aspiration, and circulation. The animal tissues are permeated by the fluids con- stantly in motion, conveying to the sepa- rate molecules the elements for their nu- trition to be selected by aspiration. The substances penetrating the tissues through their pores, taken up by imbibition or as- piration, are conveyed into these currents of fluids permeating the tissues. Those that are soluble or mixable with the fluids are dissolved in or united to them, are car- ried rapidly into the vascular or general circulation, diffused throughout the econo- my, and produce often in a few minutes their specific action on the particular or- gans with which they possess relations from their inherent powers. Others that are insoluble, or immixable with the fluids, penetrate but slowly into the interior of the organism, or they remain in the tissues ex- citing only a local impression. The fluids penetrating and permeating the tissues, are the red blood, and white blood or lymph, mixed together in the large vessels and highly vascular organs, but separated in the tissues.. The ves- sels which give to their movements a centripetal direction are veins for red blood, lymphatics for the white blood. The substances absorbed into the tissues may, according to circumstances not yet established by experiments, be carried into the lymphatic circulation, or into the ve- nous circulation; and the one or the other may be the means of diffusing them throughout the economy. The lymphatic system may exercise other offices than that of mere vessels. The nu- merous glands composing so large a portion of the system indicate other operations. Their presence is an obstacle to the free movement of the fluids in the lymphat- ics, and they are largely furnished with red blood, an indication always of some important function. They may exercise digestive or other action on the matters absorbed. Lacteal absorption appears to possess something of a specific character. Ac- cording to numerous experiments, colour- ing and other substances introduced into the intestines are never detected in the lac- teals. The contents of the latter are exclu- sively chyle. These experiments require to be repeated. The observations have been made on the contents of the efferent vessels proceeding from the mesenteric glands; the fluid of the afferent vessels, or those convey- ing the matters absorbed from the intestines to the mesenteric glands, has been overlook- ed. Now, it is completely established, that in the glands a direct communication exists with the veins, and other substances than the chyle taken up by the lacteals may, in this manner, pass into the veins, and not appear in the efferent lacteals. Chyle, the fluid found in the lacteals, is not prepared by the digestions of the alimentary canal. It is not absorbed as perfect chyle from the intestines. It is elaborated in the lacteals or more properly the mesenteric glands. These last, then, (the efferent lacteals and mesenteric glands,) are the organs accom- plishing chylosis, or the formation of per- fect chyle from the crude production of the gastric, duodenal, and intestinal digestions. ABSORPTION. 121 The immediate active power operating the imbibition or absorption of bodies has not been demonstrated. It can at present only be conjectured. Dutrochet has sup- posed it to be electro-galvanism; and it is certain that this power causes the trans- port of fluids and even solid particles. It is a general physical law, shown in the re- searches of Dr. Mitchell, that gases and fluids penetrate each other in certain ra- tios, and it is well known that porous bodies possess the power of absorbing or imbibing and condensing both fluids and gases. Char- coal is a strong illustration of the fact; and even a fine crack in a bell glass, as Dob- ereiner first observed, will absorb and transmit a gas contained within the vessel. Analogous to these physical laws, is the general organic law demonstrated by Ras- pail, that every organized vesicle—the or- ganic atom—has the power of aspiring or imbibing, and expiring; a double and indi- visible function. By this power may be conceived all the results of organization. The atomic organic vesicle aspires fluids and solids, condenses them, assimilates or unites to the product formed, and rejects by repulsion or expires the products foreign to its nature, or in other words unassimila- ble. These phenomena are positive. The active physical force productive of them, is undetermined. To call them vital is merely to acknowledge them unknown. The absorption of substances from sur- faces in the manner indicated, can be easily understood; but certain tumours, coagula of blood effused in the organs, the callus tophi, &c, surrounding recently fractured bones, are also removed by absorption. The man- ner in which bodies possessing considerable consistency and solidity are thus dissipated by the absorbing faculty, has not been satis- factorily explained. The common solution of the problem, that they are eaten up by the absorbents, is a supposition too gross to be admitted. It is not however, all tu- mours that can be removed by absorption. Those that possess a certain degree of firmness and consistency, as the fibrous tumours, tuberculous deposits, encephaloid or medullary sarcoma, gelatinous fluid in- closed in fibrous cysts, all consisting of in- soluble materials, are never taken up by absorption. The tumours most readily dis- persed are the swellings of the lymphatic glands. These being cellular in structure, their enlargement is caused in most in- stances by accumulation of fluids in them, and hence they are more susceptible of dispersion by absorption. The removal of coagula of blood effused in the brain, as in apoplexy, when the pa- VOL. I. 11 tient survives the attack for some time, is accomplished by a particular process ob- served by Serres. The cellular tissue condensed by the pressure, forms a mem- brane surrounding the coagulum. It then secretes a fluid, which, acting on the co- agulum, dissolves it, reduces it to the fluid state, when it is susceptible of being ab- sorbed, and must be absorbed. How far a similar mode of action may occur in other instances has not been ascertained, but it is by no means improbable that a correspond- ing mode of digestion may be exercised on the matters introduced into or deposited in the tissues. What appears to countenance this conjecture is, the impossibility of re- moving by absorption those morbid produc- tions whose materials would resist strongly the disaggregating power of gastric diges- tion. An experiment of Spallanzani is cor- roborative of this view. A calculus of a given weight was placed in a wound, which was then made to cicatrize. After a certain period the wound was reopened, and the calculus was found to be destroyed in form and greatly diminished in weight A se- cretion had been established by the irrita- tion it had caused, and the fluid thus form- ed had acted as a digestive juice. J 3. Therapeutic and Pathological Re- lations.!. Absorption is intimately connect- ed with the therapeutics of many medicinal substances. The greater portion of them possess specific relations with particular organs or tissues, acting on them exclu- sively in a specific mode. This relation would appear to consist in the adaptation of the properties or inherent powers of the medicinal substance to the mode of vitality of the tissue. But for the display of this relation, the molecules of the medicinal substance must be brought into immediate contact with the tissue it affects, and this is accomplished by its absorption. In the higher animals, external absorp- tion consists, as we have endeavoured to show, of two distinct processes—imbibition and circulation. The first is limited to the tissue, and is modified by the texture of the tissue. Every distinct tissue possesses dif- ferent absorbent powers, depending proba- bly on its texture, and enjoys a positive re- lation in this respect with different sub- stances. This is a part only of a universal phenomenon. It is seen in the relations of various bodies in regard to light and heat. Bodies possess absorptive textures of dif- ferent capacities for these matters; whence result the various colours, as certain rays are absorbed or reflected, and the varying conducting powers for heat. This differ- 122 ABSORPTION. ence in the absorptive texture of the dif- ferent tissues, and even divisions of the same general structure, will account for the diversity of actions in many articles having nearly similar properties. Some affect the gastro-mucous membrane, when in contact with it; others, not very dissim- ilar, pass over that surface and influence the intestinal mucous membrane; and others display their activity only on that of the large intestines, leaving the other portions of the alimentary canal undisturbed. Some purgatives applied to the denuded cuta- neous surface are absorbed and will purge; others excite a violent irritation on the skin, but do not occasion their specific ac- tion on the intestines—they are not ab- sorbed. Tartar emetic aprfied to the skin, causes pustular irruptioiuftffifnifesting the energy of its active powf£ but does not in the least disorder the stomach. Its solu- tion injected into the veins, excites imme- diate vomiting. Applied to the skin, it is not absorbed; it does not enter the circula- tion, or it would manifest its action in the stomach. The absorption of medicines, necessary, in most instances, to their, therapeutic ac- tions, may be prevented, first, by the tex- ture of the surface to which they are ap- plied, and second, by the condition of the circulation. The texture is subject to fre- quent modifications, the result of a patho- logical state. It may be turgid from ex- cess of fluid, arid from defect of secretion; it may be permanently changed, hardened, softened, altered into an anomalous struc- ture: these, and other alterations in the texture, will affect the absorbing energies of the tissues or totally suspend them. In the congestions, and consequent remora of the circulation, so frequently existing in the gastro-intestinal mucous membrane, in the advanced period of fevers, medicinal substances and remedies addressed to that surface, fail to produce their effects. Pa- tients in this state cannot be salivated, the mercurial medicine remains on the surface to which it is applied; stimulants, diuretics, diaphoretics, disappoint of their expected operation. Even fluids cease often to be absorbed, and accumulate in the stomach and intestines, where they are found with the remedies administered before death. The tolerance, as it has been termed, of many medicines, which at first give rise to great disturbance, may proceed from this cause. The local irritation and inflamma- tion they excite, provoking a congestion of the surface and stagnation of the circula- tion in the tissue, suspend its absorption, and, consequently, their action is restrict- ed to a merely local impression on a very limited space. The condition of the circulation will also further influence the therapeutic action of remedies depending on their absorption. If the circulation be arrested in a surface to which medicinal remedies are addressed, or greatly enfeebled by congestions, the consequence of irritation, or prolonged in- flammation, or if the circulation be enfee- bled from any other cause, the transporta- tion and diffusion of the substance cannot be effected, and the therapeutic action must fail. The tissue may imbibe some of its molecules, but, if they be not constantly removed by the circulation, their continu- ous absorption must cease. These are some of the circumstances in which absorption interests therapeutics, and should possess a due weight in estimating the production of the therapeutic operation of remedial and medicinal agents. 2. In its physiological relations, absorp- tion holds an elevated rank in the actions of the economy. It is, as has already been announced, one of the several acts which together constitute the compound phenom- enon of nutrition. The elements of the organized tissues decomposed in the ac- tions of life, are removed by its exercise, carried into the general circulation, and thence expelled in the forms of the excre- tions. The whole process of nutrition is directly connected with, and dependent on, its regular performance. Nutrition is indirectly not less dependent on this pro- cess. The nutritive principles derived from the exterior are introduced into the economy by means of absorption. The sus- pension of this process, by any of the causes that control it, vitiates or interrupts the whole phenomenon of nutrition. If not restored, a wasting and slow perishing of the being ensues. The well-being and existence of the whole economy, is thus dependent on the healthful and regular exercise of absorption. 3. Absorption, on the doctrine advocated in this article, must be intimately concerned in general pathology. Its special patholo- gy is necessarily obscure, and must, in a great measure, be conjectural and supposi- tive. In general pathology, absorption as- sociated with the organic phenomena, will be involved in all the aberrations they ex- perience. A dependency of the texture and circulation must follow in the train of the modifications they are subjected to. The deviations it may undergo are its dim- inution and suspension, or its excessive activity. Diminution and suspension of absorption appear to be connected with ABSORPTION. 123 the congestion of the fluids, either red blood or lymph, induced by excess of irri- tation or inflammation. The fluids collect in the tissues the seat of the irritation, tur- gescence and erection ensue, a remora or stagnation results, and where erection is not a natural condition, the function of the organ is deeply assaUed or totally lost. This state is seen displayed to the senses in the conjunctiva and in the fauces; it occure in all the mucous membranes, and often in the skin. This condition frequent- ly persists after the irritation that had pro- voked it has subsided. Various stimulants, some of the metallic salts, iodine, then ap- plied, speedily dissipate the congestion, now become passive, by awakening the dormant powers of absorption. The stag- nant fluids are removed from the disturbed and overloaded tissues, and the healthy functions are restored. These instances are often mistaken for inflammations, un- accountably cured by stimulants. The lymphatic congestions, so often pro- ductive of glandular swellings and the colourless tumefactions of greater or less extent observed in the skin so frequently, in individuals of the lymphatic tempera- ment, are of the same character. Collections of serous fluids occur in the cellular tissue, and serous cysts, constitut- ing dropsical effusions. Defective or sus- pended absorption has long figured in the systematic works, as a common cause of the disease. It must be confessed that the explanation partakes more of hypothesis than demonstration. The pathology of dropsy is certainly complex: its causes are various. A vice of nutrition and impover- ished state of the blood, producing an ex- haustion of the fibrin, hematosin in the solid portions of that fluid, with great predomi- nance of the watery element leading to its effusion, is one of the most usual of the causes of dropsies. An obstruction or se- rious embarrassment to the return of the fluids by the veins or lymphatics, will also occasion the collection of fluids, constitu- ting oedema and even dropsy of the cavi- ties. In these last instances, absorption may be suspended from its dependency on the circulation. That dropsy is ever the result of a suspension of absorption alone, or simply from a loss in the equipoise of secretion or exhalation, and absorption, must be considered as extremely equivo- cal. No facts justify the conclusion. Depositions of albuminous or other viscid humours, into the cellular tissue and in the skin, in certain climates, are of frequent occurrence. They are not removable by absorption, and continue to accumulate, producing great enlargements of the limbs and other deformities. Such are the eli- phantiasis of the Arabs, glandular disease of Barbadoes, and leprosy of the Greeks. Alard and Hendy regard them as diseases of the lymphatics and lymphatic glands. The internal surfaces manifest at times defective absorption. The bronchial mu- cous membrane, in the advance of malig- nant fevers, and occasionally in other fe- vers, appears to be divested of its absorb- ing character. The blood experiences little change in its character, and the air is ex- pired as it entered. In the gastro-intestinal mucous mem- brane, absorption is sometimes lost or im- paired in the manifold changes that struc- ture is liable to. I have witnessed cases of excessive emaciation, continuing for a length of time'with an apparent integ- rity of every other function, of digestion, fecation, circulation, secretion, and in- nervation, which I was disposed to assign to defective absorption. In other cases, I have been disposed to believe that diges- tion and absorption have been rendered imperfect by the secretion of excessively viscid and tenacious mucus in great abundance, lining and adhering to the gas- tric and intestinal surfaces. These cases, relieved by active and drastic purgation with emetics, carrying off large quantities of mucous secretions, and followed with rapid restoration of flesh and embonpoint have appeared to me to depend on the cause assigned. It may be considered as doubtful, whether the excess, or too great activity of absorp- tion, exists alone as a pathological condition; at least, facts are wanting to establish such a category. In some cases, swellings of the testicles are followed with complete absorption and disappearance of the organ. This would seem to be a case of absorption existing in morbid activity. S. Jackson. Bibliography.—Mortimer. Diss, de ingressu humorum in corpus humanum. Leyden, 1724; and in Haller s Disp. Anat. Select. Lib. III. Edinburgh, 1758. Monro, Jr., (A.) Physical Essays of Edin- burgh, 1764. Monro, Jr., (A.) Observations, Anatomical and Physiological, wherein Dr. Hunter's claim to some discoveries is examined. By Alexander Monro, Jr., M. D. Edinburgh, 1758. This is a controversial pamphlet, in which Dr. Monro lays claim to the discovery of the absorb- ing faculty of the lymphatics, in opposition to Dr. Hunter. He establishes his point, and proves clearly that he had made the observation of the fact, and had demonstrated it prior to the period when announced by Dr. Hunter. Dr. Monro did not, however, abandon the doctrine of venous absorption which he still maintained. The au- 124 ABSORPTION. thority of the Hunters prevailed in opposition to these more correct views, to which physiolo- gists at a later period were compelled to return. Hr-NTER (Wai.) Medical Commentaries. 4to. London, 1761. 2d ed., 1777. , . , Sographi, (J.) Libellus in quo theoria lympha? ducluum Monroi el Hunteri, exponitur etad praxim clinicam adaptatur. 8vo. Padua, 1.66. Leonardi, (J. Gottfr.) De vi suctionis in corpore humano. Wittenberg, 1771. Winterbottom. Tentamen med. inaugur. amplectens qucedam de vasis absorbenlibus, v, cranium.) Deficiency of cranium. See Acephalus. I. H. ACRID. A term given, in general, to all substances which produce, in the or- gans of taste, a burning and irritating sen- sation, principally experienced at the top of the throat. Some vegetable, mineral, and animal substances possess this proper- ty naturally; several others acquire it by a peculiar alteration. They furnish con- diments, medicines whose action is, in general, stimulant, and a class of poisons designated by the epithet acrid, or irritat- ing. Bibliography. — Carthuser. Fundimenta Materia Medica. Wedel. De acrium, usu et abusu. Jena, 694. Gesner. Sciagraphia de acrium agendi modo. Erlangas, 1760. Renauldin. Diet, des Sc. Med. Paris, 1812. Art. Acre. I. H. ACRIMONY. Humorum acrimonia. In the humoral pathology, acrimony of the humours played as important a part as is now accorded to irritation of the solids. All diseases were ascribed to an acrimony of the fluids, which were supposed to be altered either by a spontaneous change, which caused a predominance of some one of their chemical elements, or by an ad- mixture with foreign substances of an acrid nature. Sylvius de le Boe, Professor at Leyden, the author of this doctrine, was of opinion that there were two species of acri- mony, one acid, the other alkaline. His colleague, Boerhaave, designated, in hia Institut. five species: viz. 1. A mechani- cal acrimony, consisting in the change of the molecules of the fluids, which acquired solid and sharp angles; 2. A saline acri- mony, which is muriatic, ammoniacal, acid, alkaline, fixed and volatile, simple and compound; 3. An oily acrimony, produced by a thin oil, as if burned, saline, and acrid; 4. A soapy acrimony, analogous to the animal and vegetable poisons; 5. An acrimony composed of the four preceding, or produced by acrid matters introduced in- to the body. In his aphorisms, this author re- duces the number of species to two, recog- nizing only the acid and alkaline acrimony. The history of these supposed acrimonies, as a cause of disease, is intimately connected with the exposition of the humoral pa- thology ; and it is under that head that it will be most properly considered. I. H. ACRINIA. (From a priv. and x?»u>, I separate.) A diminution in the quantity, or a suppression of secretion. 1. H. ACRODYNIA. (From axew, extremi- ty, and oSvv*;, pain.) This extremely in- definite appellation has been employed, by several of the French physicians, to desig- nate a disease which prevailed epidemi- cally in Paris and its suburbs during the years 1823 and 1829, the most striking symptoms of which were intense pains of the wrists and ancles. History of the Epidemic. The dis- ease was not confined in its attacks to any particular age, to either sex, nor, accord- ing to M. Dance, to any particular condi- tion in life; nevertheless, it occurred more frequently in adults and aged persons than in the young, in men than in women, and more commonly among the poor than among those in easy circumstances. It first attracted the attention ofthe medical men of that city in the month of June, 1828, when it made its appearance among the patients of the hospital Marie Therese, of whom thirty-six out of forty were at- tacked by it. It subsequently prevailed to an equal extent in most ofthe other hospi- tals of Paris, and among the inhabitants of many parts of the city. At the same time the disease attacked the soldiers in several of the barracks, as well as the in- mates of the prison of Montaigu. In the garrison of the Courtille, out of seven hun- dred individuals, ninety-seven were aflqet- ed with the disease. On the third day of September, 1828, it made its appearance ACRODYNIA. 195 in the barracks of Oursines, attacking five hundred and sixty soldiers out of seven hundred. In a few days, however, the dis- ease abated in violence, and soon ceased entirely. During the winter of this year, the epidemic continued in a mitigated form; but, in the month of March, 1829, it recurred with renewed violence among the garrison of the Courtille, notwith- standing the barracks had undergone a complete repair and thorough cleansing. In four days, two out of every five of the soldiers were attacked. The epidemic gradually abated during the subsequent portion of the year, and, by the middle of the winter, finally ceased. A few cases, however, were observed in 1831 and 1832. It has been supposed by some, that this epidemic is similar to that which prevailed in different parts of Germany during the sixteenth, seventeenth, and eighteenth centuries, and which is denominated by the writers of that country, kriebelkrank- heit M. Robert, in a memoir which appeared in the Journal Generate de Me- decine, CV. 15, has attempted to prove its identity with the epidemic known under the name of the Dengue. Symptoms. The invasion of the dis- ease was, in some cases, unpreceded by any premonitory symptoms; in others, it was ushered in by chills, a sense of uneasiness, lassitude, feebleness, more or less acute pain of the limbs, and vomiting. The symptoms that were the most constantly present, and which may, at the same time, be considered pathognomonic of this affec- tion, were lancinating or pricking pains, and a sense of formication in the hands and feet, particularly in the latter, with heat and swelling of those parts. During the presence of these symptoms, the pa- tients were unable to close fully their hands, and when they put their feet to the ground, it appeared to them as though they were treading upon the points of needles or of thorns. The pains always commenced in the wrists and ancles, and were very often confined entirely to these parts. In some instances, however, they extended along the legs and thighs, or the arms, to the trunk ofthe body, or even to the scalp. The pains varied in intensity. In general, they were more acute at night than du- ring the day. In many cases, the sensibility of the ex- tremities was so much augmented, that the slightest touch was intolerable; and, at the same time, painful cramps were felt throughout the limbs. At first, a sense of coldness was experienced in the affected parts; but this subsequently changed to one of burning heat, to abate which, the patients were obliged to keep their feet and hands out of bed. When the patients attempted to walk, it seemed to them, as we have already re- marked, as though the ground was strew- ed with portions of glass, or beset with sharp points. In other cases, a sensation was experienced as though the feet were enveloped in soft cotton, or in down, or as if the ground sunk beneath them at every step. In consequence of the disease ofthe lower extremities, the walk acquired a very peculiar character, the patient drag- ging his foot upon its point. When he applied the sole flat to the ground, the toes were bent back, and, of course, ele- vated. In the hands, the sense of touch became equally morbid, so that the individuals la- bouring under this affection could scarcely distinguish any object they laid hold of. To the hands of some, the smoothest and soft- est bodies felt harsh, and as though their surfaces were covered with minute points. The celebrated Picard, who died of pneu- monic inflammation, whilst labouring un- der this disease, experienced the peculiar sensation referred to, from the contact with his skin of the finest stuffs. Ordina- rily, there resulted an inability to flex or fully extend the fingers, and when these motions were attempted to be performed, pain was produced. Hence, it was with the greatest difficulty that the patients dressed or undressed themselves. In ex- treme cases, all movement of the extremi- ties was rendered impossible. The limbs remained permanently extended upon the bed, and when raised, fell down again like inert bodies. In the course of the disease, in some cases, contraction, emaciation, or paralysis of the limbs was produced, while, at the same time, very acute deep-seated pains of these parts were felt at irregular inter- vals, and were augmented momentarily by pressure. To these symptoms were very often added painful cramps of the extremi- ties, and, less frequently, subsultus tendi- num. Either at the commencement or in the course ofthe disease, a morbid state ofthe digestive organs was very generally ob- served. In some cases, this merely gave rise to loss of appetite, with a sense of full- ness and weight at the stomach; while, in others, nausea and vomiting, particularly after eating or drinking, were present. Frequently, the patients were affected with colicky pains, and, more generally, with a profuse diarrhoea, alternating often 196 ACRODYNIA. with constipation. In some instances, from twenty to thirty stools were passed in a day. Finally, in cases of a more ag- gravated character, bloody discharges took place both by the mouth and by the anus. Of these affections, the most obstinate was the diarrhoea, which has been known to continue for many weeks, and then to cease for a time, and recur at a later pe- riod. In general, however, none of the above symptoms extended beyond the first period of the disease. Occasionally, they were of so trifling a character as to render it doubtful whether they had any imme- diate connexion with the principal affec- tion. A redness of the eyes was frequently observed. It was confined either to the conjunctiva lining the eyelids, or to that of the eyeball, and was accompanied with an increased secretion of tears, augmented sensibility to light, and pricking or shoot- ing pains, with a sensation as though sand was interposed between the lids and ball of the eye. It is a curious fact, that, in many cases, these sensations were ex- perienced when not the least increased redness of the eyes was perceptible. An cedematous swelling occurred ordi- narily at the very commencement of the attack. It was most generally confined to the lips, cheeks, feet, and hands, but frequently extended also to the parietes of the abdomen, or even over the whole surface of the body. In the greater num- ber of cases, the swelling was inconsidera- ble, and unattended with much pain; it retained but momentarily the impression made into it by the finger, and, in a few instances only, produced a change in the colour of the skin. In these, the latter ap- peared paler than usual, or was covered with ecchymosed spots. In the course ofthe complaint, however, the skin underwent various changes. The hands and feet were often of an erythema- tic redness, from the very onset of the disease. This redness extended in patches over both sides of the hands; but on the feet it began at their external edge, spread gradually towards the sole, and ceased abruptly where the skin commences to cover their upper surface, forming here a kind of red line, or border. Upon the other parts of the body, especially upon the legs, it was in patches of a more or less intense hue, resembling, in many in- stances, ecchymoses. Very frequently the skin assumed a brown or blackish colour, as if it were covered with dirt. This was particularly the case upon the abdomen, the neck, and in the folds of the articula- tions. This appearance of the skin was rarely observed upon the face. The skin was also affected with various kinds of eruptions, either in the form of papula?, small conical tubercles of a deep red colour, pustules, phlycta?na?, acne, or even furunculi. These eruptions were especially observed around the feet and hands. At the part where the eruptions occurred, a desquamation of the cuticle generally took place, and was renewed several times as the new epidermis was formed. This was particularly the case on the extremities, where likewise copious local perspirations were frequent, recurring often periodically. The cutis was often laid bare in consequence of the entire de- struction of the epidermis, causing an intense redness and pain, extending to the surrounding parts. The desquamation, though less marked, occurred also on the other portions of the body: M. Chomel has seen the cuticle entirely detached from the nipple in the form of a little cap. On those parts where desquamation did not take place, a remarkable thickening ofthe cuticle occurred, particularly about the articulations of the feet. This thickening often caused the formation of a kind of elongated and very painful cushion be- tween the nail and pulp of the finger. The foregoing symptoms were unattend- ed by any very marked disturbance in the nutrition ofthe body, or by fever; at least, the amount of febrile excitement was never very considerable excepting in those cases, and at that period of the disease marked by considerable disturbance ofthe digestive organs. The patients were, ordinarily, prevented from sleeping by the pains and other un- easy sensations from which they suffered: in some cases the patients have been known to be kept awake for twenty nights in succession. The above are the principal symptoms by which the disease was accompanied; they, however, varied considerably in dif- ferent cases. In some, the morbid sensi- bility of the extremities was the most prominent phenomenon; in others, it was the disordered condition of the digestive organs; in others, again, the cedematous swellings of the surface, the brown or blackish hue of the skin, or the eruptions by which the latter was covered, were the most striking symptoms. Difference of locality appeared to have some influence in the production of certain symptoms, or at least in rendering these more predominant than others. Thus, in the prison of Montaigu, almost all the patients ACRODYNIA. 197 presented the brown hue of the skin, while this symptom was not observed in any of the soldiers belonging to the barracks of Oursine or Courtille. In the former, the prominent symptoms were numbness of the limbs, oedema of the face, ophthalmia, and vomiting; in the latter, contractions of the limbs. Again, in the Hospital La Charite, neither subsultus tendinum nor cramps were observed, whde in La Pitie a number of patients were affected with both. Acrodynia has been divided by some writers into several stages, according to the order and succession in which the different symptoms present themselves. The first stage, according to them, is that characterized by derangement of the di- gestive organs, oedema of the face and hands, ery thematic redness of the latter, and inflammation of the eyes. In the second stage we have numbness ofthe ex- tremities with desquamation of the cuticle, a brown hue of the skin, and eruptions on the surface of the body. The third stage is marked by the gradual decline of all the symptoms. But the march of the disease was far from being regular,—in some cases the first stage was absent, or, rather, the symptoms occurred in a different order. Neither were all the symptoms invariably present in every case. The disease was equally irregular in regard to its duration; being prolonged, in some instances, for several months, while in others it ceased after a few weeks. In general, however, it lasted for a considerable time. In many cases the disease abated or was appa- rently removed for several days, when it again occurred, and the patients continued to suffer from it so long as the epidemic lasted. Although in general an obstinate disease, acrodynia seldom terminated fatally. Only a few old persons, and individuals labour- ing under chronic affections of the viscera, died of it. The Hospital Marie-Therese, the inmates of which are all aged persons, is the only public institution where a number of deaths occurred: here eighteen persons sunk under the disease. Causes. Much difference of opinion exists as to the causes by which the epi- demic was produced. According to one party, the disease occurred principally among such of the soldiers as were lodged in the most humid and worst ventilated apartments of the several barracks, and among the poor who inhabited narrow and damp streets, and dwellings excluded from the air and sun. It is also stated, that during the prevalence of the epidemic bread was very dear at Paris, and hence 17* the poor, who live in a great measure upon it, were obliged to purchase that of an in- ferior quality, which was baked expressly for their use. The same kind of bread, it is likewise asserted, was used in the barracks. {Journal des Progres des Sciences Medi- cates, 1828.) On the other hand, it is maintained by M. Dance and others, that the epidemic cannot be attributed to ali- ment of a bad quality, for, if this was the case, they ask, why did not the disease prevail, equally among the soldiers in all the barracks, they being all nourished alike? At the Hospital Marie-Therese, notwithstanding the bakers and other per- sons who supplied the food consumed in that institution were changed, new cases of the disease still continued to occur, while the epidemic did not affect those in the immediate vicinity who ate food pro- cured from the same persons who supplied the hospital. In regard to the supposed production of the disease by an atmosphere rendered impure, either by defect of ventilation, by too many persons being crowded together within a narrow and confined space, or by the decomposition of animal or vegetable filth, M. Dance conceives that this could not have been the case, inasmuch as a number of the inhabitants of Paris were attacked who resided in detached houses, the air of which was in all respects suffi- ciently pure. The epidemic likewise pre- vailed in some of the most healthy of the barracks, as well in regard to their lo- cation as to their internal arrangements and police, while it did not occur in others less advantageously circumstanced; those especially in the streets du Foin and Mouffelard, whose situation is altogether unhealthy, while their chambers open only upon a narrow confined court. The apartments also the best ventilated were often those in which the greatest number of cases of the disease occurred—this was particularly the case in the barrack of the Courtille. {Did. de Med. Art. Acrodynie.) By some, the disease has been supposed to be produced and propagated by con- tagion ; the facts adduced in proof of this opinion are, however, so few and inconclu- sive as to demand no particular attention. Pathology. Equally various have been the opinions advanced as to the immediate cause of the peculiar symptoms by which this disease was characterized. On this question we can receive no light from pa- thological anatomy. In consequence of the few who died during the epidemic, and the rareness, hence, of autopsical ex- aminations, we are almost entirely igno- 198 ACRODYNIA. rant of the changes in the condition of the internal tissues connected with the disease. The lesions that have been observed, are set down by the gentlemen who made the examinations, as the result of a morbid condition of the organs, unconnected with the peculiar affection of which we are treating. By some writers, acrodynia is considered to be a species of rheumatic disease; others refer it to a concomitant inflammation of the mucous membranes and skin; others, again, believe it to consist in an inflamma- tion or irritation of the spinal marrow. This last opinion would appear to account most readily for the morbid condition of the sensibility, motility, and, in many cases, the nutrition of those parts in which the external symptoms principally mani- fested themselves. It is nevertheless true, that in the few post-mortem examinations that have been made, the spinal marrow was not found diseased, excepting in an instance or two where a paraplegia was evidently mistaken for the disease of which we are treating. Others have considered it to depend upon an inflammation seated in the cellular membrane, and M. Re- camier has suggested whether it may not be a variety of scurvy. Finally, the de- pendence of acrodynia upon inflamma- tion of the arteries or veins has been very plausibly maintained. A parallel has been drawn between the present epidemic and various others that have been presumed to depend upon a vitiated state of the grain employed for the preparation of bread in certain districts. Many of the latter were, in fact, accom- panied by most of the symptoms which characterize acrodynia; as for example, the formication, numbness of the feet and hands, amounting, in many cases, to para- lysis ; contraction of the fingers, cramps of the legs, swellings ofthe feet, and the ap- pearance upon the latter of phlycta?nae. This was particularly the case in the epi- demic which prevailed in Hesse in 1594, in relation to which a report was published by the medical society of Magdebourg. A similar epidemic occurred two centuries subsequently in England and in many parts of Germany, and was described, among others, by Waldschmied and Scheffel in 1717, and by Muller in 1742. A similar epidemic likewise pre- vailed in Bethune and Ldle in 1749, of which Boucher has left us an admirable account Treatment. The different views enter- tained in relation to the pathology of acro- dynia, gave rise to a great variety in the modes of treatment pursued by different physicians. By some, the disease was treated by bleeding, bathing, local or general, frictions and blisters, and by the administration internally of the compound powder of ipecacuanha. By others, opium, assafoetida, valerian, and the sulphate of quinine, were the remedies chiefly em- ployed. Purgatives and emetics were prescribed by others. Another class of practitioners depended on the treatment pursued at La Charite in colica pictonum; this, in the hands of M. Cayol, appears to have been attended with considerable suc- cess: while they who considered the disease to depend on inflammation of the spinal marrow, directed cups, blisters and moxa to the spine, and strychnine, &c. internally. Sulphurous baths and fumi- gations were employed by many, while M. Recamier believes that he has seen much benefit result from the administra- tion of the juice of sorrel. The treatment, however, from which the greatest amount of benefit appears to have been derived in the generality of cases, was bleeding general and topical, general and local bathing, emollients to the affected parts, sometimes rendered narcotic; in other cases, rubefacients, or astringent applications or blisters, in con- junction with a proper diet and regimen. When this treatment was persevered in for a sufficient length of time, it seems al- most always to have produced an ameliora- tion, at least, in the more prominent symptoms of the disease. Bleeding from the arm, according to M. Dance, was useful only in plethoric subjects, or in cases of accidental con- gestion. Leeches to the edges of the feet were found to reduce the erythema, but to have no effect upon the sense of numb- ness in the extremities; applied over the abdomen, they had little effect in relieving the gastro-intestinal affection; along the spine, however, to many practitioners, they appeared to produce an amelioration of all the symptoms. Bathing, either in simple hot water or in vapour, as well as sulphur- ous and aromatic baths, were not found, according to M. Dance, to produce in general much effect upon the disease- in many cases none whatever. Emollient cataplasms to the feet were seldom bene- ficial in quieting the formication in those parts, frequently they increased it. From frictions with a liniment containing either turpentine or ammonia, greater ad- vantage was derived; the same is true also of cold washes to these parts, or a lo- tion composed of a solution of acetate of ACROD—ACTjEA. 199 lead. Frictions with turpentine are said to have been very beneficial in many of the epidemics supposed to be produced by the use of damaged grain, particularly that described by Boucher. Of all the external remedies employed, blistering appears to have been the most effectual in removing the numbness and in calming the formication ofthe extremities, particularly in those cases in which the pains were not confined to the latter. Ap- plied to the limbs, but especially along the spine, blisters caused frequently a very speedy cessation of the symptoms alluded to. The moxa was employed in a very few instances only, and without any de- cided benefit. Opium, internally exhibited, produced a temporary abatement of the pains and the other uneasy sensations from which the patients suffered; but no per- manent good was derived from its use. It was principally in cases in which the disease exhibited an intermittent or re- mittent form, that the sulphate of quinine was resorted to; its use appears, how- ever, to have been unattended with any decided advantage. Bibliography.—Genest. Recherches sur Vaffedion ipidimique qui rlgne maintenant a Paris. Arch. Gen. de Med., xviii. et xix., 232, 63,357. 1828. Hervez de Chegoin. Note sur Vipidimie qui regne d Paris depuis plusieurs mois. Journ. Gen. de Med., cv., 15. 1828. Francois. Notice sur Vipidimie rignante a Paris depuis le mois de juin. Ibid., p. 360. 1828. Montault. Observations sur la Maladie ipidimique qui regne d Paris, etc. Ibid., cvi., 170. 1829. Robert. Mimoire sur Videntiti de Vipidimie de Paris et de VEpidimie des Antilles, diverse- ment connus, selonles localitis, sous les noms de Dengui, del Colorado et de girafe. Ibid., cviii., 309. Duparque. Note sur la Maladie ipidimique des pied et des mains, etc. Nouv. Bibhoth. Med. iii., 342. 1829. Cayol. Observations Mitiorologiqiies et Mi- dicales recueillies en 1829 d la Clinique de M. Cayol. Revue Med., ii., p. 48. 1830. Dalmas. Compte rendu de la Clinique de M. Chomel. Journ. Hebdom., i., 333. Chardon. De VAcrodynie on ipidimie qui a regni d Paris et dans les environs depuis Vannie 1828. Revue Med., iii., p. 57, 374. 1830. Dezeimeris. Sur VEpidimie de Paris. Journ. Gen. des Hopitaux, Nos. 2, 4, 8 et 17. De Fermon. An Epidemia nuperrime ob- servata (praesertim Lutetiae) causis, Symptomali- bus et therapeid ab aliis popularibus morbis dis- cernenda? Paris, 1830. D. F. Condie. ACROMINIAL, relating to the acro- mion. I. H. ACROMION. The process which ter- minates the spine of the scapula, and is articulated with the external extremity of the clavicle. (See Bones.) I. H. ACTiEA. Baneberry. Sex. syst. Polyandria monogynia. Nat. Ord. Ranunculacea?. Gen. Ch. Cal. 4-leaved, deciduous. Pet. 4, often wanting. Style none; stigma capitate. Berry superior, 1-celled, many- seeded. Seeds semi-orbicular. Recep. uni- lateral. Nuttall. The genus Aetata, as established by Linn.j:us, contained many plants which differed materially in their essential char- acters. Pursh therefore removed the A. racemosa to Cimicifuga, another Lin- n.kan genus; in this he has been followed by many modern botanists, and by the edi- tors of the U. S. Pharmacopceia, and U. S. Dispensatory, from which circumstance we shall consider the A. racemosa under the head of Cimicifuga, (q. v.) although this plant, does not agree with the generic characters of Cimicifuga better than with those of Aetata, as will be hereafter pointed out. The genus under consideration contains several species that are possessed of active qualities, though their use as therapeutic agents appears to be very limited. A. spicata. Baneberry. Herbe de St. Christophe, Fr.; Achrentragendes Schwarzkraut. Germ. Sp. Ch. Berries roundish. Petals length of the stamens. Raceme ovate. Leaves 2-3 ternate. Lindley. This plant is found in many parts of Europe in mountainous woods. The root is a violent purgative, somewhat analogous in its effects to the black hellebore. The berries are poisonous, as is indicated by the common name of the plant Lin- naeus states {Flor. Lappon) that their in- gestion causes violent delirium, and even death; this observation of the Swedish naturalist is confirmed by M. Lemercier, of Rochefort, who found that they, as well the plant generally, produced a species of intoxication, followed by much disturbance of the cerebral functions, and an irritation ofthe digestive organs. {Merat et Delens.) These effects, however, appear to depend on a volatile principle which is dissipated in a short time, for the dried plant has been administered in large doses without any ill consequences resulting. The principal medical use of this species is as an external application in itch. A decoction of it is said to destroy lice with as much certainty as the stavesacre. A. americana. White and red cohosh. Sp. Ch. Berries ovate, oblong. Petals shorter than the stamens. Raceme ovate. Leaves biternate. Lindley. Under this head we include both the 200 ACTiEA.—ACUPUNCT. alba and rubra, although it is more than probable that they are distinct species. But as many botanists recognize them as varieties only, and as their physical quali- ties are identical, no confusion can arise from thus uniting them This species was confounded by Linnaeus, Schoepf, &c. with the A. spicata, to which it is very closely allied, both in appearance and qualities; the berries, and probably the whole plant, possessing the deleterious pro- perties of the foreign plant. It is, however, seldom or never mad# use of except in mistake for the Cimicifuga; the full grown roots bearing some resemblance to those of the last named plant. Many writers have, however, confounded them together, and have spoken of the Aetata as identical in its medical effects with the black snake root. Merat and De Lens have mate- rially added to this confusion in attempting to correct the error. Thus they ascribe all the virtues of the latter to the former, and state that they are indiscriminately used by American physicians. This is far from being the case, and, as is ob- served by Dr. Tully, it is perhaps owing to the adulteration of the Cimicifuga with Aetata, that the expected good effects of the former have not been obtained. Bibliogaphy.—A. Jourdan. Pharmacopie Universelle. Paris, 1828. J. R. Coxe. The American Dispensatory. 8th ed. Philadelphia, 1830. Orfila. Lecons de Midecine Legale. Paris, 1821. C. F. Rafinesque. Medical Flora. Vol. U. Philadelphia, 1830. W. Tully. On Aclaa Racemosa. Boston Med. and Surg. Journ. VIII. 133. R. E. Griffith. ACTION. (From agere, to act.) The exertion of power. All matter is in a state of activity. Incessantly subjected to the influence of various forces, it is constantly undergoing changes. The processes by which these changes are effected, are term- ed actions, and from these actions result all the phenomena of nature. As there are various forces, so also are there several species of actions, thus—1st. Actions take place between the molecules of bodies, producing changes of composition: these result from a force termed affinity, and the actions which it produces are named chemi- cal; such are the action of acids upon alkalies, &c. 2d. Actions result from im- pulsion, from the motion impressed upon matter in masses; this is the effect of a force to which the epithet attraction has been given, and which acts at greater or less distances; examples of this are fur- nished by gravity, the magnet, electricity, &c. 3d. Certain actions take place only in organized bodies: these depend upon the inherent vital properties of the organs, and they are termed vital actions. When these actions are normal, of a healthy character, they are termed physiological; when ab- normal, diseased, pathological. Certain vital actions are termed functions; and by some writers the two terms have been very improperly confounded. (See Func- tion.) Organic action is employed by some physiologists as synonymous with tonicity; it has also been employed to express the actions between the molecules of organized matter, under the influence of vital force, or vitality. In therapeutics, the term action is era- ployed in a double sense: first, to designate the active force of all therapeutic agents; and in this sense we speak of the medi- cinal action in general, or the special action of a remedy on a certain organ: secondly, it is employed to indicate the primary or secondary effects of a medicinal article, as we speak of a tonic action, a sedative action, &c, taking the effect for the process by which it is produced. It is, of course, impossible to enter into the investigation of all these actions, as such an inquiry would embrace the con- sideration of every phenomenon of nature. The whole science of medicine is a history of the vital actions. I. H. ACTIVE. Having the power to com- municate action or motion; that which acts with energy. It is in the latter sense that it is employed in medicine. Thus every medicine is, strictly speaking, active, since, did it not act, it could not be a remedy; but the epithet is bestowed on such as are prompt and energetic in their effects. In physiology, it has been applied to those organs of locomotion which produce motion by their action, as the muscles. An active sensation is one in which the sense is directed to the object. Active life, of Buisson, is the animal life of Bi- chat. In pathology, it has been applied to .diseases in which there is an increased action in the affected part, and is here synonymous with sthenic, (q. v.) I. H. ACTUAL CAUTERY. (See Cautery.) ACUPUNCTURE. (From acus, a needle, and pundura, puncture.) The operation, consisting in the introduction of a needle-shaped instrument into various parts of the body, intended to act as a remedy. Historical Sketch. This operation, prac- tised from time immemorial in China and ACUPUNCTURE. 201 Japan, was not known in Europe until towards the end of the seventeenth cen- tury, when Ten Rhyne, a surgeon in the Dutch East India Company's service, gave an account of it in a Latin work published in London in 1683. Subse- quently, in 1712, Kcempfer, in the third Fasciculus of his Amatnitates Exoticat, noticed the same operation, and added some details to those published by Ten Rhyne. Deriving their information from this double source, Dujardin, in his "Histoire de la Chirurgie," mentioned the remedy in 1774, and, in 1787, Vicq- d'Azyr, published an account of it in the " Enclyclopedie Methodique." The latter author characterizes it as an irritant and stimulant remedy, which may be use- ful in overcoming spasms and restoring sensibility to organs in which this func- tion has become weakened. Neverthe- less, these two authors do not recommend acupuncture; and no practical results are to be found on record until 1810, when Dr. Berlioz first tried it in a case of pain- ful nervous disease, occurring in a young female, as recorded in his work on Chronic Diseases, &c, published in 1816. In the same work, he mentions several additional cases, in which he found the remedy use- ful. It appears, however, that the physi- cians of that period were not disposed to imitate the practice of Dr. Berlioz, but, on the contrary, attributed to it the charac- ter of temerity. Beclard, indeed, rejects the operation as useless, and sometimes dangerous. The next physician who ap- pears to have given much attention to acupuncture, was Dr. Haime, of Tours, who was led to use it from having met with the cases of Dr. Berlioz. Dr. Haime's results were published in 1819, in the Journ. Univer., and confirmed and extended in a paper by Demours, publish- ed in the 66th vol. of the Journ. General de Medecine. About the same time, Dr. Bretonneau, chief surgeon to the hospi- tal of Tours, began to employ the remedy, and made a number of experiments on in- ferior animals to determine its safety. Churchill, an English surgeon, appears to have been the next writer of any im- portance on this operation, and was the second person, (Mr. Scott, of Westmin- ster, being the first,) who performed it in England. His results, together with a short account of the mode of performing the operation, will be found in a small treatise published by him in 1821. Not- withstanding these repeated testimonies in favour of the efficacy and safety of acupuncture, no extensive series of expe- riments was made with it until 1825, when the subject was taken up anew and prose- cuted with great ardour by M. Jules Clo- quet, in the Hospital Saint Louis, which furnished an extensive field for experiment. His results were made known to the pub- lic by his pupils, M. Morand and M. Dantu ; and, from their diversified charac- ter, and the reputation of the physician under whose observation they were ob- tained, the operation immediately gained the confidence of a large portion of the medical world, and has been practised, with more or less success, by a consider- able number of observers in France, Ger- many, England, and the United States. Considering the source from which we derive the operation, and the absurd claims set up by its inventors for its possessing the power of curing almost all diseases, it is not surprising that civilized nations should have viewed it with distrust, if not with contempt. In Japan, the whole practice of medicine appears to consist in the use of acupuncture and moxa, employed accord- ing to certain rules, which the practitioner is not allowed to depart from. The points at which the operations are to be performed, appropriate for each morbid affection, are indicated by dots and lines on puppets, called Tsoe-bosi, made of pasteboard, and about two feet high. For a plate of one of these puppets, as well as for a treatise on acupuncture and moxa, as practised by the Japanese, the curious reader is referred to Sarlandiere's work on Electro-puncture. The operation is performed in the East usually by means of a hammer, by which the needle is cautiously driven into the part. One set of men, called Tentassi, in- dicate the places where the needles are to be inserted; while another set, denomi- nated Foritatte, perform the operation. The needles employed are about four inches long and very slender, and are said to be always fabricated of gold or silver. The operation is resorted to in the most opposite diseases; and the operators do not hesitate to penetrate important ca- vities and viscera, such as the stomach, intestines, uterus, &c. Form of the Instrument, its mode of Employment, &c. Acupuncture,' since its adoption as a remedy by scientific physicians, is not employed precisely as it is in the East By them it is per- formed with a slender steel needle, of various lengths, from half an inch to five or six inches, sharp, straight, well pol- ished, and furnished with a convenient handle of hard wood or ivory, about as thick as a quill. The needle should be 202 ACUPUNCTURE. well tempered, to avoid the risk of its breaking in the tissues. The handle is sometimes permanently attached; but a more convenient construction is to have it — separate, and furnished with a I steel socket, to receive the end I ofthe needle, which may be fixed I securely, after being inserted, by 1 the pressure of a small lateral I screw. The instrument which 1 we have found most convenient, is represented in the accompany- alfkT *°£ figure of half the natural U^*f size- ^he figure requires no explanation, except to point out the lateral screw, the handle of which is seen at a. By this con- struction, the operator can at pleasure fix in the handle a needle of such length as may be suited to the depth to which he proposes to penetrate, and after inserting it, is enabled to detach the handle by relaxing the screw. Eight or ten needles, of various lengths, may be all fitted to the same handle, by having them finished with cylin- drical buts, three-sixteenths of an inch long, and about as thick as a knitting- needle. These buts, being of larger di- mensions than the shaft of the needle itself, effectually prevent the instrument from burying itself in the tissues, when allowed to remain after the detach- ment of the handle; an accident which has happened many times under the notice of Berlioz and Dantu, but without being attended with any ill consequence. The needles and handle are usually fixed in a small morocco case, for their more con- venient preservation, the former being passed through some soft substance to pre- serve their points. Another arrangement is to have the needle furnished with a permanent ivory handle, to the lower part of which an ivory sheath screws, inclosing the needle when not in use; but this plan is more expensive and less convenient than the other. Where acupuncture needles, expressly made for the operation, are not at hand, their place is easily supplied by well-tempered sewing needles; their ends being covered by a small olive-shaped ball of sealing wax, to serve as a handle. The spot for the operation being de- termined on, and the needle being selected of the desired length, and secured in the handle, the operator first stretches the skin at the spot by the fore and middle finger of the left hand, and then applies the point of the instrument, supported by the thumb and fingers of the right hand. Next, by a rotation, performed alternately in opposite directions, and by a gentle pressure, the needle is made to penetrate to the intended depth. As the operation proceeds, moments will occur when the patient will experience more pain than at others; and the operator may find it necessary to stop the operation, until this goes off. Indeed, it will be best, in all cases, to pause from time to time, dur- ing the insertion of the needle, for the purpose of inquiring of the patient what modifications in the condition of the part have been experienced by him. Occa- sionally, as the needle is penetrating, it will meet with greater resistance than at first, and afterwards pass with greater quickness, just as if it had been first resisted, and then suddenly passed through some membrane. Having pene- trated to the desired depth, the handle is detached, and the needle allowed to re- main, for various periods, from 10 minutes to 24 or even 60 hours, according to the views of the operator. The Japanese have a uniform rule of letting the instrument remain while the patient makes thirty in- spirations, and no longer. M. Cloquet has insisted on the importance, in some cases, of letting the needle remain for a long time; and, accordingly, he has, in some instances, allowed an interval of five or six days to elapse before its extraction. For the remedy, used in this way, he proposes the name of persistent acupunc- ture. As a general rule, the more chronic the disease combated, the greater will be the length of time necessary for the needle to remain in the tissues. In most cases, several needles (from two to four or five, or more,) are inserted in quick succession on the same occasion; though, sometimes, a single one is sufficient to remove the pain or other affection for which the remedy is resorted to. Some operators are in the habit of pressing the needle into the flesh without rotation; but this is not an eligible plan, as it gives more pain, and causes the needle to wound the animal fibres rather than to pass between them, as it is supposed to do, when rotation is used. The pain caused by the operation is very variable. Sometimes it is nearly nothing; at other times, more or less se- vere ; but, as a general rule, the amount of it is so inconsiderable as to be totally disregarded by the patient. When, in the progress of the operation, the pain becomes suddenly severe, it may be generally made to cease, either by withdrawing the needle a little, or else by passing it for- ward for half an inch or more. By pur- ACUPUNCTURE. 203 suing either course, the point is removed from the tissue, its presence in which may be supposed to have caused the pain. In a few instances, Cloquet has observed a sudden pain to dart from the point of the needle like a shock of electricity; and the writer of this article has once observed the same phenomenon. No inference can be drawn from the occurrence or absence of pain, as to the relief the operation is likely to afford. When the needle has been in- serted into a muscle, its end is often ob- served to oscillate, in consequence of the point being carried to and fro by the con- traction of the muscle. In a great ma- jority of cases, an areola appears around the needle, after an interval varying from a few minutes to half an hour. A slight numbness is often felt by the patient; while some remark a sensation of heat, and others of cold, in the vicinity of the needle. Fainting occasionally takes place, but this too is rare; not occurring, accord- ing to the estimate of Cloquet, oftener than once in thirty times. The writer has in one case observed a disposition to faint; but in no instance complete syncope; though the extent of his experience em- braces more than fifty cases. The needle may be withdrawn by means of a pair of forceps, or by the aid of the re-attached handle. The fingers are often sufficient for this purpose, in case the needle has not been inserted very deep, and a sufficient portion of it remains out- side, to allow of its being securely seized. In taking out the needle, it is best to press upon the skin on each side of it by two fingers; otherwise the skin will adhere to the needle, and he painfully drawn out in a conical form in the act of extracting it. The removal of the instrument is almost always more painful than its insertion; and the pain is generally in proportion to the length of time it may have remained in the tissues. These circumstances are explained by the oxidation of the needles, which renders them rough, and the more so the longer they may have remained. Upon the insertion and extraction of the needle, no blood, as a general rule, ap- pears; but, occasionally, upon its ex- traction, a small drop or two is found to follow. The needle, whenever made of an oxidizahle metal, is uniformly the seat of a galvanic current, recognizable by the galvanic multiplier of Schweigger, as shown by MM. Pelletan, Jun., and Pouillet. The remedial effects of the operation, however, do not depend upon the establishment of this current; for these effects are equally produced when gold and platinum needles are used, in which no oxidation, and consequently no galvanic current occurs. As soon as the needle is withdrawn, it should be immediately polished by passing it repeatedly through an emery bag, or by rubbing it with emery paper, before being put away; and the same should be done to insure its* perfect smoothness just before any needle is used. Therapeutical Applications, &c. Nu- merous experiments, made on the in- ferior animals since the revival of acu- puncture, have shown that the operation is devoid of all danger. Beclard, Bre- tonneau, Cloquet, Velpeau, Dantu, Meyranx, and others, have shown that the puncture of arteries, nerves, and even of the principal viscera, by very fine needles, is scarcely ever followed by any serious effect. Beclard's experiments were confined to the puncture of the arteries; but those of Bretonneau extend- ed to the penetration of the stomach, brain, lungs, and heart. The latter experimenter frequently passed needles through the brains of puppies in various directions, without, in some instances, producing pain, and uniformly without causing any ac- cident or apparent inconvenience. He afterwards passed them into the heart of five puppies, and three received no injury. Finally, M. Bretonneau became so confi- dent as not to hesitate to introduce the point of a very fine needle into the bra- chial and radial arteries in his own per- son. Similar experiments on the inferior animals were made by Velpeau and Clo- quet, who confirm the observations of Bretonneau. From these results, it is natural to infer that acupuncture might be employed in the human subject, without reserve, in any part. Nevertheless, the best writers on the operation advise the avoidance of the large arterial and nervous trunks, and of the more important viscera and joints. There can be no doubt, how- ever, that the stomach and lungs have been occasionally penetrated in the human subject without the least inconvenience; but we do not recommend an imitation of the practice; and no one would think of puncturing the brain, unless to evacuate serum in extreme cases of hydrocephalus. The safety and limits of the operation being thus established, it remains merely to give an outline of its therapeutical ap- plications. And here it will be found that our knowledge is still very imperfect; as the experience which we as yet possess is not sufficient to enable us to lay down principles in the application ofthe remedy. So far as it has extended, it has shown 204 ACUPUNCTURE. that acupuncture is applicable to the cure or relief of various painful affections, when not attended with active inflammation, or dependent on organic disease. Accord- ingly it has been found useful in muscular rheumatism; chronic pains, not attended by heat or obvious inflammation; neuralgia in its various forms; sciatica; lumbago; hemicrania; strained state of the muscles from lifting heavy weights; deep-seated contusions; hiccup; cramps; uterine pains; ophthalmia, &c. It has been resorted to with occasional benefit in' paralysis; but has proved unsuccessful in the trials made with it in tetanus, chorea, aphonia, deaf' ness, &c. It has been proposed by Dr. Carraro as a means of exciting the con- tractions of the heart in asphyxia from drowning, and would probably be a justi- fiable expedient, after ordinary means had failed. He supports his proposition by the results of his experiments on kittens, which, after having been drowned until every appearance of life was extinct, were resuscitated by acupuncturing the heart. His experiments, however, have been re- peated by Dr. E. J. Coxe, of Philadelphia, and were not found to succeed. {N. Amer. Med. and Surg. Journ. H. 292.) We must infer, therefore, that there is some peculiarity in the mode of proceeding of Dr. Carraro, which requires explanation before his results can become practically useful. In rheumatism, the success of acupunc- ture has probably been greater than in any other affection. Of 129 rheumatic cases, treated by this remedy, in the practice of Cloquet, 85 were cured. Dr. Elliotson cured 30 out of 42 cases, by the same means, in St. Thomas's hospital. The writer has had a number of similar cases, and the great majority yielded to acupuncture. In neuralgia the remedy is much less successful; and some cases, re- ported as cures of this disease, were proba- bly other affections of a painful character. The late Dr. J. H. Ewing, of Philadelphia, reported one successful case of neuralgia of the face. {N. Amer. Med. and Surg. Journ. II. 77.) The writer has tried it several times in this disease, and has known it to be tried by several of his friends, but without any encouraging suc- cess. Numerous cases of its advantage in sciatica are on record, among which may be quoted the cases of Dr. Renton, {Ed. Med. and Surg. Journ. for 1830, XXXTV, 100,) and those of Dr. Graves, in the Meath Hospital, Dublin, {London Med. Gaz. July, 1831, and Lond. Med. and Surg. Journ. April, 1833.) Reca- mier and Cloquet have reported several cases of shooting uterine pains relieved by the needles, inserted obliquely into the parietes of the vagina. (Morand, Me- moire sur VAcupuncture.) In cases of ophthalmia, the remedy can be viewed only as a means of lessening the severe pains which so often attend this disease; and by no means as a substitute for the remedies ordinarily employed for combat- ing the inflammation. In these cases, the needles are inserted into the temple, or forehead, as near as convenient to the affected eye. On the same principle of relieving pain, Dr. Renton found it useful in one case of hip-joint disease. The cases of benefit from acupuncture in paralysis are few. M. Trouve, physician in chief to the hospital of Caen, reports a complete cure of the disease, of seven years' stand- ing, resulting from a fall on the back; and a case of relief by the needles, of paralysis of the upper extremities, caused by taking cold while the patient was suffering un- der salivation, is recorded as occurring, under the care of Dr. Macbraire, in the London hospital. {Lond. Med. Gaz. 1831, VII. 607.) As connected with the therapeutical ap- plications of acupuncture, may be men- tioned the proposal of Velpeau to apply it to the purpose of curing aneurism. Re- peating, in 1822, some experiments on dogs, consisting in puncturing the arteries, which he had seen performed in 1818 by his preceptor Bretonneau, he found, in several instances, that the wounded vessel became the seat of a coagulum, and was finally obliterated. The experiments were repeated and extended in 1830, in De- cember of which year, Velpeau read a paper before the Academy of Sciences of Paris, proposing acupuncture as a means of obliterating the arteries in aneurism. In all cases in which the needle remained three days, the transfixed artery was found completely obliterated. Supposing that the same results would ensue in the human subject, it would follow that those aneu- risms which are now cured by cutting down to the artery above the dilatation, and tying it, might be treated with equal suc- cess, without cutting the skin, by merely transfixing the vessel in the same situation with a fine needle. Acupuncture may be advantageously performed on the legs in anasarca, for the purpose of evacuating the serum, instead of punctures with a lancet, which are ob- jectionable, from giving rise occasionally to sloughing. It may be resorted to with benefit also in many cases of oedema, as, ACUPUNCTURE. 205 for example, of the scrotum and penis, and is never attended with the least incon- venience as a consequence of the punc- tures. (Dr. Elliotson.) Dr. Horner, of Philadelphia, resorted to acupuncture, with success, for the purpose of evacuating the serum in a case of congenital hydro- cephalus. {Amer. Journ. of Med. Sci., IV. 530.) Dr. Finch has proposed acu- puncture as a means of ascertaining the nature of tumors, and the depth at which collections of fluids may be situated. In performing acupuncture, the general rule is to insert the needle into the pain- ful or affected part; but if the nature of the part forbids this, then at the nearest safe point. The only exception to this rule is furnished by cases of neuralgia, in which, according to Cloquet, a neighbour- ing part to the one affected is most proper for the operation. According to the same authority, it is best merely to reach the painful part with the point of the needle, and not to pass it. The modus operandi of acupuncture, as a remedy, is unknown. The relief it af- fords, in some cases, is surprisingly prompt; so much so, indeed, as sometimes to im- press the vulgar mind with the idea of supernatural agency. In many instances, however, the operation produces only par- tial benefit; and requires to be repeated a number of times before a complete cure is effected. The Japanese suppose that the puncture lets out some hurtful flatus, to the confinement of which in the organs, they attribute all diseases. Among scien- tific inquirers, some suppose it to act merely by revulsion, others by stimulating the nerves and restoring to them a princi- ple of which they have been deprived by pain. Dr. Haime, and Cloquet also, hold the more probable opinion that nervous pains depend upon an inordinate accumu- lation of the nervous fluid in particular parts, and that acupuncture relieves by equalizing the distribution of this fluid. The writer adopts this opinion as the most probable; and will merely throw out the conjecture, that in many cases of local pain this accumulation of the nervous (electrical?) fluid depends upon the al- tered state of the various fasciae, or con- densed sheets of tissue, giving them the power, to a certain extent, of insulating the parts which they serve to embrace. On such a supposition, the presence of a metallic conductor, transfixing the several insulated parts, would effectually equalize the distribution ofthe fluid. Acupuncture in connexion with Elec- tricity and Galvanism. As connected vol. i. 18 with acupuncture, it is proper to men- tion, in this place, Electro-puncture and Galvano-pundure. By these terms are meant acupuncture as modified by employ- ing the needle as a conductor for the pas- sage of an electrical or galvanic current to or from the tissues. The idea of electro- puncture originated with Berlioz; but the operation itself was first put in practice by Sarlandiere, who published a memoir on the subject at Paris in 1825. The operation consists in performing acupunc- ture with a needle in the usual way, and then making it communicate with the conductor of an electrical machine. Sar- landiere considers acupuncture, thus mod- ified, to be possessed of additional valuable powers, and speaks of his success with it in the treatment of rheumatism, paralysis, gout, and many nervous affections. The superiority, however, of electro-puncture over acupuncture is not well established ; and more facts are still wanting to deter- mine upon the value of Sarlandiere's views. M. Magendie has recently read a note to the Academy of Sciences of Paris on galvano-puncture as a remedy in amauro- sis. Reflecting on the remarkable influence which the fifth pair of nerves exerts on the sight, he commenced his experiments, on animals, by acupuncturing the fascial branches of this nerve. No accident hap- pening, he extended his experiments to man. A needle was passed into the frontal nerve, at the point where it emerges from the superciliary foramen; and the patient experienced, over the whole of the corre- sponding side of the head, a sensation similar to that which is experienced when the nerve of the elbow is struck, and was enabled to indicate with precision all the subdivisions of the nerve on the superior part of the cranium. Subsequently the frontal nerve was punctured within the orbit, and finally the lachrymal nerve itself, with the effect of causing a very abundant flow of tears. The pupil was found to contract whenever any branch of the fifth pair was pricked; but no benefit was experienced to the amaurosis, for the relief of which the trials were made. M. Magendie now employed galvanism in connexion with the needles. He fixed a needle in the frontal nerve, and another in the superior maxillary, and these were made to communicate severally with the poles of a galvanic pile of twelve pairs of plates, each six inches square. Every time the contacts were established, the patient ex- perienced a painful commotion in the course of the nerves and at the bottom of 206 ACUPUNCT.—ADENIF. the orbit, the light became more sensible, and the pupil contracted. M. Magendie reported several cases of incomplete amaurosis, with or without paralysis of the muscles of the eye, in which galvano- puncture furnished very satisfactory re- sults. M. Leroy D'Etiolles has proposed galvano-puncture as a means of reducing strangulated hernia, by inducing a power- ful and sudden contraction in the loop of intestine as it exists in the sac; and he supports his recommendation by the fa- vourable results of numerous experiments on inferior animals. Bibliography—Ten Rhyne. Dissertatio de Arthritide; Mantissa Schematica de Acupundura. Londini, 1683. K^empfer. Ammnitatum Exoticarum politico- physico-medicarum Fasciculi. V. Lemgoviae, 1712. Dujardin. Histoire de la Chirurgie. Paris, 1774. Vico. D'Azyr. Encyclopidie Mithodique. Art. Acupuncture. I. p. 184. Paris, 1787. Berlioz. Mimoires sur les Maladies Chroni- ques, les Evacuations Sanguines, et VAcupunc- ture. Paris, 1816. Beclard. Recherches et Expiriences sur les Blessures des Artires. Memoires de la Soc. Med. d'Emulation. VIII. 575, 590. Paris, 1817. Haime. Note sur VAcupuncture, et Observa- tions Midicales sur les Effects Thirapeutiques. Journ. Univer. des Sci. Med. XIII. 27. Paris, 1819. Churchill. A Treatise on Acupunclura- tion. London, 1821. Parouillet. Sur les Phinomenes Electro- magnitiques, qui se manifestent dans VAcupunc- ture. Journ. de Physiologie de Magendie. Paris, 1825. Pelletan, fils. Notice sur VAcupuncture, son Historique, ses Effects, et la Thiorie, d'apres les Experiences fakes a VHbpital Saint Louis. Paris, 1825. Morand. Mimoire sur VAcupuncture, suivi d'une Sirie d'Observations recueillies sous les yeux de M. J. Cloquet. Paris, 1825. Same work. Translated by Franklin Bache, M. D. Philadelphia. 1825. Scheider (Lud.) Dissertatio de Acupundura. Berlin, 1825. Meyranx. Observations sur VAcupuncture, faites a VHbpital de la Pitii, sous les yeux de M. Bally. Archives de Medecine. VII. Paris, 1825. Carraro (Ant.) Essai sur VAcupuncture. Annali Universali d'Omodei. 1825. Sarlandiere. Mimoires sur VElectro-punc- ture. Paris, 1825. Graefe (Ed.) Medicinisch-chirurgische Neuig- keiten aus Paris. Graefe's und Wallher's Journ. &c, VIII. p. 352. Berlin, 1825. Dantu de Vannes. Traiti de VAcupunclure, d'apres les Observations de M. J. Cloquet. Paris, 1826. Bache. Cases illustrative of the Remedial Ef- fects of Acupuncturation. North Amer. Med. and Surg. Journ. I. p. 311. Philad. 1826. Ewing. Case of Neuralgia cured by 'Acu- puncturation. North Amer. Med. and Surg. Joum. II. p. 77. Philad. 1826. Coxe(E. J.) Observations on Asphyxia from Drowning. North Amer. Med. and Surg. Journ. n. p. 276. Philad. 1826. Elliotson. Note on Acupuncture in Rheu- matism. Medico-Chirur. Trans. XIII. p. 467. London, 1827. Bernstein (Joseph.) Weber den Nutzen der Acupundur in verschiedenen Krankheits fallen, &c. Hufeland's Journal, LXVII. p. 84—120. Berlin, 1828- Graefe (Ed.) Beitrag zur Eledropunclur. Graefe's und Walther's Journ. XII. p. 333—340. Berlin, 1829. Most (G. F.) Beitrag zur Acupundur. Ibid. XII. p. 449—452. Berlin, 1829. Quadri (G. B.) Acupuncturation successfully employed in Nervous Affedions of the Eye. North Amer. Med. and Surg. Journ. VII. p. 246, Philad. 1829. Blandin (Ph. Fred.) Diet, de Mid. d de Chirur. Pratiques. Art. Acupundure. Paris, 1829. Renton (John.) Observations on Acupunc- ture. Ed. Med. and Surg. Journ. XXXTV. p. 100. Edinburgh, 1830. Elliotson. The Cyclopadia of Practical Medicine. Art. Acupundure. London, 1832. Guersent. Diet de Medecine Art. Acupunc- ture. Paris, 1832. Franklin Bache. ACUTE. {Path.) This epithet is ap- plied to those diseases which are of a severe character and have a rapid progress and short duration. See Disease. Pain is said to he acute when it is sharp and pungent. I. H. ACYANOBLEPSIA. (From a priv. xvavos blue, and fitertu I see.) Defect of vision, consisting in the incapacity to dis- tinguish blue. I. H. ACYSIS. (From a priv. and xvsw to conceive.) Sterility, (q. v.) I. H. ADDEPHAGIA. (From aSSrv much, and $ayet,v, to eat) Voracity. See Buli- mia. I. H. ADDITAMENTUM. An addition to any part, which though not always, is sometimes found. It was formerly used synonymously with Epyphisis (q. v.); but is now applied only to the prolongations of the lambdoidal and squamous sutures. I. H. ADDUCTION. (From ad to, and du- cere to draw.) The action by which parts are drawn towards the axis of the body. I.H. ADDUCTOR. This epithet is bestow- ed upon several muscles which perform the office of adduction. See Muscles. I. H. ADENALGIA. (From a£Vv, gland, and afc/ytw, I suffer.) Pain in a gland. I. H. ADENEMPHRAXIA. (From 0%, a gland, and s/xfeaaau, I obstruct.) Engorge- ment of glands. I. H. ADENIFORM. (From 0%, a gland, and forma, form.) Of a glandular form. ADENITIS.—ADHESION. 207 ADENITIS. (From ae>, a gland.) In- flammation of glands. I. H. ADENOGRAPHY. (From %, a gland, and yraQu, I describe.) A descrip- tion of glands. I. H. ADENOIDES. (From abyv, a gland, and eiSoj, like.) Resembling a gland. I. H. ADENOLOGY. (From oZrp>, a gland, and toyos, description.) A treatise on the glands. I. H. ADENO-MENINGEAL. (From wbjvt a gland, and ^nyf, a membrane.) Pinel designated by this ephithet the epidemic which prevailed at Goettingen in 1760, and which was described by Rcsderer and Wagler, {Tradatus de morbo mucoso,) because the seat of that fever was in the intestinal mucous membrane, and princi- pally in the muciparous glands. It is the Dothinenteritis (q. v.) of Bretonneau. ADENO-MESENTERITIS. (From oZ*iv, a gland, (teeos, midst, and wttpov, in- testine.) Inflammation of the lymphatic glands of the mesentery. Tabies mesen- fcpripn. .!■• xl« ADENO-NERVOUS. (From aSr,i>, a gland, and ffvpov, a nerve.) Pinel has ap- plied this epithet to the plague, the princi- pal seat of which he places in the nerves and in the lymphatic glands of the arm-pit and groin. I. H. ADENO-PHARYNGITIS. (Fromoo^v, a gland, and $>af>vy£, the pharynx.) Inflam- mation of the tonsils and pharynx. I. H. ADENOPHTHALMIA. (From cw^, a gland, and o0atytos, the eye.) Inflamma- tion of the glands of meibomius. See Lip- pitudo. I- H. ADENO-SCLEROSIS. (From oc>, a gland, and ex%r;pos, hard.) Swediaur has given this name to tumefactions and indu- rations of the glands, unaccompanied with pain, and which do not become scirrhus or cancerous. I- H. ADENOTOMY. (From a6>, a gland, and tcfivu, I cut.) The art of dissecting glands. I- H. ADEPS. See Fat. ADHESION, Adhesive. (From adhat- rere, to stick to.) . According to the com- monly received acceptation of the term among morbid anatomists, adhesion may be defined to be a preternatural continuity of tissue established between surfaces origin- ally contiguous, but disconnected. With surgeons, when used in its narrowest sense, it signifies the re-establishment of the con- tinuity of parts separated by accidental in- juries, when this union is effected without the secretion of pus, or the formation of granulations. If all the morbid phenomena which result from the same cause were as- sociated under the one general head of ad- hesion, it would be necessary to give much greater extension to its signification; but, in the present article, the word will he em- ployed agreeably to the definition just given. For a further knowledge of the operations of the law upon which the pro- duction of adhesions depends, the reader is referred to the several heads under which the pathology of the different tissues and cavities is considered, and also to the gen- eral articles cicatrix, inflammation, stric- ture, suppuration, and wounds. Adhesions may take place either before or after birth, and, in the former case, may perhaps result from an original defect of organization: such appears to be the case in the congenital imperforate condition of the nose, mouth, anus, vagina, eye-lids, &c.; but these vices of structure will be considered more properly in the articles on malformation and monstrosity. The in- tention of nature in accomplishing adhe- sion, even in parts originally designed to continue separate, is always sanatory; and it is only when the process is arrested be- fore its completion, or when the functions of the organs interested experience a me- chanical embarrassment, that it becomes a source of disease: an adhesion of the peri- toneum which prevents effusion from an ulcerated intestine, is as decidedly health- ful in its tendency as that which produces the immediate union of an incised wound. It is, therefore, rather for convenience than from a strict sense of philosophical proprie- ty, that we follow Cruveilhier in dividing adhesions into two classes, the restorative and the morbid. This author appears to have been actuated by the same motive, for he says, {Did. de Med. et Chir. Prat. art. Adhesion,) that adhesion does not con- stitute a disease, properly so called; it is but an effect, a termination of inflamma- tion, and sometimes results from causes so occult as not to admit of explanation; often it prevents or remedies serious accidents, and sometimes it is provoked by art in order to accomplish important purposes, becoming, in the hands of the surgeon, a powerful therapeutic engine. The mechanism by which adhesion is effected is the same in all cases, and the bond of union is not altered in character by the nature of the tissues which it unites. It is, therefore, decidedly advisable to study first the phenomena attendant upon the process as displayed in injuries of ex- ternal parts, where everything is subject to immediate inspection, and afterwards to consider the proofs of the identity between 208 ADHESION. this restorative operation, and the coales- cence of distinct organs in situations less capable of direct examination. 1. Restorative Adhesions, or those which take place between surfaces originally continuous.—All parts of the body, when divided by mechanical means, exhibit a tendency to adhesion, but the union can only be completed under certain favoura- ble circumstances, the most important of which is the juxtaposition of the divided surfaces. The presence of a foreign body must necessarily impair the firmness of the new connexions, until it is removed either by the surgeon or by the absorbents; and the process is equally checked or ar- rested, by too great a degree of general or local debility, whether caused directly, by the violence of the accident, or consecu- tively, by excessive inflammation. This tendency to adhesion between accidental surfaces, is nevertheless so strong that it is extremely difficult to prevent it, when such an object becomes desirable in the treatment of surgical diseases. Hence it requires great care to effect the establish- ment of fistulous canals, or substitutes for obliterated passages; as in wounds of the duct of Steno, strictures of the urethra, &c.; hence, also, the frequent failure of attempts to reclose such canals when once completely formed, and converted into a part of the surface of the body by the com- plete organization of a cuticle or mucous membrane. Let us now consider the phenomena of adhesion as exhibited in one of the sim- plest possible cases, that of an incised wound. Upon the first occurrence of the accident, the face of the wound is bathed in blood, much of which escapes or is washed away by the surgeon, but a part generally remains. The wound is care- fully closed, and in a very short time a certain degree of cohesion between its edges is distinctly noticed. This occurs much sooner when blood is present, and it is then obviously due to the coagulation and mechanical action of that fluid, as it takes place even when foreign bodies are present Sometimes neither pain, redness, nor swelling, exists in the neighbourhood of the injury, but the bond of union goes on constantly acquiring firmness, and after the lapse of a few days, the part is found in its original condition, with the excep- tion of a linear cicatrix marking the direc- tion of the incision. In such cases there may exist no visible marks of irritation or inflammation, nor do we always observe the elaboration of any peculiar fluid be- tween the edges: if the first dressings are agglutinated to the wound, it appears to be only by coagulated blood. This is what Mr. Hunter considered the first or most simple form of adhesion, and he taught that the effused blood was the sole bond of union; that its colouring matter being ab- sorbed, it was converted into coagulated lymph, and became permanently organized, by its own innate vitality. That coagu- lated blood may remain for a long period as a firm bond of union between divided parts, and that it often exists to a consider- able amount in deep wounds, without apparently interfering with the progress of what has been termed union by the first intention, are facts too frequently observed to be denied by any surgeon. But it is equally certain that these coagula often remain in contact with the most delicate tissues, even for years, without producing irritation, continuing firmly adherent with- out becoming organized. Moreover, very large collections of coagulated blood are frequently absorbed, and the cavities which they occupy are obliterated without the formation of pus or induration, by a pro- cess which cannot be proved to differ from that of union by the first intention, except, perhaps, in its slower progress. It follows, therefore, that blood does not become or- ganized with facility, even under highly favourable circumstances: e. g., in effu- sions into the serous cavities: nor is it by any means certain that its presence inter- feres with those measures by which nature accomplishes adhesion when no blood is suffered to remain between the divided surfaces, which measures will be presently examined. We incline, therefore, to the opinion of Thompson, who regards ex- travasated blood as a foreign substance, which must be removed either by the sur- geon, or by the absorbents, before union can be effected. The blood is nevertheless in many cases an important auxiliary agent in favouring adhesion by its mechanical action; it is the mildest of all possible dressings, and beneath it, the vital operations go on with- out embarrassment. It coagulates with great facility when brought into contact with surfaces in a state of inflammation, and gives rise to many phenomena here- after to be noticed. (See Artery, Vein, Gangrene, &c.) In cases of wounds in which no blood remains between the surfaces, it was for- merly thought that union was occasionally effected by direct inosculation, without the interposition of any organic medium; but the doctrine of union strictly immediate, is now abandoned. The usual order of the ADHESION. 209 phenomena which attend upon simple ad- hesion in an incised wound is as follows. At the moment of the accident there is a sensation of pain, which varies in different parts, according to the nature ofthe tissue divided. This is immediately succeeded in most, if not in all cases, by a heightening of the vital energies in the part, and an afflux of fluids, constituting what was termed by Hunter, adhesive inflammation, and what is now understood by those of the physiological school as irritation. Very soon after this, the edges and surfaces of the wound are covered by an exudation of plastic matter, which fills up all inequali- ties and serves to unite the parts. It is this matter, at first fluid, but shortly ac- quiring consistence, which agglutinates the dressings a few hours after their first application, and renders their removal painful or difficult In twenty-four hours, or even sooner in many cases, this effused matter assumes the form of a membrane, not organized, it is true, but sufficiently firm to be separable in the form of a dis- tinct layer. In less than forty-eight hours it gives evidence of vascularity, for when torn by a forcible separation of the edges, blood flows freely from the ruptured ves- sels. In a few days it is completely organ- ized, and finally it becomes fibrous, and so firm that it has been doubted whether it does not possess more strength than the original structure. It is hardly possible to determine by actual observation, the man- ner in which the organization of this new matter is effected in incised wounds, but the facts collected from the examination of the same process on a larger scale, will be given hereafter. (See Pseudo-Mem- brane. Coexistent with the formation of the new membrane, we generally perceive an increased redness, more or less tumefaction, and, in the first instance, pain in the im- mediate neighbourhood of the wound ; but it cannot be denied that considerable inju- ries of this nature, sometimes recover with- out the obvious presence of any of these symptoms. This latter fact leads naturally to the question, whether adhesion is neces- sarily the effect of inflammation. It is some- what singular that Mr. Hunter, many of whose followers are in the affirmative, was himself decidedly in the negative on this point In his work on the blood, p. 168, 8vo. edit, he says, "Inosculation, how- ever, can only take place where the ex- tent of the parts divided is not great, and the opposite surfaces remain near each other; but even then, it is most probable that we must in part ascribe to another mode of union, the communication of ves- sels which takes place between the two divided surfaces; for where inosculation does not, or cannot take place, the union of the ruptured vessels is produced by the coagulation of the extravasated blood of this part, which becomes vascular." Again, at p. 180: " When the former bond of union is lost in a part, to produce a new one, a secondary operation takes place, namely, inflammation ; and if this is likewise lost, then a third mode of union will arise, which is by means of granulation." He was too accurate an observer not to have noticed that union, even when unattended by inflammation, was effected through the medium of a new layer of coagulahle lymph; but he believed that in this case the layer was furnished by the vital action of the extravasated blood, and the activity of the absorbents which removed the col- ouring matter and the superfluous parts of the coagulation. But when adhesive in- flammation took place, he thought that similar lymph was thrown out from the closed vessels, by a process analagous to secretion. Few pathologists continue to consider the effused blood as a bond of union in wounds, except perhaps in fractures, (q. v.), but there are two conflicting opinions still prevalent as to the origin of the coagula- ble lymph forming the new membranous medium of adhesion. John Bell appears to think that it is simply effused from the cut surface, without any peculiar elabora- tion, {Discourses on Wounds, part I. p. 11.), and he discards, unhesitatingly, the term adhesive inflammation, as inapplica- ble to a process which he regards as purely physiological. (Ibid. p. 23.) M. Maunoir considers the adhesion of extensive lacer- ations and flaps, which sometimes takes place without any mark of fever or inflam- mation, as a proof that the bond of union is not the result of any unusual action in the part, but that it is effected by the co- agulation and gradual hardening of the circulating juices, {Mimoire sur les Ampu- tations, p. 51.); and M. Serre, subscribes to the same opinion. " It is a phenome- non," says he, " of the same order with that which unites the ovum to the uterus." {Traiti de la reunion immidiate, p. 44.) Dr. Thompson, MM. Cruveilhier, Bres- chet, &c, on the contrary, believe that a peculiar secretory operation is necessary to the formation of the new bond, and incline to the opinion that inflammatory action is necessary to the performance of this op- eration. "If the effusion of coagulated lymph," says the first author quoted, " ever 210 ADHESION. does take place from the vessels actually divided, it would seem to depend on a change in the action of these vessels, by which they are in some measure convert ed from circulating into secreting organs." {Lectures on Inflammation, p. 169.) One of the least objectionable views of this im- portant subject of discussion is that adopt- ed by MM. Roche and Sanson. " Like the flow of blood, this exudation of the white fluids is owing to the division of the vessels of the tissues and of the tissues themselves ; when the opposing surfaces are placed in contact, this lymph is neces- sarily spread in a layer between the lips of the lesion. Driven out from its natural conduits and placed beyond the domain of vitality, it speedily coagulates. But the part is presently attacked by irritation, or rather, already painful and irritated by the effect of the accident, its irritation in- creases rapidly, its vitality is augmented, and the layer of coagulated lymph prompt- ly assumes the character of a membrane." {Nouveaux elemens de pathologie, II. 504.) It is contrary to the law of simplicity observed in all the works of nature, to suppose that the bond of union is a simple exudation in one set of cases, and a regu- lar secretion in another, or to attribute it to the vivification of blood in some in- stances, and to a peculiar result of inflam- mation in others. The occasional recovery of extensive wounds without the obvious presence of increased heat, swelling, or redness, and with no pain except that which results from the direct effect of the accident, appears to us a sufficient proof that inflammation is not necessary to the production of adhesions: it seems also to es- tablish the fact, that the natural powers of the system are adequate to the purpose, without the necessity of any remarkable ex- altation of power; and that even when such an exaltation is observed, the effusion ofthe coagulable lymph often precedes, instead of following the development of the irri- tation, the heightened action being design- ed, not for the formation, but for the vivifi- cation of the bond of union. It has been remarked by M. Serre, that there may be some change in the powers of the divided vessels by which they may be enabled to elaborate a fluid somewhat different from the lymph of circulation, without the oc- currence of inflammation. This idea, though possibly correct, is hypothetical. In the present state of our knowledge, we have no conclusive evidence to show that adhesion requires any change in the natu- -al functions of the wounded part, or that the lymph of the circulation differs essenv tially from the lymph of a false membrane before it becomes organized. If the manner in which the bond of union in injuries is effected, continues still a matter of dispute, the views of physiolo- gists as to the mode in which the new pro- duct becomes organized is not more firmly settled. It is well known that at the mo- ment of division the divided vessels are retracted by virtue of their elasticity, and that they are speedily closed by the effused coagulable lymph. The question of the simple elongation of the extremities of the vessels, is no longer in doubt; and it is almost universally acknowledged that if the divided extremities ever become con- tinuous, as they certainly appear to do, after simple incisions for the relief of Pterygia, (q. v.) it is through the medium of a new portion added to the vascular tube by the organization of the new inter- mediate membrane, and not by the elonga- tion of the original vessels, as was for- merly supposed. That secondary inosculation does take place by some means, is sufficiently proved by the direct experiments of Duhammel on six chickens, in which he divided by successive incisions all parts of an extrem- ity, without respecting any tissue, not ex- cluding the osseous, and in one instance at least, without incurring the loss of the limb: it is equally proved by the success of the trials at grafting the parts of one animal upon the body of another, as nar- rated by Hunter, as well as by many of the Taliacotian operations. All further dis- cussion of the mode by which the circula- tion is re-established between divided sur- faces, must be referred to the articles on several surgical subjects where the phe- nomena due to the law of adhesion are exhibited on a grander scale—and more especially to that on the reproduction of Bone. Whatever may be the character of the tissues involved, however dissimilar the nature of the opposing surfaces, the pro- cess of union is accomplished by the same measures. The new bond is precisely sim- ilar in all cases. In the skin, muscles, cel- lular tissue, glands, &c, union is every- where effected by the effusion of coagula- ble lymph, its organization and conversion into fibrous matter. In no instance does the tissue interested primarily reproduce itself, and if the continuity of tissue is ever completely re-established, it is only after the lapse of a considerable period of time. (See Cicatrix.) Most authors have considered the reunion of the osseous tis- ADHESION. 211 sue as an exception to this law; the pro- priety of this exception will be investigated in the proper place. (See Bone, reproduc- tion of) As like effects everywhere result from like causes, we must seek for the ex- planation of the uniformity of the pro- cess of restoratory adhesion in all the various tissues, by tracing the existence of some agent common to them all. The only agent of this universal character, is the cellular membrane. The matrix of every organ ;—capable of a vitality ap- parently independent in the lower orders of apathic animals, and composing the whole fabric of our own species in the earliest stages of foetal life, there can be no doubt that this membrane, in which the organs are originally formed, is also the active agent of their reunion and repro- duction, if the latter indeed takes place, a fact of which we entertain no question, notwithstanding there is high authority against it. (See Cruveilhier, op. cit) Restoratory adhesion, when it occurs in injuries which have no communication with the surface, and cannot be relieved from the presence of any portion of the effused blood or other fluids, takes place less rapidly ; but in the absence of the air, which facilitates the decomposition of the fluids and thus becomes a cause of inflam- mation, it takes place more certainly. The process is precisely similar to that already described; and this class df accidents was even selected by Hunter in preference to incised wounds, as furnishing the simplest exemplification of adhesion. 2. Morbid Adhesions, or those which take place between contiguous surfaces, but which were originally designed to re- main separate. Besides the morbid adhe- sions noticed in the serous and synovial cavities, the mucous and vascular canals, and between the different parts of the cu- tis vera when denuded of its cuticle, there are others equally comprised within the limits of our definition, which are seated in the cellular tissue. Commencing with the latter, we will cast a rapid glance at each of these in turn. a. Morbid Adhesions of the cellular tissue. Whenever the cellular tissue be- comes the seat of an irritation somewhat severe and continued, there is an evident tendency to adhesion around the affected spot. The first morbid effect noticed is the deposition within its cells, of a yellow- ish serum and of coagulable lymph, by which the plates of the tissue are agglu- tinated together and their permeability destroyed. A temporary barrier is thus generally formed against the progress of inflammation, which would otherwise spread itself unchecked over an exten- sive surface, as it is observed to do when this barrier is not fully completed, in con- sequence of peculiar states of the consti- tution : witness the progress of erysipelas phlegmonoides, and the diffuse inflamma- tion of the cellular tissue, of Duncan. When resolution takes place the deposited lymph is gradually absorbed, and the part either returns to its original condition, or re- mains indurated by the coalescence of the parietes of the cells, which unite in the same manner with the edges of an incised wound, constituting a proper case of pri- mary reunion. M. Cruveilhier believes that every inflammation of cellular tissue results in this species of permanent in- duration—hence, in tumours of the neck of which the roots involve the cellular membrane enveloping the principal blood- vessels, he considers extirpation impossible if the tumour has ever been inflamed ; for in such cases the adhesions render elabo- rate dissection necessary, where under other circumstances simple enucleation is all that can be required. We cannot agree with this opinion in its whole extent, for it is evident that in many cases, the con- densed membrane ultimately recovers its original condition, either by the absorp- tion of the coagulated lymph, before it be- comes organized, or by a veritable trans- formation of the new matter into free cellular tissue, of both which changes we have seen ample evidence. (See Cicatrix.) These adhesions are nevertheless exceed- ingly embarrassing to the surgeon, and cannot be neglected with impunity in forming a judgment on the practicability of an operation. In these indurations the adipose vesicles disappear, and are not again detected until after a long period has elapsed. It is on the same principle; that of the adhesion of the proximate surfaces of the cellular tissue by means of effused coagu- lable lymph, becoming organized and form- ing a new membrane; that those sero-mu- cous cysts are established which we occa- sionally see in parts subjected to frequent pressure, as beneath the skin of the elbow and instep, on the tuberosity of the tibia, &c, (See Bursa-mucosa.) and also those which sometimes remain after the absorp- tion of extensive ecchymoses, those which surround an abscess, a foreign body, a hy- datid, &c. (See Cyst.) To the like cause we must attribute the formation of fistula? of every kind. (q. v.) In all these affec- tions there exists a lining membrane more 212 ADHESION. or less analogous to the cuticle in structure, and formed in the same manner with the bond of union in an incised wound. b. Adhesions ofthe Serous Membranes. These are of very frequent occurrence, and take place on a grander scale than in any other situations. The process by which they are produced is the same in all the cavities, nor does it differ from that already described under the head of re- storatory adhesions; but in consequence of the great amount of new matter some- times thrown out, we are enabled to be- come better acquainted with some of the steps in the progress of organization in the coagulable lymph of false membranes in the thorax and abdomen, than in those pro- duced by the lesions of the cellular tissue. The strong tendency of all irritations of serous surfaces to become general through- out the cavity, is known to every one; their equally remarkable tendency to adhesion is the counteracting course by which na- ture controls this unfortunate disposition. The slightest possible injury is frequently sufficient to cause the coalescence, or rather the agglutination, of the proximate serous surfaces. Thus the pressure of a cyst or tumour in the abdominal parietes, or the presence of a foreign body in the stomach or intestines, is often sufficient to induce the adhesion of the neighbouring perito- neum, so that the cavity of that membrane frequently escapes the danger of effusion when an ulceration has caused a fistulous connexion between an abdominal viscus and the cavity of a superficial abscess, or the surface of the body. So trivial indeed are the causes which sometimes lead to these new connexions, that it is not unu- sual to find extensive adhesions after death in patients who have never been conscious of disease in the part during life. " In fine," says M. Serre, " if we admit the possibility of adhesion by simple exudation, it must follow that the presence of pseudo- membranes cannot be a positive proof of the existence of a phlogosis. This opinion, though very paradoxical, casts doubt upon a problem which has been considered as solved: we submit it to the examination of the profession. Contenting ourselves with noticing the fact, we leave the ex- planation to others." {Sur la Reunion Im- mediate, p. 49.) Upon the first occurrence of an irrita- tion, the coagulable lymph begins to collect upon the opposite surfaces of the serous membrane, precisely as it does between the lips of an incised wound. It is firmer where it lies in contact with the original structure, and in the centre it remains for some time almost fluid. This change of density is in certain cases gradual and uni- form, at other times it takes place at in- tervals, giving the new product a lamel- lated appearance. M. Cruveilhier con- siders the central portions as secreted last, and conveyed by percolation through the spongy structure of the previous layers. Beneath this new deposit the original sur- face ofthe serous tissue remains apparently unaltered. We waive all question, in this place, as to the peculiar mode in which this new bond of union becomes organized. This highly interesting question would necessarily lead us into disquisitions upon many subjects which could not be conve- niently arranged under the present head. (See Pseudo-Membrane.) That it passes through the same changes noticed in the reunion of incised wounds, is obvious, and it is equally certain that it finally takes on all the characters of proper cellular mem- brane. These adhesions, though generally some- what extensive in the commencement, be- come frequently elongated by the motion of the organs which they connect, and they then present the appearance of a tissue with large areolae, of partial septa, or of filamentous attachments, large at the ex- tremities, and more or less attenuated in the middle. This elongation is of course greater in proportion to the time which has elapsed from the first formation of the adhesion; it is effected sometimes by the yielding of the new bond itself, and some- times by an infundibular depression of the original serous membrane to which it is attached, caused by the constant dragging of the parts during their necessary move- ments. It is asserted that adipose matter is never found in accidental membranes, and al- though we have met with two cases and have heard of a third, in which this matter was apparently present in old adhesions of the pleura, the cases were not examined with sufficient care to warrant us in assert- ing that it was not located in a situation external to the serous membrane, in the infundibular depressions just noticed. Adhesion occurs much more frequently in some ofthe serous cavities than in others. The pleura presents the greatest number of instances, the peritoneum stands next in order, then the pericardium, the tunica vaginalis testis, and finally the arachnoid membrane, in which adhesions are very rare. Adhesion is frequently employed as a means of cure in cases of accidental cysts, and in dropsy of the tunica vaginalis testis. ADHESION. 213 The method of treatment consists in the evacuation of the cavity, the production of sufficient irritation, and the coaptation of the opposite surfaces by mechanical means if necessary. (See Hydrocele.) c. Adhesions ofthe Synovial Surfaces. The articular synovial tissues very rarely adhere, and their adhesions have been still more rarely observed with accuracy; but both the flocculent false membrane and the organized and cellular connexion have been met with in cases of anchylosis, (q. v.) The vesicular synovial sacks of tendons often become obliterated by adhesion, and the same result happens to their vaginal sheaths, in panaris, diseases of the joints, deep burns, &c. To this cause is due the retraction of the flexor tendons of the hand which sometimes results from long-con- tinued repose. We have seen several sin- gular instances of this kind among the devotees of Hindostan. d. Adhesions ofthe internal surfaces of vessels. The lining membrane of the arteries adheres with great facility. This is proved not only by the manner in which these ves- sels become obliterated after wounds, or the application of ligatures, but also by the his- tory of many diseases in which no other tis- sue can be a party to the process. Such, for instance, as the dry gangrene, in which the principal arteries are all obliterated for some distance beyond the limits ofthe dead matter. This obliteration may be either a cause or a consequence ofthe mortification; for it is a law of nature that whenever the blood ceases to circulate through a vessel it soon becomes obliterated. One of the most beautiful proofs of adhesion of the in- ternal surface ofthe arteries from this cause is furnished by the operation for the cure of aneurism by pressure between the tumour and the heart. The veins are more prone to suppuration than to primary adhesion, but the latter oc- curs, in many instances, after mechanical injuries, venesection, the excision of vari- ces, &c. M. Cruveilhier has even seen filamentous adhesion in the iliac veins. There is scarcely a blood-vessel in the body which has not been found obliterated in examinations post-mortem; but for details upon this subject the reader is referred to the articles on Aneurism, Artery, Vein, and Ligature. The lymphatics are generally so small that their adhesions have escaped observa- tion, though analogy would lead us to in- fer that they are not less frequent than those of other vessels. Professor Nasse once found the thoracic duct completely obliterated and converted into a cord, though the valves were still distinguisha- ble ; and Sir A. Cooper narrates three cases of partial closure of the same canal. M. Breschet, however, denies that there is on record a single incontrovertible case of the obliteration of a lymphatic vessel. {Did. de Med. art Adherence.) The par- tial obstruction of the arterial circulation in a part may induce gangrene, and that of the veins occasions oedema. e. Adhesions of mucous surfaces.—The mucous membranes, in common with the external integuments, are protected against the danger of adhesion in many parts by a proper cuticle,and where this fails,its place is supplied by a mucous effusion equally inorganic, therefore acting like a foreign body interposed between the lips of a wound. When this protecting envelope is destroyed, or changed in character by accident or disease, the cellular tissue which forms the base of the membrane acts as the same tissue is known to do un- der like circumstances in other places, and the bar to the formation of adhesion is re- moved. The same new membrane observed in injuries of other parts, is very frequent- ly seen on all the mucous surfaces. Del- pech demonstrated its existence wherever pus is secreted, (see Cicatrix,) and Cru- veilhier considers it a common conse- quence of acute mucous inflammation. But in order that it should produce adhe- sion, it is indispensable that two different portions of mucous surface should be placed nearly in contact, while both are deprived of their mucosity; and these requisites are very rarely fulfilled. Inflammation may, indeed, influence the nature of the secre- tion, so that it no longer fulfils its proper functions, and then we see the surfaces coalesce. Bichat was certainly wrong when he supposed that a loss of substance was always necessary to the formation of adhesions in mucous canals. The vagina has been repeatedly found obliterated after inflammation. Cruveilhier mentions a patient of Dupuytren in which this effect followed a laceration of the recto vaginal septum in parturition. The occlusion of the os uteri, and the obliteration of the fallopian tubes in tubular pregnancy, and in girls of ill fame, as remarked by Walter, Meckel, and Breschet, are cases equally in point. The ureter is sometimes closed above or below an arrested calculus. The gall duct, in many instances, and sometimes the gall bladder itself, have been found de- stroyed by adhesion. Cases of this kind may be found in the works of nearly all the pathological anatomists. Those pas- sages which are covered by a cuticle or 214 ADHES.—ADIANT. epithelium are, of course, protected against adhesion until that membrane is removed by accident or disease. " It is certain," says Breschet, " that the venereal virus seems to give to the mucous membranes a peculiar disposition to contract adhesions." {Op. Cit.) It is generally about the ori- fices of mucous canals, where the epider- mis still exists, that the inflammation cen- tres in venereal cases, and every surgeon knows how liable to excoriation parts thus affected become. When denuded of their epidermis, the mucous secretion is here de- ficient; hence the greater frequency of adhesion remarked by Breschet. Enough has been said to show that the mucous tissue is subject to the same gene- ral law which governs the restoratory pro- cess in other parts; but it is not the less true that adhesion takes place with great difficulty in such situations; and the in- stances in which it occurs without loss of substance are comparatively rare. In the intestinal canal they are extremely so: it is remarkable that, in artificial anus, the intestine below the injury may contract, but never becomes closed. f. Adhesions of the cuticular surfaces. The skin is never placed in juxtaposition to itself in such a manner as to contract adhesions, until after the destruction of a portion of its cuticle; it is then placed in the same circumstances with the divided cellular tissue in wounds, and may unite with any part which is retained in contact with it. The terrible deformities result- ing from burns are examples of the unhap- py effects of the law, and the beautiful operations performed within a few years for the restoration of lost features, show how useful it may be rendered by the sur- geon. Adhesion of suppurating and ulcerated surfaces. See Cicatrix. Adhesions of the osseous tissue. See Bone, reproduction of. Adhesion, as a cause of disease. See the articles on the several cavities and organs. Adhesion, as a therapeutic remedy. See Hernia, Hydrocele, Operations Rhino- plastic, <$fC. Bibliography.—Cruveilhier. Didionnaire de Midecine et de Chirurgie Pratiques. Paris, 1829. Ibid. Anatomie Pathologique. I. Paris, 1832. Hunter. Treatise on the Blood, Inflammation and Gun-shot Wounds. Thompson, (John.) Lectures on Inflammation, exhibiting a view of the general Doctrines, patho- logical and practical, of Medical Surgery. 2d Am. Edit p. 166. Philad. 1831. Bell, (John.) Discourses on the nature and treatment of wounds. Part 1st. Serre. Traiti de la Riunion Immidiate et de son influence sur lesprogres ricens de la chirurgie- Paris, 1830. Breschet. Did. de Mid. art. Adherence- See, also, the Bibliography of the several arti- cles to which reference has been made. Reynell Coates. ADHESIVE INFLAMMATION. See Arts. Adhesion and Inflammation. ADHESIVE PLASTER. See Plaster. ADIANTUM. Maiden hair. Capil- laire, Fr.; Frauenhaar, Germ. Sex. Syst. Cryptogamia Filices. Nat. Ord. Filices. Gen. Char. Sori oblong or roundish. Indusia membranaceous, arising from the margin of the frond and opening upwards. NUTTALL. Most, if not all, the species of this genus of ferns, are possessed ofthe same proper- ties ; there are only two, however, which are recognized in the Pharmacopoeias. These are so identical in their medicinal effects as to be used indiscriminately. They are slightly aromatic and agreeable to the taste. The active qualities appear to re- side in its mucilage, and the weak astrin- gent principle with which this is united. They are used in infusion in mild catarrh- al affections, but their principal employ- ment is in the celebrated Syrop de Capil- laire, one of the most popular pectoral remedies among the French. This syrup, which is a pleasant summer drink, like all other demulcent and mildly expectorant remedies, is useful in slight catarrhs, and has the advantage of not offending the stomach even when taken in large quanti- ties. It is made by infusing four ounces of the leaves in six pints of boiling water, straining the fluid, dissolving in it four pounds of refined sugar, boiling to a syrup, and adding a small quantity or orange- flower water. A.capillusveneris. Maidenhair. Capil- laire de Montpellier, Fr. ; Venushaar, Germ. Sp. Char. " Frond bipinnate, pin- nules obovate-cuneate, inciso-sublobate, seg- ments of the fertile pinnules terminated by a linear-oblong sorus, sterile ones serra- ted." Hooker. This species is found in many parts of Europe, growing in moist situations, on rocks, or by the sides of rivulets. A. pedatum. Rock fern. American maiden hair. Capillaire du Canada, Fr. Sp. Char. " Frond pedate, branches pin- nate; pinna? dimidiate oblong-lunate, up- per margin incised; sterile segments den- tate ; fertile ones entire; sori linear; stipe glabrous." Willdenow. This species is exceedingly common in the northern and ADIAPH.—ADIPOSE. 215 middle states; occurring in rich soil on hills and among rocks. At one time large quantities were exported to Europe from Canada; but of late years little has been sent. It is rather more bitter and aroma- tic than the European. Bibliography.—A. J. L. Jourdan. Pharma- ccpie Universelle. Paris, 1828. 2 vols. Svo. A. Richard. Elimens d'histoire Nalurelle Me- dicate. Paris, 1831. 2 vols. 8vo. Merat et De Lens. Diet. Universelle de Ma- tiere Medicate. Tom. I. Paris, 1829. J. D. Schoepf. Materia Midica Americana. Erlangs. 1787. C. F. Rafinesque. Medical Flora of the United States. Philadelphia, 1828. 2 vols. 12mo.- R. E. Griffith. ADIAPHROSIS. (From o priv., Sta, through, and tj>opo$, a pore.) Suppression of perspiration. I. H. ADIARRH^EA. (From a priv. and Suxppsiv, to flow.) Retention of any excre- tion. I. H. ADIPOCIRE. (From adeps, fat, and cera, wax.) A substance of a yellowish or dirty white colour, which is formed by the change that the soft parts of an animal body undergoes when exposed for a certain length of time to the action of moisture, and at the same time protected from the effects of the air. It was first discovered in removing the bodies from the burial ground of the Innocents at Paris, in 1787, and received the above name from Four- croy, who, however, classed with it seve- ral other animal substances, which more recent researches have shown to be dis- tinct. Adipocire is composed of margaric and oleic acids, united with a colouring matter, and a little potash, lime, and ammonia. As this substance is of no utili- ty in medicine, any further notice of it would be superfluous. Bibliography.—Fourcro y. Elements of Nat. Hist and Chemistry. Vol. 4th. London, 1788. Merat et De Lens. Diet Universelle de Mat. Med. Paris, 1829. R. E. Griffith. ADIPOSE. (From adeps, fat.) Fatty. ADIPOSE TISSUE, {Tela Adiposa,) thus designated, in consequence of its fatty character^ or the adeps it contains, is a structure which is widely diffused through- out the organism, and is formed of an as- semblage of minute rounded particles or vesicles of a light colour, closely agglome- rated together, which are embedded in the interstices of the common cellular or fila- mentous tissue. Art. I. Adipose Tissue, Anatomy of.— The adipose tissue exists under two forms, which, though similar in their fundamental 'characters, are, nevertheless, sufficiently distinct in some of their properties to en- title them to a separate consideration. The first is the general Adipose Tissue, or that which occupies the superficies of the body and the surface and interstices of the or- gans ; the second the medullary Adipose Tissue, or marrow, disposed within the cavities of the bones. § 1. The General Adipose Tissue.— The fatty matter which constitutes the proper base of the adipose tissue may be said, in general terms, to exist in almost every portion of the organism, but in dif- ferent degrees, and under different forms; being, in most of them, in a free state, but in some, in an intimate state of combina- tion with the structures which it occupies. We shall confine our observations princi- pally to that form ofthe tissue which is in a free state, and which is manifest to the senses without any previous chemical pre- paration. The quantity of the adipose tissue is so exceedingly variable in different indivi- duals, that no very accurate estimate can be made of the relation it bears to the whole mass of the organization. It has been supposed, however, that in a well- formed adult subject of ordinary stoutness and embonpoint, it constitutes about one- twentieth part of the entire volume of the body. But in those who are lean and ema- ciated, its quantity is considerably dimin- ished, and, in many cases of protracted dis- eases, it so far disappears as to be scarcely manifest in any situation. In some in- stances, on the other hand, its relative pro- portion is much greater than has been re- presented; and sometimes, indeed, it be- comes so inordinately developed, as to pre- ponderate, both in volume and weight, over the entire mass of all the other structures of the body. In cases of obesity, it is fre- quently accumulated in such quantity that the specific gravity of the body becomes even less than that of water. In an Italian priest of the name of Paola Moccia, it was so inordinately developed that he weighed two hundred pounds, and had a specific gravity less, by thirty pounds, than that of water, upon the surface of which he float- ed like a cork. {E. H. Weber in Hilde- brandts Handbuch der Anatomie. Band I. p. 244. Braimschweig, 1830.) The adipose tissue, though extensively diffused, is not perfectly continuous through- out its whole extent. It forms in most situ- ations a thick stratum between the skin and subjacent muscles, and generally has its quantity very much increased at those points which have to sustain considerable pressure, or are submitted to much motion; as, for the example, the buttocks, where it forms a soft cushion upon which the indi- 216 ADIPOSE TISSUE. vidual may repose with ease, in the palms ©f the hands, the soles of the feet, and in the vicinity of the large articulations. A thin stratum exists beneath the scalp, with which, and the pericranium, it adheres very intimately. It is also abundant about the face, and in the interstices of the lo- bules of the parotid gland. In the cheeks it forms large rounded masses, which con- tribute to their fullness and symmetry, and the bottom of the orbit is occupied by a considerable mass, upon which the ball of the eye reposes and moves with freedom. On the anterior part of the neck it is more abundant than on the posterior; but it ex- ists sparingly between the skin and the platysma myoides muscle: on the median line of the neck it is for the most part wanting. About the mamma?, especially in the female, and beneath the pectoral muscles, it exists in great abundance; and upon the anterior and lateral parts of the abdomen it is more abundant, in corpulent persons, than in any other situation on the superficies of the body. It also penetrates the interstices of the voluntary muscles; and in those which are composed of large fasciculi, as the gluteus, it forms a consi- derable portion of their mass. It also exists in the interstices of the fasciculi of some of the larger nerves, and between those of the ligaments, and forms considerable masses of a fimbriated arrangement in the duplicatures of the bursa? and synovial cap- sules. Turning our attention next to the inte- rior of the body, we shall find a small quantity of adipose tissue situated within the cavity of the spinal column, between the dura mater and the bone. In the cavi- ty of the thorax, it occupies the superficies of the heart, the anterior and posterior mediastinum, and the intercostal spaces. But the abdomen, of all the splanchnic cavities, contains the largest portion of adipose tissue. It forms large masses around the kidneys, within the numerous duplicatures of the peritoneum, as the omentum, mesentery, and epiploic append- ages, and exists in considerable abundance within the lateral and inferior portions of the pelvis. But however diversely disposed, its ar- rangement is everywhere directed by infi- nite wisdom. Thus, in some situations, it contributes to perfect the symmetry and beauty; in others, we find it facilitating locomotion, constituting a means of protec- tion, and filling up the void spaces between the several organs: under the same wise provision of nature, we find it wanting where its presence is not required, or where its inordinate accumulation might curb or embarrass the motions of the organs, or in- terfere with the regular exercise of their functions. Thus, it does not exist upon the choncha of the ear, within the cavity of the cranium, in the eyelids or the nose. Neither is it found in the sheaths of the vessels, in the submucous cellular tissue, the lymphatic glands, the scrotum, penis, testicles, nympha?, vagina, or uterus. It exists sparingly in the kidneys, but in the liver and spleen it is not found in a free state. The adipose tissue cannot be observed during the four first months of the foetal existence, but makes its appearance about the fifth month. It first becomes manifest immediately beneath the skin, in form of small isolated grains or particles, which continue to multiply, and finally become clustered into extensive masses, which oc- cupy nearly the whole superficies of the body. It is still, however, confined for the most part to this situation, and imparts that plumpness and rotundity for which chil- dren are so remarkable. It is only at a later period that it makes its appearance in the splanchnic cavities and upon the surface of the organs, but as age advances it be- comes abundant in these situations, and frequently acquires such a degree of de- velopment as to preponderate considerably over that which occupies the superficies of the body. There are, however, several circumstances, besides the influence of age, which have a tendency to increase or di- minish its quantity. Thus, it is more abun- dant in the female than in the male; its quantity is augmented by high living and indolence, especially if to these causes be added perfect tranquillity of mind, and an avoidance of excessive venereal indul- gence. The influence of the latter cause is strongly manifested by the great tenden- cy there is to obesity at that period of life at which the venereal desires become blunted or extinct, and by the rapidity with which domestic animals grow fat after the operation of castration, or the destruction of the functions of the testicles by any cause whatever. There seems, moreover, to be a strong disposition to the develop- ment of the adipose tissue in those organs, the functions of which have become im- paired or suspended, or which are atrophied from old age or any other cause. In many cases, indeed, such a quantity of fat is gen- erated, under these circumstances, that it seems to supplant the proper structures of the organ. We frequently find the mus- cles and even the heart of old persons al- most transformed into a mass of adeps; the ADIPOSE TISSUE. 217 kidney, when atrophied, sometimes has its place supplied by the same substance; and even the scrotum, in which we have seen the adipose tissue does not exist in the na- tural state, becomes filled up with it where the testicle has been removed by an opera- tion or destroyed by atrophy. {Jannssen, Abhandlungen von Thierischen Fette. Halle, 1786, p. 76.) According to Hul- senbusch, {Dissertatio de Pinguidine, 1728, p. 18,) it is also sometimes found within the cavity of the uterus of some animals; and it has been observed that the extirpation ofthe ovaria produces the same tendency to its developement in the female that castration does in the male. The form and density ofthe adipose tis- sue are variable in different portions of the system, according to the properties of the cellular tissue in which it is deposited. In the orbits of the eye, the cheeks, the axil- lary regions, and upon the symphisis pubis, it is soft and lax in its arrangement, and consists of considerable rounded masses. In most other parts of the body these masses are smaller, and are composed of minute clustered particles of fat, separated by their cellular tissue; but in the scalp, and in the palms ofthe hands and the soles ofthe feet, the investing cellular tissue is strong, com- pact, and fibrous. Within the cavity of the abdomen, on the contrary, it consists of con- siderable pyriform, or pedicellated masses, disposed upon the surface ofthe peritona?um and within its duplicatures. In all cases, the adipose tissue is softer and more delicate in proportion as the sub- ject is younger, and becomes more solid as age advances. There has been some dif- ference of opinion relative to the question whether the fat exists in the fluid or the solid state in the living animal. In man and the carnivorous animals, it was long since observed by Sanctorius and others that it is fluid. Haller also states that he has often observed a white pellucid fluid oil, or fat in the omentum, heart, ovaria, and extremities of living dogs and other warm-blooded animals, {Elementa Phy- siologiat, 4to, I. 28.) In many of the fish, and especially in animals ofthe whale tribe, a large quantity of fat exists in a perfectly fluid state within the cavity of the cranium. In the ruminating animals, however, it ap- pears to be much more consistent than in man, and although it is sometimes found in the fluid state, as already represented, sev- eral circumstances, such for instance as its being unable to infiltrate the cellular tis- sue, "seem to show that it must be some- what solid even in the human subject, or vol. i. ' 19 at least that it possesses much more con- sistence than many other fluids. 1. Organization of the Adipose Tissue. The adipose tissue is of a whitish-yellow colour, and though variable in its structure in different situations, it is nevertheless everywhere composed of small, rounded, oval, or flattened masses, enveloped by the common cellular tissue. These masses, when submitted to a more minute state of division, are found to be composed of a num- ber of small lobules, and these, in their turn, of an infinity of minute granules or parti- cles, closely clustered together, which have been compared to the racemose arrange- ment of a bunch of grapes, the blood-ves- sels which lead to them forming a kind of pedicle upon which the grains of fat are en- grafted. From their brilliant, shining as- pect, they have also been compared, by Monro and Clopton Havers, to a cluster of pearls. Examined with a microscope of a magnifying power of from forty to one hundred and fifty diameters, the adipose granules were found by Greussmacher, Fontana, and Monro, to exhibit an ovai configuration. Wolff represents them as being somewhat less oval than they had been described by these individuals, and Heusinger states that they are spherical. Weber also found them nearly spherical in the fat taken from the socket of the eye, which he examined twenty-four hours after death. Raspail, however, who has insti- tuted some experiments on this subject, states, that in the hog the granular parti- cles of the adipose tissue are obround, and slightly elongated, or kidney-shaped, and present on their side a small oblong point, or hilum, by which they are attached to the cellular tissue. In the sheep and oxen, they presented a number of angles and bor- ders, with intermediate facets, and resem- bled small translucent crystals of quartz; but in insects they were found to exhibit a turbinated figure, occasioned by the great depth of the hilum which formed their point of attachment to the common cellular tissue. From the similarity of these gran- ules to regular polyhedrons, the author just quoted suggests that the several facets re- sult from the mutual compression of the several particles upon each other, at their points of contact. We have ourselves veri- fied the existence of these facets and angles in the adipose tissue ofthe ox and the sheep, but we are rather disposed, with Weber, to regard them merely as an accidental condition, resulting from the solidification of the fat granules after death. These par- ticles being soft and yielding in the living 218 ADIPOSE TISSUE. state, it can be readily conceived, that in consequence of their encroaching upon each other during the act of becoming solid, they would thus acquire the configuration de- scribed by Raspail, which they would re- tain when perfectly cold. The size of the adipose granulations has been variously estimated by different ob- servers. Leuwenhoeck estimated it at about the size of the bulbs of the hair. Wolff, however, states that their volume varies in different animals, but that they are all of uniform volume in man. Ac- cording to Heusinger, the largest are about TI„, the smallest ^ parts of an inch in diameter; or from 3£ to 7^ times larger than a globule of blood. It is probable that they vary in size in the same animal at different periods of life; for Raspail found that those of the ox presented double the volume of those of the calf. There has been considerable diversity of opinion amongst anatomists relative to the question whether the adipose tissue should be considered as a structure inde- pendent of the proper cellular tissue, or a mere secretion of fat deposited in its meshes. Malpighi, Glisson, and indeed many of the early anatomists, regarded it as a kind of glandular, or at least a secretory appara- tus, destined to elaborate the animal oil. Bergin divided the cellular tissue into lamellated and adipose, the latter of which he considered as somewhat independent of the former. William Hunter, however, was the first who resorted to any elaborate arguments to prove that the fat consitutes a tissue entirely distinct from the cellular with which it is blended. This opinion has been very ably supported by Beclard, and has since been espoused by craigie, Grainger, and many other modern anato- mists. Haller, nevertheless, long since maintained that the fat is merely secreted into the common cellular tissue, and does not form an independent structure. A similar sentiment has been adopted by a majority of those who have represented that the cellular tissue is of a cellular or filamentous character; some of them sup- posing that the fat is secreted into its cells, while others have thought that it is de- posited in the interstices of its lamella? and filaments. This hypothesis has been adopt- ed by Prochaska, Bichat, Chaussier, H. Cloquet, Walther, Lenhossek, Hem- pel, and others. Wolff first demonstrated that the cellular tissue merely consists of a simple, homogeneous, gelatinous mucus, and consequently that the fat cannot be deposited in any proper cells, or between any fibres or lamella?, but is merely lodged, as it were, in this gelatinous mucus, the particles of which are forced asunder to make room for its reception. The same view of the subject has been adopted by Heusinger, Meckel, Blumenbach, Au- tenreith, Rudolphi, Treviranus, and several modern anatomists. The principal arguments adduced by Hunter and Beclard in favour of the opinion they have advocated, are the fol- lowing. If the fat, say they, were merely deposited, in a free state, in the interstices of the cellular tissue, it would not assume the regular and determinate forms which it always exhibits. Moreover, when it is immersed in warm water, and is examined under a microscope, no oil is observed to float on the surface, unless such force be employed as to tear the small granules of which the tissue is composed. If it were merely a secretion deposited like water in the meshes of the cellular tissue, as it is fluid in the living subject, it should obey the same laws as that fluid in traversing the system freely from one part to another, should pit on pressure, and be capable, like the water in an cedematous part, of being forced freely from place to place. This, say they, is never observed. These arguments, however, are inconclusive, and may be rebutted by others of still greater force. Thus, if we admit, with Hunter and Beclard, that the fat should be con- sidered as a distinct tissue, it ought to ex- ist under all circumstances, inasmuch as we have no instance of one of the constitu- ent tissues of the body entirely disappear- ing at one period, and at another assuming an extraordinary development. The fact that the eye-lids, the scrotum, and some other parts of the body, do not become loaded with fat, is not favourable to their argument, but rather corroborates the be- lief, that the cellular tissue, or rather the vessels of such parts, do not possess the faculty of secreting it; and if it were a proper and independent tissue, it could not, as is generally the case in anasarca, be sup- planted by the inordinate accumulation of fluid in the cellular tissue. It has already been stated, that the mi- croscopic granulations of the adipose tis- sue, as well as the larger masses which are formed by their union, are all united to each other by the intervention of the delicate cellular tissue. Through this lat- ter medium, numerous minute blood-ves- sels are conveyed to the granules of fat in a manner which was long since described by Malpighi, and which has, in modern times, been particularly noted by Mascag- ni. According to the observations of the ADIPOSE TISSUE. 219 former, the vessels divide and subdivide, like the branches of a tree, until their final ramifications reach the small adipose glob- ules or vesicles, which are mounted upon their extremities like the leaves of a tree. He also supposed that each vesicle con- stitutes a kind of secretory gland, furnish- ed with an excretory duct, which is con- tained within its pedicle. Muscagni has stated, that each grain is furnished with an artery and a vein, which reach it by traversing the cellular tissue occupying the interstices of the different particles, and which consequently represent so many small pedicles, all springing from one com- mon peduncle. These, by being distributed to the same mass of adipose granules, serve to unite them together in the same man- ner that a raceme of grapes are clustered together upon their stem. He also sup- poses that each vesicle is composed of an internal layer of lymphatic, and an exter- nal of sanguineous vessels. The arteries are exceedingly minute, yet they are suf- ficiently large to be filled with minute injection, especially in young subjects. Nerves have never been traced into the adipose granules, and if they exist, they must be confined to their investing cellu- lar tissue. It was long since stated by Swammerdam, that each adipose granule is contained within a kind of vesicle or membranous covering, and when the fat is liquefied, these membranes fall to the bot- tom of the vessel. Braconnot also asserts that they are connected with each other by the intervention of a very delicate membranous structure, in which they are contained in the same manner as the grains of starch in a boiled potatoe. To Raspail, however, we are indebted for the most satisfactory microscopical observa- tions upon this point. He has observed, that each mass of solid adipose substance is surrounded by a strong membranous covering or vesicle, in which no opening is perceptible. This mass is composed of an aggregate of smaller masses, likewise included within similar vesicles of a thinner and more delicate character; and these secondary masses may be divided and sub- divided until they are reduced to the primitive adipose granules, which are themselves contained in small delicate membranous vesicles, so attenuated as to be imperceptible to the naked eye, but which become manifest when they are pre- pared by immersion in boiling alcohol, and are in this state examined with the micro- scope. The adipose tissue, therefore, ac- cording to this view, seems to be composed of an external vesicle, from the inner sur- face of which others are formed of smaller size, and these latter are divided and sub- divided until they are reduced to those minute divisions, which being inflated with the adipose materials, form the primitive granules. Should the energies of the nutritive acts be so much exalted as to give rise to a multiplication or augmentation of these microscopic elements, a corresponding in- crease will also take place in the mem- branous coverings in which they are in- cluded, and there will be, under such cir- cumstances, a proportionate increase of the quantity and volume of the adipose tissue, as is observed in individuals who become corpulent, and especially in those in which this substance is developed in that extra- ordinary degree which constitutes the con- dition denominated polysarcia. On the other hand, however, should the demands of the system be such as to render it ne- cessary that these adipose materials should be appropriated to the purposes of nourish- ing the different organs, in proportion as they are removed from the delicate mem- branous cells in which they are contained, they gradually collapse upon themselves, and where they have been entirely taken up by the absorbent vessels, nothing will be found remaining but the simple lamel- lated or filamentous cellular tissue, of which the vesicles themselves were form- ed. This is precisely what takes place when the individual becomes emaciated either from disease or from a privation of aliment:—the adipose elements, which are under other circumstances generated in great abundance, entirely disappear, or ex- ist in a sparing degree, so that in extreme degrees of emaciation, not only the cellu- lar tissue, but likewise the organs, become completely divested of fat. The adipose tissue, therefore, seems merely to consist in a deposit of adipose or oily materials in the common cellular or mucous tissue. It is probably similar, as has been suggested by Raspail, to the common cellular tissue which forms the fecula of vegetables, from which it merely differs in the character of the materials which are deposited, these being, m the one, fat or oil,—in the other, starch. It will be seen then, that there is no founda- tion for the opinion of Hunter and Be- clard, who, as has been already stated, supposed that the adeps constitutes a tis- sue entirely distinct from the cellular. The fat sometimes exists in other forms than that which has been described. Ruysch long since supposed that he had discovered a free oil in the blood of a hog, 220 ADIPOSE TISSUE. and Malpighi, Glisson, Morgagni, Hal- ler, and several ofthe older physiologists, supposed that it circulates in a state of mixture with the mass of blood. This, however, has been denied by several indi- viduals of high respectability, yet modern observations and researches have clearly demonstrated that the old opinion is cor- rect, at least in some cases. Chevreul found oil in the blood, but he supposed that it merely exists there in a state of combi- nation with the various elements of that fluid. Marcet observed oil in the blood of diabetic patients, and Traill discover- ed it in the venous blood of an individual who died of hepatitis. Clarus, moreover, who carefully filtered through paper the blood of individuals who had died of a great variety of diseases, always found the paper transparent, and of an oily appear- ance. Bichat, however, as well as Be- clard and Craigie, has denied that the oil exists in its formed state in the blood, and the latter states that he had performed a number of experiments to detect these oily particles, but always without success. From this diversity of sentiment it would appear, that oil does not constantly exist in a free state in the fluid in question, yet the positive facts which have been adduced, together with the force of analogy, clearly prove, that under some circumstances, at least it does constitute a part of the circu- lating fluids. According to the observations of Chev- reul, the fat divested of its coverings, is composed of two proximate principles, which he has designated Stearine and Elaine. The first is a solid, whitish-col- oured, almost inodorous, and tasteless sub- stance, of which boiling alcohol dissolves about £ its weight. This is, however, in part deposited on cooling, in slender nee- dle-formed crystals, while the other part is held in solution. The second is of a whitish or yellow colour, lighter than water, fluid at zero, and readily soluble in alcohol, which when boiling takes up £T of its weight, and even holds it in solution when cold. It may, however, be obtained in needle-formed crystals, by submitting it to a freezing mixture. Raspail does not admit the existence of twa proximate principles. He affirms that Stearine and Elaine are merely portions, differently obtained, of the same substance, the difference of which is merely the re- sult of the manipulation employed. He ascertained that, by repeated and continued boiling and washing, Elaine was almost the only material procured. It has already been stated, that Mal- pighi and some others maintained that the fat is secreted by a special glandular ap- paratus furnished with excretory ducts, destined exclusively for that purpose. This opinion, however, cannot be sustained, and was, indeed, subsequently abandoned by its author himself. Haller adopted "the more plausible hypothesis that it is separ- ated from the blood by the extremities of the arteries; but as he supposed, on the authority of Malpighi, Glisson, and some others, that the fat exists in a formed state in the blood, and has merely to be separat- ed and deposited by the vessels, many have objected to his opinion. Bichat attributed it to a kind of process of exhalation, and Mascagni has alleged that it is deposited in a crude state by the arterial capillaries, and that the lymphatics absorb its thinner parts, and leave the thicker or oleo-adipose portion behind in a state more completely elaborated. Be this as it may, the fat is unquestionably elaborated and deposited by a secretory action of the vessels, by which it is separated from the blood, and fitted for the purposes which it has to subserve. It can scarcely be necessary to advert to the hypothesis of Sir Everard Home, who has placed the origin of the fat in the ali- mentary canal, and who supposes that it is absorbed by the vessels of the large intes- tines; much less will it be necessary to notice that of Kiegel, who imagined that it is secreted by the supra-renal capsules. These speculations are not corroborated by any conclusive facts or arguments. With regard to the offices which have been attributed to the adipose tissue, many of them, it must be confessed, are purely hypothetical. In many parts ofthe system it fills up different cavities and interstices, imparts a certain degree of rotundity and symmetry, and in some situations, as, for example, the buttocks, the palms of the hands, and the soles of the feet it serves to protect the parts under the influence of the pressure to which they are exposed. It has also been supposed to facilitate the movements of the organs, and to lubricate the surface of the skin and the articulating extremities ofthe bones, but these opinions are mere vague hypotheses. In conse- quence of its being a bad conductor of caloric, the adipose tissue has been sup- posed to act as a defence against cold, by preventing the escape of animal heat; and, in support of this conjecture, it has been affirmed that those animals which inhabit high latitudes are furnished with a thick stratum of fat immediately beneath the skin. It may possibly exercise some in- fluence in this way, but this must be ex- ADIPOSE TISSUE. 221 ceedingly limited, inasmuch as those indi- viduals who are but sparingly endowed with this substance, endure cold quite as well as those who are corpulent. A much more plausible hypothesis is that which considers it as a store of nutritive matter kept in reserve to meet any extraordinary exigencies to which the system of the in- dividual may be exposed. The probability of this opinion is corroborated by a variety of circumstances. We find that individuals who are submitted to protracted fasting, rapidly lose the adipose tissue, and become emaciated. The same thing takes place in disease whenever the digestive appara- tus is unable to furnish the requisite quan- tity of nutritive matter, which, under such circumstances, is furnished by the fat. Many animals, moreover, spend a consider- able portion of the year in a perfect state of torpidity, without deriving any subsist- ence from surrounding objects, but merely sustained by their adipose tissue, which, however abundant it may be when they enter into this state, is always completely consumed by the time their period of hi- bernation has terminated. It was, more- over, supposed by Fourcroy, that the adi- pose tissue, in consequence of the great quantity of hydrogen it contains, contrib- utes to render the products of assimilation more nutritive, by divesting them of a pro- portion of that material. § 2. The Medullary Adipose Tissue.— Besides the general adipose tissue which has been just described, we find lodged within the cavities of the cylindrical bones a considerable quantity of the same sub- stance, which, in this situation, is denomi- nated medulla ossium, meditullium, or marrow. This substance, however, is not confined to the cavities of the long bones; for while we find it presenting an elongat- ed cylinder accurately moulded to the in- ner configuration of these cavities, it also exists in their reticulated structure, in that of the short, as well as in the substance of the flat bones. It exists, likewise, to a cer- tain extent in the porosities of the com- pact osseous tissue, but is never found in those cells of the bones which are destined to circulate air, as those of the mastoid process, the frontal sinuses, the ethmoid cells, &c. It may also be discovered in the cells of the thyroid cartilage of the larynx, when it becomes ossified; but, ac- cording to Weber, it never exists in that structure while it retains its cartilaginous condition. In the medullary cavities of the long bones, the marrow is of a more solid and 19* thick consistence than in the other portions of the osseous system. It is of a lightish yellow colour, and is contained within a very delicate vascular membrane, denomi- nated internal periosteum, or medullary membrane, which, while it lines the cavi- ty of the bone, and sends numerous very minute prolongations upon the vessels which permeate the porosities of the os- seous tissues, is also so disposed as to form an infinity of small cells, in which the adeps or marrow is deposited. This mem- brane is of a texture so exceedingly deli- cate, that it can be with difficulty observed by the naked eye. By submitting it to heat, however, or immersing it in nitric or muriatic acid, it can be detached from the bone, and being at the same time rendered opaque, can be distinctly seen occupying the surface of the medullary substance, in form of a very fine pellicle, which has been not unaptly compared by Beclard to the tunica Arachnoidea. It may, moreover, be still more satisfactorily demonstrated by the plan proposed by Weber. If a sec- tion of one of the long bones containing the marrow be, in its fresh state, immersed for some time in diluted muriatic acid, the carbonic acid gas which is liberated from the inner surface of the bone will gradual- ly break up the attachments of the mem- brane with the osseous tissue, and it, to- gether with the marrow, may be withdrawn from the cavity in form of a perfect solid cylinder. The numerous minute cells formed by the ultimate subdivisions of the medullary membrane, when filled with the oily or fatty substance of which the marrow is composed, gives rise to an arrangement which seems to be composed of an infinity of minute, lightish coloured, rounded, or oval granules, which have been very accu- rately compared to a cluster of small pearls. They are closely agglomerated together, and bear the same relation to the cells or divisions of the medullary membranes, that the common fat granules do to the cellular tissue which furnishes them with a cover- ing. It is, indeed, highly probable, that the investing membrane of the medullary granules is of the same nature as the com- mon cellular tissue, rendered somewhat more vascular in this situation in conse- quence of the peculiarity of its relations. In the reticulated structure ofthe bones, the medullary substance exists for the most part in form of a free oil, placed in imme- diate contact with the osseous tissue, and consequently entirely devoid of any in- vesting membrane; at least if the mem- 222 ADIPOSE TISSUE. brane exists, it is probably a mere vascu- lar arrangement, by which the fat is elabo- rated and poured out, and again absorbed. The medullary membrane is abundantly supplied with vessels. These vessels were long since well described by Albinus and Duverney. They are mostly derived from those branches which traverse the nutri- tious foramina of the bones, which, after they have entered the medullary canal, branch out into an infinity of ramuli, which are distributed upon the medullary membrane and its numerous divisions. They seem, moreover, to form a very free anastomosis with the proper nutritive ves- sels which occupy the porous arrangement of the bones, and thus prove instrumental in establishing an intimate connexion be- tween the medullary membrane and the periosteum. When these vessels are filled with minute injection, and the marrow is carefully washed away by means of an al- kaline solution, the medullary membrane seems to be composed almost entirely of a delicate net-work of minute arteries and veins. With regard to the question whether the marrow is supplied with nerves, many anatomists of distinction have replied in the negative, and even Meckel, while he af- firms that the medullary substance of the bones is sensible, states that he had been unable to discover any nerves entering it. These nerves, however, have been par- ticularly noticed by Wrisberg and Klint. Soemmering admits their existence, but supposes that they are destined exclusively for the vessels; but J. Cloquet has traced the minute filaments of the ganglionic nerves, accompanying the nutritious artery of the humerus, into the marrow. Beclard, moreover, supposed that they might supply both the vessels and the other structures ofthe marrow. But be this as it may, the marrow is un- questionably endowed with considerable powers of sensibility. This was long since proved by the experiments instituted by Duverney, the results of which have been confirmed, in modern times, by the re- searches of Bichat, Meckel, and others. It has been affirmed by Bichat, that the sensibility of the marrow is most exquisite the nearer we approach the centre of the bone, and least towards its extremities. This has not been confirmed by Meckel. But while there can be but little doubt relative to the existence of this sensibility, it has doubtless been very much exagge- rated by some writers, and especially Bi- chat; for Lebel, in extracting a large sequestrum, had occasion to expose a con- siderable portion of the marrow, the mem- brane of which was red and highly inflam- ed, yet the individual did not complain of pain from the injury inflicted upon that substance. The medullary, like the general adipose tissue, does not exist during the early months of the fcetal life. There is no me- dullary canal in the cartilaginous bed of the bone when it is first formed, but in pro- portion as the development and the pro- cess of ossification advance, this canal be- comes distinct, traversed at first by blood- vessels, but afterwards occupied by the me- dullary membrane, which is filled by a reddish-coloured, viscous, or gelatinous sub- stance. Finally, small vestiges of adipose substance can be observed in the midst of this mass, and after the expiration of a cer- tain period the whole of the gelatinous substance is supplanted, as it were, by the marrow, which then fills up the whole of the medullary canal. Still, however, ac- cording to Isenflamm, in a child of a year old the cavity of the bone was merely oc- cupied by a darkish, red-coloured, gelati- nous substance, traversed by numerous blood-vessels. As age advances, the me- dullary canal and the marrow which occu- pies it, increase in volume, and the latter assumes a deeper yellow colour. Its quan- tity, however, varies very much under dif- ferent circumstances, and seems to be in- fluenced, in this respect, by the same laws that modify the general adipose tissue. In a medium state of embonpoint, Beclard found the marrow composed of seven parts of fat out of eight, the vessels, water, and albumen only constituting one part. In those who were much emaciated, however, he scarcely found the oily or fatty matter forming one-fourth of the entire substance. The same fact has also been noticed by Isenflamm. The marrow is, moreover, greatly diminished in quantity, or entirely disappears, under the influence of particu- lar diseases. Thus, in dropsy of long stand- ing, its quantity has been found notably diminished, and, according to Soemmering, it is sometimes completely supplanted in that disease by a kind of bloody gelatinous fluid. The same condition of the marrow has been observed by Bichat in rickets. In jaundice, the medullary substance, like many of the other solids and fluids of the body, is tinged of a deep yellow hue by the bile. The medullary membrane seems to be concerned in the two-fold office of contribu- ting to the nutrition of the bone, and the secretion or elaboration of the fatty mate- rials of the marrow. It has been ascer- ADIPOSE TISSUE. 223 tained by the experiments of Troja, that when this membrane is destroyed the cor- responding portion of the bone falls into necrosis. But as regards the use of the marrow itself, the opinions of authors are more divided. It was supposed by Duver- ney that the oily parts ofthe marrow served to impart flexibility and toughness to the bones,—an opinion which has also been adopted by Haller and Blumenbach. In corroboration of this opinion, it has been alleged that when the bones have been de- prived of their oily matter, by submitting them to heat, they are rendered highly fragile, and that, after they have been thus prepared, if they be immersed or boiled for some time in oil and gelatine, and subse- quently allowed to dry, they regain, to a considerable degree, their former strength. It should be subjoined, however, that by the process of calcination the bones are not only deprived of their oil, but likewise their animal matter, to which they owe most of their cohesiveness and their capa- bility to resist injuries, and that although they are afterwards rendered stronger by the process just mentioned, it is not in con- sequence of their former properties being restored, but from the development of new combinations, differing, in many essential particulars, from bone. Against this hy- pothesis it may, moreover, be urged, that the medullary adipose tissue does not exist in the bones of the foetus, and but sparingly in those of very young persons, yet these structures are by far more tough and flex- ible at this than at any subsequent pe- riod of life; and in old persons, in whom this tissue is very abundant, the bones, in- stead of being rendered more capable of resisting the influence of the accidents to which they are exposed, become so exceed- ingly fragile as to be broken by the slight- est causes. In birds, moreover, the long bones, instead of being filled by marrow, are merely occupied by air, yet, in propor- tion to their volume, they are even stronger than those of animals in which the medul- lary adipose tissue largely abounds. The following conjectures relative to the uses of the marrow are much more en- titled to confidence. One office ofthe ex- cavations ofthe bones seems to be to render them lighter, at the same time that they serve to increase their strength. The marrow which occupies these cavities may be considered as bearing the same relations to them that the general adipose tissue bears to the organs and tissues with which it is connected. It fills up the cavities and interstices of the bones, and at the same time constitutes a store of nutritious matter in reserve to meet any exigencies of the system. It may serve, moreover, to afford a means of protection to the delicate net- work of vessels which enters so largely into the formation of the medullary mem- brane, which, did they exist in a mere void cavity, would be liable to sustain conside- rable injury by the violent shocks and con- tusions to which the bones are constantly exposed. Bibliography.—Malpighi. {Marc.) Exercit. de Omento, pinguidine et adiposis dudibus. in Opera Omnia. Lond. 1686. fol. Duverney. De la Structure et du Sentiment de la Maelle. Mem. de VAcad. des Sc. 1700. Hunauld. Sur la Graisse. Ibid. 1732. Hoffman. Dissert, de Pinguidine, No. 8. Haller. Elementa Physiolcgia, 4to. I. 25. Lausanna?, 1757. Lorry. Sur la Graisse dans le Corps Humain. Mem. de la Soc. Roy. de Mid., 1779. Janssen. Pinguidinis Animalis Consideratio Physiologica et Pathologica. Lugd. Bat. 1784. Reussing. De Pinguidine Sana d Morbosa. Wm. Hunter, in Medical Observations and Inquiries, Vol. II. Lond. 1757. Wolff. De Tela quam dicunt Cellulosam, &c. in Nova act Acad. Sc. Imp. Pelropolit.Vl. 1788, &c, Greussmacher. Dissert de med. Ossium, in Haller. Disput Anat, VI. 391. Chevreul. Ann. de Chimie, LXXXVIII, XCIV, XCV, et Ann. de C. et de Phys. II, VI, VII. Mascagni. Prodromo delta Grande Anatomia. Seconda Edizione, Riveduto ed Illustrada da Tommaso Farnese, II. 95, &c. Milano, 1821. Also, Tav. XXIX, fig. 7. Heusinger. Syst. der Histologic 2 Band. Eisenach, 1822. Bichat. Anatomie Ginirale, nouvelle Edition, contenant les additions de Beclard et augmenUe de notes Nouvelles par F. Blandin. IV. Paris, 1830. Beclard. Elimens d'Anatomie Ginirale. Pa- ris, 1823. Meckel. Manual of General and Special Anatomy. Translated by A. Sidney Doane. 3 vols. Philada. 1832. Allmer. Dissert. Sistens disquis. anat. pin- guidin. Animalis. Jens, 1823. Raspail. Repertoire ginirale d'Anatomie et de Physiologie Path. III. Paris, 1827. Kuhn, De Pinguidine imprimis humana Lipsis, 1824. Craigie. General and Pathological Anatomy. Edinburgh, 1828. Horner. General and Special Anatomy, 2 vols Philad. 1826. Grainger. Elements of General Anatomy London, 1829. 3 Weber. (E. H.) in Hildebrandts Handbuch der Anatomie des Mensch. Band I. Braunschweie 1830. 8' Art. II. Adipose Tissue, Pathological Anatomy of.—From the views which we have expressed relative to the properties of the adipose tissue, it would be more in accordance with a natural arrangement to describe its pathological characters in con- nexion with the alterations of nutrition and secretion in the cellular tissue, to which they more properly belong. . But as we 224 ADIPOSE TISSUE. have, in compliance with common usage, made a separate article on that tissue, we shall in like manner subjoin a short expo- sition of its principal pathological condi- tions. a. Preternatural development ofthe adi- pose tissue. {Hypertrophy.)—The fat va- ries materially in quantity in different in- dividuals, and even in the same individual, under different circumstances. Hence it is difficult to determine what degree of increase should be regarded as pathologi- cal, and what merely the result of healthy secretion and nutrition. It was estimated by Quesnay, that in a healthy individual weighing 160 pounds, there should be 8 pounds of fat, and that any considerable departure from this standard, either in the way of increase or diminution, should be considered as evincing a tendency to dis- ease. Such estimates are, however, alto- gether arbitrary, inasmuch as we find the quantity of adipose substance very frequent- ly departing considerably from this propor- tion, without giving rise to the slightest disturbance of the general health, or occa- sioning any inconvenience to the individ- ual. It is only when its excess or defect are very inordinate, that they are regard- ed as resulting from a pathological state, and even then it is difficult to determine with accuracy what should be regarded as disease; for we not unfrequently find the most corpulent enjoying the most perfect health, and only suffering inconvenience from the enormous bulk of their body. The inordinate development of the adi- pose tissue may be either general or partial. In the first case, it accumulates in an un- usual quantity in all the situations in which it is usually found; in the second, in one or more organs. The first constitutes Polysarcia, some very remarkable exam- ples of which exist on record; the second forms tumours of an adipose character, which have been variously designated Lipoma, Steatoma, Physconia adiposa, &c. To these forms must also be added a third, in which there is a species of trans- formation of some of the other tissues into fat. This is particularly well exemplified in the adipose transformation of the sub- stance of the heart and the muscles of an- imal life, the liver, the ovaria, testicles, &c, which frequently takes place in ad- vanced life. The degree to which the size and weight of the body is sometimes increased by an accumulation of fat would appear incredi- ble, were it not that satisfactory exemplifi- cations come so frequently within our no- tice. This even takes place, in some in- stances, at an early period of life. Tulpius has reported the case of a child, who, when only five years old, weighed 150 pounds ; Eschenmayer, one of ten years of age, who weighed 219 pounds; Bartholin, one of eleven, 200 pounds : and two other cases have been reported, one by the French faculty, who, at the age of four years, weighed 104 pounds; the other in the Phi- losophical Transactions, who, at the same age, weighed 256 pounds. Bright, also, who at a later period weighed 616 pounds, at ten years of age, weighed 140 pounds. Sporner weighed 649 pounds; Van Leen- warden, 503; Ahrens, 450; and an indi- vidual, whose case is reported in der Sammlung auserlesener Wahrnemungen, 3 Band. p. 370, weighed, at his death, 800 pounds: the fat of the abdomen was from 13 to 14 inches in thickness. He was car- ried off by a spontaneous salivation, or, as represented by some, by fright. Two cases are also reported by Sennertus, one of whom, at thirty-six years, weighed 480 pounds; the other, 600. Of the same kind was the case of Lambert ; and many simi- lar have been recorded. Where this extraordinary development of fat takes place, the adipose matter is not confined to the superficial and interstitial cellular tissue, but is likewise deposited in enormous quantities within the splanchnic cavities; especially about the heart, in the mediastinum, around the kidneys, and in the omentum. In many cases, however, instead of being thus extensively diffused, it is confined, for the most part, to the eav- ity of the abdomen, and then gives rise to the condition denominated Obesitas, or by some Physconia adiposa. In either case, when the development of fatty substance is very considerable, it encroaches upon the organs, and gives rise to great embar- rassment of their functions. As we have already expressed our be- lief that the fat is deposited by a secretory process of the vessels, or of the cellular tissue in which it is lodged, it is evident, if this opinion be correct, that its preter- natural accumulation must depend, either upon an increased activity of the parts con- cerned in its elaboration, an enfeebled ac- tion of the absorbent vessels which are em- ployed in its removal, or the united agency of these two causes. But, notwithstanding we may satisfy ourselves thus far, relative to the cause ofthe condition under consid- eration, the precise condition, or conditions, of the organism concerned in its develop- ment is not so easily determined. Beddoes supposed that one cause might be a defect of oxygen in the system, and it is remark- ADIPOSE TISSUE. 225 ed by Good, that fat unquestionably con- tains less oxygen than muscle, and that sea-scurvy, in which the oxygen is per- haps reduced to its smallest proportion, i3 never announced by meagerness, but full- ness of habit, which is often its first symp- tom. This is corroborated by the observa- tions of Trotter, who affirms that, when a negro becomes rapidly corpulent, he never fails to fall a prey to sea-scurvy. There are, moreover, other circumstances which favour the truth of this conjecture; as, for example, the condition of hibernating ani- mals, or those which, during the cold sea- son, remain in a state of torpidity, in which the respiratory function is so far suspended that a sufficient supply of oxygen is not afforded to effect the usual changes in the blood, and the carbonacious matter, as well as the hydrogen, which in the natural state are thrown off by the lungs, and which form the predominant ingredients of fat, are suffered to accumulate in the system, and thus furnish a sufficient quantity of nutritive matter in reserve, to sustain the life of the animal during its season of in- activity. It has, moreover, been remarked by Von Gr^fe and others, that the respi- ratory apparatus of corpulent individuals is less perfectly developed than in others, and that the liver, spleen, and indeed all the abdominal organs, have been found un- usually large. This fact, therefore, may either be construed in favour of the hypo- thesis of Beddoes, or of that which has been adopted by many modern physiolo- gists—that one of the offices of the liver and spleen is to separate carbon and hydro- gen from the blood, and that whenever any impairment of this office occurs, a preter- natural accumulation of fat takes place, in consequence of the retention of those two materials. In favour of this latter opinion, the facts may be urged, that animals usual- ly become fat after the extirpation of the spleen; that some chronic affections of the liver create the same condition; that a free and continued use of those substances which contain an abundance of carbon and hydro- gen, (alcoholic potations for example,) not only excite corpulency, but likewise give rise to an enlargement of the liver; and, finally, the fact stated by Graefe, that the latter organ is preternaturally large in those who are affected with extraordinary obesi- ty. The offices of the skin, of the kidneys, testicles, &c, seem, moreover, to have some agency in its development. It has been remarked by Bichat, that during a fog of twenty-four hours' duration, thrushes, orto- lans, and red-breasts, become so fat that they are scarcely able toget out of the way ofthe sportsman; and the influence of cas- tration in giving rise to corpulency is well exemplified in eunuchs and various domes- tic animals. In addition to this, it may be alleged, that as the respiratory function seems to have some agency in the process, there is probably some modification of the act of sanguification, by which the blood is rendered less appropriate for healthy nu- trition, and acquires a preponderance of carbon and hydrogen. There seems, also, to be some peculiarity in the relative de- velopment or energy of the ganglionic and cerebro-spinal nervous systems; the latter, especially, being characterized by a want of power or activity; from which circum- stance such individuals are mostly of a sluggish or leuco-phlegmatic habit, slow of comprehension, and oftentimes not alto- gether undeserving the appellation "fat and stupid." It has, indeed, been correct- ly remarked by Bichat, that inordinate obesity should rather be regarded as an evidence of a want of energy of the sys- tem, and a sluggish activity of the absorb- ent system, than of an opposite condition; a fact which is fully- corroborated by the declaration of Trotter, to which we have already referred. When the preternatural development of the adipose tissue is confined to some par- ticular portion of the body, it gives rise mostly to the formation of tumours of varia- ble size and configuration, which have been denominated Lipoma, Steatoma, Adipose sarcoma, &c. They are generally situated in the subcutaneous cellular tissue, but are likewise frequently found within the ab- dominal cavity, in connexion with the pe- ritoneum. Though sometimes small, they have been seen weighing as much as fifty or sixty pounds; forming an enormous mass attached to the back, buttocks, or even to the face and other parts of the body. They are at first generally obround, and slightly compressed, but when they form upon parts of the body where the skin and cellular tissue are lax and easily elongated, they often become pyriform, or pediculated, and are merely suspended by means of a small neck, consisting of the elongated skin and a small quantity of fat. They are also frequently lobulated upon the surface, and seem to consist of an agglomeration of rounded masses of fat, the irregularities of which can be felt through the skin. It is found, indeed, on cutting into them, that in this respect, they do not differ from the natural adipose tissue; being, like it, com- posed of several rounded masses of fat loosely grouped together, and united by the intervention of the common cellular 226 ADIPOSE TISSUE. tissue, which, while it forms a condensed covering, or capsule, investing their whole surface, sends numerous partitions through the substance of the tumour, which furnish a kind of secondary covering for each of its divisions. This covering, as well as the partitions, is generally traversed by a few blood-vessels, which furnish the only cir- culation with which the tumour is supplied; and when the size of the diseased mass is considerable, the investing cellular tissue generally becomes hypertrophied or thick- ened, so as to render it more compact and resistant These primary masses, like those which belong to the natural adipose tissue, may be divided into others of small- er size, and these again into the primitive adipose granules, which, as has been re- marked by Monro and Beclard, do not differ from those which exist in the natu- ral state. In their organization, therefore, they do not differ from the healthy tissue. (See Tumours.) Those which form in the cavity of the abdomen, often attain a considerable vol- ume, and are more frequently pediculated than those which are developed externally. They may take place either in the omen- tum, in the epiploic appendages, or be- neath the peritoneum, and when situated in the vicinity of the linea alba, or any of the natural apertures of the abdomen, they may protrude, and give rise to an adipose hernia, or liperocele. Those which are de- veloped exterior to the peritoneum, are but sparingly supplied with blood-vessels, and are so loose in their arrangement, that they can frequently be spread out like a portion of the omentum. (See Abdominal tumours.) Sometimes small encysted tumours are formed beneath the skin, and even in the substance of the organs, which contain a fatty or oily material, much softer than the substance which constitutes the tumours just described. The animal oil, indeed, frequently exists merely in form of small particles, floating in a darkish-coloured melicerous fluid; sometimes mixed with small fragments of tuberculous matter, and occasionally contained in small cells, formed by the common cellular tissue somewhat condensed. In some instances, the contents of the cyst possess more of the properties of adeps, and are disposed in masses of a more solid consistence, but still much softer than common fat. These masses are merely attached to the walls of the cyst by minute blood-vessels and delicate shreds of the filamentous tissue, and may be turned out with great facility, leaving the walls of the capsule entire. They are formed most frequently on the back, the scalp and face, about the eyelids, and occasionally in the ovaria. With the preternatural development of the adipose tissue, must likewise be enu- merated its deposition in the interstices of some of the tissues and organs, and in sit- uations which it does not naturally occupy. These conditions have been incorrectly described by some pathologists under the appellation of adipose degenerations. In accordance with the views of Beclard, we are disposed only to regard them as examples of the accidental development of fat. When this takes place in the in- terstices of the muscles and other tissues, the natural structure of the part becomes atrophied, and is partially or entirely sup- planted by the encroachment of the fat. This is observed in the adipose transform- ation of the muscles, heart, liver, &c, which so frequently occurs in advanced life ; in the deposition of adipose tissue in the scrotum and ovaria, after castration, or after those organs have been wasted or destroyed by disease, within the cranium, on the internal surface of the mucous membrane, and in other situations in which it is not found in the natural state of the organs. (See Path. Anat. ofthe muscles.) b. Preternatural deficiency, or Atrophy of the adipose tissue. A deficiency of the adipose tissue is far more frequently ob- served than the opposite condition. It oc- curs in different degrees, from a slight diminution to an entire absence of all ap- preciable evidences of fat possessing its usual characteristics. The first is of fre- quent occurrence, and may be induced by a variety of causes; the second is but rarely met with, and probably never takes place, except as a consequence of long- protracted diseases, or profound organic lesions involving structures essential to life. There are, indeed, but very few cases in which the adipose tissue is entirely an- nihilated, and probably none in which visi- ble indications of free oil may not be de- tected in some portion ofthe system, how- ever extreme the emaciation. It has been remarked by William Hunter, that ana- sarcous dropsy is the only condition which is capable of completely removing the ad- ipose tissue, and that in those individuals in which this disease is inveterate, the heart and mesentery are often found as free from fat as in the youngest children. Bichat, however, has correctly observed, that the adipose substance and the serosity do not of necessity mutually exclude each other, since in most cases of anasarca, even where the infiltration is very great ADIPOSE TISSUE. 227 a considerable quantity of subcutaneous adeps may still be recognized. (I. 77.) This we have had repeated occasions to observe, even when the cellular tissue has been completely loaded with water: the fat under such circumstances being con- verted into small dark, gray, coloured pel- lets, not dissimilar in appearance to the sub- stance of a common slough of the cellular membrane. In phthisis pulmonalis, more- over, in tabes mesenterica, and, in short, in most diseases attended with extreme emaciation, portions of fat may be found occupying some of the tissues; and even in those individuals who have undergone such a degree 0f atrophy as to entitle them to the appellation of walking skeletons, more or less fat still exists, either in a formed state, or in the condition of a free oil. In such cases, the latter may always be found in the bones, infiltrated with some of the tissues, or mingled with some of the circulating fluids. The principal causes of this atrophy of the adipose tissue are, long-continued fast- ing, as is exemplified in hibernating ani- mals, or a defective or unwholesome ali- mentation; profound organic lesions of parts essential to life; extensive purulent depositions; the influence of the depress- ing passions; long-continued and intense application; excessive evacuations either of blood, or of the secretions of the body; exposure to intense heat; great bodily fa- tigue or laborious exertion; protracted dis- eases, especially such as involve the nutri- tive or respiratory acts; long watching or loss of sleep, &c. &c. A state of ana?mia either arising from a defective sanguifica- tion, or any other cause, always induces this condition. d. Alterations of texture taking place in the adipose tissue. It has been ques- tioned by some whether the adipose tissue is susceptible of inflammation. The fila- mentous or cellular tissue which invests it and occupies the interstices of its pellets and granules, is certainly liable to be thus affected; and it was long since very cor- rectly remarked, that inflammation taking place in a part greatly abounding with fat has a remarkable tendency to terminate in gangrene and sloughing. This is often observed in the omentum, when protruded into a hernial sac; in the mass of adeps which surrounds the anus, and in various other situations. It has, moreover, been remarked by Craigie, that the adipose cushion which surrounds the vessels, is sometimes the seat of a bad inflammatory action, terminating in fetid and sloughy suppuration. He subjoins an example of inflammation of the adipose cushion ofthe kidney, in which the whole of this sub- stance was converted into an ash-coloured, fetid, semi-fluid pulp, mixed with shreddy filaments, and in which the sloughing pro- cess had opened a passage from the fat of the left kidney into the interior of the arch of the colon. A similar instance is reported by Turner in the fourth volume ofthe Transactions ofthe College of Phy- sicians. Craigie seems to think, that the influence of this tissue may have some participation in the development ofthe pe- culiar phenomena of diffuse cellular in- flammation. {General and Path. Anat. p. 62. Edinb. 1828.) When inflammation attacks a part con- taining much of this tissue, as after wounds and operations, the fat is speedily removed by absorption, merely leaving the cellular tissue and other parts with which it is blended to effect the reparation of the breach. The same phenomenon is ob- served in the medullary adipose tissue af- ter fractures, amputations, and other inju- ries involving the substance of the bones. At the point at which the fracture occurs, and in its immediate vicinity, the marrow is speedily removed, and the vascular me- dullary membrane pours out a peculiar plastic lymph, which, in becoming solid and ossified, fills up the corresponding por- tion of the cavity, until the consolidation of the fracture is completed, and is then absorbed, in its turn, to give place to the marrow, which is again deposited by the vessels of the membrane. (See Frac- tures.) The medullary adipose tissue, like that which is situated elsewhere, is liable to some variations as regards quantity. It is diminished in hydropic affections, and in various other diseases attended with ex- treme emaciation. We have repeatedly seen it almost entirely destroyed in the large cylindric bones in persons who have been a long time affected with syphilis, and its place supplied by dark, red-colour- ed sanies; sometimes by a fluid of the con- sistence of honey. The medullary mem- brane, under these circumstances, has been found entirely destroyed, and the internal part of the bone carious or necrosed. In the disease called spina ventosa, or medullary exostosis,—also, in internal ne- crosis, and medullary abscess, the marrow is destroyed, and the medullary membrane is either disorganized, or submitted to im- portant changes of structure. Indeed, these diseases generally have their origin in this membrane, and not in the proper substance of the marrow, as has been 228 ADLPSIA—ADYNAMIA. sometimes asserted. It is remarked, more- over, by Beclard, that in persons affected with rickets, the membrane of the marrow is frequently found thickened and indurat- ed. This, however, as well as the carcin- omatous degenerations which occasionally occur within the cavity of the bones, can- not properly be considered as diseases of the adipose tissue, but of the membrane by which it is invested. Those organic alterations which have been described under the appellation of lardacious degenerations, have no proper- ties in common with the adipose tissue. They merely consist of a state of hyper- trophy of the common cellular tissue, and need not be described in this place. The fat itself does not seem to be capa- ble of undergoing any proper degenera- tion ; but in some rare instances it may become the seat of accidental develop- ments. In animals especially, it not un- frequently has various entozoa? generated within its substance, and even in the hu- man subject these animals are found in it. In a female, aged twenty years, who died of apoplexy after a difficult labour, Trent- ler found within the left ovaria a hard tumour, about the size of an ordinary nut, composed of cellular and adipose sub- stances, in the midst of which there was a small cavity as large as a pea, in which was discovered a living worm. When taken out and put into water, it was ob- served to move. He has described and figured it under the appellation of Hexa- thyridium Pinguicola; {Obs. anat. path. p. 19.) but it has been since described by Zeder and Rudolphi, under the name of Polystoma Pinguicola. {Rudolph. Ento- zoor. Hist. Nat. II. 455. Amst. 1809.) E. Geddings. ADIPSIA. (From a, priv. and Si^a, thirst.) Absence of thirst. L H. ADJUVANT. (From adjuvare, to aid.) An auxiliary. A medicine added to a phar- maceutic preparation, to aid the action of the principal ingredient or basis. I. H. ADNATA. Epithet formerly applied to the conjunctiva. I. H. ADOLESCENCE. (See Age.) ADULT. (See Age.) ADULTERATION. (From adulter are, to alter or falsify.) The sophistication or alteration of articles, so that they appear of good quality without having the efficacy they should possess. More space would be required than is consistent with our plan to devote to it, to point out all the frauds that are practised in the trade of drugs and pharmacy. The principal adulterations and substitutions, however, will be noticed under the head of each article. I. H. ADVENTITIOUS. Accidental or ac- quired. Said of diseases which are neither constitutional nor hereditary. Also of tissues which result from a morbid action. I. H. ADYNAMIA, ADYNAMIC. (From a, priv. and Swa/itj, strength.) The term adynamia has been employed in various significations. In its general acceptation, and from its etymology, it is perfectly sy- nonymous with Debility, and as this word is the most common, and least likely to be misunderstood, it will be best, in accord- ance with our plan, to treat of the subject under this last head. It is proper here, however, to explain briefly the significa- tions which have been attached to the term Adynamia by the principal nosologists. Vogel has grouped together in one class, upon which he has bestowed the term adynamia, all cases of diminution or aboli- tion of energy in the sensations, in volun- tary motion, and in the natural functions; and he has, moreover, especially given it to one genus of this class, which comprises all cases of extreme debility, in which the patients are incapable of moving in bed, or ofsupportingthemselvesinasittingposture. Cullen, in his nosology, has bestowed the name adynamia upon an order of dis- eases, the characters of which are, " a dim- inution ofthe involuntary motions, whether vital or natural." Thus he differs from Vogel, in not comprising under this head either the diminution or abolition of the sensations, or that of voluntary motion; and, on the contrary, he ranges under it the diminution of involuntary movements. Pinel employed this word to express the excessive muscular debility attendant upon certain fevers commonly termed putrid, and for which epithet he substituted that of adynamic. This innovation was gener- ally adopted in France, and the employ- ment of the term became very common. The school of this distinguished professor, in applying the term to a particular febrile condition, of which it indicated, as they be- lieved, the nature and principal character, made adynamia in fevers an important point of doctrine, and one of the questions which was long the subject of controversy. Finally, in recent times, some physicians have bestowed the epithet adynamia upon that state of stupor and of general and ex- treme debility which accompanies gan- grene of internal organs, and in some cases gangrene of external parts, the action of very deleterious gases, and that of miasma when violent. iEDOIOD.—jESCULUS. 229 " Struck," observes M. Roche, " by the apparent state of adynamia observed in some diseases, and the more so as the state of the science rarely permitted them to ascertain the proximate cause of these affections, and to discover their nature— influenced by the terrors of patients, in whom debility always caused great alarm— and misled by false theories, physicians long regarded muscular weakness, the di- minution of the sensations or of the energy of the functions, in a word, adynamia, as the principal thing in most diseases—as the disease itself. In consequence of this idea, they have sought for therapeutic means, in stimulating, tonic, and irritating substances, to remedy what was almost always a symp- tom only, and hence arose that incendiary treatment of which we happily see nothing but the vestiges in the practice and writings of physicians of the present day. It is not one of the least of the services which M. Broussais has rendered to science, his having demonstrated that adynamia is scarcely ever essential, that in a great ma- jority of cases it is the symptom of an in- ternal inflammation, that its degree is in proportion to the intensity ofthe inflamma- tion and the importance of the organ af- fected, and finally, that the best means of relieving it is to remove by an antiphlogis- tic treatment the phlegmasia? which induce it" {Did. de Med. "et de Chirurg. Prat.) I. Hays. iEDOIODYNIA. (From ouSoia, organs of generation, and oSvvr;, pain.) Pain in the organs of generation. I. H. ^EDOITIS. (From aiSoia, organs of generation.) Inflammation of the external organs of generation. I. H. iEDOPSOPHIA. (From cuSota, organs of generation, and ■botyo;, noise.) The dis- charge of air from the urethra in men, and from the vagina in females. I. II. JEGILOPS, JEgylops, Egilops. cuyiTuo,},. (From ot|» a goat, and u^, an eye.) This epithet was given by the Greeks to an ul- cer seated over the lachrymal sac, but not communicating with it; and which usually resulted from the opening of a small ab- scess of this part. (See Anchilops.) I. II. jEGOPHONY, Egophony. (From ax%, a goat and $uvr, voice.) Voix chevrotante, goat's voice. This epithet has been be- stowed by Laenneo upon the tremulous or subsultory sound produced within the chest by the voice, as heard on the application of the ear to the chest; when the natural resonance of the voice in the bronchial tubes is rendered more distinct by the compression ofthe pulmonary texture, and vol. i. 20 modified by its transmission through a thin layer of fluid, between the lamina of the pleura, in a state of vibration. (See Aus- cultation ofthe voice.) L H. AERAPHOBIA. (From arfi, air, and $)oi3o$, fear.) Dread of the air. This symp- tom is not unfrequently attendant upon hydrophobia, hysteria, and other nervous affections. I. H. jERUGO. (From ats, copper.) The oxide of any metal, but more particularly applied to that of copper. {Aerugo aris.) yESCULUS, Horsechestnut Buckeye. Ropkastanic, Germ.; Ippocastano, Ital. Sex. Syst. Heptandria Monogynia. Nat. Ord. Hippocastanea?. Gen. Ch. Calyx, ventricose. Corol. 4 to 5 petals, unequal, pubescent, inserted into the calyx. Caps. 3-celled. Persoon. This genus is composed of but few spe- cies, most of which are natives of the United States, where they are known un- der the name of Buckeye. Only one of these plants has been used in medicine, though it is probable that they are all en- dowed with similar properties. JE. hippocastanum, Linn. Marronier dlnde, Fr. Sp. Ch. Leaves digitate, leaf- lets 7; flowers in terminal pyramidal spikes. This species, which is common in gar- dens and public walks in Europe, and is not unfrequently cultivated in the United States, is a native of Asia. It was first introduced into Europe in 1615, and the original plant brought to Paris was to be seen a few years since in the garden de Soubise. (Merat et De Lxns-) The parts used in medicine are the bark and the fruit especially the former, which early attract- ed the attention of physicians as a bitter tonic and febrifuge, and for many years no doubt existed as to its possessing these powers in an eminent degree. When, how- ever, the general war in Europe obliged the continental nations to resort to indige- nous substitutes for cinchona and other foreign drugs, a course of experiments was undertaken in France, to ascertain the real value of the horsechestnut bark as a febrifuge, which presented the most con- tradictory results; for, whilst in the hands of some practitioners, it proved most emi- nently successful, others declared that it was wholly inefficacious in the cure of paroxysmal diseases. From a careful com- parison of these contradictory accounts, it would appear that although the bark ofthe horsechestnut is indubitably endowed with the properties of the bitter tonics, and may be useful in some cases, it can by no means 230 AFFECTION—AFFUSION. be considered as a substitute for cinchona. It is the bark of the young branches only that is used; this is to be gathered in the spring, deprived of its epidermis, and dried. In this state, it is in thin pieces, of a reddish brown colour on its external surface, but paler within, of an astringent and slightly bitter taste. The dose in substance is about a drachm. It is also given in decoction, extract, &c. It has been analyzed by several chemists, as Henry, Vauquelin, Planche, &c. ; the latest examination of it, however, is that by Pelletier and Cav- entou, who found that it contained a red- dish astringent substance, a greenish oil, a yellow colouring matter, an acid, gum, &c., but no alkali or fecula. The fruit is bitter and disagreeable, but is eaten by some animals. It contains a large propor- tion of fecula, which, when freed from the bitter principle, is an excellent substitute for arrow-root This fecula also forms a paste of great tenacity, and which has the additional advantage that no insect will attack it, and is hence well suited for book- binders, &c. The fruit, when dried, is also used to make issue peas. Mr. F. Canzo- neri, of Palermo, has given an account of a peculiar principle which he detected in the nuts of the horsechestnut, and terms JEsculine. More recent observa- tions, however, have proved that this sub- stance is only a kind of extract containing sulphate of lime. The American species, which belong to the sub-genus Pavia, are in all probability possessed of nearly the same properties as the JE. hippocastanum. Their fruit is, however, endowed with more activity, as, when fresh, they will intoxicate fish. Bibliography.—Zannichelli. Leltera intor- no allafacolla dell Ippocastano. Venetiis, 1733. Baume. Elimens de Pliarmacie. 9th ed. Paris, 1818. Caillard. Sur I'ecorce de marronier d'Inde. Paris, 1805. Bourses. Reflexions sur Vemploi de I'ecorce tTcesculus hippocastanum. Journ. gen. de Med. xxxv. 34. F. Canzoneri. Sur le marronier d'Inde, &c. Journ. de Pharm. ix. 539. F. A. Michaux. Arbres foresliers de VAme- rique. Paris, 1826. J. R Coxe. The American Dispensatory. 8th ed. Philada. 1831. Merat et De Lens. Did. univer. de Mat. Med. I. Paris, 1829. R. E. Griffith. AFFECTION. (Phys. Path.) The dif- ferent changes or modifications which the mind or body may experience. It is also employed synonymously with disease. (qv.) I.H. AFFECTIVE FACULTIES. The pro- pensities and sentiments are so denomi- nated by Gall and ^pirzheim. (See Faculties.) I. H. AFFERENT. (From affcro, I bring.) The vessels which convey lymph to the lymphatic glands are so termed. I. II. AFFINITY. Proximity, suitableness. conformity of things to one another; re- semblance of objects in form, exterior habitude and structure. Employed in chemistry to express the force which, act- ing upon the particles of matter at insen- sible distances, causes them to unite and combine with each other exclusively, or in preference to any other combination, and which maintains them in union. (See At- traction.) It is also used in physiology, {vital af- finity,) to designate the force which gov- erns the various compositions and decom- positions in living bodies, and which is believed to be often opposed to chemical affinity. It is probably the same force, its results modified by the peculiar apparatus or structures in which the changes are ef- fected, or by the circumstances under which the particles are brought in prox- imity so as to act upon one another. (See Force.) I. H. AFFLUX. (From affluere, to flow to.) A flow or determination of humours to- wards a part. See Fluxion. AFFUSION. Affusio, Lat. (From af- fundere, to pour upon. A therapeutic agent, which consists in pouring a fluid over the whole or a part of the body. River or spring water is usually employed, though salt and sea water are sometimes used. Affusion differs from the other modes of applying water to the surface of the body, less in effect than in form. Thus in what is termed aspersion, the fluid is projected in drops like rain; in immersion, a part, or the whole of the body is entirely plunged into it; in the douche, the fluid is made to strike upon some particular part in a con- tinuous manner, and with a certain force; hi the shower-bath, it falls in a sudden shower upon the head and upper parts of the body, &c. The temperature of the water used being generally from 56° to 66° Fah., affusion may be regarded as almost exclusively a refrigerating process, always implying the use of cold water, unless warm be expressly mentioned. When the application is made in a gen- eral way, the patient is usually seated naked in an empty bathing-tub: if he be too weak to support himself, he should be laid upon a sheet, and held over the tub by assistants. This last plan will likewise AFFUSION. 231 be requisite, when the affusion is to be specially directed upon the abdomen and genital organs. The state of the pulse and heat of the body must be examined and noted, and the quantity and tempera- ture of the water required, properly ad- justed. A few drops may at first be sprin- kled upon the face, after which a continued stream may be poured from a bucket or other wide-mouthed vessel, in the beginning rather gently, and afterwards suddenly, and so directed over the body as not to occasion a painful shock. To effect this last object, it will be best to direct the stream first upon the shoulders and back, as these parts are less sensitive to the impression of cold water than the front of the body. After this, the stream may be directed upon the top of the head, and finally upon the more susceptible parts in front An interval of some seconds is generally interposed be- tween each affusion, as by making them with little or no intermission, they may create too much uneasiness to the patient; and if directed upon the head, interfere with respiration. After a sufficient appli- cation, the extent of which is to be deter- mined by circumstances yet to be ex- plained, the patient is to be well dried with warm towels, wrapped in a warm sheet, and placed in bed. When it is requisite to apply the affu- sion to the head only, a cape of oil-cloth, or other suitable material, may be put around the neck, which, with the superior parts of the trunk, have been previously so en- veloped as to protect them from the im- pression of the cold water. When it is deemed necessary to produce a determina- tion to the inferior parts of the body, the patient may be placed on a stool in the bathing-tub with his feet in warm water, or even immersed to the hips in a tepid bath. The primary effect of affusion is to pro- duce a sudden and general shock, succeeded by a diminution of the heat and sensibility ofthe surface. The skin contracts and loses its colour, the capillaries impelling their contents of blood and lymph to the inte- rior parts. The cutaneous exhalation is suspended, whilst absorption is supposed to be increased and the papilla? are elevated, producing that kind of roughness of the surface popularly termed goose-flesh. The sudden determination of the blood, and other circulating fluids to the interior, doubtless explains the cause of that em- barrassment experienced in the functions of the viscera, more especially of the heart and lungs. Sometimes the pulse is so con- tracted and slow as to be almost imper- ceptible. The respiratory movements are performed with difficulty and irregularity, the inspirations and expirations being short, hurried, panting, and broken, as in sighing or shuddering. With infants these effects, together with the terror and restraint to which they are subjected, sometimes make it necessary to suspend the affusions sooner than would otherwise be desirable. After the affusion, the system gradually recovers from its perturbation, the skin re- laxing, and becoming soft, smooth, and moist, the organic movements resuming their regularity, the warmth returning, the pulse becoming less contracted, and more full. These phenomena vary singularly, according to the number, duration, and in- tensity of the applications, nature of the disease, and constitution and habits of the patient As already observed, the water employed is usually about 56° or 66° of Fah. But this is not a positively established temperature, and may be varied to suit circumstances. It is sometimes necessary to use water of still greater coldness, whilst at others it will be requisite to raise the temperature, if the patient be either too feeble or too susceptible. Under these last mentioned conditions, it may perhaps be advisable to commence the affusions with tepid water, or water with its chilliness taken off. The duration of affusions can only be determined by the effects produced, the intensity of the disease, or the force of re- action with which the patient may be en- dowed. Sometimes eight or ten affusions will suffice, whilst at others twenty or thirty will be found necessary, and it may even be requisite to recur to them again. The intervals between the affusions should be very short, in order to prevent or keep down reaction. From the immediate effects produced by cold affusionsjthey are evidently to be re- garded as a perturbating agent of great energy, requiring much discrimination and sound judgment to regulate its application. Judiciously employed, they will almost al- ways be found to produce a notable dimi- nution of the heat ofthe body, a reduction of the pulse, and what must often be re- garded as a great advantage, these seda- tive effects will not be attended by the debility which follows a recourse to blood- letting. With some feeble constitutions, their use may occasion too much weakness; and should the chilliness continue without any reaction, it will be necessary to dis: pense with them entirely, and resort to means of internal and external excitement. The application of affusions, to be salutary, 232 AFFUSION. should always leave the patient with a sense of greater strength and general com- fort than he had previous to their use. When, on the contrary, their employment is not indicated, the patient will recover his warmth with difficulty, and remain oppressed, restless, and feeble. The writings of Hippocrates, wherein frequent mention is made of cold affusions, show that the Greeks in his day, and per- haps long before, were acquainted with their curative properties. It would appear that they were chiefly employed in the treatment of causus or ardent bilious fe- ver, typhus causodes, tetanus, gout, rheu- matism, cerebral affections, and, in gene- ral, all diseases accompanied with acute pains. The Roman authors scarcely mention affusions; still it is known that they made great use of baths. The Arabian writers are equally silent upon the subject; and through the middle ages they would ap- pear to have been almost lost sight of as a curative resource. In the commencement ofthe eighteenth century, when every species of knowledge began to improve, the curative virtues of affusions were again recognized as appli- cable to several diseases. Kozmpfer, in 1712, witnessed their successful employ- ment for the cure of measles, by the phy- sicians of Java. After this, various writers testified to their excellent effects in the treatment of many acute diseases, both epidemic and contagious. Among these were, Hahn, in 1737—Samoslowitz, in 1777—Wright, in 1780—Valentine, in 1785—Currie, in 1798—Giannini, in 1802—&c.: so that before the close of the century mentio'ned, and beginning of the present they were universally admitted as most valuable therapeutic agents. The late Dr. Currie, of Liverpool, is to be re- garded as the chief English authority upon the subject of affusions, and if not the first to introduce them into practice in his country and elsewhere, is perhaps to be considered as mainly instrumental in making their utdity more extensively known, and pointing out the precise dis- eases and conditions under which they may be employed with most advantage. We shall therefore give a concise account of his practice, which appears to have been founded upon much experience and close observation; referring, for more mi- nute details, to his "Medical Reports," published in 1798 and 1804. The fevers in which affusions were chiefly employed by Dr. Currie, were of the kinds commonly designated low typhus and nervous. The time preferred for ap- plying them was the period of exacerba- tion, one of which at least occurs every day, generally in the afternoon, being in- dicated by increased thirst, restlessness, flushing and internal heat. The height of the fit was considered the best and safest time, when no sense of chilliness was present, and the heat of the surface was steadily above the natural temperature, there being neither general nor profuse perspiration. Dr. Currie appears to have erred by omitting a caution in respect to the complication of other diseases with continued fever; such, for example, as that of pneumonic inflammation, or other dangerous affections ofthe lungs, to which cold affusion must be deemed inadmissible. The usual effect of cold affusions, as employed by Dr. Currie, was to lower the temperature of the body from 2° to 6° Fah., and lessen the pulse from two to twenty beats per minute, and sometimes even more. Where the application of cold affusions has produced effects unusually severe, a cautious use of warm cordial drinks, in small quantities, is recommend- ed ; together with frictions to the extrem- ities, and warm applications, such as a bladder of hot water, to the pit of the stomach. In cases favourable to the prac- tice, the fever was sometimes subdued by one affusion, administered on the first or second day of the disease. Each applica- tion generally removed the symptoms for the time being, and a few repetitions, on successive returns of the paroxysms, in two or three days terminated the disease. " Though I have used," says Dr. Currie, "the cold affusion in some instances so late as the twelfth or fourteenth day of contagious fever, with safety and success, yet it can only be employed at this ad- vanced period in the instances in which the heat keeps up steadily above the natu- ral standard, and the respiration continues free. In such cases, I have seen it ap- pease agitation and restlessness, dissipate delirium, and, as it were, snatch the pa- tient from impending dissolution. But it is in the early stages of fever (let me again repeat), that it is always to be employed, if possible; and where, without any regard to the heat of the patient, it is had re- course to in the last stage of fever, after every other remedy has failed, and the case appears desperate (of which I have heard several instances), can it appear surprising that the issue should sometimes be unfavourable V In the advanced periods of disease, Dr. Currie generally preferred the use of AFFUSION. 233 water only 15° or 20° below the natural heat of the body. After the eighth or ninth day, he often simply sponged the whole body with tepid vinegar, to which he sometimes added water. But where the heat remained considerable, he still persisted in the use of cold affusion. In intermittent fevers, where the pa- tients were vigorous, affusions applied before the period of the cold fit, often suc- ceeded in preventing the paroxysm entire- ly. Where weakness presented an obstacle to this practice, the cold fit was allowed to pass, and the affusion applied during the hot stage, when thoroughly formed; the effect was generally to produce a solution of the paroxysm for the time being, and four or five repetitions finally removed the disease. Dr. Currie was not deterred from the use of cold affusions by the presence of eruptive diseases, or even by ptyalism from mercurials, provided the proper re- strictions were attended to. In small- pox, he employed them successfully, regu- lating their employment by the heat, and other criteria; provided the patient's sensations of heat were confirmed by the thermometer. In the confluent form, he was doubtful of the utility of this applica- tion. A medical friend of his reported to him, that he had employed them advan- tageously in the commencement of scarla- tina, in which disease they arrested the eruption and soreness of the throat. The French physicians have, in gene- ral, opposed the use of cold affusions in eruptive fevers. M. Jolly observes, that instead of their proving useful in scarlatina and measles, he regards the remedy as rarely necessary, little to be relied upon, and even very hazardous, inasmuch as it may subject the patient to dangerous reper- cussion. When, therefore, the eruption is backward, he greatly prefers warm affu- sions, or baths of short duration, the tem- perature of which is gradually increased, or which are rendered more exciting by the addition of some stimulating article, such as flour of mustard, the acetic and hydrochloric acids, &c. He in fact only admits of the application of cold affusion in these diseases, where there is a compli- cation of inflammation of the brain and its meninges, on which occasions they sliould be restricted to the head alone. Although the French practitioners mani- fest more tardiness in the employment of cold affusion as a therapeutic agent than those ofthe other parts of the European con- tinent or those of England or America, still they would appear, according to our view of the subject, to have put forth the 20* most rational explanations of their modus operandi, in regard to which various opin- ions have been maintained. Some, for ex- ample, have thought that their chief effect was to promote a salutary reaction. Others, that they operated upon the nervous sys- tem as a perturbating agent Others, again, regarded them as the most decided contra-stimulants. M. Jolly, most of whose views upon the subject we are inclined to adopt does not consider either of the fore- going opinions as exclusively correct He thinks their operation is, in all respects, assimilated to the refrigerating applica- tions, being like them a means of sedation or repercussion when prolonged, and of stimulation when applied only instantane- ously. All the difference in the effects arises from the fact, that the affusion being extended over a larger surface, produces more decided and intense impressions than the mere local applications of cold. Affusions, like all other cold applica- tions, when employed at the commence- ment of inflammation, will prevent the perception of pain by the brain, and consequently all reaction on the part of this organ, thus arresting in its develop- ment the morbid process which tends to produce inflammation. This is upon the principle that inflammation has its seat in the capillary vessels over which the heart exerts but a feeble action, but upon which the nervous system, on the contrary, ex- ercises the most powerful influence; inso- much that it is considered that inflamma- tion always owes its primary origin or development to the action or agency of the nervous system. From this view it is in- ferred, that to put a stop to the pain and nervous irritation, constituting the primary condition and inseparable element of in- flammation, is to stop this in its birth. Af- fusions may, therefore, according to M. Jolly, be regarded as acting by direct se- dation, as when continued or kept up for a longer period than common. Stopping short of this, their effect is to provoke con- secutive reaction, or general or local ex- citement. M. Jolly thinks that they should never be employed with this intention, but solely for the purpose, and as a means of producing direct sedation. He says, that lie has several times succeeded in arrest- ing, with cold affusions upon the head, the phenomena of pain in neuralgias, burns, and other painful affections, the seats of which were more or less distant from the cerebral centre. This has led him to pro- pose them as a means calculated to relieve those pains felt after amputation, as if in the limb separated. "I am persuaded," 234 AFFUSION. says he, " that every local application of cold, as well as every narcotic agent employed upon a painful part, only ex- ercises a sedative effect through either a direct or indirect influence upon the brain; so that it appears to me a matter of indifference to employ sedatives, refri- gerants, or opiates, either upon the direct centre of sensibility, or upon the seat of pain, wheresoever this may be, if the parts be not denuded so as to afford an absorbing surface to the narcotic medicine." These theoretical views are in conformity to the practice pursued by almost all authors who have treated upon cold affusions, the ap- plication of which they recommend to be made either at the moment of exacerba- tion, or at the first onset of inflammatory disorders: that is to say, according to the reasoning of M. Jolly, " whilst the affec- tion consists merely hi a nervous irrita- tion." Employed later than this, affusions must prove either useless, or more or less hurtful. It must also be observed, that ac- cording to the writer last mentioned, the state of calmness and sedation which usu- ally follows the employment of this reme- dy, may be only transient, in which case it will be necessary to recur to the operation until the force of reaction, that tends to re-establish itself after each instantaneous application of cold is fully overcome. The proper duration of the affusions is, with M. Jolly, the most important consideration in their employment, as exerting the great- est influence over the results to be ob- tained. Local affusions produce effects much less strongly marked, unless when applied to parts endowed with extreme sensibility, such as the abdomen and thorax. But these applications are seldom resorted to in af- fections of the abdominal cavity, and would perhaps prove dangerous in those of the thorax. It is, above all, in affections of the cerebro-spinal system, that affusions, ap- plied to the head and track of the spinal marrow, have been employed with the most striking advantages. We have already referred to the chief diseases in which they were resorted to by the father of medicine, who also re- ports, that by their use, he had facilitated the reduction of strangulated hernias; several modern surgeons attest their utility in such cases, in which their good effects are doubtless occasioned by the contrac- tions they excite in the superficial muscles. Some authors speak of their relieving what are called nervous colics. Hippocrates, in his 5th Book of Epidemics, gives the case of a lady, who laboured under intes- tinal pains of such violence as to endanger her life, and who was promptly relieved by thirty affusions administered over the whole body. Dr. Bird, of Rees, in Sax- ony, testifies to having employed them with success in cases of nervous rheuma- tism, (or as the French writers term them, neuralgies externes.) They were applied at the height of the paroxysm, and M. Jolly adds his testimony to their utility in such cases, observing, however, that al- though the applications are incontestably capable of allaying promptly the pains which characterize the paroxysms of neu- ralgia, they appear little calculated to pre- vent their return. In Russia, it is said, that cold affusions are so commonly* resort- ed to, that nearly all acute diseases are in their commencement treated by them. Cases have been recorded by Wray, Copland, Jackson, Wedekind, and others, in which affusions have been employed with advantage in instances where per- sons had been poisoned by preparations of opium. Their effect, in these cases, was probably to prevent congestion and cere- bral hemorrhage, the same, in fact, upon which their utility rests in obviating the danger from drunkenness, and all deter- minations of blood to the brain. In the cases of puerperal peritonitis, re- ported as having been successfully treated by cold affusions, the trials were chiefly made by English practitioners. It is one of the characteristics of puerperal fever, that patients, labouring under it, seek re- lief from cold substances, both as drinks and external applications, warm ones be- ing insupportable. From analogy, there- fore, cold affusions might be rationally in- ferred to be useful. But experience would seem rather in favour of the application of cold in a more simple form. The use of cold affusions in arresting uterine haemor- rhage, is amply attested by numerous re- ports of successful cases. Cold affusion has been employed with signal success, in the resuscitation of per- sons thrown into a state of asphyxia, by exposure to deleterious gases in wells, pits, mines, &c, in the asphyxia of new-born children, and also in cases of suspended animation from the effects of lightning. Some authors have recommended them in several affections to which their utility is, to say the least, equivocal. Such are the gout, notwithstanding the authority of Hip- pocrates, rheumatism, (Tissot,) croup, (Hardes and Baumbach,) tetanus, &c. Affusions are contra-indicated, as more or less hazardous, in persons of a naturally feeble constitution, and in whom reaction AFTER-PAINS. 235 takes place with difficulty. Also with the plethoric, and such as are predisposed to apoplexy, or some internal congestion. They are also injurious in most chronic affections, in those acute diseases where an internal organ is the seat of inflamma- tion, in aneurismal and even in catarrhal affections. The more particular indications for the use of affusions, in each disease, will be noticed in the articles on those diseases; all that was proposed in the present arti- cle was to point out the mode of employ- ing the remedy, its effects, and to indicate in a general way the principal affections in which it is employed. G. Emerson. Bibliography.—Hippocrates. De liquid usu. Cirillo. Of the use of cold water in fevers, &.c. Philosophical Trans. XXXVI. 142. Lon- don, 1729-30. Wright, (Wm.) Practical observations on the treatment of acute diseases, particularly those of the West Indies. Med. Facts and Obs. VII. Lon- don, 1797. Samoilowitz. Lettres sur les expiriences des frictions glaciates pour la guirison de la peste et autres maladies putrides. Paris, 1781. Wright, (Wm.) Observations on the use of cold affusion in the treatment of Small Pox. Lon- don Med. and Phys. Journ. XIX. 272.—His claims to the original use of cold affusion in ty- phus fever. Same Journal, XX. 81. Jackson, (Robt.) A treatise on the fevers of Jamaica, &c. London, 1791. Currie, (J.) Account of the remarkable effeds of a shipurreck, on the mariners; with experi- ments on the influence of immersion, &c. Philos. Trans, for 1792. LXXXII. 199. Maclean. An inquiry into the nature and causes of the great mortality among the troops in St. Domingo. London, 1797. Currie, (J.) Medical Reports on the effects of water, cold and warm, as a remedy in fever and other diseases, &c. Liverpool, 1798. 4th edit. London, 1805. Marti neau. On the affusion of cold water in fever. London Med. & Phys. Jour. III. 51. (1800.) Reeve, (Henry.) Historical Sketch ofthe use of the affusion of cold uxtler. Same Journal, IV. 397. (1800.) Garnett. On the external use of cold water in fever. Same Journal, V. 12. (1801.) Currie, (James.) On the affusion of cold wa- ter. Same Journal, V. 381. (1801.) Dimsdale, (W. P.) Cases of Typhus, in which the affusion of cold water has been applied, &c. Same Journal, IX. 206. (1803.) Dewar. On the efficacy of the cold affusion in ardent fever. Same Journal, XI. 21. (1804.) Reid. On cold ablution in scarlatina. Same Journal, XI. 27. (1804.) Giannini. De la nature des fievres, et de la meilleure mithode de les trailer; avec quelques cc~ rotlaires sur la nature des convulsions, sur le traitement et Vextinction des fievres contagieuses; sur Vusage des immersions froides, &c Trad. de l'ltalien, par N. Heurteloup. Pari*. 1808. Dalrymple, (W.) Case of Trismus, in which the affusion of cold water was successfully em- ployed. Edinburgh Med. and Surg. Journ. I. 294. (1805.) Jackson, (Robt.) An exposition of the prac- tice ofaffusing cold water as a remedy in fevers; &c. Edinburgh, 1808. Ralston, (Robt.) Case of Mania, wherein the repeated affusion of cold water upon the head, conjoined with topical applications of water, with vinegar and sal ammoniac, were productive of the most salutary effects. New-York Med. Repos. XV. 142. (1812.) Prioleau, (T. G.) On the use of the cold affu- sion in Tetanus and convulsive disorders. Amer. Med. and Philos. Register, III. 8. N. York, 1813. Wray and Copland. On the treatment of poisoning with opium, by cold affusions. London Med. Rep., June, 1822. Wedekind, in Hufeland's Journal, for Feb 1824. An interesting memoir on the use of affu- sions in intermittent fevers. Jackson, (Saml.) Case of poisoning with opi- um, successfully treated by cold affusions. Philad. Journ. Med. and Phys. Sc. VIII. 150. (1824.) Cross, (J. C.) Case of poisoning by opiums successfully treated by cold affusions. Same Journal, VIII. 398. This case was treated by Dr. Richardson, in June, 1821. Uber die dusserliche Anvendung des kalten Wassers in hitzigen Fiebern. Drei Preisschriften der Herren Frbtich, Reuss und Pitschaft. In Hufeland's Journal der practischen Heilkunde. Supplementstiick des Jahrgangs, 1822. Berlin. Jackson, (S.) Cases of nervous irritation, ex- hibiting the efficacy of cold affusions as a remedy. N. A. Med. and Surg. Journ. II. 250. Philad. 1826. Herbst, (E. F. G.) Upon the utility of cold affusion in cases of poisoning by hydrocianii acid. Lond. Med. and Phys. Joum. N. S. VI. 387; from Meckel's Archives, No. 2,1826. Tili.et, (L. S.) Cases illustrative ofthe effects of copious and long continued affusions of cold water, in external inflammations. North Am. Med. and Surg. Journ. V. 58. Philad. 1828. Doucet. Mimoire et Obs. sur le traitement de Telanos traumatique, par les Douches froides. Nouv. Biblioth. Med. I. 339. Paris, 1828. Re- published in Transact. Med. Novem. 1832. Jolly. Art. Affusion. Diet, de Med. et de Chirurg. Prat. Paris, 1829. Guersknt. Art. Affusion, in Diet, de Med. 2d ed. Paris, 1832. For the completion of this Bibliography, see the articles on Cold, Baths, and on the various diseases in which affusions are employed. I. H. AFTER-BIRTH. The placenta and membranes of the ovum are thus denomi- nated. I. H. AFTER-PAINS. After delivery, the alternate contractions of the uterus are re- newed, and are called after-pains—or the pains which succeed to the expulsion of the contents of the uterus. These pains arise, most probably, from the presence of coagula, after the placenta is separated and expelled from the uterine cavity. The surface from which the pla- centa has been separated, has innumerable vessels terminating on it, all of which pour out more or less blood, until the uterus contracts with so much force as to prevent farther bleeding. But, until this is effected, coagula form, and being foreign bodies, provoke anew the contraction of the uterus, 236 AFTER-PAINS. —for, from the exertions this organ has been forced to make, its irritability appears to be increased, and this in most cases to a very considerable degree, and especially in women who have borne several chil- dren. This rule, however, is not constant; as we have seen a number of cases, where after-pains never followed delivery, though the patients have had several, or even many children. In these instances, however, it must be remarked, that the tonic contrac- tion of the uterus was always sure to follow quickly the expulsion of the placenta, and thus prevent the formation of coagula. Women who have very rapid and easy la- bours, are more obnoxious to after-pains than those who have more tedious and painful labours. This is owing to the sud- den state of vacuity in which the uterus is left, which thus impairs the force of the tonic contraction; and consequently in- creases the liability to the formation of coagula. After-pains rarely follow a first labour, owing, doubtless, to the tonic power of the uterus being more perfect, under favourable circumstances, with a first, than with subsequent labours—for, the irrita- bility ofthe uterus appears to be increased by every additional labour; hence the cer- tainty of the occurrence of after-pains', after almost every labour except the first, and their nearly uniform increase in in- tensity after each subsequent labour. It would seem, that whatever stimu- lates the uterus suddenly, without in- creasing its tonic power at the same time, will provoke its painful or alternate con- tractions ; and this is frequently done even by a sympathetic influence, as by the application of the child to the breast for the purpose of sucking, or from passions or emotions of the mind; and hence, we may conclude, that it is the irritability of this or- gan that is exalted, by the previous parturi- ent efforts. For the production, however, of after-pains, it is essential that the tonic power of the uterus be exerted to a cer- tain extent, before the spasmodic or alter- nate contraction can take place; for if the uterus loses its irritability, so far that the tonic contraction cannot take place, we do not find after-pains; but the converse of this does not hold good; for the more perfectly the tonic power exerts itself, the less is the liability to the spasmodic contraction, or after-pains. Therefore, when after-pains exist, the following conditions of the uterus must obtain: First, the tonic con- traction must have taken place to a cer- tain degree; second, the blood thrown out by the vessels exposed by the separation ofthe placenta, must coagulate within the cavity of the uterus, and there act as for- eign bodies, and stimulate this organ to the effort of throwing them off; or, thirdly, its irritability must be so exalted, that irrita- tions in parts remote from the uterus, but with which the uterus sympathizes, may provoke it to painful contraction—in a word, oblige it to continue the parturient effort, after the necessity for such effort has ceased. After-pains recur, for the most part, more slowly, but not much less regularly, than the previous labour pains, and are at- tended by efforts equally strong, and some- times more than equally painful. During this contraction, the uterine globe is found to sink lower in the pelvis; to become much smaller, and harder; and followed by the discharge of fluid blood, or a coagulum of uncertain size. We say, of uncertain size; as this will vary in proportion to the capacity of the uterine cavity, or the state of the os uteri. If the former be pretty large, we shall have coagula form, in an equal proportion; and if the latter be pretty firmly contracted, only the more fluid por- tions of the blood will escape, and the co- agulum remain behind; but if the os uteri be not well contracted, or will easily yield to the efforts of the fundus and body, the coagulum expelled may be large, and fol- lowed by the flow of fluid blood recently poured out It sometimes happens, that the os uteri remains so firmly closed, that the coagula cannot escape; then the wo- man's sufferings are much increased; the fundus of the uterus rises above the um- bilicus, is very sore to the touch, and pre- vents the woman from lying in any other position but on her back; the pulse be- comes excited, and fever and delirium sometimes follow, to the great terror of the inexperienced practitioner. The urine becomes suppressed, and the lochia cease to flow. This case has sometimes been mistaken for puerperal fever. The efficient cause of after-pains has been altogether mistaken by the ignorant; so much so, indeed, as to induce them to withhold ail remedies from the suffering patient. They suppose that there is a definite number of coagula contained within the uterus; which number, they say, must be expelled, before these pains will cease. They therefore deprecate all means calculated to appease these pains ; holding it hurtful not to have these co- agula thrown off: hence, the woman is doomed to long, severe, and unnecessary suffering, because it is said that "after- pains are wholesome." The contrary opinion now fortunately prevails; and means are eagerly sought, to control these unnecessary and painful efforts of the uterus; and the patient and AFTER-PAINS.—AGATHOSMA. 237 the practitioner may felicitate themselves when the remedial means shall succeed. As the principal cause of after-pains is the imperfect tonic contraction ofthe ute- rus, it follows that whatever secures this in the most certain manner, will tend to diminish, if not prevent, the occurrence of this affection. To this end, a proper management of the labour will very much contribute. We would say, that this con- sisted, first—in not officiously interfering with the natural progress of this process, by attempting to dilate the os uteri when rigid; by abstaining from the administra- tion of stimulating food, drinks, or medi- cines, and from the unnecessary exhibition of ergot, or of laudanum. Secondly— by rupturing the membranes when the os uteri is fully dilated, or easily dilatable. Thirdly—by permitting nature to finish the delivery of the body of the child after its head is in the world. Fourthly—by in- stituting frictions upon the abdomen, over the region of the uterus, before any at- tempt is made to deliver the placenta. Fifthly—by not using force to relieve the uterus of the after-birth. Sixthly—by again recurring to frictions upon the abdomen, after the discharge of the placenta. If this plan be followed, the tonic contraction will be much increased in power; and, in the same degree, will the severity of after-pains be abated, though not always overcome. Therefore, should they occur under the ordinary form of mere uterine contrac- tion, camphor or opium, or both, should be resorted to, as soon as they appear. Cam- phor is equally, if not even more certain, to overcome the morbid irritability of the uterus, than opium. It should be given in powder, or in the form of julep, in ten- grain doses, repeated every half hour, hour, or two hours, as necessity may re- quire. If in powder, the following mode of exhibition answers perfectly well. R. Camphor. 9ij.; Alcohol, gutt. x.; f. pulv. div. in Chart, iv. These powders are to be mixed in syrup or mucilage of any kind, and given as just suggested. If the form of julep be preferred, the following is a neat one. R. Camphor. 3ij.; Alcohol. q. s. f pulv. adde; Pulv. G. Arab. 3ij.; Sacch. alb. q. s.; Aqua? pura?. gvj.—M. Of this, a table-spoonful may be given every half hour, hour, or two hours, as the necessity may demand. To opium, there is sometimes a consti- tutional opposition. When this idiosyn- crasy prevails, it is unfortunate, but it is not always insurmountable; for the peculi- arity is rather against the drug in its com- mon form, than against its proximate prin- ciple. The sulphate of morphia, for in- stance, in quarter-grain doses, in solution; or the denarcotized laudanum, in forty- drop doses, may be given advantageously, when the other forms cannot be tolerated. Opium, however, is sometimes ineligible in any form, owing to the febrile condition of the system. Camphor, then, merits the preference, when the woman's suffer- ings demand relief. It is occasionally necessary to premise blood-letting; but this is very rare. Should coagula be retained, as above noted, no dose of camphor or opium will abate the suffering, until they be ex- pelled. Their expulsion must be solicited by frictions over the region of the uterus, or by the application of moist warmth to the abdomen. Avery thick pancake of fried flour and water, between the folds of a nap- kin, applied to the abdomen, is almost sure to cause the expulsion of these coagula. After they are forced off, if pain continue, it should be treated as above suggested. There is a form of pain, which we can scarcely look upon as a modification of after-pain, that I have never seen noticed by authors. It is a severe and continuous pain at the extremity of the sacrum and coccyx. It begins the instant the child is expelled, and continues to an indefinite period, with excruciating severity. It is to be overcome by the remedies above suggested, properly persevered in. After-pains are not always seated in the uterus. We once knew them located in the knee; and once, in the jaw. They yielded to the above treatment. Many other remedies have been pro- posed for the relief of after-pains; as, the oil of juniper, sweet oil, and the hydroci- anic acid ; but the latter article has alto- gether failed, in our hands. W. P. Dewees AGALACTIA. (From o, priv. and yc&a, milk.) Absence or suppression of the secretion of milk. (See Sucklmg.) AGARIC. (See Boletus.) AGATHOSMA. {Botcmy.) Sex. Syst. Pentandria Monogynia.— Nat. Ord. Diosmea?. Gen. Ch." Calyx five-parted. Petals ten, unequal, inserted in the calyx. Nectary five-lobed, inserted in the calyx." Lindley. This genus was separated by Willde- now from the Diosma. It includes sev- eral species, which, as well as those of Diosma, are natives of the Cape of Good Hope. The plants belonging to both genera are small shrubs or un- der-shrubs, and are remarkable for the odorous properties of their leaves, which are employed by the Hottentots to scent the grease with which they rub their 23S AGAVE.—AGES. bodies. The generic titles are expressive of the agreeable odour of the plants; both being derived from the Greek word oaprt, smell, to which is prefixed, in one instance, the epithet oyoflo?, good, and in the other, dwy, divine. The odour, however, is either not equally agreeable in all the species, or produces different impressions upon the organs of different individuals; for Thun- berg found it insupportably offensive in the bodies of the men whom he employed to drive his wagon. It depends on a vola- tile oil, contained in numerous minute transparent glands with which the leaves are furnished. It is probable that the sev- eral species of the two genera are some- what analogous in medicinal properties; but it is the Agathosma crenatum which has attracted most attention, and which has been adopted as officinal, by the Dub- lin College, under the name of Diosma crenata, or Buchu. The latter name was derived from the language of the Hotten- tots, who apply it indiscriminately to the dif- ferent species which they use as perfumes. A. crenatum, Willd., Hort. Berol.— Diosma crenata, Thunberg; Ph. Dub.— Buchu.—Gekerbter Buccostrauch, Germ. —Sp. Ch. "Leaves ovate, crenate, dot- ted beneath. Flowers axillary, solitary." Lindley.—This is an evergreen shrub, with a stem from one to four or five feet high, the branches of which are scattered, or in whorls, and bears upon short petioles, ovate or lanceolate, crenate, coriaceous leaves, dotted on their under surface. The flowers are white, and stand singly at the axils of the leaves. The fruit is a stellate capsule, containing black shining seeds. The leaves are the part used in medicine. (See Buchu.) Geo. B. Wood. AGAVE. {Botany, and Mat. Med.) Sex. Syst. Hexandria monogynia. Nat. Ord. Bromeliacea?. Gen. Ch. " Corolla superior, six-parted, erect. Filaments longer than the corolla. Anthers versatile." Elliot. This genus of plants, which is peculiar to America, is closely allied to, and has been often confounded with, Aloe. Sev- eral of the species are employed in medi- cine and in the arts, though it is difficult to assign to each their peculiar properties, as many distinct species were confounded, by the earlier writers, under the common name of A. Americana. Thus, the A. Mexicana, which was separated by La- marck, appears to be identical, as respects \ I its physical qualities, with the original"^ AGES. Hx««., Gr.; JElas, Lat.; Age, species; whilst the Cubensis furnishes Fr.; Alter, Lebensalter, Germ.; Eta, Ital. roots which possess some of the medical {Phys.) The term Ages is applied, in virtues of Sarsaparilla. physiology, to the several stages through A. Americana. American aloe. Agave d'Amerique, Fr.; Maguey, Span. Sp. Ch. Stemless. Leaves dentate, prickly. Scape branching. Corolla narrower about the middle. Stamina exserted. Style longer than the stamens.— Willdenow. This plant is a native of many parts of South America, and is employed for a va- riety of purposes. From the juice, which is furnished in large quantities, at certain seasons of the year, by the leaves, is pre- pared a honey; but this juice is generally permitted to ferment, when it forms a vinous liquor, known under the name of Pulque. From the leaves, which are very fibrous, is made an excellent thread, which was in use among the Mexicans before the arrival of Cortez. Acosta terms this plant Auve de las maravillas, from the number of uses to which it is applied in the arts. As a medicinal agent, the Agave appears to have been too much neglected, if full credit is to be given to its eulogists. There, however, can be no doubt but that a de- coction of its root has proved fully equal to Guaiacum, in the cure of syphilis, and more particularly those cases aggravated by the exhibition of mercurials. It has also been eminently successful in the treatment of scrofula. The fresh juice is also used as an external application to ulcers. The A. Mexicana, Lam., is used for all the above purposes, in Mexico. Bibliography.—Hernandez. Historia Na- tural de Mexico. Roma, 1651. I. Quer. Flora Espanola. Madrid, 1762. F. X. Balmis. Demostracion de las eficaces virtudes. &c. en las raices de dos plantas de Nue- va-Espaua, Arc. Madrid, 1794. N. Guibourt. Hisloire abregie des drogues simples. Paris, 1826. Merat et De Lens. Did. universel de Mat. Mid. I. Paris, 1829. R. E. Griffith. AGENESIA. (From a, priv. and ywtaif, generation.) This epithet, in its most or- dinary acceptation, is synonymous with impotence and sterility, {q. v.) It has also been employed in modern times, to desig- nate the vices of conformation, consisting in the absence of certain parts and result- ing from an arrest of development (See Monstrosity.) I. H. AGENT. (From agere, to act) That which has the power of acting or of pro- ducing effects. This term is exceedingly general in its signification. There are va- rious species of agents; as hygienic, mor- bific, therapeutic, &c. I. H. AGES. 239 which the human body passes during its progressive development and subsequent decay, from the period of birth to that of its final dissolution. The facts connected with the formation and growth of the various organs of the human body in utero, belong to the his- tory of intra-uterine life, and will be con- sidered in the article Foztus. Of the various and important mutations which the living organism undergoes be- tween birth and death, every one is aware. By the poet, they have been compared to the successive seasons of the year, and hence the expressions spring-time and summer, and autumn and winter of exist- ence, have become to be among the most familiar in our language. Upon the physiologist devolves the task of tracing the changes in the condition of the different organs, by which the several ages of life are produced, and of establish- ing, in relation to each, important general facts for the guidance of the pathologist, the therapeutist, and the medical jurist. At the moment when the human being emerges from the womb, and enters upon the enjoyment of a separate state of exist- ence, it presents physiological as well as physical characters, which it preserves during a certain period, altogether distinct from those which are proper to it in the subsequent periods of life. All of the organs are imperfectly developed, while many of them are as yet merely rudi- mental, and the whole of the functions of life are confined almost exclusively to those of nutrition. By degrees, however, the different parts of the system become more perfectly organized—the body in- creases in size, and exhibits an augmenta- tion of strength and vigour, until finally all the organs acquire that complete de- velopment which capacitates them for the active performance of their respective functions. As the organism thus gradu- ally approaches towards maturity, impor- tant modifications are presented in its physical characters, as well as in its vital phenomena. The characteristics of in- fancy are exchanged for those of child- hood ; these are succeeded in due time by those of youth, and finally the whole sys- tem having acquired its entire growth and vigour, and all its functions being brought into full activity, it assumes the character- istics of the adult age. To all appearance, it now remains for a longer or snorter pe- riod entirely stationary. But soon symp- toms of decay present themselves—organ after organ loses a portion of its energy— its functions are performed less perfectly, and finally cease entirely. The decrepi- tude of old age creeps on more or less quickly, and the strength and vigour which characterized previously all the phenomena of life, give place to constantly increasing debility and languor. At length some or- gan, essential to life, ceases to act, and vitality becomes quickly extinguished in every part We perceive, therefore, that the distinc- tion ofthe whole period of human existence into various stages has a real existence, be- ing founded upon those laws by which the growth and decline of the organism are governed. Each of the principal organs of the system becoming in its turn devel- oped, and its functions added, as it were, to those already in existence, as it arrives with more or less rapidity towards its maximum of vitality, must necessarily modify the organism, as well by increas- ing the number and extent of the vital phenomena, as by its enjoying, for a sea- son, a predominance of activity. An equally striking, but different kind of modification is produced, as each organ, after arriving at maturity, loses by degrees its excita- bility, until it can no longer respond to its appropriate stimuli, and its functions cease. The several stages of growth, maturity, and decline, differ very considerably in their duration. The development of the organism is at first accomplished with great rapidity, but it becomes gradually more and more slow until the age of maturity is attained; while, on the contrary, the decline of the organism is at first very gradual, but increases in rapidity as the period of dissolution approaches. It is, therefore, during the middle term of ex- istence, that the system undergoes the least change: it even appears then to the care- less observer to remain entirely stationary. This, however, is not the case. There is, in fact, no interval—no period of repose in the living body, between the point at which the several organs cease to grow, and that where their decline commences. The moment they have arrived at their full development, is that when their decay commences. Hence, however striking the difference between the physical and vital phenomena peculiar to the period of infancy, and those of youth, maturity, or old age, there is a very great difficulty in defining accurately the limits by which the contiguous ages are separated from each other. To deter- mine, for example, at what precise period infancy ceases, and childhood commences; what line of separation exists between the latter and the age of adolescence, or be- 240 AGES. tween this and adult life—or when it is that man loses the distinctive character- istics of virility, and assumes those of old age. Each stage glides so gradually and imperceptibly into that which succeeds, as to cause not unfrequently a blending of the phenomena peculiar to both. The number of years that have elapsed since birth, affords no certain indication of the physiological age. Climate, moral and physical education, diet, regimen, and va- rious other circumstances, produce so pow- erful an influence either in retarding or accelerating the development of the organ- ism, that the same physiological age will occur in one individual five, six, or seven years sooner or later than in another. Thus the age of puberty, especially in fe- males, is attained in tropical climates at a period of life at which, in colder regions, the individual is still scarcely emerged from infancy. In fact, all those circum- stances which influence the duration of existence, either in extending or diminish- ing it, exert a similar influence upon the duration of each of the physiological ages, and the rapidity of their succession. Thus, in warm climates, the stage of infancy is extremely short^ that of puberty is early attained; the period of maturity arrives, and passes with equal rapidity, and the decrepitude of extreme old age is experi- enced, when, in colder climates, the sys- tem is still in the enjoyment of all its vigour. A luxurious life, heating aliments and drinks, an early excitement of the sex- ual appetite, and the excesses of all kinds, to which certain individuals deliver them- selves without restraint, produce a similar effect in accelerating all the stages of life, and shortening the entire duration of exist- ence. On the other hand, in temperate climates, and by a life of temperance and of activity, the several stages of life linger long, and succeed to each other by slow and imperceptible gradations, and the ap- proach of old age and of death is retarded to a very late period. Bebe, the celebrated dwarf of the king of Poland, ran through all the stages of existence, and died in his twenty-third year, with all the marks of extreme old age; while, on the contrary, in Henry Jenkins, of Yorkshire, and Thomas Parr, of Shropshire, England, the period of old age did not arrive until they had lived, in the one instance, an hundred and fifty, and in the other, an hundred and forty years. Various attempts have been made to distinguish the ages by certain physiolo- gical characters. Thus, by some writers, life has been divided into the stages, first, of growth; second, of stability; and third, of decay; and by others, into the stage during which the organs of generation are inactive; that in which they are active; and finally, that in which they have ceased to act. Both of these divisions are, how- ever, too general and incomplete to serve as a useful classification of the phenomena of growth at the different epochs of exist- ence. The ages have likewise been di- vided by physiologists, with greater accu- racy, into those of lactation, terminating with the eighth month, being the period during which the child is confined solely to the breast; 2dly, that of dentition, end- ing with the seventh year, being the pe- riod which elapses between the commence- ment of the first and that of the second dentition; 3dly, that of childhood, ending with the fourteenth year, or commence- ment of puberty ; 4th, that of puberty, ending with the twenty-first year, or the completion of the growth of the body; 5th, that of youth, ending with the thir- tieth year; 6th, that of maturity, ending with the fiftieth year; 7th, that of decline, ending with the sixtieth year; and 8th, that of old age, comprehending the re- maining portion of existence. It will be perceived, however, that while important physiological changes distinguish, with tolerable accuracy, the first series of ages here enumerated, the division ofthe latter series is in a great measure arbitrary, and will differ in almost every individual. We prefer, therefore, to adopt the usual dis- tinction of the ages into those of infancy, childhood, youth, maturity, and old age. A more accurate division might probably be suggested; the foregoing recommends itself, however, by its simplicity, and by its corresponding with that most generally followed by modern physiologists, while it corresponds with the most striking changes that occur in the organism during the pro- gress of life. The study of the several ages is not only interesting as a branch of general physiology; it is highly important, also, to the physician in a pathological point of view. The condition ofthe various organs in the different stages of their develop- ment ; the predominant activity of one or other at certain periods; the state of each during maturity, and the gradual decrease in their energies subsequently, modifies in a very great degree, the character and march of the diseases which occur at the several stages of life. Thus the great size and vascularity of the brain, during in- fancy, the extreme delicacy and excita- bility of the skin and mucous membranes, AGES. 241 and the great development of the lym- phatic system, render these parts more frequently than any others the seats of dis- ease. Their susceptibility to morbid im- pressions is increased, during childhood, by the process of dentition, and the increased activity ofthe digestive and nutritive func- tions. During both ages, the morbid actions, whichoccur, very generally assume the sub- acute form, and in many cases produce ex- tensive disorganization, before any very vio- lent or alarming symptoms are manifested. In youth, diseases assume a more intense and acute character. While the alimentary canal and brain are equally liable to be their seat, the skin and lymphatic system are more seldom affected than in infancy and childhood. During the age of adoles- cence, the sanguineous system of red blood predominates, giving rise readily to acute hemorrhages, and violent inflammations of those organs in which the red capilla- ries abound. During the period of matu- rity, the entire organism having arrived at its greatest degree of perfection, and the action of each part being in harmony with that of the rest, a greater resistance is presented to the influence of morbific causes than at any other period of life; hence the diseases of this age are, generally speak- ing, fewer and more simple in their char- acter, unless, as is more commonly the case, from irregularities in the nutritive functions, during the preceding ages, or from undue and long-continued excitement of particular parts, one or more organs have acquired a morbid development and predominant activity, in which case they will readily become the seat of disease. As the period of old age creeps on, the balance between the energy of the several organs being, to a greater or less extent, broken up, and the vitality of each being dimin- ished, morbid action is of more ready oc- currence than in middle life; it is in gen- eral, however, of a less violent and acute character than in youth or mature age. In the decline of life, the sanguineous system of black blood predominates; venous con- gestions, chronic hemorrhages, and effu- sions of serum into the several cavities, are among the more common of the dis- eases incident to old age. Not less important is the study of the ages in a therapeutical point of view. During the early periods of life, all vio- lent remedies should be carefully avoided; in a large number of the diseases of in- fancy and childhood, the most simple means will be found the safest and most effectual. Abstinence, bland diluents, bathing, gene- ral or local, the application of leeches and vol. i. 21 mild revulsants, are the remedies that will most generally be sufficient for the remo- val of the diseases which then occur. As, however, the organism becomes developed, and its vital energies increase, its dis- eases assume a greater degree of intensity, and demand a more active treatment for their removal. While, during the decline of life, at the same time that the remedies are adapted in power to the violence of the morbid action, care should be observed to spare, as much as possible, the enfee- bled energies of the system; recollecting, that at this period of life, all violent im- pressions are sustained with difficulty, re- action taking place but feebly and imper- fectly, and the recuperative powers of the system being much less active than at any former age. A knowledge of the condition of the several organs during the different stages of existence, is finally indispensable to the medical jurist, to assist him in determin- ing many nice and important points in cases of presumed infanticide, in questions of identity, and in certain cases of mur- der, &c. $ I. Infancy. Infantia d non fando, Ijat; because of the inability to talk; vrxiotris, Gr.; Enfance, Fr.; Kindheit, Germ.; Infanzia, Ital. The age of infancy extends, agreeably to the division we have adopted, from birth to the commencement of the second dentition, or, generally speak- ing, until about the seventh year. Accord- ing to M. Halle, this period of life in- cludes three distinct physiological epochs. The first extending from birth to the com- mencement of the first dentition; the second, comprehending the period occupied in the process of dentition; and the third, extending to the appearance of the per- manent teeth. a. Organization. At birth, the entire organism is but imperfectly developed. The body measures from seventeen to twenty-one inches in length, and in weight varies, agreeably to the repeated observa- tions of Professor Chaussier, from six to nine pounds. The skin is of an extreme delicacy, and of a deep red colour. It is, also, more vascular, and more freely sup- plied with nerves than in after-life. After a few weeks, however, it loses its deep red tint, changing by degrees to a dirty yel- low, and finally assuming a degree of whiteness which it seldom retains in after- life. But during the whole period of in- fancy, it exhibits great irritability, and is very liberally supplied with blood. The head and abdomen of the young infant are of a bulk disproportionately large, com- 242 AGES. pared with that of the rest of the body. The pelvis is small and contracted, and the inferior limbs have a much less degree of development than the superior; seve- ral months, indeed, elapse, before, the lat- ter acquire a size proportionate to that of the other parts. The muscles are at first soft, pale, and gelatinous; they contain but a small amount of fibrine, and, in com- mon with all the soft parts, are destitute of firmness. All the tissues abound in lymph, and the lymphatic vessels and glands have a development and activity far superior to what they possess in after- life. The limbs of the infant are round, smooth, and plump, as well as all the prominent parts on the exterior of the body. This arises from the large amount of fat, and soft cellular tissue filled with serum, which is interposed between the skin and muscles. As infancy advances, the fat diminishes, and the cellular tissue becomes more dense, while the exhalation into its cells is lessened; the outlines of the muscles are, in consequence, rendered more apparent, and the form of the limbs and trunk, especially in males, is some- what changed. In the early period of in- fancy, the bones are still in a great mea- sure oartilaginous; the central cavity of the long bones can scarcely be said to ex- ist, and the sinuses in those of the head are not at all, or but imperfectly, developed. The digestive canal is of very conside- rable size: the liver has a bulk greatly disproportionate to the residue of the ab- dominal organs, but the gall bladder is small, and the portal veins and the spleen are but little developed. The omentum is peculiarly delicate, and almost entirely de- void of fat The pancreas and kidneys are large, while the urinary bladder is small, having a more elongated shape than in the adult, and is placed rather above, instead of within the pelvis. The size ofthe renal capsules is much greater than in after-life. The lungs, which in the fastus were small, dense, and of a brownish colour, expand immediately after birth to double their former bulk, and become soft, crepi- tant, and of a rosy hue. Though of less specific gravity than in the fcetal state, in consequence of the air which pervades their cells, yet their absolute weight, from the greater amount of blood transmitted to them, is doubled. The ventricles of the heart, and the principal arterial trunks, are of considerable size, while the auri- cles, and large venous trunks, have a much less development The organs of the external senses, with the exception of that of smelling, are fully formed in the infant, and the nerves dis- tributed to them are large. The nose is small, and the nasal fossa; are either want- ing, or imperfectly developed. The larynx is very small, both in depth and diameter, and presents no protuberance at the ante- rior part of the neck. The thymus gland, which, in after-life, almost entirely disap- pears, is now of considerable size. During infancy, the brain is large in size, but of a soft and almost fluid con- sistency ; the same is also true of the spi- nal marrow, and of the cerebral and gan- glionic nerves. The genital organs of both sexes, though fully formed in the infant, are but little developed; the clitoris and nympha? of the female are often, however, disproportionately large in comparison with the other parts. Until the termination of the first period of infancy, the general organization and appearance of the body undergo but little change. The infant, however, gradually increases in size and weight. The head, though still voluminous, diminishes in the relative size it bears to the rest of the body; while the pelvis expands, and the in- ferior extremities become longer, and more fully developed. The softness of the tis- sues diminishes gradually, and they ac- quire a greater degree of density. The fat and serosity become reduced in quan- tity, and although the temperament is still decidedly lymphatic, the predominance of the white fluids over the blood diminishes, as the termination of infancy approaches. The bones lose, by degrees, their cartila- ginous form, by the constant increase of ossification. The central cavities of the long bones, and the sinuses and other cav- ities of those of the face and head, become more fully developed. The articulations acquire greater firmness, and those of the extremities augment in bulk. The jaws become more expanded; and about the sixth or seventh month, the first teeth make their appearance, and by the end of the second year, when the first dentition is completed, each jaw contains ten. These teeth, which have received the popular denomination of milk-teeth, are retained until about the seventh year, when the second dentition commences, and the per- manent teeth successively make their ap- pearance, to the number of twenty-eight. As the termination of infancy approaches, the larynx augments in size; the muscles lose, by degrees, their gelatinous charac- ter, become more fibrinous, and acquire more and more of the deep red colour which distinguishes them in after-life. During the entire period of infancy, the AGES. 243 digestive and nutritive organs maintain their predominance. The lungs gradually develop themselves, but still preserve their great vascularity, the smallness of their cells, and a degree of density superior to that which they acquire in the subsequent ages. The heart and blood-vessels under- go but little change until towards the ter- mination of infancy. The disproportion in the size of the liver, especially of its middle lobe, decreases gradually. The gall-bladder augments in capacity, and the urinary bladder assumes more of an ovoid form, and sinks lower into the pelvis. The organs of hearing, of sight, and of taste, undergo but little change during this age. The cavities of the nose, as well as of the mouth, however, become more de- veloped, and the sense of smelling, and probably that of taste, more acute and dis- criminating. The disproportionate size of the brain diminishes; it increases in consistency, its convolutions become more apparent, its colour less red, and the proportion of its medullary matter is increased. The same is true of the medulla spinalis, and of the nerves. The organs of generation under- go but little, if any change, until towards the age of puberty. &. Functions. Immediately after birth, the function of respiration commences. The lungs and chest dilate, and the exter- nal air rushes into, and distends the pul- monary cells; while the closure of the com- munication which in the fa?tus exists be- tween the two auricles of the heart; the obliteration of the umbilical vessels, and of the arterial and venous canals, cause the whole of the blood received by the right side of the heart, to pass through the lungs, and there to become arteriaiized by its contact with the atmospheric air. From this period, the arterial and venous blood circulate, each in its distinct set of vessels. Respiration, once established, continues without interruption, as in the adult; it is however more frequent, and is accomplish- ed almost entirely by the action of the intercostal muscles. Examined by the stethoscope, it is found to be louder, also, than in after-life, as though the bronchial ramifications experienced a greater degree of dilatation, and received a proportionately greater amount of air. The circulation, which is accomplished in the same man- ner as in the adult, is much quicker and more rapid. The pulse of the infant is in consequence more quick and frequent, beat- ing one hundred strokes and upwards in a minute. It gradually, however, decreases in frequency with the approach of child- hood. Soon after birth digestion commences, and during the entire period of infancy is peculiarly active, demanding an almost constant supply of the food furnished by nature in the breast-milk of the mother. This food, which is the only kind adapted to the peculiar condition of the digestive organs in the earlier months of existence, increasing in consistency as the energies of the stomach become more developed, is fully adequate for the support of the sys- tem, until the commencement of the first dentition, when a more substantial aliment would seem to be required. The appear- ance of the teeth, the augmented size of the salivary glands, and the increased bulk and strength of the muscles subservient to mastication, enable the infant, after the first year, to partake of solid food, which the stomach then digests with facility. The whole of the functions concerned in the nutrition of the system, are equally active with those of digestion. The process of assimilation predominates considerably over that of decomposition, as is evinced by the constant growth of the body, and the rapid development of certain organs. The discharges from the bowels are fre- quent, and passed almost involuntarily. In the earlier periods of infancy, they differ from those in after-life, by their lighter colour, their curdy appearance, and by the absence of any decided fetor. After the first year, they become less frequent, darker coloured, and exhale a stronger odour. They are then, also, more under the com- mand of the will. The urinary secretion is in full activity at birth, but the urine is at first pale and watery, and scarcely con- tains any of those peculiar principles which distinguish it in after-life. The benzoic acid exists in a larger amount, generally, in the urine of infants, than in that of adults. The exhalant function of the skin is extremely active during this age, and from this circumstance, and the great ex- citability of the dermoid tissue, it is readily augmented by a slight stimulation, and as readily checked by a trifling diminution of temperature. Calorification is at first feeble, the heat of the body in young in- fants being, according to the investigations of Edwards, several degrees less than in the subsequent periods of life. For seve- ral months after birth, the infant suffers severely from the influence of a cold at- mosphere, and the proper temperature of its surface can be maintained only by suf- ficient clothing, and other artificial means. By degrees, however, the process of calori- 244 AGES. fication acquires a greater degree of en- ergy, and the body becomes less sensible to the influence of atmospherical vicissi- tudes. The functions of relation commence at birth, and are rapidly developed during in- fancy, but do not attain their utmost per- fection until a subsequent age. The mo- ment the infant emerges from the womb, it commences to cry, and to move its body and its limbs in different directions. If the breast be now presented to it, it will seize upon the nipple and instinctively perform the complicated movements of the mouth, lips, and tongue, required in the act of sucking. It is difficult to decide upon the actual cause which prompts the first cries of the infant, and the agitation into which its limbs are thrown. They would appear, however, to be occasioned by the uneasy sensations to which the sudden entrance upon a new state of existence gives rise. During the first weeks of life, the ex- ternal senses are but slightly developed; the infant is nevertheless sensible to the impression of cold, and experiences pain when the skin is irritated or wounded: very soon, however, the existence of the sense of touch is manifested. The sense of taste is, also, exercised very early; that of smell, however, is but imperfectly devel- oped until a later period, in consequence of the incomplete state of the nasal cavities, and the limited extent of the Schneiderian membrane. It is not until about the fifth or sixth week that any indication is pre- sented of the exercise of sight or hearing; but subsequently to this period they speed- ily acquire their full development. Hun- ger, thirst, and the instinctive desire for the constant admission of fresh air into the lungs, are among the internal sensations which are first experienced: they have, during infancy, the same general charac- ters which they exhibit in after life. Those sensations which prompt to the exercise of the voluntary muscles, and probably those connected with the evacuation of the contents of the bowels and bladder, are experienced at a very early period. As infancy advances, the first of these sensations are more intense, perhaps, than in the after stages of existence. So soon, indeed, as the muscles become sufficiently developed, and the locomotive organs gen- erally have acquired adequate strength and vigour, the infant, during its waking hours, is in almost constant motion; while in health, a state of inaction, for a single instant, would appear indeed to be to it one of actual suffering. At birth, and for several months subse- quently, the imperfect ossification of the bones, the disproportionate size of the head, the smallness and obliquity ofthe pelvis, the laxity ofthe articulations, and the imperfect development of the muscles, render the erect posture and progression impossible. By degrees, however, the inferior extrem- ities acquire an augmented size, the bones become more solid, the articulations firmer, the spinal column better adapted to sustain the weight of the body; while, at the same time, the muscles increase in bulk and in strength. The infant is now ena- bled to sit upright and to creep about on all fours, and by the end of the first year assumes the erect posture and is able to walk. From this period, all the move- ments of the body become daily more firm, prompt, and active; and from the very great suppleness of the entire frame, the child pursues with ease and delight all those muscular exercises which require facility and quickness of motion rather than strength or skill. During the first weeks of existence, the intellectual and moral faculties are en- tirely wanting. The whole external world appears, in a certain sense, to be, as it were, shut out from the infant. Uncon- scious of existence, it awakes merely to satisfy the instinctive calls for food, and when these are appeased, falls again into a state of repose. A state of sleep would seem, indeed, to be that which is the most natural to it at this period. The little be- ing is only wakeful and restless when suf- fering from pain, hunger, thirst, or other uneasy sensations. But, by degrees, as the brain becomes more perfectly organized, and sensibility is rendered more acute and discriminating, the infant exhibits greater intelligence ; its eye takes cognizance of the objects by which it is surrounded, and distinguishes them from each other; its ear also becomes sensible to sounds. It commences now to know its parents or its nurse, and to distinguish them from the other individuals of the family, and from strangers. It manifests desires and will; it experiences affection, aversion, anger, joy, and grief; it becomes capable of laughter and of genuine tears: about the end of the first year, sometimes sooner, it attempts the pronunciation of words, and very soon the infant is possessed of speech. Its pronunciation is at first very defective, and from the imperfect state of many of the organs of speech, the tones of the in- fantile voice are weak, shrill, and deficient in modulation; nor do they attain to their full perfection until some time after pu- berty. AGES. 245 At the end of the first year, less time is passed in sleep. Nevertheless, the con- stant exercise to which the waiting hours are devoted, renders it still longer than in the subsequent ages; while the repose is much more perfect and profound. At this period, the intervals of sleep are very ir- regular : whenever the senses or the mus- cles become fatigued, slumber immediately ensues; but as the age of infancy ad- vances, and the period of wakefulness is prolonged, sleep occurs only at regular pe- riods, and most generally during the night From the end of the first year to the termination of infancy, the development of the intellectual faculties proceeds regularly. The senses rapidly acquire their utmost degree of activity, and the perceptions become prompt and rapid. The memory has at this period a very great activity and extent—enabling the infant not only to treasure up the ideas excited by the physical and other proper- ties of the thousand objects which sur- round him, but the words also, or the names which have been affixed to them, as well as those by which the various sen- sations and wants which he himself expe- riences, are expressed. A knowledge of the prominent qualities of external objects, and of language, is, in fact, acquired al- most exclusively during infancy and child- hood. While the faculties of observation and retention are thus active, those of comparison, reflection, judgment, and of reasoning, are in a great measure absent. It is by instinct, or from present sensations only, that an infant appears to judge and to reason: hence the numerous errors into which he constantly falls, and the necessity of giving, by a proper education, a correct and useful direction to his ideas. From the want of reflection, judgment, and experience, the infant is credulous, docile, and ingenuous—he is pleased with trifles, and lives, as it were, for the present moment only. All the affective faculties, if we except those connected with the reproductive in- stinct manifest themselves in a striking manner during the latter periods of in- fancy, and give rise to their appropriate expressions and gestures. Thus the young being exhibits the feelings of attach- ment and aversion, of anger, vanity, jea- lousy, pride, and shame ; and the frequent and unrestrained indulgence of one or other of these passions, unless a judicious moral culture is early commenced, causes it to obtain a predominance which will materially affect the character and happi- ness of the individual in after life. 21 * c. Pathology. The delicacy of the skin during the earlier stages of infancy, its extreme irritability, and very great vascu- larity, render its several tissues peculiarly liable to disease of various grades, from the simplest rash to the most violent in- flammation terminating rapidly in exten- sive disorganization ; and from the action of causes which, in the adult, would' scarcely produce any morbid effect. In- fancy is, in fact, the age when eruptive complaints most commonly prevail: thus, in casting our eye over the list of cuta- neous affections, it will be found that the great majority of them, especially of the more acute varieties, are more liable to occur during the infantile age, than at any other period. The mucous membranes also present, at this age, the same delicacy of structure, and the same predominance of vascularity and irritability, as the skin; consequently, different degrees of irritation or of inflam- mation are readily excited in them. Bron- chitis, pneumonia, and croup, destroy, in fact, a large number of infants. But it is the gastro-enteric mucous membrane that is the chief seat of disease in in- fancy. A slight excess of food, or that which is too stimulating, or unadapted to the state of the digestive organs at this period of life—a trifling reduction of the temperature of the skin, personal impuri- ties, or any degree of impurity in the at- mosphere, will in general give rise to colic, vomiting and purging, aphtha?, tym- panitic distensions of the abdomen, and the other phenomena of acute or chronic in- flammation of the stomach and bowels. Softening and perforation of the stomach, constituting the disease to which the de- nomination Gastro-malacia has been ap- plied by the German writers, most fre- quently occurs during infancy. The in- flammation, in many instances, extends from the stomach to the mesenteric glands, occasioning their enlargement and disor- ganization, attended with enormous dis- tension of the abdomen, and extreme emaciation of the body, either in conse- quence of the defective digestion of the food, or the impediment to the free pas- sage of the chyle through the diseased glands. Inflammation frequently extends also from the digestive mucous membrane to the peritoneum: it here generally as- sumes a very chronic form, and sooner or later causes an effusion of serum into the cavity of the abdomen. During infancy, the larjre size of the brain, the delicacy of its structure, its ex- treme vascularity, and ».!qual efficacy which are more readily pro- curable. It would be superfluous to ad- vert to the various preparations of this ar- ticle and their particular applications; it is sufficient to state, that, externally it is employed in fomentations, baths and cata- plasms, and internally, in infusion, in syrup and in a conserve which enjoys a high re- putation as a demulcent in irritations and inflammations of the respiratory organs. The powder is also used to give consist- ence to many pharmaceutical preparations. As almost all the Malvacea? possess the same mucdaginous properties, several of them are advantageously substituted for vol. i. 27 the Marsh mallow in practice; some of them, in fact, present much higher claims to notice; thus, the Hibiscus esculentus or Okra abounds in a bland mucilage, which might be advantageously employed as an emollient in many of the phlegmasia?. Bibliography.—F. S. Ratier. Traiti ell- mentaire de Matifae midicale. II. 33. F. Foy. Cours de Pharmacologic I. 351. A. J. L. Jourdan. Pharmacopie UniverseUt- I. 640. N. Guibourt. Histoire abregie des drogues simples. I. 293. Merat et De Lens. Diet univ. de Maliere midicale. I. 202. Bacon. Journ. de Pharmacie. XIII. 19. Plisson. Journ. de Pharmacie. XIII. 188. R. E. Griffith. ALUM. (From alumen, Latin for alum.) Alun, Fr., Dan., Swed.; Alaun, Germ.; Allume, Ital.; Alumbre, Span. Alum is a double salt, consisting of the sulphate of alumina, united with the sul- phate either of potassa or ammonia. When the second base is potassa, the salt is called potassa-alum, or simply, alum; but when this base is ammonia, it is called ammo- niacal alum. The officinal alum, how- ever, is the potassa-alum; and this va- riety of the salt is to be understood, when- ever, in the following remarks, the simple term is employed. Discovery and Preparation. The dis- covery of alum dates from a very early pe- riod, and is attributed by Beckman to the Asiatics. For a long time, it was brought to Europe from the East In the fifteenth century, several manufactories of it were established in Italy; and in the following century, others were set up in Germany, Spain, England, and France. Alum is sometimes made by the direct combination of its constituents; but more usually from certain minerals, which con- tain either the salt ready formed, or its principal ingredients. When prepared by direct combination, clays are selected as free as possible from iron and carbonate of lime, and dissolved in dilute sulphuric acid. The sulphate of alumina thus formed is then crystallized into alum by the addi- tion of the requisite quantity of sulphate of potassa. This process is sometimes pur- sued in France. The minerals principally employed in the manufacture of alum, are aluminous schists and alum-stone. The schists are roasted, during which opera- tion, the sulphur of the sulphuret of iron which they contain is oxidized, and passes to the state of sulphuric acid. This then combines with the alumina and potassa, bases which, in conjunction with the per- oxide of iron, magnesia, and silica, form 314 ALUM. the incombustible part ofthe mineral. The roasted mass is exposed to the air for some time, after which it is lixiviated. The alum formed dissolves, but it is rendered impure by the presence of peroxide of iron, from which it must be purified by re- peated crystallizations. The alum-stone is principally worked at Tolfa in Italy. This mineral contains all the constituents of alum, but with a large excess of alumina in a hydrated state. By a gentle calcina- tion, the water of the hydrate of alumina ig driven off) whereby the excess of this earth becomes insoluble. The calcined mass is exposed to the air for several months, after which it is lixiviated. The solution obtained, by proper concentration, yields alum, exceedingly pure, known in commerce by the name of Roman alum. In Great Britain, alum is prepared from a species of aluminous schist, by a process similar to the one first described. In the United States, it is manufactured to a suf- ficient extent to supply the domestic de- mand. The process usually followed in this country, is by the direct combination of the ingredients. In Maryland, it is manufactured from an ore found at Cape Sable, consisting of lignite, clay, sulphuret of iron, and sand. Upon treating the dif- ferent alum minerals with a view to their conversion into alum, the potassa present in them is usually insufficient to convert the sulphate of alumina into the double salt, and hence the necessity, in almost all instances, of adding the sulphate or some other salt of potassa, in order to crystallize the alum. Ammoniacal alum, or the sulphate of alumina and ammonia, is sometimes manu- factured in France, where it is formed by adding putrid urine to a solution of sul- phate of alumina. This variety of alum re- sembles the potassa-alum so exactly, that it is impossible, by mere inspection, to distin- guish the two salts from one another. Their taste, mode of crystallization, and action on vegetable colours, are perfectly similar. The ammoniacal alum, however, may be distinguished by the circumstances that when calcined, it is" reduced to the state of pure alumina, and when rubbed up with a fixed alkali and a little water, the odour of ammonia is perceived. Besides ammoniacal alum, there are several other varieties of this salt, known to the chemist, but not employed in medi- cine or the arts. These are the soda-alum, lithia-alum, &c. In all these varieties, the peculiarity consists in the substitution of some other base for the potassa, the al- umina never being replaced by any other substance, as it is essential to the consti- tution of the 6alt Properties of Alum. Alum is a white, slightly efflorescent salt, crystallizing in octohedrons and possessing a sweetish, astringent taste, and acid reaction. It dis- solves in between 14 and 15 times its weight of cold water, and in three-fourths of its weight of boiling water. When heated a little above the boiling point, it undergoes the aqueous fusion, and by a continuance of the heat, it loses its water, and becomes a dry, white, opaque mass, called dried or burnt alum. Exposed to a violent heat, it gives off oxygen, together with sulphurous and sulphuric acids; and the residue consists of alumina, and sul- phate of potassa. It is decomposed by a number of substances, with which it is, consequently, incompatible in prescrip- tions. Among these are the salts of lime and of magnesia, the carbonates of potassa, soda, and ammonia, the muriate of ammo- nia, the tartrate of potassa, and the greater number of metallic salts. It may be asso- ciated, however, with the corrosive chlo- ride of mercury and the metallic sul- phates without decomposition. Composition. Alum was supposed to be simply sulphate of alumina, until it was proved by Descroizilles, Vauquelin, and Chaptal, to contain the sulphate of a sec- ond base, which is either potassa or ammo- nia. The exact composition of alum is still a matter of doubt When its second base is potassa, it probably consists of three equivalents of sulphate of alumina 174, one of sulphate of potassa 68, and twenty- four of water 216 = 478. In the other kinds of alum, the sulphate of potassa is replaced by one equivalent of the sulphate of the second base, whatever this may be. Several sorts of alum are distinguished in commerce, according to their source; as Roche alum, English alum, alum ofthe Levant, Roman alum, &c. Roche alum is esteemed a pure kind, and is said to be so called from Roccha, a town in Syria, whence it is stated to have originally come. This term, however, is often used in a different sense, being applied to alum which has been crystallized in mass at the time of its manufacture. Roman alum, characterized by its being slightly covered with a pink powder, is the mo6t esteemed in Europe, on account of its freedom from oxide of iron ; while the other commercial kinds contain from five to seven parts in a thousand of this oxide, and are, therefore, less fit to be employed in the processes of dyeing. Iron may be detected by adding to the solution of the alum, a few drops ALUM. 315 of ferrocyanate of potassa, which will cause a greenish-blue colour. According to Ber- zelius, alum may be freed from iron, either by dissolving the salt in the smallest possible quantity of boiling water, and then stirring the solution as it cools, or by repeated solutions and crystallizations. Therapeutical Applications. When alum is applied to a highly vascular tissue, its first effect is to expel the blood from the vessels, and to diminish the redness of the part; but by its long application, the condition first produced disappears, and is succeeded by a true inflammation. When taken into the stomach, it appears capable, either by being absorbed, or by producing a sympathetic action in remote parts, of restraining the secretions in certain con- ditions of the system. For these reasons, alum is classed as an astringent, and is considered as one of the most powerful in the Materia Medica. When alum is given in doses, incau- tiously increased, it produces pain in the stomach, nausea, vomiting, and finally colic and diarrhoea. When its use is long con- tinued in small doses, it frequently in- duces obstinate constipation. In persons with narrow chests, and irritable bronchia?, the administration of alum is apt to pro- duce a dry, short cough, showing that the remedy has the property, under peculiar circumstances, of being directed in its ac- tion to the pulmonary organs. According to Orfila, alum, given to man in very large doses (as an ounce or two), would not prove poisonous, because it is probable that it would be promptly expelled by vomiting. He is led to this opinion from his experi- ments on dogs, which experienced no other inconvenience from large doses of alum than vomiting and purging, and recovered in one or two hours. When, however, the oesophagus was tied and vomiting prevent- ed, the animals perished in a few hours from inflammation of the stomach and bowels, and the irritation thence propa- gated to the nervous system. Alum is used as a remedy in two prin- cipal ways,—internally, to act on the gen- eral system, and locally, to affect particu- lar parts. Its therapeutic applications will, therefore, be most conveniently arranged under these two heads. 1. Internal Employment. At one time, alum was alleged to possess febrifuge prop- erties, rivalling those enjoyed by the Pe- ruvian bark; but this supposition has been long since disproved. The classes of dis- ease, in which it is most usually employed as an internal remedy, are hemorrhages and inordinate secretions, when not attend- ed with obvious inflammatory action. The hemorrhages to which it is supposed to be particularly applicable as a remedy, are those for the cure of which depletants are either inadmissible, or have been pushed as far as the state of the system would seem to warrant. Accordingly, it has been recom- mended by practitioners in certain condi- tions of hemoptysis and hematemesis. In memorrhagia, occurring at the time of the decline of the menses, Dr. Dewees has often found alum-whey useful. In chronic diarrhoea, it has sometimes been employed with advantage, especially when conjoined with opium, which serves to correct its ir- ritant, without interfering with its astrin- gent property. It has also been used with benefit in some cases of diabetes, and in incontinence of urine, when depending on debility of the sphincter of the bladder. In the peculiar disease called Colica Pictonum, dependent on the poison of lead, the concurrent testimony of a number of practitioners goes to show the decided effi- cacy of alum. In this disease, it may be supposed to act, in part, on chemical prin- ciples, by converting the poison into the insoluble sulphate of lead. The introduc- tion of this practice is attributed to Gra- shius, who published a Dissertation on Col- ica Pictonum at Amsterdam in 1752; and the same treatment was subsequently highly recommended by Dr. Thomas Per- cival, in his Medical Essays. The prac- tice is at present pursued by a number of physicians of the hospitals of Paris, and with satisfactory success. The alum, in these cases, may be given, mixed with sugar, spermaceti, or gum arabic, or made into a julep with the latter substance. 2. Local Employment. Alum is used, locally, in certain inflammations of a pecu- liar character, which attack the mouth, throat, and air-passages, and may be con- sidered as acting, not only by its astringent power, but by its escharotic and stimulant properties; whereby it substitutes a new action in place of the one in which the diseased inflammation consists. In elonga- tion of the uvula, and enlargement of the tonsils, as well as in the advanced stages of common inflammatory sore-throat after sufficient depletion, it is often useful in the form of a gargle; in which cases it is bene- ficial chiefly by acting as an astringent. In aphtha? of the mouth and throat, it is one ofthe best remedies that can be employed. In those anginose affections, attended with peculiar, membranous exudation, giving the deceptive appearance of ulcerated sur- faces,—the diphtheritis of M. Breton- neau,—the topical application of alum has 316 ALUM. been highly recommended by this practi- tioner ; and his report of its efficacy has been amply confirmed by other French writers. When the affection occurs in adults, a solution of the salt, more or less strong, with the addition of vinegar and honey, is the proper form for using the remedy; but in the cases of children, it is necessary to proceed by the method of in- sufflation. For this purpose, a drachm of finely powdered alum may be placed in one end of a tube, and then blown, by means of the breath, into the throat of the child. The most favourable time for ef- fecting the insufflation is the moment when the child, in the act of crying, draws a long breath; as, when performed at that moment, the particles ofthe alum are sure to be drawn into the trachea itself. M. Trousseau, who describes this operation in the " Dictionnaire de Medecine," and bears decided testimony to its efficacy, re- commends that it should be repeated five, six, or eight times a day. Each insufflation is followed by efforts to vomit, and an abundant flow of the saliva, both of which effects subside in the space of a quarter of an hour. M. Trousseau adds, that where the diphtheritis has not extended to the interior of the larynx, it rarely fails to yield in a few days to the effects of this treatment. Alum is sometimes employed with bene- fit in the inflammation ofthe vulva attended with membranous exudation, which occa- sionally attacks women and very young girls. A solution of the salt is beneficial also as a lotion in pruritus vulva?, and as an injection in some cases of memor- rhagia, and in leucorrhcea, when the dis- charge is not attended with heat, or active inflammation. In uterine hemorrhage also, alum has been deemed a good topical ap- plication, either applied in saturated solu- tion by means of a sponge inserted into the vagina, or in the form of powder dusted on a tampon. This salt, likewise, is employed as an ingredient in collyria, for various diseases and states of the eye ; but these uses can be detailed with greater advan- tage under the head of the diseases of that organ. It is useful occasionally in exces- sive salivation, and, according to M. Ben- nati, in certain cases of aphonia. Alum is frequently used by the surgeon in solution as a stimulant astringent to in- dolent and flabby ulcers; and in powder, either with or without calcination, as a gentle escharotic to such ulcers, and to fungous granulations and excrescences. When used in substance, the part is thick- ly sprinkled over with the salt, and, if an ulcer, covered with compresses of lint. Certain moist fungous vegetations, which occur on the glans penis or prepuce, or at the verge of the anus, may, in many cases, be caused to shrivel and disappear by being powdered over with calcined alum. Alum is contra-indicated in diarrhoeas, accompanied with pain or inflammation, as also in irritable conditions of the stomach. In hemoptysis, it is inadmissible, unless after the signs of pulmonary irritation have entirely disappeared; for otherwise, it would be likely to stimulate the bron- chial tubes too violently and thus produce dangerous results. The dose of alum varies with the object in view in prescribing it, from five grains to two scruples. The average dose is from 6 to 8 grains, repeated several times a day. In colica pictonum, Dr. Percival recom- mends 15 grains to be given every third, fourth, or fifth hour; and in the same disease, M. Kapeler, physician to the hos- pital Saint-Antoine at Paris, has given, for many successive days, from half a drachm to three drachms daily, in mucilage of gum arabic. In urgent cases of hemorrhage, 20 grains have been recommended at a dose, to be repeated every hour or two un- til the bleeding abates. Large doses are apt to produce pain, nausea, and vomiting, effects in a measure obviated by conjoin- ing with it opium or an aromatic. For external use, a cold saturated solution is generally preferred. When prescribed in collyria, it is proper to begin with very small quantities of the salt, and after- wards to increase it, if its effects should render this expedient. Pharmaceutical Preparations. Alum is variously combined and prepared for medical use. When prescribed in colica pictonum, it is sometimes advantageously associated with opium. Two parts of alum, mixed with one of dragon's blood, formed the anti-hemorrhagic pills of Helvetius. Alum-whey is made by boiling two drachms of alum in a pint of milk, and straining the decoction, of which two flui- drachms are a dose. The officinal prepa- rations of alum contained in the United States and British Pharmacopoeias are the following:— 1. Alumen Exsiccatum—Dried alum. Commonly called calcined alum, or burnt alum. This is a white powder, made by melting any quantity of alum in an earthen or iron vessel, and continuing the heat, until the water of crystallization, amount- ing to nearly half its weight, has been dis- sipated, and the salt is rendered dry. The ALUM.—ALUMINA. 317 dry matter is then reduced to powder. In making this preparation, the capacity ofthe vessel should be at least three times the bulk of the alum, to afford space for the calcined product, which swells up re- markably into a light, white, opaque, po- rous mass, of a hemispherical form, having some resemblance to a mushroom. Alum, by being thus dried, is so far altered in its properties, as to take a long time for solu- tion ; a circumstance which has led some chemists erroneously to assert that it is rendered partially insoluble by calcination. Dried alum has sometimes been given in- ternally, but its appropriate use is as an escharotic for the use pf the surgeons. 2. Cataplasma Aluminis—Alum cata- plasm. Alum curd. This is peculiar to the Dublin Pharmacopoeia, in which it is directed to be made by shaking the whites of two eggs with a drachm of alum, so as to form a coagulum. It is sometimes pre- pared by stirring the white of eggs briskly in a saucer with a lump of alum, until co- agulation is produced. This preparation is used, inclosed between folds of cambric, in ecchymosis of the eye, and particu- larly in purulent ophthalmia. Alum curd, when mixed with the tincture of camphor (camphorated spirits), forms a useful lini- ment in chilblains, and for fortifying the skin against the effects of frost 3. Liquor Aluminis Compositus—Com- pound solution of alum. This was for- merly called Bates's alum water, and is made by dissolving two drachms, each, of alum and of sulphate of zinc in a pint of boiling water, and filtering the solution through paper. It is a powerful astrin- gent solution, employed for cleansing foul ulcers, and as an injection in gleet and leucorrhoea. When used as a collyrium, it requires to be very much diluted with water. This solution is officinal only with the London College. 4. Pulvis Aluminis Compositus—Com- pound powder of alum. This powder, which is directed only in the Edinburgh Pharmacopoeia, is formed by rubbing to- gether into fine powder, four parts of alum and one of kino. It is the Pulvis Styp- ticus of former Pharmacopoeias, and is an improvement on the anti-hemorrhagic pills of Helvetius. The substances, of which it is composed, react chemically on each other, but it is not probable that its medi- cinal effects are thereby impaired. It is used in monorrhagia and chronic diar- rhoea, and externally, as a styptic, to re- press hemorrhage. Uses in the Arts. Alum is employed by skin-dressers, by tallow-chandlers to ren- 27* der the tallow more firm, by paper-makers to prevent the ink from sinking into paper intended for writing, and by manufacturers of Prussian blue; but the principal con- sumption of it is caused by the various processes of dyeing. Bibliography.—Helvetius. Recueil des Me- thodes pour la Guerison de diverses Maladies. A la Haye, 1710. Bergmann, (Torb.) Sur Vempoisonnement par Valun. Dans les Memoires de I'Acad. de Suede. 7. XXXVIII. Seydler, (G. L Lud.) Diss, de Alumine ejus- que usu medico. Leipzic, 1772. Herz. Von der Wirkung des Alauns im Harn- flusse, in the Neuen Beitragen zur Naiur-und Arzneiwissenschafl of Selle. I. 124. 1782. [On the. Action of Alum in Diabetes, &c.] Lindt, (Jo. Lud.) Diss, de Aluminis virtute medica. Gottingue, 1784. Percival, (Thomas.) Essays, Medical, Phi- losophical, and Experimental. 4th edit War- rington, 1788. Thenard. Traiti de Chimie. in. Paris, 1827. Begin, (L. J.) Diet, de Medecine et de Chi- rurgie Practique. Art. Alun. II. Paris, 1829. Berzelius. Traiii de Chimie. IV. Paris, 1831. Orfila and A. Trousseau. Diet, de Mede- cine. Art. Alun. Paris, 1832. Thomson, (A. T.) Elements of Materia Me- dica and Therapeutics. London, 1833. Franklin Bache. ALUMINA. (From alumen, Latin for alum.) A peculiar earth, very abundant as a component part of the globe, present in clays to which it gives their character- istic properties, and an essential base in the constitution of alum. It sometimes occurs pure and crystallized under the name of corundum; and, at other times, transparent also, when it forms the pre- cious gems called sapphire and oriental ruby. Associated with potassa and silica, it exists in feldspar and mica, minerals which ordinarily constitute granite and gneiss; and in various states of combina- tion, it is present in a great number of other minerals. Alumina may be obtained pure from or- dinary alum, after being purified from iron, by dissolving the salt in four or five times its weight of boiling water, and then add- ing to the solution a slight excess of car- bonate of potassa. A bulky hydrate of al- umina will be thrown down, which, after being well washed with hot water, still re- tains a small portion of the alkali. To remove this, it is necessary to dissolve the precipitate in dilute muriatic acid, and to throw it down anew by means of pure ammonia or its carbonate. The new pre- cipitate, after being well washed, and ex- posed to a white heat, is pure alumina. When ammoniacal alum can be procured, an easier process is merely to expose this 318 ALUMINA.—ALUSIA. salt to a strong heat in a platinum cruci- ble, until it ceases to lose weight By this treatment, the sulphuric acid and ammo- nia are wholly expelled, and nothing re- mains but the pure earth. Properties. Alumina is a white, taste- less, inodorous powder, soft to the touch, adherent to the tongue, and very refrac- tory in the fire. By the action of heat in ordinary furnaces, it contracts and hardens without melting; but when exposed to the intense heat produced by the compound blow-pipe of Dr. Hare, it may be fused into a limpid globule. Its specific gravity is about 2. Though insoluble in water, it is capable of forming a ductile mass with that liquid, a property which renders it proper for the fabrication of all kinds of earthenware, in which, from the common- est pottery to the most costly porcelain, it is always present as an essential ingre- dient, associated with a portion of silica- Alumina is soluble in solutions of caustic potassa and soda, but scarcely so in ammonia. It unites with various acids, and forms salts characterized by a sweetish, astringent taste, and by being generally deliquescent and abundantly soluble in water. When treated with po- tassa, soda, or ammonia, they are decom- posed, yielding a precipitate of alumina, soluble in an excess of the two former. None of the salts of alumina are used in medicine except alum, which is described under a separate head. (See Alum.) According to Berzelius, alumina may be distinguished from all other substances by its solubility in caustic potassa, by its property of yielding alum with sulphuric acid and potassa, and by the character of becoming of a beautiful blue colour with- out fusion, upon being moistened with ni- trate of cobalt and exposed to a strong heat. Composition. Alumina is found, on an- alysis, to be a metallic oxide, consisting of one equivalent of a peculiar metal, called aluminium, weighing 10, and one equiva- lent of oxygen 8 = IS. According to Berzelius, however, whose analysis dif- fers from the above both in the ratio ofthe constituents, and in their presumed mode of atomic combination, the earth consists of two equivalents of aluminium 27.4 and three of oxygen 24 = 51.4. Aluminium is in the form of a grayish powder, which, examined in the sun, is found to consist of minute scales possessing the colour and lustre of tin. When heated to redness, it burns vividly, combines with oxygen, and is converted into alumina. In oxygen it burns with insupportable brightness. This metal, though partially obtained by Sir H. Daw, and Berzelius and (Ersted, was first completely isolated, and its metallic nature demonstrated, by Wohler, in 1828. Therapeutical Application. It is only latterly that alumina has been employed by a few practitioners as a medicina Judg- ing from the slender experience as yet had of its use, it may be considered to act as an absorbent, ,and to be particularly appli- cable to the treatment of diarrhoea and dysentery. Dr. Ficinus has used it in some obstinate cases of these diseases, and with encouraging success. For the cases of infants, he considers it superior to chalk or the carbonate of magnesia. The form of alumina which he employed was the precipitate, obtained from alum by the car- bonate of potassa and afterwards dried; and the dose in which he gave it was 8 or 10 grains, rubbed up with a little sugar or gum arabic. Occasionally he found ad- vantage from combining it with opium, camphor, or aromatics. Franklin Bache. ALUSIA. (From c&dihs, aberration.) Illusion, Hallucination. Dr. Good has be- stowed this epithet upon a genus of dis- eases which he thus characterizes. " The judgment perverted or overpowered by the force of the imagination; the spirits permanently elevated or depressed; the feelings of the mind depicted in the coun- tenance." This genus comprises two spe- cies, Alusia elatio, or sentimentalism, and A. hypochondriasis, low spirits : it is the former only which will be considered here. The latter will form the subject of the ar- ticle Hypochondriasis. Dr. Good defines the former species as follows. " Romantic ideas of real life; ardent and exalted fancy; pleasurable feelings; frequent pulse; great activity; eye keen and lighted up; countenance confident and animated." This species embraces the following varieties: a Heroica. Chivalry. Romantic gallantry. f3 Facetosa. Crack-brained wit y Ecstatica. False inspiration. 8 Fanatica. Fanaticism. These species are thus graphically de- scribed by Dr. Good in his Study of Medi- cine. "o A. elatio heroica. The age ofthe first of these varieties, that of chivalry or romantic gallantry, has nearly if not alto- gether departed. It may be regarded as a generous and high-spirited flight of the imagination, that gives a visionary colour- ALUSIA. 319 ing to the external world, and combines, without a due degree of discrimination, ideas of fact with those of fancy. Like many of the varieties of empathema or ungovernable passion, it may lead to or be combined with ecphronia or insanity. I have sometimes had to attend patients who, having spent the greater part of their days and nights over the most captivating novels of the present day, had acquired so much of this falsity of perception as to startle their friends around them, and to give evident proof, that they were of a mind occasionally deranged, though, when the attention could once be seriously en- gaged, capable of being brought down to the soberness of external objects and real life. These have commonly been ladies unmarried or without a family, about the middle or a little beyond the middle of life, of a nervous temperament, fine taste and fancy, but whose education had been directed to subjects of superficial or ex- ternal ornament, rather than of intrinsic excellence. Their manner has been peculiarly courteous, their conversation sprightly and figurative, and their hand ready to aid the distressed. But it has been obvious, that in all they were saying or doing they had some ideal character in their minds, whose supposed air, and lan- guage, and manners, they were copying; and the distressed were always most sure of relief, and of a relief often beyond the necessity of the case, whose story Was combined with some perilous adventure, or sentimental catastrophe. In former times, however, when the wild and daring spirit of romance formed the subject of popular study, and The spinsters, and the knitters in the sun, And the free maids that wove their threads with bones, Were wont to chant it, this bewildering triumph of the imagina- tion over the judgment was far more com- mon, and carried to a much higher pitch. The high-toned and marvellous stories of La Morte d'Arthur, Guy of Warwick, Amadis of Gaul, The Seven Champions of Christendome, and the Mirror of Knight- hood ; the splendid and agitating alterna- tions of magicians, enchanted castles, dra- gons, and giants, redoubtable combatants, imprisoned damsels, melting minstrelsy, tilts and tournaments, and all the magnifi- cent imagery of the same kind that so pe- culiarly distinguished the reign of Eliza- beth, became a very frequent source of permanent hallucination. The historian of Don Quixote adhered strictly to the tenour of his times in representing the li- brary of this most renowned knight as filled with romances of this description, and himself as being permanently crazed by an uninterrupted perusal of them. And that the same morbid effect was not con- fined to Spain, and was, indeed, common to our own country, we know from the se- vere but just invectives of Ascham against this class of writings, and his complaints of the disordered turn they had given to the public mind ; and still more from the necessity Shakspeare felt himself under in making all his maniacal characters, whether really or but pretendedly so, deep- ly versed in the prose or poetical romances of the day, and throwing forth fragments of exquisite force or beauty in the midst of their wildest and most discordant rav- ings: Lear, Edgar, and the heart-broken Ophelia are in this respect alike gifted, and show to what sources their reading had been directed. Without an attention to these casual glances, it is impossible to understand the meaning of the sentiment, and its force or feeling is lost upon us, as in the following burst of Ophelia, which consists of a string of quotations, or allu- sions to picturesque customs: " You must sing Down a-down an you call Mm adown-a. O, how the wheel becomes it! It is the false steward that stole his master's daughter." We have not space for the explanation, but it may be found in the commentators, or in the interesting and elaborate history of " Shakspeare's Times," by my early and valued friend Dr. Drake. (3 A. elatio faceloso. The second vari- ety of the present species, that of crack- brained wit, is derived rather from the pe- culiar temperament of the individual, than from any particular habit or train of read- ing; for, in general, few persons have given themselves less time to read, study, or even think, than those who are possess- ed by it. It is characterized by high spirits, a sportive and rampant imagination, and a flow of facetious ebullient wit, incapable of restraining itself. It is hence often poured forth on most improper occasions, and hesitates not to sacrifice a friend at the shrine of a jest. There are some persons, who possess by nature so perpetual a tide of excitement, that their high spirits seem seldom or never to ebb, and so irresistible a propen- sity to this kind of verbal merriment that no change of circumstances can deprive them of it. Sir Thomas More, who per- haps overflowed with this disposition in a very high degree, is well known to have been facetious on his own scaffold. It is not always, however, nor, as we 320 ALUSIA. have just observed, even for the most part, that the man of ready wit is, like Sir Thomas More, a man of ready judgment, or sound learning. The apprehension, ne- cessary to constitute the one, is widely different from that necessary to constitute the other, as we had occasion to remark under a former genus: and hence viva- cious sallies, taunts, and repartees not only may co-exist with a deranged condition of mind, but are frequently a result of it. And on this account the court jester of former times, whose office succeeded to that of minstrel, was commonly denomi- nated the king's fool, as uttering from the unbridled liberty of speech that was al- lowed him, humorous flashes of rebuke, which no man in his sober senses would have ventured upon; and which seemed, to adopt the language of Jaques, who was himself not unjustly accused of wearing the same livery, to show that in his brain, Which ifi as dry as the remainder biscuit After a 'voyage, lie hath strange places cramm'd With observation, the which he vents In mangled forms. y A. elatio ecstatica. The third vari- ety, or ecstatic illusion, is also a pleasura- ble hallucination; and consists in a sense of false inspiration, or a visionary boast of some preternatural endowment, in the course of which the judgment is so far perverted as to mistake the energetic no- tions ofthe imagination for realities; so that the victim of the delusion believes in apparitions, affects an intercourse with the world of spirits, or lays claim to a power of working miracles. This morbid afflatus has often been aped by cunning impostors to serve their own interests with the multitude: and there is no great difficulty in conceiving, that it is in many cases a real and serious halluci- nation, when we reflect on the ease with which such impostors themselves are ca- pable of deluding the populace and work- ing them up into false ecstasies, and espe- cially of inveigling them into a hearty belief of their own miraculous powers. When the passions of men are once 6et afloat, and the subject presented to them is full of the marvellous and the terrible, they are too apt to confound the false with the real, and are prepared to proceed to whatever extremities the magician may choose to lead them. We are told by Lu- cian that when Archelaus, a celebrated Greek actor, performed the part of An- dromeda in the tragedy of Euripides, sev- eral of the spectators were seized with a delirium; some, at the time of perform- ance, others, a day or two afterwards; during which they did nothing but de- claim in a theatrical manner, and piteously lament the fate ofthe persecuted princess. Burton, therefore, has some reason for re- marking, that what the impostors before us, or the brain-sick enthusiasts whom they imitate, once broach and set on foot, "be it never so absurd, false, and prodigious, the common people will follow and believe. It will run like murrain in cattle, scab in sheep. Nulla scabies superstitione scabior; as he that is bitten by a mad dog bites others, and all in the end become mad. Either out of affection of novelty, simpli- city, blind zeal, hope and fear, the giddy- headed multitude will embrace it, and without farther examination approve it." {Anatomy of Melancholy. Part III. sect. iv. 1. 3.) The genuine enthusiast is always pos- sessed of a warm imagination, and gene- rally of a nervous temperament, and deli- cate frame; and a long series of elevated abstraction on religious subjects, combined with protracted fasting, has ordinarily been the harbinger of the fancied afflatus. Such was the discipline by which the lovely, and blooming, and sincerely devout Saint Teresa was prepared for ecstasies and visions, and led to impose upon herself and all that beheld her; and seriously to be- lieve, in the fervour of her mind, that her body was lifted from the earth: and that she heard the voice of God, saw our Lord with St. Peter and St. Paul standing on her left hand; by the first of whom the cross, which was at the end of her beads, was miraculously transformed into four large gems, incomparably more precious than diamonds; with many other marvel- lous revelations, which we cannot find room to detail. Though it should be no- ticed, that devils appeared to her as well as blessed spirits, whom she always kept at a distance by sprinkling holy water; and that she was an eye-witness to the joyful escape from the flame of purgatory of the purified souls of father Peter of Al- cantara, father Ivagnez, and a Carmelite friar. {Butler's Lives of the Saints, in loco.) It is not necessary to produce otiier ex- amples, though many might be brought from our own times. A cure is extremely difficult to be obtained; and I am afraid that even Mr. Ixxike's admirable chapter on Enthusiasm would be read to no pur- pose. In one instance, the enthusiast seems to have been brought home to him- self by a pleasant and ingenious stratagem of his superintendent at Venice. This AMAUROSIS. 321 visionary had conceited himself to be Elias, and, like the prophet, had determined upon fasting forty days. The keeper, fearful that he would never hold out, and that he should lose his patient, dressed up a man in the attire of an angel, who was intro- duced to him in no ordinary manner, and informed him, that he was commissioned from Heaven to bring him food. The sup- positious Elias took it, was afterwards al- lowed to find out the trick, and thus, at the same time, found out his own imposi- tion upon himself. 8 A. elatio fanatica. From the influ- ence which we have seen such enthusiasts, or even pretended enthusiasts, capable of producing upon the mind ofthe multitude, when roused by the solemnity and awful- ness of the revelations that are supposed to be disclosed to them, we can easily see how fanaticism, constituting the fourth variety of the present species, may obtain an ascendency, and even rage with all the ramifying power of an epidemic: consist- ing of religious flights of the imagination, predominant over the natural feelings as well as the judgment, excited by the calls or doctrines of those who affect to be pre- ternaturally gifted, or who possess an equal influence over the mind by the high sanction of priesthood, profound learning, or any other respected authority: and often urging to a voluntary and inappropriate submission to severe privations, mortifica- tions, and tortures; or to the torture and massacre of those who profess different creeds. Examples, as in the last variety, may be found in every age and religion, but chiefly in times of gross ignorance and barbarism; where the general mind has been too little informed to distinguish between truth and sophistry, and the passions have been un- disciplined to restraint. It is hence of no importance what religion or superstition is to be inculcated ; for those that are true, and those that are false, have been equally laid hold of by enthusiasts and impostors to produce the same end, and effect the same triumph by means and machinery that could only be furnished from the in- fernal regions. Hence the blood and raving of the prophets of Baal; the Curetes or Phrygian priests, and the delirious votaries of the Indian Juggernaut; the cruel and senseless penances and punishments sus- tained in many of the convents and nun- neries of Lam ism, and still more so in those of many Catholic countries. Hence the terrible sufferings of the Waldenses, the furies of St Bartholomew's day, the fires of Smithfield, and the dark and dole- ful cells, the whips, and wires, and pin- cers, and pullies, and all the infernal para- phernalia of the Inquisition. Hence, in ancient times, the matrons of Canaan and of Carthage were instigated to throw their own children into the flames, and sacrifice them to the gloomy deity whose anger it was held necessary to appease; and hence in more modern days, Philip II. of Spain was goaded to impeach a son, of whom he was little worthy, before the Chamber of Inquisitors, to bespeak their condemnation of him, and to take effectual care that he should be poisoned, as soon as his sentence had been pronounced. The cure of these diseases belongs rather to colleges of general instruction, than of medicine. Individual cases of en- thusiasm and fanaticism have existed, and will probably continue to exist, in all ages; but when the general mind is well inform- ed, and the social feelings and virtues are duly estimated and widely cultivated, the wild-fire will burn in vain, and meet with little or no fuel to support its rage." I. H. ALVEOLAR. Appertaining or relating to the alveoli. I. H. ALVEOLUS. (Diminutive of alveus, a cavity.) This epithet is given to the cavi- ties in the margins of the two jaws, in which the roots of the teeth are lodged. See Bones. I. H. ALVINE. (From alvus, the abdomen.) Relating to the abdomen. Alvine dejec- tions, the feces. I. H. ALYSMUS. (From aa.v«, I am restless.) oXvuftoj, Gr. Restlesness, inquietude. Swe- diaur has applied this epithet to a genus of diseases. Obsolete. I. H. AMAUROSIS. (From ojuoi^oa), I obscure,) ttjuau^oo'ij, Gr.; Gutta serena, Suffusio ni- gra, Lat.; Amaurose, Fr.; Die Schwarze Staar, Germ. This epithet is applied to designate the partial or total loss of sight, resulting from an impairment of the nerv- ous apparatus of vision. A knowledge of this apparatus is consequently an essential preliminary to the study of Amaurosis. It would be out of place, and involve repe- tition, however, to treat of that subject here; this will be more properly done in the articles Eye and Vision, to which we must refer. There are a few con- siderations, however, of so much im- portance, and a knowledge of which is so necessary for the perfect understanding of the subject of this article, that it is requi- site to invite attention to them. For the perfect performance of vision, it is necessary that the retina be capable of receiving correctly the impressions of 322 AMAUROSIS. the rays of light; that the optic nerve be able to transmit these impressions to the sensorium, and that the cephalic organs, (the anterior tuberculi quadrigemina, the corpus geniculatum externum and the tu- ber cinerium, the portions ofthe cerebrum destined for that purpose,) be capable of receiving them. The organs just enumer- ated, may be considered as the especial, but not as was formerly believed the ex- clusive, apparatus of vision. For the per- formance of this function, the concurrence of other nervous organs is requisite. The sensibility of the retina is due to the fifth pair of nerves; without whose concurrence, the retina is incapable of acting as a sen- tient organ, as is amply proved by the ex- periments of Majendie, Bell, Desmou- lins, &c.; and further by the consequences of injuries of this nerve. The retina is, moreover, in communication with other nerves, and there is reason to believe it to be, to a certain extent, subject to*their in- fluence. The connexion between the re- tina and great sympathetic appears to be well established. Branches of the latter may be traced upwards, from the first cer- vical to the cavernous ganglion, whence branches pass to the lenticular ganglion, and M. Ribes {Mem. de la Soc. Mid. d'Emulat. VII. 99,) and others, have shown that filaments proceed from this last named ganglion to the iris, giving more minute branches, in their course, to the retina. Branches from the cavernous ganglion also communicate with the third, the first divi- sion of the fifth,and the sixth pair of nerves. Further, the ophthalmic artery, with its ramifications to the iris and retina, is in- vested with filaments of the sympathetic. It will not consequently excite surprise, that morbid states of the sympathetic should impair the sense of sight; that it does so, is shown by the experiments of Mayo, {Anat. and Physiol. Comment. No. II. p. 4.) He found that when the great sym- pathetic is divided on one side of the neck of a dog, the pupil becomes fixed and contracted, and the nutrition of the eye interrupted. If the experiment be per- formed on both sides, the pupils become fixed and dilated. F. Petit has shown that the section of the cervical portion of the great sympathetic occasions dimness of vision, {Acad. Roy. des Sc. 1727;) and this explains the impairment of sight, which results from some wounds ofthe neck. The retina, optic nerve, and cephalic organs of vision, being thus the especial nervous apparatus of eight, its entire in- tegrity is necessary for the perfect per- formance of this function; and every pa- thological condition of any one of the or- gans which constitute this apparatus, will occasion an impairment of vision, or its entire loss—and it is to designate the blindness resulting from these causes, that the term amaurosis is employed. The first branch of the fifth pair, the third, sixth, and great sympathetic nerves concur in this function, hence its integrity is also im- paired by various lesions of these nerves. It will thus be perceived, that amaurosis does not consist in a particular patho- logical condition of a single organ, but that it is a result of various morbid states of one or more of several different or- gans. Amaurosis, it must consequently be manifest, is not a disease, as it is usu- ally considered, but a symptom—it is one of the ultimate results of diversified and even opposite pathological states, as will be hereafter shown, of several organa This appears, to us at least, to be the true view of the subject, and to be the only mode of considering it, which can dis- embarrass it from the difficulties and ob- scurities in which it has hitherto been in- volved. If the morbid conditions produc- tive of this symptom were well determined, all that would be necessary here, would be to refer to the articles on the several pa- thological states of the organs concerned in the function of vision. In the present imperfect state of our knowledge of the functions of the nervous system, this can- not be done with perfect precision, and on this account we shall devote some pages to the consideration of this symptom. General description of Amaurosis; its march, duration, varieties, predisposing causes, &c.—Amaurosis consists in an al- teration of the function of vision, which is impaired in all possible ways and degrees— there is a defective perception ofthe form, colour, and proportion of objects; in the re- lation of these last to each other; an aug- mented or diminished sensibility to light; and perception of the most various im- aginary objects and colours. At the com- mencement of this affection, there is often only a slight dimness of sight; ob- jects are seen but imperfectly; they ap- pear more or less obscured by a cloud or haziness; the letters of a book appear con- fused, indistinct, and run into each other; the eye is soon tired, and waters, or be- comes blood-shot if exertion be continued. The failure of vision in some instances is at first only occasional, for a short time, and after longer or shorter intervals, {amau- rosis vaga); at others it is partial, or ex- AMAUROSIS. 323 tends to a part only of the field of vision. Sometimes near objects are not clearly seen, whilst those more distant are per- fectly distinguished, {presbyopia;) at times the reverse occurs, {myopia.) In some cases, there is at the commencement great increase in the sensibility of the retina, amounting to real intolerance of light, {photophobia.) Under such circumstances, the patient sometimes discerns for a short time, that is, for a few moments, or more rarely for a longer period, even the small- est objects in an extremely weak light, as clearly as the best eye can see them in the light of day; while, at other times, he can- not distinguish even larger things in the same light (Beer, Lehre, II. 326.) This increased sensibility of the retina may be- come so considerable, that the presence of light cannot be borne; at least it causes severe pain in the eye and brow, with dis- charge of tears, and confusion of all ob- jects. Mr. Lawrence has seen a patient in whom, although amaurosis had existed for some time, and advanced considerably, the smallest light could not be borne; and he remained constantly in a room with the very crevices of the shutters carefully stopped up. (p. 509.) When this exalted sensibility of the retina increases, a shining glare appears before the eye, sometimes with rainbow colours, occasionally tremu- lous, surrounding and confusing objects. A light cloud may pass before the eye; or luminous and fiery points, flashes, or streaks, may be seen. Blue or yellow flashes, or globes of fire, are seen in the dark, or when the lids are closed. This glare of light, and these various luminous appear- ances, often continue when the sensibility of the retina has been completely extin- guished, and lead the patient to indulge in the hope that his vision may be restored. (Lawrence, p. 509.) More commonly, the sensibility of the retina, instead of being increased, is dimin- ished; involving the necessity of a power- ful impression to produce any effect, and leading the patient in attempting to dis- tinguish objects to seek as much light as possible. In addition to the defects of sight, {vitia visus,) just noticed, various others may be enumerated as resulting from impairment of the nervous apparatus of vision. Objects are sometimes perceived with prismatic colours, or halos around them; sometimes they appear completely altered in colour; for example, as if seen through a yellow glass, {visus coloratus, chrupsia.) A very Frequent phenomenon is broken or interrupt- ed vision, {visus interruptus.) The eye misses parts of objects; letters or words are lost in reading, and the patient moves the whole head to search them out Some- times the upper or lower half, or the right or left half, is not seen, {visus dimidiatus; hemiopsia.) Sometimes a small part only of the retina retains its sensibility, and such things only are seen as are placed in a particular direction with respect to the eye. Slight movements of the head or eye, put the latter out of its proper posi- tion for vision, and it is not easily brought back again to its right place. Things sometimes appear deformed or distorted; crooked, mutilated, shortened, lengthened, or inverted, {visus defiguratus, metamor- phopsia;) sometimes as if enveloped in a mist or cloud, which may be light, dark, or changeable, or apparently composed of minute objects coalescing; {visus nebulo- sus.) This cloud becomes thicker and more extensive, until the perception of ob- jects is destroyed. A common symptom in incipient amaurosis, is the appearance of floating or moving bodies before the eye; {visus muscarum; myodesopsia.)— Dark or semi-transparent threads, spots, streaks, insects, rings, chains, and indeed minute substances of every description, seem to float before the eye, moving rap- idly upwards and then falling, more con- spicuous and more troublesome in imped- ing vision in a clear light, or in looking at a white or light object A single black speck is called scotoma; the more numer- ous moving bodies are called musca voli- tantes. It is not uncommon for the patient to see before the eye a black disk, which increases in size as the affection proceeds, becoming larger and larger, until at last it covers the field of vision. As the mov- ing bodies increase in number, they be- come more completely opaque, and unite so as to form a net or thick veil, more or less completely enveloping whatever the patient looks at {visus reticulatus ). This net appears dark in a clear light, or against a white ground; while in the dark it is shining, and whitish or yellowish. Double vision {diplopia, visus duplicatus) is a common circumstance in incipient amau- rosis. The affected eye deviates from its proper direction, or squints, so that the optic axes do not correspond. Hence ob- jects are seen double; the two images sometimes being equally clear, though the second is generally fainter. The two may be close together, or at some distance; and the second may be above, below, or at one side of the first. When either eye is closed, vision with the other is single. The movements of the two eyes coincide 324 AMAUROSIS. in certain directions, so that the double sight is only partial. In some instances the patient sees well during the day and is blind at night, hemeralopia (q. v.); or vision may be imperfect during the day and better at night, nyctalopia (q. v.) The pupil and iris of amaurotic patients generally exhibit various conspicuous changes. The former is often considera- bly dilated, even in the strongest light; sometimes it is equally and permanently contracted. Its form is also often changed, being oval, oblong, or angular, at different points of its circumference. It may differ from its central situation in the iris, being most frequently displaced upwards and in- wards : in such cases the margin generally presents irregularities. In many cases, the clear blackness which characterizes the normal state of the opening is lost, and the pupil has, instead, a dull, smoky, or cloudy discolouration of a greenish, gray- ish, or leaden cast; sometimes it is of a yellowish-green, much like that of glau- coma. The healthy retina is transparent, and the dark choroid seen through it gives the pupil its black colour. If the texture of this nervous expansion be changed by disease,a corresponding alteration in the ap- pearance of the pupil may be expected. Beer states that the pupil may be reddish, or really red, or yellowish-white, in amau- rosis, and that in such cases the discolour- ation is obviously in the fundus of the eye and concave. We have seen one distinct example of this, in which the lower and outer portions of the bottom of the right eye were of a bright red, and the upper and inner of a brilliant yellow, passing into a green. This is what Beer denominates amaurotic cat's-eye. Mr. Lawrence thinks that such appearances would denote or- ganic disease of the eye-ball, rather than amaurosis, in the strict, sense of the term. In the case to which we have alluded, the colouration was manifestly in or beneath the retina: the transparent tissues of the eye were entirely unaffected. The iris was formerly very erroneously supposed to be motionless in amaurosis. In some individuals, whose sight is perfect, the iris possesses but little mobility; and occasionally it is motionless with unim- paired vision, (Lawrence, p. 514;) on the contrary, the full power of motion some- times exists in complete amaurosis. (J anin, {Obs. Chirurg. fasc. If. pp. 65, 66,) has mentioned two instances of this; two more came under the observation of Schmucker, (Vermeschte Chir. Schrifter, 13,) and several have been seen by Richter, {Obs. Chir. II. 63.) Mr. Shaw relates, {Med. Chirurg. Trans. XII. 188,) a case in which the vision of the right eye was entirely lost, although the eye appeared to be in every respect perfect; that is, whether the other eye was open or shut, the pupil of the blind eye contracted and dilated with perfect regularity. When the amaurotic eye was directed towards the sun, the sound one being closed, the pupil of the former contracted, and when the hand was put before the eye, it dilated. Yet, not- withstanding this sensibility of the eye to light, the power of vision was so complete- ly lost, that although a lighted candle was brought close to the child's face, she was not sensible of it until she felt the heat of the flame. Mr. Lawrence relates the case of a lady 56 years of age, who had lost, with- out obvious cause, the sight of her right eye, and whose two eyes were so com- pletely alike, that he could not discern which was amaurotic; the independent, as well as the associated action of the iris, was perfect, and both pupils were of the same size under similar circumstances. {Treatise, p. 515.) In a boy, totally blind from hydrocephalus, whose case is related by Mr. Lawrence, (p. 497,) the motions ofthe iris were unimpaired. Mr. Travers also records two cases of amaurosis de- pendent upon a circumscribed tumour within the orbit, pressing upon the optic nerve, in which the motions of the iris were " even vivacious." (p. 188.) Several instances of an active state of the iris, in cases of amaurosis, have also been seen by Mr. S. Cooper {Surg. Did. I. 29.). In many cases in which the affection is confined to one eye, the iris of the amau- rotic eye moves in harmony with the other, after its independent action is destroyed. In complete amaurosis of old date, accom- panied with change of colour in the iris, Mr. Lawrence has sometimes seen the associated action perfect, when the strong- est light, directed on the affected eye with the other closed, has caused no sensation nor change in the state of the pupil (p. .515.). No explanation has as yet been given, why the pupil should, in some cases of amaurosis, remain fixed and unaltered by the exposure of the eye to the different degrees of light, while in others it is as sensible to the stimulus of light as a perfect eye. We do not as yet possess any conclusive evidence on this question, but circumstances seem to prove thu9 tar, that the motions of the iris depend upon other causes than merely the state of AMAUROSIS. 325 the retina, and that they are probably entirely controlled by the ciliary nerves. Amaurosis occurs at all ages, but it is most frequent at or after the middle pe- riod of life, especially about the cessation of menstruation in females. Sometimes it is congenital, and instances of this are recorded by Gibson {Ed. Med. and Surg. Journ. VII. 398), Monteath {Transla- tion of Welter's Manuel. II. 82), Law- rence (p. 516), &c. Beer says that amaurosis often results from an hereditary predisposition {Lehre. II. 442), and in this he is sustained by Lawrence, who asserts that the influence of peculiar hereditary formation in predis- posing to amaurosis is unequivocal, (p. 517.) The former writer relates that in one family, the females, even in the third generation, become completely and incura- bly amaurotic, as soon as menstruation ceases; but they who have borne children escape. M. Sanson has seen a family, con- sisting of a father and four children, two sons and two daughters, all of whom be- came amaurotic at the age of twenty-one years, (p. 98.) The progress of amaurosis is exceed- ingly various. In some instances it occurs suddenly ; we have met with one case in which it was instantaneous, and Mr. Law- rence has seen a few instances in which persons having gone to bed with perfect sight have been totally blind the next morning. Sometimes days, weeks, months, and even years, elapse before vision is al- together lost. Not unfrequently the im- perfection of sight reaches a certain point and then becomes stationary. This affec- tion may be simple, or complicated with glaucoma, cataract, hydrophthalmia, &c.; or it may be transient or permanent, peri- odical and even intermittent, coming on at regular or irregular intervals. A man, whose case is related by Richter {An- fangsgr. der Wundarzn. c. 3. kap. 14"), became blind at twelve o'clock in the day, when the upper eye-lid used to hang down paralytic. The attack always lasted twen- ty-four hours. On the following day at twelve o'clock the sight used to return, and the patient then suddenly regained the power of raising the upper eye-lid, and he would continue able to see for the next twenty-four hours. Whenever he took bark, the length of the paroxysm was dou- bled, the interval remaining the same; that is, the patient was blind for forty-eight hours and retained his sight for only twen- ty-four. This writer states that periodical amaurosis commonly depends upon gastro- intestinal irritation, as from worms, &c, or vol. i. 28 irregularity in the menstrual discharge; but that sometimes it is manifestly a symp- tom of intermittent, the patient being blind during the paroxysm and regaining his sight as soon as the fit is over. Beer is of opinion that periodical amaurosis is chiefly observed in chlorotic, hemorrhoidal, hys- terical, and hypochondriacal subjects. Diagnosis. Blindness from delect in the nervous apparatus of vision, may be confoumiad, in some cases, with the same symptom resulting from cataract or glau- coma, but the diagnosis is usually not diffi- cult The colour of the pupil, which is whitish in cataract, and usually clear in amaurosis, will generally serve to distin- guish the former from the latter. There is one variety of cataract, that termed black cataract, in which the diagnosis is not so readily formed; but this affection is rare, and on regarding the pupil in pro- file it will be observed to exhibit a metallic reflection like bronze. When the amaurosis is complete, it may be distinguished from the blindness from cataract by a peculiar vacant stare very characteristic of the former. On entering a room, instead of looking at persons or surrounding objects, the eyes are directed forwards with the lids wide open, and fixed in a kind of gaze on vacancy. There is a want of movement in the eye-balls and the head, and a quiescence of all the external parts whose motions ordinarily harmonize with those of the direct visual apparatus, which immediately betray the state of the case even to an inexperienced observer. This vacant stare does not occur in cataract Although the patient may be unable to discern objects, he looks about, as if conscious that vision still existed. In short, the state of the eyes, eye-lids, and surrounding parts, with the mode of carry- ing and moving the head, are expressive of blindness in the one case, of sight in the other. (Lawrence, p. 512.) Amaurosis may be distinguished from glaucoma by the presence of the symptoms of the latter, in addition to impairment of vision. These symptoms are the deeply- seated green discolouration of the pupil, and the altered colour of the iris. If, as it sometimes happens, the pupil should be also dilated and fixed in the commence- ment of the affection, the distinction will be still more easy. The colour of the iris is not always changed in glaucoma; green discolouration of the pupil is sometimes seen in amaurosis, while a sluggish or mo- tionless state, of the iris and dilated pupil is common to both. Hence the distinction is difficult in some cases. It is more im- 326 AMAUROSIS. portant in reference to prognosis than treatment; for the same means are appli- cable to both affections, though the chance of benefit is much less in glaucoma than in amaurosis. When there is a wish on the part of the patient to deceive, as is sometime3 the case, the diagnosis of amaurosis is exceed- ingly difficult, as there ire often no symp- toms positively indicative of the existence of amaurosis, at least none which cannot be simulated—the patient alone, can esti- mate justly, in most cases, the degree of diminution of sight or its total loss. The dilatation and immobility ofthe pupil, long considered as characteristic of this form of blindness, we have seen are not always present, and on the contrary sometimes ex- ist without amaurosis, as in mydriasis or paralysis ofthe retina. It may be moreover simulated by introducing a few drops of extract of belladonna into the eye, or by taking internally some preparation of this plant. When, however, the patient pos- sesses the power of seeing, it is not easy for him to resist an instinctive disposition to close the eye-lids when an unexpected menace is made to strike the eye. Great importance was attached to this by Mor- gagni and others, as a means of detecting simulated amaurosis; but experience has shown that it is not to be depended upon: A man of firmness and sufficiently prac- tised, can support without wincing or clos- ing his eye-lids the approach of a bright light or any object with which we may threaten to strike or seize the eye ; more- over, when'amaurosis is incomplete, the patient having some perception of objects, seeks to avoid, by closing his eyes, those which threaten to wound them; and final- ly, some patients who are completely blind, are endowed with such acuteness of sense, that they are aware of the ap- proach of bodies which may injure them, and avoid such with great skilfulness. (Sanson, p. 104.) Amaurosis having been discussed in a general way, it is now to be considered in reference to the pathological states from which it may arise. We have stated that for the perfect performance of vision, it was necessary that the retina be capable of correctly receiving the impressions of the rays of light; that the optic nerve be able to convey these impressions to the sensorium; that the cephalic organs be capable of receiving them; and finally that certain nerves distributed to the eye and which concur as accessories in the function of this organ, be in a normal state. This seems to suggest a natural classifica- tion, which, though it must be admitted not to be entirely faultless, since two or more of these organs may be affected at the same time, and causes which act upon one may have their action transferred to another, appears to us to be obnoxious to fewer and less serious objections than any other that we have seen proposed, and therefore we shall follow it. 1. Amaurosis from lesion ofthe retina. The retina is the seat of visual impres- sions, and every lesion of it, of whatever description, impairs the performance of its function. Amaurosis is hence a constant symptom of every morbid state of this or- gan. In the article Retina, pathological states of, the various morbid derangements to which this tissue is liable will be enu- merated ; all that will be requisite here is briefly to enumerate the morbid derange- ments which have been discovered on post mortem examination of patients who had been amaurotic. The retina has been found with its vessels injected, (Prochas- ka, Rognetta) ; separated from the cho- roid by varicose vessels, (Plouquet), by serous effusion, (Scarpa, Ware, Zinn, Wardrop, Heusinger), and by hydatids, (Portal) ; firmly adherent to the choroid by lymphatic exudation, (Graefe's Jour- nal); thickened, firm, and opaque, (Por- tal, Sanson), converted into a white fibrous membrane, firm and like an apon- eurosis, (Demours) ; with numerous blood- vessels and yellow spots, (Langfnelck); often green, (Sanson) ; ossified, (Haller, Morgagni, Rousseau, Sanson) ; partly fibrous and partly osseous, and of vari- able thickness, (Majendie); with trans- parent vesicles developed in it, (Haller, Morgagni, Heister, Zinn, Sanson); af- fected with malignant disease, (War- drop) ; atrophied, (Beer, Wardrop, Scar- pa) ; and Fabricius Hildanus, Heister, &c. have quoted instances in which it had even entirely disappeared. Causes. Amaurosis being a constant result of every irritation of the retina, or its consequences,—derangement in the nu- trition of this organ,—whatever is capa- ble of exciting irritation in this structure, may be enumerated among the causes of amaurosis. The consideration of these agents more properly belongs to the sub- ject of Retinitis, (see this article); but it appears expedient here, to inquire into the influence of certain causes supposed to in- duce amaurosis by acting upon the retina, without occasioning any lesion of structure in this organ. Beer, Benedict, and other German writers, maintain that amaurosis may be caused by various articles of food, and by many of the substances employed in medicine. Beer {Lehre, II. 445) enu- AMAUROSIS. 327 merates among these, the vegetables which have the property of dilating the pupil; as belladonna, hyosciamus, stramonium, and cherry laurel; opium, succory-coffee, bitter beers, bitter almonds; gentian, quas- sia, simaruba, centaury, cynoglossum; am- moniacum and galbanum; and the various preparations of lead. The first four vege- tables occasion a dilatation of the pupd, and as Mr. Lawrence (p. 523) observes, the attendant temporary confusion and diminution of sight seem to depend not upon any immediate influence exerted by those articles upon the retina, but on the dilatation of the pupil, and go off in pro- portion as that opening recovers its natural size, without any permanent injury to sight. It appears to us probable that in moderate doses these vegetables act prin- cipally upon the nerves of the iris, but in excessive doses they seem also to act upon the brain. Christison states that opium in large doses generally causes contraction of the pupil, which is sometimes excessive. {Treatise on Poisons, 2d ed. 648.) The facts collected by this learned writer seem to show that this drug produces no organic injury of the nervous apparatus of vision. The influence of the roots of the wild suc- cory (often employed in Europe as a sub- stitute for coffee) in producing amaurosis, seems, notwithstanding the assertion of Beer, to be extremely doubtful. Bene- dict {Handbuch. V. 97) has never seen a well-marked instance. Equally problem- atical is the influence of beer, bitter al- monds, and the vegetable bitters and gums above enumerated. The researches of Dr. Christison afford no confirmation of the opinion of Beer, relative to the influ- ence of lead over the functions of the retina. Diagnosis. The retina may be sus- pected to be the organ affected, in those cases of amaurosis in which there is broken or interrupted vision, or in which portions only of objects are seen. It rarely happens that the whole of the retina is, from the commencement, equally affected, and hence objects are seen in certain positions better than in others. When this tissue is inflamed, the central portion of the ex- pansion, which is the usual seat of im- pression, loses its sensibility first; the cir- cumference, which does not undergo the same degree of habitual exertion, retains its powers longer. Hence patients can frequently see objects placed laterally, par- ticularly on the temporal side, after the power of distinguishing them in the di- rect line of vision is totally lost (Law- rence, p. 511.) (See Retinitis.) Treatment. We have seen that the variety of amaurosis under notice, is one of the phenomena attending upon or re- sulting from irritation of the retina. The treatment will hence be more naturally considered under the head of Retinitis; all that we shall attempt here is to point out the general indications. In acute re- tinitis no difference of opinion exists as to the most active antiphlogistic measures being demanded. But in chronic retinitis, this is not the case, and we believe that the most injurious measures are ordinarily pursued for its cure. This form of retinitis is extremely insidious. There is little manifest inflammatory action; the nutri- tion of the part becomes deranged, the substance of the retina is changed—its fine pulpy texture is lost—it becomes in- capable of receiving visual impressions, and sinks to the level of organs destined to fulfil less important offices. Patients here find that they have difficulty in per- ceiving objects in ordinary light, and that they require a very strong one for the pur- pose ; hence they term it weakness of sight; suppose that their imperfect vision results from debility; and that the organ requires to be strengthened. Too many physicians give into this idea, and pre- scribe tonics and stimulants of all kinds, both local and general. The impropriety of such pathological views and the injuri- ous nature of the practice which follows, have been strongly and judiciously com- mented on by Mr. Lawrence, (p. 507.) We are not prepared to aver that imper- fection of sight is never produced by what has been called debility of the retina, but which would be more properly termed anemia of that tissue. The blood (white or red) is an essential constituent of the organism ; in the structure of each tissue in a normal state, a certain amount of this fluid enters ; if this quantity is in excess or defect, it equally constitutes a patholo- gical condition. Now while it may be confidently asserted in respect to the re- tina that its morbid states are most usually the consequences of irritation, and ubi ir- ritatio ibi qffluxus; it is not to be denied that in some cases it may be in an anemic state. Such instances are, however, ex- ceedingly rare, and are readily recogniza- ble. They probably never occur except in cases of general anemia, and here the brain suffers even more than the retina; they will therefore be noticed under the variety arising from affection of the brain. (See also Retinitis, and Anemia.) 2. Amaurosis from impairment of the optic nerve. The integrity of the optic 328 AMAUROSIS. nerves may be impaired by external inju- ries, as by fractures of the anterior basis of the skull, with displacement of the or- bital parietes; and by punctured wounds of the orbit. They may be stretched, and thus rendered incapable of performing their functions, in consequence ofthe pro- trusion ofthe globe by accident or disease, and they may be also injured by tumours formed in their vicinity, and involving «r compressing them in some part of their course. Tumours of this description have been found of various kinds. Thus they have been met with scirrhus, by Plater, Riolan, Wandeler, &c. ; steatomatous,by QShme ; osseous,by Haller, Schmucker, Beer, &c. ; tuberculous, by Sauvage; en- cysted, by Paw, Schmucker, &c. Boer- haave gives a case in which the optic nerve was compressed by an exostosis of the optic foramen; Blegny found a calcu- lus near the origin of one of the optic nerves; and Beer has in three instances found hydatids between the coverings of the optic nerve, by the pressure of which the medullary matter appeared to have been displaced. Tumours of the pituitary gland also constantly produce incurable amaurosis more or less complete according to the volume of the tumour, by pressing on the optic nerve, as is shown by the ob- servations collected by M. Raver {Archiv. Gin. III. 350). It may be interesting to state that according to this writer, persons affected with blindness from this cause, exhibit an apathy and disinclination to move, quite characteristic. Wepfer, Vieussens, De Haen, Leveque-Las- source, Ward, Rullier, &c. have report- ed many cases of amaurosis from pressure on the optic nerves by the pineal gland in a state of enlargement and disease; and a very remarkable one is related by Sanson {Did. de Mid. et Chirurg. Prat. II. 89), in which no trace could be discovered of this gland, but in its place there was found a cyst of the size of a small pullet's egg, filled in part with a liquid, fatty, yellowish matter, mixed with blood, and with a yel- lowish, solid, friable, caseous or tubercu- lous substance. Effusion into the ventri- cles may also occasion pressure on the optic nerves, and thus destroy their func- tion. Hence amaurosis is a commom symp- tom in hydrocephalus. Mr. Lawrence states that " Mr. Langstaff's museum con- tains some specimens, in which the third ventricle is enlarged by the accumulated fluid, and its parietes bulged in front so as to press on the united portion of the optic nerves." (p. 496.) This distinguished sur- geon relates also a case in his own prac- tice, in which, on post-mortem examina- tion, the same condition was observed. Another cause of this form of amaurosis is the aneurismal dilatation of the cere- bral arteries. It was a conjecture of the late Mr. Ware that this symptom might not unfrequently be owing to the dilata- tion of the circulus arteriosus. " Should then the dilatation," he observes, "take place in the posterior portion of the circu- lus arteriosus, so as to compress the nervi motores occulorum, the consequence will be, that the eye-lids and probably the eyes also will lose the power of motion. But if the dilatation happens in the anterior portion ofthe circulus, as the compression will then be on the optic nerves, the sight must, of course, be destroyed. And should the dilatation take place in both portions, so as to occasion a compression both on the optic nerves and the nervi motores oculo- rum at the same time, while the eye-lid9 will thereby be rendered immovable, the eyes also will be deprived of sight and motion together, (p. 400.) A case of am- aurosis from aneurism ofthe right anterior cerebral artery compressing the right optic nerve, is recorded by Mr. Spurgin. {Lond. Med. Repos. June, 1825. p. 443.) In a preparation in the possession of Professor Schmidler, of Friburg, taken from a prin- cess of Baden, who was for a long time blind, there is an aneurism of the central artery of each retina compressing the optic nerves. {Diet, des Sc. Mid. XXXV. 20.) The disorganizations observed in the optic nerve in this form of amaurosis, are exceedingly various. Botal, Buchwald, and Gallereux, have seen them softened and ulcerated; Gallereux discovered a hard, grayish tubercle of the size of a hemp-seed, in the left optic nerve of a pa- tient affected with amaurosis of the corre- sponding eye. Chesneau found one of the optic nerves covered with a kind of gyp- seous crust; Bonnet has seen these nerves firm and very friable; and this last author and Birminger have found them twisted. Ruland saw one of them distended with serum ; Zinn found the central artery and vein dilated. But one of the most fre- quent alterations met with, and of which instances have been seen by Vesalius, Scultetus, Cecalpinus, Riolan, Mor- gagni, Valverde, Santorini, Heiland, Isenflamm, Rolfinck, and others, is the withering and atrophy of one or other of the optic nerves. (Sanson. Did. de Mid. et de Chir. Prat. 87-8.) Rostan found these nerves flattened, diminished in cali- bre, in a state of atrophy, of a reddish appearance like a small arterial tube, and without any resemblance to the whitish cord which they ordinarily represent. {Re- AMAUROSIS. 329 cherches sur le ramollissement du cer- veau. 2d ed. 28—31.) Dr. Monteath, in a note to his translation of Weller's Man- ual of the Diseases of the Eye, states that on examining the sheaths of the optic nerves, he ascertained in one instance that their medullary matter had been complete- ly removed; and a case is recorded by Travers {Synopsis, p. 442-3) in which the optic nerves to and from the ganglion optic um were shrunk or rather absorbed ; so that they appeared flat instead of cylin- drical, and of a straw colour instead of a silvery whiteness. In slitting, and cutting them across, he says it was evident that only the sheath ofthe nerve remained, the medullary substance had entirely disap- peared. Demours found the nerve in nearly half its extent as it were in a state of suppuration, and reduced into a liquid of dirty white colour. {Traiti des malad. des yeux. I. 74-6.) Beer {Lehre, II. 580-1) gives the following account of the morbid changes which he has met with in this form of amaurosis. "The diseased alterations which I have hitherto met with, have consisted of true induration of the optic nerve, and adhesion of it to the sheath. Within the cranium, the gray and completely shrunken optic nerves, as far as to their connexion with the brain, have been without a trace of medullary matter; the thalami nervorum opticorum have had their natural appearance; the neurilema has been destitute of medulla, tough, not easily torn, and has consisted of a simple vascular membrane. On one occasion, though both eyes were perfectly blind, and had been so for the same length of time, the nerve of the left eye only with its neu- rilema were in this state of atrophy as far as the sella turcica, while that of the right eye was indurated and closely adherent to its sheath, without being in the least shrunk. Between the union of the two nerves and the brain, they were in a per- fectly normal state. The left corpus stri- atum was so hard that it required a strong and sharp scalpel to divide it, but its col- our and form were natural. The plexus choroideus was wanting on this side. In three amaurotic patients of this kind, I found hydatids in the sheath of the optic nerve, the medullary substance being ap- parently pushed aside; and on the most careful examination, I could not discover the lenticular ganglion {Augennervenk- noten)." (Lawrence, 503.) ' Diagnosis. In speaking of the amau- rosis vvhich results from disease of the op- tic nerves or their sheaths, Beer states {Lehre, II. 578) that " it is developed slow- 23* ly, commonly in one eye only, seldom in both. A black cloud appears before the eye, and becomes gradually thicker, while the patient experiences an annoying dis- tortion of objects, without the smallest un- easy sensation in the eye or head; he only feels a slight sensation of pressure in the back of the orbit, as if the globe were pushed out of the socket, of wh'ch, how- ever, there is no appearance. In the very beginning of the affection, the pupil is con- siderably dilated, and the pupillary margin of the perfectly motionless iris is angular at various points, so that the pupil often presents an irregular pentagon or hexa- gon. Gradually, but very slowly, a glau- comatous degeneration of the vitreous hu- mour, and even of the lens, occurs, form- ing the only kind of glaucoma that I have hitherto seen without any varicose affec- tion of the blood-vessels of the globe. At last the eye is visibly lessened, but com- plete atrophy does not take place." (Law- rence, p. 502.) Treatment. It must be evident that little can be expected from medicine, in this form of amaurosis; all that can be done is to re- lieve some of the concomitant symptoms. 3. Amaurosis from affections of the Encephalon. Amaurosis is a constant re- sult not only of all lesions of the ence- phalic organs of vision, as from plethora and its opposite condition anemia; from ir- ritation and its consequences, congestion, softening, induration, suppuration, &c. but it is also produced by the compression of those organs from tumours of various kinds, tubercles, hydatids, fungous hema- todes, sanguineous and serous effusions, abscesses, &c. in other parts of the brain; and finally, exostosis, caries or various sar- comatous growths of the bones, especially where these diseases are so situated as to interfere with the portion of the brain with which the optic nerves are in relation. Plethoric persons are in general able to produce a degree of congestive amaurosis at will, by stooping, tying their neckcloth tight, and the like. (Mackenzie, p. 796.) Boerhaave relates the case of a man, who, whenever he was intoxicated, laboured under complete amaurosis, which came on by degrees, increased with the quantity of wine, and after the intoxication went off, his vision returned. {De Morb. Ocvl. p. 75.) On the contrary, temporary amauro- sis is frequently witnessed from exhaustion. When syncope is produced by loss of blood, sight appears to be the sense which first fails, and which recovers last. Examples of amaurosis resulting from abscesses in the brain, are reported by Ballonius, {Pa- 330 AMAUROSIS. radigmata, Hist. 7.); by Pelargus, {Med. Jahrg. III. 198.) ; Peyronie, {Mim. de VAcad. Roy. de Chir. I. 212.) ; Schaar- schmid, {Berlin Nachrichte, 1740, No. 26.); Langenbeck, {Neue Bibl. I. 61.); and Mr. Travers, {Synopsis, 143.) The latter author has recorded an instance in which a firm lardaceous tumour, of the size of a garden bean, situated on the same side as the blindness, compressed the optic ganglion and nerve at its origin from it. (p. 151.) Mr. S. Cooper has seen a case of amaurosis in which a tumour as large as a middling-sized apple was found in the anterior lobe of the brain, attended with protrusion of the eye and vast destruc- tion of the bones. Mr. Travers has seen amaurosis produced by a medullary fungus of the brain. A case occasioned by disease ofthe thalamus, is related by Villenei ye {Journ. de Mid. continui, 1811, Feb. p. 98); another of a tumour of the thalamus on the same side as the blindness, is re- corded by Ford {Med. Commun. I. No. 4); and other swellings in various parts ofthe brain are described in Ephem. Nat. Cur. Dec. 3. Ann. 9 and 10. Obs. 253; De Haen's Ratio medendi, P. 6. p. 271; Journ. des Scavans, 1697; Muzell's, Wahrnehm. II. No. 13 ; Plater, Obs. I. 108; Thomann, Annalen fur 1800, p. 400, &c. (Cooper's Surg. Did. I. 42.) For practical purposes, it will be con- venient to arrange the lesions of the brain which give rise to amaurosis, in three classes: 1st. Degenerations both of the cephalic organs of vision and of the other parts of the brain; 2d. Congestion, whe- ther resulting from irritation, general ple- thora, or impediments to the circulation; and 3d. Anemia of the brain. This is manifestly not the place to enter into the consideration of these aflections. (See Brain, Tumours, Plethora, Anemia, &c.) But as in amaurosis from these lesions, the treatment must in many instances be regu- lated by the causes which give rise to them, it may be expected that we should briefly enumerate those causes. The first class of disorders may be pro- duced by all causes capable of exciting irritation of the brain, and deranging its nutrition; as external injuries, and the long-continued action of the causes next to be enumerated. The causes ofthe sec- ond class, are general plethora, or what- ever tends to favour congestion in the brain, as occupations requiring a stooping posture, lying with the head very low at night, pressure on the jugular veins by tumours, or other impediments to the flow of blood from the head; prolonged expo- sure to the sun, forced exertions of the mind, excess of passion; the pregnant and puerperal states; suppression of accustom- ed discharges, as of hemorrhages, or from hemorrhoidal humours, of perspiration, of the menses, of the secretion of milk, of the lachrymal secretion, or that from the Schneiderian membrane; the stoppage of suppuration from the ear, the drying up of issues or of old ulcers; the suppression of cutaneous eruptions; the excessive use of stimulants; the deglutition of poisonous substances, as belladonna, stramonium, solanum dulcamara, fish poison, various fungi, animal poisons, opium, tobacco, the excessive u6e of snuff, &c.; and occasion- ally by certain articles of diet. Beer states that he had twice under his care, a female who was attacked with amaurosis whenever she drank chocolate, and that on leaving off this food, she never after- wards had any complaint of her eyes. In this class may also be enumerated, a load- ed state of the bowels, and the irritation of these organs by worms, and indigestible or foreign matters. It is well known that the presence of worms in the intestinal canal sometimes gives rise to all the symp- toms of hydrocephalus, strabismus, impair- ed vision, &c. A case of complete amau- rosis in a child, which was instantly cured on a worm being puked up, is recorded by Mr. Welsh, {Trans, of Massachusetts Med. Soc. I. 87); and another is related by Mr. Lawrence, in which this symptom immediately disappeared on the rejection from the stomach, by vomiting, of a bead. Metastasis to the brain of rheumatism and gout, seems also to be a cause of amauro- sis, though the existence of such an affec- tion as gouty or rheumatic amaurosis, as described by Beer, has been justly doubted by Mr. Lawrence. The causes which induce anemia of the brain, or exhaust the vital energies of this organ, are excessive hemorrhage, leucorr- hoea, menorrhagia, diarrhoea, and other dis- charges ; profuse secretions of urine (dia- betes), of saliva (ptyalism), of seminal fluid from too frequent venery, or from masturbation, of milk from protracted suckling, &c.; and in this category are usually arranged typhoid fevers. The diagnosis of this form of amaurosis can only be determined from a careful and minute investigation into the history of the case, and will often be involved in great obscurity, both from the inherent difficulty of the subject, and the inaccuracy with which patients describe their feelings, and the imperfect account they give ofthe pro- gress of their symptoms. When amaurosis arises from morbid changes in the brain or skull, it usually attacks, according to Beer, AMAUROSIS. 331 both eyes together, or at least one very soon after the other; the blindness also commences very slowly, with appearances as if every object looked at were perverted or disfigured. There is, however, no black cloud, but rather an obscurity or confusion of every object. The disease in this stage is also accompanied with frequent giddi- ness, ugly luminous spectra, and, for the most part, with aversion to light, uncom- monly lively motions of the iris; a con- tracted pupil, angles in the upper and lower portions of the pupillary margin of the iris; an evident turgescence of the blood- vessels of the eye, gradually augmenting with most violent head-ache into actual cirs- ophthalmia; frequent convulsive motions of the eye and eyelids, and strabismus of one or both eyes, ending in a true devia- tion of one or both of these organs from their natural positions. Under these symp- toms, vision is afterwards entirely abol- ished ; and the head-ache, though subject to remissions, grows so much worse, extend- ing back to the spine, that the patient is often nearly frantic, and, indeed, after a time, a destruction of the external senses takes place, followed by that of the intel- lectual faculties. The first of the exter- nal senses lost, is always the hearing, which infirmity is next followed by loss of smell, or taste, or both these senses toge- ther, and then the memory, and other in- tellectual powers, decline. In this stage of the disorder, the eyeball not unfre- quently protrudes from the orbit, a patho- gnomonic symptom, to which Beer at- taches great importance as an infallible criterion of a diseased state of the bones of the orbit, of the parts which invest this cavity and of the optic nerve and dura ma- ter, in the sella turcica. In such cases, complete mania now usually follows, and this sometimes in its most violent form, unless the patient happen to be first carried off by paralytic symptoms; life, under these circumstances, never lasting any considerable time. (Cooper's Surg. Did. I. 42). Treatment. The treatment of amau- rosis has been, almost without exception, entirely empirical; but in none ofthe forms has it been more so, than in that under consideration. To enter into the conside- ration of all the measures that have been employed for the relief of this symptom, would occupy many pages, and be produc- tive of little advantage, as authors have not designated the forms of amaurosis in which the remedies they have administered were successfully employed, and the tenta- tive practice hitherto resorted to, is not only discreditable to the practitioner, but often subjects the patient to great distress and protracted pain, without affording the slightest relief. It is only by acquiring a knowledge of the pathological state from which this symptom results, and the cause of that pathological condition, that we can hope to arrive at any rational method of treatment, or be enabled to determine the cases which are curable, and those in which the subjection of the patient to se- vere remedies is an unjustifiable piece of cruelty. From the extremely diversified and even opposite conditions which give rise to this symptom, relief has sometimes followed the administration of a great va- riety of remedies, and of very different properties; and as the character of the cases has been but imperfectly or not at all designated, each of these remedies has been highly lauded by the successful em- ployer, as a cure for amaurosis; whilst con- stant disappointment has resulted from its administration by others. If amaurosis is, as we think that we have shown it to be, not a disease, but a symptom resulting from various causes, this disappointment need not create surprise. The details of the treatment of this symptom belong to the affection from which it arises: all that can be required here, is, after pointing out these affections, to notice the general indications for the cure. Amaurosis resulting from the first class of causes, is for the most part hopeless: it is here but one, and often not the most im- portant of the evils produced by degenera- tion of the brain or its envelope, and re- quires no special treatment The treatment of amaurosis from the second class of causes, must to a conside- rable extent be regulated by the particular cause. General plethora is to be relieved by bleeding, general and local, low diet, and the usual antiphlogistic measures: (see Plethora). Local plethora is to be re- moved by topical bleeding, and revulsives, and the removal of the cause of the con- gestion. Stooping postures, or whatever favours the flow of blood to the head, should be avoided. When there has been a sup- pression of an accustomed discharge, this should be restored, or another substituted in its place. When it results from the in- gestion of a foreign or poisonous substance, the stomach should be emptied by an emet- ic ; when from worms or a loaded state of the bowels, the latter should be evacuated by proper remedies: (see Worms, Consti- pation, &c). Great confidence has been placed in emetics, followed by what are termed resolvents, by Schmucker, Rich- 332 AMAUROSIS. ter, and Scarpa, not only in those cases in which the symptom manifestly arose from sympathy with disordered stomach, but generally in cases of imperfect amau- rosis. Schmucker {Chirurg. Wahrn. Th. I.) states that he has often seen soldiers become suddenly blind on forced marches, particularly in hot weather, and when they had much to carry. A venesection imme- diately, and the day after three grains of tartar emetic, generally restored 6ight If recovery did not take place, the jugular vein was opened, the medicine repeated the following day, and a blister applied; which means were generally successful. The other remedies had probably more to do with the cure than the emetic. Some- times this writer gives the Tartar Emetic so as to produce only nausea. Richter {Anfangsg. der Wundarzneykunst. III. 5 448) recommends emetics and purgatives where there is reason to suspect the exist- ence of acrimonious matters in the prima? via?; and he relates elsewhere {Comment. Soc. Reg. Scient. Gcetteng. IV.) the case of a patient, who had become blind after being in a violent passion, whom he restor- ed to sight by an emetic administered the following day. Scarpa {Treatise, p. 458, &c.) says that, " by an attentive examina- tion ofthe nature and causes ofthe imper- fect amaurosis which admits of a cure, it is found, from the careful observations of Schmucker and Richter, that this disease is most frequently derived from a morbid excitement or irritation in the digestive or- gans, from sordes, or from worms, espe- cially in children, either alone, or accom- panied with general nervous debility, in which the eyes participate sympathetically. Agreeably to these principles, in the greater number of cases of recent imperfect amau- rosis, the principal indication of cure which the surgeon ought to fulfil in the treatment of this disease, is that of unload- ing the stomach and prima? via? of the cru- dities, worms or morbific stimuli, and af- terwards of strengthening the gastric sys- tem, facilitating the digestion, and at the same time exciting the whole nervous sys- tem, and particularly that of the eyes, which are affected and rendered torpid by a sympathetic connexion." " With respect to the first part of the treatment of imperfect amaurosis," he adds, "the intention is perfectly answered by emetics and internal resolvents (antiphlo- gistic purgatives). In the class of emetics experience has taught that the antimonium tartarizatum, is preferable to every other, and that when given afterwards, in small and divided doses, it answers the purpose of a resolvent medicine, the action of which may be increased by conjoining it with gummy or saponaceous substances. In the treatment of the imperfect amauro- sis, therefore, which is most frequently sympathetic, and depending on acrid mat- ters in the prima? via?, it will be proper at first, in the greater number of cases, to dissolve, for an adult, three grains of tar- tarized antimony in four ounces of water, of which two table-spoonfuls may he taken every half-hour, until it produces nausea, and afterwards abundant vomiting. On the following day he should be ordered to take the resolvent powders, composed of one ounce of the crystals of tartar, and one grain of the tartarized antimony, di- vided into six equal parts, of which the patient should take one in the morning, another four hours afterwards, and the third in the evening, during eight or ten successive days. This medicine will usu- ally produce a slight nausea, and some evacuations of the bowels more than usual, and perhaps, after some days, even vomit- ing. But if, during the use of this opening powder, the patient make ineffectual efforts to vomit, and complain of a bitter taste and want of appetite, without any amendment of sight, the emetic should be repeated, and even a third and fourth time, if the presence of the morbific stimuli in the stomach, bitter taste, tension of the hypo- chondria, acid eructations, and tendency to vomit, require it. For it not unfrequently happens, that the patient, on the first ac- tion of the remedy, throws up only water, with a little mucus; but on repeating the emetic, after the nauseating powder has been used for some days, a considerable quantity of yellowish-green matter will be thrown up, which will greatly relieve the stomach, head, and eyes." (p. 458-460.) " The respect," observes Mr. Lawrence, (p. 544), "justly due to the names of Rich- ter and Scarpa, would naturally lead us to try a mode of treatment which they have so strongly recommended. I have accordingly employed their plan in some instances which appeared favourable, but entirely without success. I have seen no case of amaurosis cured, nor even relieved, by such measures. On the contrary, after the ineffectual trial of emetics and nause- ants, I have removed the disease by the abstraction of blood, and the other treat- ment already-described. I have therefore entirely abandoned the use of emetics in amaurosis. I should not consider them safe, if general plethora, determination to the head, or active disturbance of the reti- nal circulation, were present." Except, in- AMAUROSIS. 333 deed, in the cases we have indicated, that is, where amaurosis results from the pres- ence of a foreign or poisonous substance, little, we should conceive, can be ex- pected from emetics, and where there is confirmed gastric irritation, jthe tartar emetic must of course aggravate it. Amaurosis from the third class of causes, requires tonics, and a removal of the de- bilitating causes from which it originates. If from protracted suckling, the child must be weaned; if from profuse evacuations, they must be arrested. It is sometimes necessary, however, in addition to these measures, to resort to revulsives, and even sometimes to topical depletion; while at the same time, tonic3, a nutritious diet, &c, are administered. Mr. Middlemore recommends in these cases the endermic application of strychnia immediately above the eye-brow. (See Anemia, Suckling, &c.) 3. Amaurosis from lesions of the ac- cessory nervous apparatus of vision. We have already shown that this apparatus consists of the fifth pair of nerves, the great sympathetic, and the third and sixth pair of nerves. We shall consider the effects upon vision of the lesion of each of these nerves, separately. A. From lesion of the fifth pair. It has been known since the earliest periods of our science, that injuries in the neighbour- hood of the fifth pair of nerves impaired vision, though the reason why this occurs is the discovery of modern times. Thus, Hippocrates observes, " The sight is ob- scured in wounds which are inflicted on the eye-brow, or a little higher." (Coan Prognostics, No. 510.) Examples of am- aurosis from this accident have been re- corded also by Morgagni, Camerarius, Pinel, Sabatier, Beer, Wardrop, Tra- vers, Mackenzie, &c, and we have our- selves repeatedly met with them. Injuries, compression, and even irritation of this nerve, from organic lesions of the brain, or its membranes, the bones of the crani- um, or parts in the course of its branches, seem to be constantly attended with im- pairment of vision. Dr. Copland has met with a case in which the sight of one eye was nearly lost in consequence of the pressure upon the frontal branch of the fifth pair of that side, by a common boil; when the boil broke, vision was soon re- stored. The extirpation of a cyst, situated three inches above the left eye-brow, was, in a case related by Demours, followed by amaurosis the day after the operation. The impairment of vision, from wounds of this nerve, sometimes instantly follows the accident, at others it does not come on until long after the wound has healed; and according to Wardrop (II. 180), it is only when the frontal nerve is wounded or in- jured and not entirely divided, that amau- rosis is produced; for he says that im- pairment of vision following a wound of this nerve may be sometimes cured by completely dividing the trunk nearest its origin. "A gentleman received an ob- lique cut in the forehead, which, from its direction and depth, must have injured the frontal nerve. The wound was not accompanied by any severe symptoms, and soon healed. But afterwards the vision of this eye began to fail, and in a few months was completely destroyed ; the pupil was much dilated, the iris was not influenced by variations of light, and had slight trem- ulous motions. A sailor got a blow on the edge of the orbit, from a ramrod, during an engagement, at the place where the frontal nerve passes on the brow. The vision of that eye was instantly destroyed, and when we saw him several years after the accident, the eye remained amaurotic, with a dilated and immoveable pupil: a cataract had formed in the other eye. An officer at the siege of Badajos, received a deep wound on the eye-brow, by a piece * of a shell, which, from its direction, must have injured the frontal nerve. Great in- flammation and pain succeeded the wound, the vision ofthe eye became gradually im- perfect, and, after a few months, was en- tirely lost. The pupil was very much di- lated and immoveable, and the crystalline lens opaque." (Jacob, p. 66.) Amaurosis results not only from injury of the supra-orbitar branch of the fifth pair of nerves, but also from lesions of other branches of this nerve. Beer men- tions an instance in which it was caused by injury of the infra-orbitar branch; and Jacob witnessed the case of an officer, in whom a ball wounded some branches of the portia dura, in which the injury was followed by amaurosis. Professor Galen- zowsky has recorded a case in which it resulted from irritation of the superior maxillary branch of the fifth pair. The patient, a man 30 years of age, of good constitution, was suddenly attacked with a violent pain shooting from the left tem- ple. This pain, at first remittent, in about two months suddenly became intense, and the patient found that he could not see with that eye. About a year afterwards, the pain in the eye became so violent that the patient went to Wilna, determined to have the eye extirpated, if no other rem- edy could be found. Professor Galen- zowsky found the eye totally insensible to light, with the pupil dilated, and no other visible alteration. The pain, which was 334 AMAUROSIS. not then so severe, consisted in violent occasional pricking or darting sensations in the left temple and parts around the eye. The first molar tooth of the left side was carious; it had not caused much uneasi- ness; and the tooth-ache, when it ex- isted, had not coincided with the pains in the temple and eye. The professor determined on removing this tooth, and having done so, was surprised to see a small foreign body at the extremity of the fang. When drawn out, it proved to be a small splinter of wood, about three lines in length, which had probably been introduced in picking the teeth. The pain ceased almost entirely, and on the same evening the eye began to be sensible to light Vision gradually improved, so that, on the ninth day, the patient could see as well with the left eye as with the right, after a blindness of thirteen months. {Archiv. Gin. XXIII. 261.) Mr. Travers has seen an incipient amaurosis distinctly arrested by the extraction of a diseased tooth, when the delay of a similar opera- tion had occasioned gutta serena, on the op- posite side, two years before (p. 299); and Richter relates the case of a lady who had been blind for years, but experienced a short recovery of her sight on having a tooth extracted. {Anfangsgr. &c. 1. III. kap. 14.) Defective vision frequently at- tends neuralgia in the vicinity of the eye. The remedy upon which most reliance is placed for the cure of amaurosis from injury of the frontal nerve, is the division of the nerve. " The only hope of relief," says Mr. Guthrie, " that we are at present acquainted with, lies in a free incision made down to the bone, in the direction of the original wound; and even of the efficacy of this, I am sorry I camot offer testimony from my own practice, having failed in every case in which I tried it." Mr. Hennen says that he has met with one or two cases of amaurosis from wounds of the supra-orbitary nerve, in which the perfect division of the nerve produced no alleviation of the complaint, but after some time, the eye partially recovered. {Mili- tary Surgery, p. 350.) We have in sev- eral cases had recourse to the moxa,— sometimes unsuccessfully, at others with great advantage. We have now under treatment, a gentleman, who, upwards of a year since, was thrown from his gig, and severely injured. Among other wounds, was one over the eye, caused by that part striking the edge of a cask, against which he was violently thrown. About two months since he applied to the writer, with paralysis of the upper lid and of the abductor muscle of the eye, dilated pupil and imperfect amaurosis. The ap- plication of a moxa over the seat of in- jury produced a decided amendment in the ptosis; and a second application, two weeks subsequently, completely re- moved this affection and caused a great improvement in the vision of the eye. There still remain paralysis of the abduc- tor muscle and a slight indistinctness of vision, for which we propose to apply a moxa over the mastoid process. Mr. Hey {Med. Obs. and Inquir. V. I.) narrates a case of amaurosis following a wound of the frontal nerve, cured by electricity, and it appears to us that it is in such cases most good is to be expected from this remedy. The mode in which Mr. Hey applied electricity in the above case, was as fol- lows. The patient was first set upon a stool with glass feet, and had sparks drawn from the eyes and parts surrounding the orbits, especially where the superciliary and in- fra-orbitary branches of the fifth pair of nerves spread themselves. After this ope- ration had been continued half an hour, she was made to receive, for an equal time, slight shocks through the affected parts. In a few days, sight began to return, and in less than three months it was quite re- stored. Majendie has employed with suc- cess in some cases of this form of amau- rosis, acupuncturation, with galvanism. He introduced one needle into the frontal nerve, another into the upper maxillary, and brought the needles into repeated con- tact with the two poles of a voltaic pile. {Journ. de Phys. VI. 156.) It is in this form of amaurosis, also, that recourse may be had, with advantage, to the application of small blisters (rather larger than half a dollar) to the head, as employed by Du- puytren. He applies them successively to different parts of the head and forehead, placing on a fresh one as soon as the for- mer has ceased to discharge. When the fifth pair of nerves are af- fected within the cranium, in addition to more or less imperfection of vision, there are inflammation of the eye ending in ul- ceration and opacity of the cornea, insensi- bility of the conjunctiva and the other parts supplied with common sensation by the fifth pair, with loss of taste in the cor- responding side of the tongue. In a case of a young man, an epileptic, recorded by M. Serres {Anat. Comparie de Cerveau. II. 67), the ganglion of the fifth pair on the right side was found, on dissection, to be swoln, of a yellow colour, and less vas- cular than usual; and the nerve where it AMAUROSIS. 335 seems inserted into the pons Varolii, was changed into a yellow gelatinous substance, like the ganglion, which substance trans- mitted small processes into the pons, in the direction of the fasciculi of the insertion of the nerve. In this case the right eye, eye-lids, and half of the tongue, had been during life deprived of sensation, while the same parts on the opposite side possessed it perfectly. Little, if anything, is to be expected from medical treatment in such cases. B. Amaurosis from affections of the great sympathetic. Ir the commence- ment of this article, we described the con- nexion existing between the retina, iris, and great sympathetic. This connexion explains the derangement of the functions of the eye which results from some wounds of the neck: may it not also explain the development of amaurosis from gastro- intestinal irritations, in some cases? We have already referred the defect of vision arising from this irritation to the transfer- ence of this last to the brain, and that such is generally the case is shown by other symptoms of cerebral affection being usu- ally present; but this is not always the case, and in such instances it is possible that the irritation may be communicated to the retina and iris, by the course indi- cated, (see Ribes, O. C. 99.). C. Amaurosis from an affection of the third pair of nerves. This pair, as has been proved by Mr. Mayo, is requisite to the motions of the iris, and it is also dis- tributed to the muscles of the globe, except the abductor. The imperfection of vision from lesions of this pair of nerves, is the result of the imperfect action of the pupil and of the inability to direct the eye pro- perly to objects. Little attention has been bestowed upon this form of amaurosis. D. Amaurosis from an affection of the sixth pair of nerves. Mr. Jacob says, that he has seen a well-marked case of amau- rosis with distinct and undoubted paralysis of the abductor muscle, disabling the pa- tient from turning the eye outward, and obviously depending upon compression or disease of the sixth pair of nerves (p. 66). We have met with a case of the same kind. The indistinctness or confusion of vision appears to depend upon the loss of parallelism of the eye. Most benefit may be expected in these cases from moxas to the mastoid process, and repeated blisters. See Retinitis, Hemeralopia, Nyctalo- pia, Muscat Volitantes, &c. &c. Bibliography.—Heister. Apologia et uberior illustratio Systematis sui de calarada, Glauco- mate, et Amaur si. Altorf, 1717. (Eme. Diss, de Amaurosi. Leipzic, 1748, and in Haller, Disp. Chir. II. 265. Janin. Letlre sur une maniere de trailer la goutle sereine. Joum. de Med. 1773. XXXIX. 440. Schmucker. Chirurgische Wahrnehmwigen. Berlin, 1774.—Ibid. Vermischt. Chirurg. Schrif- ten. Berlin, 1780. Trnka. Historia amaurosecs, &c. Vienna, 1781, 2 vols. 2d ed., ibid, 1787. Richter. De amaurosi, in Nov. comentar. acad. Gottingensis. IV. 77, (1774).—in Obs. Chi- rurg. II. Gottingen, 1775. Hey. An Account of the effects of Electricity in the amaurosis, in Med. Obs. and Inquiries. V. 1. London, 1776. Richter. Anfangsgrunde der Wundarzneik- unde. Gottingen, 1790. Ware. Chirurgical observations relative to the eye. London, 1792.—A description of four cases ofthe gutta serena, cured by electricity: To which is added two cases ofthe like nature, in which the chief means of cure ivas a mercurial snuff. Mem. of Med. Soc. of London. III. 309. (1792.) This snuff is composed of one grain of Turpeth min- eral, and eight grains of powdered liquorice root. One fourth of the powder to be snuffed up the nose once or twice in the day. To render the powder more effectual, Mr. W. directed the pa- tient to inhale the steam of warm water into the nose previous to the use of the snuff G. Flajaxi. Collezione d'osservazioni, refles- sioni di chirurgia. Roma, 1803. IV. 173. De AVenzel. Manuel de Voculisle, ou diction- naire ophthalmologique. 2 vols. 8vo. Paris, 1808. D. G. Kieskr. Ueber die Na!.ur,die Ursachen, Kennzeichen und Heilung des Schwarze Staars. Gottingen, 1811. 8vo. Beer. Lehre von den Augenkrankheilen. Wien, 1817. Langenbeck. Refiexionen uber die Natur, Ursachen und Heilung des Schwarzenslaars.—In Langenbeck's neue Bibloth. de Chirurg., &c. I. 51—187. Hanover, 1815. Scarpa. Osservazicmi sulle malattie degli oc- chi. Venice, 1802. Translated by Briggs, 2d Ed. London, 1818. 8vo. Ware. Observations on Gutta Serena. 3d ed. London, 1812, 8vo. Benedict. Monographic des Grauenslaars. Breslau, 1814, 4to. Wardrop. Essays on the morbid anatomy of the human eye. II. chap. 45. London, 1818, 8vo. Guilliq Nouvelles recherches sur la catarade et la goutle sereine. 2d ed. Paris, 1818. Stevenson. On the nature, fyc. of the different species of amaurosis. London, 1821. L. F. Gondret. Considirations sur Vemploi du feu en midecine, suivies de Vexposi d'uit moyen ipispastique propre a supplier la cautiri- sation, &c. (pommade ammomacale). 2d. ed. Paris, 1819.—Observations d'amaurose commu- niquies an cerclc midical. Paris, 1820.—Refu- tation du rapport de M. Lisfranc a I'Acad. Roy. de Med., en dale du 5 Mai, 1830. Paris, 1830. Majendie. Note sur Vapplication directe du galvanisme mix verfs de Vorbite, et de Vemploi de ce moyen pour la cure d' I'aumorose. Journ. de Phys." VI. 156. Paris, 1820. Demours. Traiti des maladies des yeux. Paris, 1818. 3 vols. 8vo. and 1 vol. PI. 4to.—Precis des maladies des yeux. 8vo. Paris, 1821. H. Serre. De la cautirisation de la cornee comme moyen propre d corriger d'une maniire promple d sure les aberrations de la vue avec di- latation des pupilles. Ephemeridcs medicales de Montpelier, 1827. IV. 113. 386 AMBER G. Frick. A Treatise on diseases of the Eye. Baltimore, 1823. B. Travers. A Synopsis of the diseases of the Eye and their treatment. 3d ed. London, 1824. Benedict. Art. Amaurosis, in Encyclopiidi- schea Wiirterbuch der Medicinischen Wissen- schaften. Berlin, 1828. Sanson. Art. Amaurcse, in Diet, de Med. et de Chirurg. Prat. Paris, 1829. J. A. Robertson. Remarks on Amaurosis, vyith cases. Edinburgh Med. and Surg. Journal. XXXII. 291. (1829.) J. J. Knox. Remarks on Amaurosis, In Glas- gow Med. Journ. III. 124. Glasgow, 1830. Middlemore. On the utility of strychnia in certain forms of amaurosis. Midland Med. and Surg. Reporter. II. and III. (1830-1.), and in American Journ. Med. Sc. VII. 243; IX. 228. The forms of amaurosis to which this remedy is '•onsidered applicable, will be pointed out in the articles Retinitis, and Nux vomica. S. Cooper. Dictionary of Practical Surgery, with notes and additions by D. M. Reese. M. D. New-York, 1830. 8vo. Weller. Traiti Iheorique et Pratique des maladies des yeux. 3ded. Translated into French by Dr. Jallat. Paris, 1832; also into English by Dr Monteith. Glasgow, 18—. Rognetta. Recherches sur les causes et le si- ege de Vamaurose. Rev. Med. Dec. 1832. p. 371. W. Mackenzie. Practical Treatise on the diseases of the Eye. London, 1830. 8vo. and Bos- ion, 1833. Marjolin. Art. Amaurose, in Diet, de Med. 2d ed. Paris, 1833. W. Lawrence. A Treatise on the diseases of the Eye. London, 1833. I. Hays. AMBER. (Derived from the Arabic.) Succinum, Lat; Succin, Ambre jaune, Karabi, Fr.; Bernstein, Germ.; Ambra, Ital.; Sucino, Span. Amber is a peculiar fossil resin, of ve- getable origin, occurring usually in small, detached, irregularly rounded masses, in tertiary formations in different parts of the world. It is found in France, Switzerland, Sicily, Greenland, and other countries; but most abundantly in Prussia, along the uthern coast of the Baltic Sea, whence the principal part of the amber of com- merce is derived. In the United States, it has been discovered at Cape Sable, in Ma- ryland, and in New-Jersey. It is usually associated with lignite and bituminous wood, but occasionally with clay mixed with the debris of trees, probably belong- ing to the natural order, conifer at. Properties. Amber is a brittle, inflam- mable solid, of a vitreous fracture, usually transparent though occasionally opaque, and capable of receiving a fine polish. Its colour is usually different shades of yellow, but sometimes it is reddish-brown, or deep brown. It is tasteless, and, when cold, has no smell, but when heated, it exhales a pe- culiar aromatic odour. Its density varies from 1.65 to 1.7. Exposed to heat, it melts at the temperature of 548°, with alteration of properties. Subjected to distillation in a retort by means of a gentle heat, it yields first a sour liquor; next an acid sublimate which is deposited in the neck of the retort; afterwards a colourless oil, becoming brown and thick; and, towards the end of the operation, a light yellow sublimate, which collects in the posterior part of the neck. Throughout the whole process, a small portion of imflammable gas is disengaged. The acid sublimate is called succinic acid, and exists ready formed in the amher. The sour liquor con- tains this acid, as well as a small portion of acetic acid. The oil is empyreumatic, and is called oil of amber. The yellow sublimate is a kind of pyretine, so called by Berzelius; that is, a substance, analo- gous to resins, obtained from ordinary re- sins by destructive distillation. It was dis- covered by Vogel, by whom it was called the volatile resin of ambi r. Composition. According to Berzelius, amber is a complex substance, containing the following proximate principles:—A volatile oil; two resins, soluble both in alco- hol and ether; succinic acid, amounting to 4£ per cent.: and a bituminous substance, which resists the action of all solvents, and constitutes the principal part of the amber. Its ultimate constituents, apart from the ashes, are, according to Drapiez, 7.31 of hydrogen, 80.59 of carbon, and 6.73 of oxygen; and the ashes, amounting to 3.27 per cent, consist of 1.54 of lime, 1.1 of alumina, and 0.63 of silica. Pharmaceutical uses. Amber is used in pharmacy for the preparation of suc- cinic acid and oil of amber. Succinic acid will be noticed in its alphabetical place, but the oil will be described here. Oil of amber—Oleum Succini—is ob- tained by distilling powdered amber, (mix- ed with an equal weight of sand to pre- vent it swelling too much), with a gra- dually increasing heat, by means of a sand bath, from a retort into a receiver. The retort is generally directed to be of glass; but as this substance will not bear the re- quisite degree of heat for obtaining the whole of the oil, it is better to use an iron or porcelain one. The oil comes over to- gether with an acid liquor, on the surface of which it floats, and may be separated by means of a separating funnel. As thus obtained, it is an empyreumatic viscid li- quid, of a yellowish-brown colour, and pe- culiar, characteristic smell. In this state, it is impure, and fit only for external appli- cation, and for the preparation of artificial musk. For internal employment, it re- AMBER.—AMBERGRIS. 337 quires to be rectified, when it takes the name of Oleum Succini Redificatum. The rectification is performed by distilling the oil with six times its volume of water, until two-thirds of the water come over. The oil which distils at the same time, and floats on the surface of the water, is then separated, and preserved in well-stop- ped bottles. In the Swedish Pharmaco- poeia, it is directed to be purified by a very gentle distillation from wood charcoal, the operation being suspended as soon as the oil comes over coloured. Rectified oil of amber, when perfectly pure, is colourless, as fluid as alcohol, and of the specific gravity of 0.758. As it usually exists in the shops, however, it has a light yellowish-brown colour. It has a strong, peculiar odour, and a hot acrid taste. It is insoluble in water, soluble to a certain extent in diluted alcohol, and in all proportions in anhydrous alcohol. By exposure to the light, it slowly changes in colour and consistence, and becomes at last black and solid. When dissolved in 24 parts of alcohol of 0.83, and the solu- tion mixed with 96 parts of water of am- monia of 0.916, the oil is disengaged, but held in suspension, so as to form a milky fluid, having a modified odour of ammonia, called eau de luce, or aqua lucice, some- times employed as an excitant in fainting. (Berzelius.) Artificial musk {moschus factitius) is prepared, according to Berzelius, by add- ing, drop by drop, three parts of fuming nitric acid to one of unrectified oil of am- ber. The acid is decomposed, and the oil is converted into an acid resin, which is to be kneaded in pure water until all the ex- cess of acid is removed. The substance which remains is yellowish-brown, viscid, and of a peculiar smell, which recalls the odour of musk. It reddens litmus, and dis- solves sparingly in water and more abun- dantly in alcohol. It consists, according to Setterberg, of three resins, two soluble in boiling oil of turpentine, the third, not. It is used in medicine in the form of a tincture, made by dissolving one part of it in eight parts of alcohol. Therapeutical Applications of Oil of Amber. In a rectified state, it is esteemed stimulant and antispasmodic. Accordingly it has been employed with advantage in various spasmodic affections, such as teta- nus, epilepsy, hysteria, whooping-cough, and infantile convulsions. The dose is from five to fifteen drops, given in the form of mixture, prepared with sugar or gum arabic. The unrectified oil is used with advantage as an embrocation to the affect- vou i. 29 ed parts in chronic rheumatism and palsy, and to the spine in the convulsions of in- fants. For the latter purpose, it should be mixed with an equal measure of lauda- num, and dduted with three or four parts of olive oil and of brandy. Franklin Bache. AMBERGRIS. Ambregris,Fr.;Grauer Amber, Germ. This is a solid, opaque, fatty substance, usually of a grayish brown or ash colour, variegated or striated with lighter marks. It is about the consistence of wax, has a less specific gravity than water, and is very inflammable. It possesses a strong odour somewhat resembling that of musk, and a vapid, oleaginous taste. It is in- soluble in water, but is dissolved by hot alcohol, ether, and the oils both fixed and volatile. It is by no means homogeneous in its composition, being generally mixed with fragments of fish and sepia;. From the analysis of Bouillon-Lagrange, it ap- pears that it is composed of adipocire, resin, benzoic acid, and carbon. {Ann. de Chim. XLVII. 68.) Pelletier and Ca- ventou, however, consider the adipocire of Lagrange to be a peculiar animal prin- ciple analogous to Cholesterine, and which they have termed Ambreine. {Journ. de Pharm. VI. 49.) But although this sub- stance forms the greatest proportion of ambergris, and has been deemed its essen- tial principle, it appears to be wholly in- active, whilst the virtues of the article re- side either in the resin or in an odorous principle distinct from either. There are several varieties of ambergris in com- merce, the relative values of which are very different. 1. White ambergris, which is scarce and but of little value, consisting almost wholly of Ambreine, with very little of the odorous principle. 2. Brown am- bergris, which has a peculiar unpleasant smell, and is externally smooth, as if cov- ered with a skin. 3. Black ambergris, which, though of a better quality than the two former, is by no means equal to 4, Ash-coloured or true ambergris. It should also be borne in mind, that there are few articles which are so liable to adulteration; much that is met with in commerce being a mixture of various resins and gums. The adulteration can always be detected by the aid of heat, as the true ambergris volati- lizes almost entirely, leaving only a trace of carbon, whdst all the adulterations or imitations of it give a more or less volu- minous residue of carbonaceous matter. Ambergris is found on sea coasts, float- ing on the sea, or in the intestines of the 338 AMBERGRIS.—AMBULANCE. t occurs of various ofthe gastric organs; and numerous writers spermaceti whale. shapes and sizes, in pieces weighing from half an ounce to two hundred pounds. It is chiefly found in the Atlantic ocean, on the coast of Brazil, on those of the islands of the Indian Archipelago, China, &c.; but it would appear that the finest has been obtained on the coast of Madagascar. The most opposite and ridiculous opinions have been promulgated as to the origin of this substance. Thus it has been consid- ered as a species of camphor, a vegetable gum, a marine fungus, a mixture of de- composed wax and honey, an excremen- tial product of certain birds, &c. The first author who attributed it to the whale was Marco Polo, but the credit of devel- oping its true origin is generally given to Dr. Swediar, who describes it as an in- testinal concretion or bezoar formed in the intestines of the spermaceti whale. This opinion is confirmed by the experience of the Nantucket whalemen {Med. Repos. 2 hex. I. 417), and is now generally enter- tained. Before the publication of the me- moir of Swediar {Philos. Trans. 1783), Dr. Boylston of Boston, and the Hon. Paul Dudley, both stated, in the same work, that it was produced by the whale : they derived their information from old and experienced whale-fishers, who all agreed that it occurred only in the male, and was contained in a cyst. {Philos. Trans., abridged. VII.) Within a few years, Vi- rey has asserted that it is a kind of adi- pocire, resulting from the spontaneous de- composition of certain species of sepia?. {Journ. de Pharm. V. 385.) From the circumstance of ambergris almost always containing fragments of the usual food of the whale, and from there being the strong- est testimony of its being found m the in- testines of these animals, there can be no doubt of the correctness of Swediar's supposition. This fact also controverts the theory of Pelletier and Caventou, that it is a kind of biliary calculus. Before leaving this subject, it may be mentioned that the information received by Boyle, from a Dutch merchant, that it is of vegetable origin {Philos. Trans., abrid. HI.), is not as devoid of truth as might be supposed, as Aublet, in his Histoire de la Guyane, mentions a vegetable substance produced by a tree in Guyana, which pos- have spoken of it in high terms in the treat- ment ofthe Neuroses. The older Pharma- copoeias contain numerous formula? for its administration. At the present time it is seldom employed as a medicinal agent, especially in this country; though, from the concurrent testimony of numbers of eminent practitioners as to its powers, it has perhaps been too much neglected in favour of articles of less value. It is now chiefly used as an ingredient in perfumes and other articles for the toilet. Bibliography.—G. Neumann. Disquisitio de ambra grisea. Dresden, 1736. J. Fothergill. Essay upon tlte Origin of Amber. London, 1744. Donadie. Dilails sur Vambregris des cotes de la Guyane. Journ. de Physique. XXXVI 232. F. S. Ratier. Traiti Elimentaire de Matihe Midicale. I. 103. T. Thomson. A System of Chemistry. 1st Am. ed., with Notes by T. Cooper. Philada. 1818. IV. 337. W. Ainslie. Materia Indica, &c. I. 15. N. Guibourt. Histoire abregie des drogues simples. II. 457. A. Richard. Elimens d'histoire naturelle mi- dicale. I. 100. Merat et De Lens. Didionnaire de Mature Midicale. I. 225. M. Desmarest. Traiii des Falsifications. 76. Paris, 1828. The Dictionary of Merchandise. 25. Philada. 1805. The Medical Repository. New-York, 1804. 2 Hexade. I. 417. R. E. Griffith. AMBLYAPHIA. (From apfti* dull.) Insensibility of touch or general feeling. (See Paralysis.) I. H. AMBLYOPIA. (From aufavs, dull, and o^tj, sight.) Aju/fovurtio, Gr.; Hebetudo visus. Lat. Dullness of sight. Hippo- crates appears to have employed this word to signify the dimness of vision to which old people are subject. {Aphor. XXXI. Sect. 3.) Some writers extend its signification to all the forms of dimness of sight, unattended with opacity in the trans- parent tissues of the eye; thus making it a generic term including several species, as far-sightedness, near-sightedness, im- perfect amaurosis, &c. By most modern writers, however, its meaning is restricted to the imperfection of vision arising from impairment of the nervous apparatus of this function. (See Amaurosis.) I. H. sesses most of the sensible properties of^ AMBULANCE. (From ambulare, to ambergris. Ambergris at one time enjoyed a high reputation in medicine, as a restorative and antispasmodic. Rhazes thought it was endowed with special action on the heart; Riverius recommends it in atony walk.) A term of military surgery, and meaning, in its entire signification, a mova- ble hospital or place of succour for the wounded, formed for the occasion, on a field of battle. Where large bodies of men are en- AMBULANCE. 339 gaged in warfare, one or more establish- ments of this kind ought to be attached to every division of an army, as a part of its staff or general service, and follow all its movements. All orders touching its duties should emanate from head quar- ters, except in some instances of special service ; its equipment ought therefore to be kept entirely distinct from the medical service of regiments, but so arranged as to be made auxiliary to the latter on any oc- casion requiring it. A properly organized ambulance must present the features of a hospital, but un- encumbered with heavy articles. As its duties last only for short periods on any particular occasion, as it establishes itself at a given point to wait the result of an action, attends for the time to the wound- ed, dismisses them to the next stationary hospital, and is off again immediately to follow the motion of head quarters, so it is necessary that every article not absolutely wanted, be omitted in its equipment, with the view of leaving its movements as light aud easy as possible. The intention of an ambulance is to af- ford to the wounded a prompt and easy transportation from the ranks while in combat, to concentrate a body of medical men upon any particular point or points of an extended line of battle, and to transport along with them their instruments, medi- cines, and nurses. This arrangement has a beneficial effect upon the minds of sol- diers, in affording to them the certainty that wherever they may be wounded, effi- cient assistance is at hand; also, in slight wounds many may return again to the ranks on being dressed,—besides which, it prevents those desertions from the line, professedly under the show of bearing off a wounded comrade, and which every man who has been engaged in an active cam- paign knows to weaken a force very much, when an action is protracted and severe. Humanity, and the efficiency of the ser- vice, therefore require that every numer- ous body of soldiers should have its flying hospital or ambulance. In the wars of a former period, the ap- pointments of hospitals were so imperfect that the quantity of misery was much in- creased, and it was frequently necessary to abandon the wounded, or to consign them to the doubtful and unskilful atten- tions of the inhabitants of the neighbour- hood of a field of battle. The greater per- manency of military establishments in modern times, and a well-digested system of management, have proved the impor- tance and economy of saving, by all proper assiduities, the lives of the soldiery, as great expense is avoided in enlistments, and skilful inured veterans are preserved for the line of an army, instead of unedu- cated recruits, who, from the novelty of the exposure and mode of life incident to military affairs, more readily become sick and unfit for duty. This innovation in the cause of humanity is traced by the French writers, to Henry IV., king of France and Navarre; indications of it may, however, be found in the ninth century, under the emperor Leo VI., who made war upon the Hungarians, Bulgarians, and Saracens. The following are the leading consider- ations in the establishment of an ambu- lance : The officering or personal—the material or mechanical part—and its duties. It is recommended that an army, in taking the field, be provided with every- thing necessary to the wants of the sick; as much disappointment is said to arise, even in Europe, from a dependence upon requisitions. It should therefore be cal- culated that in any given body of men, one fourth or a fifth at least will in a cam- paign have to pass through the hospitals, in consequence of wounds and accidents. To which we should also add, that if suc- cess follow the movements of an army, many wounded of the enemy must be treated, and both humanity and magna- nimity require that there should be no dis- tinction between our own wounded, and prisoners of war in that condition, but that the kindest offices be extended with an equal hand to both. Recollections of this kind, emanating from such circum- stances, are frequently the most precious of a soldier's life, and the feelings which they generate serve much to diminish the ferocity of war. In an active campaign, and with a small body of troops, the esti- mate of one fourth for wounded will prob- ably be found rather low. In the campaign of 1814, for example, on the Niagara fron- tier, in which the writer participated as Hospital Surgeon's Mate, and where about three thousand regular soldiers opened and conducted the operations, with but very few recruits during the summer, his opin- ion, from a general recollection founded upon nearly the whole of the wounded having either reported at or passed through the hospital at Buffalo, which was for the most of the time under his charge, is that one half of the whole number, or fifteen hundred at least, must have suffered from wounds of various intensities. It is, how- ever, difficult to obtain perfect accuracy except where tabular statements are kept, and as he has not preserved copies of re- 340 AMBULANCE. ports to head quarters, reliance must be placed upon the uncertain deductions of general reminiscence. The following calculations are founded upon the presumption of fifteen hundred men being wounded, which in European service would accrue to a body of six or seven thousand troops, and in our own, perhaps to a smaller number. We would also admit three general engagements, each productive of five hundred wounded, so as to make, in the whole campaign, fif- teen hundred men to be attended to. 1. In regard to the personal or officer- ing. There should be a chief surgeon— two junior surgeons—and six assistant sur- geons : a quarter-master—a steward—and fifty nurses, one to every ten men. The present practice of the French army is to enlist the latter for the specific duty, which has the advantage of securing experienced attendants, and of preventing companies from being broken up by a detail upon them for hospital duty, or by retaining their men in hospital for this purpose, which is a frequent cause of dispute be- tween hospital surgeons and the officers of the line. There ought also to be a num- ber of females for washing and cooking, but they will come in of course with their wounded husbands, so that it is unneces- sary to make regular enlistments of them. An experienced cutler, to keep instru- ments in order, ought to be attached to the ambulance. All the medical officers should be mount- ed, and a few extra horses for expresses allowed. 2. In regard to the material or equip- ment. There should be two carriages for the conveyance of instruments and hos- pital stores. The best form of them is that of a long box with a hip roof cushioned on the ridge, so that it may be occupied as seats. The box should be divided into two rows of compartments, each side having a lid moving on hinges. (See accompanying figure.) All the articles ought to be prop- erly classified and put away in these com- partments in such manner that they can be readily got at. Several complete sets of instruments, all the varieties of surgical dressings, including splints and bandages, medicines, camphorated spirits and brandy, ought to be on the list. There should be four carriages hung low on springs, each one being seven feet long by four wide: to the sides may be appended moveable seats, somewhat like those of the Irish jaunting car. They should have good thick mattresses at the bottom. The object of these carriages is to receive the wounded; the worst cases may be laid on the bottom, and a file of slighter wounded be placed on each side. (See accompanying figure.) These car- riages traverse the field of battle, and pick up the soldiers wherever they may be found. Several litters should also be kept, to be carried by the hand; two long poles con- nected by a blanket answer the purpose. Baron Percy has, with the same view, in- vented what he calls a Brancardier, a kind of hand-barrow, which may be taken to pieces at pleasure, and which must answer the purpose remarkably well. 3. The position of the Ambulance. When an action begins, the ambulance should be placed in the rear of the line, at a sufficient distance from the range of can- non-shot. Adjoining houses ought to be put in requisition, and if there be not enough of them, hospital tents should be erected, and an abundance of straw or hay for bed- ding got ready. In the French service, an order from head quarters commonly de- fines the position of the ambulance, which should be regulated by a sufficient propin- quity to the field of action—by its being on elevated ground—and near a supply of water. These dispositions being made, one por- tion of the corps should remain on the spot, to attend to the wounded who arrive; another ought to be as near as possible to the seat of action, with their carriages, to attend to the wounded who retire from the line, and they should be well furnished AMBULANCE.—AMENORRHCEA. 341 with all the apparatus for stopping hemor- rhage immediately, and should join in, as occasion may require, with the surgeons of the line. The action being over, and all the wounded assembled in the ambu- lance, the medical force concentrates itself on it, and then completes those operations which the hurry of their engagements may have suspended for the time. At as early a period as practicable, a classification of the wounded should be made—the lightest cases sent back to their regiments—the next in grade requiring some time for their recovery, detached to the nearest stationary hospital, and the worst cases retained. The usages of civ- ilized warfare do not permit any interrup- tion to them, even in case of the oppo- site party proving victorious; on the con- trary, it is incumbent on the victors to add, by every means in their power, to their comfort The surgeons who have most distin- guished themselves in this department of military surgery are Larrey and Percy, both of whom have contributed much to its perfection. The specification of each in- strument, and of the apparatus in use, would be a catalogue of a Surgical Arma- mentarium, which any well-educated man can make out, the items of which are, however, too numerous for present inser- tion. Bibliography.—Larrey. Mimoires de chi- rurgie mUitaire. Paris, 1812-17. Percy. Art. Despotats, in Diet, des Sciences Med. Paris, 1814. J. Goerke. Kurze Beschreibung der bei den konigl. preussischen Armee staat findenden Kran- kentransportmitlel fiir die auf d. schlachlfelde schwer Verwundeten. Berlin, 1814. In 8vo. 4 pi. J. C. Wendt. Uber die Transportmittel der verwundeten und kranken Krieger. Copenhagen, 1816. Begin. Art. Ambulance, in Diet, de Med. et de Chirurg. Prat. Paris, 1829. Lagneau. Art. Ambulance, in Diet, de Med. AMENORRHCEA. (From a priv., w, a month, and ptw, I flow.) The broad sense in which the term Amenorrhcea is frequently employed, though too compre- hensive for practical purposes, seems to be justified by its etymology. Thus it is made to signify, first, the failure of the menstrual action, at the period of life at which it is usual for it to appear. Second, the default of this action, after that discharge has been commenced, and for a longer or shorter time persisted in; and this suspension owing to the influence of any adequate cause, with the exception 29* of pregnancy, and suckling. Third, me- chanical or physical obstructions; as an imperforate hymen. Fourth, an impervi- ous os uteri. Fifth, its final cessation, at a remote period of female life. Sixth, the stoppage of this discharge, during the con- tinuance of some remote chronic affection; as phthisis pulmonalis, or other chronic diseases. Now, between the first and second, and between the third, fourth, fifth, and sixth, of these conditions, there cannot exist the slightest analogy, either anatomically, or pathologically. In the first, the defect al- most always arises from the imperfect de- velopment of the organs on which the menstrual discharge depends; namely, the uterus and ovaries. In the second, this defect in development does not exist, as is evident, since this fluid has been produced, but its farther secretion is interrupted by certain remote causes, to be named pres- ently. The third and fourth consist of merely mechanical interruptions, and are to be relieved by mechanical means, alone. The fifth consists in a defect of power in the parts that were wont to produce the menstrual fluid at the earlier part of life, agreeably to the order of nature, though neither the eye nor the knife may be able to discover, or trace, any anatomical change in either the ovaries or the secreting sur- face of the uterus itself. Consequently, in the first, second, third, and fourth, we may have every rational hope, that by proper treatment, the defects may be removed and the function restored; while in the fifth, it would be at least preposterous, if not injurious, to attempt the restoration of the lost power of the uterus and ovaries by constitutional treatment In the sixth, the same want of analogy exists; espe- cially with the first and second; for in the symptomatic amenorrhcea, the secret- ing surface ofthe uterus is engaged in the formation of a new production, namely, tubercles, or profuse secretion. We shall therefore limit the term Amenorrhcea to three conditions of the uterus; 1. where the uterus is tardy in taking on the pro- cess of menstruous secretion; 2. where this secretion is interrupted by some idio- pathic morbid cause; 3. where these causes act indirectly. In our account of this affection, we shall confine ourselves to the first second, and sixth conditions enumerated above; and give to the third, fourth, and fifth, separate considerations. (See Hymen, im- perforate ; Os Uteri, impervious; Menses, final cessation of.) For it will be found that by giving each of these subjects an 342 AMENORRHCEA. independent situation, practical views can be more fully and efficiently explained. Pathology. As we are altogether ig- norant of the efficient cause of menstrua- tion, we cannot pretend at the present time to ascertain, either the anatomical or physiological condition of the uterus and its dependencies, in amenorrhcea, unless it be merely the degree of development it may have enjoyed. It is true that Mor- gagni mentions a certain state of engorge- ment in the uteri of women who had died, according to his statement, either just be- fore, during, or immediately after this pro- cess—but a mere state of congestion will not lead us to any certainty respecting the efficient cause of menstruation, a conges- tive condition of the uterus being seen in several of its affections, without men- struation being one of their attendants. Something more is then required, than the mere fullness of the vessels of that organ; but what that something is, we may con- jecture, though we cannot prove—much must, consequently, be taken for granted, if we pursue an hypothesis. All we do know, is, that a certain con- dition of the uterus and its appendages is absolutely necessary for the secretion of the menstruous fluid; and that it requires a normal state of both, to produce it, under certain conditions of these organs, at the proper period, and when the female is neither pregnant nor stickling, nor passed the menstrual period of life. But when the uterus ceases to secrete the menses from an idiopathic morbid cause, we are at a loss to say in what the pathological change consists; for, so far as we know, death has never taken place from the mere absence of the catamenial discharge ; or without other lesions being produced, which may again indirectly act upon this organ, so as to change a present, or pro- duce, a new pathological condition. We must therefore wait for further observa- tion, before we can establish the pathology of the uterus, in the species of amenor- rhcea under consideration. Division of Amenorrhcea. We shall consider Amenorrhcea under the following heads. 1. The tardy appearance of the menses —or the retention of the menses—the " emansio mensium" of authors. 2. Where this secretion is interrupted after it has taken place for a longer or shorter time, by other causes than preg- nancy or suckling, but which causes pro- duce an idiopathic affection of the secret- ing portion of the uterus. 3. Where this evacuation is indirectly arrested.by the influence of certain chronic affections of other viscera. 51. Ofthe tardy appearance ofthe men- ses ; or the retention of the menses, the "emansio mensium," of authors. The term " emansio mensium" of systematic writers, is by no means well adapted to explain the condition of the female previ- ously to the first eruption of the menses. It conveys the idea that the flow is pre- vented by some mechanical cause—a cir- cumstance altogether at variance with the fact; for that which is not formed, cannot be retained; yet, we shall be compelled to employ the term, until one is invented to express the condition of a part, or a gland, previously to that degree of development which will enable it to perform its ulti- mate offices. The uterus may therefore be considered, at this time, to lack the power to secrete the menstrual fluid, rather than to have that power suspended or de- stroyed. In a practical point of view, this distinc- tion should not be lost sight of; for there is a great difference between the want of a capacity, and the suspension of one; and on this distinction in the present in- stance, much will depend, in the manage- ment of the two cases—in the first in- stance, it may very often be proper only to temporize; while the other will require many times, a well adjusted and active treatment Nature appears to have had an impor- tant design in the establishment of the menstrual discharge in the human female —for its abnormal absence, whether ori- ginal or accidental, is always attended by barrenness. A similar importance appears to be attached to the occasional discharge from the vagina of every quadruped, and perhaps extends even to the whole of the Mammalia; for though the discharge in the latter is not strictly menstrual, with very many animals, it nevertheless ap- pears to be a sign of as much certainty of the capacity of the uterus to become impregnated, as it does with the human female, who menstruates—and, without a normal condition of this discharge, neither becomes impregnated, even under, in other respects, the most favourable cir- cumstances. We must not then wilfully shut our eyes against the obvious import of this discharge; especially in the hu- man female—namely, it being a declara- tion of the condition of the uterus to be- come impregnated, and its capacity to foster and protect the product of such im- pregnation. This arrangement in the infe- rior animals has a like identity of object. AMENORRHCEA. 343 The only remarkable difference between the discharge in question, in the inferior animals that possess it, and in the human female, is, that in the former it never ap- pears but at the period of calescence and desire; while in the latter, a state of ve- nereal excitement is not necessarily an at- tendant upon the flow of the catamenia. In this, as in everything else of God's providence, we see nothing but marks of infinite wisdom and consideration; for, to what disgusting scenes should we be sub- jected, were the inferior animals not con- trolled by this periodicity; and how much would mankind suffer, as social beings, were the female influenced by other than the existing laws that govern the instinct of procreation! In descanting on the capacity to pro- duce the menstrual discharge—the laws which govern it—together with its final cause, fancy has but too often taken pre- cedence of reason, and fable usurped the place of sober facts. What can be more preposterously fanciful than the opinions of Puny, and of many later writers whom we shall not stop to name, respecting the acrid qualities and baneful influence of this discharge; notions in support of which not a single fact can be adduced calculated even to excite suspicion. The discharge is in fact no less innocuous, than important, to the female economy. Whatever other opinions and specula- tions the inveterate theorist may indulge in, the following facts with regard to the menstrual discharge, cannot be controvert- ed, though they may give rise to dis- crepant deductions. First; that this discharge never appears as the fulfilment of one of the laws of the system, but at a comparatively advanced period of female life. Second ; that when it does appear as a normal product of the uterus, it marks, with great certainty, the capacity of this organ to become impregnated—this marks, or constitutes, the period of puberty. Third; that this great object, namely, procreation, is seldom, or perhaps never attained, but when the catamenia are in a completely normal state. Fourth; that this function continues, during the most befitting period of female life, for the objects for which it is insti- tuted ; and it is the sign of her aptness to become impregnated. Fifth; that after this period has elapsed, this discharge ceases altogether; or, if it continue, from some change in either the ovaries or uterus, or both, it becomes no longer a certain sign of the capacity just spoken of. Sixth; that after the final cessation of the menses, the ovaries cease to furnish ova fitted for impregnation, or the uterus ceases to cherish them, if they have been impregnated—therefore, the menses when healthy, are, up to this period, the sign at least, of the capacity of the female to be- come fecund ; and without this condition, she ever remains barren. Farther, that this discharge is the sine qua non to im- pregnation, as this never takes place be- fore the secretion of the menstrual fluid, nor after it has ceased to be formed. We disbelieve those instances purporting to contradict this belief. (See " Diseases of Females," by the author of this paper. Art. History of Menstruation.) From what has been said, it must be evi- dent that the menses never appear (nay, cannot, in their best manner,) until the uterine system has arrived at its full de- velopment. That this takes place at dif- ferent periods of the life of females, living under considerably different temperatures —heat advancing, and cold retarding, this sign of puberty. That the period of pu- berty must arrive before the uterus fur- nishes the menstrual fluid; but that this period, even under the same latitudes, may be sooner or later; owing to the influence of certain physical causes out of, or to cer- tain physiological ones within, the body— either, or both, tending to hasten or retard uterine development, according to the na- ture of these causes. Thus, all modes of life which have a tendency to increase the uterine circulation, will hasten its develop- ment. Among the most powerful and certain of these causes, are climate and modes of life—but it is not our intention to attempt an explanation of their modes of action, in this place; it is sufficient for every prac- tical purpose, that we induce a belief in their agency, as this admission leads to the successful treatment of the " tardy appear- ance of the menses." The period of life at which the menses appear, be this sooner or later, is denomi- nated "puberty;" because the female at this period (caeteris paribus) is, as we have just stated, capable of impregnation, and of supporting its ordinary consequences ; and not before. This period is not invari- able, as we have already said; being much earlier in hot climates, than in cold. In Asia, Africa, and South America, it is not unusual, as we are informed by much concurrent testimony, for this discharge 344 AMENORRHCEA. to make its first appearance, even at eight, but often at nine, and very con- stantly at ten—while in Lapland, and other arctic positions, it does not take place until eighteen or nineteen. This statement of the influence of cli- mate upon the female system, has been universally conceded; all travellers con- firm it; and all physiologists admit it, even up to the present time. We are there- fore not a little surprised to find this general belief disputed by Mr. Robert- son. {Edin. Med. and Surg. Journ. for Oct. 1833.). " This opinion," he remarks, " which is general, appears to be erroneous; and this doctrine naturally suggests ques- tions, the solution of which they have not so far as I know, attempted. It might be asked, for example, whether in countries where the catamenia flow, as they allege, at the age of nine years, this sexual pre- cocity is manifested by the mind, equally as by the body 1 or whether the mind re- mains till a later period, infantine? or whether the female, in all her faculties, mental and bodily, exhibits this early de- velopment 1" Now, Montesquieu has, by Mr. Roberton's own showing, answered this question, by declaring that the mind is not developed in equal proportion ; and on this fact he builds an argument in favour of polygamy. And Professor Fer- guson declares, that in the East, women become slaves, because their minds are not sufficiently developed to bear up against the encroachments of man, at the moment of their greatest, but evanescent beauty; for then they become the objects of the most ardent love. But it is not necessary to our present object, to inquire into either the civil or political consequences of this early men- struation ; it is sufficient that we establish the fact, that climates of different degrees of temperature, have a marked influence upon both animal and vegetable life; and that upon the human female, especially, this influence appears to be abundantly manifested by the different periods at which puberty arrives; and withal, when this period does arrive, the female is capa- ble of fecundation, and of overcoming all its ordinary penalties; for it cannot be supposed that the Deity would be so idly capricious as to impose this condition, with- out guarding the female, at the same time, against any unusual risk consequent upon that condition. We know from our own proper experi- ence, that in proportion as we advance south, the period of puberty becomes earlier: a Mexican lady, on whom we are now in attendance, assures us that she was married before she was twelve, and was a mother before 6he was thirteen. Nor is this an extreme case; the same lady informs us that menstruation generally takes place very early, and that many are mothers by the time they are thirteen. In our climate (40° N. lat.) the general pe- riod of menstruation is from fourteen to sixteen—in this, however, as in every cli- mate, there may be exceptions—but they are only exceptions to the general rule, and must not be taken for the rule itself, as Mr. R. appears inclined to do: since he "entertains a doubt, whether the period of puberty is nearly so uniform as we are taught in books to consider it;" because he had met with a few exceptions to the usual law of nature in regard to this period. But unfortunately for this gentleman's thesis, he has given a table purporting to be cor- rect, of the answers of 450 women, to the interrogatory, " at what period did you first menstruate.'" which proves that" at the pe- riods of 14 and 15, more than double the number were found to have menstruated, than at 10, 12, or 13 collectively; and nearly one third more than at 16, 17, and 18 collectively; and nearly seven times more than from 19 to 20. And what is truly remarkable, is, that there were fewer at 16 than at 15 or 14; though we have chosen to extend the range from 14 to 16. Is it not then evident, that from 14 to 15 is the most constant period of puberty in the latitude of Manchester (England), where the observations were made 1 We have already stated, that in our latitude (40° N.), this rule obtains very uniformly; but Mr. R. has given our location a much broader range than he should have done, when he did us the honor to quote from us upon this subject; by saying that our ob- servations were made in "North Ameri- ca ;" an extent of country that embraces almost every climate on the face of the earth—extending from 72° north latitude, to 70° 30' south latitude; that is, 64£ de- grees, or 3870 geographical miles; or 4500 British miles. We might readily extend our remarks upon Mr. R's observations; but we have said enough to prove, first that there is a fixed general period of puberty in every remarkable difference of latitude; and sec- ond, that in this, and nearly similar lati- tudes, this period is from the 14th to the 16th year. It is a little remarkable that Mr. R. should adopt for the support of his hypo- AMENORRHCEA. 345 thesis, the exceptions to a rule, rather than the rule itself—thus he thinks his reasoning strengthened by a case related by Mr. Thorpe, of a girl of eleven years of age, who became pregnant, and was safely delivered, without unusual difficulty, of a full-grown child. But we are at a loss to perceive the value of this case to the point at issue; it only goes to confirm the correctness of our definition of the term puberty, and not the uncertainty of this period in respective latitudes. This case is one of the exceptions to the general rule, as is proved by the table furnished by Mr. R. himself, from which it appears that there were but 10 cases of men- struation, at the age of eleven years. But this case proves that in even precocious healthy menstruation, impregnation may take place after the same manner as where the period of eleven years marks the ordi- nary arrival of puberty—or of menstrua- tion ; for in the case referred to, Mr. R. admits that this process had preceded preg- nancy. But we shall urge nothing further in support of the position we have assumed, namely, that each remarkable difference in latitude or climate has its own epoch for the arrival of puberty—and that the knowledge of this particular fact is of the first importance towards the successful treatment of tardy menstruation. Indeed, if this circumstance be not constantly kept in mind, the management of such cases will always be uncertain and empirical, and very often highly dangerous. We have seen the worst consequence follow the ill-timed administration of emmena- gogue remedies; nor can this create sur- prise, when highly stimulating medicines are addressed to the uterus with the inten- tion of forcing it to the exercise of a func- tion that it is incapable of performing; its organization not being sufficiently devel- oped for it to take on the process of men- strual secretion. Causes of the tardy appearance ofthe menses. We have stated above, that for the production of the menses it is abso- lutely necessary that the uterine system be completely developed ; since no organ can successfully perform its ultimate function, unless that organ be perfect, or nearly so, in its arrangement. It will therefore fol- low from this corollary, that whatever may interfere with the regular development of the uterus and its appendages, will pre- vent the secretion of the menstrual fluid, properly so called: such causes may be, temperament, leucorrhoea, imperfect devel- opment, anemia, cold, passions or emotions of the mind, chronic affections, &c. &c. A. Temperament. It is said that this in- fluences the development ofthe body; and that the lymphatic is more liable to this in- terruption, than any other; and our own ob- servations incline us to believe the imputa- tion to be just. For in this temperament the circulation is languid, slow, and feeble; the muscular system is soft, yielding, and without much force; and this observation extends even to the heart and blood-ves- sels. The absorbent system acts feebly, and permits the formation of a larger quantity of fluids than the due proportion for the solids; hence, the serous infiltra- tions into the cellular tissue, which give character to this temperament, together with a pale or cadaverous skin; the latter also showing the languid state of the cir- culation. Even the brain appears to par- ticipate in this general want of energy, as the subject of it is averse to both mental and bodily exertion; consequently, the uterine system will be tardy in its devel- opment, as, for the most part, it is the last to be perfected, its functions not being called into requisition until the female is considerably advanced in life, or until its duties can be available—for, as a general rule, development takes place in the order of necessity for such development But let it be remarked, that there is no one of the temperaments that may not have, oc- casionally, from some cause or other, a tardy or feeble development to attend it We are sure we have seen the menses tardy in the sanguineous, and also in the nervous; at least as far as definition will characterize these several conditions of the human system. Nor is it absolutely necessary that every other system of the body should fail in normal development to implicate the ute- rine ; the reverse of this is sometimes the case; and among such are some of the most obstinate, and uncertain to be reliev- ed. Thus we see females have their os- seous system early and rapidly expanded, but accompanied by a flaccid, feeble, and ill-developed muscular system. The girl is then said to be large, or tall, for her age; she is weak, readily fatigued, and the heart and blood-vessels easily excited to increased action; the chest is flat; the shoulders round; the scapulee prominent; the neck long; the face pale, and frequent- ly bloated, especially in the morning; the mamma? undeveloped ; the pubes not sup- plied with hair; the pulse frequent and small; hands and feet cold, and disposed 346 AMENORRHCEA. to be damp; the appetite craving improper or indigestible things, &c. In a word, the girl has the appearance of more years than have actually passed. There are cases of sudden and anormal partial development or aberrations of nutrition, which are sure to be attended by general debility, and thus interrupting the expansion of the uterine system. B. Leucorrhoea. This debilitating dis- charge is an almost constant attendant upon this peculiarity of system, and not unfrequently becomes an efficient cause of the non-appearance of the menses, by preventing the healthy and essential con- gestion from taking place in the uterus itself; and to such a mischievous length does this discharge extend sometimes, as to cause that peculiar state of the system called Chlorosis. Some have considered chlorosis as a cause of the tardy appear- ance of the menses; whereas it is only the product of leucorrhoea, combined with amenorrhcea, of which it is sometimes the active cause. C. Imperfect development. In some cases, a partial cause, arising from an anormal condition of the uterine system, may give rise to the non-appearance of the menses; thus, either the ovaries or the uterus may be but partially or imperfectly developed, either condition of which will with great certainty be the cause of this amenorrhcea. Of both of these conditions, Morgagni and others give examples; and two have been observed by ourselves. D. Anemia. This may also produce the same consequences. Anemia may be in these cases, general or partial, either of which will produce the same effect In all cases of this kind, whether general or par- tial, the arterial calibre is reduced; and this in proportion to the degree of the ane- mia. If general anemia prevail at a period of life at which development is progressing, it will necessarily be suspended in every portion of the body. But if it be partial, some one particular organ may suffer from the want of the quantity of blood neces- sary to its development. And as the ute- rine system is the last to be unfolded, it may, and most probably does, suffer oftener, more extensively, and more certainly, than any other organ, if anemia occur about the period of puberty. We have just stated that Morgagni and others have furnished instances of ex- tremely small or undeveloped uteri and ovaries. Now, this failure of nutrition may arise from some deficiency in ana- tomical arrangement, or from a want of determination of blood to these organs. If it be from some anatomical imperfec- tion, the structure may be such as to pre- vent these organs from profiting by the natural tendency to plethora or congestion at the pubescent period of life. Or if it be from the want of determination of blood to these parts, it is probably owing to strong determinations to other parts; and hence the rapid and precocious develop- ments of other portions of the body—and hence the common expression, thafgrovvth has exceeded strength." Either of these conditions may become a cause of the tardy appearance of the catamenia; or in some cases, of the entire absence of the menstrual discharge, during the whole life of the female. The same may be said of some of the viscera, when in a state of congestion; as, the liver, spleen, lungs, stomach, or brain. Thus, girls are found to menstruate later, who live in marshy countries, where intermittents are com- mon, than those who dwell in elevated, dry situations; though there may be in the latter, an extension of the general frame. This is most probably owing to the tenden- cy of this species of fever to produce con- gestion in the liver or spleen, which diverts the natural current of blood from the ute- rus, at a period when, for the purposes of the system, this organ should have a more than ordinary flow to it—thus the en- gorgement of one Oigan may produce anemia in another. The same may be said of that hypere- mia of the lungs, which ends in hemor- rhage from these organs; especially when this is so often repeated at a period so near, or even at puberty, as to prevent the appearance of the menses. In these cases, the lungs are said to perform a vicarious office with the uterus—but this is no other- wise so, than with the liver or spleen, as just stated above; for though the discharge of blood from the lungs may become peri- odical, and the period of return be month- ly, it must not be looked upon as a com- pensating discharge, or to have been insti- tuted in lieu of the menses, notwithstand- ing it may interrupt their appearance at the expected or proper time. The same may be said of the stomach, when hema- temesis is produced; or of the brain, when determination to it is strongly marked, especially when it is followed by epistaxis. It has been remarked by several patho- logical writers, but especially Andral, that the activity of the secretions of several of the tissues, as, the serous, mucous, and cu- taneous, furnish a very disproportionate quantity of fluid, when compared with the quantity of red blood that is transmitted to AMENORRHCEA. 347 them. In proof of this, we need only call ♦o mind, abdominal dropsy; the watery dis- arges from the bowels, in cholera; and the colliquative sweats, in phthisis pulmo- nalis. So the uterus, when in a state of anemia, may furnish an unnatural quantity of fluid; as in leucorrhoea, either purulent or serous, and thus perpetuate the exhaust- ed state of this organ. Now, in this blood- less state of the uterus, it cannot derive a sufficient quantity of nutritive fluid, for its development—or, if it do, a great pro- portion is immediately carried off, by the inordinate secretions of its internal mem- brane. Thus it becomes evident, that ane- mia will be a powerful cause of amenor- rhaea; and that it produces this state of the uterus, in one of two ways—first, by preventing development and second, by interrupting that degree of congestion in this organ which is essential to the men- strual function. In either of these cases, there may be present, either a general or a local anemia, and as this condition may influence our therapeutical views, it should always be kept in mind. In general ane- mia, there may not be the slightest evi- dence of uterine development; or there may be a partial display of it. In the first, there will be the entire absence of the sympathetic developments; in the second, there may be slight swellings of the mam- ma?, and a sparse protrusion of capilli upon the pubes. The first may also be known by there being no vaginal discharge; while in the second, this may be moderate or profuse. The degree of development being, in some measure, determined by the quantity of this discharge; and as a general rule, the first will be less certainly man- ageable (caeteris paribus), than the sec- ond; for in the first, we must not only relieve the state of anemia, but wait for the proper degree of development of the uterus after the system has been furnished with a greater quantity of blood, and that of better quality; while in the second, the menstrual secretion may take place, after anemia is relieved, by merely directing our views to the leucorrhoeal state of the uterus and vagina; for this discharge is always unfavourable to the first eruption of the menses, by acting as a topical deple- tion, (though it manifest a better general condition of the uterus;) and thus pre- venting or removing the menstruous con- gestion. Of this, however, we shall have occasion to speak again. E. Cold, cither generally or partially ap- plied, may, if excessive, or if operative at the moment the menstrual congestion is forming in the uterus, be the cause of the tardy appearance of the menses, by remov- ing this condition; which, as we have said before, is essential to the formation of the menstruous blood. When this state of the uterus is thus suddenly removed, some one ofthe other viscera will become engorged, and hemorrhage may ensue. Of this we have seen a striking case very lately; in a small, but well-devel- oped girl, rather under fourteen, who had all the premonitory symptoms of the men- strual eruption—as slight fever, head-ache, pain in the hips and loins, slight uncolour- ed discharge from the vagina, soreness and distension of the mammas. On an oc- casion she was sent some distance, in a se- vere, cold rain, without proper protection, especially of her feet. She returned very cold and wet; and before she could be made comfortable, she was seized with a vomiting of blood, to a considerable ex- tent It was, however,- finally arrested by mustard pediluvia, as warm as could be borne; sinapisms over the whole abdomen —that is, from the sternum to the pubes, until considerable irritation was produced on the skin; together with an enema of a saturated solution of common salt and warm water. Whether nature will make another effort to produce the catamenia at the proper time, we cannot say, as the proximate period has not yet arrived. We have put her upon the use of the Tinct. Lyttse, in hopes it may aid nature in her effort. This cause (cold) is more mischievous, at the period of female life that we are now considering, than is generally admit- ted, principally owing to the reprehensible state of ignorance in which the girl is kept by an over-fastidious mother. This ill- timed delicacy cannot be too much repre- hended—for we hold it to be the bounden duty of every mother to instruct her daughters on a subject that so vitally af- fects their comfort; or perhaps their lives; we have seen too much evil arise from this omission, to pass over in silence, this neglect of duty. The ill-timed use of the cold bath is very frequently and justly chargeable with interrupting the menstruous secretion at the moment it was about to make its ap- pearance—therefore, this remedy or lux- ury should be prohibited at the approach of puberty; or it should be very rarely and cautiously indulged in. F. Passions or emotions ofthe mind, &c. These affections of the sensorium certain- ly have a control over the uterine func- tions ; but their power, in our estimation, is very limited in the species of amenor- 348 AMENORRHCEA. rhcea now under consideration. For they cannot well exist sufficiently long to inter- rupt uterine development; and without they do this, it will be difficult to un- derstand how they can prevent the secre- tion of the menstrual fluid, if the uterus be properly prepared for this office; as the tendency of these causes is to hurry the general circulation, and sometimes to produce such strong local determinations as would seem rather (a priori) to be fa- vourable than unfriendly, at certain mo- ments, to the appearance of the menses. Terror has sometimes accomplished, in a moment that which long medical disci- pline had failed to effect. Of this, a re- markable instance fell under our notice many years ago. A young lady, between fifteen and sixteen, apparently pretty well developed, had become chlorotic, notwith- standing she had the best advice the city could afford. She was reduced to great feebleness; and a number of alarming symptoms were present—as cough, indi- gestion, swelling of the feet and ankles, leucorrhoea to a great extent, &c. She was recommended, as a dernier resource, to try sea-bathing. She accordingly went to the sea shore for this purpose. The third day after her arrival at a bathing- place, and before she went into the surf, she was tempted by the inviting appear- ance of a tree of apples to enter the or- chard to procure some of the fruit They were, however, beyond her reach; and to secure some, she lifted up a piece of a rail to strike the distant fruit—to her extreme terror, a snake was observed to lie immediately under it She threw down the piece of rail, and fled as fast and as far as her weakness would permit; she fainted and fell—but upon recovering from this state of exhaustion, she found herself in the situation she had so long and anx- iously desired. From this moment her health improved, and was, in the course of a short time, entirely restored. It is true, that grief may continue to suspend the menstruous secretion, where, from the degree of development the ute- rus had given every promise for the per- formance of this function. But in such cases, the interruption will be but tempo- rary, if there be a suspension of the re- mote cause. Of this, we have seen sev- eral examples. On the other hand, how- ever, if this affliction of mind occur be- fore such a degree of development had taken place as would justify the expecta- tion that menstruation was about to ensue, it will with great certainty, if the grief be profound, suspend its farther progress. Of this we have also seen instances. It would seem from these facts, that moral causes may, from the difference of their nature, have very opposite effects upon the uterine system at a period ap- proaching puberty, or when it has abso- lutely arrived, (save that the menstrual ac- tion had not commenced,) or at a period more remote. That on the one hand, 6ome of them, such, for instance, as by their operation shall increase or will hasten the circulation and the more general distribu- tion of the blood, will not operate in an unfriendly manner in all instances—while others, by their contrary tendency, will suspend, and sometimes for a long time in- terrupt, uterine development and thus produce all the evils such suspension can create. G. Chronic Affections. These causes are by no means uncommon, and are almost always irremediable, because the diseases which have suspended the natural func- tions ofthe uterus, as phthisis pulrnonalis; chronic affections ofthe liver, spleen, pan- creas, stomach, and intestines, are in them- selves incurable. Such instances of retard- ed menstruation as have either of these diseases for their cause, can only be reme- died by the removal of these causes; and therefore should not be specifically pre- scribed for, however strongly we may be urged by the anxious friends of the un- fortunate patient It is the common be- lief of every body out of the profession, and we may safely add, of but too many in, that the suspended function of the uterus is the cause, instead of the effect, of the chronic affection; and in consequence of this belief they importunately urge com- pliance with this assumption—but let us beware how we adopt this opinion ; as we may hasten to a fatal issue, a disease that might, by proper management, have been kept a long time at bay. For the proper management of such cases, see the dis- eases above enumerated, Phthisis, &c. But chronic affections much more rarely produce mischief in this species of amen- orrhcea, than in the one next to be con- sidered, namely, where the catamenia have been interrupted by some immediate cause, as in idiopathic amenorrhoea, (q. v.). Diagnosis. It is thought to be very diffi- cult by some, to distinguish between these two states—that is, which is the cause, and which the effect—but if our experi- ence have not misled us, we think the fol- lowing signs will sufficiently designate them. When a chronic affection is the AMENORRHCEA. 349 primary disease, and is of pretty long standing, and especially if it be incurable in itself, it will be found, though it act slowly upon the uterine system, that it will interrupt both general and local de- velopment very soon after it has acquired a threatening aspect Now the uterus and its appendages being involved in this gen- eral consequence, they will not of them- selves be unfolded, nor will they give rise to the sympathetic developments which depend upon them; as, the enlargement of the mammas, the production of hair upon the pubes, &c. Should this happen at a period a little later, that is, after development of the mammas have com- menced, that development will proceed no farther, or will most probably retrograde. But it must be remarked, that in order that these affections may be capable of in- terrupting or suspending uterine develop- ment, they must become chronic, and per- haps uniformly incurable—for in their acute form they have no such tendency. If this be true, and we have no doubt of its being so, the previous history of the case will aid the diagnosis very much, and lead with more certainty to the knowledge of the primary disease. H. Idiopathic Amenorrhcea. If the sus- pension of the menstrual secretion be the primary affection, it will not produce mischief until after a long time; and, until after uterine development is so com- plete as to be capable of furnishing the expected discharge, though this is pre- vented by the operation of some remote cause, as the sudden or long-continued application of cold; very long fasting; very innutritious diet; consuming grief, &c. For unless nature has regulated and established the balances of the system, and the uterine functions are on the point of taking place, we have every reason to believe that the equipoise of the various viscera is not disturbed from this cause, any more than in the male. This belief is founded upon three cases of the entire want of the menses in women from twen- ty-two to thirty years of age, who enjoy as fair a portion of health as females ordina- rily do who menstruate regularly. And farther, because when this suspension takes place while puberty is pending, it will be found upon investigation that the uterus and vagina have secreted more than an ordinary quantity of fluid, and this peri- odically augmented—giving evidence thus, of its approaching capacity to furnish the menstrual fluid. Symptoms. In enumerating the symp- toms to which the " tardy appearance" of vol. i. 30 the menses gives rise, we shall confine ourselves exclusively in this instance to such as follow the failure of this discharge at the period at which it should appear; all other things being equal. In these cases, the development of such parts as unfold themselves by a sympathetic influence or consent, we suppose, have given evidence of a condition of the uterus, that declares it prepared, or nearly so, to take on the menstrual action, but which some cause or other has interrupted, and thus de- ranged a function every way essential to the well-being of the system in general. For whenever the uterus and its ap- pendages are in a pathological condition, to a degree that will suspend their func- tions, there will be no catamenial secre- tion. But this suspension is rarely {imme- diately) followed by ill health: on the con- trary, we have seen many cases where there was a lapse of several months be- fore the general system was placed in a pathological condition—and before this takes place, the female is not to be sub- jected to medical discipline ; as the recu- perative powers of the system alone will very frequently be sufficient to establish the suspended function. When, on the other hand, we find the girl losing her bloom and strength; when we see her spirits flag, and she becomes the prey of gloomy apprehensions; when her stomach loses its wonted powers, and becomes whimsical in its selections of food; the circulation becomes hurried by trifling exertion ; the heart palpitates, and a sense of suffocation is felt upon going up stairs, or up any other ascent; when the slightest unexpected noise or event shall throw her into nervous agitation; when she becomes watchful, until day dawn; emaciates rapidly, and her ankles swell; and when leucorrhoea, to a greater or less degree, adds its might to the other symp- toms, the patient may then justly claim the' best efforts of her physician. The symptoms we have just detailed, are not the uniform attendants on this state of the uterus—though the greater part will be sure to present themselves, as the in- terruption may be of longer or shorter con- tin uance. Head-ache, cold feet and hands, with a pale and almost bloodless skin, also belong to the list of evils. Constipation, or the opposite condition of the bowels, will present themselves; and that state of the system called chlorosis will soon ensue. From what we have said, it will be per- ceived that the want of the catamenial flow may be caused by three different con- 350 AMENORRHCEA. ditions of the uterus. First where devel- opment is incomplete; second, where it is complete or very nearly so, but, owing to certain influences, the discharge does not take place; and, third, where the failure is not owing to causes directly connected with the uterus and its appendages; or in other words, where this tardy menstrua- tion is owing to the influence of certain chronic diseases in other parts of the system. Now, these several conditions must not be treated by one general plan, if we expect success to follow our endeavours— on the contrary, each state of the ute- rus must be ascertained carefully, that we may not fall into an unsuccessful, empir- ical routine. Diagnosis of condition first. We have already declared, that an organ cannot perform its final functions, until that organ be completely, or very nearly developed, or its organization be perfected. In the condition under consideration, we believe the development of the uterus to be im- perfect, because, there is an absence of the sympathetic developments. Thus, the mammas remain undistended; the pubes are not covered with hair; the voice has undergone no change; the neck is not in- creased, nor does the brain discover any augmented powers. Now, the absence of these signs would alone distinguish this first condition from the second, were this not aided by the general good health of the female. For in this condition, as in every other where the perfection of an or- gan is concerned, the system at large will not suffer from the want of a function of any one of the viscera, when that absence is owing to the period for development of any given viscus having not yet arrived— just so with the uterus—the system suffers nothing from the want of the menstrual discharge, if the period for its formation is not yet completed—or in other words, when its organization is not perfected. Such being the case, this condition should not be the subject of medical treat- ment ; for the non-appearance of the cata- menia is not owing to a pathological state of the uterus, but to the absence of a cer- tain physiological condition of this organ itself. Therefore, the mere absence of the menstrual discharge, under the circum- stances just pointed out, must not be con- sidered as disease, be the development of other portions of the body what they may. Hence the propriety of dividing condition first into two states—1st, where develop- ment has not commenced as above stated ; and 2d, where it has made some progress. In state 2d, it is nevertheless true, that the development of the uterus may be slow, when compared with the expansion of the other portions of the body, and the number of years the subject has attained; or it may be more rapid, but still incom- plete. In such cases, and they are far from being rare, we may constantly ob- serve the effects of uterine development, in such parts of the body as should, agree- ably to the order of nature, in a normal condition of the system, feel the influence of this progressive development; (as the pubes, the mammas, the throat, neck, &c.) and thus should serve as guides for our re- medial means, if we hope to base our the- rapeutical views upon just and rational principles, or upon well ascertained physi- ological laws. For it would be as idle, to say the least, to attempt the immediate production of the menses, by any plan we could adopt, in state 1st, as it might be successful in state 2d. These states conse- quently claim particular attention in a practical point of view, whenever we may be consulted for their relief. There is one sign, when it exists, which has never de- ceived us, so far; though we would not wish to be understood to say that we look upon it as infallible—for there may be ex- ceptions ; we allude to, a discharge from the vagina, of mucus, either slightly coloured, or nearly transparent; especially if it have a periodical increase or return—this cir- cumstance is also worth bearing in mind. Added to this latter symptom, there is pain in the back, hips, and down the thighs, especially at the periods at which this dis- charge is found to be augmented; to- gether with slight micturition. Now, in state 1st there is an absence of all these signs, though the female occasionally may have the appearance of more general, but less particular development. Treatment of condition first. From what has already been said, it will be per- ceived that patients of state 1st of this di- vision are not considered as proper cases for medical treatment; though they may profit much from well-directed hygiene. In cases of the kind we are now consid- ering, the practitioner should never lose sight of the principle just laid down— namely, that no organ can properly per- form its assigned functions until its de- velopment is perfected—consequently, the uterus cannot yield the menstruous fluid, until the part which elaborates it is sufficiently developed, to secrete it. It would therefore be idle, we must repeat, AMENORRHCEA. 351 if not entirely subversive of the constitu- tion, to subject the female to a course of what is called emmenagogue medicines. For though we may aid development, un- der proper circumstances, we cannot ab- solutely originate it: this must be the act of the system—at least it must be be- gun by the influence of the laws that gov- ern the successive developments of the body. Let not the practitioner, then, be influ- enced by selfish motives, in cases of this kind—the only interest to be studied, is the welfare of his patient; and if this mo- tive govern, he will, for the most part only have to direct proper diet and exer- cise ; or occasionally, such remedies only as may be necessary to the state of the general system, but without reference to the uterine in particular. Therefore, we shall, for the sake of perspicuity, charac- terize the two conditions in which patients of this class may present themselves, into, 1st such as have no constitutional dis- ease ; and 2d, such as have. 1st. When a female arrives at the age at which it is common for the menses to appear, and they fail to do so, it is the al- most universal belief that this must arise from the failure of a uterine function, which, if not removed, will occasion speedy, and perhaps incurable, ill health ; than which, there cannot be, generally speaking, a greater error. For age, in the abstract, has nothing to do in the case. Not that we deny (for wc have already conceded) that the catamenia generally flow, at a certain age of the female, in every particular climate ; but, because the laws which govern the general devel- opments of the body are put in force at certain periods, (by an original design of the Creator,) as these developments be- come essential to the well-being of the in- dividual ; yet, in certain cases, this law may fail to govern uterine development, at the usual period. And do not the facts in- sisted on in the commencement of this ar- ticle, prove that more than mere age is necessary for the production of the cata- menia, since they take place at various pe- riods of female life 1 whereas, were this se- cretion governed solely by the age of the female, it should take place at nearly the same time, in every habitable part of the globe. And that this process is dependent upon the degree of development of the uterine system, is made certain by the fact, that the uteri of some women at eighteen, or even twenty, are as incapable of rendering the menstruous discharge, as at the age of but five or ten. There- fore, our therapeutics must not be influ- enced by the years of the female, but by the degree of development at which she has arrived. Now, should a girl of from fourteen to sixteen or seventeen, who has never men- struated, be presented for medical advice, but who is in the enjoyment of good health, and who has not, agreeably to testimony, or observation, given any signs of develop- ment—that is, of enlarged mammas, and the other tokens just mentioned, she must not be looked upon as in a condition for medical treatment, merely because she has arrived at or exceeded, the period at which the menses are generally wont to appear in other females under the same latitude. But let your opinion be candidly stated, to this effect, with an earnest caution to the friends of the patient, not to interfere with the economy of nature, before signs of in- ability on the part ofthe uterus to produce this discharge, be made manifest. For we have every reason to believe, that until this happen, the system suffers nothing by the absence of the catamenia; and that the general health never depreciates until nature has made an effort to establish this discharge and has failed in the attempt Condition second of Sec. 1, or the non- appearance of the menstrual discharge, where there is evidence of uterine devel- opment. Here we must make another dis- tinction, of practical importance, namely, that the loss of general health may not constantly depend upon an unsuccessful attempt to establish the menses, but may perhaps as often depend upon a patholo- gical condition of some of the other vis- cera of the body; and to distinguish these states from each other is a matter of great interest to the patient. If the ill health proceed from the first cause, namely, a want of power, or of con- dition, of the uterine system to produce the menses, that effort though unsuccess- ful, will be accompanied by a certain de- gree of development of the parts sympa- thetically influenced by the organization of the womb and its appendages. If, on the other hand, the ill health depend upon an abnormal condition of some other viscus than the uterus, there will be in general an absence of the developments which mark the period of puberty. Therefore, the first supposition places the patient in state second of division the first, and will be treated of under that head; and the second will properly belong to the third general division of our subject, namely, where amenorrhcea is symptomatic. In state 1st it is, however, every way 352 AMENORRHCEA. desirable that the girl so circumstanced should be placed in the situation best calcu- lated to preserve her health, by urging a proper degree of exercise, on foot, on horseback, dancing, &c. Also, by a well- regulated diet of digestible and bland food —avoiding over-stimulation of every kind, and keeping the bowels open, rather by a suitable diet, than by cathartic medicines. It, however, occasionally happens, from causes not always easy to ascertain, that the whole system is in a state of debility, without any one organ being, strictly, in a pathological condition; yet, a state of general anemia prevailing, the ap- pearance of the menses may be retarded beyond the usual period. In these cases, we do not suppose any special organic lesion, but such an abstraction, or ab- sence of vital force, as will prevent a regular and well-timed development of the several systems, and in an especial man- ner, the uterine, as this is the last to be unfolded, and is very dependent upon the normal condition of the other systems, for its perfection. Under such circumstances, it is noways surprising that menstruation is delayed; and this without the necessity of sup- posing the general system, or any par- ticular portion of it, in a state of dis- ease. Thus, a long-protracted illness; scanty fare, and an unhealthy atmosphere; long-continued, over-exertion, such as the duties required in manufactories; feeble original stamina; &c. &c. will produce this condition. In such cases, the patient sums up her situation in a few words, by declaring she has " no particular complaint —only she is so weak." The stomach, bowels, liver, kidneys, brain, &c. perform their functions regularly, if not vigorously; we have then only a general feebleness, or want of energy, to contend with; and for which, tonics are the remedies, aided by the abstraction, as far as possible, of the deleterious causes. Of the tonics in such cases, the prepa- rations of iron are decidedly the most efficacious—and of these, the. phosphate, claims the preference. Of this, we give from four to five grains, four or five times a day, in powder, or in the form of pill. If the appetite be bad, two or three grains of the extract of gentian may be added to each pill. Or if the bowels be tardy, a quarter of a grain of aloes may be added, instead ofthe extract of gentian. A nour- ishing diet should accompany the prepara- tions just named; and these should be aided, when practicable, by well-directed exercise. By this last we mean such as shall not be carried so far as to produce fatigue. The last observation is one of great moment, and should always be attended to, if profit be expected from exercise. There is no error more common than over- exertion, under the name of exercise; for fatigue is always followed by weakness. We do not mean by fatigue, a little lassi- tude from motion—for this is constantly the consequence of exercise, even when not carried to excess, and is perhaps not exceptionable. But exertion should never go beyond this; lest fatigue, which is an excess of lassitude, follow, and thus rob exercise of all its advantages. Dancing, riding on horseback, shuttle- cock and battledore, skipping the rope, and swinging, are modes of exercise, the most desirable, as well as the most efficient. In these, the mind participates in the general benefit, by its being kept upon the alert, as well as constantly amused. Billiards, when they can be commanded, especially when walking or riding is ineligible from the state ofthe weather, is one ofthe best possible modes of exercise, as well as one of the most fascinating to the mind, keep- ing it constantly in a state of pleasurable excitement. The surface of the body should be care- fully protected against the vicissitudes of the weather—therefore flannel next the skin, is always to be worn. The feet sliould also be guarded against wet and cold, by proper coverings—nothing answering better for this purpose than the indian rub- ber over-shoes. The legs should be cov- ered by stockings, and the thighs by drawers. Treatment of State Second. Agreeably to our division, this state consists in amen- orrhcea caused by some constitutional de- fect which indirectly interrupts the nor- mal development of the uterine system, by placing the greater part, or all, of the na- tural functions in a pathological condition; as girls of lymphatic temperaments are wont to be about the pubescent period. Now in such cases, there is almost con- stantly defective development ofthe gene- ral system, and with which the uterine participates—it would be therefore only a waste of time to attempt the direct produc- tion of the menses by the medicines term- ed emmenagogue. All that should be attempted in such cases, is to favour the general devel- opment of the body, by means of diet and exercise; and if forced to give medicine by the importunity of friends, we should resort to a temporizing plan, AMENORRHCEA. 353 giving any inert substance by way of al- lowing time to the system to produce the necessary development of theuterus. This plan of proceeding is of more moment than may at first sight appear—we have seen fatal consequences follow the neglect of it. Where development of the uterus pro- ceeds slowly, it may be assisted by the general means mentioned above; especial- ly by the preparations of iron. But in these cases, evidence of such development is sure to appear in the parts that indicate puberty. We may here employ such rem- edies as have an indirect influence upon uterine development—of these, the aloes has a decided advantage, and the follow- ing formula has been found to answer extremely well. R. Gum. aloes, sue. 3ss; Pulv. Rhcei. 3j; 01. Caryoph. gutt. iv; Sapo. venet gr. viij; Syr. Rhcei. q. s. M. f. pil. LX. S. One of these may be taken every night at bed-time, or every other night, or of- tener if necessary; the object being to keep the bowels regularly open, but not purged. A train of nervous symptoms are wont to show themselves; as does, sometimes, leucorrhoea. The former may be quieted by valerian, assafetida, Hoffman's anodyne liquor, &c.; the latter, by the tincture of cantharides, &c. In these cases, a dis- crimination of importance is to be made— namely, that this affection only merits at- tention when the general health suffers. It sometimes happens that the uterus, &c. have been fully perfected, but the menstruous secretion does not take place; owing most frequently to leucorrhoea, re- lieving the congestion essential to this se- cretion. When this is the case, the girl generally complains, and this periodically, of pain in the back, hips, and loins, with a sensation of fullness in the pelvis, which is sometimes attended by a forcing, or bearing down. Sometimes there is peri- odically a serous discharge, resembling, leucorrhoea, though differing from it, in be- ing thinner, more transparent and recur- ring at about a menstrual period. These cases are relieved promptly by the Tinct Lyttas, if leucorrhoea attend; in doses of twenty or thirty drops, three times a day; or if near the period of re- turn of the above named symptoms, by the infusion of madder, in the proportion of an ounce (powdered) to a pint of boil- ing water; this should be simmered for a few minutes, allowed to settle, and strained —a few cloves may be added to make it 30* more palatable—and sugar, if desired. A wine-glass-full is to be given every three hours. During the whole treatment, a strict at- tention must be paid to diet, exercise, clothing, &c, as recommended above. And should this case be attended by anemia, the chalybeates must be added to the treatment. Sect 2. Of the default of the menses, after having been regularly, or partially established. Causes. A variety of causes, if permitted to act, may interrupt the men- struous secretion, however regularly it may have been established previously; of these causes, cold improvidently applied either before, during, or immediately after the flow, will cause an interruption. When the suppression is owing to cold applied in the interval of menstruation as a remote cause, there is no immediate inconveni- ence experienced for the most part, nor is the woman sensible that any injurious ef- fect has been produced, until the failure at the next period warns her that mischief has been done; but even then, no unplea- sant feelings arise, nor perhaps for several succeeding periods. Symptoms. If the menstrual interrup- tion implicates the system, one of the first symptoms noticed is languor, succeeded by paleness, emaciation, and a variety of what are termed nervous symptoms; such as palpitation of the heart a sense of suf- focation, especially on rising any ascent, and leucorrhoea—this latter, however, rare- ly takes place in women who have not been generally subject to this complaint, before there is a general deterioration of health, and thus points out the necessity of imme- diate succour. Nature herself very often restores this discharge without the interference of the physician, and for this reason it is not al- ways a case for medical care; on the con- trary, we rarely prescribe for recent cases, but wait until it becomes doubtful whether the powers of the system unaided will be sufficient for this purpose. So soon as this suspicion, however, arises, we are instant- ly upon the alert. We believe this to be the proper management of such cases; as we are very sure that much mischief has arisen from the too early application of re- medial means. For this reason we wait for evidence that the system requires aid, by the symptoms just named presenting themselves; but which rarely happens un- til the menses shall fail to appear, after the lapse of the third or fourth period, unless this absence should be accompanied by a 354 AMENORRHCEA. more or less profuse leucorrhoea; for this will make the system flag somewhat ear- lier. Treatment. Few complaints ofthe sys- tem are prescribed for with such evident empiricism, as the "suspension of the menses;" yet no one of them requires more accurate discrimination—for no one remedy or mode of treatment will succeed in all cases. With a view, therefore, to the more complete understanding of the indications to be followed in the variety of amenorrhcea now under consideration, we shall divide the condition of the system into three different states—for it is owing to the want of these distinctions that its treatment is often unsuccessful. 1. Where the arterial system has not departed, or but very little, from its na- tural or healthy standard; 2. Where its action is too much exalted; 3. Where it is below its natural stand- ard. 1st. Where the arterial system is but little or not at all excited, we need not employ any active depletion, but we must be careful not to administer any violent stimulants, as large doses of the spir- ituous tinctures, a rich full diet of both durable and diffusible stimuli, savin, oil of pennyroyal, &c, lest we convert this state of the system into one of high action, and thus defeat the objects of our prescrip- tions. On the contrary, we should order a milk and vegetable diet; the bowels to be kept sufficiently or regularly open; an abstinence from every kind of liquor, and a freedom from much exertion or ex- ercise. By keeping this rule in view, we gain much time for ourselves, and much advan- tage for our patients; for by it we prevent the necessity of combating fever, or a high degree of arterial action, and thus give to our remedies a more undisturbed possession of the system, and consequently a better opportunity to effect their ulti- mate object We are aware that this is not the view that is generally taken of the state of the system, or of the mode of treatment; but an ample experience un- questionably decides in its favour. We would vary our treatment in this condition, as the expected period may be nearly, or more remotely, at hand. In the first case, it would be well, a day or two before the arrival of the period, to try the decoction of madder, as already suggested; to bathe the feet, before going to bed, in the warm mustard bath, and give an alo- etic purge. If the period be more distant or has just passed, we should commence with Tinct Lyttas, in thirty or forty-drop doses, three times a day, using the means just named, at the time then pointed out. In this plan, perseverance is necessary for some two or three months; at the end of which period it rarely fails to effect the pur- pose for which it is prescribed. If, during the use of these means, the general health is found to improve, we may calculate with much certainty that they will ultimately succeed ; and especially if leucorrhoea be an attendant, and it is found to abate. Should these remedies, however, fail, and the complaint become chronic, we should employ the volatile Tincture of Guaiacum, made according to the follow- ing formula. R. Pulv. G. Guaiac. Z'iv ; Carbon. Sodas vel Potass. 3iss; Pulv. Pimento. 3j; Al- cohol Dilut. fej ; M. and digest for a few days. The aqua ammon. is to be added pro re nata, in the proportion of one or two drachms to every six ounces of the tinc- ture, according to the state of the system. A tea-spoon-full of this tincture is to be given every morning, noon, and evening, in a wine-glass-full of sweetened milk; or what is more agreeable, in a glass of sher- ry, Teneriffe, or Madeira wine, if this be admissible. Should it open the bowels too freely, a few drops of laudanum must be added to each dose. Or should it not prove sufficiently aperient, a little resin of jalap or powdered rhubarb may be added. This medicine seldom or never fails in chronic idiopathic amenorrhcea; accord- ingly we place more reliance upon it in the cases proper for its use, than any other remedy. It is true, it may fail in some in- stances even of idiopathic amenorrhcea; but these constitute only exceptions. It will certainly fail, in symptomatic amen- orrhcea, from phthisis pulmonalis, &c. &c. and where this disease arises from an or- ganic lesion of the uterus. When these conditions can be ascertained, this remedy should be withheld, not only as useless, but perhaps mischievous. An Italian physician, Lavagna, has highly extolled injections, per vaginam, of a solution of ammonia. His mode of using this substance is, to add ten or twelve drops of aq. ammon. pur. to every ounce of milk; of which several ounces, that is, two or three, may be thrown up the vagi- na by means of a female syringe, four or five times a day—it should excite a glow, but not produce pain. If the first be not felt a few drops more of the ammonia may be added ; if the second, a little less must be used. We regret that we cannot add our tes- AMENORRHCEA.—AMIDINE. 355 timony to that of others, in favour of this remedy, as it has utterly failed in our hands, though pushed to the full extent we dared, in several instances; and this, un- der as favourable circumstances as we could well select. 2. Where arterial action is exalted. This state must be carefully distinguished from either the preceding or the following, as the success of remedies will mainly de- pend upon the discrimination. In the state under consideration, the first indication is to reduce the force of arterial action, by blood-letting, from the arm, or preferably from the foot; by a strict antiphlogistic regimen, and by purging. After the pulse is reduced to the proper standard by these means*, the patient is now in the condition to receive benefit from the remedies named for State 1, and must be treated in like manner in every respect, casteris paribus. It may be well to mention, en passant, that cold suddenly applied at the time the men- ses are flowing, will not only check the flow, but also give immediate rise to hys- terical or colicky affections. These must be treated upon general principles, by bleed- ing, purging, warm bath, &c. The best remedies for the colicky pains, are camphor, and purging with the elixir proprietatis. 3. Where the force of arterial action is below the natural standard. In these cases, it is not the pulse alone that betrays the languid state of the system; for all the symptoms of anemia wdl be present. Nor is this condition confined to the very young girl; it is often to be found at the more advanced periods of life, and has for its cause, in the cases we are treating of, the " idiopathic amenorrhcea." In such cases, the preparations of iron, tonics, the bitters, suitable exercise, and a generous diet, are the remedies. Sect. 3. Where the menstrual evacua- tion is arrested by the influence of certain chronic affections of other portions of the system. We shall not dwell upon this division of our subject, longer than to caution the young practitioner against mistaking the effect, for the cause, of ill health. We have already endeavoured to give the di- agnoses of these two conditions, to which we now refer—for the practitioner may be assured, that every attempt to restore men- struation, when its stoppage is symptom- atic, will prove unsuccessful, until the ori- ginal disease be removed. It is then, and then only, that any attempt should be made for this purpose, if nature does not relieve the embarrassment herself. But should the cause of amenorrhoea be removed and the menses fail to appear, the patient should be treated according to one of the three states we have supposed the arterial system to be in while labouring under this complaint. Wm. P. Dewees. Bibliography.—Stahl. De mensium mulie- brium fluxu secundum naturam, et suppressione prcelernalurali. Jena, 1694. A. Hamilton. A proposal of a new method of curing obstructed menses. Tn Essays and Obs. Phys. and Literary. II. 403. Edinburgh, 1756. This method consists in compression of the fe- moral arteries. Austin. Letter on die effect of eledricily in removing obstructions of the menses; with re- marks by Vie late Dr. D- Clark. In Essays and Obs. Phys. and Lit III. 116. Edinburgh, 1758. Chambon de Montaux. Maladies des files, des femmes, &e. &c. 2d ed. Paris, 1799. Vigarous. Cours ilimentaire des maladies des femmes. Paris, an. 10. W. Shearman. On the connexion which sub- sists in certain cases between Amenorrhaa and Phthisis Pulmonalis. In Edinburgh Med. and Surg. Journal, for Jan. 1810; and in Eclectic Re- pertory, I. 453. Philada. 1811. Thomann. De fluxu menslruo ejusque vitiis. Wurtzbourg. 1796. Royer—-Collard. Essai sur Vaminorrhie ou suppression du flux menstruel. Theses de Paris, 1802. N. Chapman. Some account ofthe use ofthe Polygala Senega in obstinate Amenorrhaa, in the Eclectic Repertory, II. 90. Philada. 1812. Caleb Miller. Cases of Amenorrhcea, &c. treated with phosphate of iron, in New-England Med. and Surg. Journal. III. 338. Boston, 1814. Burns. Principles of Midwifery, including the diseases of women and children, with addi- tions by Prof. James. Chap. XIII. New-York, 1831. J. W. Gloninger. Cases of Amenorrhea suc- cessfully treated by injections of aqua ammonia', in New-York Medical and Physical Journal, III. 182. (1824.) Th. Guibert. De Vemploi de la tiribenthine contre Vaminorrhie et les fleurs blanches, in Re- vue Medicale, III. 32. Paris, 1827. Moulin. Du diagnostic et du traitement de Vaminorrhie et des fleurs blanches—succes de la saignie contre ces maladies. Ibid. p. 39-56. Gardien. Traiti d'accouchement d des mala- dies des femmes d des enfans. 2d ed. Paris, 1816. T. P. Hereford. On Amenorrhaa, in Amer- ican Medical Recorder, XIII. 204. Philad. 1828. C. Loudon. On the cure of amenorrhaa by leeches to the mamma', in Edinburgh Medical and Surgical Journ. XXXVIII. 61. (1832.); and in Am. Journ. Med. Sc. XL 207. Locock. Art. Amenorrhoea, in the Cyclopaedia of Practical Medicine. London, 1832. L. C. Roche. Art Aminorrhie, in Diet, de Med. et de Chirurg. Prat. Paris, 1829. Desormeux and Paul Dubois. Art. Aminor- rhie, in Diet, de Med. Paris, 1833. Dewees. A Treatise on the Diseases of Fe- males. 4th ed. Philada. 1833. I. H. AMIDINE. (From Amidon, Starch.) (See Amyline, and Starch.) I. H. 356 AMMONIA. AMMONIA. (From Sal Ammoniac, the name of one of the principal salts of ammonia, so called by the ancients, from its being found in abundance in the neigh- bourhood ofthe temple of Jupiter Ammon.) Ammonia is a peculiar inorganic alkali, consisting of nitrogen and hydrogen, and distinguished from the fixed alkalies by its non-metallic constitution and gaseous nature. On account ofthe latter property, it is frequently called the volatile alkali. It exists in small amount in the mineral, vegetable, and animal kingdoms;but when obtained in large quantities, is always a product of art In the mineral kingdom it occurs as muriate of ammonia in the neighbourhood of volcanoes, and, in very small quantities, in the native oxides of iron, in clays, and some other minerals. In a free state, it has been detected by Chevallier and Lassaigne in certain plants, as the Chenopodium vulvaria, the Sorbus aucuparia, &c, and variously com- bined, in certain animal secretions. Some- times it becomes formed in the inorganic kingdom, when a body is oxidized at the same time by air and water, as when iron filings are exposed to a moist air; and it is a constant product ofthe decomposition of azotized organic matter, whether animal or vegetable, when undergoing putrefac- faction or subjected to an elevated tempe- rature. Animal matter, on account of its being rich in nitrogen, is almost exclusively em- ployed for obtaining ammonia. For this purpose it is subjected to destructive dis- tillation. The ultimate constituents of this matter, with the exception of fat which contains no nitrogen, are hydrogen, carbon, oxygen, and nitrogen. These elements, by entering into new combinations, give rise to a number of new products, among which the most abundant is ammonia. The animal matters usually employed in this distillation are refuse horns and bones. Sometimes woollen rags and cut- tings are employed. Formerly the horns of the hart were used, and hence has arisen the popular name of this alkali, hartshorn. The materials are distilled in a cast-iron cylinder, placed horizontally over a reverberatory furnace. One ex- tremity of the cylinder is so arranged as to open and shut conveniently, and forms the place at which the matters are intro- duced ; while the other terminates in a capacious curved tube which passes into a cask. This, by means of other tubes, is made to connect successively with a number of casks, from the last of which, a tube is turned back, so as to terminate in the furnace, where the incondensible products are emitted and consumed. This latter tube should contain several parti- tions of wire-gauze, in order to prevent the flame from retroceding and causing explosions. The products consist of water, empyreumatic oil, a small quantity of ace- tate and hydrocyanate of ammonia, to- gether with a large quantity of impure carbonate of ammonia, partly dissolved in the water, and partly in a concrete state. All these substances, except a small por- tion of the water, are new products, gene- rated by a new arrangement of the ele- ments of the animal matter. The impure carbonate of ammonia, ob- tained as above explained, is the parent of all the ammoniacal compounds; since it is concerned, either directly or indirectly, in the production of every individual of the class. When its solution is allowed to filter through a stratum of sulphate of lime (plaster of Paris), it is converted into sulphate of ammonia; and this latter, by being heated with chloride of sodium (common salt), gives rise to muriate of ammonia which sublimes, and sulphate of soda which remains as a fixed residue. In this manner having obtained the muriate of ammonia, we possess the most conveni- ent salt for yielding gaseous ammonia, or the alkali in question in a pure state. Preparation of Ammonia. Being pos- sessed of the muriate, all that is necessary in order to obtain ammoniacal gas, is to mix the salt in fine powder with twice its weight of pulverized lime, and to expose the mixture to a gentle heat The muri- atic acid combines with the lime, while the ammonia is evolved. As it is largely absorbed by water, it must be collected over mercury. Properties. Ammonia is a transparent, colourless, gaseous fluid, having an acrid and hot taste, a pungent smell, and a strong alkaline reaction. Its specific grav- ity is 0.59. On account of its strongly stimulating properties, it is irrespirable, the glottis closing spasmodically, when the attempt is made to breathe it When a lighted taper is immersed in the gas, it is extinguished, but just before it goes out its flame is enlarged in consequence ofthe combustion of a small portion of the gas. When passed over heated iron or copper, it is decomposed, and these metals under- go a remarkable decrease of density, at- tended, in the case of the former metal, with an increase of weight, amounting to 11£- per cent, caused by the absorption of nitrogen. When mixed with any gaseous acid, as, for example, the carbonic or muri- AMMONIA. 357 atic, it immediately forms a white precipi- tate like snow, consisting of the carbonate or muriate of ammonia. This property forms a very delicate test of the presence of ammonia, and may be taken advantage of to detect the gas, when all other means fail. For this purpose, it is merely ne- cessary to hold a glass stopper, wet with muriatic acid, near the liquid supposed to contain ammonia; whereupon the stopper will be surrounded with a white vapour, in case the alkaline gas be present. Ammonia may be condensed into a li- quid either by a cold of — 40°, or by the combined influence of cold and pressure. In the condensed state, it is colourless and possessed of a high degree of fluidity, and lias a specific gravity of about 0.76. Ammonia is absorbed in large amount by water, and to a considerable extent by alcohol. The liquids which result are used in medicine under the names of water of ammonia and ammoniated alcohol, and will be noticed in detail among the phar- maceutical preparations, forming the se- quel to this article. Ammonia is an important salifiable base, and as such forms a numerous class of salts. These are all colourless and possess a sharp and saline taste; and, with the exception of the fluoborate of ammonia which is liquid, are solid at ordinary tem- peratures. They are easily distinguished from other salts by the fact, that, when mixed with a hydrated fixed alkali, or with an alkaline earth, they disengage ammonia, recognizable by its smell, or by its forming a white fume around a glass rod, held over the mixture after having been dipped in muriatic acid. The greater number of them are neutral, though sev- eral possess an alkaline reaction, and an ammoniacal odour. The former always contain water, while the latter are anhy- drous. When exposed to heat, some of the ammoniacal salts volatilize without decom- position ; others abandon their ammonia while the acid remains; but the majority of them suffer a mutual decomposition of their acid and base ; the hydrogen of the ammonia forming water with the oxygen of the acid which is reduced either in whole or in part, and the nitrogen being set free. Many of the salts of ammonia, when their solutions are evaporated, lose ammonia and become acid. Hence it is necessary, when it is wished to crystallize these solutions, to add, upon the comple- tion of the evaporation, a sufficient quan- tity of ammonia to make up for that which is lost. A number of the ammoniacal salts are interesting either in a chemical or medical point of view. Those used in medicine will be described among the pharmaceu- tical compounds of ammonia, described at the end of this article; the remainder will be noticed in this place. Sulphate of ammonia is obtained on a large scale from the impure carbonate of ammonia, already mentioned; and is made extensively for the sole purpose of being sublimed with common salt in the fabrica- tion of muriate of ammonia. The impure carbonate in solution is mixed with pow- dered sulphate of lime, or made to filter through a layer of this salt. By double de- composition, sulphate of ammonia and car- bonate of lime are generated. According to Berzelius, the sulphate is sometimes formed by mixing a solution of the impure carbonate with one of sulphate of iron (green vitriol), or sometimes of alum. The ammonia combines with the sulphuric acid, and the oxide of iron, or alumina is precipi- tated. In England the sulphate of ammo- nia is frequently obtained from the ammo- niacal liquor generated in coal-gas works, and in Scotland, by lixiviating the soot of sulphureous coai. However obtained, it is a colourless salt, of a sharp, bitter taste, soluble in twice its weight of cold water, and in about its own weight of boiling water. It consists of one equivalent of acid 40, one of ammonia 17, and two of water 18 = 75. Nitrate of ammonia is easily formed by saturating nitric acid by means of carbonate of ammonia, and evaporating the solution. This salt is deliquescent and very soluble in water. It is obtained either in prisms, fibrous crystals, or a brittle compact mass, according to the temperature at which its solution is evaporated. It is interesting as being the most convenient substance from which the nitrous oxide can be ob- tained ; for when heated to a temperature of between four and five hundred degrees, it is totally resolved into this gas and water. Its composition is one equivalent of acid 54 to one of base 17 = 71. Soda-phosphate of ammonia was for- merly called microcosmic salt, and fusible salt of urine, and is employed in the same manner as borax, in assays with the blow- pipe. It exists in considerable quantities in the urine, from which it may be obtain- ed by evaporation. When exposed to the air, it effloresces and loses part of its am- monia. It consists of one equivalent, each, of phosphate of ammonia, and phosphate of soda, united with ten equivalents of water. Oxalate of ammonia is very much em- 858 AMMONIA. ployed by the chemist as a reagent for de- tecting lime, with which the oxalic acid forms an insoluble oxalate of lime. It is formed by neutralizing ammonia with ox- alic acid. It is a crystallized salt, very sol- uble in water, consisting of one equivalent of oxalic acid 36, one of ammonia 17, and two of water 18 = 71. Succinate of am- monia is employed in analysis for the pur- pose of separating the peroxide of iron from other oxides. The solid salt is al- ways acid; and hence when dissolved in water to be employed in precipitating iron, the solution must be neutralized before it is used; for otherwise, the precipitated succinate of iron would be dissolved in the process of washing. Composition of Ammonia. This alkali consists of one equivalent of nitrogen 14, and three of hydrogen 3 = 17; or, in vol- umes, of one volume of nitrogen and three volumes of hydrogen, the four volumes condensed into two. That this is its com- position in volumes is made evident by the result of its analysis by electricity; for when subjected repeatedly to the electric spark, two volumes are resolved into four of a mixture, one-fourth of which is nitrogen, and three-fourths hydrogen. Scheele was the first chemist who ascer- tained that the constituents of ammonia were nitrogen and hydrogen; but it was Berthollet who determined with any precision the proportions in which they are combined. It has already been mentioned that the neutral salts of ammonia contain water. Resting mainly upon this fact Berzelius has formed a theory respecting these salts which assigns to them a metallic oxide base, and thus makes them assimilate, in composition, with the salts of the fixed al- kalies. In all these ammoniacal salts, Ber- zelius supposes one equivalent of ammo- nia and one of water to form a peculiar metallic oxide, with which the acid is combined. Thus the ammonia consists of one equivalent of nitrogen and three of hydrogen, and the water, of one equiva- lent of hydrogen and one of oxygen. The hydrogen of the water united with the constituents ofthe ammonia is supposed to constitute a peculiar compound metal, call- ed by Berzelius ammonium, consisting of one equivalent of nitrogen and four of hy- drogen ; and the oxygen of the water is alleged to constitute, with this ammonium, a metallic oxide. When mercury is elec- trified in contact with muriate of ammo- nia, it combines with the elements of am- monia, but with an excess of hydrogen, and becomes greatly enlarged in bulk without losing its metallic properties. This experiment, Berzelius considers to prove that what the mercury gains,* must be me- tallic matter; as otherwise it would lose its metallic character. With the exception of the presumption created by this experi- ment, ammonium is altogether a hypothet- ical substance. The theory which sup- poses its existence is plausible ; but there are several strong objections to its truth. Thus ammonia is confessedly a strong al- kali ; and it would be contrary to all ana- logy to suppose that by gaining more hy- drogen, it could become metallic. In fact, it would be making a metal contain an al- kali, instead of the alkali, a metal, as is the case with the fixed alkalies. It may be objected also, that the theory does not explain all the cases of the ammoniacal salts; for besides the salts of ammonium, Berzelius is forced to admit the existence of salts of ammonia, as where a dry acid, carbonic acid for example, combines with dry ammonia. Therapeutical Applications. Ammonia, as used in medicine, is variously com- bined ; and in its different combinations, its effects on the animal economy are in many cases different. In the gaseous state, or when combined with water, it acts as a powerful irritant and stimulant In the former state and diluted with air, as emit- ted from the water or carbonate of am- monia, or from a mixture of the muriate with Hme or carbonate of potassa, it is applied as an excitant to the nostrils for nervous head-ache and fainting. The sub- stances employed are generally scented with some agreeable volatile oil, and in this state form the contents ofthe different smelling-bottles of volatile salts, so fre- quently employed. For an account of the general effects of ammonia upon the system, and its thera- peutical applications, the reader is referred to the head of carbonate of ammonia; as this is the form under which the alkali is most commonly employed as a remedial agent; and the remarks applicable to the carbonate, are for the most part applicable also to ammonia in its caustic state. The peculiar effects of the other medicinal combinations will be mentioned under the head of each. Pharmaceutical Preparations. The chief pharmaceutical preparations of am- monia are water of ammonia, ammoniated alcohol, muriate, carbonate, and bicarbo- nate of ammonia, and the solutions of ace- tate of ammonia and of hydrosulphate of AMMONIA. 359 ammonia. These several preparations will be noticed, under distinct heads, in the order here named. Water of Ammonia.—Aqua Ammo- nia, Ph. U. S. et E. This preparation, usually called liquid ammonia, is obtain- ed, according to the U. S. and Edinburgh Pharmacopoeias, by heating, in a glass re- tort placed on a sand bath, a mixture of one part of muriate of ammonia with one and a half parts of lime, the latter, previ- ously to the mixture, being slaked with a sufficient quantity of water; and allowing the ammoniacal gas, as it is evolved, to be absorbed by a portion of distilled water. By the superior affinity of the lime for the muriatic acid, muriate of lime is formed; and at the same time gaseous ammonia is evolved, which is absorbed by the distilled water. According to the London and Dub- lin formulas, a solution of muriate of am- monia is added to slaked lime, and a de- terminate quantity of the liquid drawn over by distillation. Here the rationale is the same as when the preparation is ob- tained by the other process; the only differ- ence being that the water intended to ab- sorb the ammonia is present in the retort and is distilled over, more or less saturated with the gas, into the receiver. Water of ammonia is generally prepared on the large scale by the manufacturing chemist Li order to save the expense of glass retorts, a cast-iron boiler is conveni- ently employed, furnished with a copper head, communicating with two glass ves- sels, the first empty, to detain any impuri- ties which may distil over with the gas, the second, half filled with distilled wa- ter. When a strong liquid ammonia is re- quired, the water employed to absorb the gas should equal in weight the muriate de- composed. The manufacturing chemists generally make a strong preparation, and afterwards dilute it sufficiently with wa- ter, to bring it down to the medicinal standard. Sulphate of ammonia when act- ed on by lime, will yield ammoniacal gas, and, hence, may be substituted in this process for the muriate. M. Payen has proposed it for this purpose, and states that its employment affords economical results. Properties. Water of ammonia is a colourless liquid, of an acrid taste, and pe- culiar, pungent smell. It acts as a caustic on animal matter, and blisters by its con- tact the tongue and skin. It has a strong alkaline reaction, and instantly changes turmeric paper to reddish-brown, when held over its fumes. Cooled rapidly to 40° below zero, it assumes a gelatinous consistency; but when gradually refrige- rated to the same point, it crystallizes in long needles possessing a silky lustre. When heated sufficiently, it enters into ebullition with disengagement of the gas; its boiling point being always lower, in proportion as it is more concentrated. It has a very strong attraction for carbonic acid; and hence, if insecurely kept it ab- sorbs this acid, which may be detected by the preparation effervescing with acids, or by its affording a precipitate with lime- water. When perfectly pure, it evaporates in a glass capsule without residue. It com- bines with oil, and forms a liquid soap, and dissolves resins and other vegetable prin- ciples. Its specific gravity varies with its strength, being always less, in proportion to its concentration. When as concen- trated as possible, its density is 0.875 at the temperature of 50°. Its officinal strength is by no means so high; but varies somewhat according to the different phar- maceutical authorities agreeably to which it is made. It is 0.939 in the Edinburgh Pharmacopoeia, 0.944 in that ofthe United States, 0.950 in the Dublin, and 0.960 in the London; the amount of gaseous ammo- nia present varying, between the extremes, from about 10 to 16 per cent. The French medicinal water of ammonia is stronger than any of these preparations, as it has a specific gravity of 0.923 and contains about 20 per cent of ammonia. Composition. When water is fully satu- rated with ammonia, it takes up about one- third of its weight, or 430 times its volume of the gas, and increases in bulk about two-thirds. It is seldom obtained, how- ever, so concentrated as this, but varies exceedingly in strength, according to the care with which it is prepared. In order to facilitate the determination of the pro- portion of the gas in different samples of liquid ammonia, tables have been con- structed, showing the per centage of am- monia corresponding to different densities. The following table, constructed by Sir H. Davy, is of this kind, and may prove use- ful to the practical chemist Specific Gravity. Ammonia per cent 0.8750 32.50 0.8875 29.25 0.9000 26.00 0.9054 25.37 0.9166 22.07 0.9255 19.54 0.9326 17.52 0.9385 15.88 0.9435 14.53 0.9476 13.46 0.9513 12.40 0.9545 11.56 0.9573 10.82 0.9597 10.17 0.9619 9.60 0.9692 9.50 360 AMMONIA. In using this table, all that is necessary is to take the specific gravity of any sam- ple of water of ammonia, and, then, by in- spection, to ascertain the per centage of ammonia corresponding thereto. Therapeutical Applications. Water of ammonia is stimulant, antacid, rubefacient and vesicatory. As a stimulant, it is oc- casionally employed in hysteria, fainting, asphyxia, and similar affections, for the purpose of rousing the vital powers. As an antacid, it is a useful remedy in heart- burn, and for the relief of sick head-ache when dependent on acidity. The dose is from 5 to 20 drops, according to its strength, largely diluted with water to prevent its caustic effect on the mouth. The water of ammonia of the Edinburgh College is inconveniently strong for internal use, and hence that College have directed an Aqua Ammonia Diluta, of one-third the strength of the strong preparation. Externally, wa- ter of ammonia is used as a rubefacient, being the chief ingredient of several lini- ments. The liniment of ammonia or vol- atile liniment {Linimentum Ammonias, Ph. U. S.) is a liquid soap, made by mix- ing half a fluidounce of water of ammo- nia with two fluidounces of olive oil, and is very much used as a stimulating lini- ment in rheumatic pains and sore throats. The compound camphor liniment {Lini- mentum Camphorce Compositum, Ph. L. et D.) is a solution of camphor in a mix- ture of water of ammonia and spirit of lavender, and is used for the same pur- 4 poses as the liniment of ammonia. The liniment of mercury {Linimentum Hy- drargyria Ph. L.) is prepared by mixing an ounce of camphor, rubbed up with 15 minims of alcohol, with 4 ounces, each, of mercurial ointment and lard, and 4 fluid- ounces of water of ammonia. It is used as a stimulating liniment and discutient in glandular swellings and venereal tumours, as swelled testicle, buboes, &c. When water of ammonia is employed as a vesi- catory, a piece of linen of the size of the blister desired, is wet with it and applied to the part intended to be vesicated. When this effect is required, it is doubtful whe- ther the weaker waters of ammonia would prove sufficiently irritating. Toxicological Properties. Poisoning by water of ammonia is exceedingly rare, on account of its pungent odour, which pre- vents its being taken by mistake. Orfila concludes, from • his experiments on dogs, that it acts as an irritant poison, producing death, sometimes by acting on the nervous system, particularly the spine, and some- times by producing an inflammation ofthe alimentary canal, and secondarily a lesion of the brain. In cases of poisoning by this alkali, it is supposed that diluted vinegar, acting by its neutralizing power, would form the best antidote. Unfortunately the poison acts with great rapidity, and hence the necessity of extreme promptitude in applying the necessary remedies. If the patient survive the first shock, the consecu- tive inflammation must be combated by the usual antiphlogistic remedies. Ammoniated Alcohol. Spirit of Am- monia.—Alcohol Ammoniatum, Ph. U. S. et E. This preparation, according to the United States and Edinburgh Pharmaco- poeias, is merely a solution of ammonia in alcohol (rectified spirit). The nearest cor- responding preparations of the London and Dublin Colleges are solutions of carbonate of ammonia, in proof or rectified spirit. That of the London Pharmacopoeia is made by distilling a mixture of muriate of am- monia, carbonate of potassa, and proof spirit. By double decomposition, carbonate of ammonia is formed, which distils over with the proof spirit, while the muriate of potassa remains behind. The Dublin for- mula consists in simply dissolving the officinal carbonate {sesquicarbonate) of ammonia in rectified spirit During the solution, just so much carbonic acid is extricated as to convert the sesqui- carbonate into the regular carbonate, of which 30 grains are dissolved in each fluidounce of the spirit, to form a satu- rated solution. Therapeutical Applications, &c. Am- moniated alcohol is a colourless liquid, of an exceedingly pungent smell and acrid taste. The corresponding preparations of the London and Dublin Colleges have the same general properties, though in a mild- er degree, on account of the ammonia con- tained in them being carbonated. It is sometimes given as a stimulant in doses of from 20 to 50 drops in a wine-glass-full of water. When these compounds are im- pregnated with aromatics, they constitute the aromatic ammoniated alcohol, and aromatic spirit of ammonia, preparations much more employed, on account of their grateful taste, than simple ammoniated alcohol. Ammoniated alcohol is employed as a menstruum for certain medicines, forming a class of preparations called ammoniated tinctures; among which may be enume- rated the ammoniated tinctures of guaiac, opium, Peruvian bark, and valerian, the ammoniated spirit of meadow-saffron, and AMMONIA. 361 the fetid and succinated spirits of ammo- nia, the latter preparation being intended as a substitute for the eau de luce. Muriate of Ammonia.—Ammonia; Mu- rias, Ph. U. S.—L. et D. This salt exists in nature, being found in the craters of cer- tain volcanoes, and occasionally in coal mines. It occurs, also, ready formed, in the urine and dung of some animals. For- merly it was prepared only in Egypt where it was obtained by sublimation from the soot of camels' dung. At present it is made in different cities in Europe by pure che- mical means. The process consists in mixing the crystallized sulphate of ammo- nia, obtained in the manner already de- scribed, with common salt and exposing the mixture, placed in stone-ware vessels, to a quick heat By double decomposi- tion, there are formed muriate of ammonia, which sublimes into the upper part of the vessels, and sulphate of soda, which remains behind. Sometimes the sulphate of ammo- nia and common salt are dissolved toge- ther in water, and the mixed solution is evaporated to the point of crystallization ; whereupon the muriate of ammonia crys- tallizes first and sulphate of soda after- wards. The muriate is then placed in co- nical moulds to drain, and afterwards the masses are piled up and dried. The crys- tallized muriate of ammonia, thus obtained, is not so pure as the sublimed; as it gene- rally contains a portion of sulphate of soda. Properties. Sublimed muriate of am- monia is in the form of concavo-convex se- mitransparent cakes, of great tenacity, and difficult to be reduced to powder. Its taste is sharp and saline, and its specific gravity 1.45. It dissolves in 2.72 parts of cold water, and in its own weight of boiling water, and is soluble also in alcohol. It crystallizes generally in feathery crystals, less frequently in cubes or octohedrons. By the action of chlorine on its solution, a violently detonating liquid, called chloride of nitrogen, is formed. It is readily re- cognized by the combined indications of lime, which extricates the ammonia, and of strong sulphuric acid, which sets free white vapours of muriatic acid. It consists of one equivalent of muriatic acid 37, and one ammonia 17=54, or two volumes of each, condensed into a solid. Berze- lius, by supposing the hydrogen of the acid to be transferred to the ammonia, makes it a chloride of ammonium. It is employed in the arts for preserving metals bright preparatory to soldering, and in some ofthe processes of calico-printing. Pharmaceutical Uses. Muriate of am- monia is used in pharmacy for the produc- VOL. I. 31 tion of gaseous ammonia by the action of lime, and for the preparation of carbonate of ammonia, ammoniated iron, and ammo- niated mercury. Therapeutical Applications. Muriate of ammonia is deemed an alterative, and sti- mulating diaphoretic and diuretic. It has been used in catarrhal and rheumatic fe- vers, and in pneumonia, bronchitis, pul- , monary catarrh, and other inflammations, after their first violence has abated. Its al- terative effect has been found beneficial in the treatment of indolent tumours, visceral obstructions, catarrh of the bladder, leucor- rhoea, and affections of the bowels, charac- terized by increased mucous secretion. According to Sundelin, it is a good remedy in amenorrhoea, when dependent on atony ofthe uterus, and in sub-inflamma- tory chlorosis. The dose is from 5 to 30 grains. Externally applied in solution, it is a va- luable remedy. Sometimes it is employed at the moment it is dissolved, as a sedative lotion to the head in mania, apoplexy, and violent head-ache, in which cases it acts by the cold which it produces. It is frequent- ly applied, also, as a stimulating discutient to indolent tumours. The lotion may be formed by dissolving an ounce of the salt in a pint of water. Carbonate of Ammonia. Mild volatile alkali.—Ammonia: Carbonas, Ph. U. S. et D. The officinal carbonate of ammonia is obtained from the muriate, usually by subliming it with carbonate of lime or £ chalk. The carbonic acid combines with the ammonia, and the muriatic acid with the lime, so as to form chloride of calcium and water. The carbonate of ammonia and water sublime together, forming a hydrated carbonate, and the chloride of calcium is left behind. The Dublin Col- lege forms this preparation by subliming the muriate with carbonate of soda, and the rationale is similar to that just given; the only difference being that the residue is chloride of sodium, or common salt, instead of chloride of calcium. In conducting this process, the retort should be of earthen- ware, and have a wide cylindrical neck; and the receiver should be cylindrical also, to facilitate the extraction of the sublimed carbonate. The decomposing salt, whether carbonate of lime or of soda, should be used in excess, to insure the complete de- composition ofthe muriate; for, otherwise, a part of this would be apt to sublime along with the ammoniacal carbonate. The use of carbonate of soda is said to afford a whiter product, but is objectionable on the score of expense. 362 AMMONIA On a large scale, carbonate of ammonia is generally made by subliming the usual materials from an iron pot into a large earthenware or leaden receiver. Accord- ing to Payen, sulphate of ammonia may be substituted for the muriate with economi- cal results; and when used, the residue will of course be sulphate of iime. Carbo- nate of ammonia is manufactured in large quantities from the ammoniacal products, obtained in the distillation of coal, in coal- gas works; but when thus obtained, it is apt to have a slight smell of coal tar, and to leave a blackish matter when dissolved in acids. Properties. Carbonate of ammonia, when fresh, is in white, moderately hard, trans- lucent, crystalline masses, of a fibrous tex- ture, pungent smell, and sharp penetrating taste.. It possesses an alkaline reaction, and when held under a piece of turmeric paper, changes it to brown, owing to the ammonia which escapes. When long or carelessly kept, it gradually passes into the state of bicarbonate, becoming opaque and friable, and much less pungent In this state, it should never be put up in pre- scriptions for the officinal carbonate. It is soluble in twice its weight of cold water, and in less than its weight of warm water. Its solution is officinal with the British Col- leges ; but in this state, it is not a good pre- paration, as it is liable to change by keep- ing. Boiling water decomposes it, with ef- fervescence of carbonic acid. It dissolves £ abundantly in diluted alcohol, and with ef- fervescence of carbonic acid, in alcohol of 0.836. When heated on a piece of glass, it ought to evaporate without residue; and if turmeric paper, held over it, undergoes no change, it is a proof that it has passed into bicarbonate. Carbonate of ammonia is decomposed by acids, the alkalies whether pure or car- bonated, lime-water, magnesia, muriate of lime, supertartrate of potassa, corrosive sub- limate, acetate and subacetate of lead, the sulphates of iron and zinc, and the prepa- rations of iron, with the exception of the tartrate of iron and potassa. Composition. This salt consists of three equivalents of carbonic acid 66, two of am- monia 34, and two of water 18=118. The medicinal carbonate of ammonia, when per- fect, is, therefore, a hydrated sesguicarbo- nate, and not a sK&carbonate, as it is call- ed by the London and Edinburgh colleges. It is considered by these authorities to be a sub-salt, on the ground of its having an alkaline reaction; but this depends upon the weak saturating power of carbonic acid, and not upon its amount being less than the equivalent quantity. By the best modern chemists, the plan has been adopt- ed of applying the simple saline name to any salt which is neutral in composition, that is, which consists of one equivalent of acid to one of base, without reference to its mode of reaction with test paper. The mutual decomposition of the salts employed in forming this preparation, would produce, if no loss occurred, a regu- lar carbonate of one equivalent of acid to one of base. In order to account for the production of the sesquicarbonate, it may be supposed that from every three equiva- lents severally of regular carbonate and of water generated, one equivalent of am- monia and one of water are lost; so that nothing would remain to sublime but the exact ingredients of the hydrated sesqui- carbonate. Franklin Bache. Effects upon the System. As the medi- cal properties of carbonate of ammonia dif- fer from those of its alkaline base only in degree, it is proposed to consider the gene- ral subject of ammonia in its relations to the system under the present head. When, in any case, one of the preparations con- taining the alkali in its caustic or carbo- nated state is considered more applicable than the others, it will be particularly de- signated. Ammonia is a general stimulant of the vital functions. Taken internally, it pro- duces excitement with a feeling of warmth in the stomach, quickens the motion ofthe heart and arteries, increases the heat of the skin, elevates the nervous actions, and, if in moderate quantities, augments the va- rious secretions. Its strongest local ten- dency is to the skin; although, under fa- vourable circumstances, it may be directed with some force to the kidneys or uterus. It differs from the narcotic stimulants in exerting no peculiar influence upon the brain. In large doses it is said to prove emetic. It is a powerful antacid; pure ammonia having a higher neutralizing power than any other alkaline base. It probably acts as a medicine, partly by a di- rect stimulant impression upon the sto- mach, which may be sympathetically pro- pagated, partly by entering the circulation and thus coming into contact with all parts of the system. Swallowed in over- doses, it inflames the stomach; and in a concentrated state, acts as a corrosive poi- son. Death may result either from its im- mediate disorganizing operation upon the parts with which it comes in contact or, according to Orfila, from its influence upon the nervous centres. Huxham re- lates the case of a young man who had AMMONIA. 363 contracted the very singular habit of chew- ing carbonate of ammonia. Hemorrhage occurred from his nose, mouth, stomach, and bowels; his teeth fell out; and he died in a short time of hectic fever. {Essay on fevers, p. 308.) In the case of an epilep- tic patient reported by Nysten, who was made to inhale ammonia, and had a drachm of the liquid alkali poured into his mouth, violent inflammation supervened in the mouth, throat, oesophagus, and air pas- sages; and death resulted in forty-eight hours, without any convulsive affection, or any obvious cerebral disorder. Dissection exhibited no other morbid phenomena than marks of inflammation in the parts touched by the alkali. {Gazette de Santi, 21 Mai, 1816.) A similar case is recorded in the Edinburgh Medical and Surgical Journal (XIV. 642); but no post-mortem examina- tion was made. In the Revue Midicale (XVII. 205), an instance is related in which intoxication produced by prussic acid was relieved by the inhalation of am- moniacal vapour, at the expense of a severe inflammation of the mouth, throat and bronchial tubes, from which, however, the patient recovered in fifteen days. From these facts M. Trousseau has inferred, that the poisonous influence of ammonia is, in general at least, confined to the local irritation which it occasions. {Did. de Mid. II. 385.) The painful impression produced by the alkali, in its concentrated forms, upon the tongue and palate, usually prevents it from being swallowed; so that fatal consequences from its imprudent use are very rare. Two cases have occurred to the author of these remarks, in which the aromatic ammoniated alcohol has been taken undiluted into the mouth with a view to its being swallowed. It was, how- ever, in both instances, immediately dis- charged ; and no other consequences re- sulted than a severe inflammation of the mouth and throat, which was ultimately relieved. In one instance, a considerable portion of the tongue was denuded of the cuticle. The treatment proper in poison- ing by the volatile alkali has been describ- ed under the head of Water of Ammonia. Applied to the nostrils, in a diluted state, as it escapes from the materials which pro- duce it, or rises spontaneously from some one of its preparations, ammonia excites a pungent rather agreeable sensation, and pro- duces a stimulant impression, which is felt, to a greater or less degree, throughout the nervous system. The shock thus produced is sometimes so severe, when the vapours are highly concentrated, as to occasion syncope, and even death. An instance of the former effect was witnessed by Merat and De Lens; and professor Percy has related a case of the latter, in which the son of an apothecary perished, notwith- standing the immediate application of remedies, from the breaking of a bottle full of ammonia. {Did. de Mat. 'Mid. IL 236.) Even when the effects are less im- mediate, there is danger of violent and fatal inflammation from the inhalation of ammoniacal gas or vapours in a concen- trated state. Upon the skin ammonia acts as a pow- erful irritant, producing a rubefacient, vesicatory, or caustic effect according to the strength of the preparation employed, or the length of time during which it is applied. Those preparations ofthe volatile alkali in which it exists in the caustic state, as water of ammonia, and ammoniated alco- hol, are more powerful in their local effect, but do not act more efficiently as general stimulants, than the carbonate, probably because the pure alkali, when taken into the stomach, is converted into the carbon- ate before it reaches the circulation. A practical inference from this fact is, that caustic ammonia sufficiently diluted may be used most advantageously as a local irritant or stimulant, and the carbonated alkali, with a view to its influence on the system. In whatever form ammonia is given, its stimulant action is comparative- ly brief; so that to maintain a given im- pression, it is necessary to repeat the dose at short intervals. Therapeutic Applications. Ammonia "is susceptible of a great variety of therapeutic applications, and has been very extensively employed. The purpose to which it is best adapted is that of elevating the ac- tions of the system, in states of debility suddenly induced or attending acute dis- eases. In typhus fever, and in the latter stages of other fevers when they assume the typhoid form, it may be resorted to at an earlier period, and with greater safety, than almost any other stimulant. To these complaints it is peculiarly adapted by its want of any especial action on the brain, as well as by its diaphoretic properties, which obviate that unpleasant heat and dryness of skin so apt to be produced or aggravated by medicines which excite the circulation, without having any tendency to increase the cutaneous secretion. It may also be given advantageously in the exanthemata, such as small-pox, scar- let fever, and measles, when they assume a low or typhoid form, and require stimu- lation. In the unpleasant and alarming 364 AMMONIA. condition of these complaints which some- times attends upon a tardy or repelled eruption, it occasionally proves useful, by bringing on or restoring the affection of the skin; and for this purpose it may be em- ployed more safely than most other stimu- lants, on account of the comparative brev- ity of its action, which prevents the inju- rious continuance of the artificial excite- ment after reaction has been established. For precisely the same reason, it is ap- plicable to the prostrate state of the system which sometimes suddenly occurs at the commencement or in the progress of febrile complaints. The indication, in these cases, is usually to bring about reaction with as little prolonged excitement as possible; and the carbonate of ammonia is well cal- culated to meet this object. Even the phlegmasias, when they degen- erate into the typhus condition, may be treated advantageously by this stimulant. In proportion to its ability to elevate the vital powers, it has less tendency than most other substances of its class to increase existing inflammations, unless seated in the parts with which it is brought into im- mediate contact when administered. Thus it is highly useful in pneumonic inflamma- tions attended with prostration, particularly in that form which is usually known by the name of bilious pneumonia. It may be employed also in typhus dysentery, certain low states of puerperal peritonitis, malig- nant sore throat erysipelas and carbuncle attended with enfeebled action, external gangrenous inflammations, and gouty or rheumatic affections accompanied with a cool skin, a feeble pulse, and other signs of general debility. In all the cases above enumerated, and others of an analogous character, the car- bonate is preferable to the other ammoni- acal preparations. Care should always be taken in administering it to graduate the dose to the wants of the system, and to di- minish or suspend it, if it should be found to increase the heat and dryness of the skin and frequency of pulse, or to aggra- vate any existing inflammation. It is usu- ally best, unless in urgent cases, to com- mence with a small dose—four or five grains, for instance—and gradually in- crease, as the symptoms may appear to demand, to ten grains or more. The dose should be repeated every hour or two hours, in order to maintain a uniform im- pression. When no signs of cerebral in- flammation exist, the volatile alkali may often be advantageously alternated with wine-whey, which, if taken warm, har- monizes admirably with the ammonia, in supporting the failing powers of the sys- tem, and maintaining a warm and moist state of the surface. The influence ofthe volatile alkali upon the nervous system has led to its employ- ment as an antispasmodic in various com- plaints, such as hysteria, epilepsy, tetanus, &c.; but any power which it may possess of allaying convulsive movements, other than such as is connected with its stimu- lant property, is very feeble; and practi- tioners at present seldom resort to it with this view. Nevertheless, it has been re- garded by some French physicians as one of the most effectual remedies in tetanus, when very largely given—to the amount, for example, of half an ounce daily, in di- vided doses. {Did. de Mid. II. 389.) In spasmodic affections of the stomach, unconnected with inflammation, it is cer tainly a valuable remedy. Examples of this kind we have in translated gout and rheumatism, flatulent colic, dyspeptic gas- trodynia, and cholera morbus, in all of which ammonia may be used with advan- tage. In that vague uneasiness of stomach, arising from deficient nervous energy, which is often a distressing accompaniment of dyspepsia, it is also frequently benefi- cial by its warming and cordial influence. Where the gastric affection is connected with acidity, the alkali is peculiarly use- ful. Its union of antacid and cordial prop- erties renders it, indeed, a highly valuable remedy in cardialgia, and those various disordered sensations, such as vertigo, de- ranged vision, and sick head-ache, which depend on the presence of acid in the stomach. When the acid is abundant, the ammonia may be advantageously combined with other alkaline remedies, 6uch as the carbonate of soda, carbonate of potassa, or magnesia. We are told that ammonia is employed, with much success, in the relief of ruminating animals suffering under a gaseous distension of the paunch arising from the extrication of carbonic acid gas. The alkali, in consequence of its strong affinity for carbonic acid, absorbs the gas already extricated, while it suspends the fermentation of the food by which it is produced; and the consequence is the im- mediate disappearance of the distention. {Bull, des Sc. Mid. de Ferussac, Mai, 1826.) It has been suggested that the remedy may sometimes prove serviceable, in a similar manner, in the human subject In all cases, in which the ammonia is ad- dressed particularly to the stomach, its caustic form is preferable to that of the carbonate; and the most pleasant and ele- gant preparation is the Aromatic Ammo- AMMONIA 365 niated alcohol of the U. S. Pharmacopoeia. This may be given in a dose varying from ten drops to a fluidrachm, largely diluted with water, and repeated more or less fre- quently, according to the duration and ur- gency of the symptoms. As a stimulant diaphoretic, ammonia has been recommended in chronic rheumatism and certain states of palsy, and may no doubt have proved occasionally serviceable in these complaints; but it is at present not much employed in either, except in the form of ammoniated tincture of guaiac, which is often and very beneficially pre- scribed in rheumatic affections. Under the impression that it possesses expectorant powers, it has been used in chronic catarrh, the latter stages of whoop- ing cough, humoral asthma, the chronic bronchial affection which succeeds ill- cured measles, and in the declining stage of phthisis. It does not, however, appear to possess any peculiar tendency to act on the pulmonary organs; and if it be produc- tive of good in these complaints, as it oc- casionally is, when they are complicated with general debility, the result must de- pend merely on its stimulant operation. It frequently happens, in pectoral complaints of long duration, that the remaining strength of the patient is insufficient to enable him to discharge the mucus or pus which collects in the air-cells and bronchial tubes, and suffocation, is the necessary con- sequence, unless relief is afforded. The volatfle alkali, under these circumstances, sometimes proves serviceable by imparting to the muscles concerned in expectoration, sufficient power to throw off the accumu- lated secretion. In this way it may be the means of saving life in diseases of a cura- ble character, and may afford great relief in the closing scene of some that are in- curable. Ammonia has been recommended inter- nally in amenorrhcea, and may prove use- ful in the same manner as any other sti- mulant, by exciting the circulation at a time when the system is predisposed to the menstrual effort, but is, of itself, unable to establish the secretion. Dr. Neumann, of Berlin, cured a case of diabetes mellitus, which succeeded an at- tack of ascites in a woman of a feeble and hysterical constitution, by the continued use, for four months, of carbonate of ammo- nia, given at first in the dose of five grains thrice daily, and afterwards increased to fifty grains in a day. {Journ. of For. Med. Sc. and Lit. III. 718.) High commendation has been bestowed upontiie volatile alkali as a remedy in lues 31* venerea; but experience has satisfactorily shown that it has no peculiar anti-syphili- tic virtues; and if it sometimes prove use- ful in the latter stages of the complaint, the effect is to be ascribed to its general cor- dial influence on a debilitated and depra- ved condition of the system. The same may be said of its use in scro- fula, in the ulcerated 6tates of which it is asserted to have been beneficially em- ployed. No credence whatever can be at- tached to the favourable reports of its in- ternal use in cancer. Some writers speak of the employment of carbonate of ammonia as an emetic, in the dose of thirty grains or more; but its operation in this way must be at best un- certain, and it should never be confided in alone. It is possible that its addition to the ordinary emetic medicines may be useful in certain cases of languid stomach or gen- eral debility, in the former by awakening susceptibility to their action, in the latter by counteracting their exhausting influ- ence. Ammonia has long enjoyed considerable credit as an alexipharmic. It was intro- duced into notice as an antidote to the poi- son of venomous serpents, about the year 1747, by Bernard de Jussieu, who believ- ed that he had used it successfully in the case of a student who had been bitten in the hand by a viper. Since that period, numerous reports have been made in its favour in similar cases. Mangili, an Italian author, has reported cases of its success in the bite of the viper. {Sul veleno della vi- pera, 1809.) Sonnini witnessed the cure of a young Indian, bitten by a serpens echu natus, by means of the external and inter- nal use of the eau de luce, which is an am- moniacal preparation. Writers both in the East and West Indies, have recorded cases of the successful employment of ammonia in the bites of the venomous serpents of those countries. (Chapman, Elements of Therapeutics, &c. II. 159.) Dr. Ramsay, of South Carolina, has also recorded cases of its successful use. (Eberle, Treatise on the Mat. Med. II. 177.) In the American Journal of the Medical Sciences, (I. 341.) three cases are detailed by Dr. J. Moore, of Mississippi, one of the bite of a rattle- snake, the two others of the bite of a mock- asin, which he asserts to be still more ven- omous than the rattlesnake, in all of which cures were effected by the use of water of ammonia, taken internally, in the dose of a tea-spoon-full repeated in half an hour or an hour, and applied externally to the bite by means of pledgets of lint moistened with it Dr. Moore speaks also of fourteen other cases 366 AMMONIA. of unequivocal character, which had been treated under his own eye, during a period of twenty years, with similar results. If faith can be attached to medical testimony, it would appear that the volatile alkali really possesses considerable power over that state of system produced by the poison of ser- pents ; although Fontana declares, from his own experience, that it is rather injurious than useful, and cases have been recorded in which it proved wholly inefficacious. It is certain, that of individuals bitten by poi- sonous serpents, many are but slightly or not at all affected, and others recover with- out the use of remedies; so that a physi- cian might be led into error by attributing to the medicine effects which would have equally occurred without it; but from the details presented, particularly in the cases recorded by Dr. Moore, it is scarcely pos- sible to resist the inference that the'ammo- nia was the real cause of cure. Negative testimony, unless abundant and various, cannot be admitted as conclusive against statements of positive experience ; as the circumstances of the case, and the mode of applying the remedy, may be different At all events, ammonia is well worth a trial in all cases of the kind alluded to; but it should never be relied on to the ex- clusion of means calculated to remove the poison at once from the wound, when the opportunity is offered of doing so, before it has begun to affect the system. In all in- stances it is recommended to combine its local with its internal use. It is customary also to employ ammonia in the bites of venomous insects, the stings of bees, wasps, hornets, &c.; but these are seldom so severe as seriously to affect the constitution, and the internal use of the remedy is, therefore, in general, unneces- sary, while the local injury may usually be treated with greater comfort to the pa- tient by refrigerant than by rubefacient ap- plications. In the horrible disease which re- sults from the bites of rabid animals, ammo- nia, though recommended by some authors, is altogether inadequate to afford relief. The use of the volatile alkali as a coun- ter-poison has not been confined to cases resulting from the bites of animals. It has been supposed also to possess the property of counteracting various vegetable poisons, such as prussic acid, alcohol, and ergot. As an antidote to the poisonous effects of prussic acid, it was proposed by Mr. Mur- ray, of London, whose experiments with it upon inferior animals were so satisfactory that he expressed his willingness to take himself a sufficient quantity to destroy life under ordinary circumstances, provided a competent person should be at hand to apply the remedy; but other experimenters have not been equally successful; and no one at present considers the alkali as competent to prevent the fatal effects ofthe poison. (See N. Amer. Med. and Surg. Journ. VIII. 421.) The most that it can do is to afford relief in mild cases; and it is possible that when the struggle between the influence ofthe acid and the powers ofthe system is very nearly balanced, ammonia might turn the scale in favour of the latter. Prussic acid acts as a powerful sedative, immedi- ately reducing the vital energies and ac- tions; ammonia, by its stimulant proper- ties, may possibly, in some instances, sup- port life, till the poison has ceased to act The gas, as it escapes from the watery so- lution, (aqua ammonias of the shops,) may be applied to the nostrils, and inhaled mix- ed with the atmospheric air into the lungs; and the same solution may be swallowed, sufficiently diluted with water. Care, how- ever, must be taken that the application be not made in sufficient intensity to induce serious inflammation ofthe air-passages. There can be no doubt that ammonia possesses the property, to a certain extent of dissipating the inebriating effects of spi- rituous liquors. M. Girard, of Lyons, is believed to have first made the fact public; and it has since been confirmed by the ob- servations of other physicians; but the remedy is effectual only in mild cases of drunkenness, and not uniformly in these. It probably acts merely by its excitant in- fluence over the nervous system. Small doses of the water of ammonia, or of the aromatic ammoniated alcohol, may be given at short intervals, in a wine-glass-full of sweetened water. M. Courhaut believes that he has found in ammonia a certain remedy against the dangerous effects of ergot. He gives the water of ammonia internally, and at the same time applies it to the part threaten- ed with gangrene; and he assures us, that of three hundred patients treated in this way he has lost only one. {Did. Univ. de Mat. Med. I. 241.) The stimulant pro- perty of ammonia may render it useful in the disease ascribed to ergot which is of a typhoid character, as we know it to be use- ful in ordinary typhus; but the cases of M. Courhaut prove almost too much. They must have been very slight to have been cured in so large a proportion; and the sus- picion cannot but arise, that they might have terminated in the same way without the remedy. Dose and mode of administration. The dose of the carbonate of ammonia is from AMMONIA. 367 five to fifteen grains. It may be given in the form of pUl, or in that of aqueous so- lution, which is preferable. Pills of it may be made with powdered gum arabic and syrup, or with some soft extract as that of chamomile, and should be dispensed in a wide-mouthed phial, which should be kept well stopped. If put into a box, they would be apt to lose a portion of their strength in consequence of the escape of a part of the ammonia. The solution may be rendered less unpleasant to the taste, and less irri- tating to the throat when swallowed, by the addition of loaf-sugar, gum arabic, and some aromatic volatile oil. The following formula may be used :—R. Ammonias Carbonatis 3j; Acacias gum. pulv, Sac- char, alb. aa 3ij; Aquas Menth. Pip. fjvj; mist. fiat. Of this solution a small table- spoon-full contains five grains of the car- bonate. The dose and mode of exhibition of the other preparations of ammonia are stated under the heads of these preparations re- spectively. External and Local Use. The uses of ammonia as a local application are scarce- ly less various than those for which it is internally employed. One of the most common is to produce a stimulant impres- sion upon the nostrils, and, to a certain ex- tent upon the respiratory organs, in order to relieve nervous languor and faintness, and to rouse from syncope either partial or complete. In slight cases, it is suffi- cient to employ the common smelling- salts, consisting of carbonate of ammonia scented with some aromatic volatile oil; but when a stronger impression is required, it is necessary to resort to the water of ammonia, or to the ammoniated alcohol. Great success was obtained by Sage in re- covering animals from a state of asphyxia, resulting from the inhalation of carbonic acid gas, by means of ammoniacal vapours applied to the interior nares and to the bronchial tubes; and the practice is well worthy of being imitated upon the human subject. The ammonia may act, in this case, not only by its excitant powers, but also by its affinity for the carbonic acid, which it completely neutralizes. But in all instances of syncope or insensibility in which the volatile alkali may be employed as a nasal stimulant care is requisite not to apply it in too concentrated a state ; as dangerous if not fatal inflammation of the nostrils, trachea, and bronchial tubes, may otherwise result An instance has been already related in this essay, in which death occurred, in an epileptic patient, from the too free application of ammonia during one of his paroxysms. To the skin, ammonia may be applied as a rubefacient and vesicatory. With a view to the rubefacient effect, it is used in external rheumatic and gouty affections, in local palsy, in chronic indolent tumours to promote their resolution, and in various internal inflammations in their incipient or chronic state, as, to the neck, in inflam- mation of the throat, and to the chest, in catarrhal complaints, particularly in in- fants. For these purposes, the water of ammonia is usually employed in connexion with from four to eight times its bulk of olive oil, as in the volatile liniment or Linimentum Ammonia; of the U. S. Phar- macopoeia. This may be applied by rub- bing it on the part affected, or by placing upon the part a piece of flannel saturated with the liniment. Caution is requisite not to use the liquid ammonia in too con- centrated a state, lest vesication and pain- ful ulceration should be the consequence. Sometimes the ammonia is associated with camphor, as in the Linimentum Camphorce Compositum ofthe London Pharmacopoeia. The carbonate of ammonia is sometimes used for the same purpose, powdered and mixed with three times its weight of ex- tract of belladonna, or other narcotic ex- tract, and then spread upon leather. Such a plaster is peculiarly useful in local pains of a rheumatic or neuralgic character. Another mode in which ammonia is em- ployed as a rubefacient, is in a plaster made by melting together one ounce of soap and two drachms of lead-plaster, and then adding half a drachm of muriate of ammonia. The muriate of ammonia is de- composed by the alkali of the soap, and the ammoniacal gas gradually liberated. The application of the plaster should be renewed every twenty-four hours, in order to maintain a prolonged impression. Dr. Paris states that he has used this plaster with advantage in pulmonary affections, and in rheumatism of the muscles of the chest (Paris's Pharmacologia.) In cases of great violence or urgency, water of ammonia may sometimes be em- ployed advantageously to excite speedy vesication. For this purpose, it may be used in severe neuralgia, or dangerous spasm of the stomach, or in cases of great and sudden prostration accompanied with insensibility, in which a powerful external impression is demanded. Vesi- cation by means of ammonia may also be resorted to when our object is to obtain very quickly a denuded surface, in order 368 AMMONIA. to apply remedies calculated to affect the constitution through the medium of cuta- neous absorption. A piece of flannel satu- rated with the liquid may be rubbed upon the part until the cuticle is removed ; but where sensibility remains, this operation is too painful to be borne, in consequence of the contact of the alkali with the de- nuded points of surface, during the whole period requisite for the completion of the process. A better plan is usually to form a compress of several thicknesses of linen, or patent lint, of the shape and size of the intended blister; then to saturate this with the strong water of ammonia, and having applied it to the part, to supply the evapo- ration of the ammonia by fresh additions till vesication results. In this way, a blis- ter may usually be produced in fifteen or twenty minutes. Simply to moisten a piece of paper or linen with the liquid and to apply this to the skin, will often fail, in consequence of the rapid volatilization of the gaseous alkali; and even the plan above mentioned does not always succeed in the time specified. It has been proposed to employ for this purpose a piece of pre- pared agaric, of which one surface is spongy and will serve to imbibe the liquid ammonia, while the other is smooth and compact, and will tend to prevent the es- cape of the gas. The French use an oint- ment prepared by introducing an ounce of lard into a bottle, melting it and when it is about to congeal, adding an ounce of water of ammonia of the sp. gr. 0.92, then closing the bottle, and agitating brisk- ly till the ingredients are thoroughly mix- ed. This is called "pommade ammonia- cale de Gondret," and may be employed either as a rubefacient or vesicatory. In the former case it is rubbed upon the skin diluted with lard, in the latter it is ap- plied in its undiluted state upon a com- press. In ten or fifteen minutes after the application of the ointment, occasionally in a shorter time, the cuticle usually rises if the preparation has been properly made. As soon as this happens, the dressing should be removed, as otherwise a super- ficial eschar may be formed. Ammonia is sometimes employed exter- nally in order to change the nature of mor- bid action in the surface to which it is ap- plied. For this purpose it has been used in burns and chilblains, in cancerous and scrofulous ulcers, and in various cutaneous eruptions. It has been employed also to stimulate or cauterize the indolent surface of fistulous ulcers. M. Lavagna recommends the use of water of ammonia as an injection in amen- orrhcea. In fourteen cases he succeeded by this plan in bringing on the menstrual discharge, sometimes in twenty-four hours, and at furthest in five or six days. He em- ployed a mixture of ten or twelve drops of the ammoniacal liquor with a fluid- ounce of warm milk, and repeated the in- jection several times a day. The prac- tice, however, is not likely to be generally imitated in this country. MM. Merat and De Lens state that they have, in several instances, employed a similar injection, with advantage, in simple leucorrhoea. Geo. B. Wood. Bicarbonate of Ammonia.—Ammonia: Bicarbonas, Ph. D. This variety of the carbonate is officinal only with the Dublin College, and is directed to be obtained by saturating the officinal solution of carbo- nate of jimmonia, with carbonic acid gas. ■ The solution obtained is allowed to rest, in order to form crystals, which are to be dried without heat, and kept in a well- stopped bottle. It may be formed also by exposing the sesquicarbonate for a long time to the air;when every two equiva- lents of the salt may be supposed to lose one equivalent of ammonia. Properties, &c. Bicarbonate of ammo- nia is a more permanent salt than the ses- quicarbonate, and is much less soluble in water, requiring eight times its weight of that liquid for solution. It has a mild taste, not at all alkaline, and scarcely reacts as an alkali. It possesses, though in an infe- rior degree, the medicinal virtues of the carbonate; but has the advantage, accord- ing to Dr. Barker of Dublin, of affording the practitioner the means of prescribing ammonia in a convenient and palatable form. The dose is from six to twenty-four grains, dissolved in cold water as hot wa- ter would decompose it. Composition. This salt consists of two equivalents of carbonic acid, one of am- monia, and two of water. The composition of the sesquicarbonate has already been given, as three equivalents of acid to two of ammonia. But, besides these two car- bonates, a third exists, not used in medi- cine, which consists of one equivalent of acid to one of base, and which may there- fore be called the regular carbonate. It is formed when one volume of dry carbo- nic acid is mixed with two volumes of dry ammonia. This salt cannot exist in solu- tion, for by the action of water it is con- verted into the sesquicarbonate. Solution of Acetate of Ammonia.— Liquor Ammonia Acetatis, Ph. U. S. et L. This solution is most readily formed by saturating either the diluted acetic acid AMMONIA.—AMMONIAC. of the U. S. Ph., or distilled vinegar with carbonate of ammonia. The quantity of the salt necessary to saturate a pint of the acid (sp. gr. 1.009) is within a few grains of seven drachms. The most convenient way of ascertaining the point of saturation, is by the alternate use of litmus and tur- meric paper. It is best, however, to allow a slight acidity to prevail; as this will probably arise from the presence of a small portion of carbonic acid, which will be dis- sipated by time. Properties. Solution of acetate of am- monia has generally a yellowish colour; but when made of pure materials, it is lim- pid and nearly colourless. Its taste is Baline, and resembles that of a mixture of nitre and sugar. It should not be made in quantities; for, if long kept its acid be- comes decomposed, with generation of a portion of carbonate of ammonia. As for- merly prepared under the name of Spirit of Mindererus, it was made from the im- pure carbonate of ammonia,obtained by dis- tilling bones, which contains a portion of empyreumatic animal oil. When thus prepared, it contains a portion of ammo- niacal soap, the presence of which, accord- ing to Chaussier, increases the tonic and diaphoretic properties of the salt This solution is incompatible with acids, alka- lies whether pure or carbonated, lime- water, magnesia, corrosive sublimate, the sulphates of magnesia, iron, copper, and zinc, and the nitrate of silver. When it contains free carbonic acid, it produces with the acetate and subacetate of lead, a precipitate of carbonate of lead, sometimes erroneously taken for the sulphate of this metal. When the solution is evaporated, one portion ofthe salt rises with the water, and another abandons its ammonia; and hence it is difficult to obtain this acetate in a crystallized state. It may be obtain- ed in this state, however, by allowing a hot saturated solution to cool in a well- corked phial; or in a solid state, by sublim- ing a mixture of muriate of ammonia, with an equal weight either of dry acetate of potassa or of lime. It consists of one equivalent of acetic acid 51, and one of ammonia, 17 = 68. When crystallized, it contains seven equivalents of water. Therapeutical Applications. Solution of acetate of ammonia is a valuable stimu- lating diaphoretic, which may be often ad- vantageously employed in advanced stages of fevers, particularly when attended with restlessness and want of sleep, According to the particular indications present, it is sometimes combined, with good effect with nitre and antimonials, camphor, or opium. It is sometimes used externally, as a stim- ulating application, in cynanche paroti- dea, and in certain cutaneous eruptions. The dose is from half a fluidounce, to a fluidounce and a half, repeated every three or four hours. It may be conveniently exhibited in febrile cases, mixed with an equal measure of carbonic acid water. Solution of Hydrosulphate of Am- monia.—Liquor Ammonia: Hydrosulpha- tis, Ph. U. S.—This preparation is made by saturating water of ammonia with sul- phuretted hydrogen, (hydrosulphuric acid gas). It is a liquid of a greenish-yellow colour, very fetid smell, and disagreeable taste. It is characterized by giving col- oured precipitates with neutral metallic solutions, for which it is much used as a test. When treated with acids, it is de- composed, with effervescence of hydrosul- phuric acid, and deposition of sulphur. As a medicine, it is said to act as a powerful sedative, lessening the action of the heart and arteries, and producing nausea, vomit- ing, vertigo, and drowsiness. It was in- troduced into practice by Mr. Cruick- shank as a remedy in diabetes mellitus, for the purpose of lessening the morbid appetite which often attends that disease; and it has been used with the same inten- tion by Dr. Rollo and others. The dose is from five to six drops in a tumbler-full of water, repeated several times a day, and gradually increased until giddiness is produced. Franklin Bache. AMMONIAC. Ammoniacum, U. S. Ph. Gum ammoniac.—Gomme ammoniaque, Fr. ; Ammoniak, Germ. Origin of Ammoniac. The ammoniac- um of the ancients was obtained, accord- ing to Pliny and Dioscorides, from Lybia, and is generally supposed, upon the author- ity of the latter of these writers, to have derived its name from Ammon or Ham- mon, the Lybian Jupiter, near whose tem- ple, in the desert of Cyrene, the plant pro- ducing it was said to grow. Jackson, in his account of Morocco, states that ammo- niac is derived from a plant, resembling the European fennel, but much larger, growing in the sandy plains in the interior of that country. It abounds in a milky juice, which oozes out through punctures made by a horned beetle, and hardening by exposure, falls to the ground and mixes with the red earth of the plains. It is col- lected by the natives, and is much employ- ed in fumigation and as an external appli- cation in disease, but is not exported. This may possibly be the ammoniacum of an- cient authors; but it is conjectured by Mr, 370 AMMONIAC. Don, that the drug was formerly as at pres- ent procured exclusively from Persia, and that coming to Europe through Armenia, it received the name of Armeniacum, which was afterwards corrupted into Am- moniacum or Armoniacum, by which the drug was indifferently called. In support of this derivation, he adduces the fact, that the name of the apricot was sometimes written, by ancient authors, malum Armo- niacum. There is no satisfactory evidence that any of the ammoniac of commerce is at present procured from Barbary or an- cient Lybia, or that the product observed by Jackson in Morocco is identical with the drug now sold in the shops. Much difference of opinion has existed as to the character of the plant which produces the true ammoniac. Chardin, in his travels, speaks of it as very common in Persia. Lemery considered it a Ferula, and gave it the name of F. ammonifera. Olivier, who travelled in Persia, without reaching the district where the plant is found, also believed it to be a Ferula, from information which he received concerning it Will- denow, however, having sown some seeds picked from a parcel of ammoniac, and suc- ceeded in raising a plant which proved to be an Heracleum, concluded that this was the real source of the drug, and gave it accordingly the name of Heracleum gum- miferum. This plant has, on his authority, been recognized in the British and United States Pharmacopoeias. But Willdenow himself admits that he could obtain no gum-resin from it, though he ascribes the fact to the coldness of the climate at Ber- lin. Subsequently the plant has been as- certained to be identical with the H. Pyre- naicum of Sprengel, which is not uncom- mon in the mountainous regions of Europe, and neither yields any juice when wound- ed nor possesses any of the sensible prop- erties of ammoniac. The idea, therefore, that it is the source of this gum-resin has been abandoned. From an imperfect spe- cimen of the ammoniac plant, brought to Paris by M. Fontanier, who resided many years in Persia, and visited the district where the drug is collected, MM. Merat and De Lens were induced to return to the former belief that it was a Ferula, and considered it properly entitled to the desig- nation given it by Lemery. {Did. Univ. de Mat. Mid.) It appears, however, from a paper recently published by Mr. David Don in the Transactions of the Linnasan Society (Vol. XVL part iii. p. 599), that all former conjectures were erroneous, and that the plant belongs in fact to a new genus, which he describes under the name of Dorema. The specimen from which he drew up his description was procured by Colonel Wright upon the spot where the ammoniac.plant abounds, and exhibits positive evidence of its genuineness in the small tears of the gum-resin with which every part of it is covered. Botanical and Commercial History. The genus Dorema belongs to the Linnasan class and order Pentandria Digynia, and to the natural order Umbellifera. [The following essential character is given by Mr. Don:—"Discus epigynus cyathifor- mis. Achenia compressa, marginata; cos- tis 3 intermediis distinctis, filiformibus. Vallecula: univittatas. Commissura 4-vit- tata."] It is closely allied to Ferula, but is distinguished by its large cup-shaped epigynous disc, its completely sessile flow- ers, and its solitary resiniferous canals. The plant is entitled by Mr. Don, Dorema Am- moniacum. It has a perennial root, which sends up a cluster of large, petiolate, sub- bipinnate leaves, and one or more vigorous stems, jointed, branching, and from three to seven feet in height It grows sponta- neously in the Persian provinces of Irak and Fars, and is particularly abundant in the arid plains in the vicinity of the town of Jezd Khast, on the borders of these two provinces. M. Fontanier was informed that it grows also in Khorasan. The whole plant abounds in a white milky juice, which exudes on the slightest pressure. According to Captain Hart, it is pierced, when in full perfection, in all directions, by innumerable beetles, armed with an anterior and posterior probe, of half an inch in length; and through the punctures thus made, the juice exudes. {Trans, of the Med. Soc. of Calcutta, p. 369.) Major Willock, who had opportu- nities of personal observation, states that the juice exudes chiefly from the principal stems, and either concretes upon them in lumps, or falls to the ground. It is gather- ed by the villagers in summer or autumn, and sold to the traders, by whom it is con- veyed to Bushire upon the Persian Gulf From this port it is taken partly to India, whence it enters into general commerce; partly up the Red Sea, so as to reach Eu- rope by the route of Alexandria. It is brought to this country chiefly from Cal- cutta. Varieties. Ammoniac comes in tears, and in masses. 1. The tears are of an ir- regular form, more or less spherical, of va- rious sizes, from that of a millet-seed to that of a hazel-nut sometimes separate, sometimes adhering, externally yellowish or brownish-yellow, with occasionally a AMMONIAC. 371 tinge of red, internally whitish, opaque or but slightly translucent at the edges, com- pact homogeneous, brittle when cold, and breaking with a conchoidal shining frac- ture. By the heat ofthe hand they soften and become adhesive. They are often mixed with impurities, particularly with the seeds of the ammoniac plant, from which they may be readily separated by picking them out by the hand.—2. The masses, which are often of considerable magnitude, are of a darker colour, and less uniform structure, presenting, when broken, a dirty gray or brownish surface variegated by whitish shining spots, and apparently consisting of the tears embed- ded in a cementing substance, and fre- quently mixed with foreign matters, such as seeds, fragments of stems or leaves, and sand or other earths. They are usually softer than the tears, and are sometimes plastic and adhesive at ordinary tempera- tures. The tears are preferred for internal use, as they are more readily separated from impurities. The ammoniac in mass may be purified by boiling it with a little water, straining it through a coarse linen or hempen bag, and evaporating by a moderate heat to the proper consistence; or by dis- solving it in diluted alcohol, filtering and evaporating. From the coarser impurities it may be separated by powdering it in cold weather, and sifting the powder, which afterwards agglutinates. It is said that under the name of purified gum-ammoniac, a mixture of this gum-resin with inert substances has sometimes been sold. The remark, however, applies ra- ther to the markets of Europe than of this country. General properties and composition. The odour of ammoniac is peculiar, some- what analogous to that of galbanum, and stronger in the mass than in the tears. The taste is nauseous, bitter, slightly sweetish, and somewhat acrid. The specific gravity is 1.207. The gum-resin is brittle and even pulverizable in cold weather, but soft- ens and becomes adhesive with a moderate heat, though it does not melt. It is inflam- mable, burning with a white flame, and emitting fumes of a strong, resinous, slight- ly alliaceous odour. It is partially soluble in water, alcohol, ether, vinegar, and alka- line solutions. By trituration with water it forms an opaque milky emulsion, which gradually deposits the resinous portion, and at length becomes clear. The alcoho- lic solution is transparent but is rendered milky by the addition of water. Bucholz found in 100 parts of ammoniac, 22.4 parts of gum, 72.0 of resin, 1.6 of bassorin, and 4.0 of water including volatile oil and loss. Braconnot obtained analogous results. Hagen succeeded in procuring the volatile oil separate by repeated distillation with water. It had a penetrating disagreeable odour, and a taste which was mild at first, but afterwards nauseous and bitter. The resin of ammoniac is wholly dissolved by alcohol, and by the fixed and volatile oils, but only partially so by ether, which di- vides it into two resins, one soluble, the other insoluble in that menstruum. Effects upon the system. Ammoniac is moderately stimulant and feebly antispas- modic, and possesses the property of excit- ing, to a greater or less degree, most of the secretory functions. Its action appears to be directed peculiarly to the bronchial mucous membrane, and its influence in pro- ducing or facilitating expectoration is that for which it is most valued; but it may also be made to operate as a diaphoretic, diu- retic, or emmenagogue, by administering it in suitable combination, and in appro- priate conditions of the system, and by em- ploying measures calculated to give its stimulant properties the desired direction. In small doses it produces only a gentle ex- citement ofthe stomach ; but when freely given, it is apt to occasion gastric heat and uneasiness; and in large doses often purges. Therapeutic use. Ammoniac has been used as a medicine from the time of Hip- pocrates. The complaints to which it ap- pears to be best adapted, are chronic affec- tions of the pulmonary organs, in which it acts as a stimulant expectorant, promoting the bronchial secretion when deficient, and restraining it within manageable limits when so copious as to oppress the lungs by its superabundance. It may be given with occasional advantage in chronic ca- tarrh, catarrhus senilis, chronic pneumonia, asthma, the secondary stage of peripneu- monia notha, and in the latter stages of phthisis. It should not, however, be em- ployed in cases attended with inflammatory excitement either local or general. From a neglect of this caution, it sometimes pro- duces injury, and Cullen observes that he has frequently found the mischief arising from its heating properties greater than the benefits resulting from its expectorant powers. It has been recommended in hoarseness, and may possibly prove advan- tageous, in some instances, after all symp- toms of acute inflammation have subsided. When given in complaints of the respira- tory organs, ammoniac is usually associated with other expectorants, as with squills, assafetida, ipecacuanha, and tartar emetic, 372 AMMONIAC. and sometimes with muriate of ammonia, which is supposed to exercise a beneficial influence over diseases of the mucous membranes. Dr. Chapman speaks favour- ably of a mixture of ammoniac and nitric acid, in cases in which a large accumula- tion of purulent or viscid matter exists, with feeble and difficult expectoration. The fumes ofthe gum-resin, resulting from its decomposition by heat have sometimes been inhaled in cases of chronic catarrh. It is said that ammoniac is used with ad- vantage to augment the flow of urine in dropsical affections, and to support the sali- vation in small-pox. {Edinburgh New Dispensatory, 1830.) But its diuretic ac- tion is too feeble and uncertain to render it a useful remedy in dropsy; and the pro- priety of employing it to stimulate the sali- vary glands in variolous diseases is very doubtful, even allowing it to possess the power. It has been occasionally used in ame- norrhoea, and in chlorotic and hysterical affections depending on that disease. Com- bined with myrrh, aloes, or the chalybeates, it may sometimes add to the efficacy of these medicines, in uterine obstructions; but its virtues as an emmenagogue are very feeble, and it is not often used in this capacity. In atonic leucorrhoea, it is said to have been given with some advantage. By the older physicians ammoniac was considered as a useful remedy in obstruc- tions of the abdominal viscera, and in the various morbid conditions arising out of such obstructions, as hypochondriasis, dys- pepsia, and chlorosis. With this view of its operation, Richter recommends it com- bined with assafetida, tartarized antimony, &c, in amaurosis. If it operate usefully in these complaints, it is probably by the revulsion which it establishes towards the alimentary mucous membrane. Some writers speak in strong terms of its beneficial influence in certain obstinate colics which they suppose to depend upon the presence of a viscid mucus in the bowels. We may admit the fact that spasmodic pains in the bowels are occa- sionally relieved by ammoniac, without at the same time admitting the supposition as to their cause. The probability is, that this gum-resin affords relief, under such circumstances, in the same manner as assafetida, by its gently excitant and anti- spasmodic properties. Ammoniac should not be given when the stomach is inflamed, or much irritated, though symptoms may exist which appear to call for its use. By a neglect of this caution, it has frequently done mischief in pectoral complaints. Dose and mode of administration. The dose of ammoniac is from five to thirty grains. In pectoral complaints it should be given in small doses, of six or eight grains for instance, repeated three or four times a day, or more frequently, according to the circumstances of the case. In the quantity of twenty grains, or more, it is apt to affect the bowels. It may be given in pill or emulsion. In the former state, it is usually associated with other substances, as with squill, ginger and soap, in the Pilula: Scillce Composite of the London and Dublin Pharmacopoeias, and with squill, cardamom, and liquorice in the Pilula: Scillitica: of the Edinburgh col- lege. The emulsion may be made by rubbing up the ammoniac with water gradually added, with or without the addi- tion of gum arabic. It is frequently called lac ammoniaci, from its opaque milky ap- pearance. The proportion of the ingre- dients in the Mistura Ammoniaci of the U. S. Ph. is two drachms of the gum-resin to half a pint of water. The dose of this preparation is about a table-spoon-full. A fluidrachm of strong nitric acid may some- times be advantageously added to the mixture. External use. Ammoniac has enjoyed considerable reputation as a discutient ap- plication in chronic scrofulous swellings, and other indolent tumours, especially those of the joints. It is employed in the form of a plaster {Emplastrum Ammo- niaci), which is prepared, according to the U. S. Ph., by dissolving the gum-resin in vinegar, then straining, and evaporating to the proper consistence. It acts by its stim- ulant property, which is sometimes so con- siderable as to produce an inflamed papular eruption ; and a fatal case of diffuse inflam- mation resulting from its use in disease of the knee-joint, has been described by the late Dr. Duncan, of Edinburgh. The dis- cutient properties of ammoniac are thought to be increased by associating it with mer- cury; and a preparation under the name of Emplastrum Hydrargyri cum Ammo- niaco, is directed by the London and Dub- lin colleges. The plaster, as prepared by the latter college, is preferable; as the mer- cury is extinguished by means of turpen- tine, which adds to its efficacy, instead of by sulphurated oil employed for the same purpose by the London college, which weakens the effect of the mercury by forming with it an inactive sulphuret Geo. B. Wood. AMNESIA. 373 AMNESIA. (From a, priv. and ^mj, memory.) A loss or defect of memory. Memory being intimately connected, if not identical, with those faculties of the mind by which our ideas are acquired or formed, will, of course, vary with the lat- ter, in extent and activity, in different in- dividuals. Entire loss or deficiency of memory, in the strict sense of the term, is extremely rare; when it does occur, it constitutes, necessarily, a state of fatuity, more or less complete. Hence it is met with only in certain cases of idiocy, or as- sociated with the general imbecility of ex- treme old age. Partial deprivation or de- fect of memory is, however, very common. In many cases it would appear to be con- genital, depending, in all probability, upon an imperfect development of certain por- tions of the brain. Thus, from the earliest periods of childhood, in numerous in- stances, a very great difficulty or even utter inability exists to acquire and retain words or numbers, or to recollect persons, places, or events; and this defect or defi- ciency in the powers of memory often con- tinues throughout life, and cannot be over- come by the utmost degree of application or attention. Frequently, however, the de- ficiency of memory is produced by a vari- ety of causes to which the individual is subjected during childhood or even at a later period of life. One of the most fre- quent of these, independently of direct le- sions of the brain, is an injudicious system of education, by which the activity of the different intellectual organs is but imper- fectly developed, and the harmony which ought to exist between them is in conse- quence destroyed; or the organs of the mind become exhausted and incapable of performing properly their functions, from the very common error of overloading the memory with too great a variety of sub- jects at too early a period, or, in other words, before the different parts of the brain have acquired their complete organ- ization and firmness. In after-life, a fre- quent cause of defective memory is men- tat inactivity. The power of memory, in common with all the faculties of the intel- lect is increased by regular exercise, often to a very surprising extent; while, on the other hand, it is weakened, we might al- most say destroyed, when called but sel- dom into action. A certain degree of at- tention is essential to the perfection and accuracy of memory; hence, they who ex- hibit but little application of mind have invariably a defective memory. Too long continued or intense application of the mind islikewise an occasional cause of de- vol. i. 32 fective memory. The intellectual organs, in this case, are over-excited, and, from the morbid state into which they are, in consequence, thrown, cannot perform their functions with their usual facility and reg- ularity. In all those diseases in which the brain is affected either primarily or secondarily, the memory, in common with all the intel- lectual powers and faculties, is more or less impaired, and often, for a period, en- tirely suspended. When a partial disor- ganization of the brain has taken place, the loss of memory is most generally per- manent. Occasionally, however, a loss or defect of memory is almost the only mor- bid symptom under which the patient la- bours, and it is to these cases that, in pa- thology, the term Amnesia is ordinarily restricted. Thus, an individual who had previously possessed the most active mem- ory, will suddenly be deprived of its exer- cise either in relation to words, things, numbers, or places, while in all other re- spects his intellectual functions are not perceptibly impaired. In other cases, the deprivation of memory occurs more gradu- ally. There is first experienced a consid- erable difficulty in recalling to the mind a particular idea, or the word or sound by which it is expressed: this difficulty in- creases every day, until at length it amounts to a total incapability. Amnesia comes on occasionally without any apparent exciting cause. In many in- stances it is occasioned by blows or falls upon the head, producing fracture of the skull, or injury of the brain. Most gene- rally, the defect of memory is apparent im- mediately after the receipt of the injury; but sometimes it is not perceived until after the lapse of several hours, or even days. In a large number of cases, it is after recovering from an attack of apo- plexy, or other disease of the brain, that the loss of memory is apparent One of the most common affections productive of amnesia, is epilepsy, particularly when the paroxysms are very violent and of fre- quent recurrence. In investigating the nature and causes of amnesia, we shall be compelled to adopt the opinions of the phrenological school, in relation to memory; that it is not, namely, a distinct faculty of the mind, but one of the general attributes of the different ele- ments of which the intellect is composed ; in other words, that memory is the excit- ing to activity, by the power of the will, the knowing and reflecting faculties ofthe mind, in consequence of which the ideas those faculties had previously formed or 374 AMNESIA. acquired, are recalled. It is by this ex- planation alone, that we can account for the difference in the powers of memory possessed by different individuals ; for the fact that in one person the memory shall be peculiarly active in relation to words or numbers, but strikingly deficient in refer- ence to persons or places, and vice versa ; or those cases in which the memory of events or dates is entirely lost, while in regard to all other ideas it is as active as ever. It is true that some of the facts con- nected with the subject of amnesia are to- tally inexplicable by the phrenological or any other system of mental physiology; it is only by a more numerous collection of accurate observations that we can hope to arrive at the correct pathology of all the varieties of this curious affection. The most common form of amnesia is a total inability to recall a particular word, or the name of a certain object. Persons so affected lose entirely the recollection of certain words or names, while they can re- call with perfect ease all others. M. Cu- vier relates the case of an individual who had lost the memory of all substantive nouns, so that in conversation, whenever these should have occurred they were in- variably omitted. (Rochoux, Recherches sur VApoplexie.) Bouillaud cites an in- stance in which the memory of substan- tives and adjectives was destroyed, while there was a perfect integrity of the mem- ory of things. " We know, also," he adds, " that the celebrated Broussonnet who died of an affection of the brain, was deprived solely of the memory of substantives. {Traiti de I'encephalite.) Pinel gives the case of a notary, who, after an attack of apoplexy, forgot his own name, and those of his wife, his children, and his acquaint- ance. {Sur Taliination mentale.) A some- what similar case is related by Bouillaud. The father ofthe late Dr. Watson, Bishop of Landaftj subsequent to an attack of apo- plexy, forgot entirely the name of his eld- est son, and inquired many times a day the name of the lad that was at college, and yet he was able to repeat correctly hundreds of lines out of classic authors. {Life of Bishop Watson.) In a case re- lated by Dr. Jackson of this city, a sudden congestion of the brain suspended tempo- rarily the memory of words, without any other disorder ofthe intellect. In this very interesting case, ideas were formed, com- bined, and compared; those of things, events, and time, recalled without difficul- ty ; but there was a total loss of the facul- ty of conveying ideas by words, though not by signs; the defect was not confined to spoken language, but also extended to written language. {American Journ. of Med. Sciences, III. 2720 Professor Dick- son of Charleston, S. C., relates in the Journal last quoted, (VII. 359), an instance in which there occurred a complete amne- sia in relation to names, while the memo- ry of numbers and of things remained per- fect It is somewhat curious, that in this case the patient was deprived of the pow- er of reading words, but not numbers. The attack was produced by a sudden con- gestion of the brain. In the instance of the notary referred to by Pinel, the patient was rendered incapable of either reading or writing correctly. Rush notices a case of amnesia occurring in a citizen of Phil- adelphia, who, in consequence of a slight paralytic disease, forgot the names of all his friends, but could designate them by their ages, which he had previously learn- ed. {Diseases of the Mind.) A very un- common variety of defect of memory is re- lated by Dr. Fahnestock {Amer. Journ. Med. Sciences, XI. 413), in which the am- nesia was in reference only to proper names; the perception of the patient be- ing at the same time clear, his memory otherwise distinct, his judgment sound, and his business habits unimpaired. In this case the defect was occasioned by a partial congestion of the brain. We have ourselves met with a curious instance of amnesia occurring in a patient suddenly affected with a slight paralysis, in which there was merely an inability to recollect the letters composing the surname of the individual. He could pronounce his full name accurately, but was unable to write or spell, during the continuance of his dis- ease, his surname. A number of examples are given by Bouillaud, of individuals who preserved perfectly the memory of persons, beings, events and facts, but who had totally forgolten the names and words by which they were accustomed previously to express their thoughts. {Re- cherches Cliniques.) Similar cases are referred to by other writers. Amnesia in regard to words presents many strange varieties, all of which it would be impossible for us to describe in the present article. In some instances, one word is substituted invariably for an- other, or a certain name or idea is invari- ably expressed in a different language, without apparently the patient being him- self always aware of the substitution. Many cases of this kind are on record. Sir Alexander Crichton relates one, which occurred in an attorney; who, if he want- ed bread, would ask for his boots, and AMNESIA. 375 though enraged when the latter were brought him, would still call out for his boots or shoes. In like manner, if he wanted a tumbler to drink out of, it was a thousand to one but he would call for the ordinary chamber utensil, or, if this were wanted, would call for a tumbler or a dish. {On mental derangement, I. 370.) An in- stance occurred to Dr. Chailly {Archives Ginirales, 1828) of an individual who was suddenly attacked by partial congestion of the brain, while playing at the game of tric-trac, and lost immediately all recollec- tion of substantive nouns, for which he in- variably substituted the words sonnez and six cinq, terms used in the above game. Dr. Rush knew a gentleman affected with amnesia, who, when he wished a knife, call- ed for a bushel of wheat. Wepfer relates three instances, in which the patients, all of whom were Germans, called the objects around them only by Latin names. Many instances are on record in which the memory of things, persons, numbers, or events, was destroyed, while in all other respects the memory was perfect Amnesia in relation to localities is of very common occurrence. Savary cites an instance in which an individual, after an attack of malignant fever, lost himself in those parts of London with which pre- viously he was perfectly acquainted, and could not recognize even his own dwell- ing. John Hunter was suddenly attack- ed with this species of amnesia, in 1789, while on a visit at the house of a friend. He did not know in what part of the house he was, nor even the name of the street when told him, nor where his own dwell- ing was; he had no conception of anything existing beyond the room he was in, and yet was perfectly conscious of his loss of memory. He was sensible of impressions of all kinds upon the senses, and hence looked out of the window, although rather dark, to see if he could be made sensible of the situation of the house. The defect of memory went off gradually, and in less than half an hour recollection was perfect- ly recovered. (Home's life of Hunter.) Gall knew a bookseller's assistant, who, after recovering from a brain fever, could not again " learn to remember how and where the books in the shop were placed, with which he had been before so well ac- quainted." {System of Craniology, Lon- don edition, 1807.) We have ourselves known one or two instances of this kind, in which the individuals, at other times perfectly familiar with the streets, sudden- ly lost their recollection of localities, and were obliged to inquire in what part ofthe city they were. Persons are sometimes suddenly af- fected with a total inability to recall par- ticular sounds, even those of the most common occurrence. Salmuth mentions a case in which the patient could not pro- nounce certain words, but could neverthe- less write them. Rush relates an instance of the loss of the sounds of words, but not of the letters of which they are composed, the patient being obliged to spell every word that he employed to convey his ideas. Some individuals, remarks Calmeil, lose the faculty of reproducing certain musical tones, and are hence obliged to give up singing. In some instances there is a complete forgetfulness of events, time, and place, with a perfect recollection of persons and names. Rush relates cases of this kind. The most curious form of amnesia is that, in which the memory of all foreign and acquired languages is lost. Loyer- Villermay cites the case of a man who had forgot the French, but could converse fluently in the Piedmontoise. {Maladies de la mimoire.) In St. Thomas's hospital, London, a man was admitted some years since, with an affection of the brain, who, as he grew better, spoke in a language which his attendants did not understand. A Welsh milk-woman accidentally going into the ward, heard and conversed with him. It was then ascertained that the pa- tient was a native of Wales, but had left that country in his youth, forgotten his na- tive dialect, and used English entirely for the last thirty years; and that he had now entirely forgotten the English language, and suddenly recovered the Welsh. In Hufeland's Journal {December, 1828) it is stated that the late Dr. Schoerf, a Ger- man physician of considerable eminence, on recovering from a severe and danger- ous attack of fever, found that he could not recollect a word of Latin, though in other respects his memory was perfect. But after a few days of convalescency, he gradually recovered his knowledge of that language, so that by the time he was per- fectly restored to health, he was as good a Latinist as before his attack. Dr. Rush re- lates the case of an Italian physician who died in the city of New-York, in 1798, of the yellow fever. In the commencement of his disease he spoke nothing but Eng- lish, subsequently he could express himself only in French, and on the day of his death he spoke only in his native tongue. There is sometimes an entire loss of 376 AMNESIA. written language. Bcerhaave notices an instance of this, which occurred in a Span- ish tragic author. This person, in conse- quence of an acute fever, not only forgot all the languages he had formerly learned, but even the alphabet and was under the necessity of learning again to spell and read. {Pralectiones Academical, IV.) Dr. Rush also cites the case of a clergyman, in New-Jersey, who, subsequent to an at- tack of malignant fever, forgot everything he had learned, including the alphabet, and had to commence his education anew. One day, however, whilst repeating his gram- mar, he suddenly called for a Latin classic he had begun to read previously to his at- tack, and at that moment all he had learn- ed before revived in his memory. An entire loss of memory, as we have already remarked, is extremely rare, and is always associated with idiocy: but the memory may be entirely and even perma- nently lost in relation to a certain series of events, without the patient exhibiting the least defect of intellect in other re- spects. Thus cases are on record, in which everything that occurred to the patient during one or more days has been entirely forgotten. According to Lucretius, the persons who recovered from the celebrated plague of Athens, lost entirely the recol- lection of past events, and many for a time knew neither themselves nor their friends. Orfila states that upwards of one hun- dred and fifty soldiers of the French army, who had eaten of the berries of the Bella- donna, became affected with the most alarming symptoms of cerebral disease, and after their recovery none of them pre- served the recollection of what had occur- red during their illness. {Toxicologic) A female who had given birth to an infant, became affected with disease of the brain, and forgot entirely all that occurred for many months subsequently to her delive- ry, insisting that the child had been born but a few days. After recovery from a state of complete intoxication, many indi- viduals have not the slightest recollection of what had passed around them during the period of an entire week. Abercrom- bie relates a highly interesting case of the total loss of memory in reference to a pe- riod of nearly twelve years, which occur- red in a lady who was greatly reduced by a severe and neglected diarrhoea. She had resided in Edinburgh for nearly twelve years, the recollection of which portion of her life she had entirely lost. Her ideas were consistent with each other, but they referred to things as they stood previous to her coming to that city. {Diseases of the Brain, p. 300.) Many more examples of the various forms of amnesia might be presented. The foregoin;:, however, are sufficient to illustrate the general proposition, that the memory of a certain class of ideas may be lost, either for a time, or permanently, while the power of the intellect, in all other respects, shall be entirely unaffected. Symptoms and progress. In many cases, as we have already noticed, the at- tack of amnesia occurs suddenly, in per- sons otherwise apparently in perfect health, and as suddenly disappears. Thus many individuals, when their minds are labour- ing under any unusual excitement, lose entirely the command of language, or are unable to recall a particular phrase, or even some particular word. How frequent- ly do we find persons, who on ordinary oc- casions express their thoughts with great clearness and fluency, but when called upon to address a public assembly, cannot recall a single idea, or frame the simplest sen- tence ! In all these cases, the amnesia disappears with the emotion of the mind which produced it. In general, the attack of amnesia is preceded by pain ofthe head, particularly of the forehead, as Wepfer long since remarked : this pain, which is noticed in nearly all the cases on record, is accompanied ordinarily with more or less defect of vision, dullness of intellect, and the other symptoms of cerebral con- gestion. In other instances, the defect of memory is more gradually developed; the patients are then generally the first to per- ceive it, and point it out to their physician; though cases are on record, in which the individuals labouring under amnesia were totally unconscious of its existence. When the defect of memory has been produced by an injury inflicted upon the brain, or is the consequence of some se- vere affection of that organ, it is often, not until after the patient has become conva- lescent, that it is observed. In chronic affections of the brain, terminating even in partial disorganization of its substance, the amnesia may constitute, for a consider- able time, the most prominent, almost the only symptom of disease. The progress of all the varieties of am- nesia is of course variable, depending en- tirely upon the nature and extent of the lesion of the brain upon which they de- pend. When the brain is affected simply with partial irritation and congestion, the amnesia may cease spontaneously within a tew days or even hours; in other cases it AMNESIA. 377 may endure for weeks, and when disorgani- zation of the brain has taken place, for the remainder of life. In some instances, the amnesia has assumed a remittent form. In the Transactions of the Academy of Sci- ences of Paris, is the case of a young man who was deprived of memory during the heats of summer, and regained it again when the cool weather set in; and it is stated of Milton that his memory was far less active in warm than in cold weather. When dependent upon an acute affec- tion of the brain, the amnesia, in general, disappears with the symptoms of the latter, or as the mind and body of the patient regain their ordinary vigour. In those cases which succeed to an attack of apo- plexy or paralysis, the memory is frequent- ly completely restored, as the blood effused in the brain becomes absorbed, and the cicatrization of the ruptured fibres of the brain is effected. In many instances the amnesia disappears even though the para- lytic affection of the limbs remains per- manent. Exciting causes. The exciting causes of amnesia are all those circumstances which, directly or indirectly, produce irri- tation and congestion, or inflammation and disorganization ofthe brain. Hence, it has been found to follow blows or falls upon the head, and wounds of the brain. Cases of this kind are related by Morgagni, Cal- meil, and by nearly all the surgical wri- ters. Baron Larrey, in particular, has recorded in his surgical memoirs, nume- rous instances of wounds from swords or bayonets, penetrating the brain, through the orbits, in which the memory for words was lost, but not that of things. Amnesia has, also, been produced by excessive ap- plication of the mind, violent paroxysms of anger, inordinate grief, and the other de- pressing passions. It has also been fre- quently brought on by a vicious course of life, particularly excess in venereal pleasures. One ofthe most common causes of amnesia is, perhaps, the unnatural excitement of the genital organs in youth. We have at- tended, remarks Calmeil, many young persons, who had, in the commencement of their studies, manifested the most happy dispositions, but in whom the memory be- came soon impaired, in consequence of the practice of onanism, and other species of debauchery. {Did. de Mid. Art Am- nesie.) The suppression of the hasmorrhoidal flux, of the menstrual discharge, or of any habitual evacuation from the body, by pro- ducing congestion of the brain, frequently 32* gives rise to amnesia, which often disap- pears the moment these discharges are re- established. Exposure to intense cold, or to excessive heat, over-fatigue, intemper- ance in eating and drinking, or the habitual use of intoxicating drinks, are likewise fre- quent exciting causes of amnesia. Certain poisons, as opium, cicuta, belladonna, hyos- ciamus, and stramonium, very generally produce a deprivation of memory. Cal- meil states that he has frequently found the immoderate use of mercury to produce a similar effect. Profuse hemorrhages, or excessive evacuations of blood, as well as profuse and long-continued diarrhoeas, the want of food, or the use of that of an unwholesome quality, have likewise been known to produce a very marked diminu- tion of the power of the memory. Autopsic appearances. The autopsic appear nces in the brains of those who have d ed whilst labouring under amnesia, have been extremely various. As in case of other diseases, the symptoms of which, during the life of the patient have indi- cated a very considerable derangement in the functions of the brain, subsequent to death no morbid appearance could be de- tected sufficient to account for the defect of memory; the irritation and congestion giving rise to it having, in all probability, ceased with the life of the organ. In the greater number of instances, however, effusions of blood were discovered in the brain, or softening of its substance, or various abnormal productions, especially in the substance of the cerebrum. Pathology. Amnesia has, by some wri- ters, been styled a paralysis of the organ of memory, and by others partial apoplexy. But neither of these propositions conveys any definite idea as to the seat or nature of the lesion by which the deprivation of the memory is produced. That amnesia is caused by a lesion of some portion of the brain, is rendered evident as well by the particular circumstances under which it occurs, as by the pheno- mena which ordinarily accompany it, and the appearances discovered in the bodies of those who have died whilst labouring under this affection. As in the case of apoplexy, the morbid condition of the brain may consist simply in a state of irritation and congestion, or of more or less complete disorganization of its substance; the differ- ence in the extent and seat of the conges- tion or disorganization giving rise in one case to a complete suspension of all the in- tellectual and sentient faculties, and in the other to a loss of memory only. The fact 378 AMNESIA. is, that in a large number of the cases of amnesia, the defect of memory occurred subsequently to an apoplectic attack. If we admit with Spurzheim and his adherents, that the memory of each series of ideas formed by the intellect is distinct, and dependent upon the activity of differ- ent organs, it must be evident that the affections of the brain giving rise to an amnesia in relation to events, or persons, must be differently seated from that which gives rise to an amnesia in relation to numbers, words, or localities. This fact, however, has as yet not been demonstrated by a sufficient number of accurate obser- vations, to permit us to draw any positive conclusions in regard to it. But, it has been attempted to be shown, by the history of numerous cases, as well as by the result of post-mortem examinations, that all the varietiesof amnesia depend upon disease of the anterior lobes of the cerebrum, and it is in this portion of the brain that accord- ing to Spurzheim, all the organs upon the activity of which memory depends, are seated. M. Bouillaud, in particular, has collected a number of interesting facts and dissections, which prove, as he conceives, that it is upon a lesidn of those portions of the brain which are situated immediately behind the orbits of the eyes, that the loss of memory in relation to words, or the general signs by which we express our ideas, depends. {Recherches Cliniques.) Calmeil, {Did. de Mid.) on the other hand, states that he has met with nu- merous cases of an almost total loss of memory, in which the anterior lobes of the cerebrum were found unaffected af- ter death, the disease of the brain being "seated at a distance from the frontal re- gions : and a similar statement is made by other writers. Negative cases, such as those just referred to, appear to us, how- ever, to prove nothing more than that amnesia may occur without an actual dis- organization of the anterior lobes of the brain. We do not conceive it to be neces- sary, in order to prove the position advan- ced by Bouillaud and others, that a diseased state of the anterior lobes of the cerebrum should invariably exist after death. They may be affected during the life of the patient, sympathetically, from disease of other parts of the brain, and the irritation and congestion thus produced may disappear with the cessation of life. We know, that in some ofthe most marked attacks of an apoplectic character, no dis- ease whatever of the brain has been de- tected after death; but would any one infer from this that the brain had not been mor- bidly affected during the life ofthe patient, or that the intellect and consciousness were destroyed without the organs upon which these faculties depend having deviated from their healthy condition 1 There is, nevertheless, a very considera- ble difficulty in explaining many of the forms of amnesia, even admitting that the principles of mental physiology adopted by the followers of Gall and Spurzheim, are true to their fullest extent, unless we are prepared to admit a distinct organ for the formation and memory of almost every dis- tinct idea. Thus, as we have already shown, one individual will lose the memory of substances only, another of adjectives, another of proper names; while in other instances, it is only a particular name, word, or phrase, which the person affected finds it impossible to recall to his recollec- tion. M. Bouillaud has, it is true, at- tempted to solve this difficulty. To explain these curious facts, he remarks, we must necessarily admit that the cerebral organ appropriated to articulate language, is composed itself of many distinct parts, each one of which presides over the forma- tion and memory of a different class ofthe words which constitute language. In other words, that different portions of the organ of language are appropriated to nouns, adjectives, verbs, and so on, and that each of these portions may become diseased independently of the others. {Traiti de VEnciphalite, p. 289.) But not only will we have to admit with Bouillaud, this subdivision ofthe organ of articulate language, if we receive his ex- planation as correct, but we must go far- ther, and suppose an organ, or portion of an organ for the words of every language which an individual is capable of acquiring; for we have seen, that amnesia may extend to one or more languages, while in regard to others the memory is as perfect as ever. It is not, however, our intention to enter, in the present article, upon an examination of the true physiology of memory; much in relation to it is still involved in obscu- rity, and requires for its elucidation a far more extended series of observation than we now possess. In the present state of our knowledge, it is even difficult, if not impossible, to estimate correctly the man- ner in which the memory is deranged by those lesions that have been detected after death, in subjects who have laboured under amnesia. The only conclusions that would appear to be clearly deducible from the facts on record are, 1st That whenever the cere- brum, particularly its anterior lobes, is the AMNESIA.—AMOMUM. 379 seat of irritation and congestion, or of in- flammation, the memory is altered to a greater or less extent, frequently entirely suspended, and is again restored to its nor- mal condition when the morbid state of the brain is removed. 2d. When particular portions of the brain become disorganized, or the seat of any permanent lesion, the memory is impaired or completely destroy- ed, and is then incapable of being re-estab- lished. Treatment. The proper treatment of amnesia will depend entirely upon the state of the brain, pointed out by the particular phenomena accompanying each case: it will be unnecessary, therefore, to consider it in detail in the present article. The abstraction, as far as possible, of all the remote and exciting causes that may be presumed to have given rise to the af- fection, is all-important in every case, and with a properly regulated diet and regi- men, will often be sufficient to restore the powers of the memory, even when, for a time, they have been completely lost. In the majority of instances in which the loss of memory occurs suddenly, in persons otherwise in perfect health, it will be found by an attentive examination of the concomitant symptoms, that a partial congestion of the brain has taken place. In such cases, bleeding, either general or local, or both, according to circumstances, will be demanded, together with purga- tives, cold applications to the head, coun- ter-irritants to the extremities, perfect quietude of mind and body, and a very re- stricted diet When the amnesia is perceived in the stage of convalescency from apoplexy or acute affections of the brain, great advan- tage will be derived from blisters or an issue at the nape of the neck, cold spong- ings ofthe scalp, and frictions ofthe surface generally. Care should be taken, also, not too soon to excite or fatigue the mind by intellectual labours of any kind, or by the ordinary cares of business. When the pa- tient's strength is sufficiently recovered, a short journey will often be decidedly bene- ficial. Where disorganization has taken place in the brain, the amnesia, in the majority of cases, will remain during the life of the patient. Bibliography.—Cancellieri. Dissertazione mtorno agl' dolati di gran memoria ed a quelii devenuli smemorali. Rome, 1815. Louver Villermav, Essai sur les maladies de la mimoire. Memoirea de la Socicte de Mede- cine de Paris. 1817. Rush. Medical inquiries and observations upon the diseases of the mind. Philada. 1818. Bouillaud. Recherches cliniques propres d dimontrer que la perte de la parole correspond a la lision des lobules anlirieurs du cerveau. Paris, 1826. Bouillaud. Traiti de VEnciphalite. Paris, 1825. Jackson. Case of amnesia. American Jour- nal of the Medical Sciences, III. Dickson. Case of amnesia. Ibid. VII. Fahnestock. Case of partial congestion of the cerebrum. Ibid. XI. Zabriskie. Case of amnesia, cured by cup- ping. Ibid. XIII. 568. D. F. Condie. AMNIOS, or AMNION. The internal membrane of the foetal envelope. See Ovum. I. H. AMNIOTIC. Appertaining to the Am- nios. Amniotic fluid, liquor amnii, the fluid contained in the amnios, vulgarly termed the waters. See Ovum. Amniotic acid. See Allantoic acid. I. H. AMOMUM. {Botany.) Sex. Syst. Monandria Monogynia. Nat. Ord. Scitamineas. Gen. Ch. Corol. with interior border unilabiate. Anther double, with an entire or lobate crest. Caps. 3-celled, 3-valved. Seeds many, arilled. Roxburgh. Much confusion and uncertainty has ex- isted as respects the characters of the ge- nera composing the natural order of the Scitamineas, and more particularly with regard to the genus under consideration. As left by Linn^ius the genus Amomum included a variety of plants which later researches have shown to possess very dif- ferent characteristics, and hence have been assumed as types of distinct genera. (See Alpinia, Zinziber, &c.) The genus, as now limited by Roscoe and Roxburgh, is a very natural one, and includes many plants pe- culiar to tropical climates, furnishing aro- matic seeds which are in general use among the inhabitants as condiments, and are also recognized in our Pharmacopoeias as useful stimulants and adjuvants. Although most of the ancient writers on the materia medica speak at some length of Amomums, it is by no means certain that they alluded to the plants now known under this name: those, however, who are desirous of judging for themselves on this point, may consult Theophrastus. IX. 7., Dioscorides, I. 14., and Pliny, XII. 13. Among the species which furnish aro- matic seeds analogous to the true Carda- moms, and which are used as substitutes for them, the following are the most re- markable, and require notice, as tending 380 AMPHIARTHROSIS.—AMPUTATION. to elucidate the history of the different anatomists, but as it is rarely used at pres- kinds of Cardomoms of commerce. (See ent there appears no necessity for our oc- Cardamoms.) cupying any space in investigating the 1. A. cardamomum, Linnjeus. Carda- precise meaning in which it has been em- momum minus, Rumphius. Amboy. V. 65. .ployed. I- H. Sp. Ch. Leaves short-petioled, lancec-M AMPUTATION. (From Amputare, late. Spikes half immersed in the earth, which means literally to cut or lop off a loosely imbricated, with villous, lanceolate, acute, one-flowered bractes. Lip with the anterior margin three-lobed. Roxburgh. This species, which is a native of Sumatra and other Indian islands, furnishes seeds which approach very closely in most par- ticulars to the lesser or true Cardamoms, and are used as a substitute for them by the Malays. 2. A. angustifolium, Linnaeus. Sp. Ch. Leaves broad, lanceolate. Spikes elevated, linear-oblong, compact, elevate; bractes oblong, rather pointed. Lip obovate, cuneate, entire. Roxburgh. This species is a native of Madagascar, and is considered by some writers to fur- nish the Grains of Paradise, though these are generally attributed to the A. grana Paradisi, Linn. It would appear, how- ever, that the plant described by him under that name was the Ellelari 2. of Rheede. Hort. Malabar, XI. t 6., which Lamarck has made a variety of his A. racemosum. Besides these species, there are many others which afford analogous seeds. Thus, the A. aromaticum, Roxburgh, found on the eastern frontiers of Bengal, where it is known by the name of Mor- ung elachi, furnishes seeds which are used as substitutes for the true cardamoms, as are also those of the A. maximum, Rox- burgh. (See Cardamoms.) Bibliography.—W. Ainslie. Materia Indi- ca, I. 53. London, 1826. W. Roxburgh. Flora Indica, I. 37. Seram- pore, 1820. VV. Roscoe. Transadions Linnaan Soc. VIII. London, N. Guibourt. Journal de Chimie Midicale. Paris, 1832. A. Richard. Elimens d'hisloire midicale, II. 414. Paris, 1831. Merat et De Lens. Did. universel de Mat. Mid. I. 254. ■ R. E. Griffith. AMPHIARTHROSIS. (From auft, both, and opepwoij, an articulation.) This term was devised by Winslow, to desig- nate certain articulations, in which the articulating surfaces are not in immediate contact, but connected by a more or less flexible and very strong intermediate sub- stance, admitting of but limited motion. Such are the articulations of the bodies of the vertebras with one another. This term has been differently applied by subsequent part which is superfluous.) Amputatio, Lat This term has been employed ty surgeons to designate the operation by which a member, or a part of a member, is removed, either for the purpose of saving the life of the individual, or of liberating him from the suffering and inconvenience to which the limb exposes him. Amputa- tions are generally performed upon the ex- tremities, but may likewise be executed upon the trunk of the body. This latter operation, however, is generally designated by the term Extirpation, (q. v.), while the term Amputation is restricted to the ope- ration by which we remove the extremi- ties by means of cutting instruments. Ex- cision, and Resection, which have an an- alogous signification, must not be con- founded with the term Amputation, in- asmuch as it will be seen by a reference to those words, that they are employed to designate very different objects. Amputations may be divided according as they are performed upon the continuity or in the contiguity of the bones; the operation in the first case being carried through the shaft or the substance of the bone, and in the second between their ar- ticulating extremities. They are, more- over, differently performed, according to the nature of the member, the character of the disease, or the predilection of the surgeon. Sometimes the member is re- moved by what is called the circular inci- sion, sometimes by a single or double flap, and occasionally by a combination of these two methods. Each of these plans will have its advantages in particular cases, but in some instances either may be employed, according to the choice or predilection of the operator. § 1. History of Amputation. Surgeons were doubtless directed originally to the removal of a limb by amputation, from ob- serving the manner in which nature effects the spontaneous separation of a member when affected with gangrene and sphace- lus. This remark is made, in fact, by the author of one of the treatises attributed to Hippocrates {de Articul. p. 831. Spren- gel). This writer states, that the greatest danger the surgeon has to apprehend from the removal of a limb, is the alarming hemorrhage which is liable to ensue from the division of the vessels. Celsus AMPUTATION. 381 (Lib. VII. cap. 33.) is the first author who has described the method of per- forming the operation. He directed the parts to be divided between the dead and living structures down to the bone, but in such a manner as to include a small por- tion of the living parts: the flesh then to be separated to a small extent from the bone, and the operation to be completed by sawing through the latter, a little above the level of the incision, so as to leave a sufficient quantity of the soft parts to be drawn over the face of the stump. To ar- rest the hemorrhage, he directed a sponge, saturated with vinegar, to be bound upon the face of the stump. It is a little extra- ordinary that he did not employ ligatures for this purpose, inasmuch as he was in the habit of resorting to them to arrest hemorrhage in other operations. Archi- uenes commenced the operation by the ap- plication of a tight ligature or bandage to the member, for the purpose of preventing the flow of blood. He also sprinkled the limb with cold water, and, according to some, applied ligatures to the vessels them- selves. This being done, he drew the in- teguments upwards, and confined them there while he divided the soft parts and the bone, and then cauterized the whole face of the stump with a red-hot iron, to prevent hemorrhage. He afterwards re- moved the band or ligature, and dressed the part with a double compress dipped in a mixture of salt and garlic, and subse- quently with oil and cerate. Nearly the same plan was recommended by Heliodo- rus, who, as well as Celsus, reprobated the practice of amputating through the articulations, so strongly advocated by Galen on account of the facility of its execution. Paulus ^Egineta condemned the practice advised by Celsus of di- viding the sound parts, but recommended that the incision should be made in their vicinity. He, however, as well as JEtius and Avicenna, applied the actual cautery to the face of the stump. The Arabians trusted the separation of the member to the operations of nature, and relied upon Armenian bole and other styptics to com- mand the hemorrhage. Albucasis prac- tised the operation "by dividing the soft parts with a red-hot knife, and promoting the separation of the eschar by the appli- cation ofthe balsam of sulphur,—a method which was subsequently adopted by Fa- bricius Hildanus. Theodoric de Cer- via employed the method of Celsus ; but with a view of diminishing the sufferings of the patient, he administered a large dose of opium and hyosciamus before the operation. Guy de Chauliac, however, was opposed to every mode of amputation, and contented himself with enveloping the diseased member in plasters of pitch, which were drawn so tight as to give rise to a sloughing of the member, in which state it was suffered to remain until it was separated by the efforts of nature. Hans de Gersdorf employed the method of Celsus, but after removing the member, he drew a hog's bladder over the face of the ttump, instead of resorting to the ac- tual cautery. Barthelemy Maggi intro- duced an important improvement in the operation of amputation, by adopting the precaution to preserve a sufficient quan- tity of integuments to cover the face of the stump. Fabricius ab Aquapendente, actuated by the dread of hemorrhage, made his incision through the dead parts: Fal- lopius resorted to the actual cautery, to arrest the flow of blood; and it was not until the time of Ambrose Pare that the ligature was employed for that purpose. To secure the bleeding vessels this last named surgeon used a curved triangular needle armed with a ligature, which was made to include the parts from which the blood flowed. Many surgeons, however, objected to this plan, on account of the pain it inflicts; and notwithstanding its important advantages, Pierre, Pigrai, Plazzoni, and Rossi, continued to resort to the actual cautery. Botallus recom- mended a plan which is only remarkable for its cruelty. It consisted in the use of a kind of machine, formed of a broad sharp hatchet, rendered sufficiently heavy by the addition of lead to cut through the mem- ber, on being suffered to fall upon it from a height. This method was also commend- ed by Van Hoorne, for the amputation of bones affected with spina ventosa. Wiseman applied a tight bandage around the member, about two inches above the line of separation between the dead and living parts, and while the integuments were drawn upwards, he divided the soft parts with a falciform knife, down to the bone. He then detached the periostium to a small extent with the back of the knife, and sawed the bone in the usual manner. To command the hemorrhage, he employ- ed the ligatures of Pare, and then brought the integuments over the face of the stump, and confined them there by means of su- tures and strips of an adhesive character, disposed in form of a cross. He condemned the actual cautery, and the red-hot knife; but to maintain the dressings properly ad- 382 AMPUTATION. justed, he drew a bladder over the extrem- ity of the stump, and confined it there by several turns of a roller. The invention of the tourniquet by Morel, in 1674, constitutes an important epoch in the history of the operation of amputation. Surgeons had been previous- ly obliged to trust to the constricting force of the bandage to command the flow of blood during the operation; but the instru- ment of Morel now furnished them with a much more secure and convenient meth- od of accomplishing that purpose. It was accordingly very generally adopted, and, with various modifications, still continues to be employed by most operators. It will be seen from what has been stated, that a majority of even the ancient surgeons were anxious to preserve a suffi- cient quantity of the soft parts to cover the face of the stump; but Lowdham was the first who, more effectually to accomplish this object recommended that the incision should be made obliquely from below up- wards, so as to form a flap of the necessa- ry extent to cover the end of the bone. He may therefore be considered as the originator of the flap operation, which has since been variously modified by Verduin, Sabourin, Garengeot, Ravaton, Le Dran, Vermale, O'Halloran, White, Pott, Desault, Larrey, Langenbeck, Klein, Rust, Textor, Guthrie, Roux, Lisfranc, Dupuytren, Syme, Liston, Maingault, Mott, and others. The ope- ration by the single circular incision, which was originally recommended by Celsus, has also been submitted to various modifi- cations, by which its advantages have been very much increased. Cheselden and Petit, instead of accomplishing the divi- sion of the whole of the soft parts by a single incision carried directly down to the bone, divided this stage of the opera- tion into two acts. During the first, they divided the superficial parts, which were drawn forcibly upwards; the deep-seated parts, consisting of the muscles, were di- vided by a second incision. Others, with a view of securing a better covering for the stump, have submitted this part of the operation to a variety of modifications. Gooch, B. Bell, Callisen, Boyer, Du- puytren, Hey, and a majority of modern surgeons, divide the soft parts by three cir- cular incisions; the first of which is car- ried merely through the skin and integu- ments, the second through the muscles, and the third through the structures im- mediately surrounding the bone, while these parts are forcibly drawn upwards by an assistant. Richter even recommended four circular incisions to be practised; but Louis and Desault accomplished the same object by means of two incisions; one carried through the integuments and superficial muscles, and the other through the deep-seated muscles, down to the bone. Alanson also proposed an im- portant improvement in the method of amputating. After dividing the integu- ments by a circular incision while drawn forcibly upwards by an assistant he dis- sected up the cellular tissue with the point of his knife, until he bad secured a sufficient quantity of skin. With the edge of his knife directed obliquely up- wards, he then cut down to the bone in the same direction, and making the point of the instrument revolve round the bone, while its edge was maintained in the ori- ginal position, with a bold circular sweep he achieved the division of the whole of the muscles, in such a manner, that when the bone was sawed through, the face of the stump represented a hollow cone, the apex of which was directed upwards. But while the method of operating proposed by Alanson is fraught with difficulties which are almost insurmountable, the ob- ject he proposed by it of gaining a flap of sufficient extent, may be easily attained by various procedures which have been adopt- ed in modern times, and which have doubt- less been founded upon the proposition ori- ginally made by him. § 2. Circumstances which require the operation of Amputation. Amputation may justly be considered one of the most desperate resources ofthe surgeon. In most other cases, the numer- ous means furnished by his art enable him to restore the suffering organs to health; but in the conditions requiring amputa- tion, there is either such an injury of the living structures, or such an aggres- sion committed upon the vital powers, as to render it indispensable to sacrifice the diseased member to obviate the inevitable destruction of the patient's life. It there- fore becomes a matter of the utmost con- sequence to determine, as far as prac- ticable, those cases which call for this appalling and desperate resort, and to distinguish those in which the life of the individual and the enjoyment of the use of his members, may be preserved without resorting to such a formidable al- ternative. The rapid improvements which have taken place within the last half cen- tury have fortunately reduced, in a re- markable degree, the number of cases which require amputation; yet with all these advances, we have still to regret AMPUTATION. 383 that the imperfection of the art continues to render it necessary to practise that ope- ration under a great variety of circum- stances. Future observation will, doubt- less, diminish still further the cases which now oblige us to resort to such an expedi- ent; yet it is too much to be feared, that there will always be conditions which can- not be remedied by any other course of procedure. In the present state of our knowledge, all that we can do, in consid- ering the cases which require amputation, will be, to lay down certain general princi- ples, to which many exceptions must of course arise, in particular cases, and under peculiar circumstances. With regard to the precise cases which call for the sacrifice of a member, there has ever existed considerable difference of opinion, some restricting the operation to so small a circle of cases, as almost to ex- clude it from the resources of the surgeon, while others, swayed by false judgment, or actuated by an overweening desire to enjoy the eclat of operating, have often resorted to it, when the exigencies of the case did not require it to be adopted. Of the first class, were Faure, Gervaise, Bouchard, Dionis, Salchow, Schmuck- er, but above all Bilguer, who carried his objections against amputation so far as scarcely to admit of its being practised in any case. The views of this last named surgeon were strongly combated by many of his contemporaries; and subsequent ex- perience has fully demonstrated, that many valuable lives may be saved, which would inevitably be sacrificed by an adoption of his principles. But in making this asser- tion, we would by no means be under- stood as wishing to hold out any justifica- tion of those who resort too frequently to the operation, in cases which do not re- quire its performance. The following may be considered as a fair expression of the indications which require amputation. When an individual is affected with a disease or injury of a member, which, in the present state of the science, is incurable, or which is rendered so, either by the fault of his constitution, or the circumstances in which he is placed, and which at the same time endangers his safety, or will, by its nature, render him a cripple for life, the removal ofthe part by an operation, will be called for. (Rust, Handbuch der Chirurgie, I. 538. Berlin, 1830.) We shall therefore proceed to speak of some of these conditions. A. Of Gangrene and Sphacelus. Al- though gangrene and sphacelus were for- merly considered as the only conditions that rendered amputation necessary, there are many cases in which the members are extensively involved by them, which do well without the operation. It has, indeed, been affirmed by many distin- guished surgeons, that mortification, ab- stractedly considered, can never call for amputation, they alleging that the system is capable, in a majority of cases, of liberat- ing itself of the disease, and repairing the injury inflicted by it; and where such ca- pability does not exist, that, as amputa- tion cannot remove the cause of the mala- dy, no advantage can accrue from resorting to it, but that by its performance we infliet upon the patient a painful and hazardous mutilation of his members, without securing to him any corresponding benefit. There are, however, many cases of gangrene and sphacelus in which amputation will not only be advisable, but constitute the only means of safety; and we are only sur- prised to find individuals so distinguished in the annals of modern surgery as Rust and Kluge, either forbidding the operation under such circumstances, or restricting its application to so small a number of cases as greatly to limit its usefulness. When the mortification is of limited extent;—when it is confined to the super- ficial parts, or, extending profoundly, does not implicate the important blood-vessels and nerves which are essential to the pre- servation of the integrity of the vitality of the member, the operation cannot be necessary; but the powers of the system, assisted by the skilful co-operation of the surgeon, will be adequate to accomplish a cure without the sacrifice of the part. But should the energy of the system be too feeble to bear up under the aggressions committed upon it, or the recuperative powers inadequate to ward off the ravages of destruction, a timely removal of the member by amputation will be essential to the safety of the patient, inasmuch as, if the case be left to run its course, the system will sink under the influence of the irritation. This course will also be necessary, where the principal vessels and nerves of a member have been destroy- ed, and consequently where it cannot receive a sufficient supply of blood and nervous influence, to maintain the integri- ty of its nutritive acts. Nor is the cause by which the mortification is produced, without its importance in deciding upon the propriety of resorting to the operation. An axiom for a long time prevailed upon this subject, which interdicted the inter- ference ofthe surgeon in all cases of morti- 384 AMPUTATION. fication while the disease continues to pro- gress, and only allowed the operation to be practised after the establishment of a dis- tinct line of demarcation between the dead and the living parts. This rule of practice, which was strongly inculcated by Sharp, Pott, and others, has had many zealous advocates, and is still espoused by surgeons of respectability. The extensive experi- ence, however, of numerous military and hospital surgeons, has shown, that it ought not to be adopted without considerable hesitation. Should the death of the part proceed from an ossification or obliteration of an important vessel,—from some per- verted condition of the vital powers of the system, the influence of some disease in- volving many of the functions essential to life, or from the ingestion of some delete- rious agent amputation cannot, of course, correct or remove the cause from which the mischief proceeds, but if performed before the progress of the destructive pro- cess has been arrested, can only inflict un- necessary suffering upon the patient and after all expose him to a re-development and perpetuation of the disease. The con- stitution being in fault, the amputation of the member will merely be a removal of the effect, the cause still continuing to op- erate. In such cases, the surgeon should content himself with instituting such gen- eral and local treatment as will be best suited to the deranged condition of the organic operations, and endeavour thereby to exalt the conservative powers of the system to that degree of energy, which will enable them to arrest the march of destruction, and set up an effectual barrier against the further progress ofthe disease. While it continues to advance, he ought not to think of operating, but should pa- tiently wait the development of a line of demarcation between the dead and living parts,—an event which proclaims that the powers of life have sufficiently rallied to provide for their own preservation, and the operation is now only called for, to remove a source of irritation, which, if the cure were left to the tardy process by which the suffering organs seek to relieve themselves, would wear down the energies of the system, and jeopardize the life of the individual,—or it is resorted to for the purpose of obviating the deformity which is frequently apt to arise from the pro- cedure by which the parts are separated,. when left to their own resources. In this form of gangrene, therefore, which has been denominated Idiopathic, or constitu- tional, the establishment of a line of de- marcation between the part deprived of its vitality, and that still alive, affords the only signal for the operation; and the question whether it should be per- formed, must be determined by the extent of the disease, the parts it involves, and the possibility or impossibility of saving the member without endangering the lite of the patient. If a large extent of the soft parts, together with the important ves- sels and nerves, have been destroyed, and the bone is denuded for some distance, amputation will be indispensable; it will also be necessary when the mortification is less extensive, provided the powers of the system are too feeble to enable them to cast off the part which has become de- prived of its vitality. In extensive traum- atic gangrene, or that form of the disease proceeding from injury, if it be attend- ed with an extensive destruction of the soft parts, either from the diseased process itself, or from the preceding injury;—if it has been occasioned by a contusion or laceration with a simultaneous compound or comminuted fracture of the bone, ampu- tation should be early resorted to, although the disease may still be progressive; am- ple experience having demonstrated, that, under these circumstances, it will not be proper to delay until the establishment of a well-defined line of separation between the dead and living structures indicates the ar- rest ofthe disease. It is under these circum- stances that it has been found necessary to depart from the old axiom, adverted to above, which interdicted the operation while the gangrene is progressive. The experience of Derante, Larrey, and Kirkland, long since led them to ques- tion the correctness of this rule of practice, and to amputate in traumatic gangrene while the disease was progressive; and the advantages and necessities of this course of procedure have been fully con- firmed by the subsequent observations of Larrey himself, and by the experience of Guthrie, Langenbkck, Ciielius, Hennen, Lawrence, Hutchinson, Wagner, Busch, and others. Indeed, if we were to delay in such cases for the limitation of the gan- grene, we should find, that in many in- stances, no such limitation would be devel- oped, and the disease would advance with rapid strides to the destruction of the life of the individual. It is highly important therefore, so far as the question of ampu- tation is concerned, that a distinction should always be drawn between idiopa- thic and traumatic gangrene, inasmuch as the course to be pursued in the two cases is essentially different—the first always requiring that the operation should be AMPUTATION. 385 delayed until the progress of the gangrene has become arrested, whereas the second demands the performance of amputation at as early a period as practicable, otherwise it will proceed untd it destroys life. B. Fractures. A simple fracture of one of the extremities, can never of itself justify a resort to amputation, but this ac- cident may be complicated with such other injuries as to render it expedient or neces- sary to remove the limb. Compound and comminuted fractures, however, much more frequently exact that procedure, in- asmuch as there is not only a fracture of the bone, but at the same time such exten- sive contusion and laceration of the soft parts,—such destruction of important blood- vessels and nerves, that the vital powers succumb under the shock to which they are exposed, extensive sphacelus ensues if the part be not removed by an opera- tion, and death will be speedily induced. It is possible, nevertheless, to save many limbs which have suffered compound and comminuted fractures of apparently the worst kind, and the surgeon ought al- ways to consider it his duty to allow the patient every justifiable chance for the preservation of his member, but should never suffer his anxiety for the attainment of this end, to carry him so far as to sacri- fice the life of his patient. The surgeon's situation is one of great responsibility, and the most acute exercise of his powers of judgment will be necessary, to enable him to decide when to sacrifice the limb to preserve life, or when he should at- tempt to save both life and limb. It was formerly the rule to regard almost every case of compound fracture of a large bone, as one requiring immediate amputation. Pott protested strongly against the adop- tion of such a principle, and happily illus- trated in his own case, the powers of the system when seconded by judicious treat- ment to bring about a restoration even under very unpromising circumstances. At the present time, compound and com- minuted fractures are managed upon the same principles that direct us in the treatment of those of a simple kind, and instead of considering them generally as calling for immediate amputation, it is seldom found necessary to resort to such an alternative, except in extreme cases. When the bone is extensively comminuted or broken into several pieces, if the soft parts be not at the same time extensively contused or torn, the member may be generally saved, especially if the principal vessels and nerves escape unhurt Under these circumstances, the loose pieces of vol. i. 33 bone should be picked away, and the limb submitted to such treatment as is calculat- ed to prevent or subdue inflammation, and to obviate the consequences to which it is apt to lead. This course will be especially advisable, when the accident has taken place near the central portion of one of the cylindrical bones; but, should it occur in the immediate vicinity of a large and import- ant articulation, and be complicated with great injury of the soft parts, a successful issue can seldom be hoped for, as extensive gangrene will be almost certain to ensue, and life can only be saved by a timely recourse to amputation. The mere pro- trusion of the extremity of the bone in a compound fracture cannot require amputa- tion, even though the soft parts be con- siderably injured; but should the violence by which the accident is produced, give rise to a destruction of the principal ves- sels and nerves, contuse or lacerate the muscles, the tendons, and other structures, so as to destroy their vitality, amputation will be indispensably necessary, and ought not to be delayed. It should be remarked, however, that the circumstances of the patient and his situation at the time, will exercise an important influence on the de- cision of the surgeon. On the field of battle, on ship-board, and in large hospi- tals, it will often be necessary to sacrifice limbs which in private practice might be easily preserved. C. Dislocations. The simple displace- ment of a bone, can never constitute a necessity for amputation. But unfortu- nately some accidents of this kind are attended with such an extensive injury of the soft parts, or even of the bones them- selves, that the removal of the member may become necessary to save the life of the patient This is not unfrequently the case in that form of the injury attended with a protrusion of the bone through the surrounding parts, constituting what is called a compound dislocation, which, when the accident occurs in one of the large ar- ticulations, sometimes gives rise to such extensive constitutional irritation, or alarm- ing gangrene, as speedily to terminate the existence of the individual. Injuries of this kind are, indeed, of so formidable a character, that some of the army surgeons have laid it down as a rule, that amputa- tion should be performed in all cases of compound dislocation of the ankle joints, and this practice was adopted to a certain extent by J. L. Petit, though his own ex- perience furnished him with numerous cases in which such injuries did well without the member being removed. With regard 386 AMPUTATION. to the propriety or impropriety of amputat- ing for compound dislocations, much must depend upon the kind of articulation involv- ed, the extent ofthe injury, and the nature of the parts implicated by it. Such a proce- dure can seldom be proper when the joint is small and of a simple character. But when the injury is inflicted upon the large hinge joints, as the knee and the ankle, the consequences involved are of a much more serious character. Still it is not im- possible, even under these unfavourable circumstances, to preserve the member. As a general rule, if the head of the bone has merely protruded through the soft parts, without being fractured or violently contused, without inflicting extensive in- jury upon the important vessels and nerves, or the other structures surround- ing the joint, the limb may be saved by returning the bone to its situation, main- taining it in an easy position, and vigor- ously combating inflammation. The operation, therefore, ought not to be per- formed under such circumstances, until a proper attempt has been made to preserve the member. But should the part become involved in an extensive gangrene, it must be immediately resorted to, otherwise the disease will extend with such rapidity as to occasion death before any line of separation can be established. In more desperate cases, where the bones are frac- tured or violently contused, when the soft parts are extensively lacerated and bruis- ed, the principal arteries and nerves torn up, and the tendons and their sheaths seriously injured, any attempt to save the limb will generally be at the hazard of the life of the individual, as even under the best directed course of treatment, gangrene or tetanus generally supervene, and run on rapidly to a fatal termination; or if these consequences should not ensue, violent constitutional disturbance is gene- rally developed, or profuse suppurations take place in the joint, attended with caries and exfoliation, »nder which the patient will sooner or later succumb, if he be not relieved by the timely performance of the operation. It must nevertheless be confessed, that even some of the worst cases occasionally do well; yet by acting upon the principle of endeavouring to save the limb in all such instances, although we may be occasionally successful, it will be at the expense of many lives. Judging from our own experience, we should say, that in compound dislocations ofthe ankle joint attended with extensive injuries of the important soft parts surrounding the articulation, the case will very generally terminate fatally if amputation be not performed; and this will be especially apt to occur where the constitution of the individual is feeble, or has been broken down by intemperance. It is neverthe- less the duty of the surgeon, in all cases where there is the slightest probability that the limb can be saved, to make an effort for its preservation. (See Ankle, Dislocations of.) Compound dislocations of the knee are of rather rare occurrence; but when they do take place, they are very generally fol- lowed by formidable consequences. In some instances, indeed, the popliteal ves- sels and nerves are torn up, while most of the other structures are extensively con- tused and lacerated, so as to render it im- possible for the nutritive acts of the mem- ber to be supported. The heads of the bones themselves may be fractured or vio- lently injured, so as to lay the foundation for intense inflammation of the parts con- cerned, and other alarming results. All such complicated cases require immediate amputation, and any attempt to save the limb will almost invariably lead to the destruction of the patient by gangrene, tetanus, or extensive suppuration and irrita- tive fever. But should the bone merely protrude, without inflicting much injury upon the vessels and nerves, or the other structures connected with the articulation, the limb may be very generally saved, and an attempt ought always to be made to preserve it previously to resorting to the operation. (See Knee, Dislocations of.) Dislocations of the astragalus frequently involve serious consequences, even where the integuments are not broken. They are very apt to be succeeded by gangrene, which, extending rapidly, soon terminates fatally. The unsuccessful issue of such cases induced Boyer to recommend that amputation should always be performed where the bone is completely displaced, and the result of subsequent observations has in a great degree confirmed the cor- rectness of this rule, though successful results have sometimes been obtained by pursuing an opposite course. D. Caries, Necrosis, and Exostosis. When one of the cylindrical bones be- comes profoundly involved in caries or necrosis, although nature properly aided by the resources of art is generally com- petent to bring about a restoration to health, amputation nevertheless presents itself in some cases as the only means by which the life of the patient can be pre- AMPUTATION. 887 served. Should the disease ofthe bone be of limited extent, and only involve the superficial portion of its shaft, or even if it implicate the entire thickness of the lat- ter, and be unattended with any extensive fistulous openings or sinuses in the soft parts,or profuse and wasting suppurations, the recuperative powers of the system will generally prove adequate to detach the dead portion from the living, and all that will be necessary for the surgeon will be to withdraw the sequestrum, and to treat the case upon general principles. Even where no such separation is accom- plished, whether the necrosis be situated upon the surface or within the cavity of the bone, the dead portion may be removed by the trephine, a Heys saw, or by the mallet and gouge, and the member may be preserved. Such cases, however, are always tedious, and generally inflict con- siderable disturbance upon the system. The process by which the dead bone is de- tached and thrown off is slowly accom- plished, and as the system is suffering during the whole period by profuse suppu- rations and exhausting irritation, the indi- vidual, if the disease be extensive, will sometimes become exhausted before a cure can be consummated. This will be espe- cially apt to occur if the reticulated struc- ture of the articulating extremities of the bones, together with the joints, be involv- ed, or even if nearly the whole extent of the shaft be implicated, provided there be at the same time numerous and extensive sinuses or fistulas, profuse and unhealthy suppuration, a broken-down or feeble con- stitution, and a high degree of hectic fe- ver. Such a concurrence of circumstances will generally require amputation, inas- much as the powers of life will be found too feeble to bear up under so much suffer- ing. It should, however, always be borne in mind, that the resources of the system are very great; that cures are frequently accomplished under circumstances appar- ently of the most unfavourable character; and consequently, we should reserve the operation as a last resort, and only perform it where we find that the system is rapidly giving way under the influence ofthe dis- ease, and that a cure cannot be accom- plished by any other course of procedure. Amputation should not be performed on account of an exostosis, except when the magnitude of the tumour, or the peculiar- ity of its situation, completely disables the member, or interferes with the execution of some important function. Even then the operation cannot be often necessary; for, by removing the morbid growth itself from its connexions with the bone, all the difficulties may be removed, without de- priving the individual of the use of his limb. A case may occur, however, in which extirpation of the tumour cannot be accomplished, and the amputation of the member may become necessary. E. White Swelling, and other diseases of the joints. Diseases involving the ar- ticular cartilages, the reticulated extremi- ties of the bones, and the other struc- tures which enter into the formation of the joints, are generally attended with great disturbance of the constitution, and not unfrequently lead to very distressing consequences. The various conditions which have been vaguely described under the appellation of white swelling, though generally differing from each other at the commencement, for the most part lead ul- timately to the same consequences. The morbid action may have its origin in these cases either in the synovial membrane, the articular cartilages, or the reticulated structure of the bones. In either event, all these structures may be destroyed; the synovial membranes and cartilages become extensively ulcerated; the bones themselves involved in a profound and disorganizing caries; the cavity of the joint be filled with a large quantity of of- fensive purulent matter, intermixed with the debris of the osseous and cartilaginous tissues; and besides, the surrounding soft parts may be perforated by numerous fis- tulas, or traversed by sinuses, from which matter is constantly draining, or which merely give exit to a small quantity of un- healthy sanies. With these conditions there is also violent constitutional disturb- ance, consisting at first of an intense irri- tative fever, but gradually acquiring all the characters of hectic, with profuse night sweats, much pain and suffering, wasting diarrhoea, and prostration of strength, all which, if not arrested, terminate sooner or later in death. But however urgent the demand for amputation may be under some of these circumstances, the surgeon should not be hasty in sacrificing the member. The increased resources of modern sur- gery furnish means of conducting many such cases to a favourable issue without that operation, and many limbs are now saved by judicious treatment, which in for- mer times would have been submitted to the knife. But with all our advantages and improvements, necessity still obliges us in many instances to resort as a last remedy, to amputation. Should the dis- ease proceed so far as to give rise to a large accumulation of matter in the joint 388 AMPUTATION. and an extensive destruction of the carti- lages and bones, and if the individual be at the same time worn down by hectic and diarrhoea, the operation cannot be longer delayed, but should be immediately per- formed. While, however, the genera] health remains but little impaired, and the structures surrounding the joint retain their integrity, or are not traversed by fistulous openings, and if the cartilages and bones be not at the same time extensively involved in ulceration and caries, it would be premature to remove the limb, inasmuch as by perseverance in a proper course of treatment the disease may be cured. It is moreover an important fact that even after extreme emaciation and exhaustion have been induced by the constitutional suffering, the system rallies promptly after the operation, and the patient speedily re- gains his former state of health. Amputation has also been proposed by some surgeons on account of the develop- ment of adventitious cartilages within the knee joint. This has even been advised by Kluge ; but it is exceedingly question- able if such a case can ever require so formidable a procedure. Most surgeons prefer the removal of the cartilages them- selves,—an operation which, though some- times attended with fatal consequences, has nevertheless been often practised with success. F. Gun-shot and other contused and lacerated wounds of the extremities. Few accidents to which human nature is liable, more frequently create a necessity for am- putation than violent contused and lace- rated wounds, whether occasioned by pro- jectiles propelled by gun-powder, as amidst the horrors of war,—splinters of wood, as in naval engagements,—by an individual becoming entangled in machinery,—by the blow of obtuse bodies falling from a height,—or where the subject of the acci- dent himself falls or is thrown so as to come in violent contact with any body ca- pable of inflicting such an injury. In either case, the soft parts are generally violently contused or lacerated,—the muscles, ves- sels, and nerves, are reduced to a kind of pulp or jelly,—the bones are crushed or comminuted,—the vitality of the struc- tures receives such a shock that they speedily become gangrenous,—and the march of destruction is so rapid, that un- less it be arrested by speedy amputation, the individual soon falls a victim to its ravages. Such cases are frequently very embarrassing to the surgeon, for it is ex- ceedingly difficult to discriminate between those in which the limb may be saved by judicious treatment, and such as re- quire that it should be sacrificed for the more important purpose of preserving life. In confiding too much in the resources of the art and the sanative powers of nature, many invaluable lives have been sacrificed, which might have been saved by amputa- tion : and on the other hand, it is equally certain, that limbs have been removed which might have been preserved. The results of experience, indeed, have been so various in relation to such accidents, that we scarcely find any two surgeons incul- cating the same principles; some restrict- ing amputation to a very limited number of the worst kind of cases, while others have advised it under many circumstances where the injury is comparatively trivial. Where there is so much discrepancy, it is difficult to prescribe any positive laws, and all that can be done is to lay down certain general rules, which of course must be liable to many exceptions, arising from the local circumstances of the indi- vidual, the strength of his constitution, and the facilities and advantages which may exist for conducting the treatment of the case. Thus, on the field of battle, from the number of cases which have to be at- tended to, the few conveniences which are at hand, and the distance to which the wounded have frequently to be transport- ed, many limbs must of necessity be sacri- ficed, which under the favourable cir- cumstances existing in private practice, might be saved. Also, in crowded and ill- ventilated hospitals, where all injuries evince a tendency to become gangrenous, or to assume an unhealthy character, am- putation must be more frequently perform- ed than in many other situations. There are various circumstances attend- ing contused, lacerated, and gun-shot wounds of the extremities, which will render amputation necessary. When a cannon-ball, the velocity of which is somewhat expended, strikes one of the members in such a manner as to glance off from it, although the skin may not be broken, there will frequently be such a violent contusion of the soft parts beneath,—so much injury of the vessels, muscles, and nerves,—and in many cases also of the bones, that the parts are ren- dered incapable of executing their vital acts, and will speedily run into mortifica- tion, if the limb be not removed. Even if the vessels and nerves be not torn, they are often so much contused, that the functions of circulation and innervation AMPUTATION. 389 are suspended in the affected parts and in those situated lower down, and sloughing and gangrene must inevitably ensue. In other cases, the soft parts, including the principal arteries and nerves, may be so extensively contused and lacerated by a cannon-shot, the fragment of a shell, splin- ters of wood, musket-shot, &c.—the bone may be so bared, contused, or shattered, and part of the circumference of the limb so profoundly injured, as to render imme- diate amputation necessary. Nor can there be the slightest question of the propriety ofthe operation under such circumstances; for if it be neglected, or too long delayed, extensive mortification or tetanus wili sooner or later supervene and destroy the patient. In some instances, however, the limb may be saved, even though consider- ably lacerated, provided the principal ves- sels and nerves have escaped injury, and the bone has not been extensively commi- nuted. Amputation will also be generally necessary where a member has been vio- lently crushed by the passage of a heavily laden wagon or car over it, so as to mash the bones, and inflict a violent contusion upon the soft parts ; as also in those cases in which a limb has been carried away by a cannon-shot, the bursting of a bomb, or where it has been torn off by machinery; for in the former case, gangrene will in- evitably ensue, and in the latter, the parts are left in such a ragged and lacerated condition, with the bone at the same time projecting, that they will not heal until after considerable sloughing has taken place; and even then, the protrusion of the bone is so considerable that it cannot be covered by the soft parts, and the stump presents an irregular, unseemly appear- ance. To obviate these latter difficulties, it is proper to substitute a clean inci- sion for the irregular division of the parts accomplished by the accident. It may, moreover, be affirmed in general terms, that amputation will be requisite in all cases of gun-shot wounds in which the bones of either the arms or legs are ex- tensively shattered; and it has been cor- rectly remarked, by Gr.s:fe and Guthrie, that injuries of this kind affecting the low- er extremities, much more frequently call for the operation than those of the arm. Velpeau says, that when both the tibia and fibula are extensively shattered, the case will generally require amputation; and Ravaton long since observed, that a similar accident taking place in the thigh, will be almost constantly fatal if the operation be not performed. Accord- ing to Schmucker, not more than one 33* can be saved out of seven without ampu- tation, and nearly the same observation has been made by Lombard. Ribes places the importance of the removal of the mem- ber in such cases in a still stronger point of view. He states, that of ten cases sub- mitted to the most careful treatment, not one terminated favourably; and that at the Hotel des Invalides, containing about four thousand individuals, he had been unable to find a single one who had been cured of such an accident. Nearly the same re- sults have been observed by most of the army surgeons of extensive experience, and especially by Percy, Larrey, Hen- nen, Gaulthier de Claubry, S. Cooper, Guthrie, Thomson, and others. The sur- geons who treated the wounded of July, 1830, in France, were not much more suc- cessful. Lisfranc succeeded in one case at La Pitie: Dupuytren also saved one individual without amputation; and Ar- nel mentions three others which did well. Somme cured two out of eight, at Antwerp, and a few other instances of success were obtained at Paris and Brussels. Velpeau, however, was unfortunate in the only case which fell under his management, al- though the fracture appeared to be of not a very bad character. {Medecine Opera- toire, I. 285. Paris, 1832.) It is certainly the duty of the surgeon to use every exertion to preserve the mem- ber, in all cases where there is a proba- bility of his being able to do so; but when an attempt to accomplish that object is fraught with such hazard to the life of the individual, it is certainly unjustifiable to jeopard his existence for the sake of the limb. Wounds and injuries of the joints, also frequently require amputation. This is especially true of the larger hinge joints, as the knee, ankle, elbow, and wrist. A simple penetrating wound, inflicted by a sharp instrument, even though it enter the articulation and give exit to the syno- vial fluid, will not of itself demand such a procedure ; yet, from the nature of the structures implicated, and the violent constitutional disturbance to which they are capable of giving origin when in- tensely inflamed, such consequences fre- quently supervene upon accidents of this kind, as to render it necessary to remove the limb. Should the articulation be pen- etrated by a musket-ball, a fragment of a shell, a splinter of wood, or any other ob- tuse body,—should the soft parts and the ends of the bones be violently contused or lacerated, or the latter fractured or corn- minuted, there ought to be no hesitation 390 AMPUTATION. with regard to the propriety of amputating. Gangrene or tetanus will almost invariably ensue, and if they should not, such violent inflammation and constitutional disturb- ance, together with profuse exhausting suppuration, tedious caries, and exfoliation, will take place, as to cause the patient to fall a victim to the protracted irritation. Sometimes, however, it will be better to re- sort to the resection or excision of the in- jured articulation, than to remove the en- tire limb, inasmuch as by adopting the for- mer course, the utility of the member will be in part preserved, while the mutilation and deformity inflicted upon the patient will be less considerable. Bilguer con- demned amputation in some of these cases, and several successful results have been obtained by different surgeons, without re- sorting to that operation. But when these are compared to the innumerable reverses which have followed the neglect of ampu- tation, it must be apparent to every candid mind, that to sacrifice so many individuals for the attainment of an occasional fortunate issue, can be regarded in no other light than as a wanton tampering with human life. G. Extensive suppuration and ulcera- tion affecting some part of the upper or lower extremities. There are but few cir- cumstances connected with a process of suppuration or ulceration of the extremi- ties, which can render it necessary or ex- pedient to resort to amputation. Where extensive deposits of matter form, the fluid should be evacuated; fistulas and sinuses be freely laid open, and ulcers managed by appropriate constitutional and local treatment. If the bones or articulations be not involved in the disease, these means will generally be found efficacious, and amputation not be requisite. In some in- stances, nevertheless, extensive purulent deposits take place in some part of the member; the matter becomes diffused in the interstices of the muscles; the vessels, nerves, and bones are laid bare; hectic, diarrhoea and emaciation ensue, and if relief be not afforded, the individ- ual will be exhausted by irritation. These are cases in which it may be proper to consider the propriety of removing the limb. Reasoning a priori, the operation would seem to promise important advan- tages, yet experience has by no means realized what reason had encouraged us to hope. The removal of the source of irritation has, it is true, in a few instances, been followed by a successful termination; yet in a large majority of in- stances in which amputation has been practised under such circumstances, the purulent deposits have shown themselves subsequently at some other point, and the patient has eventually fallen a victim to his disease. Velpeau states, that in every instance in which he had seen the opera- tion resorted to, the individual died, and extensive purulent deposits were found in the abdominal viscera; and our own expe- rience has furnished us with nearly the same results. If the general health be but slightly impaired, the operation can never be justifiable, however extensive and pro- fuse the suppurative process; and when the constitution is already exhausted, the nu- tritive and assimilative acts profoundly perverted, and the functions of circulation and innervation worn down by disease, should the individual possess sufficient stamina to endure the operation, the recu- perative powers of his system are so en- feebled, that he will almost invariably suc- cumb under the additional injury inflicted upon his organism. Of suppuration connected with a dis- eased condition of the bones and joints, we have already spoken as a condition re- quiring amputation. A mere suppuration within the cavity of an articulation does not of itself require the removal of the member. But it sometimes happens, that the synovial membranes, cartilages, bones, and capsules become so extensively involv- ed, that such a procedure is rendered indis- pensable for the preservation of life. The course of the surgeon under these circum- stances, must be guided by the extent of the disease and the sufferings of the pa- tient ; and even when these are considera- ble, it will often be better to excise the diseased articulation than to remove the entire limb. With regard to the propriety of ampu- tation for extensive ulcers of the extremi- ties, much must depend upon the extent of the disease and the effect it has on the constitution, or the inconvenience it occa- sions to the individual. It has been stated by Langenbeck, {Nosologic und Therapie der Chirurgeschen Krankheiten, II. 678. Gotting. 1823) that the limb should only be removed in those cases which are at- tended with such an extensive destruction of the soft parts that these cannot be regen- erated. It should always be remembered, however, that where this condition has been allowed to exist for years, the system becomes, as it were, habituated to it:—the diseased part performs the office of a drain, or excretory organ, which it is often dan- gerous to remove, unless a seton or issue be inserted, as a temporary substitute. In all cases of this kind, the operation can only AMPUTATION. 391 be considered one of complaisance, and not of necessity, and should only be per- formed in those cases in which the mem- ber is so great a source of encumbrance to the individual as to disqualify him for the ordinary offices of life; and even under these circumstances, great circumspection ought to be observed, lest, by attempting to liberate our patient from a bodily embar- rassment, we sacrifice his life. H. Large Aneurysmal Tumours, which were by the older surgeons enumerated amongst the causes requiring amputation, can never demand such a step, except where they are complicated with some other condition; as extensive caries ofthe bones, gangrene or sloughing; or such a profound destruction of the soft parts, as to render it impracticable to save the limb. In all other cases, the treatment should be conducted upon the principles furnished by the multiplied resources of modern surge- ry. Nor are we disposed to admit the pro- priety of removing the member on account of hemorrhage, either primary or second- ary, inasmuch as it will always be practi- cable to cut down and secure the vessels at another point, or to command the bleed- ing by some one of the numerous means ordinarily employed for that purpose. I. Fungus H&matodes. Encephaloid, Cancerous and other degenerations. These formidable heteroclyte degenerations to which the extremities in common with other parts of the body are liable, have too often baffled every variety of treatment, and even set the knife of the surgeon at defiance. They are for the most part in- sidious in their development, but so exceed- ingly rapid in their march, that in many cases, before we can be fairly apprized of the nature, of the disease, the internal organs have already become so extensively contaminated as to render the success of any operation altogether abortive: the re- moval ofthe primary affection is soon suc- ceeded by its re-development in some other situation, and the disease runs on with rapid strides to a fatal termination. It is still possible, however, for some of these degenerations, when they are of limited extent, and do not implicate the substance of the bones, to be removed without sacri- ficing the limb. Yet in by far the greater number of these, where a considerable ex- tent of the limb is involved—where the bones themselves are also implicated, and especially when the disease presents the characters of fungus hasmatodes, or ence- phaloid or melanotic degeneration, experi- ence has demonstrated that speedy ampu- tation presents the only means of rescuing the individual from inevitable destruction. Even this resource sometimes disappoints all our hopes, the disease soon making its appearance at some other point, and ad- vancing with such rapidity as .to render it impossible to arrest its progress. The re- moval of the member, nevertheless, some- times succeeds, even under unpromising circumstances, and should always be prac- tised where there is the slightest prospect of success. We, in one case, amputated in the immediate vicinity of the trochan- ters, where nearly the whole of the thigh from the knee upwards was involved in extensive encephaloid degeneration; and, notwithstanding the inguinal and iliac glands were greatly enlarged, nearly the whole stump healed up by the first inten- tion, and the individual has had no return of the disease. In adopting this course, it will always be advisable to perform the operation at a considerable distance from the seat of the disease. In a case of fun- gus hasmatodes of the tarsus, in which Grossheim removed the member below the knee, he found a kind of degeneration which was inclosed in a proper membrane, extending for some distance above the in- ternal malleolus, along the course of the posterior tibial nerve, to which it was at- tached by loose cellular tissue, without, however, implicating its neurilema. {Lehr- buch der Operativen Chirurgie Zweiter Theil. p. 524. Berlin, 1831.) If the ope- ration had been performed below the limit of this degeneration, the disease would doubtless have been re-developed, and the case have terminated fatally. It is, how- ever, always difficult to determine the precise limit of the disease; for, although the external parts may appear healthy, it often happens that some of the deeper- seated structures are profoundly involved. We once examined an individual who died of a fungus hasmatodes developed upon the internal side of the tibia, and, notwithstand- ing the morbid affection did not seem to extend very high, the course of the prin- cipal vessels, throughout the whole extent ofthe thigh, and even in the abdomen, was surrounded by a diffluent pulpy material, resulting from the dissolution of the degen- erated encephaloid mass. Amputation will also be demanded when the bones are affected with the condition denominated spina ventosa, osteosarcoma, &c., as well as in that affection of the os- seous tissue, which has been designated by modern pathologists under the appellation of colloid degeneration. Kluge and many other surgeons, have, moreover, recom- mended the operation to be performed for 392 AMPUTATION. the removal of limbs affected by elephanti- asis, and it has been often practised with success under such circumstances. K. Tetanus has been supposed by some surgeons, especially Larrey, to require amputation. Any individual, however, who will give himself the trouble to re- flect upon the nature of this accident, will be at once convinced that the removal of the original injury cannot overcome the important changes to which it has already given rise in the cerebro-spinal centre. The condition is altogether traumatic at its commencement, but in a short time after the injury is inflicted, such vital mod- ifications are developed by it, that the per- version of function which is thus originated, will continue to act, although its original source be removed. We accordingly find, that in nearly all the cases in which am- putation has been performed for the pur- pose of arresting tetanus, the disease has progressed, without being influenced in the slightest degree by the operation. This happened in two cases, even to Larrey himself; and it has fallen to our lot to see every case terminate fatally, in which the operation was resorted to. So unfortu- nate, indeed, have been the general re- sults of this practice, that it is con- demned by a large majority of modern surgeons, and the very small number of successful cases which have occurred, cannot be considered as at all sufficient to justify its adoption as a general rule. Indeed, it may be affirmed, that universal experience is decidedly against the opera- tion. The reports of Sir James M'Grigor, deduced from the extensive experience of the surgeons of the British army, are highly unfavourable to its adoption, and the same remark may be made in re- lation to the results obtained by the French. Even Larrey himself confined it to chronic cases, which are of rare occurrence; and Sir A. Cooper interdicts it in these cases, declaring that it is un- justifiable, inasmuch as the individual often recovers without this proceeding. It has, indeed, been very correctly observed I by Rust, {Handbuch der Chirurgie, I. 512. Berlin, 1830.) that by resorting to amputation after the spasms have' become developed, we merely amputate the wound, but not the tetanus. L. Amputation from complaisance. Under thi6 head may be enumerated those cases where amputation is not necessary for the preservation of the life of the indi- vidual, but in which it may be sometimes resorted to on account of some acquired vice of conformation of one of the ex- tremities, which renders it an encum- brance to the individual, and disqualifies him for the common offices of life, and the enjoyment of its comforts. Numerous examples fall under the observation of the surgeon, which, from the impatience of the individuals to be disembarrassed of the deformity and inconvenience to which they are exposed, render it necessary that he should decide upon the propriety or im- propriety of amputation. Of this kind,are permanent and rigid distortions of the members, partial or complete anchylosis of the joints, extensive, ancient and incurable ulcers, sinuses, fistulas, artificial joints, &c. none of which endanger the life of the in- dividual, while most of them are a source of so much inconvenience as to render the sufferer anxious to be relieved. With re- gard to incurable ulcers, we have already spoken; anil we can now only subjoin, that in a large proportion of the other condi- tions enumerated, the propriety of ampu- tation is exceedingly questionable. It is a curious fact, and one which has been fully established by experience, that operations performed under such circumstances, are generally followed by fatal consequences, notwithstanding the condition of the pa- tient is such as to promise a successful issue. Too much circumspection cannot therefore, be observed by surgeons in yield- ing to the earnest entreaties of individuals, some of whom evince so ardent a desire to be released from their troubles, that they are willing to incur every hazard, and will insist on having the member amputated, although fully apprized that the result may be fatal. Numerous cases have been re- ported which place this subject in the strongest point of view, and show how im- portant it is that the practitioner should never so far lose sight of moral rectitude, as to undertake an operation which can- not be necessary, and which may jeopard the life of his patient In 1821, a stout, robust individual, in the enjoyment of full health, entered the H6- pital St. Louis, with the fixed determina- tion to undergo the amputation of the thigh, on account of an anchylosis of the knee, which obliged him to walk with a crutch. Richerand used every endeavour to dissuade him from his purpose, by de- picting to him in the most glaring colours, the hazardous consequences which it in- volved, but finally yielded to the inflexible entreaties of his patient. The operation was accordingly performed, and everything seemed at first to promise well; but he was shortly attacked with an ataxic fever, which terminated fatally on the fifth day. AMPUTATION. 393 A similar example is reported by Pelle- tan. In 1825, an old soldier, wearied with a chronic enlargement of the leg, accom- panied with an ulcer of long standing, situated behind the malleolus, presented himself at the clinical wards of l'ecole de Medecine, with the determination to have the limb amputated. All the arguments and entreaties which could be urged by Roux, were in vain, and finally yielding to the importunities of the individual, the operation was performed without the occurrence of any untoward circumstance. A train of symptoms was nevertheless soon developed, which terminated fatally at the end of a week. Velpeau re- ports similar instances, and in one case in which he merely amputated the in- dex finger at its articulation with the metacarpal bone, in consequence of a permanent flexure of that member upon the palm of the hand, although the in- dividual finally recovered, he was affected during a whole fortnight with the most alarming symptoms. {Midecine Opira- toire. I. 280.) These cases point out very forcibly the impropriety of adopting a procedure fraught with danger, for the removal of a comparatively trivial inconvenience; and the surgeon should, therefore, always be convinced of the necessity of the opera- tion, before he yields to the solicitations of those who request it to be performed. 5 3. The period most favourable for amputation. There is no point connected with the subject of amputation, which it is more important to determine, than the pe- riod at which the operation can be most suc- cessfully performed, and few unfortunately have given origin to so much diversity of opinion. The importance of the question relates more especially to those cases in which the operation becomes necessary on account of external violence inflicted upon the member, and those in which it is demanded for the removal of a limb affect- ed with gangrene, though it is not unim- portant in cases of a chronic character. In the first set of cases, it is called primi- tive amputation where the operation is performed on the spot, or within a short period after the receipt of the injury; and consecutive, where it is not practised until after the expiration of several days, or subsequent to the subsidence of the dis- turbance which follows the accident. These are the points upon which the dis- cussion has mainly turned,—one party advocating immediate amputation, while the other has as strenuously insisted upon the propriety of delaying it until the tumult ofthe system aroused by the injury has entirely subsided. The practice of immediate amputation in gun-shot wounds requiring that opera- tion, was long since strongly recommended by Wiseman, {Chirurgical Works,) who has been generally considered as the father of English Surgery; and was much insisted on by Le Dran, {Traiti des Plaies d'armes a feu, Aph. 9.), who expressly de- clares, " that where the amputation of a limb is indispensably necessary in the case of a gun-shot wound, it ought to be done without delay," and "that if there is a sure means of preventing the inflamma- tory symptoms, or bad consequences re- sulting from injuries of the joints, it is that of quickly removing the limb." It should be stated, however, that in 1625, long before the publication of Wiseman's opinion on this subject, primary amputation had been recommended by Du Chesne. This last named surgeon was convinced of the danger of amputating after inflam- mation had developed itself, and very wisely recommended the removal of the limb before that event took place. Ran- by also advised a similar practice, and states several instances which fell under his own observations, during the cam- paigns of Flanders, strongly corroborative of the correctness of his opinion. {The method of treating gun-shot wounds, 1781.) The question, however, was most strongly agitated by the French Academy of Surgery, which in 1756 made it the subject of its prize for that year. On that occasion two memoirs were produced, which out of many others were alone considered as possessing any important claims; one by Faure, a military sur- geon ; the other by Le Conte, who was engaged in private practice at Arcueil. The prize was awarded to the former, on the ground that his opinions were sup- ported by experience; but both advocated the doctrine of delaying the operation whenever it was practicable to do so, even though it should from the first be manifest that amputation would be in- dispensably necessary. The recommenda- tion of Faure purported to have been founded upon the results of ten cases of secondary amputation, reserved ex- pressly for the occasion, after the battle of Fontenoi, all of which were success- ful. This success appears at first sight so satisfactory, and so much greater than that which is generally obtained, that if there could not be brought forward any circumstances to invalidate the conclusions involved, it would be impossible longer 394 AMPUTATION. to dispute the comparative merits of pri- mary and secondary amputation. It should be stated, however, that both Faure and Le Conte, have each designated a con- siderable number of cases, in which im- mediate amputation is indispensably neces- sary, and in which the individuals could not possibly survive until the arrival of the favourable period for amputation which they have prescribed. It is expressly stated by Faure, that where a member has been carried away—an important articulation violently fractured—the bone of an extremity shattered, with an ex- tensive destruction of the soft parts, or the bones been minutely comminuted and surrounded by a considerable contusion of the soft parts, with laceration of the ten- dons and aponeurosis—where the struc- tures of the large joints are torn, and the bones are simultaneously fractured, or where the main artery is lacerated and the hemorrhage cannot be controlled by any other means, it would be dangerous to defer the operation. {Prix de VAca- dimie Royale de Chirurgie. III. 334. 8vo. Paris, 1819.) Under all these circum- stapces, he subjoins, that the prompt abstraction of the injured part is the only means possessed by the art that can be opposed successfully to those conse- quences still more formidable, which will inevitably supervene if amputation be delayed. It is clearly manifest, therefore, that although secondary amputation may have been performed successfully, in the whole ten cases, as stated by Faure, we have no assurance that an equal or greater num- ber of individuals may not have been lost by the delay of the operation, who might have been saved by its prompt adoption on the field. No allowance having been made for these cases, the facts and argu- ments adduced are far from being conclu- sive; and it was, we think, with much reason that Boucher objected to the validity of the inferences drawn by the Academy of Surgery. There is no satis- factory evidence that these ten cases would not have done equally well if im- mediate amputation had been practised; and acting upon this supposition, it is manifest that by postponing the operation until the subsidence of the troublesome symptoms, a large proportion of patients who cannot survive until that period, and who might be saved by early amputation, must be inevitably lost Boucher, who has carefully examined all the grounds taken by Faure in his memoir, has demonstrated three periods, at which it will he proper to resort to the operation. 1. The period intervening between the receipt of the injury, and the develop- ment ofthe accidental symptoms, to which it gives rise. The tension, inflammatory swelling, throbbing, acute pain, fever, &c. which constitute the ordinary conse- quences of gun-shot wounds, do not make their appearance suddenly, but are sooner or later developed, according to the extent and complications of the wound, and the nature of the constitution of the patient. 2. Where the symptoms developed are more or less capable of disturbing the system. 3. The period at which the urgency of the symptoms has either abated or entirely subsided,—corresponding to that at which Faure recommended the operation to be performed. (Boucher, Mimoires de V Acadimie Royale de Chirurgie. II. 326 8vo. Paris, 1819.) The operation may be performed suc- cessfully at either of these periods, yet if a candid appeal be made to the results of experience, especially to that ofthe Army and Navy Surgeons, whose opportunities of observation are the most extensive, it will be seen that primary amputation in gun-shot wounds has been attended with far more fortunate results than the prac- tice recommended by Faure and Le Conte, and which was also subsequently advised by Hunter, Lombard, Levielle, and others. Indeed many surgeons en- gaged in private practice have been fully aware of this fact, and we accordingly find Pott, John Bell, and several others, recommending immediate amputation be- fore the correctness of the practice was fully established by those who had a more ample field for observation. Even Schmucker, who succeeded Bilguer, as Surgeon-in-Chief of the Prussian Armies, and who was much opposed to amputa- tion, recommends in express terms, that when the operation is necessary it should be performed before inflammation makes its appearance, {Chirurgische, Wahrne- mungen. II. 500.); and Boy gives the same advice, (Wedekinds Nachricht uberd. Franz. Kriegs, spitalwesen. I. 1797.) Larrey, whose authority is of the highest value upon all points relating to. military surgery, is a warm advocate for immediate amputation, not only in the worst cases of gun-shot and other wounds, but in all acute diseases in which it is impossible to save the limb, {Clinique Chirurgicale. III. 514. Paris, 1829, also Campaigns, trans- lated by Dr. Hall, Baltimore, 1814.) To AMPUTATION. 395 him, especially, is modern surgery indebt- ed for having first established this practice as a principle, the correctness of which has been subsequently confirmed by Guth- rie, Hennen, Hutchinson, Thomson, Sam- uel Cooper, Gouraud, and which has been acknowledged and acted upon by Rust, Kluge, Dupuytren, Richerand, Roux, Marjolin, Lisfranc, Gossheim, Langenbeck, Blandin, Velpeau, and in- deed most modern surgeons. Whenever, therefore, it is possible to resort to the ope- ration before the inflammatory symptoms make their appearance, if it is determined that the limb cannot be saved, there should be no delay in amputating after the patient has sufficiently recovered from the effect of the shock to render it safe to operate. The propriety and necessity of this course have been fully confirmed by experience. Dubor states, that during the American war in 1780, the French surgeons were unsuccessful in almost every case of am- putation, because the operation was de- ferred ; while those of the American army, who operated on the spot, saved nearly all their patients. Fercoc, who had the treat- ment of the wounded after the celebrated naval engagement of the first of June, 1794, represents that out of a great num- ber upon whom immediate amputation was performed, only two died, and their death was occasioned by tetanus. The surgeon of the Timiraire, which was taken by the English, influenced by the advice of their surgeons, delayed the operation, and had the mortification to see all his wounded perish before the period for consecutive amputation arrived. (Larrey, Op. Cit. p. 515.) The same striking contrast was ob- served by Masclet, after the engagement at Aboukir. Eleven cases in which imme- diate amputation was practised all did well, while three others, in which the ope- ration was delayed eight days, terminated fatally. After the affair of Newbourg, Baron Percy performed eighty-two imme- diate amputations, out of which number only six terminated fatally; and Larrey saved twelve out of fourteen. The same preponderance of success attending pri- mary over secondary amputations, was ob- served in the British army during the Pe- ninsular war, as is satisfactorily demon- strated by the documents obtained by Sir James M'Grigor. It appears from those documents, that out of 551 amputations performed in hospital, within the space of six months, when of course the operation was consecutive, 265 were unsuccessful; whereas, out of 291 cases, in which the operation was practised on the field of bat- tle, only twenty-four terminated fatally,— making the ratio of unsuccessful cases in secondary to those which occurred in pri- mary amputation, 15 to 2. (Guthrie on Gun-shot Wounds, &c. p. 228. London, 1827.) A still more extraordinary success attended primary amputation in India. Ac- cording to the official return of Dr. Burke, out of eighty cases in which that practice was pursued at Buhrpore, every one ter- minated favourably, (Sir G. Ballingall's Military Surgery, p. 410. Edinburgh, 1833.); and it is stated by Del Signore, who accompanied the French expedition into Egypt, that after the battle of Nava- rino, he lost only one patient out of thirty in which the operation was immediately performed, while he saved only twenty- five out of thirty-eight cases after second- ary amputation. Similar results were ob- tained after the French revolution of July, 1830. Velpeau states that nearly a hun- dred amputations were performed at the several hospitals of Paris, of which num- ber by far the greater proportion were suc- cessful, when the operation was practised early. Nearly all the cases of primary amputations terminated favourably, while most of those which were secondary ended fatally. {Medecine Opiratoire. I. 293.) Taking all these facts into considera- tion, the question so long agitated relative to the comparative advantages of primary and secondary amputation, may be consid- ered as fairly settled in favour of the for- mer, and the practice recommended by Faure and Le Conte, and inculcated by the old French Academy of Surgery, is proved not only to be erroneous, but fraught with dangerous consequences. There is, however, one fact stated by Sanson and Ballingall, which must not be passed over in silence. These sur- geons affirm, that the striking advan- tages of primary over secondary ampu- tation observed in military practice do not take place to the same extent in civil hospitals. Attempts have been made to explain this circumstance upon the opera- tion of causes partly moral and partly physical, and there can be no doubt that such influences do frequently impress very important modifications upon the success of an operation. The moral depression ex- perienced by an individual, who has per- haps a large family dependent on his ex- ertions for support, and who finds himself suddenly, and frequently by imprudence, deprived of the ability of furnishing them with subsistence; would naturally tend to place the system in a condition highly un- favourable to amputation. To this must 396 AMPUTATION. also be added the fact, that he has been ac- customed to active and wholesome exer- cise in a pure and salubrious atmosphere, and that he is suddenly transferred to the crowded and contaminated wards of a civil hospital, which are apt to excite fever even in an individual in perfect health, and it will be readily conceived why an operation should under such circumstances be less fortunate than with the soldier, who is seldom exposed to the operation of such causes. The principal arguments which have been urged by those who condemn imme- diate amputation, have reference to the condition of the patient and the chance that limbs may be sacrificed, which by delaying the operation might be pre- served. It is well known to all surgeons who are conversant with the phenomena of gun-shot and other violent wounds, that these accidents frequently inflict an alarm- ing shock upon the individual, and some- times occasion a temporary prostration or a suspension of the vital powers. As John Bell has forcibly expressed it, "the individual is overtaken with an awful trembling and disorder of the nervous system: the bravest cannot resist it; and the most acute physiologist cannot tell whether it is a disorder of the body or a tumult of the mind." "There is an instant affection of all the body, a trembling and unaccountable sinking with- in, yellowness of the face, paleness of the extremities, a failing of the pulse, and a livid wound from which no blood is discharged." {Discourses on the Na- ture and Cure of Wounds. I. 132.) This state of the system has been very justly urged by the advocates of consecu- tive amputation against the propriety of performing the operation immediately. But what sensible surgeon would ever think of removing a limb in such a state of the system 1 Such a practice has never been recommended, and we feel assured would never be adopted by any man who is at all conversant with the principles of his pro- fession. There is always a period inter- vening between the receipt of the injury and the development of the inflammatory symptoms,—a period which was very ac- curately designated by Boucher, at which the operation should be performed. Until the patient is aroused from the stupor oc- casioned by the shock sustained by his nervous system, the operation will be haz- ardous, and it should always be a rule to delay until the powers of animation are re- suscitated,—until the nervous system re- sumes its functions, and the heart and ar- teries emerge from their state of oppres- sion, whether that event take place in one or twenty-four hours. Thus long it will be proper to wait, and no longer. If the operation be delayed until the inflamma- tory symptoms have become fairly devel- oped, we shall frequently have suffered a golden opportunity to escape, in which all of the patient's salvation may be involved, and deprive him too frequently of the only chance between life and death. What- ever is to be done must be done quickly, "and where there i* plainly a necessity for losing a limb, the sooner it is done the better," provided the individual has sufficiently recovered from the depression of the vital powers occasioned by the in- jury. (Le Dran, Op. Cit.) When, however, circumstances render it impracticable to resort to primary am- putation, and the inflammatory symptoms have already made their appearance, all our hopes of success must rest upon our ability to conduct the patient safely through the stage of excitement, fever, and suppu- ration, and bring him to the period recom- mended by Faure as the most favourable for the operation. Amputation must not be thought of while the whole system is in this tumultuous condition, except it should be demanded by the rapid progress of gangrene, in which case the removal of the limb, as we have already attempted to show, ought not to be delayed. Did not experience itself teach the hazardous con- sequences of amputating while the stage of inflammation is at its height both rea- son and analogy would deter us from the adoption of such a course. What, in effect, is the general conduct of the surgeon un- der such circumstances in relation to other operations 1 He does not practise lithoto- my without previously bringing the sys- tem to a proper condition ; neither does he operate for cataract while the eye is af- fected with acute inflammation. The re- moval of a member, therefore, which is al- ways productive of a much more violent commotion of the system, should be regu- lated by the same principles; and if the operation has been neglected until the vi- tal powers are thrown into a tumult, it should be still further delayed, and the surgeon must direct all his energies to control the inflammatory action, and in- duce a calm favourable to the success of the amputation. The only circumstance which can justify or require a departure from this rule is a marked tendency of the wounded limb to run into gangrene. Here it would be dangerous to wait for the de- velopment of a well-defined limit between the dead and the living parts: death will AMPUTATION. 397 ensue before such an occurrence can take place, and the concurrent experience of most modern surgeons of extensive ob- servation, has confirmed the correctness of the practice so ably inculcated by Lar- rey, of immediate amputation in cases of traumatic gangrene. Langenbeck has very correctly observed, that under such circumstances, there is "periculum in mora," and he states that he has some- times amputated with the most fortunate results, even where the limb was enor- mously swollen, but had not yet become gangrenous. {Nosologic und Therapie der Chirurgischen Krankheiten. IV. 266. Gotting. 1830.) This practice should not be adopted, however, except where morti- fication is inevitable, and then it must be regarded as a matter of necessity, and not of choice. Should this necessity for amputation, during the persistence of the inflamma- tion, not exist the surgeon must content himself with such treatment as will be calculated to bring about a calm in the conflicting acts of the living organism; and when that is induced, which will gen- erally be within a period varying from 15 to 25 or 30 days, the member may be re- moved with much greater probability of success than at any other moment, except that which has been designated as the most advantageous for primary amputation. Here, however, much must depend upon the constitution ofthe individual, the condition of the limb, and the state of the internal or- gans. The patient is too frequently exhaust- ed by profuse suppuration and hectic, or becomes affected with a formidable lesion of some of the important viscera, so that, should the operation be performed with the greatest care and judgment, the issue will often bo unfortunate, on account ofthe en- feebled vital energies being incompetent to sustain the additional aggression thus made upon them. But if the removal of the member has been necessary from the commencement, and there is now no possi- bility of preserving it, amputation must be regarded as the " unicum remedium," and should be practised, although the chances of success be unpromising. There are, nevertheless, some circumstances which will render the operation altogether hope- less. These consist, for the most part, in the existence of a dangerous or incurable disease in some part or organ essential to life; as phthisis pulmonalis, hasmoptysis, general or local dropsy, lumbar abscess attended with caries ofthe spine, a disease ofthe heart or large vessels, an abscess of the liver, an ulcerated condition of the in- vol. i. 34 testines with chronic diarrhasa, an indica- tion of the development of a cancerous or some other similar condition higher up than the point at which it will be possible to amputate, and such a profound implica- tion of the system in a general scrofulous, syphilitic, scorbutic, or rheumatic diathe- sis, as to give rise to a re-development of the disease at some other point, after the member has .been removed. Extreme de- bility may, moreover, constitute a counter- indication to the operation. Yet experience has demonstrated, that in many cases where the debility is considerable, the removal of the violent and exhausting irritation kept up by the diseased limb, is soon followed by a rapid improvement of the corporeal energies of the system, and a speedy re- storation to health. Under many of these circumstances, much may be accomplished by judicious preparatory treatment, and accordingly, such a course should always be adopted as will have a tendency to put the constitution of the patient in such a condition as will best qualify it to endure the operation. 5 4. The most eligible point for the performance of amputation. Upon this point there is far less difference of opinion at the present day, than in former times. Many of the ancients recommended the incision to be always made through the mortified parts, and although Celsus pre- scribed a different procedure, their advice was generally followed, until its impropri- ety was exposed by Wiseman. Since his time, it has been the established practice to cut through the living parts, either at, or a little above, the line of demarcation by which they are separated from the dead. This rule is now never departed from where amputation proper is performed, and a different course is only adopted, when the object is merely to disembarrass the limb of the gangrenous structures. As regards the precise part of the mem- ber upon which the operation should be performed, it must be determined by the necessities of the case, founded upon the situation and extent of the disease, the condition of the structures, and the mem- ber, or part of the member, affected. The operation may be performed either through the substance of the bone, or through the articulation; the one or the other of which should be preferred, according to the limb that may be affected, and the character of the joint. In fixing upon the point at which it should be executed, we have what is called the point of election, and that of necessity; but in many cases, the first is entirely wanting, in conse- 398 AMPUTATION. quence of the disease being so situated as to leave us no alternative but to amputate at a particular place. It may be laid down as a general rule, that the member should be removed at that point which will insure the effectual extirpation of the disease, and the preser- vation of the greatest possible quantity of the limb. Thus, in cases of gangrene, where the sloughing process has been arrested, the incision should be made im- mediately above the line of separation be- tween the dead and living parts; but when it is still progressive, it must be made suf- ficiently remote from the seat of the dis- ease to insure its passage through parts which are healthy. If this precaution be neglected, it will often be found, that although the operation is performed on parts which externally have a healthy ap- pearance, the incision will be carried through structures which are in a sloughy condition, and the disease will be renewed and extended with increased rapidity. Where the member is affected with an encephaloid or carcinomatous degenera- tion, or any specific form of disease which would be liable to recur, great care must be taken to operate at a point sufficiently removed from the seat of the disease, to insure the extirpation of the whole of the part involved in the morbid affection. The same rule must be observed in other cases, when the affection of the bone extends higher up than that of the soft parts; for although the latter may exhibit a healthy aspect, the former may be so extensively involved as to perpetuate the disease after the member has been amputated, unless the operation be performed upon a healthy portion of the bone. A simple induration of the structures, however, can never re- quire the sacrifice of a considerable por- tion of the limb. Such a condition is generally excited by the long-continued influence of local inflammation existing in a fistulous passage, or some other morbid state of either the bone or the soft parts, and will speedily disappear after the re- moval of the source of irritation. It has been recommended not to amputate in the vicinity of a large joint, and as a general rule, this precept should be observed. There are, nevertheless, cases in which it ought to be departed from. Should a disease or injury of the leg or arm, be situated so high up as to leave no alternative but to amputate in the vicinity of the knee or elbow, or above those articulations, the former procedure must be adopted, inas- much as those joints are so useful to the individual, that they ought not to be sacri- ficed, except from absolute necessity. Larrey, and several other surgeons, have amputated with complete success, even through the reticulated substance of the head of the tibia, and thus preserved the use of the articulation, by which a great advantage was secured in the adaptation of a wooden leg. It is desirable to perform the operation upon that portion of the limb which is ca- pable of affording the best flap or covering for the stump. Hence, in amputating the upper and lower extremities, the operation can be better performed through the calf of the leg, or the thick part of the arm, than in the vicinity of the ankle or wrist, because of the thinness of the integuments in these latter situations, and the greater difficulty of obtaining union by the first intention. To secure these advantages, however, too much must not be sacrificed. Amputations generally do well in the ten- dinous parts of the leg and arm, and as it is important to save as much of the member as possible, when the disease or injurv is situated low enough down to admit of the operation being performed at these points, the objects to which we have ad- verted can never constitute a sufficient rea- son for unnecessarily sacrificing a member which may be useful to the individual. There is one other rule of practice to which we are anxious to advert. It has been the practice with many surgeons, when the humerus or femur has been shattered in the immediate vicinity of their articulations, either by musket or cannon- shot and when the soft parts have been extensively contused or lacerated; or when a necrosis of these bones occupies the same situation, to resort to amputation at the shoulder or hip joint This conduct is ex- ceedingly improper. The operation may, in a majority of such cases, be successfully performed through the continuity of the bone, and the individual will thus be saved the pain and hazard of an amputation through the articulation. The advice of Baron Larrey, to amputate at the shoul- der joint in preference, whenever there is not room to operate so low as the attach- ment of the deltoid muscle, should never be followed. It is founded upon the pre- sumption that the extremity of the bone will be drawn towards the side, and occa- sion a protrusion of its extremity, and likewise upon the apprehension of the ir- ritation of the brachial plexus of nerves, likely to result from the application of a ligature to the artery so high up. Expe- AMPUTATION. 399 rience has shown that the first difficulty can be easily prevented by the use of a small pad or compress, inserted in the ax- illa ; and the second does not apply more to this operation than to that at the shoul- der joint. Whenever, therefore, there is space enough to saw the humerus imme- diately below its tubercles, or the femur through the point at which its shaft and neck unite, that procedure ought to be adopted in preference to the operation through the hip or shoulder joints. Or should these bones be extensively shatter- ed or necrosed, with a simultaneous im- plication of the soft parts, rendering the sacrifice of the members indispensable; if the heads of the bones have escaped, it will sometimes be better to divide the soft parts in the most advantageous manner, and pick away the fragments of bone, or the sequestrum, than to operate at the ar- ticulations. (C. Bell, Two Lectures, &c.) J 5. Comparative advantages of Am- putation through the continuity and in the contiguity of the bones. It has been already stated, that by amputation through the continuity of a bone, is meant that op- eration by which the bone is sawed through, while that which is practised in their con- tiguity, consists in the removal of a mem- ber through one of its articulations. Amputation at the joints was condemn- ed by Celsus, but was particularly recom- mended by Galen, as the most expeditious and safest method of performing the ope- ration. The opinion of the latter was combated by Heliodorus, who insisted upon the superior advantages of amputat- ing through the continuity of the bones. His advice was generally adopted by sur- geons, until Brasdor and Larrey, in modern times, again called the attention of the profession to the advantages of ope- rating at the joints, and the latter proved, by his success in the campaigns of the French army, the reality of these advan- tages. Since that time, it has been satis- factorily demonstrated by repeated experi- ence, that many of the fears which were formerly entertained relative to cutting into an articulation, were for the most part groundless; and if it is not safe to ampu- tate through the larger hinge joints, this operation can be more advantageously per- formed through some of smaller magni- tude, than at any other point. At the present time, therefore, the merits of both methods are acknowledged, and the one or the other is adopted, according to their in- dividual adaptation to the part which is to be removed. The only difficulty consists in determining the cases in which one method should be resorted to in preference to the other, and in deciding which will be the easiest and safest to the individual. The characters of the joints themselves, together with a knowledge of their com- parative tendencies to suffer from injuries inflicted upon them, should be our princi- pal guide upon this point It will thus be generally observed, that the hazard attend- ing amputation at the articulations will be always in a ratio with their extent and the complicated character of their arrange- ment. The hip and shoulder joints, those of the phalanges of the fingers and toes, of the metatarsus and metacarpus, wrist &,c, present a less extent of surface, and are more simple in their arrangement than those of the knee and elbow. Hence it has been found by repeated observation, that amputation may be safely performed at those points, whereas, at the elbow and knee, especially at the latter, though some- times successful, it is by far a more hazard- ous operation, and occasionally gives rise to formidable consequences. Nor is it diffi- cult to explain this difference of result. The knee joint presents a large extent of surface, covered by cartilage and synovial membrane, the latter of which presents numerous reflexions, which increase its extent. The expanded extremities of the bones, moreover, which contribute to the formation ofthe joint are besides composed of a delicate reticulated structure, which, as well as the other parts of the apparatus, is very liable to take on extensive inflam- mation. This process, when once devel- oped, not only occasions severe constitu- tional disturbance, but frequently termi- nates also in troublesome suppuration and caries, by which the life of the individual may be jeoparded. The elbow, to a cer- tain extent, presents an analagous arrange- ment, and is also liable to similar accidents, though in an inferior degree. Amputations, therefore, performed at these articulations, have been generally found less successful than those that are executed at other points; and such alarming symptoms have sometimes been developed, that many sur- geons have been deterred from resorting to the operation, especially at the knee. There is, besides, another fact to be taken into account in determining upon the com- parative advantages of the two methods of operating. The cartilages, in conse- quence of their peculiarity of organization, and the feebleness of their vital powers, take on less readily the adhesive form of inflammation than the bones themselves; and when a large extent of such a surface is exposed, it sometimes happens, that, 400 AMPUTATION. although the flaps unite as under ordinary circumstances, a cavity remains in relation with the central part of the stump, in which tedious suppurations take place, and retard the cure. To this accident the knee joint in particular is much exposed, and it may also occur at the elbow. Those, how- ever, which present less extent of surface, are not so liable to any serious conse- quences; and it has been found, accord- ingly, that amputations through them, prove as successful as those which are practised upon the continuity of the bones. Influenced by these and other principles, surgeons of the present day seldom ampu- tate at any but the smaller and more sim- ple articulations. The operation at the shoulder and hip, are only practised from absolute necessity, and these articulations being simple and of limited extent, the operation, especially at the shoulder joint, generally proves successful. At other points it is different: we have our choice to amputate at the joint or through the substance of the bone, and the one or the other place should be adopted, according as it may be more advantageous or safer to the patient. The phalanges of the fingers and toes, the bones of the meta- carpus, metatarsus, carpus, and tarsus, and the wrist, may be generally amputated with greater facility through their articula- tions than by any other procedure, and with these joints this method should be generally preferred:—we say generally, because there are a few exceptions, which we shall point out under the head of the individual amputations. The operation is never performed at the ankle joint, be- cause of the impracticability of saving a sufficiency of soft parts to form a flap. As no possible advantage can accrue from merely saving the condyles of the femur and humerus, and as amputation at the knee and elbow always exposes the indi- vidual to unnecessary hazard, the opera- tion should never be performed at those points. Whether amputation be performed at the articulations, or through the continuity of the bones, there are two leading meth- ods in general use, to which all the modi- fications may be referred. The first, which is of the greatest antiquity, is by what is called the circular incision; the second, by a single or double flap. 5 6. Preparation of the patient previ- ous to Amputation. The operation of am- putation is always attended with much pain, and various preparatory means have been recommended with a view of dimin- ishing the sufferings of the patient. For this purpose, some ofthe ancient surgeons required the individual to inhale by the nose the vapours of certain narcotics, but in modern times, they have been generally administered either by the mouth, or by injection. Laudanum or opium have been most employed, but when their adminis- tration has been considered improper, hy- oscyamus and other narcotics have been substituted. Graefe insists much upon the propriety of abating the nervous sensibility by means of appropriate remedies, before the operation; and with this object, when opium is not contra-indicated by a general plethoric condition of the system, idiosyn- crasy, or any other cause, he recommends that about sixteen drops of Sydenham's liquid laudanum should be administered to the patient To those who have been ac- customed to the use of the article, the dose may be increased; but he remarks that it should never be carried to the ex- tent of producing an unpleasant determina- tion to the head. After the nervous system has been brought under the soothing influ- ence of the narcotic, the individual, he assures us, will bear the operation with much less suffering, and will generally escape the horripilation which is so apt to supervene when this precaution is neglect- ed. Instead of the chills which so fre- quently follow the operation, he will gen- erally fall into an easy, tranquil slumber, from which he will awake much refreshed. When the anodyne cannot be administered by the mouth, without creating unpleasant consequences, he prescribes it by injection. For this purpose, he employs a drachm of laudanum, or a scruple of the root of bel- ladonna, in three ounces of chamomile tea, to be thrown into the bowels four hours before the operation. In some cases, the belladonna used in this way produces a more happy effect than any of the preparations of opium. When neither can be employ- ed, he always uses a simple injection, for the purpose of removing irritation from the bowels, and obviating the necessity for the patient to rise to stool until sufficient time has elapsed after the operation to allow its effects to subside. {Normen fiir die ablosung grosserer Gliedmassen, p. 43. Berlin, 1812.) These views are certainly judicious: but perhaps it will be advantageous to give a greater quantity of anodyne by the mouth than the dose recommended by Grjefe. We have generally administered from forty to sixty drops of laudanum, and have witnessed no bad consequences from its employment. It is possible, however, for an over-dose of the narcotic to excite a AMPUTATION. 401 kind of erethism ofthe cerebro-spinal cen- tre, of a mischievous tendency; and it has besides been urged against its employment under these circumstances, by Rust and Kluge, who are opposed to its administra- tion, that it exposes the patient to second- ary hemorrhage. It has been proposed by some, with the view of diminishing nervous sensibility, to screw the tourniquet very tight around the member, so as to compress the nerves; and for this purpose, Graefe even recom- mends a second tourniquet without a pad to be applied above that which is used to command the artery. We can perceive no advantage likely to result from the adoption of this course; but on the con- trary, have sometimes seen almost as much pain induced by the violent con- striction of the instrument, as from the amputation itself. Among other acts of preparation, the mind must not be neglected. Much ofthe success of an important operation depends upon the fortitude of the individual to en- dure it with confidence and firmness. His resolution should be fortified by soothing encouragement, and every precaution be taken to prevent the energies of his nervous system from sustaining a vio- lent shock from the overpowering influ- ence of fear or apprehension. Doubtless all the vaunted effects of animal magnet- ism, of which we have heard so much within a few years, are to be attributed to the confidence inspired by it in the mind of the patient. In the present state of our knowledge at least, the full latitude of our credulity will not admit of our allowing it any other influence. The most favourable period for the per- formance of this, as well as other opera- tions, is in the morning. But there is no period of the twenty-four hours, and no season of the year, at which it may not be safely resorted to. The surgeon, in the se- lection of the time, must be governed by the circumstances of the case : and when these are urgent, he should act promptly, and without delay. If, however, the con- dition of the patient be such as not to ren- der it important that the operation should be immediately performed, it will always be better to defer it, when the system is labouring under any inordinate nervous or vascular excitement, and if a female, especially during the period of the men- strual flux. 5 7. Apparatus and Instruments neces- sary in Amputation. The apparatus and instruments necessary in the amputation of the members are variable, according to 34* the kind of operation adopted, and the point at which it is performed. It will be proper, however, to enumerate all that will be requisite in the execution of the operation upon any part of the body. There should be two good tourniquets, the straps and buckles of which have been previously tested, to determine their strength. Or, in cases of emergency, where this instrument is not at hand, a strong bandage, or a silk handkerchief, may be tied round the member, and ren- dered sufficiently tight by inserting be- neath it the end of a stick, the hilt of a sword, or any convenient thing which may be at hand, with two or three turns of which the band may be twisted until it is rendered tight enough to command the circulation. For the same purpose, there sliould be provided a key, or boot-hook, with the end wrapped with lint or old lin- en, for the purpose of compressing the ar- tery. Knives of different configurations and dimensions are employed, according to the kind of operation that is to be per- formed. They should always be of a length proportionate to the volume of the mem- ber. They were formerly made large, and of a falciform shape, that they might di- vide the greatest possible quantity of the soft parts by a single stroke. Louis first pointed out the imperfections of the curved instruments, and since his time they have been mostly abandoned. At the present time they are made entirely, or almost, straight upon the edge, and generally ter- minated by a point moderately sharp, or by one somewhat obtuse, and rounded or con- vex upon the edge, so that it may be em- ployed in dissecting back the integuments. Those employed by most of the English surgeons have the blade broad and mode- rately thick, and the back gradually round- ed off towards the point; while the French, and especially Lisfranc, have them made light narrow, and sharp at the point. Those which are employed in the flap ope- ration should be long enough to pass with facility through the most fleshy part of the member, and to allow room for the free play of the instrument,—should be narrow, and sharp on both edges, and terminated by a point ground dagger-fashion. Those for the hip joint should be about 12 inches long, and three-fourths of an inch broad near the handle. For the shoulder, the in- strument need not be more than 8 inches in length. A catlin of smaller dimensions will be more convenient for the amputa- tion of the arm, fore-arm, elbow, wrist carpus, tarsus, &c, the size being always regulated by the dimensions of the part 402 AMPUTATION. For the amputation between the bones of of sufficient dimensions to prevent the the tarsus, and in the carpo-metacarpal ar- pinching of the instrument, which is al- ticulations, Lisfranc employs a very nar- ways embarrassing, and sometimes causes row catlin, because such an instrument the bone to be splintered before it is divid- can be more readily accommodated to the ed. Guthrie has recommended one range different manoeuvres of the operation. For of the teeth of the saw to be directed ob- the amputation by the circular incision, the liquely forward, and the other backwards, late Professor Smith, of Yale College, em- so that the instrument may act as well dur- ployed a knife somewhat shorter than that ing its retreat as its propulsion—There can in common use, but almost uniformly con- be no advantage in this method of construc- vex on the edge from heel to point, con- tion. In former times, most surgeons em- cave on the back, and terminated by an ployed a kind of bow saw, constructed up- obtuse bevel at the extremity. Gratfe's on the same principles as the instrument knife is narrow at the heft, and broad at the still used for the amputation of the meta- other end. The edge from the handle to carpal and other small bones, and the same within a small distance of the other ex- kind of saw is still preferred by some very tremity is very slightly concave, but from able operators of the continent; but it is thence out presents a strong convexity. The less steady, and far inferior to the common back is thick, rounded off, and perfectly amputating saw. straight, and the end of the instrument is The best retractors are made of kid skin, truncated at a right angle with the back; or chamois leather, but when this is not at this truncated extremity as it approaches hand, coarse muslin will answer very well. the edge gradually terminating in its sharp For the thigh, a piece 8 inches wide, and convex portion. The object proposed by 14 inches long, should be divided length- Gr^efe, in giving his knife this peculiar wise, from one end to the middle, and the configuration, is, that in the act of making end of the slit should be rounded out so as the oblique circular incision, the surgeon to adapt it to the contour of the bone. Holes may rest the thumb and index finger of his are sometimes cut in the ends, or rings are left hand upon the back near its extremity, attached, to receive the fingers of the as- and thus have a better command of it sistant, but these can be very well dispens- There should also be one or more large ed with. For the leg or fore-arm, the re- convex scalpels, sharp-pointed bistouries, tractor must be divided into three tails, one a retractory of soft leather or strong cloth, of which must be passed through the in- with two or three tails, according to cir- terosseous space. Neither here nor on the cumstances; a good amputating saw with arm will it be necessary to have it so large an extra blade, a metacarpal saw, bone for- as for the thigh, but merely wide enough ceps, one or more tenaculums, a pair of ar- to cover the face of the divided soft parts, tery forceps with a slide or spring, and se- and protect them from the saw. veral crooked needles armed with ligatures. Artery forceps are generally constructed In dressing the stump it will be necessary with a slide, by which they can be fixed to have a sufficient supply of silk or am- upon the extremity of the vessel; but the mal ligatures, of different sizes, and pro- best are the spring forceps recommended perly waxed; adhesive plaster spread and by Professor N. R. Smith. The instru- cut into strips; lint made into pledgets and ment has a spring projecting from the in- spread with cerate; compresses; a roller side ofone of the blades, and passing through bandage of coarse muslin three inches wide, a hole in the other. On this spring there and three or four yards in length; sponges, is a catch, which, when the blades are firm- and warm and cold water; wine and wa- ly compressed, takes hold of the blade, ter; bottles filled with hot water, or a which it pierces, and keeps the instrument chafing-dish with burning charcoal to warm closed.—(N. R. Smith, Surgical Anatomy the adhesive plasters; towels, &c. &c. ofthe Arteries, 4to. p. 17. Bait. 1832.) We employ a saw about three inches All these implements should be arranged longer than that in common use, the handle upon a table or a tray, in the order in which of which is so attached as to form an obtuse they will be required, and placed in a sitti- angle with the blade. In consequence of ation where they can be conveniently hand- this arrangement, much more force is ed to the surgeon. They should be cover- thrown upon the teeth of the instrument ed with a towel or cloth until the operation at each propulsive effort, than when the is commenced. handle is placed on the same line with the The patient is generally placed on a ta- blade, and it cuts through the bone in nearly ble covered with a mattress or several fold- one half the time. The teeth should al- ed blanket?, and with his head and shoul- ways be widely set, so as to form a furrow ders elevated. When, however, the ope- AMPUTATION. 403 ration is to be performed at the shoulder joint upon any part of the arm, the hand or foot the sitting posture will be either necessary, or may be adopted from choice. In the larger amputations, several assis- tants will be requisite, and none should be selected for so important an office but such as have sufficient firmness and address to entitle them to full confidence. Each one has his particular duties to perform, and they should all be so disposed as not to em- barrass each other, or be in the way of the operator. One manages the circulation, either by the tourniquet or other means; a second grasps the member above the point at which it is to be taken off, ready to draw up the integuments, turn back the flaps, or apply the retractor; a third supports the member below, and holds it steady; a fourth hands the instruments as they are required, while others support the patient, and be- stow upon him whatever attentions may be called for in the course of the operation. It must not be inferred from what has been said, that all these implements and at- tentions will be requisite in performing the operation of amputation. We have detail- ed what ought to be at hand under favour- able circumstances. But in cases of emer- gency, on the field of battle, in a naval en- gagement at sea, &c. many of these pre- parations must be dispensed with, and the apparatus simplified. This a skilful sur- geon will always know how to do. Suc- cessful amputations have often been per- formed with a few simple implements. With a silk handkerchief twisted round the limb to command the hemorrhage, a scalpel, pocket-knife, or razor, to divide the soft parts; a common saw to cut through the bone, and a few ligatures, any of the members may be amputated, if not with as much dexterity and ease to the patient, with nearly as good a prospect of success, as with the most complex apparatus. § 8. Means of commanding the hemor- rhage during the operation. The ancient surgeons, awed by the dread of hemor- rhage, and ignorant of the proper means of commanding it, generally contented them- selves with either amputating through the dead parts, or dividing the structures with a red-hot knife, and afterwards applying the actual cautery. But although this prac- tice was generally adopted, there are rea- sons for supposing that the ligature may have been employed in amputation by some of the ancient surgeons, as it was certainly recommended in other opera- tions by Celsus, Archigenes, and others. Circular compression was also employed by some of them, and it was upon this principle that the garter or field tour- niquet afterwards invented by Morel, was founded. This, as we have already explained, consists merely of a band tied round the member, and afterwards render- ed sufficiently tight to compress the artery by inserting the end of a small stick be- neath the band, and twisting it To render the compression more effectual, a large compress was generally fixed over the course of the artery, and to prevent the skin from being folded and pinched, a roller bandage, or folded compress, was fixed round the member, with a piece of concave horn or w7ood beneath the portion of the garter or band which was to be twisted.— This arrangement will be found very con- venient, in cases of emergency, when the common screw tourniquet invented by J. L. Petit, is not at hand. The last named in- strument, however,deserves the preference when it can be obtained, inasmuch as when once properly adjusted, it does not require so much attention from the assistant, and can always be rendered tighter or slacker merely by turning the screw. In adjusting it, the pad or cushion should be placed im- mediately over the artery, and the instru- ment itself so arranged in relation to the strap as to be fixed and screwed directly upon the pad. It is particularly important to have the buckle of the strap sufficiently removed from the frame of the instrument to prevent it from being arrested by it in turning the screw, otherwise serious em- barrassment might occur in the course of the operation. Some surgeons make a few turns of a roller round the limb before the torniquet is applied, to prevent the skin from being pinched by the strap, and this will be found a useful precaution. Although the tourniquet of Petit, im- proved and variously modified, is generally employed by modern surgeons, and is, un- der all circumstances where it is applica- ble, the safest means of commanding the hemorrhage during the operation, it cannot be applied in amputation at the hip and shoulder joints, or in the immediate vicinity of those articulations, and is liable to seri- ous objections even under the circumstan- ces to which it is applicable. The act of tightening the strap is always attended with great pain, by folding and pinching the skin, and violently constricting the deeper-seated parts. The application ofthe constriction to the whole circumference of the limb prevents the return of the ve- nous blood from the member, and conse- quently as soon as the first incision is made, a profuse gush of that fluid takes place, which, in debilitated subjects, it is often 404 AMPUTATION. important to preserve. This can be gene- rally prevented by applying pressure im- mediately upon the course of the artery, while the circumference of the limb is left free. And finally, it so constricts the mus- cles, that they cannot retract when divid- ed, and the consequence is, that so soon as the instrument is removed, they do so in an unequal degree, and render the face of the stump irregular and uneven.—These con- siderations have induced many distinguish- ed surgeons to abandon the tourniquet, and rely upon the simple compression of the artery either with the thumb or fingers of an assistant or the extremity of a common key or boot-hook, wrapped with old linen or soft cloth. This plan is now very gene- rally adopted by the French and German surgeons, and we always prefer it when we have an assistant in whom we can repose full confidence. The tourniquet, it must be confessed, is safer, and for that reason should be adopted where a proper assistant is not at hand. But in amputating at the shoulder or hip, there is not room for the application of this instrument, and we are consequently com- pelled to rely upon compression. The in- strument invented by Dahl for the com- pression of the axillary artery has been found inconvenient, and has in modern times given place to the compression of the subclavian where it crosses the first rib, be- hind the scalenus anticus muscle, or below the clavicle. The object is easier accom- plished at the first point, because there the vessel is superficially situated, and the rib furnishes a solid point of support. To fa- cilitate this end, the shoulder should be de- pressed, and the head of the patient inclin- ed towards the opposite side. If it be on the left side, the assistant, standing in front, fixes the palm or face of the extremity of the thumb immediately above and behind the clavicle, and on the outer side of the posterior border of the sternc-mastoideus muscle, and directs the pressure obliquely downwards, backwards, and slightly in- wards towards the upper surface of the first rib. When the artery of the right side is to be compressed, he may either stand be- fore or behind the patient, (Langenbeck.) The artery may also be compressed below the clavicle, by having the shoulder ele- vated ; but it cannot be so safely accom- plished here as above. The best method of doing it is, to feel for the coracoid pro- cess, and apply the pressure immediately upon its inner side, between the pectoralis major and the deltoid muscles (Langen- beck). The brachial artery can be easily compressed where it courses along the inner margin of the caraco-brachialis and biceps muscles, at any point between the head of the humerus and the vicinity of the joint, the bone throughout all this distance fur- nishing a solid point of resistance.—The crural artery is superficially situated where it escapes from the abdomen, behind Pou- part's ligament, and in front of the hori- zontal ramus of the pubis. It is at this point situated about midway between the spine ofthe ileum and the symphisis pubis, and may be easily compressed against the horizontal branch of the latter bone. J 9. Amputation by the circular inci- sion. This is by far the most ancient me- thod of performing the operation of am- putation. It was recommended by Cel- sus and all the writers of antiquity, and is even at the present time more frequently employed tiian any other. It has, how- ever, been submitted to a diversity of modifications, some of which it will be proper to mention. Celsus, and most of the ancients, divided the integuments and muscles by a single incision carried down to the bone,—a practice afterwards adopted by Gersdorf, Tiieodoric, Wiseman, and in more modern times, by Mursinna, Rust, Dupuytren, Kluge, and others. During the accomplishment of this act, an assistant is required to grasp the circumference of the member with both hands, and draw the soft parts forcibly upwards, while they are divided, so as to secure a sufficient cover- ing for the stump. A much more usual method, however, is by what is called the double circular incision, first proposed by Maggi, and brought into notice by Petit and Cheseldex. They divided the inte- guments by the first incision, while an as- sistant retracted them as much as possible, and then by a second incision, commencing on a level with the edge of the retracted integuments, they divided the muscles down to the bone. By this procedure, they were enabled to preserve sufficient^integu- ments to invest the face of the stump, which in the method just described was al- so covered by the muscles. The operation may be very well performed in this man- ner where the diameter of the limb is not considerable, or the consolidation of the cellular tissue has not firmly united the skin with the subjacent muscles. But where the member is very large, or the skin is immovable, it will be difficult to preserve sufficient integuments. To obviate these difficulties, it is cus- tomary, after making the first incision in the manner prescribed, to dissect up the integuments from the muscles, and turn them back like the cuff of a coat, and AMPUTATION. 405 then to divide the muscles on a level with the reversed integuments. There is, how- ever, considerable difference of opinion re- lative to the quantity of integuments that should be saved, and the depth of the first incision. There is also some diversity of sentiment relative to the advantage of making the first cut by a full circular in- cision carried entirely round the member by a single sweep of the knife, or by two half circular incisions, one on the inner, the other on the outer side ofthe member, terminating in each other. The first is de- cidedly preferable, as it can be more expe- ditiously executed than the second. It is re- commended by Mursinna, Kluge, Graefe, Zang, Dupuytren, and most ofthe French surgeons. The operation by two half cir- cular incisions, however, is preferred by Langenbeck, Rust, and many of the sur- geons of Great Britain and America. Rust makes the first half circular incision upon the under-part of the member, and then bringing the knife in front, carries the second from the internal extremity of the first, across the anterior part of the limb, to the point at which it terminated. Langen- beck, on the contrary, makes the anterior incision first. As regards the quantity of skin to be saved, it must be determined by the diame- ter of the limb. J. L. Petit made the in- cision through the skin only an inch below the point at which the bone was to be saw- ed ; but this method would not, where the member is large, secure sufficient integu- ments to cover the face of the stump. A much better precept is that recommended by Schreger, Hey, Brunninghausen, Lassus, and others; to make the extent of the detached or retracted integuments equal to one half the diameter of the member, according to Rust, one third, or one sixth its circumference. Thus, should the thick- ness of the limb be four inches, two inches of skin should be saved. In all cases, nevertheless, care must be taken not to dissect the integuments from the fascia or muscles farther than necessary, since if this precaution be neglected, the stump will be more apt to slough. Hey, Roux, and Syme, have strongly insisted upon the ob- servance of this precept. The first merely directed the integuments to the extent of half an inch on the back part of the limb, in amputating the thigh, and three quar- ters of an inch in front. The second con- tents himself with dividing a few of the filamentous bands ofthe cellular tissue, and when this will not allow a sufficient retrac- tion of the integuments, divides a few of the superficial muscles in the manner prac- tised by Louis. By many surgeons the depth of the fir6t incision is not deemed a matter of much importance. Some, however, have pre- scribed particular rules in relation to it.— Gr^fe, Hennen, Guthrie, and Hutchin- son, recommend that the incision should be carried through the fascia so as to divide the superficial fibres of the muscles, with the view of facilitating the retraction of the integuments, and thus doing away with the necessity for much dissection. Hey, Brunninghausen, Langenbeck, Roux, and others, merely divide the integuments and leave the fascia entire. The reason alle- ged for this practice by Langenbeck is, that the aponeurosis serves to bind the muscles together, so as to prevent them from re- tracting irregularly where they are divided. We do not consider it a matter of much consequence whether the fascia be divided or not, provided the incision is fairly carri- ed through the skin all round the member, and to insure this latter result it will cer- tainly be less painful, as correctly remark- ed by GRiEFE, to divide the fascia and su- perficial fibres of the muscles, than to be obliged to make several cuts to complete the division of the skin. An assistant should grasp the member firmly with both hands a little above the point at which it is to be amputated, and draw them forcibly upwards. The surgeon may be placed on the outer or inner side, according to circumstances. With a large amputating knife grasped in his right hand, the edge of the instrument towards him, he carries it beneath the member, and bringing it over its anterior external part, if he is standing on the inner side, and vice versa, he inserts the edge near its heel, and cutting from thence towards the point, carries it round with a steady sweep, so as to terminate the incision at the point at which it was commenced. During the ex- ecution of the first part of this act, the hand is placed in a strong state of pronation, and the operator, with his right foot in advance, throws himself forward by flexing the knee: but towards its termination, he gradually approximates more to the erect posture, and brings his hand to a state of supina- tion.—The incision should always be made perpendicular to the skin, and never ob- liquely, as recommended by Mynors. It has been correctly remarked by Graefe, that when the integuments are thus bevel- led off, they cannot be so neatly approxi- mated, and therefore do not heal so rea- dily as under other circumstances. After 406 AMPUTATION. the incision has been thus carried round the member, the assistant should still re- tract the integuments, while the surgeon, either with the point of his knife, or with a common scalpel, cuts through the dis- tended bands of filamentous cellular tis- sue, and secures that degree of retraction which may be necessary for the preserva- tion of a proper covering. It is neither necessary nor proper to thrust the knife deep between the muscles and the tegu- mentary coverings, as is too frequently practised, inasmuch as the simple traction of the parts, while the filamentary bands are cut asunder, will secure the de- sired object, without the infliction of so much injury. Nor do we think it advisa- ble to revert the skin, as is done by many surgeons, inasmuch as the muscles may be divided high enough without thus con- tusing and injuring the soft parts. The division of the muscles, or the sec- ond incision, is variously executed by dif- ferent surgeons. Most of these variations may, nevertheless, be reduced to three heads: 1, the division of the whole of the muscles by a perpendicular incision made on a line with the edge of the retracted integuments, and carried down to the bone; 2, the section of the superficial stratum of muscles first, and after they have been retracted, the division of the deep-seated above the line of the first in- cision; and 3, the section of the whole muscles by a single sweep of the knife, its edge, while it is conducted round the limb, being directed obliquely upwards, so as to make the face of the stump resemble a hollow cone. The first of these methods was original- ly recommended by Celsus, and is perhaps more generally practised than any other. He however directed, that after the mus- cles were divided, they should be detach- ed, a small distance, from the bone, so as to admit of its being sawed higher up than the line of the incision, (lib. VII. cap. 33.). This method of operating was adopted by B. Bell, but most modern surgeons have not deemed it necessary to dissect the muscles from the bone. Louis and Le Dran recommended and practised the second method. But instead of limiting the first incision to the integu- ments, they achieved the division of the latter with the superficial stratum of muscles, by a single sweep of the knife, and after they were forcibly retracted, the deep-seated muscles were incised down to the bone, by a second cut. The object proposed by Louis in the adoption of this procedure, was, the prevention of the sugar-loaf or conical stump, which he con- ceived to be produced by the muscles re- tracting to a greater extent than the skin, and thus leaving an inadequate quantity of soft parts to furnish a full and rotund bolster of flesh around the bone. With the same view, Desault divided and dis- sected up the integuments in the usual manner, and then incised the muscles by two acts, as recommended by Louis. Botii these plans of operating have been adopted by some modern surgeons, and that of De- sault, with the modification of making the incisions through the muscles with the edge of the knife directed obliquely up- wards, is more generally practised than any other modification of amputation by the circular incision. Valentin, acting upon the supposition that important advantages would be se- cured by having all the muscles in a full state of relaxation when divided, proposed that the position of the member should be changed during the section of each set of muscles. When he wished to divide the muscles situated upon the inner part of the thigh, he had the limb carried inwards, and vice versa, during the division of the external. He also flexed the leg during the incision of the flexors, and extended it while the knife was carried through the extensors. A similar rule of practice was recommended by Portal; but Mursinna has advised a course directly the reverse. He recommends, during the division ofthe extensor muscles of the thigh, to have the leg forcibly flexed, and extended, while the flexors are divided. No advantage, however, can result from thus complicating an operation which is exceedingly simple; and decidedly the best general rule, what- ever method of amputation be adopted, is that recommended by Rust,—to place the limb in a slightly flexed position, so as to have all the muscles as nearly as possible in the same state of extension. The third method of dividing the mus- cles, consists in carrying the edge of the knife obliquely upwards, while it is made to sweep round the limb. This procedure was originally recommended by Alanson, whose plan of executing it was, however, so difficult, that few have ever attempted it, and many have even declared it to be im- practicable. The integuments being firmly grasped and drawn upwards by an assistant, he divided and dissected them from the fascia in the usual manner, and then stand- ing on the outer side ofthe member, he ap- plied the edge of his knife under the edge of the supported integuments, upon the inner edge of the vastus internus muscle, and cut AMPUTATION. 407 obliquely through that and the adjacent mus- cles, upwards as to the limb, and down to the bone, so as to lay it bare, about three or four finger-breadths higher than is usu- ally done by the common perpendicular circular incision. He now drew the knife towards himself; then keeping its point upon the bone, and the edge in the same oblique line already pointed out for the former incision, he divided the rest of the muscles in that direction all round the limb; the point of the knife being in con- tact with, and revolving round the bone, through the whole of the division. (Coop- er's Surg. Did. Art. Amput.) Loder advocated the operation of Alan- son, with some modifications; and with still more important changes, its principles have been adopted by a majority of modern surgeons. It forms the basis of the opera- tion of Graefe and Dupuytren, and, in- deed, of nearly all those which are prac- tised at the present day,—the object of all of them being to divide the soft parts so as to obtain a conical excavation, whether this be accomplished by the oblique inci- sion of Alanson, Graefe, Dupuytren, &c, the separate division ofthe superficial and deep muscles, as practised by Louis and Le Dran, or the triple circular incision, while the parts are forcibly retracted, as recommended by Desault and Hey. With the view of increasing the depth of this excavation, we have already stated that Celsus detached the deep-seated muscles from the bone, to a small extent. The same plan was adopted by B. Bell. Gooch extended this dissection to the extent of an inch above the line of the incision of the muscles, and Guthrie as far as three or four inches above that point. The same practice has been commended by Helix), Davidge, and others, and Velpeau states that by adopting it the muscles can be more neatly adjusted over the end of the bone. We are not sensible of any advan- tages it is capable of affording, and, as we have already stated, there is no necessity for its adoption. After all, these diversified modifica- tions are of much less importance than might be inferred from the numerous dis- quisitions to which they have given origin. The operation may be very well performed by either of the plans which have been mentioned, but the following will perhaps be found the most convenient and expeditious method of securing all the objects proposed. The patient being conveniently placed and everything properly disposed, the ope- rator, by a single circular sweep carried steadily round the limb, divides the integu- ments fairly down to the muscles. The assistant still drawing these upwards, he next, with a few strokes with the point of the knife, or a common scalpel, divides the connecting bands of cellular tissue, until a sufficiency of skin is saved to cover the face of the stump. The extent of this dissection should of course be regulated by the diameter of the limb. In the thigh three or four inches will be required, but in the leg, arm, &c., a smaller quantity will suffice. The integuments, as we have already suggested, need not be reversed, as no advantage can accrue from that pro- cedure. Inserting his knife a second time, on a line with the margin of the retracted parts, and with the edge directed obliquely upwards, the assistant still grasping the member with both hands, and retracting the structures, he makes a second circular cut through the muscles down to the bone, or at least so deep as to allow the more superficial to be drawn upwards. A third cut is next made in the same manner, in- serting the edge of the knife, held, as be- fore described, upon the base of the small cone formed by those muscles which are deepest seated, which is to be carried fairly down to the bone all round its circumfer- ence. By adopting this plan, the divided integuments and muscles will form a regu- lar hollow cone, the centre or apex of which will correspond to the bone at the point at which it is to be divided by the saw. Where the member contains two bones, as in the leg and arm, besides the precautions already designated, the point ofthe knife should be made to glide in the interspace of the bones, while it is describ- ing the circular evolution, as advised by Lisfranc ; or if the operator is not expert, the structures which are situated between the bones may be divided with a common catlin, after the completion of the circu- lar incision. Sawing the bone is a part of the opera- tion of amputation to which some of the ancient surgeons attached much import- ance ; and even some of the moderns, in- fluenced by the apprehension of tetanus, exfoliation, &c, from the injury of the periosteum, have advised great precaution in the division of that membrane, and its detachment from the bone, so as to have it entirely out of the reach of the teeth of the saw. To obviate these difficulties, Wiseman, and many of his successors, carefully scraped the bone, so as to denude it of its periosteum. This practice, how- ever, was justly condemned by Alanson, J. L. Petit, and others, and has in modern times been considered by a majority of the 408 AMPUTATION. best surgeons as highly improper. Guth- rie states that he has often sawed through the bone, without previously touching the periosteum, and the stumps have been as soon healed, and with as little inconveni- ence as any others. {Loc. Cit. p. 278.) It should nevertheless be stated, that Gr^ife, Walther, and Brunninghausen, recom- mend the periosteum to be detached. The first divides that membrane at the point at which the bone is to be sawed, and rakes it downwards so as to be out of the way of the instrument The two last, how- ever, strip it upwards, to the extent of half an inch or more, so that with the muscular fibres which are attached to it a partial covering for the edges of the bone after it is sawed may be preserved, which will serve to protect the surrounding parts, —a precaution they think of great im- portance when the bone presents a sharp angle, as is the case with the tibia. These precautions, however, are altogether use- less. It was long since stated by J. L. Petit and Richter, that when the bone is thus extensively denuded, the saw is apt to be applied upon the middle point be- tween the retracted edges of the perios- teum, and consequently, that the part of tlie denuded bone remaining above the point of division, will be left to exfoliate. All that is necessary is to divide the mem- brane at the point at which the saw is to be applied, so that it may not become en- tangled in the teeth of the instrument Various means of supporting and pro- tecting the soft parts during the act of sawing the bone have been devised, but no one is so good as the common leather or linen retractor already described. It should be somewhat wider than the diam- eter of the limb, and where there is but a single bone, slit in the middle one half its length: where there are two bones, the slit end must have three slips, one of which must be passed through the inter- osseous space. Graefe has advised the application of the undivided extremity of the retractor over the anterior part of the divided soft parts, and the two divisions to be crossed behind, and so adjusted as to protect the posterior soft parts of the mem- ber. Velpeau, however, thinks that it will be more advantageous to apply the undi- vided portion of the bandage posteriorly. We have never observed that it was a matter of any consequence in what man- ner the retractor was applied, provided the termination of the slit was made to embrace the bone accurately, and the two extremities were equally drawn. If the bandage should be allowed to fold upon the bone, or the parts be unequally re- tracted, it is apt to catch the teeth of the saw, and embarrass the operator. The soft parts and the periosteum being divided, and the retractor applied, the ope- rator fixes the thumb-nail of his left hand upon the bone at the point at which it is to be divided, to guide the saw, the heel of which he fixes upon the bone, and then making a slight pressure on the instru- ment, he draws it slowly and steadily to- wards him from heel to point, so as to form a superficial groove, the depth of which is increased by two or three light and steady alternate sweeps backwards and forwards. Having thus established a channel of suf- ficient depth to prevent the saw from slip- ping, he may conduct his strokes with greater rapidity and force, always making them long and free, and taking care, when the bone is nearly divided, to saw slower, so that it may not be splintered. The assistant, who supports the limb, should also be particular, during this step of the operation, not to allow any flexure which can pinch the saw, or fracture the bone. When there are two bones to be sawed, as in the leg and arm, the saw should be first made to play upon one of them until it forms for itself a groove, after which, by depressing or elevating the handle, it should be brought to bear upon both. The smaller of the two, however, must be cut through first Should any spiculas re- main after the section of the hone, they must be removed by the bone-nippers or a scalpel. Some surgeons, indeed, have advised that the sharp edge of the bone should always be rounded off, to prevent it from injuring the soft parts when they are brought down over it. §10. Amputation with a single or dou- ble flap. In the method of amputating by the circular incision, the covering for the face of the stump is either derived from the integuments, or from them and the su- perficial muscles. These coverings are taken equally from the whole contour of the member. In the flap operation, on the contrary, one or more flaps are formed, composed of the muscles and integuments, which, when laid down and adjusted, serve to cover the stump. It has been generally supposed that this method of amputating was first proposed by an English surgeon named Lowdham, who described it in a letter written to Young, which was published in 1679, in the Currus triumphalis e terebintho of the latter individual. According to Spren- gel, however, the flap operation was de- scribed by Celsus, Maggi, Leonidus, He- AMPUTATION. 409 liodorus, Pare, Hildanus, and many others, who wrote long before the time of Lowdham and Young. But notwithstand- ing that it was recommended by these au- thors, it did not attract much attention until revived and modified by Verduin of Amsterdam, and Sabourin of Geneva, the former of whom insisted upon its advan- tages over the circular method when em- ployed for the amputation of the leg. Though strongly opposed by many con- temporary surgeons, it soon gained many advocates, and was afterwards espoused by Morand, La Fa ye, Garengeot, Le Dran, Vermale, Ravaton, Quesnay, O'Hal- loran, and others. Ravaton and Ver- male applied it to the amputation of the thigh, which they practised by making two flaps. In more modern times, the flap operation, variously modified, has been es- poused by Desault, Larrey, White, Hey, Loffler, Langenbeck, Klein, Beck, Textor, Kern, Koch, Rust, Grossheim, Guthrie, Dupuytren, Lisfranc, Roux, Syme, Velpeau, Blandin, &c. The operation may be performed with either a single or with two or more flaps. The first method was adopted by Lowd- ham, Verduin, and Sabourin, in the am- putation of the leg, and has been applied by various modern surgeons to the ampu- tation of the shoulder, arm and fore-arm, elbow, wrist carpal and metacarpal bones, the fingers and toes, the tarsus and meta- tarsus, and the knees. The cases to which it is applicable, or in which it has been re- commended, will be designated in connex- ion with the particular operations. The method with two flaps is more extensively applicable, and is more gene- rally preferred. It has been differently ex- ecuted, according to the object proposed, or the predilection of the surgeon. All flap operations, however, are performed either by cutting from without inwards, or by plunging the knife through the thick part of the member, and bringing it out so as to form a flap of the proper dimensions. The first of these methods, though some- what more tedious than the second, is pre- ferred by many operators, because of the greater facility afforded by it in regulating the form and dimensions of the flaps. The other procedure, however, is infinitely more prompt and consequently less painful to the patient. The operation of cutting from without inwards may be performed so as either to make the flaps of the integuments alone, or of them and the muscles together. Ktrkland practised the former of these methods. He made an oblique incision vol. i. 35 through the integuments, first on the pos- terior, and then on the anterior face ofthe member, so as to form two semi-elliptical flaps. These incisions were directed with a regular curve, with its convexity in- clined downwards, and described the out- line of the flaps. They were commenced upon the centre of the inner or outer part of the member, and terminated at the op- posite point, after having been carried, the first obliquely behind, the second in front The tegumentary flaps thus formed were then dissected up, and turned back to the extent of half the diameter of the mem- ber, and the whole integuments being re- tracted, the muscles were divided by a cir- cular incision down to the bone. By adopt- ing this plan, an angular portion of integu- ments is removed from the internal and external portions ofthe flaps, so that when the latter are brought down upon the an- terior and posterior portions of the stump, their edges are neatly approximated in a transverse direction, and the folding or puckering ofthe integuments which takes place at the angles of the wound in the circular operation is prevented. The late Professor Davidge, ofthe Uni- versity of Maryland, improved the opera- tion of Kirkland by incorporating with it the principles of the method of B. Bell. Instead of forming the two semi-elliptical flaps upon the posterior and anterior part of the member, as recommended by Kirk- land, he made one external and the other internal, so that when approximated, the seam formed by their union extended from before backwards. He formed the two flaps by first making two lateral cuts with the large knife, mutually approaching above and below, to each other, to within two inches; and then, with an ordinary scalpel, bringing them into union in the centre of the thigh, before and behind, gradually ascending to about an inch and a half above the level of the first two lat- eral cuts. A better method is that prac- tised by Dr. Thomas Wright, who forms the flaps by a dexterous sweep ofthe scal- pel, first on the one side, and then on the other. (Davidge's Physical Essays. II. 95. Baltimore, 1814.) The operation is more frequently prac- tised without dissecting the integuments from the muscles, they being merely di- vided by the first incision and retracted; which done, a second incision is made upon a line with their margin, through the muscles, and down to the bone. This pro- cedure should always be preferred when the parts are incised from without inwards, inasmuch as a better tegumentary covering 410 AMPUTATION. will be thus preserved, than when the skin, cellular tissue, and muscles, are all divided by a single sweep of the knife. It has been objected to it, that the operation is by the two incisions unnecessarily pro- tracted, and the patient is consequently submitted to more pain than where only a single incision is made. These objections, however, are without much weight when the advantages secured are considered, and if we allow them to be valid, the best means of obviating them will be to transfix the member by the side of the bone, and divide the structures from the centre towards the circumference,—a plan, which, though condemned by many surgeons, has been adopted by a great number of others, and which we have always found more prompt and convenient than that just described. The method of forming the flaps by extending an incision obliquely from the surface to the bone, is preferred by Pott, Loffler, Langenbeck, Dorsey, Guthrie, Beclard, Dupuytren, N. R. Smith, and others. Chelius forms the first flap in this manner, and then transfix- ing the member on the other side of the bone, by introducing the knife at the angle of the first incision, he forms the second flap by cutting from within outwards. Ravaton, Le Dran, and B. Bell, divide the integuments and muscles by a circular incision, and then make a longitudinal cut upon the external and internal part of the member, the inferior extremities of which fall upon the circular incision. A similar method is recommended by Schreiner. Nearly all others, who prefer the flap amputation, execute the operation by thrusting a long narrow catlin through the member, first on one, and then on the other side of the bone, and cutting from thence towards the circumference. After the flaps are formed and held back, the muscles which adhere to the bone are divided by a circular incision. As a general rule, the length of each flap, where two are formed, should be a little more than one half the diameter of the member, and it is advised by most sur- geons to make both as near as possible of the same shape and dimensions. Guthrie, however, in amputating the thigh, makes the inner larger than the outer flap; but we are not sensible of any advantage that can be secured by such a procedure. Most generally one flap is formed upon the inner and the other upon the outer part of the member, but this step ofthe operation must often be determined by the condition of the soft parts, the member, or part of the member upon which the amputation has to be practised, and other circumstances which wdl be pointed out under the indi- vidual operations. Le Dran, Siebold, Zang, and others, have recommended that the flap containing the large vessels should be formed last; while Desault, and Rust, in the thigh especially, have advised the inner flap to be formed first, so that the soft parts situated on the outer side of the thigh may be drawn sufficiently outwards to admit ofthe second being made as large as the first The different modifications necessary to be observed in forming the flaps, and the principal methods of executing the flap operations, so as to adapt them to particu- lar cases, will be described under the indi- vidual amputations, and need not be detail- ed here. The question of the comparative advan- tages of amputation by the circular incision and the flaps, has given rise to much dis- cussion, and can only be decided by exa- mining their relation to particular cases. The flap operation, though strenuously advocated by many able surgeons since the time of Lowdham, has not been much employed until within the last thirty years. At the present time it is preferred by most of the surgeons of the continent of Europe; but although the authority of Liston, and Syme, has contributed to bring it into favor in Great Britain, the circular incision is still most frequently employed there, and in America. We are inclined, both from reason and personal experience, to prefer the flap operation in a large majority of cases, and we are pleased to observe, that in proportion as ancient prejudices are overcome, the members of the profession are every day becoming more sensible of its advantages. It has been urged against amputation with the flaps, that it exposes a greater extent of surface than the circular incision; that the muscles are divided unequally; that the operation is more painful than by the circular incision; that greater diffi- culty is experienced in securing the bleed- ing vessels, in consequence of their being divided obliquely; and, finally, that the flaps are apt to slough, because of the extent of muscular substance involved. These objections have induced many to give the preference to the circular incision, taking it for granted that they were well founded. Reiterated experience has de- monstrated that most of them are altogether imaginary. As regards the first objection, it must be apparent to every one who is conversant with the subject, that, as in the operation by the circular incision sufficient AMPUTATION. 411 soft parts must be turned up to cover the face of the stump, and no more is done in the flap operation, there can be no great difference in the extent of surface exposed. Nor can we see that the muscles are more unequally divided: in the one case they are cut obliquely, and in the other in a direction nearly perpendicular to their axis, and as the divided surfaces from each side have to be brought in contact, the obliquity ofthe incision in the flap operation will be decidedly more advantageous in favouring an accurate apposition of the parts. If pain be insisted on as an objection, it will apply in a greater degree to the circular incision. The pain of all operations is in an inverse ratio with their quickness. That the circular operation is tedious, every one will allow who reflects upon the mul- tiplicity of its steps. First, there is the cautious circular incision of the skin; the change of knife; the dissection of the skin; its turning back; the change of knife; the adjustment of the assistant's fingers, that they may not be cut off by the relentless sweep which divides the muscles; the change of knife; the separa- tion of the muscles from the bone; the division ofthe periosteum; the application of the retractors, and, lastly, the sawing ofthe bone. (Syme, Edinb. Med. <$> Surg. Journ. XXI. p. 29. 1824). If these facts be considered, it must be admitted that the flap operation, as it can be more promptly executed, is by far the least painful of the two. We have not experienced any diffi- culty in securing the vessels in conse- quence of the obliquity of their division, nor do we believe that others have been less fortunate. The sloughing we main- tain will be more apt to follow the opera- tion by the circular incision, than where flaps are formed; because in the former case, all the delicate vascular connexions which exist between the integuments and muscles being cut up, it necessarily follows that their vitalism must be more impaired, than when they are left entire, and conse- quently they will be more liable to slough. But while we insist on the advantages of the flap amputation, we would not be considered as recommending its indiscrimi- nate adoption. There are cases in which the circular operation should be preferred, and as both methods will succeed very well, it should be left to the operator to select that which is best adapted to each individual case. j 11. Amputation by the oblique or oval method. The method of amputating by what Scoutetten has denominated the oval incision, was, according to Velpeau, proposed by Chasley, in 1803, or 1804. Langenbeck, who has been its most zeal- ous advocate, recommended it in 1809, and since then it has been adopted in particular cases by Beclard, Guthrie, Richerand, Scoutetten, Blandin, Vel- peau, and many others. It has been appli- ed by Guthrie to the amputation at the shoulder joint, and by several others to the removal of the bones of the carpus and tar- sus, to which it is well adapted. Scou- tetten has furnished a critical examina- tion of its advantages, and has proposed to apply it to several cases in preference to the ordinary methods of amputating. The chief peculiarity of the oval method is, that the incision is made from without inwards, and is carried obliquely round the member so as to represent the letter V inverted, the acute angle being directed upwards, and the obtuse portion down- wards. Thus, in amputating at the shoul- der joint by this method, the acute extrem- ity corresponds to the acromian process of the scapula, while the obtuse extremity passes along the axillary face of the arm, the two limbs being situated, one in front, and the other behind the shoulder joint round which the whole incision is carried in an oblique direction. It is sometimes performed by two cuts. By the first the integuments are divided completely round the member, and after they have been retracted, the muscles are divided by a second sweep down to the bone. Some operators, however, accom- plish the division of the whole of the soft parts by the first cut. The former method should be preferred at the shoulder, or wherever the member to be amputated is voluminous. Whichever method be adopted, the upper part of the incision should extend a little above the point at which the bone is to be sawed, and ought, as a general rule, to occupy the part ofthe member upon which the soft parts present the least thickness. The different modifications of this meth- od will be described with the individual amputations, when the cases to which it is more especially applicable will be point- ed out. § 12. Management of the bleeding ves- sels after the removal of the member By whatever method the operation is perform- ed, the first object that claims the atten- tion of the surgeon, after the removal of the member, is the bleeding vessels. It has been already stated that the ancients, though certainly not entirely ignorant of the use of the ligature, relied principally upon cauteries and styptics for the purpose 412 AMPUTATION. of arresting the hemorrhage which suc- ceeds amputation. Since the advantages of the ligature have been determined, these caustics, and styptics, the white agaric, and a variety of means formerly employed, have been entirely abandoned. They cannot be relied upon, and produce much injury when applied to the face of the stump, by destroying or diminishing its capability to unite by the first intention. The same objections hold good against the styptic solutions and powders which have been recently recommended by Binelli, Talrich, Halma-Grand, and Bonafoux. They have been found adequate to arrest the flow of blood in animals, but it is ques- tionable whether they would succeed in man; and even admitting their adequacy, they should not be employed, for the reason assigned above. The same detrimental effects, as regards union by the first inten- tion, are produced by the alum cut into a cone, and introduced into the extremity of the vessel, which has been found success- ful in commanding the flow of blood. The ligature is the most appropriate, and, indeed, the only means that can be securely relied on, for commanding the hemorrhage from large arteries. The ma- terial most generally employed for liga- tures is common sewing-silk, but various other articles have been adopted; as soft leather, cat-gut, the intestines of the silk- worm, French kid, buck-skin, &c. It is stated that strips of leather were employed by Ruysch for securing the artery in ope- rating for aneurism; but to Dr. Physick, to whom American Surgery is so much in- debted, the credit of introducing the use of animal ligatures is unquestionably due. He uses for this purpose, small slips of French kid rolled into the proper shape, which are applied to the vessel in the usual manner, and cut off close to the knot The great advantage of these ligatures is, that being composed of an animal substance which becomes readily dissolved in the discharges of the wound, they are either thrown off with them, or absorbed. From this cause, they excite less irritation than those made of silk, and are consequently more advan- tageous where union by the first intention is desirable. This practice has been much employed by American surgeons, and also by some of the English. Dr. Jameson speaks favourably of buck-skin ligatures; and Norman, Sir A. Cooper, and some other English surgeons, have obtained very satisfactory results from the use of catgut. The animal ligatures were also employed in France, by Beclard. It is proper to state, however, that in some instances where they have been applied to large vessels, they have been dissolved before the obliteration ofthe vessel was obtained, and secondary hemorrhage has ensued. On account of an apprehension of this ac- cident, many surgeons do not employ them, except for vessels of small size, and this is doubtless the safest practice. As regards the size and shape of the silk ligatures, much difference has exist- ed in practice. Before Jones and others insisted upon the necessity of dividing the two inner coats of the artery by the con- striction of the ligature, those of larger size were employed. The English sur- geons generally used several threads of silk, twisted together to make them round, while the French so disposed the threads as to make the ligature flat Scarpa em- ployed small flat bobbin, and interposed between it and the vessel, a small roll of adhesive plaster, to prevent its coats from being injured, and to bring the inner sur- face ofthe walls more accurately in contact. These large ligatures, acting as they do like a foreign substance, generally excite considerable irritation and suppuration, and thereby prevent immediate union. To obviate these effects, it was long since pro- posed to cut off one end close to the knot: a practice which is now very generally adopted. With a view of correcting the evil still more effectually, it was proposed by Veitch, as early as 1806, {Edinb. Med. and Surg. Journ. II.) to tie the bleeding vessels with a single thread of fine silk, and to cut off one end close to the knot. An attempt has indeed been made to carry this practice still farther:—to use a single thread of fine dentist's silk, and to cut away both ends, merely leaving the knot and loop which include the vessel. The first printed account, according to Hennen, {Military Surgery, 2d ed. p. 183. Edinb. 1829.) of the practice of removing both ends of the ligature, was furnished by Launcelot Haire, a surgeon of Essex. It has since been recommended by Hen- nen, Maxwell, Wilson, Watson, Del- pech, Lawrence, and others. The last named gentleman, besides advising the ends of the ligatures to be cut off, com- mends the employment of a single thread of fine dentist's silk. {Med. Chirurg. Transactions, VI.) It must not be concealed, however, that notwithstanding this procedure has fre- quently succeeded very well, the knot of silk has sometimes given rise to the forma- tion of abscesses and troublesome suppu- ration. Cases of this kind have been re- ported by Cross, Downing, and Guthrib; AMPUTATION. 413 and S. Cooper and Collier, although they adopted the plan here recommended with success, did not find it more advan- tageous than the common method. In Ger- many, it has been condemned by Schreger, Walther, Rust, and Grossheim, and at the present time it is not extensively em- ployed in any country. The plan recommended by Veitch, should be adopted for the smaller arteries, while for the principal trunks, a ligature composed of two or more threads may be employed. One end should always be cut close to the knott and when several liga- tures are applied, the remaining ends should be brought out at the nearest angle of the wound; or if one or more of them be placed in the centre of the stump, they may be brought out at the nearest point between the adhesive strips. Roux, who adopts the practice of uniting the stump by the second intention, recommends all the ligatures to be brought out at the lower angle of the wound, because, in that situ- ation, they will form a kind of drain for the escape of the discharges. The plan advised above will be much less objection- able, as creating fewer obstacles to the healing of the stump. To draw out the extremity ofthe bleed- ing vessel for the purpose of tying it, some surgeons prefer the tenaculum of Brom- field, while others employ the artery for- ceps. We have generally found the former the most convenient instrument The point ought to be very sharp, and well polished. The end of the vessel should be cautiously transfixed, without including any of the adjacent structures, and then slightly drawn out, so as to permit the assistant to fix the loop ofthe ligature upon it. When this is accomplished, the two ends are to be cautiously drawn, while with the point of the index finger, the slip of the loop is pressed down upon the vessel. It should always be secured by a double knot, and particular care be taken not to include the vein or the accompanying nerves. The principal artery being secured, those of smaller size are to be sought by gently sponging away the blood and slacking the tourniquet or diminishing the compression. Every vessel that bleeds must be secured; for although it is a bad practice to apply too many ligatures, it is still more so, to be obliged, after the stump has been dressed, to open it on account of secondary hemor- rhage, or to expose the patient to the irri- tation and.suppuration likely to arise from an accumulation and confinement of gru- mous blood. Sometimes considerable venous hemor- 35* rhage takes place, which is difficult to control. To overcome this difficulty, it has been proposed by Desault, Hey, and Graefe, to include the artery and vein in the same ligature, by passing one point of the forceps into the mouth of each vessel, and drawing them out together. Hennen also states, that he has frequently tied the vein, without any bad consequences. In some instances, however, in which this practice has been adopted, an alarming phlebitis has taken place, and destroyed the patient It is always hazardous, and should not be resorted to, except from urgent necessity. Very alarming effects have also resulted from including the nerve in the ligature, and in some cases it has given rise to tetanus. When, as is sometimes the case, consid- erable hemorrhage takes place from the nutritious artery of the bone, it should be arrested by the introduction of a small plug of wax or soft wood, by a lint com- press, or, what will generally be effectual, by twisting or lacerating the mouth of the vessel with the points of the forceps. When merely a slight oozing continues after the arteries have been tied, the stump should be sponged with cold water. Astringents ought never to be employed under such circumstances. They irritate the wound, excite inflammation, and cre- ate an obstacle to immediate union. If a small vessel bleeds, it should be secured, and time must be allowed for the ener- gies of the patient to rally from the shock of the operation: for it frequently happens, that after reaction commences, many ves- sels which did not previously pour out blood, bleed profusely, and render it neces- sary to open the stump. To obviate this, some surgeons, as Parrish, Klein, Du- puytren, Lisfranc, and others, have pro- posed to leave the stump open for some time after the operation: a practice which we have seen adopted with advantage, not only as a precautionary means against hemorrhage, but likewise, as we are in- clined to think, in facilitating union by the first intention. Other means of arresting hemorrhage have been proposed. One of these is tor- sion of the extremity of the vessel, which has within the last few years excited con- siderable attention amongst the French surgeons. It is stated by Velpeau, that he was led to this discovery in 1826, by some experiments made on dogs; but it appears that he did not apply it to the hu- man subject, until the 13th November, 1828. A warm discussion has been carried on between this surgeon and Amussat, 414 AMPUTATION. relative to their claims to priority in this alleged discovery. A reference to the labours of their predecessors and contem- poraries would have convinced them that there is no novelty in the procedure recom- mended by them. Torsion has been repeat- edly employed by surgeons for the purpose of arresting hemorrhage from small arte- ries. It was put in execution by Dr. Bushe of New-York, in a case of amputation of the thigh, which he performed in Decem- ber 1826. He arrested the hemorrhage from all the vessels, except the femoral, (four in number,) by twisting the cut extremities in a square-beaked forceps, fur- nished with a sliding bar and two nuts. In 1827, he adopted the same procedure in an amputation of the thigh, one of the fore- arm, one ofthe foot, and in a case of extir- pation of the testicle. In July 1828, it was again practised by him in an amputation of the thigh. All these operations, it will be seen, date anterior to that practised by Velpeau, and if torsion of the arteries were to be regarded as a modern discovery, the merit would be certainly due to Dr. Bushe, in preference to the French sur- geons. But he does not claim the honour. He states that both Galen, and Guy de Chauliac, recommend torsion, and cites from the former author the following pas- sage to prove the correctness of the asser- tion : " Quinimo si vas unde profluit alte sit demissum, certius ipsius turn positum intelligat turn etiam magnitudinem, praste- ria venane sit an arteria; post hasc, injecto unco, attollat ac modice intorqueat." {New- York Med. Chirurg. Bullet. II. p. 212. 1832.) Since 1828, torsion for the purpose of arresting hemorrhage has been practised to a considerable extent in France, Ger- many, England, and America, and although it has been found successful, the result has proved that it possesses no advantages over the ligature, and that it is much less safe. It ought never to be confided in where the vessel is large, and should, if employed at all, be confined to arteries of small calibre. To accomplish the torsion, the divided end of the vessel is to be seized and drawn out with a pair of artery forceps, furnished with a slide or spring, taking care to have it separated from the other structures. A second pair of forceps is then to be fixed on the vessel in the bottom of the wound, so as to grasp it in a trans- verse direction, with which it is to be supported, while seven or eight turns are made upon its extremity with the first instrument; or the artery may be held between the nails of the index finger and thumb, while torsion is made with the forceps. This method, recommended by Velpeau, is more simple than those pro- posed by Amussat and Kluge, and is equally effectual. Amussat employs two forceps with elongated rounded blades: one to draw out and twist the vessel, while the other is used to support it in the bottom ofthe wound. Contusing or lacerating the cut end of the small vessels with the tenaculum or forceps will often be found sufficient to stop them from discharging blood. But this procedure should never be relied on, except for such branches as are too small to require the ligature, and which merely give rise to a slight oozing. It has even been proposed to dispense with the ligature and all the usual means of arresting hemorrhage after amputation, and to rely upon compression applied upon the course of the principal vessel. Koch. surgeon of the Hospital of Munich, states that he has adopted this practice for more than twenty years. He merely applies a graduated compress upon the course of the principal arterial trunk, and confines it by means of a roller bandage extending from the stump to the trunk of the body. He then approximates the wound, and heals it by the first intention. The same success has not attended this procedure in the hands of other surgeons, and we think it should never be imitated. When the artery is so profoundly embed- ded in the soft parts as to render it impos- sible to isolate and draw it out sufficiently to apply the ligature, a common curved needle armed with three or four threads of silk should be introduced into the soft parts first on one, and then on the other side of the vessel, and the ligature drawn so as to include a part of them, together with the artery. Should the artery be so much ossi- fied as to be incapable of sustaining the ligature applied in the usual manner, a cone of soft buck-skin large enough to fill its cavity may be passed into its orifice, and there secured by a soft flat ligature of the same substance, tied around the vessel in the usual manner. The plan proposed by Velpeau, of reverting the extremity of the artery, and thrusting it into the soft parts, is unsafe, and as it secures no advantages, ought never to be employed, except for very small vessels. § 13. Dressing the Slump. After all the vessels have been secured, and the oozing from the stump has ceased, all coagula of blood should be carefully spong- ed away, and the parts wiped dry with a AMPUTATION. 415 soft towel; the surgeon should then assort the ligatures, and place them in the situa- tion which he wishes them to occupy, arranging those which are nearest the circumference so that they may be placed in the angles of the wound, and bringing out the others in the centre. The edges ofthe flaps must next be brought together, and maintained in their proper situation. But in this stage of the dressing, a different procedure must be adopted, according as it is proposed to obtain immediate or second- ary union. When the surgeon is desirous of uniting the stump by the first intention, it is import- ant that the corresponding surfaces of the flaps should be brought in accurate con- tact, and that no foreign substance be interposed. If the silk ligatures be used, one end should be cut close to the knot, as already directed, and if chamois leather or buckskin, nothing but the knot itself should be left. Coagula of blood must also be care- fully removed; for if suffered to remain between the faces of the stump, they always excite much irritation, and not unfrequently give rise to suppuration. The edges of the skin, being neatly approximat- ed in a line corresponding to the direction of the flaps, when the operation is per- formed in that manner, are to be confined with strips of adhesive plaster, which are to be brought over the end of the stump, and placed so as to leave sufficient space between each for the escape of the dis^" charges. It was formerly the practice to use sutures for this purpose, and although they have been abandoned by most modern surgeons, there are still some who con- tinue to employ them. Graefe uses a single suture of flat bobbin, or narrow tape. Sutures have also been highly recom- mended in modern times by Hey, Bene- dict, and Delpech. We have never found them necessary, and in one case in which we employed them in a flap amputation of the leg, they did considerable mischief After the adhesive stripes have been applied, a piece of lint spread with simple cerate should be laid over the face of the stump. To furnish additional support, a roller bandage must next be applied so as to extend from the stump some distance up the member. This may be applied by lay- ing one end longitudinally upon the limb, and carrying the bandage, by reversing it in opposite directions, oven the face of the stump, so as to form a cross, and ascending with it by spiral turns to the necessary height By Alanson, and Louis, the first turns of the bandage were made upon the trunk, whence it was carried downwards by circular turns to the base of the stump. This practice is also recommended by Richerand, and S. Cooper, with the view of bringing the muscles more completely over the face of the bone. The masses of lint compresses, the malta cross, the woollen cap, and a variety of means formerly employed, are neither necessary nor proper. The wound must be kept cool, and should be as little encum- bered as possible, and the more simple the dressings, provided they serve to keep the edges of the wound in contact, the better. This principle is now acknowledged by the best English, American, and German surgeons, and ought never to be neglected. Some difference of opinion has existed in relation to the direction that should be given to the line formed by the juxtaposi- tion of the flaps or integuments. In most cases this must be determined by the man- ner in which the flaps are formed, the con- figuration of the member, &c.; but in amputation of the thigh by the circular incision, the line of union may be either made transversely, perpendicularly, or in a diagonal direction. Each of these methods has had its advocates, but if union is to be obtained by the first intention, it is of little consequence which is adopted. Alanson recommended the first, and it has been followed by a majority of English surgeons. Hutchinson has insisted much upon its advantages, on account of the tendency the pressure of the limb will have, when laid upon a pillow, if the line of union is made perpendicular, to force asunder the inferior or posterior angle of the wound. It is also recommended by Graefe. Most surgeons on the continent, however, unite the wound so as to form a line from before backwards, and this method not only admits of a more accurate approximation of the soft parts, but when suppuration takes place, allows a more ready egress to the discharges. The stump being dressed, the patient must be put to bed, and the member fixed upon a pillow in such a manner that the parts remote from the wound shall bear the greater part of the pressure. A mattress should be preferred to a feather bed, and when it is desirous to keep the stump wet with cold water, a practice in general use among the Spanish surgeons, and which we have used with advantage, the pillow may be covered with soft oiled silk. When it is the object of the surgeon to obtain mediate, consecutive, or what has been generally denominated union by the second intention, the dressings must be somewhat different In such cases it is 416 AMPUTATION. ♦ustomary to fill the face of the stump tions, and claim for their procedure advan- with lint, or some other substance, to pre- tages which far more than counterbalance vent the parts from uniting, until the pro- any difficulties incurred by it. The cure cesses of suppuration and granulation have is more speedily accomplished ; the indi- become completely established. Some vidual $ saved from the long-protracted even have used for this purpose pieces of pain, suppuration, and hectic fever, which sponge or agaric, which are interposed be- are occasioned by keeping the stump open; tween the flaps, so as to keep them from the bone is not so apt to protrude, and be- coming in contact. Whichever of these materials are employed, after the cavity of the wound has been thus filled, the soft parts are brought over and confined in the manner directed above. Where secondary union is determined upon, a better method will be that practised by Dr. Physick, and recommended by Dorsey, of merely in- terposing a thin pledget of lint between the edges of the wound, so as to prevent the skin from adhering. {Elements of Surgery. II. 301. Philad. 1818.) Few questions relating to surgical prac- tice have given rise to more discussion than that of the comparative advantages of immediate and consecutive union after amputation. In former times it was con- ceived to be a highly hazardous procedure to attempt to unite the edges ofthe wound by the first intention. It was considered indispensably necessary that the parts should be allowed to disgorge themselves freely by a profuse suppurative drain es- tablished from the face of the stump; that the end of the bone should be allowed to come necrosed; the soft parts retract less; and a conical stump, which is so frequent a consequence of the opposite practice, is seldom developed. The extensive and daily experience ofthe English and Amer- ican surgeons, by whom immediate union is advocated, has fully demonstrated these advantages; and from the opportunities which we have had in witnessing the comparative merits of the two procedures, in the French and English hospitals, and in America, we have no hesitation in as- serting that the advantages are decidedly in favour of immediate union. No feature in French surgery struck us as being so palpably bad as the treatment of amputa- tions, and we saw no operations so unsuc- cessful. Individuals of good constitutions, not unfrequently were submitted to pro- tracted suffering and wasting suppuration, from keeping the stump open, when it might have been healed in three weeks; and in some instances, we are inclined to think, that an irritable and gleety stump, with severe constitutional disturbance, ter- exfoliate, and that the system should have ^piinating in death, were developed by fill time to accommodate itself to the new con dition of the member, and to the changes which take place in the distribution of the circulating fluids subsequent to the opera- tion. From these and other motives, many ofthe surgeons of the continent especially the French, still insist upon the advan- tages of uniting the stump by granulation; and some «f them even affirm that ampu- tations thus treated are more successful than those in which immediate union is attempted. It has been urged, that when the latter practice is adopted, the blood which oozes from the smaller vessels is confined in the bottom of the wound, and gives rise to troublesome suppuration and the development of deep sinuses; that the ing the wound with lint under circum- stances where a successful issue might have been readily secured by the adoption of an opposite course. From a faithful survey of the whole grounds, we would lay it down as a rule, that immediate union should be attempted in all cases where the structures are healthy, and not in a sloughy condition. We are not sensible of any bad effects that can possibly result from it. We may sometimes fail in accomplishing it; but even then we lose nothing by the attempt; for suppuration and granulation wdl take place, and we shall have as many facUities for accomplishing union by the second inten- tion, as we should if we had sought it from patient is more exposed to extensive con- the first. Even when the parts are not en- stitutional disturbance and tetanus; and that where the amputation has been prac- tised for a disease of long standing, the internal organs are apt to become exten- sively diseased, or even the seat of puru- lent abscesses. The English surgeons, on the contrary, by whom the practice of immediate union was first instituted, and who have adopted it as a constant rule of conduct, deny the validity of these objec- tirely healthy, they ought to be placed as nearly as possible in apposition, taking care not to constrict them with the strips and bandages. Leeches, poirlRpes, or stim- ulating applications, according to the cir- cumstances of the case, can be as well ap- plied with the stump in that condition, as when its edges are forced asunder by lint; and if we should merely succeed in ob- taining union to a limited extent, the ad- AMPUTATION. 417 vantage will be considerable, as the part to be healed by granulation will be there- by diminished. Nor do we conceive con- secutive union necessary, where the am- putated member has become a kind of habitual drain, inasmuch as by appropriate constitutional treatment, together with the establishment of a seton or issue at some other point, any mischievous consequences which would be apt to ensue may be ob- viated. The second dressing should, under or- dinary circumstances, be deferred to the fifth or sixth day. But in some instances, where considerable oozing of blood takes place from the vessels after the stump has been dressed, it becomes confined within the bottom of the wound, and acquires such offensive or irritating qualities as to render it necessary to remove the first dressings at an earlier period. As the first dressings are generally very firmly agglutinated with each other, in consequence of their being saturated with blood, and its subsequent drying, great care must be taken in the removal of them, not to tear up any adhesions of the edges of the wound which may have form- ed, and to avoid inflicting unnecessary pain upon the patient. To facilitate their de- tachment they should be carefully soften- ed by throwing a gentle stream of tepid water upon them, until they will separate easily; and while the surgeon removes them, an assistant should carefully support the stump, making a gentle pressure against its sides, to prevent the edges from separating. After the roller and pledgets of lint have been removed, if the stump is large, it will be advisable to remove only one adhesive strip at a time, supplying its place with a new one, before the next is detached, thus obviating the necessity of suddenly depriving the stump of all its support. After the stump has been cleans- ed with a soft 'sponge, or a dossil of lint and wiped dry with soft linen, the adhesive strips must be applied as before. Over them should be laid a pledget of lint spread with cerate, or spermaceti oint- ment and the whole confined by a roller, as in the first dressing. The subsequent dressings must be managed upon the same principles, and should be renewed as often as the circumstances of the case may re- quire. The ligatures come away at differ- ent periods. Those of the small arteries generally become loose about the fifth or sixth day, and those of the principal trunks, about the tenth or twelfth. Sometimes, however, they are retained for several weeks, and keep up more or less suppura- tion in the vicinity. After sufficient time has elapsed for them to become detached, very gentle traction should be made at each dressing, taking care never to use sufficient violence to tear them away. Should they not become loose in the course of two or three weeks, they may be cut away by means of a small, beaked knife, having a slight notch or groove upon the beak to direct it along the course of the thread. 5 14. Accidents consecutive to Ampu- tation, a. Hemorrhage. It not unfre- quently happens that more or less bleed- ing takes place from the stump after the dressings have been applied, even though all the vessels which poured out blood at the time of the operation may have been secured. This arises from the renewal of the energy of the circulation, which takes place after the system has had sufficient time to recover from the depressing influ- ence inflicted upon it by the shock of the operation. To obviate this occurrence, it will always be proper to delay some time before the dressings are applied, so that any small vessels which may be capable of pouring out blood, after reaction has taken place, may be discovered and se- cured. Another cause of immediate con- secutive hemorrhage is the slipping of the ligature, in consequence of its not having been properly secured upon the vessel, or a division of the tunics of the latter by the ligature, in consequence of their having lost their natural powers of resistance from the influence of disease. It, moreover, sometimes happens, that after the expira- tion of several hours, a kind of vital ere- thism is excited in the stump, which dis- poses the capillaries to pour out blood in such profusion as to demand the attention of the surgeon. Considerable hemorrhage may also take place from the veins, in con- sequence of the bandages being applied so tightly upon the limb as to interrupt the free return of the blood through those ves- sels; and it has been asserted by Hey, that in some instances he has seen the same effect produced by a circular con- striction of the integuments above the stump, requiring them to be divided on each side. We much question, however, if such a condition is ever likely to be de- veloped in a sufficient degree to obstruct the passage of the blood through the veins. From whichever of these causes the hemorrhage proceeds, we should never open the stump, except where the neces- sity is absolute. That operation is always productive of extreme pain, and is regard- ed by the patient with horror. In most 41S AMPUTATION. cases, where the bleeding is not profuse, it will merely be necessary to remove the roller and compresses, to slightly elevate the stump, and expose it freely to the cool air, or to keep it wet with cold water, or covered with ice. If the hemorrhage is venous, the simple removal of the bandage will generally be sufficient; and we have several times seen considerable arterial bleeding, where it proceeded from small vessels, arrested by uncovering the stump, and exposing it to the air, or wetting it with cold water. Should these means not prove efficient, pressure must be made upon the course of the principal artery of the limb, by means of a press artery, a properly arranged compress, or a tourni- quet so adjusted as to compress the vessel, without interrupting the return of the ve- nous blood. In some instances, pressure, kept up for the short space often minutes, by means of the thumb, or some convenient instrument fixed upon the course of the main artery, will effectually command the bleeding. When the hemorrhage is more profuse, and cannot be commanded by any of these means, the stump must be opened. If the accident occur shortly after the ope- ration, it will be easy to secure the bleed- ing vessel. But if this cannot be done, it may sometimes be commanded by means of a piece of soft sponge, or agaric, con- fined for some time upon the extremity of the artery. Hemorrhage sometimes takes place from the stump at a much later period, and pro- ceeds from a very different cause. From a want of a proper degree of plastic power in its tunics, 'the vessels take on ulcera- tion at the point at which they are included in the ligature, or they become affected by a kind of sloughing process, by which the ligature is thrown off before obliteration can be accomplished. This latter condi- tion is especially apt to occur after ampu- tations which have been performed during the progress of gangrene, in consequence of the structures above the limits of the dead parts having taken on something of the gangrenous tendency. The ulcerative condition is particularly liable to take place where the artery is affected with ossification, or any one of the forms of degeneration to which it is liable. It likewise supervenes in many instances, from a preternatural softening or fragility of the arterial tunics. Consecutive hemorrhage, resulting from these causes, generally occurs at an ad- vanced period; seldom before the tenth or twelfth day, and frequently after the third week. It is always a formidable ac- cident and difficult of management The ligature to the orifice of the bleeding ves- sel is no longer practicable, except by in- cluding a portion of the soft parts, as was done in one case by Sanson, after separat- ing them with a stroke of the bistoury from their surrounding attachments. Petit in- vented a kind of tourniquet by which he was enabled to confine a piece of sponge or agaric upon the extremity of the vessel so as to command the hemorrhage; but it has not been found of sufficient utility to insure its employment by modern surgeons. The same materials, however, may some- times be advantageously bound upon the part, by means of a compress and roller, properly adjusted upon the limb. It will also be proper to apply compression upon the course of the artery, in the manner prescribed above, or by means of a com- press and bandage. Should all these means fail, the only resource left for the surgeon, is to cut down upon the course ofthe main arterial trunk, some distance above the stump, and secure it in a ligature, as in the treatment of aneurism. This opera- tion has been particularly recommended by Roux, who has practised it several times with success, and it has also been employed advantageously by Dupuytren, Delpech, Sonne and others. It should, nevertheless, be stated, that in some in- stances, the ligature of the vessel has not arrested the flow of blood, the latter being kept up by the anastomosing vessels. Blan- din met with a case in which this was ob- served, and Hey and Guthrie represent that it will not always succeed. Gouraud has indicated a form of con- secutive hemorrhage produced by the ne- crosis of the end of the bone. At each dressing, there is an oozing of blood from between the dead and the living parts, which cannot be arrested, either by com- pression, or any other procedure, except the resection ofthe dead parts. (Velpeau, p. 348:) We have witnessed an example of hemorrhage from this cause, after an amputation of the leg, where the whole stump had healed, except a small fistulous opening in the vicinity of the fibula. On one occasion, a profuse hemorrhage took place from that aperture, and on examining it, the end of the bone was found dead and detached from the shaft. It was drawn away with a pair of dressing forceps, and the bleeding did not recur. b. Phlebitis. The inflammation of the veins which sometimes succeeds amputa- tion, is by far, one of the most formidable accidents to which the individual is ex- posed. It gives rise to an alarming dis- AMPUTATION. 419 turbance of the natural acts of the system, and by becoming extensively diffused, fre- quently destroys the life of the patient. These disturbances constitute a train of phenomena, which similate very closely the characters of a malignant fever, con- sisting of small, frequent irritable pulse, a pungent or burning heat of the skin, ter- minating in profuse clammy sweats, stu- por or delirium, dark dry tongue, great prostration of strength,—in short, all the symptoms which mark the worst forms of fever. The stump becomes somewhat tense and swollen, and the torture inflicted by the removal of the dressings is almost insuffer- able. Its surface becomes gleety, or is covered by a viscid, grayish-coloured mat- ter. All healthy suppuration is suspended, and if partial adhesions have formed, they are broken up, and the bone becomes ex- posed. A diffused tenderness and burning pain are frequently extended along the member, especially in the track of the principal vessels, and not unfrequently there is more or less tumefaction of the whole limb. All these accidents have been long familiar to most surgeons, but they were at a loss to explain their source. The most rational solution that for a long time suggested itself, was, that they are excited by the free absorption of purulent matter from the face of the stump, and its subse- quent diffusion with the mass of the circu- lating fluids, to various and remote parts of the system. It is certainly true, that the injection of certain substances into the veins produces a train of phenomena pre- cisely similar; but it is only in modern times we have been taught, that all these symptoms or consequences are the result of the development of an inflammation of the veins. These vessels are not only foand inflamed in the immediate vicinity of the stump, but exhibit strong traces of the same condition in various and isolated portions of the system. Hence, the opinion which attributed the mischievous conse- quences to the direct extension of the dis- ease along the tunics of the vessel towards the heart, cannot be sustained; but it is far more probable, as has been maintained by Velpeau, and many of the French pathologists, that the alarming condition in question may be with more propriety attributed to the pus mingling itself with the blood, and being with It transported into the various organs of the economy, irritating the internal surface of the vas- cular system, exciting inflammation and suppuration at various points, and develop- ing all those phenomena which have been shown by experiment to be produced by the injection of putrid and irritating sub- stances into the veins. c. Purulent deposits in the organs. Very intimately connected with the acci- dent just described, is the development of purulent deposits in different tissues and organs, after amputation. These collections were long since noticed by Quesnay, who did not however, properly understand their character. Within a few years, they have been carefully investigated by Blandin, Marechal, Dance, Ribes, Velpeau, and others, who, although not in accordance with each other in their conclusions, have elicited much useful information. They may take place in any ofthe organs or tissues, but are most frequently met with in the lungs, liver, spleen, beneath the serous and mucous surfaces, and in the cellular tissue. Their size varies from a mere point up to a large excavation, simi- lar to those which are occasioned by the disorganization of a mass of crude tubercles. They have, indeed, when seated in the lungs, been often confounded with tuber- culous degeneration: hence it has often been inferred, that the death of the patient has been rather occasioned by that disease, than by the consequences of the operation. Different conjectures have been offered in relation to the manner in which these deposits are formed. Quesnay supposed, that the pus existing already formed within the arteries, was deposited by them in different situations. Ribes, Velpeau, and Marechal, have maintained that the mat- ter is first developed within the stump, and then taken up by veins or lymphatics, and transported to the points at which the depositions are made. Others have attri- buted its formation to phlebitis, and Blan- din ascribes it to local inflammation taking place in the substance of the organs or tissues, and concurs with Dance in the belief, that the blood, rendered more fluid by commingling with the pus, becomes extravasated into the interstices of the cellular tissue, and into the substance of the organs, there giving rise to a limited ecchymosis, or a number of minute pete- chia?, which, under the influence of a par- ticular form of inflammation, finally ter- minates in suppuration. Be this as it may, it is certain that phlebitis has more or less participation in the condition, and it is seldom that one is seen without the prece- dence or existence of the other. {Did. de Med. et de Chirurg. Prat. II. 227.) (See Abscess, metastatic.) d. Abscesses and sinuses of the stump and limb. The abscesses which form after amputation differ in no essential particular from those which are ordinarily developed 420 AMPUTATION. under other circumstances. Sometimes the edges of the flaps unite by adhesive inflam- mation, while the bottom of the wound takes on suppuration, and the matter being , unable to escape, accumulates so as to form an abscess. Caries or necrosis of the bone, the • irritating influence of the ligature, &c, also conspire to excite suppurative inflammation, and to favour the develop- ment of these abscesses. Sometimes, when the purulent accumulation is considerable, and the matter cannot escape, it travels along the limb in the interstices of the muscles, or in the course of the synovial sheaths, and thus occasions extensive bur- rowing sinuses. The latter accident is more apt to occur after amputation at the wrist, or through the articulations of the tarsus, and in many instances it has occa- sioned very disastrous consequences, ren- dering it necessary to make numerous irtcisions and counter openings to give exit to the matter. This should always be done as soon as an abscess has formed in a stump, whether it be small or large, and if the pus has a free outlet there need not be much apprehension entertained of its retarding the cure, unless there be some local cause to keep up the irritation. e. Caries and Necrosis ofthe Bone. It was formerly supposed, that the injury inflicted on the bone by the action of the saw, would almost necessarily give rise to a subsequent exfoliation or necrosis of its substance; and the practice which was generally adopted, of keeping the stump in a perpetual state of irritation by impro- per dressings, and of maintaining a long- continued suppuration, could not fail to render it of frequent occurrence. Under the more rational course pursued by modern surgeons, death of the end of the bone after amputation, is much more rarely met with than formerly. It may never-. theless take place under any method of treatment, and may proceed from several causes. The injury inflicted upon the bone itself will sometimes so far impair its vital powers, as to render it incapable of sustain- ing the integrity of its structure. A lace- ration or detachment of the periosteum may also occasion the death of the bone, and the same consequence not unfre- quently ensues from its extremity not being sufficiently covered with the soft parts. This sometimes takes place even after the stump has cicatrized, in consequence of the integuments retracting so much as to press the cicatrix against the end of the bone. Under these circumstances, the cicatrix generally ulcerates, and exposes the end of the bone, which, being unpro- tected, exfoliates, or becomes affected with necrosis. This result may be generally prevented by the application of a bandage, which should be so adjusted as to coun- teract the contraction of the muscles, and thereby diminish the pressure upon the cicatrix. There is still another cause of the death of the bone, which has not untfl lately attracted the attention of surgeons. It is the inflammation of the marrow, or more properly of the medullary membrane. It was noticed by Ribes, Guthrie, Cruveil- hier, and Beclard, but was not particu- larly described until Renaud published a memoir on the subject in the Archives de Medecine. This inflammation, it appears from various facts cited by him, determines the death of the corresponding portion of the bone, a detachment of the periosteum to an extent corresponding with that ofthe disease, and the development of purulent deposits in the vicinity. In the cases observed by Renaud, there was a general doughy feel of the stump without apparent inflammation, a free discharge of pus on pressure, acute pain after the first dress- ings, and in several instances, a yellowish suffusion of the stump, and of the wound. (J. Cloquet, Did. de Mid. 2d ed. II. 455.) It sometimes happens, after amputation ofthe leg below the knee, that the weight of the soft parts of the calf of the leg drags so forcibly upon the skin, which occupies the angle of the tibia, that it sloughs, and denudes the bone, which, being no longer covered and protected, takes on a carious or necrosed condition. This accident can be easily prevented by placing the mem- ber in such a position as to secure a proper support for the soft parts, and prevent them from exercising so much traction in the direction designated. When caries or necrosis of the bones of the stump takes place, it will seldom be necessary for the surgeon to do more than to secure a free exit for the discharges, and to pick away any pieces of bone as soon as they become detached. The appli- cation of cauteries and escharotics, so much resorted to by the older surgeons, has been properly laid aside by modern practitioners ofthe art. Nor will it be necessary to saw through the bone higher up, except where the protrusion is so considerable as to expose a great extent of its surface, and thus render it impracticable to cover it with the soft parts after the dead portion is detached. In some instances, however, this painful operation will become neces- sary, and in executing it great care should be taken to detach the muscles from the AMPUTATION. 421 bone to a sufficient extent to furnish an adequate covering for the latter. f. Conical Stump. This accident i3 gen- erally complicated with the preceding. It generally arises from a neglect of the pre- caution to preserve a sufficiency of the muscles and integuments to completely cover the bone; from the latter being sawed too low; from carelessness in the application of dressings, or the frequent employment of such as are of a highly irri- tating character; the preternatural con- traction of the superficial stratum of mus- cles; and, above all, a sloughing of the soft parts, by which the bone is left bare and prominent. It was of frequent occur- rence in the hands of the older surgeons, but since the improvements which have been made in modern times in the method of performing amputation, and treating the stump after the operation, it is rarely met with. It is now seldom seen in practice, except as a consequence of some fault in the performance of the operation, or mis- management or neglect in the after treat- ment. The practice of healing the stump by the first intention has greatly dimin- ished its frequency, and if proper precau- tion be observed in executing the opera- tion, and conducting the subsequent dress- ings, it cannot take place except as a con- sequence of extensive sloughing of the muscles and integuments. Although it occurs most frequently before the stump is healed, it is sometimes developed after it has become wholly united,—the retraction of the muscles drawing the cicatrix so forcibly over the end of the stump, that ulceration or sloughing of the new skin takes place, and the bone protrudes. To obviate the occurrence of this con- dition, which, when it takes place, is always a source of distress to the patient, and, in a majority of instances, of discredit to the surgeon, the rules which have been laid down above for the performance of the op- eration, should never be neglected; and, to prevent the inordinate retraction of the muscles from occurring, they must be confined, and fairly drawn over the end of the bone by the proper adjustment of a roller bandage, extended from above down- wards, as recommended by Louis, Alan- son, and Richerand. If, after the bone has been sawed, it is found that it cannot be properly covered with the soft parts, it will be better, as suggested by Guthrie, to proceed at once to divide it higher up, than to be obliged afterwards to submit the patient to all the pains and horrors of secondary amputation. Should the bone protrude, notvvithstand- vol. i. 36 ing all the means used to prevent it, the subsequent treatment must be dictated by the condition of the stump. Where the protrusion is slight, it may be safely left to nature, the surgeon contenting himself with the removal of the carious or dead bone, as soon as it becomes detached; but where so much of the bone is exposed as to render it impracticable to cover it with soft parts, after its dead portion is separat- ed, it will become necessary to resort to resection, or secondary amputation. Sa- batier particularly recommends this pro- cedure, and represents, that although he had repeatedly sawed off the end of the bone, no bad consequences ensued. In several instances, however, in which sec- ondary amputation has been performed by other surgeons, the cases have had a fatal termination. g. Gangrene and sloughing of the stump. Where amputation is performed upon a part of a member not altogether healthy, or upon an individual of feeble constitution or intemperate habits, the muscles and integuments are apt to become gangrenous and slough away. We have already adverted to this accident as one of the causes of protrusion of the bone, and where it does not produce that effect, it always retards the cure. It must be treated upon the general principles which regu1- late the management of a similar condition taking place under'other circumstances.^ In camps and crowded hospitals, however, there is a species of gangrene of a far more formidable character, which prevails as an epidemic, and seizes upon every wound or injury which may happen to be brought within the sphere of its influence, and which, where it is prevalent, constitutes the principal cause of the failure of ampu- tation in such situations. (See Hospital Gangrene.) Should the stump become affected with this condition, the speedy removal of the patient into a pure and salu- brious atmosphere will furnish him almost the only chance of recovery. Should the soft parts become extensively involved, and the bone be laid bare by sloughing, ampu- tation must be practised without delay, above the seat of the disease, even though the gangrene be still progressive. Success has sometimes been obtained by this course, even under the most unpromising circum- stances, and the patient should never be resigned to his fate while there is a shadow of hope. Variousother accidents sometimes super- vene upon amputation, which it will not be necessary to describe, as they must be treated upon general principles. They are 422 AMPUTATION. erysipelatous inflammation, spasms, teta- nus, the re-development of the disease for the removal of which the member was amputated, &c. Bibliography.—A. Cornelii Celsi. De Me- dicina. Lib. Oct FABRICIUS AB AdUAPENDENTE. Oper. Chir. Ambrose Pare. CEuvres, Liv. VI. Lyon, 1664. James Young. Currus Triumphalis i tere- bintho. 8vo. London, 1679. Richard Wiseman. Chirurg. Treat. Folio. London, 1692. Hoffman, (Fred.) De Amputat. Memb. Spha- celat. 4to. Halle, 1696. Verduin. De nova Artuum decurtandorum ratione. Amst 16%. Hilscher. De Artuum Amputat. rite admin- istrand. 4to. Jena, 1718. Petit, (de Namur.) Dissertation sur VAmpu- tation, &c. Mem. de I'Acad. des Sc. 1732. Dionis. Cours des Opiralions Chirurgicale. Paris, 1736. H. F. Le Dran. Observations de Chirurg. Pa- ris, 1731.—Traiti des Opirations. 8vo. Paris, 1742. Monro. Remarks on the Amputations of the larger extremities, in Med. Essays and Obs. of Edinburgh. IV. 321. 1738. Garengeot. Traiti des Opirations. 3 tomes, 12mo. Paris, 1748. Morand. Opuscules de Chirurgie. Paris, 1750. Sharp's Treatise on the Operations of Sur- gery, and his Critical Inquiry into the present state of Surgery. Louis. In Memoires de 1'Academic Royale de Chirurgie. II. and IV. JBagieu. Examen de plusieurs parties de la Chirurgie. Paris, 1756-57. Muller. De emendata membra amputandi ^ratione. Giessen, 1759. Heister. Inst. Chir. Amstelod. 1750. Dahl. Diss, de Humeri Amputat. ex articulo. GStting. 1760. Bilguer. De memb. Amputatione rarissime administrand. aut quasi abroganda. 4to. Halle, 1761. Vermale. Observat. el remarques de Chirurg. Prat. Manheim, 1767. Gooch. Chirurgical Works. Norwich, 1767. Ravaton. Traiti des Plaies par armes a feu. Paris, 1768. O'Halloran. Treatise on Gangrene, with a new method of Amputation. London, 1765. White.. Cases in Surgery. London, 1770. Valentin. Recherches Critiques sur la Chi- rurgie Moderne. Amst 1772. Salzman. De nova artus memb. Amputand. modo. 4to. Argent. 1772. Boucher. In Memoires de I'Acad. Roy. de Chirurg. 4to. II. Brasdor. Recueil des pieces qui ont concoru pour le prix, &c. Bromfield. Chirurgical Observations and Cases. London, 1773. Pezolt. De Amputat. memb. disput. Gott. 4to. 1778. * Schmucker. Vermischte chir. Schrift. 8vo. Berlin, 1779. J Pott. Remarks on the necessity &c. of Am- putation. London, 1779. Alanson. Practical Treatise on Amputation. London, 1779. Kirkland. Thoughts on Amputation. Lon- don, 1780. * Wrabetz. Histoire d'un bras sipari sans amputation. Frib. 1782. Mynors. Practical Thoughts on Amputation. Birmingham, 1783. Sardy. Deabusu Ampul memb. Montpel. 1783. Matienssen. De AmpuL per incisionem. Strasb. 178a B.Bell. System of Surgery. Edinburgh, 1785. Loder- Progr. de Alansonii nova amputa- tionis methoda. Jena, 1784-1785. Ploucquet. De Amputat. membrorum incru- enta. Tubing. 1786. Flajani. Osservazioni pratiche sopra Vampu- tazione, &c. Rome, 1791. Gladbach. Super Amputat. Marbourg, 1791. Coll. Diss. Med. Marburgens. fasc. II. No. 2. Mursinna. Neue Med. Chirurg. Beobachtung. Berlin, 1796. Callisen. Systema Chirurgia HodierruB. 2 vols. Hafnise, 1798. 2d ed. 18 . Sabatier. Midecine Opiratoire. 3 vols. Pa- ris, 1796. Nouv. edit., avec des Notes de M.M. Begin et Sanson. 4 vols. Paris, 1825. Haar, in Ausserlesene Med. und Chir. Abhand- lung. Leipz. 1800. Haase. Ampulationis ossium pracipua qua- darn momenta. Leipz. 1801. Larrey. Relation Chirurgicale de VArmie de V Orient. Paris, 1803. Ibid. Mim. de la Chirurg. Militaire. Paris, 1812; and the Translation of the same by Prof. Hall, of the University of Maryland. 2 vols. Baltimore, 1814. Van IIoorn. De iis, qua in partib. memb. Erasert. osseis amp. vulneratis noland. sunt. 4to. figd. 1803. Desault. OEuvres Chirurgicales, par Bichat. Translation of the same by E. D. Smith. 2 vols. Philad. 1814. P. F. Walther. Abhand. aus dem Gebeit der Prak. Med. und der Chirurgie, &c. Lands. 1810. Kloss. De Amputat. Humeri ex Articulo. 4to. Francof. 1811. C Bell's Operative Surgery, various editions. Art. Amputation, in Encyclopedic Methodique. Pelletan. Clinique Chirurgicale. III. 183. Graefe. Normen fiir die Abtosung. grosserer Gliedmassen. 4to. fig. Berlin, 1812. Hey's Practical Observations in Surgery. 3d ed. London, 1814. W. W. Fraser. An Essay on the Shoulder Joint Amputation. 8vo. London, 1813. Brunninghausen. Erfahrungen und Bcmerk- ungen ueber die Amputat. 8vo. fig. Bamburg. Pariset et Petit. Art. Amputation, in Dic- tionnaire des Sciences Medicafes. Paris, 1812. Tonaille—Larabrie. Quelques considira- lions sur les Amputations a la suite des plaies d'armes d. feu. Theses de Paris, 1814. Kern. Ueber die Handlungsweise bei Absetzung der Glieder. 8vo. Wien. 1814. Ph. J. Roux. Mimoire sur la riunion immi- diate apres les Amputations. 8vo. Paris, 1814. Voyage a Londres, ou parallete enlre la Chirur- gie Francaise et la Chirurgie Anglaise. 8vo. Pa- ris, 1815. Benedict. Einige wort ueber die Amputation in den Krieggspitaleren, &c. 4to. Breslau, 1814. H. Robbi. De via et ratione qua dim Mem- brorum Amputatio Instiluta est. 4to. Lipz. 1815. Carree. De VAmputation ccmsidirie comme moyen curatif dans les accidens de dibUili qui suivenl ou accompagnent les grandes plaies, &c. Theses de Paris, 1815. No. 9. AMPUTATION.- Volpi, (Tommaso.) DeU'Amputazione delta frandi estremita. Saggio di osservazioni, &c. Milan, 1814. Davidge. Physical Sketches, Sec. Baltimore. Lisfranc et Champesme. Mimoire sur VAm- putation du bras dans Varticulation de Vepaule. Bvo. Paris, 1815. Lisfranc Mimoire sur VAmputation dupied dans Varticulation tarsc-metatarsienne. 8vo. fig. 1815. Ibid. Mimoires sur VAmputation sea- pulc-humerale, coxo-femorale, et tarso-mdalarsi- enne. Archiv. de Med. I. et II. Paris. Klein. Pradische Ansichten beieutensten Chir. Operat. 4to. Stuttgard, 1816. Mann, (James.) Medical Sketches ofthe Cam- paigns of 1812-13-14, in Canada, &c. Dedham, 1816. Dorsey's Elements of Surgery. 2 vols. 8vo. Philadelphia, 1818. Montf.ggia. Instituzioni Chirurgiche. V. Fi- rense, 1820. Textor. Von der Zahl derjenigen, welche durch Absetzung grosserer Gliedmassen geheill werden., in Neuer Chiron. II. Hennen- Principles of Military Surgery. 8vo. London, 1829. Charles Bell. Illustrations of the great ope- rations in Surgery. Fol. plates. London, 1821. Richter. Anfangsgrunde der Wundarznei- kunst. Vimont. Considirations ginirales sur VAm- putations dans la continuiti des membres. Theses de Paris, 1821. No. 67. Maingault. Traiti des diverses amputations qui se pratiquent sur le corps humain Fol. planch. Paris, 1822. Camus. Essai sur VAmputation des membres. Theses de Montp. 1822. Mann. Observations on Amputation at the joints. New-York Med. Repos. N. S. VII. 14. (1822.) Hubbard. On Amputation performed at joints. Same Journal. VII. 264. James Syme. Remarks on Amputation. Edinb. Med. and Surg. Journal. XXI. 1824. Liston. Observations on Amputation. Ibid. p. 42. Begin. Art. Amputation, in Dictionnaire abre- gee des Sciences Medicales. Paris, 1825. Gibson. Institutes of Surgery. 2 vols. 8vo. Philada. 1832. Coster. Manuel des Opirations Chirurgi- cales. 12mo. Paris, 1825 ; and translation of the same by John D. Godman. M. D. Philada. 1825. Averill. Short Treatise on Operative Sur- gery, with additions by John Bell, M. D. Philad. Maunoir. Mimoires sur les Amputations, &c. 8vo. Geneva and Paris, 1825. Schreger. Grundriss der Chirurgisch. Ope- rat. 8vo. Nuremburg, 1825. Hutchinson. Practical Observations in Sur- gery. 2d ed. London, 1826. Zang. Blutiger Heilkuns&icher Operat. 5 vols. 8vo. Wien. 1821. A. Cooper. Surgical Lectures, edited by Tyr- rel. 3 vols. Boston. 1833. Guthrie. On Gun-shot Wounds. 3d edit. London, 1827. . Bierkowskie. Anatomisch-Chirurgisch. Ab- budungen nebst Beschreibung der Chirurgisch. Operat. Fol. plates. Berlin, 1827. D'Egremont. Giniralitis sur les Amputa- tions des membres. Theses de Montpellier. 1827. No. 78. Scoutetten. La mithode ovahnre, ou tiou- velle mithode pour amputer dans les articulations. 4to. fig. Paris, 1827. -AMYGDALUS. 423 Grossheim. Art. Amputation, in Encyclopte- disches Wurterbuch der Med. Wissenschaften. Berlin, . Also, Lehrbuch der Operat. Chi- rurg. 8vo. II. Berlin, 1831. Hello. Considiralions sur Amputations des membres. Theses de Paris, 1829. No. 258. Samuel Cooper. Surgical Dictionary. New- York. 1830. Ibid. First Lines of the Practice of Surgery. Philada. 1830. Boyer. Traiti des maladies chirurgicales. 12 vols. 8vo. Paris, 1814. 1827. Smith, (N. R.) Surgical Memoirs. 8vo. Bal- timore, 1831. Chelius. Handbuch der Chirurgie. 2 vols. Leipz. 1829. Rust. Theoret-Prakt. Handbuch der Chirurg. I. Berlin, 1830. Jobert. Amputationis Artuum diversas me- thodos exponere ac inter se comparare. 4to. Pa- ris, 1830. Langenbeck. Nosologic und Therapie der Chirurg. Krankheit. 4 Band. Gott. 1830. Liston. Elements of Surgery. 3 vols. Edin- burgh, 1832. Ph. F. Blandin. Art. Amputation, in Dicti- onnaire de Med. et de Chirurg. Pratique. Paris, 1829. Velpeau. Nouveaux Elimens de Midecine Opiratoire. 3 vols. 8vo. fig. Paris, 1832. Cloquet. Art. Amputation, in Dictionnaire de Medecine. 2d ed. Paris, 1833. Villette. Mimoire sur Vepoque pricise ou une amputation doit Ure pratiquie, a la suite des fradures compliquics de plaies et aulres accidens graves, in Gazette Medicale de Paris, 15 Juin. 1833, p. 427. E. Geddings. AMYGDALUS. {Botany.) ^ Sex. Syst. Icosandria Monogynia.—Nat. Ord. Amygdaleas. Gen. Ch. Calyx five-cleft, inferior. Pe- tals five. Drupe with a nut perforated on its surface. Lindley. 1. Amygdalus communis.—Almond- tree.—Amandier, Fr.; Gemeiner Man- delbaum, Germ.—Sp. Ch. " Lower serra- tures of the leaves glandular. Flowers sessile in pairs." Lindley.—This is a small tree, about twenty feet high, with numerous spreading branches, which are covered with a brownish bark, except the young twigs, which are beautifully green. The leaves are alternate, petiolate, lanceo- late, pointed, serrate with glands at the lower serratures, veined, three or four inches long, and of a bright green colour. The flowers are large, of a pale red col- our varying to white, with very short pe- duncles, and are usually placed in numer- ous pairs upon the branches. The fruit is ofthe peach kind, with the outer covering thin, tough, dry, and marked with a longi- tudinal furrow, where it opens when fully ripe. Within this covering is an ovate, compressed, brittle shell, of a light brown colour, marked with pores on its outer sur- face, and inclosing an oblong-ovate, flat- 424 AMYGDALUS. tish kernel, pointed at one end and round- ed at the other. There are several varieties of this spe- cies of Amygdalus, differing chiefly in the size and shape of the nut, the character of the shell, and the taste of the kernel. Two varieties are generally recognized by botanical writers—the Amygdalus com- munis dulcis, and the Amygdalus com- munis amara—the former bearing sweet, the latter bitter almonds. Some botanists consider these as distinct species, under the names of A. dulcis and A. amara; the former characterized by glands upon the petiole, and by the length of the styles greatly exceeding that of the stamens—the latter, by the absence of glands on the pe- tiole, and by the length of the styles about equalling that of the stamens. The stem, moreover, of the bitter almond, is said by Hayne to be always lower, in its native country, than that of the sweet almond. Some botanists make a third species out of the soft-shelled variety, in which the petals scarcely exceed the calyx in length, and the shell of the nut is very thin and fragile. It is called Amygdalus fragilis, and coin- cides with the dulcis in this respect, that its kernel is always sweet The almond-tree has been long culti- vated in various parts of the south of Eu- rope, and grows wild in Greece, Syria, and Barbary. In the more northern parts of Europe, though it is occasionally cultivated, its fruit does not attain the same perfection as in the warmer latitudes. The trunk ex- udes a gum closely resembling that of the cherry-tree, with the property of swelling up and forming a soft viscid mass with water, but not dissolving in that liquid. The kernel of the nut is the officinal part. (See Almonds.) 2. Amygdalus Persica.—Peach-tree.— Pecher, Fr.; Pfirsichbaum, Germ.—Sp. Ch. " Leaves with all the serratures acute. Flowers sessile, solitary." Lindley. The peach-tree is so well known that a de- tailed description would be superfluous. Linn.eus divides this species of Amygdalus into two varieties—that with downy fruit, or the common peach, and that with smooth fruit, or the nectarine. The latter is by some botanists- considered a distinct spe- cies; but it is asserted that both fruits have sometimes grown on the same tree, and even on the same branch, and one in- stance is mentioned of a single fruit par- taking of the nature of both. Though the native country ofthe peach- tree is not certainly known, it is generally believed to have been brought originally from Persia It is cultivated in all parts of the civilized world where the climate is sufficiently temperate, but nowhere, per- haps, in greater abundance than in the United States. A gum exudes from the stem, resembling that of the almond and cherry-trees; but it is employed for no useful purpose. The fruit constitutes an exceedingly grateful, and for most persons a wholesome article of food. It abounds in saccharine matter, which renders its juice susceptible of the vinous fermentation; and in some parts of this country a distilled liquor is prepared from it, called peach brandy, which by some persons is highly esteemed. The dried fruit is largely consumed in the form of pies, puddings, &c.; and, when stewed with sugar, is an excellent laxative article of diet, well adapted to cases of conva- lescence attended with torpid bowels. The officinal parts of the tree, are the leaves, the flowers, and the kernel of the fruit. The leaves, as well as the young tioigs, have the peculiar odour which character- izes various products ofthe genera Amyg- dalus and Prunus. Their taste is agreea- bly bitter, and somewhat austere. They yield by distillation a volatile oil similar to that of bitter almonds, upon which their odour and taste, as well as their medical virtues, chiefly depend. (See Almonds.) They are said to be laxative, and by some are at the same time considered astrin- gent ; but their powers, in either of these respects, are feeble and not to be relied on. As anthelmintics they have been employed with great reputed success. In the form of infusion, they are highly recommended in morbid irritability of the bladder and urethra. Half an ounce of the dried leaves are macerated in a pint of boiling water for three hours, and half a fluidounce of the tea given for a dose three times a day. The flowers, including the calyx, should be collected before they are fully blown. They should be quickly dried, and kept in tin canisters excluded from the air and light They have the characteristic aro- matic odour before alluded to, which they retain to a certain extent when dried. Their taste is bitter like that ofthe leaves. They are gently laxative; and a syrup pre- pared from them is used to a considerable extent in Europe, in infantile cases. Like the leaves, they are also considered anthel- mintic. A drachm of the dried flowers, or half an ounce of the fresh, given in in- fusion, is the dose as a vermifuge. The kernels, though considerably small- er than bitter almonds, bear a close resem- blance to them in appearance and proper- ties, and probably in chemical constitution, AMYL.—AMYR. 425 and might be substituted for them without disadvantage, in all cases to which the latter are applicable. In this country they are much used by the confectioners to flavour cakes and liqueurs. Bibliography.—Rees's Cyclopadia. Art. Amygdalus. Woodville. Medical Botany. 2d edit. Lon- don. 1810. Ungnad. Dissertatio de Mala Persica. Fran- cofurti ad Viadrum, 1777. Geo. B. Wood. AMYLINE. (From ajuiAov, starch.) Amidine, Fr. A yellowish-white, very friable, semi-transparent, inodorous, insipid substance, very soluble in hot and slightly so in cold water, insoluble in alcohol. It is produced by the reaction of hot water on starch. It was discovered and described by Th. De Saussure. (See Starch, and Fecula.) I. H. AMYLUM, Amylon, Amyleon or Amy- lion. (From a priv. and pvVri, a mill, be- cause formerly made without the assistance of a mill.) Starch. (See this word.) I. H. AMYRIS. {Botany.) Sex. Syst. Octandria Monogynia.—Nat. Ord. Terebintaceaa, Juss. Gen. Ch. Calyx four-toothed. Petals four, oblong. Stigma four-cornered. Ber- ry drupaceous. Willd. The genus Amyris, as understood by LiNNiEus, embraced the genus Idea of Aublet, characterized by having its fruit in the form of a capsule. The two are now considered as distinct by most botan- ists. A third genus has been formed out of the Amyris of Linnaeus, by Kunth, with the title of Balsamodendron, distin- guished by the position of its stamens, which are hypogynous instead of being epigynous. But as the three genera, ad- mitting them to be distinct, are closely allied in botanical character, and are treat- ed of under the same head by the best writers on Materia Medica, it will be most convenient to present, in one view, the few remarks in relation to them which are required by the plan of this work. 1. A. clemifera, Linn.—Idea Icicariba, De Candolle.—Sp. Ch. " Leaves ter- nate, also quinate-pinnate, tomentose be- neath." Willd. Sp. Plant. This is the plant noticed by Marcgrave under the name of Icicariba, which has been adopt- ed by De Candolle as the title of the species. It is a small tree or shrub, growing in Brazil, and is supposed to be the source of the resinous substance called elemi, brought from South America. (See Elemi.) 2. A. Gileadensis, Linn.—Balsamo- dendron Gileadense, Kunth.—Sp. Ch. "Leaves ternate entire; peduncles uni- floral, lateral." Willd. Sp. Plant—A. Opobalsamum, Linn.—Sp. Ch. "Leaves sessile, leaflets pinnate." Willd. Sp. Plant.—In Willdenow's edition of the Species Plantarum, the A. Gileadensis and A. Opobalsamum, are given as dis- tinct species; the former being consid- ered as the source of the balm of Gilead. the latter of the Mecca balsam. Willde- now, however, admits that they may possi- bly be mere varieties of the same plant, depending upon difference in age or soil. Woodville and other writers of authority , are inclined to think them identical. It is certain that balm of Gilead and Mecca balsam are merely different names for the same product, to which other names also have been given, according to the place of its collection or export, as balsam of Judea, of Egypt, of Grand Cairo, of Constanti- nople, &c. {Did. de Mat. Mid. I. 269.) There can be no great error in ascribing it to one plant, which may properly be called the balm of Gilead tree. This is a shrub or small tree, of a stunt- ed appearance, with numerous spreading, crooked, thornless branches, which, when broken, exhale a strong balsamic odour. The leaves, which consist of one or two pairs of small obovate leaflets, with an odd one at the end, are thinly scattered upon the branches. The flowers are minute, of a white colour, and disposed upon the young shoots, three on a common footstalk, of which only one is productive. The fruit is small, roundish, pointed, of a brown colour, and composed of an exterior cover- ing which opens by four valves, and an interior smooth nut. The plant is a native of Arabia and the opposite coast of Abys- sinia. It is said to have been transplanted at a very early period to Gilead in Pales- tine, from which its highly valued product received the name by which it is most generally known. The Arabs call the tree balassan, which is supposed to have been the origin ofthe terms balsam and balm. Besides the balsamic juice, which is obtained by exudation or by decoction, (see Balm of Gilead,) other products of the plant have been employed. The small branches, broken into fragments, were formerly known in Europe under the name of Xylobalsamum, and the fruit under that of Carpobalsamum. Both have, in a feeble degree, the agreeable odour and medicinal properties of the juice; but neither is at present used, at least to any c nsiderable 426 AMYRIS.—ANACARD. extent According to Bruce, who has been followed by Woodville and Thom- son, the names just mentioned were appli- ed to the balsam itself as obtained from the wood and fruit respectively; but this is contrary to the concurrent statement of other authors whom we have consulted. 3. A. Myrrha.—Balsamodendron Myr- rha, Nees von Esenbeck.—Sp. Ch. " Stem fruticose arborescent; branches squarrose, thorny; leaves ternate; lateral leaflets much smaller than the terminal one; all obovate, obtuse, obtusely denticulate at the end, smooth; fruit acuminate." Nees von Esenb.—This is a small branch- ing tree, with a whitish-gray bark, and with its extreme branches rough and terminating in spines. The leaves are small, the terminal leaflet scarcely exceed- ing half an inch in length. The flowers also are small. The fruit, which stands singly on a short footstalk at the axil of the leaves, is ovate, pointed, brown, and about half an inch long. The tree is a native of Arabia, and probably also of Abyssinia. It was seen upon the borders of Arabia Felix by Dr. Ehrenberg, a German travel- ler, who collected from the surface of its bark a gum-resin precisely similar to myrrh, of which, therefore, it is supposed to be the source. (See Myrrh.) From spe- cimens of the plant taken by Dr. Ehren- berg to Germany, it was referred by Nees of Esenbeck, to the genus Balsamoden- dron of Kunth. Other species of Amyris, besides those above described, have attracted some atten- tion from medical and pharmaceutical writers, though their products are not recognized as officinal in the Pharmaco- poeias.—1. The A. ambrosiaca of Lin- neus, {Idea Guianensis and Idea hep- taphylla of Aublet, Idea Tacamahaca of Kunth,) is a tree growing in Guiana and Brazil, and yielding a resinous juice which becomes concrete on exposure, and is used in S. America for the purposes of incense. According to Martius, this resin- ous product is called elemi; but it differs from the substance usually known in com- merce by that name. It was formerly imagined that ambergris was the concrete juice of this tree, altered by the action of the water of the ocean, into which it was supposed to have fallen. A variety of the resin called Tacamahac, has also been referred to it, though upon insuffi- cient grounds.—2. The A. Caranna of Humboldt, {Idea Caranna,) grows in Venezuela, and perhaps also in Mexico, and is said to yield a resinous concrete juice called caranna; but according to Bonastre, several different substances are found in the shops under that name. None of them are used in medicine, at least in the United States.—3. The A. hete- rophylla, of Willdenow, {Idea Aracou- chini, of Aublet,) is a native of Guiana, and the West Indies, and yields a fluid, rod- dish, transparent terebinthinate juice, which is collected in small calebashes, where it hardens. It has an odour like that of Peruvian balsam, and was employed by the natives as a vulnerary, and as a per- fume.—4. The A. Kataf of Forskhal, {Balsamodendron Kataf, of Kunth,) is an Arabian tree, which is interesting only as having been supposed by Forskhal to be the source of myrrh, which, however, has subsequently been shown to be the product of a different species.—5. The A. Zey- lanica, which inhabits the island of Cey- lon, is supposed by Geiger, I know not on what authority, to be the origin of the oriental elemi, which was used by the ancients as a medicine, though at present scarcely to be found in the drug-shops of Europe or the United States. Geo. B. Wood. ANABLEPSIS. (From o*a, again, and f3ta rtw, I see). Restoration of sight. I. H. ANACARDIUM. {Botany.) Sex. Syst. Euneandria Monogynia Nat. Ord. Terebintaceas, Juss., Anacar- diacea:, Lindley. Gen. Ch. Calyx, five-parted. Petals, five, reflexed. Anthers, nine, with one filament barren. Nut reniform, upon a fleshy receptacle. Willd. Sp. Plant. A. oeddentale, Linn.—Cassuvium po- miferum, Lamarck.—Cashew-nut tree. This is the only species of the genus. It is a small tree, fifteen or twenty feet high, with large, oblong-obovate, entire, coriace- ous, shining, alternate leaves, and small, red, odorous flowers, disposed in close pani- cles. It grows in the tropical regions of Asia and America, and is cultivated in some ofthe West India islands. A gum exudes spontaneously from the bark, bearing some resemblance to gum Arabic, but consisting partly of gum and partly of bassorin, and therefore not entirely soluble in water. It is the gomme dAca- jou of French writers. In this country, it is not used. The fruit is the part most employed. It consists of a fleshy, pear-shaped receptacle, supporting at its summit a hard, shining, kidney-shaped nut, which has two shells with a black juice between them, and a sweet oily kernel within the interior shell. The receptacle is red or yellow, and of an ANACARD.—ANAGAL. 427 agreeable, acidulous, somewhat astringent taste. It is sometimes eaten. Its juice, which is recommended as a remedy in dropsical complaints, is converted by fer- mentation into a vinous liquor, from which a spirit is obtained by distillation, much used in the preparation of punch, and esteemed diuretic in the West Indies. The nuts are commonly called cashew nuts, and were at one time officinal under the title of anacardia occidentalia. They were so named from their resemblance to the anacardia orientalia, or fruit of the Sem- ecarpus Anacardium, produced in the East Indies, and formerly employed as a medicine in Europe. The black juice con- tained between the outer and inner shell is extremely acrid, and when applied to the skin produces severe inflammation followed by blisters or desquamation. Even the fumes which arise from it when the nuts are roasted, often produce great irritation of the skin; and the worst case of exter- nal poisoning which has ever come under our notice originated from this cause. The face was so much swollen that for some time not a feature was distinguishable; but the tumefaction ultimately subsided without leaving any permanent effect behind. The juice is employed, in the West Indies, as a local remedy in warts, corns, ringworms, and obstinate ulcers; and it is said that females sometimes apply it to their face, for the sake of the fresh- ness and delicacy of complexion which fol- low the desquamation produced by it. The kernel has a sweet agreeable taste, and may be eaten either raw or roasted. It is used as an ingredient in puddings, &c, and as an addition to cocoa in the prepara- tion of chocolate. It becomes rancid by age. The black juice of the nut, as well as a milky juice which flows from the tree when wounded, is used for marking linen, upon which it leaves an indelible dark stain> Geo. B. Wood. ANACATHARSIS. (From un, up- wards, and %aOaipHv, to purge.) Purgation upwards. Hippocrates employed this term to express the expectoration of phlegm or pus from the lungs; but by some subse- quent writers its signification was extend- ed to all evacuations by the mouth, thus including vomiting, salivation, and expec- toration. I- H. ANACATHARTICS. Medicines which produce Anacatharsis. I- H. ANAGALLIS. Pimpernel. Mouron rouge, Fr.; Rothes Gauchheil, Germ. Sex. Syst. Pentandria Monogynia. Nat. Ord. Primulaceas. Gen. Ch. Col. 5-cleft. Cor. rotate, 5-lobed. Stam. filaments hirsute. Caps. globose, opening hemispherically, many- seeded. Nuttall. Sp. Char. Stem procumbent; leaves ovate, sessile, dotted beneath; segments of the corolla dilated, crenate-glandular. Torrey. This pretty little plant is far from uncommon in most parts ofthe United States, in cultivated land of a sandy or gravelly nature. It flowers all summer, the corolla, however, only opening in fine weather, and infallibly closing on the ap- proach of rain: hence it has been called the poor man's weather-glass. The Pim- pernel, like some other plants, is found in almost every part of the globe, though it is indigenous to Europe alone, but, as is the case with the Leontodon, Cerostium, &c. soon makes its appearance, wherever colo- nies of Europeans establish themselves. The Pimpernel owed its introduction into the Materia Medica, to a belief in its alexipharmic virtues. As early as the time of Dioscorides, it enjoyed a high reputa- tion as an antidote against certain poisons, and especially that of the viper; but its greatest celebrity has arisen from its sup- posed powers in the cure of hydrophobia. The first author who appears to have recom- mended it in this disease, was Rufus, of Ephesus, as early as the year 97: his eulo- gies of its never-failing efficacy have been substantiated by a multitude of writers of eminence. Notwithstanding this united tes- timony in its favour, it gradually fell into neglect until, towards the beginning ofthe present century, when attention was call- ed to it, from the astonishing cures which were said to have been effected with it in Russia. In this country, also, it has long been celebrated, especially among the Ger- mans of Pennsylvania, one of whom com- municated an account of the plant and its virtues to the legislature of that state, in 1802. Among the advocates for its use, was Dr. Muhlenberg. Notwithstanding all the testimony in its favour, the Pimpernel has been found as inefficacious in the cure of hydrophobia, as the equally celebrated Scullcap, and affords another instance of a remedy obtaining a high character, when in fact it is wholly destitute ofthe powers which are attributed to it. At the same time, there can be no doubt that this plant is possessed of some active qualities. It has a marked acrimo- ny with a slightly bitter taste; and from the experiments of Orfila, it appears that 428 ANAL.—ANAPH. it is capable of producing a violent inflam- mation of the stomach; and M. Angelot, of Grenoble, states that he met with a case where eight ounces of the expressed juice caused a long-continued and violent super- purgation. Besides its anti-hydrophobic virtues, the older writers considered it as a valuable remedy in mania, dropsy, phthi- sis pulmonalis, &c.; but its real medicinal properties are yet to be discovered, and in all probability a careful examination of them will prove that this plant is wholly un- worthy of a place in the Materia Medica. There are several varieties of this plant; one, which is the most common, having red flowers, and another with blue. These have been thought, by some botanists, to be dis- tinct species; but this opinion is evidently erroneous, as difference of colour alone ought never to be assumed as a specific character: added to which, Ray states that he has met with specimens of the Pimper- nel with white flowers. Bibliography.—Schrader. Diss, de Ana- gaUide. Halae. 1760. Lemke. Diss, de anagallidis viribus, &c. Ro- stock, 1790. 8vo. T. Short. Medicina Britannica, &c, with appendix, by J. Bartram. Philada. 1751. J. E. Smith. English Botany, 529. London, 1799. Orfila. Traiii des Poisons, II. 275. Paris, 1827. J. Mease. The Domestic Encyclopaedia, by A. Wallich. 1st Am. ed. Philada. 1803. Art. Anagallis. Merat et De Lens Did universel de Mat. Mid. I. 276. Paris, 1829. C. F. Rafinesque. Medical Flora, U. 190. Philada. 1830. R. E. Griffith. ANAL. (From anus, the fundament.) Appertaining to the anus. I. H. ANALEPSIS. (From a*a, afresh, and topfiwsw, to take.) This epithet has been employed in several significations: 1st. To denote restoration of strength after disease; convalescence; Galen :—2d. A species of epilepsy arising from disorder of the stom- ach, and with which the patient is subject to be frequently and suddenly seized; Gil- bert:—3d. The support given to a frac- tured limb; Hippocrates. I. H. ANALEPTICS. Analeptica. A class of remedies suited to restore a loss of the forces of the system, when exhausted by disease or any other cause. This term in its fullest signification would embrace the whole range of stimulants, and is thus used by the earlier writers, whilst at pres- ent it is wholly rejected, or restricted to substances of an alimentary nature. As is observed by Cullen, the meaning of this term is so ambiguous, that it should never be employed. In fact, how can we define the limits of this class 1 as every agent which tends to restore the wasted forces, as repose, sleep, exercise, &c., is, strictly speaking, an analeptic. If, on the other hand, we merely include under this head, those alimentary substances which are of easy digestion and furnish a copious supply of chyle, the objection tu this term is by no means removed, as the effects of these do not differ in any respect from food in general. See Convalescence, Diet, Food. R. E. Griffith. ANALYSIS. (From ewaXwu/, to ro- se! ve.) The resolution of anything, ma- terial or intellectual, into its elements. Analysis in Physics and Chemistry, de- notes decomposition, that is, the separation of what is complex, into its constituent parts. It would be foreign to the objects of this work to enter into the consideration of the means by which this is effected. Analysis in Metaphysics, or the Philo- sophy of Mind, signifies the process of decompounding our thoughts into their simplest elements, or of resolving our in- tellectual operations into their primary principles. The analytic method of in- vestigation is at present employed in all the branches of human knowledge, and is that by which the most important results in the sciences have been obtained. Its application to anatomy, gave origin to the doctrine of the tissues, (General anatomy,) and further applied to Physiology and Pa- thology, it constitutes the basis of Physio- logical Medicine. (See Method.) I. H. ANAMNESTIC. (From wauvfjaa, re- membrance.) This term has a double sig- nification. 1st It is employed to designate medicines supposed to strengthen the memory. It is unnecessary to state that there are none which possess that power. 2d. It is applied to every circumstance anterior to the disease which can elucidate its nature or seat. An antecedent disease, an affection, a passion, any excess what- ever, a fall, &c, previous to the attack of the existing disease, are so many anam- nestic signs. All morbid predisposing or occasional causes should be arranged among these signs, when they have ceased to exist. I. H. ANAPHRODISIA. (From a priv. and a$po&tt*], Venus.) Absence of venereal desires. This may depend on functional or moral causes, and may be temporary or permanent; as, however, it is a cause or symptom of Impotence or Sterility, we refer to those heads. R. E. G. ANAPH.—ANASARCA. 429 ANAPHRODITE. (Same derivation.) One who does not experience venereal de- sires. I. H. ANAPLEROTIC. (From avon^pow, I fill up.) An epithet given to medica- ments which were supposed to possess the property of promoting the growth cr gran- ulation of the flesh in wounds, ulcers, &c. Obsolete. I. H. ANASARCA. (From am, through, and crapl, the flesh.) Called also, by the older writers, leucophlegmatia—pituita alba— veternum hyderos; and by others, hydrops txlernus—hydrops generalis \e\ hydrops cellularis. That form of dropsy in which the effused fluid is contained in the cellu- lar tissue, particularly that portion of it, which is interposed between the skin and muscles. When the effused fluid is con- fined to the cellular tissue of a particular part as of the face or extremities, it is more commonly denominated cedema; the term anasarca being applied to the disease when more generally diffused over the surface of the body. As it is our intention, under the general head of dropsy, to enter very fully into the pathology and treatment of the morbid effusions of a seriform fluid, which occur in the several cavities of the body, we shall confine ourselves, in the present article, to a very brief consideration of those points which have a more strict reference to the form of the disease just indicated. Anasarca, either by itself, or complicated with dropsy of the abdomen or chest, is a disease of very frequent occurrence, and may affect persons of all ages, of both sexes, and of every rank in life. It commences, ordinarily, by an cedema- tous intumescence of the feet and ankles, which at first is chiefly perceptible towards evening, especially when the patient, dur- ing the day, has been pretty much in an erect posture; and it disappears during the horizontal posture of the body assumed at night. Frequently, however, the effusion commences in the cellular tissue of the upper extremities, or of the eye-lids and face; and in other cases, it seems to take place at once over the whole surface of the trunk and limbs. When the first symptom of the effusion is an asderna of the feet, this gradually in- creases, and becomes permanent; at the same time, the swelling extends, with more or less rapidity, to the legs, thighs, and ab- domen, and reaches, finally, the chest, face, and upper extremities—the skin becoming thus, throughout nearly the whole of its extent, more or less distended. The coun- tenance appears bloated; the eye-lids, scro- tum, and integuments ofthe penis, acquire often an enormous bulk, and assume a kind of semi-transparent appearance. The lips lose their vermilion tint and the colour of the skin is very commonly pale or sallow. When pressure is made with the finger upon the parts occupied by the swelling, a pit or depression is formed, which, in most cases, very slowly disappears. In general, those portions of the body in which the effusion has taken place, have a soft, ine- lastic, or doughy feel; but as the distension of the cellular membrane augments, the skin becomes more firmly distended, is less compressible, and has a smooth glossy aspect. In some instances, a portion of the fluid becomes effused beneath the cuticle, particularly on the extremities, which it raises in the form of a vesicle. The cuti- cle, also, in many cases, cracks and gives rise to a constant oozing of an aqueous fluid. In other instances, the skin is said to allow a passage to a similar fluid through its pores, a circumstance, however, which we have ourselves never observed, not- withstanding the very ample opportunities that have been afforded us for studying the disease with considerable minuteness. Attendant upon anasarca, there is very generally a sense of lassitude or disinclina- tion to exertion; a troubled and wheezing respiration, which increases as the swelling augments. Frequently, there is a cough, and an expectoration of thin mucus. The pulse is very variable, being in some cases full, hard, and active, and m others, small and corded;—in other cases, again, it is slow and oppressed. The state of the pulse, or indeed any of the other general symptoms, it is scarcely possible to indicate with any degree of precision, as they will vary greatly, according to the different causes by which the effusion into the cel- lular tissue has been produced, and the morbid condition of the internal organs, with which it is accompanied. The appetite, however, very commonly fails; the skin is often cooler than natural, or even decidedly cold; but in numerous instances, we have, on the other hand, found the heat of the surface to be consid- erably increased, while, at the same time, the face was flushed, and all the ordinary symptoms of fever were present. There is almost always more or less thirst, and a diminution in the urinary se- cretion, which varies in its colour/ and other properties. The bowels are com- monly costive, and the cutaneous exhala- tion is either very much diminished, or entirely suspended. The foregoing constitute those phenom- 430 ANASARCA. ena by which anasarca may be easily re- cognized, and readily distinguished from every other morbid intumescence affecting the superfices of the body. But in many cases other symptoms are also present, de- pendent upon the affection of some inter- nal organ, or upon a complication of the anasarcous swelling with serous effusion into the cavity of the abdomen or thorax, or into both. According to Ayre, {Re- searches into the Nature and Treatment of Dropsy,) in the latter cases, the internal dropsy almost invariably precedes that of the cellular tissue. The progress, duration, and result of anasarca, will depend, very much, upon the cause by which the effusion has been produced, and the nature and extent of the internal lesions which accompany it. Of itself, it is an affection by no means very fatal, and when simple or unaccom- panied with serious disease or disorganiza- tion of some important viscus, it is not dif- ficult of cure. The skin becoming moist; the thirst less; and the urine increasing in quantity while the swelling gradually diminishes from the superior portions of the body, are to be considered favourable circumstances. In a few cases the anasarcous swelling ceases by a spontaneous crisis; either by a very copious flow of urine, or watery purging, or a profuse perspiration suddenly occurring. In some rare instances, the dropsy of the cellular tissue has been observed all at once to disappear, while at the same time extensive serous effusion occurs in the cavities of the head, chest or abdomen, or simultaneously in all of them. This fact was noticed by Portal {Observations sur Vhydropisie); and several interesting ex- amples are recorded by Andral {Clin. Mid. I. 132.). The external swelling in these cases disappears suddenly, and the patients are immediately seized with great difficulty of breathing, or sink into a state approaching to apoplexy. The impedi- ment to respiration, and the soporose symp- toms, rapidly augment and finally termi- nate in death. On dissection, the cavities of the brain and ofthe pleura are found to be distended with serum, while the cellu- lar tissue of the exterior of the body pre- sents scarcely any traces of effusion. (Dance.) By the autopsical examination of ana- sarcous subjects, the subcutaneous cellular tissue is discovered to be loaded with a se- rous fluid, which escapes upon every inci- sion. The more deeply seated cellular tissue is often similarly distended, and in some cases that likewise which is inter- posed between the fibres of the muscles. When the anasarca has continued for a length of time, the muscles themselves appear soft and pale; the blood is deprived of its plasticity, and of its bright scarlet hue; the heart ordinarily contains a few coagula, soft, and almost colourless. These latter phenomena are, however, almost ex- clusively confined to those chronic varie- ties of anasarca which are dependent upon extensive disease of some important or- gan, or upon long-continued impedimenta to the free passage of the blood through the veins. In what may be termed the acute forms of anasarca, the solids are less affected; and the blood is less serous, and during life, when drawn from a vein, speedily coagulates and is covered often with a thick buffy coat. According to Portal, when the ana- sarcous effusion has been of long standing, the cellular tissue becomes more or less thickened, and its cells augmented greatly in size. Sometimes the skin itself, as well as the adipose and mucous tissues, acquire a great increase of thickness and of densi- ty, and are infiltered to a greater or less extent with serum. Anasarca, as well as all the other forms of dropsy, is, strictly speaking, a mere symptom or effect of various morbid states of the different tissues and organs of the body. It may be dependent, 1st upon a diminished activity in the forces by which the circulation of the blood is accomplish- ed : 2dly, upon an impediment to the free passage of the blood through the veins: 3dly, upon a diseased condition of the kid- neys : and, 4thly, upon a certain grade of inflammation affecting the subcutaneous cellular tissue. To one or other of these causes it is believed that nearly all cases of anasarcous effusion may be referred. In some instances it is probable that sev- eral of these causes may coexist render- ing the effusion more extensive, and, at the same time, its treatment peculiarly difficult and unsuccessful. 1. From diminished activity in the cir- culation of the blood. Anasarcous intu- mescence from this cause, constitutes the simplest variety of dropsical effusion. It is in most instances local, being confined en- tirely to the lower extremities, and readily disappears as the vigour of the heart, and of the muscular system generally, is re- stored. This variety of the disease is com- monly met with in persons labouring un- der considerable exhaustion from profuse hemorrhages, excessive discharges from the bowels, fatigue and long fasting, and ANASARCA. 431 during convalescence from long-continued and debilitating diseases. To the same cause is probably to be referred the cede- matous swellings so common in persons who remain inactive in an erect position during the greater part of the day, and in those, who, without using a proper amount of muscular exercise, pass their lives in sedentary occupations. According to Ray- er {Sur Vhydropisie), the effusion in these cases results from the venous circulation of the lower extremities being rendered much slower than natural, in consequence ofthe inactivity as well as diminished con- tractility of the muscles of those parts. 2. From impediments to the free circu- lation of the blood, particularly obstacles to the return of the blood through the veins. Anasarca from this cause, is one perhaps of the most common and intracta- ble of the varieties of external dropsy. The impediments to the circulation giving rise to the effusion into the cellular tissue may proceed either from disease of the lungs, liver or other organ; from a contraction of the orifices of the heart and other morbid affections of that organ; from a diseased condition or obliteration of the great venous trunks of the chest, abdomen or limbs, or from pressure upon these vessels, in some part of their course, by tumours in their vicinity. The pressure of the gravid ute- rus, tight ligatures upon the limbs, and other temporary impediments to the ve- nous circulation, often give rise to an cede- matous swelling, which disappears almost immediately upon their removal. In the variety of anasarca under consid- eration, the effusion always manifests itself first in, and is frequently confined entirely to, those parts of the body situated above or below the point in reference to the heart at which the impediment to the free passage of the blood exists. Thus, when it is owing to an affection or compression of the veins of the abdomen, it is in the feet and legs that the osdema is first perceived; but if the impediment exists in the veins of the up- per portions of the body, the osdema will invariably commence in those parts from which the obstructed veins originate. Ge- nest, in a very interesting paper on ana- sarca, contained in the Gazette Mid. de Paris, for 1833, (I. 569.) maintains that ef- fusion into the cellular membrane accom- panying organic lesions which prevent the free circulation of the blood, is in many cases to be considered rather as a concom- itant symptom, than as a phenomenon ne- cessarily dependent upon such lesion. In- dependently of the circumstance of the lesions often occurring without giving rise to any degree of dropsical effusion, he conceives that his position is established by the fact that the anasarcous swelling will frequently disappear, at least for a long time, under the influence of a variety of causes, while the organic lesion remains stationary, or even increases in extent. 3. From a diseased condition of the kidneys. Dr. Bright, of London, was the first who pointed out the very common de- pendence of dropsical effusions upon in- flammation and disorganization of the kid- neys {Reports of Med. Cases. London, 1827.); and his conclusions were subse- quently confirmed, to a certain extent, by the observations of Dr. Christison, of Edinburgh {Ed. Med. and Surg. Journ. Oct. 1829.), and more recently by Dr. Gregory, of the same city. {Ed. Med. and Surg. Journ. Oct. 1831.) In all these cases the urine was found to contain a considerable amount of albu- men, being more or less coagulable by heat; and according to the experiments of Dr. Christison, it is deficient in urea and in its peculiar salts. Although we cannot subscribe to all the conclusions of either Dr. Bright or Dr. Christison, there can be no doubt whatever, in our opinion, that a very large class of anasar- cous effusions are attributable mainly to a diseased condition of the renal glands. In this class, according to Genest, are to be included many of those cases of external dropsy ordinarily referred to a commencing organic affection in other organs. The fact is, that irritation and the other morbid states of the kidneys, have been, hereto- fore, too much overlooked, and hence it is only by their remote effects, and when they have produced such extensive disor- ganization, as to be, in a great measure, incurable, that they first attract the atten- tion of the practitioner. In nearly all the cases of anasarca pro- duced by one or other of the causes now enumerated, the intumescence occurs gradually, and is soft, very compressible, and preserves for a considerable time the pits made into it by the finger, or by the pressure of the clothes. It changes rea- dily its place, and the effused fluid has a tendency to accumulate in those parts which are the most depending. The tem- perature ofthe skin is in general reduced, and the surface of the body occupied by the swelling has a pale, dull white or sal- low hue, and when the distension is very considerable, it is smooth and glossy. The urine is for the most part transparent, co- lourless, and without any particular sedi- ment. 432 ANASARCA. 4. From inflammation of the subcuta- neous cellular tissue. That anasarca is frequently dependent upon this cause, in the same manner as hydrothorax and asci- tes are produced by a particular grade of inflammation affecting the serous tissue of the chest and abdomen, we believe with Dr. Ayre, by whom this point has been very fully and ably examined, there cannot be a doubt. It may be said that in the cases of anasarca referred to this cause, the symptoms of inflammation are absent But we ask, what symptoms of inflammation 1 We are certainly not to expect those pecu- liar to the inflammation of other tissues, nor even those phenomena attendant upon the more violent grades of inflammation which affect occasionally the cellular membrane. The fact is, that the symptoms of that grade of irritation which in the serous tissues gives rise to an increased effusion of a seriform fluid, are extremely obscure, and often the first indication we have of its existence is the appearance of an hydropic affection. The variety of anasarca now under consideration is ordinarily produced by ex- posure to cold and moisture, by the sudden suppression of some habitual dis- charge, by various acute affections of the skin, especially scarlatina, and ex- tensive erysipelatous inflammation. Ac- cording to Dance, it is the present va- riety of anasarca which frequently occurs in robust females about the period of pu- berty, when menstruation is retarded or irregular; and at the commencement of pregnancy. It is probably to a similar cause that we are to attribute the exten- sive cedema by which rheumatic and other inflammations of the joints and extremities are so frequently accompanied, and which we occasionally observe as a symptom of irritable ulcerations ofthe legs; as well as the general effusion into the cellular tissue produced by the application to the skin of certain vegetable poisons, as the rhus toxicodendron, &c. We have likewise observed this variety of dropsy to occur, in numerous instances, in persons labouring under extensive irritation of the stomach and bowels. It is said also to be very fre- quently occasioned by imprudently enter- ing upon a too stimulating diet in the early stage of convalescence from acute diseases. Anasarca from inflammation of the sub- cutaneous cellular tissue is most gene- rally simple, being very rarely complicated with dropsy of the internal cavities. The intumescence occurs suddenly, and spreads with great rapidity; it is for the most part firm and elastic, and preserves but momen- tarily the depression made into it by the finger. It is more generally diffused over the surface of the body than in the other varieties; and the effused fluid is less in- clined to accumulate in depending parts. The temperature of the skin is often increased, and in place of the dense sallow, or pallid hue observed in anasarca from other causes, there is frequently an increas- ed redness of the surface, with a sensation of heat or formication, with pains of the back, head and extremities, flushing ofthe face, and occasionally well-marked exacer- bations of fever. The pulse is more or less hard, full and frequent, and the urine is occasionally of a deep red colour and sedi- mentitious. Treatment. In the first variety of ana- sarca, little is required excepting to restore strength to the body, and increase the vigour of the circulation, by a light nour- ishing diet, by frictions of the surface, by exercise in the open air, and a proper re- gulation of the bowels. The use of the warm bath, and light tonics, may occasion- ally be found beneficial. As the energy of the muscles increases, and the circu- lation assumes its normal activity, the effusion disappears entirely. Should, how- ever, the cedema persist, some ofthe milder diuretics may be exhibited, and repeated according to circumstances. In the second variety of anasarca, the treatment will vary according to the nature ofthe organic disease by which the effusion is accompanied. The removal of this, when practicable, is the more import- ant indication, as the effusion will very generally at the same time disappear; or at least may be removed' afterwards by very simple remedies. Unfortunately, however, in too many instances the former is beyond the reach of our art; but even in such cases it is always important to attempt the reduction of the anasarcous swelling, as we may in this manner afford very considerable relief to the patient, often protract his existence, and render him comparatively comfortable for a long period. Bleeding from the arm, adapted in extent to the age, strength, and general condition of the patient will frequently be found decidedly beneficial. When admissible, the milder hydragogue cathartics, particu- larly the compound powder of jalap, or a combination of gamboge and cream of tartar, one, two, or three grains of the former, to three or four drachms of the latter, will often reduce very rapidly the swelling; the only cases in which these remedies would appear to be of doubtful propriety, are those in which the patient is labouring under considerable exhaustion, ANASARCA. 433 or in which the stomach and bowels are in a state of decided irritation. From diuret- ics we have seldom, in this variety of ana- sarca, derived any very striking results. The squill, digitalis, and calomel, may, however, be tried. The acetate and tar- trate of potass have in many cases been found beneficial, and it is probable that in some instances advantage will be derived from the use of the vinum seminis colchici, as well as from the terebinthinates. Alter- ative doses of mercury have been highly recommended; it is only, however, when they may be presumed useful in removing the organic disease by which the effusion is produced and kept up, that we can expect much good from their administra- tion. The remedies ordinarily prescribed with a view to the removal of serous effusions will be more fully treated of under the general head of dropsy. Their particular adaptation to the variety under considera- tion must be left to the judgment of the practitioner; whose decision will have to be influenced, in a great measure, by the peculiar circumstances of each case. Genest recommends strongly small punctures into the cellular tissue as an effectual means of facilitating the evacua- tion of the effused fluid. Although we have repeatedly made trial of this means, we must confess that we have seen very little, if any good, result from it In the third variety of anasarca, or that dependent upon disease of the kidneys; our treatment must vary according as these organs are simply in a state of inflamma- tion or engorgement, or are already more or less disorganized. If the disease be recent the amount of albumen in the urine being but small, and especially if at the same time, a small quantity of blood is occasionally voided with it; if there be experienced a sense of pain or uneasiness in the loins, increased in the act of rising or by the motions of the body, and if the patient be'young and ple- thoric, and his system is still possessed of considerable strength and vigour, bleeding from the arm, repeated according to cir- cumstances, and from the region of the kidneys by means of cups, repeatedly appli- ed ; a state of rest; mild demulcent drinks, and a well regulated, but abstemious and unirritating diet will frequently, in a short time, remove the renal disease, as well as the effusion into the cellular tissue. The patient, however, must be extremely cau- tious in his subsequent mode of living, to prevent a relapse. When, however, the morbid phenomena vol. i. 37 have been of long standing; the urine being loaded with albumen and the patient's strength is exhausted, and his constitution presents a general cachectic condition; there is reason to believe, that the tissue of the kidney is more or less disorganized. We can only hope in such cases to palliate the more urgent symptoms. The repeated application of leeches to the loins may be still required, followed by the formation, at that part of an issue, or the introduction of a seton; the patient at the same time being put upon a properly regulated diet, and debarred the use of all stimulating food and drinks. The reduction of the anasar- cous swelling is to be attempted by mild saline purgatives, as the citrate and super- tartrate of potass, and by diuretics, particu- larly the squill and digitalis, combined with small doses of opium or cicuta. When the inflammatory affection has been subdued by depletion, Dr. Bright conceives that advantage will in many cases be derived from turpentine and the Peruvian balsam: for ourselves, we should prefer in such cases the copaiba. In one or two instances, where the feeble but extensive beat ofthe heart led that gentle- man to suspect the existence of a soft and flaccid state of the kidneys, a combination of sulphate of quinia and squill removed entirely the dropsical effusion, and effec- tually restored the patients to health. Uva ursi has likewise been found useful in some of the cases of anasarca attended with diseased kidneys. Anasarca from sub-acute inflammation of the cellular tissue may in general be very promptly, and permanently removed by bleeding from the arm, governed in its extent and repetition by the symptoms of each case, and the age, strength, and other circumstances of the patient. In a large number of the cases belonging to the pre- sent class of dropsies, the prompt and judi- cious employment of the lancet is all-im- portant Without the early and often the repeated use of blood-letting, but little hope need be entertained from the beneficial operation of purgatives or diuretics. The detraction of blood is of itself often suffi- cient to dissipate the anasarcous swelling, or when this is not the case, but little diffi- culty will be experienced afterwards, in its removal by the milder hydragogue cathar- tics, or by those remedies which act princi- pally upon the kidneys. In some instances leeches to the anus will be found highly beneficial, especially when the dropsy has succeeded to the sudden suspension of the hasmorrhoidal flux, or when it is suspected to be conjoined with chronic irritation of 434 ANASARCA. the intestinal mucous membrane, {Ann. de la Mid. Phys. Aug. 1831.) Dr. Ayre, in cases of cedema, in which the local " serous inflammation" still subsists, directs the application of leeches and cold evaporating washes to the surface; observing not to commence with the latter, until twelve hours after the leeches have been used, to guard against exciting inflammation in the wounds made by them. In cases of ana- sarca likewise, leeches are recommended by the same author, to the extremities or those parts of the body in which the serous tissue, is most affected. We believe this practice to be a judicious one, from which, in numerous instances, the most decided good effects will be derived. In regard to the propriety of the application of at least cool air to the skin in the treatment of the active varieties of anasarca, some useful hints will be found in the writings of Dr. Parry, (London, 1825). Next to the lancet, the remedies from which the greatest amount of good will be derived, in the variety of anasarca now under consideration, are the milder hydra- gogue cathartics. There are few cases in which their employment will not be pro- per ; and their use may often be persisted in, until the effused fluids are entirely evacuated, when we are precluded from the employment of almost any other active remedy. The tartrate or super-tartrate of potass, either by itself, or combined with jalap or gamboge, and repeated at such in- tervals as to produce copious fluid discharges from the bowels, will often, after the em- ployment of blood-letting, in a very short time remove entirely the dropsical swelling. In the active variety of anasarca, we indeed possess few more effectual remedies than the cream of tartar: Dr. Home, of Edin- burgh, states that, in his hands, it cured radically fourteen out of twenty of the cases in which it was employed. Dissolved in a large quantity of water, it forms also a very excellent diuretic drink, in the gen- erality of cases. Various diuretics will likewise be found advantageous in the present variety of ana- sarca. Nitre and squills, or nitre, gamboge and digitalis; sweet spirits of nitre; the infusion of parsley, and the acetate and citrate of potass, have all been employed by us with good effect, after bleeding. As, however, remedies of this class are very uncertain in their operation—the mildest, in some instances producing a copious in- crease of the urinary secretion, whilst in others, the most active are productive of little or no effect—when one fails, another may be tried; taking care, however, al- ways to avoid those possessed of stimulat- ing properties. The vapour bath is recommended byGE- nest, in all cases in which there is nothing present to forbid its employment. He con- ceives that in the reduction of anasarcous swellings it is a remedy of very consider- able efficacy, and far preferable to sudorif- ics, internally. In certain cases, in which the skin appears to enjoy but little activity, it may be proper, he observes, to add to the bath various aromatic substances, or to ex- pose the patient to the fumes of the latter alone. Stork removed in five days, by fumigations of amber, an extensive anasar- cous swelling, occurring in a young girl; after various other plans of treatment had been found ineffectual. When the strengh of the patient is considerably reduced, while the skin is greatly distended, small punctures into the cellular tissue, to evac- uate the fluid, may be tried. Delamotte reports the case of a young man labouring under most extensive cellular dropsy, which was completely cured in three days, by this means alone. In regard to the diet of the patient in cases of anasarca, but little need be said. In those attended with a plethoric condi- tion of the body; with an active state of the circulation; with irritation or inflam- mation of some internal organ, or of the surface ofthe body, the diet should be very spare, and consist of such articles only as are devoid of any stimulating properties. Thin gruel, toast or barley-water, and the like, in moderate quantities, will be all that is necessary, in a large number of cases, either as food or drink. Even when the strength of the patient is considerably reduced, it will be imprudent to allow any- thing but the mildest nourishment; and even this should not be taken in too great quantity. It is unnecessary to say anything in relation to the very objectionable prac- tice often pursued by dropsical patients, and even recommended by respectable physicians, of drinking large quantities of gin and water, as a diuretic, and using wine freely, with a view of removing the debility under which they are presumed to labour. In all cases of the disease, this practice will be found decidedly prejudi- cial, and when the dropsical effusion is connected, as it so frequently is, with chronic irritation of the stomach and bow- els, or commencing disorganization of the kidneys, it cannot fail to increase all the more unfavourable symptoms, and hurry on a fatal termination. ANASTOMOSIS.—ANATOMY. 435 Bibliography.—Roeber. Fasciculum obser- vat. medieo-prac. Strasburg, 1787. Stork. Medical Works, by Carmichael Smyth. London, 1788. Maclosty. De hydrope anasarca. Edin- burgh, 1795. Vieusseux. Sur Vanasarque a la suiti de la ivre scarlatine. Rec. period, de la Soc. de Mid. I VII. Hirzel. Diss, sistens observationes circa hy- dropem maxime anasarca. Tubingen, 1808. Hourges. Observations sur la leucophlegmatie idiopathique. Jour. Gen. de Med. 1808. XXXI. 149. Burdei.. Sur Vanasarque, ou hydrcpisie du tissue cellulaire. Paris, 1810. Breschet. Sur Vhydropisie active du tissue cellulaire. Paris, 1812. Samson. Sur Vanasarque. Paris, 1813. Monegier-Sorbier. Sur Vanasarque. Paris, 1814. Richard. Sur Vanasarque, suite de la Scarli- tine. Paris, 1826. Bright. Reports of medical cases. Sec. I. On the appearances observable in diseases terminating in dropsical effusion. London, 1827. Christison. Observations on the variety of Dropsy which depends on Diseased Kidney. Ed. Med. Surg. Jour. Oct. 1829. Andral. Clinique Midicale. I. Gregory. On diseased stales of the kidney connected during life with albuminous urine. Ed. Med. Surg. Jour. Oct. 1831. Hamilton. On the Epidemic Scarlatina and dropsical affection which prevailed in Edinburgh during the autumn of 1832. Ed. Med. and Surg. Journ. July, 1833. Genest. Recherches sur Vanasarque et son traitement. Gaz. Med. de Paris, 1833. Nos. 60, and 61. Dance. Art. Anasarque. Diet, de Med. (See Bibliography of Dropsy.) D. F. CONDIE. ANASTOMOSIS. (From am, between, and o-topn, a mouth.) Communication be- tween two vessels, which do not arise from the same trunk, or at least from the same principal branch, and the purpose of which appears to be, to facilitate the circulation of the fluids. The arteries have fewest of these communications; they occur more frequently between veins; but it is be- tween the lymphatics that there are the most numerous anastomoses. I. H. ANASTOMOTICS. (Same derivation.) This term has two different significations. 1st. It has been applied to medicines which were supposed to possess the power of opening the mouths of vessels and promot- ing the circulation, such as Cathartics, Su- dorifics, Deobstruants, &c. 2d. In Anato- my, it is used to signify whatever has reference to anastomosis. I. H. ANATOMY. (From am, through, and Ttfiviw, to cut.) Literally the act of dis- section; but in its ordinary acceptation this term is employed to designate the sci- ence of the organization, or of organized bodies. On account of the inadequacy of the term to represent all the objects to which it has been applied, various others, more expressive and appropriate, have been proposed; as Morphology, Organo- logy, Zoography, Physiography, &c, which have not however, been generally adopted, because the term Anatomy has received the sanction of general usage. The objects of anatomy, considered in its fullest application, are all organized bodies, whatever their characters or im- portance, in the grand scheme of the universe. But as these objects, examined in the abstract, are diversified, so is anato- my equally varied in its application. Hence it has been divided according to the end it has in view. When applied to the deter- mination of the form, volume, relations, connexions, and structure of the human body, it is denominated human Anato- my, Anthropotomy, Anthropography, &c. When directed with the same view, to the investigation of the organization of ani- mals, it is called Zootomy; and if the ex- amination of the characters of the vegeta- ble organization be its object, it is desig- nated Phytotomy. But however multifari- ous and diversified may be the beings upon which the anatomist bestows his attention, —whether it be the obscure and simple lichen, the tiny monad or embrion, or man, who is the most complex in his organiza- tion and exalted in his attributes, the ob- ject is. the same,—the mysteries of their organic arrangements, and the determina- tion of their adaptation to the accomplish- ment of the destinies allotted to them in the great system of nature. While, however, the form, texture, re- lations, and connexions of the organization may be said to constitute the principal objects of the pursuits of the anatomist, whatever class of beings may engage his attention; in making a practical application of the principles comprised under these heads, it becomes necessary to subdivide the subject still more minutely, in order to enable him to give a lucid exposition of the details which appertain properly to each. Thus, for example, in the depart- ment of human anatomy, the organization may be examined: 1st. In relation to tex- ture alone, without regard to its form, vol- ume, or connexions. This constitutes what has, since the time of Bichat, received the appellation of General Anatomy, or His- tology. 2. The attention of the anatomist may be directed especially to the determi- nation of the outward form, the volume, weight situation, connexions and relations of the different parts of the human body, the details appertaining to which, repre- sent what is called special or descriptive 436 ANATOMY. Anatomy. Both these departments may, moreover, be considered in reference to the healthy and diseased conditions of the organization, and the particular disposi- tion, as regards the form, situation, con- nexions and relations of the parts com- prised within the several regions of the body, examined in reference to their im- portance in modifying diseases and acci- dents, influencing surgical operations, and aiding in the formation of a diagnosis. The considerations which appertain to the first head constitute what is denominated Physiological Anatomy; those of the sec- ond belong to what is called Pathological, Morbid, or Medical Anatomy; and the third forms a department of the subject to which the appellation of Topographical Anatomy has been applied, of which Sur- gical Anatomy is a part. The range of this department of sci- ence, limited, as it is, only by the vast and unknown bounds of animal crea- tion, conducts the contemplation of the anatomist beyond the mere examination of the characters and relations of the hu- man structure. Having determined the properties of the organization of his own species, and taking it as the standard of comparison, he next analyzes the struc- ture of the whole series of animals, from the most complex to the most simple; de- termines the affinities and dissimilarities ofthe same or corresponding organs in the various families and species; ascertains what parts are absent, or what superadd- ed ; what modifications take place in the different organs, to adapt them to the cir- cumstances under which they are destined to subsist; and thus not only acquires prin- ciples by which the whole range of zoolo- gical creation can be classed and grouped into families or sections, according to the affinities of their organization, but becomes enabled to penetrate into the still more interesting secrets of animal physiology. These considerations appertain to what is called comparative anatomy, which, when taken in its proper relations, is capable of affording valuable illustrations of the phi- losophy of organization. There is one ramification of it, especially, which is pe- culiarly rich in its details, and extensive in its relations. It has received the ap- pellation of Philosophical, or Transcen- dental Anatomy. Its object is the more abstract laws of the organization. It does not take particular cognizance ofthe form, volume, situation or connexions of an or- gan, but is more particularly interested in determining its existence in the different families and species; in ascertaining its relative importance; in arriving at a know- ledge of the manner in which the organ- ization becomes more perfect in ascending, and more simple or imperfect in descend- ing, the zoological scale; and in thus stu- dying its analogies throughout the whole series of beings, establishing its unity, and reducing all its varying characteristics to certain fixed and general laws, the gene- ralities of which are applicable to the en- tire animal series. Finally, there is still another species of Anatomy, of more limited application, yet exceedingly interesting in relation to its object. It takes cognizance of merely the exterior conformation of the body; and as it is more especially important to the painter and sculptor, it is denominated Pictorial, or Picturesque Anatomy. To the same head appertains the considera- tion of the varying changes which take place upon the superficies, under the ope- ration of its physiological acts, and which hence constitutes what has been called Anatomy of Expression. To make a just appreciation of the sub- ject,—to determine its application, and to estimate its importance, it will be neces- sary to enter into a brief examination of each of these divisions and to define more particularly its object. Contemplating it in these relations; as a knowledge of the elements of the organ- ization, and the simple textures formed by them, should properly precede -that of the organs themselves, General Anatomy, which has these considerations for its ob- ject, naturally presents itself as the first division of the subject § 1. General Anatomy, a. Objects of General Anatomy.—The special object of this department of the science is the anatomy of texture, under which is not only comprised a knowledge of the proper elements of the organization, but likewise of the proportions in which they combine to form the various tissues entering into the composition of the several organs and systems. The numerous and appa- rently dissimilar structures of the animal organization are all composed of similar proximate elements, and are susceptible of being reduced, by an ultimate analysis, to an assemblage of globules intermixed with a simple, homogeneous, coagulable, or coagulated fluid. The province of gen- eral anatomy is, therefore, to determine the properties of these proximate ele- ments; to explain the manner in which they combine to form the various fluids and solids of the body; the proportions in which they unite in the constitution ofthe ANATOMY. {General.) 437 combinations; the modifications impressed also retains this character in many parts upon the compounds by the various dis]x>- even where the globules are superadded, sition of their constituent atoms;—to de- as, for example, in many of the animal signate, by a rigid analysis, the several fluids. On the other hand, the coagulable fluids and solids which are thus formed; fluid in a state of coagulation, when united —to ascertain the physical and chemical with the globules, always forms a solid of properties of each; its colour, density, more or less consistence, and which has an cohesion, elasticity, expansibility, contrac- appreciable form. tility, &c, and the character of its chem- The most simple solid arrangement ical elements;—to investigate their vital formed by the combination of these or- properties, and the modifications to which ganic elements, is either filamentary or all these, as well as their composition, are laminated. In giving rise to these two subjected by age, sex, temperament, and elementary forms, the globules are differ- other causes; and finally, to ascertain the ently disposed, being in the first arranged manner in which the more simple struc- in linear series; in the second, apparently tures, endowed with their individual attri- disseminated without any very regular butes, are united to form others more com- order. In both, however, the interstices plex, and these, in their turn, combined to of the globules are filled up by the coagu- constitute the multifarious organs and sys- lable fluid in a state of coagulation. These terns ofthe animal economy. In its method, filaments and laminas unite with each therefore, it must be necessarily both ana- other in different manners, sometimes giv- lytic and synthetic. It does not merely take ing rise to a species of cellular or areolar cognizance ofthe superficies ofthe several arrangement, or the laminas alone present objects which fall within its province, but themselves in form of an attenuated, viscid, penetrates in their interior,—separates the concrete, mucous-like substance, divided various elements, scrutinizes their proper- into numerous portions, which, by having ties, and then by determining the order of their relations varied, form those cells or their aggregation, endeavors to unfold all areola?, without the concurrence of the the secret properties of their most intimate filaments. This is especially manifest in texture. Nor should it be restricted to the the substance denominated cellular tissue, investigation of the solids, as it has been when it is reduced to its elementary form, by some anatomists. The fluids are equal- and it is probable that the serous mem- ly objects calling for the exercise of its branes merely consist of expanded lamince resources, inasmuch as they and the solids of this character, in which, however, ac- possess an intimate correlation with each cording to the observations of Raspail, no other. (See Humours.) The solids form globules exist. the fluids, and these in their turn are in By various modifications and states of part converted into solids, and in part pass combination taking place between these off from the system in form of extraneous two primitive forms of organized solids, a or effete matter. The animal machine is number of proximate arrangements or tex- a perpetual laboratory, in which its atoms tures are developed, which we denominate are submitted to ceaseless change during tissues. (See this word.) every moment of existence; and to deter- The investigation of the properties of mine what these changes are, and to ap- these solids and fluids, is the object of preciate their importance in the grand general anatomy. But this investigation scheme of living nature, all the elements, must not be confined to the surface. The both solid and fluid, should be taken into several structures must be unravelled, the account. various tissues decomposed, their elements The most simple condition of every ani- isolated, and the order in which they com- mal structure is fluid. The elements of bine with each other determined. The this state of fluidity are, as already repre- complex organs must be reduced, as far as sented, an assemblage of microscopic glob- possible, to their ultimate state of analysis, ules disseminated through a homogeneous, in order to determine the moresecret prop- coagulable or coagulated fluid. The lat- erties of their texture, and their component ter may exist alone, but the globules are tissues scrupulously examined, in order to never present without the simultaneous ascertain their physical and vital proper- existence of the fluid either in its liquid ties, and the relations they bear to each or coagulated state. The consistence of other. Haying ascertained the composi- the part will depend much upon the con- tion and vital endowments of the more dition of this latter ingredient. When the simple solids, the next object is to deter- globules are not present, and the fluid is mine the manner and the proportions not coagulated, it will be liquid; and it in which they unite, to form those which 37* 438 ANATOMY. {General.) are more complex; to inquire into the modifications of structure and vitalism which are produced by these combinations, the changes to which they are submitted by age, sex, temperament, and other con- ditions—their adaptation to the functions which they are destined to execute, and their relations with each other when blend- ed to form the totality of the organic ar- rangements. The fluids, likewise, must be submitted to the same rigid investiga- tion. Their mode of formation, as well as their composition, must be as accurately as possible determined; and as some of them, as well as the solids, are endowed with vi- tality, the qualities which they derive from this endowment should be investigated, as also, the changes and modifications to which they are submitted by age, and other causes which influence them. In these investigations, the unassisted eye alone must not be exclusively relied upon. The adventitious aids furnished by physi- cal and chemical science must be called into requisition, and by the assistance of the various means of mechanical division, the help ofthe microscope, and the agency of chemical analysis, our researches must be extended even into the intimate mole- cules of the organic elements, that by as- certaining their disposition and attributes, we may discover their vital properties, and the part they perform in the general scheme of vital actions. b. Appreciation ofthe value of General Anatomy. In appreciating the importance of general anatomy, it should be consider- ed in relation to both physiology and path- ology, and, through them, to the practical details of the healing art As regards its relations with physiology, they are so ap- parent that it is scarcely necessary to discuss the subject Physiology may be defined the science of living nature. Gen- eral anatomy determines the properties of the animal organization ; analyzes the in- struments by the concurrent acts of which vitality is sustained and perpetuated; and, as the phenomena of life are merely the product of an assemblage of functions ex- ecuted by special instruments, organs, or apparatus, destined for that office, before we can appreciate the character of the acts concerned in the execution of these functions, we must be acquainted with the material arrangement or organized tex- tures by which they are accomplished. General anatomy, by analyzing, as it were, the component parts of organized bodies, teaches that they are composed of an assemblage of tissues, all differing in texture,—all presenting a difference of type,—appropriated to the execution of different functions, and possessing various degrees of vital endowment, but all con- curring, by their respective acts, in the production of those phenomena in which life consists. To estimate, therefore, the share performed by each in the accomplish- ment of these ends,—to determine the acts which are proper to each, and their exact relations with others, requires that the character of the instruments themselves, as regards their intimate texture and vital endowments, should be previously well as- certained. This object accomplished, we proceed in our investigations, from cause to effect,—we advance from data which are fixed and positive, to conclusions which are valid and unvarying, and by thus pro- gressing, from structure to function, we confine ourselves to the rules of inductive philosophy, and deduce no inferences ex- cept such as are compatible with the known properties and attributes of the powers which are instrumental in the pro- duction of the phenomena of which we take cognizance. Viewed in these rela- tions, general anatomy forms the very foundation of physiology,—constituting the source of all its postulates, and the rallying point of all its conclusions. To illustrate this proposition, let us take the mucous membranes. We find them spread out upon the whole extent of the internal surfaces of relation, lining most of the hollow organs, and presenting, in different situations, modifications by which they are adapted to the purposes they have to accomplish. They are secern- ent exhalent, absorbent, tactile, and be- sides, endowed with other offices. Thus, in the nares and on the tongue the mucous membrane contributes to form the instru- ments of special senses, while in other parts, it is mainly concerned in the devel- opment of channels of transmission; as, for example, in the larynx and trachea; the mouth, pharynx, and oesophagus; the excretory ducts of the glands; the ure- thra, &c. In relation to the office of secretion, we find disseminated over its entire surface an infinity of small crypts or follicles, which constantly elaborate a mucous fluid, by which its surface is moist- ened and protected. To enable it to ex- hale, it has myriads of vessels terminating in its substance and on its surface, and is besides sufficiently spongy or porous in its arrangement to admit of the easy transu- dation or exhalation of attenuated fluids. The same porosity, together with the ori- gin of numerous lymphatics and veins from its substance, explains its absorbent faculty. ANATOMY. {General.) 439 It is everywhere tactile, or at least endow- ed with a species of organic sensibility. These properties it derives from numerous nerves which are distributed to its sub- stance, and which, with the concurrence of minute capillary blood-vessels, form an infinity of delicate papillas, disseminated over its surface. Where it is appropriated to the purposes of a special sense, as in the nose, and on the tongue, these papillas are supplied from those nerves which are des- tined peculiarly for that office. And, final- ly, where it is merely concerned in the formation of channels of transmission, it is less complexly organized. But where the materials which have to pass over its sur- face would be liable to offend by their me- chanical or chemical properties, we find it protected by a delicate pellicle, denomi- nated epithelium, which being insensible, forms a kind of covering by which it is in a considerable degree defended against in- jury. This is the case in the mouth, fauces, and oesophagus; the urethra, anus, and vulva. In addition to this, concerned as it is in all the acts of vegetative or nutritive life, and in those which are concerned in the perpetuation of the species, we find it widely diffused,—placed in immediate re- lationship with the multifarious organs which are subservient to those purposes, consequently linked by a most intimate chain of sympathies with every portion of the animal organism, and forming at the same time, the channel by which all the materials which enter into the economy are introduced, and by which those that escape are expelled. It is the recipient of all impressions, the centre of universal sympathy, and the seat of the most impor- tant acts of organic life. Illustrations equally strong, of the con- nexion between general anatomy and phy- siology, are afforded by the examination of almost every part of the organism; and, if further evidence were required to prove the correctness of the proposition which we have laid down, they are furnished by the astonishing advances which physiolo- gical science has made since the period at which Bichat first revealed the invaluable principles of general anatomy. Applying it in the next place to pathol- ogy, we shall find its importance not less strikingly exemplified. It reveals to us the seats of diseases, and the causes of their multifarious manifestations: it explains their characters, enables us to form a due estimate of their symptoms, and to trace them to their proper source: it constitutes the only certain guide in our diagnosis and prognosis; and, as diseases consist essen- tially and totally of some derangement or perversion of the composition and vitalism of one or more of the animal solids or fluids, we can only be prepared by a know- ledge of their properties, to appreciate the character and extent of the sufferings which any one may endure, the extent to which it is concerned in the manifestation of the symptoms of the malady, the influ- ence it exercises over other structures with which it is placed in relation, and the consequences likely to result from its im- plication in the morbid process. There is scarcely a disease, indeed, in which the aids furnished by general anatomy are not necessary to enable us to interpret its char- acters. Conversant with the texture and vital properties of a mucous or serous mem- brane, we are prepared to comprehend the phenomena which it presents when af- fected with disease. However extensive their distribution, and whatever their situ- ation, the maladies which are incidental to them everywhere present something in common, and can be easily discriminated from affections of other tissues. They are, moreover, attended by a different train of phenomena from those which characterize the affections of the organs which they line, or over which they are reflected. Their consequences likewise are very dif- ferent, and they are often found leading to results which are peculiar to themselves. The same remark may be made of the other tissues. They all possess different degrees of susceptibility, and each one has its own peculiar mode of action. One or more, therefore, may become affected with disease, whilst the others escape or partici- pate in a slight degree; and, as their im- portance in the living system is different, 60 are their affections grave or simple, ac- cording to the grade of this importance. Hence, we are taught by general anatomy, that diseases are modified by the character of the tissues which they involve: that their seats are to be determined by our knowledge of the structure and vital pro- perties of the several parts of the organ- ization : that where these properties are known, we have only to regard the symp- toms as the outward manifestations or the evidences of a morbid condition of one or more parts, and to trace them to their proper origin, in order to enable us to in- terpret the whole character of a malady, pronounce a just diagnosis, and make a probable prediction of the final result or termination of the disease. The same knowledge will also direct us in the appli- cation of our remedies. The whole sci- ence of therapeutics must be based upon 440 ANATOMY. {General.) an accurate comprehension of the struc- ture and vital properties of the several por- tions of the animal organism, and of the powers of our remedial agents. The lat- ter produce their effects upon the former, by impressing upon their acts certain mod- ifications; and to understand the application of the one, and the effects which will be produced in the other by its influence, a knowledge of the properties, susceptibili- ties, and modes of action of the part upon which it is desired to make the impression, is indispensable. The importance of general anatomy, in relation to pathology and therapeutics, is, moreover, further exemplified by the aid it furnishes in tracing out the manner in which morbific or remedial impres- sions are radiated throughout the system. As the several tissues possess different sus- ceptibilities, it necessarily follows that no impression made upon any one of them, can be simultaneously diffused throughout the whole system, affecting all its parts at the same time, and in the same degree. Each one, to a certain extent, represents a system distinct and independent as regards some of its acts, yet as respects the assem- blage of acts in which life consists, they are all united in one bond of harmony, each one playing its special part in the general scheme of vital actions, but the whole concurring in the consummation of a natural series of results. The nerves will respond more promptly to the impres- sions made upon them, than the cellular tissue;—the blood-vessels, than the bones; and these latter, than parts which are less exquisitely organized. But while they are all different, as regards their liability to feel the influence of impressions made upon them, the whole are associated in one continuous chain of sympathies, and through this association, influences exercised upon any one of them, will be readily transmit- ed to the others; the order in which this transmission takes place being always, however, determined by the intimacy of the sympathies existing between the re- spective parts. The truth of many of these principles was felt and acknowledged long before the time of Bichat, and even many of the an- cient physicians divided diseases according to the textures affected; thus distinguish- ing inflammation of the pleura, from that of the lungs; affections ofthe membranes of the brain, from those implicating the substance of that organ. Even extensive applications of those principles which ap- pertain to general anatomy were made to pathology, by John Hunter, and Carmi- chael Smith, both of whom have consid- ered, somewhat elaborately, the modifica- tions presented by the phenomena of in- flammation, as it occurs in the various tis- sues of the body. The importance of thus considering disease, was, at a period some- what more recent, rendered still more ap- parent, by Pinel, who, in his Nosographie Philosophique, took occasion to class dis- eases according to the tissues of the body affected ; thus furnishing to Bichat the first hints of an undertaking, the achieve- ment of which has not only immortalized his own name, but created, as it were, a new era in medical science. The princi- ples established by him, and perfected by the labours of his successors, have given a new direction to all our investigations, and, enriched by the new lights furnished by general anatomy, the whole range of phy- siology, pathology, and therapeutics, has already become fertilized by the addition of new and invaluable principles:—patho- logical anatomy has assumed a more posi- tive and important character, and diseases being correctly interpreted, the application of remedies for their removal is every day more and more directed by fixed and well ascertained principles. What Bichat did for general anatomy, Broussais, guided by the same principles, has accomplished for pathology. He has greatly contributed to reduce it to the principles of a positive philosophy, and, although much yet re- mains to be done; by making a just appli- cation of the principles of general anato- my to the elucidation of the characters of disease, he has certainly accomplished a vast deal towards the establishment of medical science upon true and legitimate principles. Bibliography.—Lectiones Gabrielis Fallopii, de partibus similaribus. Fol. Noremb. 1675. Hoffman (Gaspard.) De partibus similari- bus liber singularis. 4to. Francof 1667. Malpighi. Opera Omnia. Folio. London, 1686. Ruysch. Opera Anat. Med. Chirurg. Ara- stelad. 1737. Haller. Elemrnta Physiclogia. 4to, 8 torn. Lausanne, 1757-1766. Vine. Malacarne i sislcmi e la reciproca influ- enza loro indagali. 4(o. Padua, 1803. Xavier Bichat. Anatomie Ginirale. 8vo. 4 vols. Paris, 1801.—Idem. Nouvelle edition, contenant les additions publiecs par Beclard, augmenter d'un grand nombre de notes nouvellea par F. Blandin. 4 vols. Paris, 1830.—The first work, translated by George Hayward, M. D. 3 vols. 8vo. Boston, 1822. Reil. Archives fiir die Physiologic 12 bdc. Halle, 1796-1815. Rudolphi (K. A.) De partibus similaribus. 4to. Gryph. 1809.—Idem. Grundrisse der phy- siologic 8vo. bde. I. Berlin, 1821. Prochaska. Disquisitio Analomico-physiolo- gica organismi corporis humani, ejusque proces- sus vitalis. C. tab. ^En. 4to. Vienn. 1812. ANATOMY. J. F. Meckel. Deutsches Archives fUr die Physiologic Bde. 1—12. Halle, 1815-1831. Walther. DarsteUungdesBichatschen systems in Schellings und Marcus Jahrbuchern der Med- ian. Bd. II. heft 1. p. 49. Gottfreid Reinhold and Ludolf. Christ. Treviranus. Vermischt. Schrift. 1816-26. J. F. Meckel. Handbuch der menschlich. An- atomie. Band I. Halle, 1815.—Traduit de l'Al- lemand. Par Jourdan and Breschet. 3 tomes. Paris, 1825.—Translated from the French, by A. Sidney Doane, A.M. M. D. New-York, 1832. Beclard. Additions a V Anatomie ginirale de Xav. Bichat. Paris, 1821.—Translation of the same, by George Hayward, M. D. Boston, 1823. Mayer. Ueber Histologie. 8vo. Bonn. 1819. C. Fr. Heusinger. System der Histologie. 2 vols. 4to. Eisenach, 2822. Paolo Mascagni. Prodromo delta grande Anatomia. 8vo. tab. Milano, 1821. P. A. Beclard. Elemens d'Anatomie Gini- rale. 8vo. Paris, 1823.—Idem. Elements of General Anatomy. Translated from the French, by Joseph Togno, M. D. Philada. 1830. Horner (Wm. E.) A Treatise on General and Siiecial Anatomy. 2 vols. 8vo. Philad. 1826. New edit. 1833. Craigie (David.) Elements of General and Pathological Anatomy. 8vo. Edinb. 1828. Weber (J. M.) Die Zergliederungskunst des Mensch. Korpers Erster Theile,AUgemiene Anat- omie. Bonn, 1826. Grainger (R. D.) Elements of General Anat- omy, &c. 8vo. Lond. 1829. Bayle et Hollard. Manuel d'Anatomie Gi- nirale. 18mo. Paris, 1826.—The same, trans- lated by S. D. Gross, M. D. Philad. Weber (Ernst. Heinrich) in Seiner ausgabe der Hildebrandt's Handbuch der Anatomie des menschen. 8vo. Brannschweig, 1830.—The first volume of this work, which is devoted to gene- ral anatomy, is exclusively written by Professor Weber. } 2. Special Anatomy, a. Its Objects and Details. Special Anatomy, as has been already represented, has for its objects the investigation of the forms and connexions of the organs individually. Far less mi- nute in its details than general anatomy, it merely takes cognizance of the exterior of the several objects which fall within its range, while the latter enters into the in- tricacies of their inmost texture, seeks to determine their composition, and reveal the properties and arrangement of their ultimate organic elements. Every animal body, we have already seen, is composed of a number of tissues possessing different properties, which, by various combinations, form organized systems destined for the execution of special functions. While, therefore, general anatomy embraces the consideration of these tissues, the province of special anatomy is to examine the form, connexions, and relations of the organs and systems which are formed by them. It is both analytic and synthetic It examines the forms and connexions of each part or organ separately or epeciaLy, {Special.) 441 and then determines the manner in which they are all united or associated in the formation of a general system of living apparatus, by which the assemblage of functions, in which life consists, are ac- complished. In these respects, likewise, it is, to a certain extent, physiological; for in the examination of its different objects, it not only takes up the organs individual- ly, but considers them in groups or sys- tems of organs, according as several of them are connected, or concur, in the ac- complishment of a special office or func- tion. Thus all the systems are considered in reference to the offices which they exe- cute, all the instruments which are con- cerned in the performance of a function being examined first individually, then collectively, and finally as associated with others appropriated to some other office. It is, therefore, divided into various parts, according to the parts or systems which it examines. The functions which are con- cerned in the preservation of animal ex- istence may be all grouped under these heads: 1. Those of relation; 2. Those of nutrition; and 3. Those of generation. The organs by which these functions are performed may be in like manner grouped in accordance with their offices, thus making a direct application of special an- atomy to physiology. In reference to the first set of functions, or those of relation, as motion is an indis- pensable requisite for their fulfilment, there is an arrangement of parts adapted to this necessity. Under this head, there- fore, we have to consider the bones, con- sisting of a series of solid compact seg- ments, of different volume and configura- tion, and variously disposed, according to the uses to which they are appropriated. They are all united in such a manner as to form a solid frame work for the other parts of the organization, some of them constituting levers for locomotion, while others are more peculiarly appropriated to the protection of the more delicate and fragile parts. That division of anatomy which treats of these parts is denominated Osteology. But to fit the bones for the performance of their offices, they must be so united with each other as to ensure both freedom of motion and great strength of arrange- ment To subserve the first object, their extremities are expanded and covered with cartilage, which is smooth, polished, and elastic. The second is secured by two means; first, by the reception of the promi- nent portion of the extremity or edge of one bone into a corresponding excavation 442 ANATOMY. {Special.) of another; and second, by means of nu- merous strong fibrous bands, or ligaments, by which they are firmly tied together, but in such a manner as not to interfere with their motion. The consideration of these particulars appertains to that de- partment of special anatomy which is de- signated Syndesmology. These portions of the locomotive appa- ratus possess no power to move themselves. They are strong and resistant, but alto- gether passive in the acts which they per- form. We accordingly find ingrafted as it were upon every portion of the bony skel- eton, an arrangement of incitable, con- tractile, fibrous instruments, called mus- cles, which, in acting under the direction of the will, impress upon the solid frame- work of the system those diversified and complex movements which are concerned in its various acts. The special considera- tion ofthe form, attachments, and relations of these instruments, appertains to that part of anatomy which has received the appellation of Myology. These muscles, however, must have something to excite them. Hence we find that they are all supplied with sensitive and inciting instruments, which are com- posed of the nervous fibre, which regulate their susceptibilities, and maintain their aptitude to contract. These instruments present a peripheral and a central portion, the first consisting of the various nervous trunks and ramifications; the second, of the brain and spinal marrow. The former convey from the latter the influence of the volition to the muscles, by which their acts are called up and regulated, and also transmit to the brain, or centre, those im- pressions which are made upon their sen- tient extremities, thus enabling it to take cognizance of their acts, and give them a proper direction. While, therefore, both the peripheral and central portions of the nervous system act conjointly and recipro- cally, in exciting and regulating muscular contraction or motion, and in accomplish- ing the acts of general sensation, the brain alone executes the more noble and impor- tant psychological operations of percep- tion, thought and volition. That depart- ment of anatomy which treats of this ap- paratus is denominated Neurology. But with this endowment alone, the in- dividual would not be able to take cogni- zance, or judge accurately, of the quali- ties of all the objects which surround him, to seek whatever is necessary to supply his wants or contribute to his gratifica- tions, or to avoid the multifarious dangers to which he is exposed. Hence his rela- tions with the surrounding world would be incomplete, and he could not provide for his existence. To supply this defect, and to array before his intelligence the whole range of creation, he is supplied with an apparatus of special senses, finely organ- ized and exquisitely endowed. The par- ticular consideration of these instruments appertains to a part of anatomy which may be called JEsthesiology. This is the condition, and these the at- tributes, of the individual, viewed in his relations with the external world. He has senses to receive the impressions of the multifarious objects which surround him. He has an intelligence to take cognizance of these impressions, appreciate their char- acters, provide for his wants, and warn him of his perils. He is possessed of in- struments of motion to act in obedience to the impulses of his volitions—to transport him from place to place—bear him over the boundless regions of the universe— place within his grasp whatever is craved by his wants or his desires—and to shun the objects of his aversions. Creation is arrayed before him; he acts upon its in- finity of objects; appropriates them to his use, or avoids them at his pleasure. The important apparatus, however, by which these purposes are accomplished, is frail and exceedingly delicate in its char- acters, and subject to ceaseless changes during every period of its existence. The materials of which it is composed merely perform their office for a limited period, and then pass away to give place to others. Hence the necessity of an ap- paratus by which a perpetual supply of or- ganic elements may be furnished, to pre- serve the organization against destruction, —by which the individual may be enabled to derive from the medium in which he lives, those materials which are proper to nour- ish and sustain him, and impress upon them such changes or modifications as to adapt them to the exigencies of his nature. We accordingly find him endowed with organs of prehension, regulated in their acts by the senses of which we have already spo- ken;—instruments for the trituration or mechanical division of his food,—others for its transport through the body, and for the separation of its nutritive from its ex- crementitious portions. This apparatus, complex in its conformation, delicate in its organization, and extensive in its relations, consists essentially of an elongated and tortuous tube, upon which are engrafted a number of glands, which pour their diver- sified secretions into it, there to perform an important part in the acts which it has ANATOMY. {Special.) 443 to execute. By a series of changes effect- ed in the food by the concurrent agency of different portions of this apparatus, aided by a play of chemical affinities—it is broken down or decomposed, its nutritive parts are subjected to new combinations, and are separated from the excrementitious portions, to be circulated by myriads of streamlets throughout the intricate tex- tures of the organs—while the latter are thrown off as effete matter. Superadded, therefore, to this apparatus, there are an infinity of attenuated vessels, which pump up, by their numerous radi- cles, the nutriment elaborated and sepa- rated by the other organs, and transmit its materials through their channels into the proper circulation—where, mingling with the blood, and undergoing still further changes, they become a portion of that fluid, and, indeed, constitute its proper ele- ments. It is through these channels that the whole materials of the organization are introduced; tthe individual thus appro- priating to his use those substances which a bountiful Providence has spread before htm, and deriving from them materials to nourish and sustain his frail and perishable organs. To insure the full consummation of these objects, however, the materials thus derived and prepared must be conveyed throughout every part of his system, in order to be brought in relation with the structures which they are destined to build up and preserve. We accordingly find, that the blood which is directly concerned in its accomplishment moves in a perpetu- al circle. It is sent out by arteries and re- turned by veins, between which the heart ia interposed, as an agent of impulse, to force it through the meandering course of the numerous vessels which it has to tra- verse. Besides this greater circle, it is, moreover, made to move round a lesser circle through the lungs, there to be brought in relation with the atmosphere, in order to part with some of its materials, and at the same time to acquire others by which it is better fitted for the purposes of life. Finally, to these parts are added nume- rous glands and instruments of exhalation, by which the waste of the organization is either separated and thrown off; or a se- crementitious fluid is formed from the blood, to be returned to it again, and be- come subservient a second time to the pur- poses of nutrition. Some of these secern- ent glands have appended to them recep- tacles, or reservoirs, for the retention of their fluids until a convenient time may arrive for their final expulsion, or until they are demanded for the fulfilment of the offices which they are destined to ac- complish. Such is the diversified and complicated apparatus concerned in the important func- tions of nutritive or vegetative life. Though different portions of it are appropriated to the execution of dissimilar acts, they all concur in the accomplishment of one final purpose. The alimentary canal receives and transmits the food, and with the glands which are engrafted upon it, prepare the chyle, and separate it from the innutrient portions of the food. The lacteals absorb it and convey it into the blood with which it is conveyed to the heart. This organ, endowed with a strong muscular arrange- ment distributes this latter fluid, on the one hand, to the lungs, through the pul- monary artery, whence, after having un- dergone important changes, it is returned through the pulmonary veins; and on the other, through the aorta, to every part of the organization, whence it is conveyed back to the heart, by corresponding veins. The glands secrete from it a diversity of fluids, and by the process of exhalation a considerable quantity of its thinner parts are constantly draining away. Thus, while digestion repairs the perpetual waste of the animal structures, the refuse and worn-out materials are constantly passing away through the instruments of excretion and exhalation. That part of anatomy which treats of the organs of digestion and depuration is denominated Splanchnology, under which head is also included the organs subservi- ent to the propagation of the species; while the consideration ofthe instruments of circulation, including the heart, arte- ries, veins, and lymphatics, appertains to the department called Angdology. The third class of functions includes those which are necessary for the perpetu- ation of the species. The instruments which are concerned in them differ in the two sexes, but in each may be divided into those for the preparation or vivification of the new being, and those of copulation. The consideration of these in like manner is generally ranged under the head of Splanchnology. There is, besides, a department of spe- cial anatomy which has for its object the history of the development or the evolu- tion of the Fcetus and its appendages. This is denominated Ovology, or Embry- ology. b. Appreciation of the importance of Special Anatomy. After the observations 444 ANATOMY. {Special.) which have been already made, but little need be said in reference to the value of special anatomy. If less important in its application to physiology and pathology than general anatomy, it is nevertheless indispensable to enable us to comprehend the arrangement and connexions of the apparatus concerned in the execution of the various vital functions. In order to comprehend and appreciate any set of phe- nomena, we must first be acquainted with the instruments which are efficient in their production; and as each function of the animal organization has a special appara- tus by which it is executed, it would be as impossible to understand its phenomena, without a previous acquaintance with parts employed in their manifestation, as it would be for the mechanist to comprehend the various revolutions of a piece of com- plex machinery, without being conversant with the arrangement of its wheels and levers. While the more minute charac- ters of structure which are revealed by general anatomy can alone serve to ex- plain the more delicate and obscure acts which are directly concerned in the exe- cution of a vital function, its generalities, and the manner in which it is associated with other functions, cannot be fully com- prehended without that knowledge which is imparted by special anatomy. Thus, general anatomy teaches that the brain is composed of white fibres and a gray pulpy substance, and that various parts of these structures are endowed with different vital attributes; but it does not show that the convolutions are the seat of a multiplicity of faculties, each one having its special locality. It points out the properties of all the tunics and humours of the eye, but leaves us in ignorance of the manner in which these parts are disposed to consti- tute one of the most beautiful and perfect specimens of an optic instrument capable of refracting the rays of light bringing them to a focus upon the retina, and thus placing the individual in direct relation with all the wonders and beauties of crea- tion. It reveals to us the structure of bone, of muscle, of mucous and serous membrane, of glands, &c, yet we are not taught by it how a bone is adapted, by its shape and its arrangement, to resist the influence of violence, or to move in ac- cordance with that mechanism which it is its office to subserve ;—how the direction and attachment of a muscle suit it for the accomplishment of a given purpose;—how the arrangement of a mucous membrane into a convoluted tube, adapts it to the ex- ecution of the complex acts of digestion, or how one portion of this tube is merely appropriated to the purpose of transmis- sion, while other portions perform the more important part of decomposing the food, and separating its nutritive from its excrementitious portions. It is true, that special anatomy, taken alone, and consid- ered in the abstract, is of comparatively little value, but when viewed in connex- ion with the anatomy of structure, its im- portance becomes manifest afid the neces- sity of an acquaintance with its details it rendered indisputable. Its utility in reference to pathology is also incontestible. As the morbid states of the organization involve the colour, con- figuration, and relations of its different parts, as well as their texture, in order to be able to appreciate the character of its lesions, it is as necessary we should be able to designate what changes these proper- ties undergo, as to determine the altera- tions which occur in their intimate tex- ture. This will be impossible, without an accurate acquaintance with the form, vol- ume, colour, situation and connexions of the several organs in their healthy state, which can alone prepare us to determine the modifications impressed upon them by disease. Nor is its importance confined to the mere discrimination of lesions; it is equal- ly great in reference to diagnosis. To de- tect the existence of disease in particular organs, their situation and relations must be clearly understood ; otherwise, when sev- eral organs are grouped together in the same region, the symptoms which are pro- per to one, might be referred to another, having no participation in the morbid con- dition. Thus, in exploring the right hy- pochondriac region in an individual affect- ed with pain, the character, situation, and relations of all the organs contained within it should be remembered, because the pain or suffering may proceed from an affection of any one of them. Thus, it may be seat- ed in the liver, gall-bladder, biliary ducts, pylorus, duodenum, kidney, the attach- ments of the diaphragm, &c. The inti- mate connexion which exists between the duodenum and the liver, through the me- dium of the gall-ducts, the nerves, veins, &c. likewise elucidates the manner in which they may become associated in dis- eased action, and the order in which their sympathies are reciprocally transmitted, and thereby enables us to appreciate the value of any train of symptoms which they may present and to refer them to their proper sources. With a view to its practical application, ANATOMY. {Topographical.) 445 special anatomy may be investigated by two different methods of procedure. Ac- cording to the first, which is most com- monly pursued, each apparatus, or system of organs, is considered separately and without a direct reference to those with which it is associated ; as, for example, under the heads of Osteology, Syndes- mology, Myology, Splanchnology, Angi- ology, Neurology, &c. Under the second, more fruitful in its practical illustrations, the whole body is mapped off into regions, which are defined by natural or imaginary lines or boundaries, and all the parts enter- ing into each are investigated, layer by layer, from the circumference towards the centre; the characters of each being scru- pulously examined, their connexions and relations accurately determined, and the influence they are capable of exercising upon diseases and operations carefully es- timated. The first, which we have al- ready considered, is Special Anatomy pro- perly so called:—the second is denomi- nated Topographical, Regional, or Sur- gical Anatomy. § 3. Topographical and Surgical Ana- tomy ;—more properly denominated Medi- co-Chirurgical Anatomy. As in the in- vestigation of special anatomy according to the ordinary method, the principal ob- ject is an application of its details to phy- siology, an order for the most part physi- ological is pursued; so, in the examination of the subject topographically, as our end is its application to medical and surgical pathology, we disregard, for the most part, those considerations which are purely phy- siological, to determine the importance of the several structures considered in refer- ence to diseases, accidents, and surgical operations. To attain the objects we pro- pose, our investigations must here take a different direction. We are still in- terested in the configuration, size, situa- tion, relations and connexions of the dif- ferent parts; but instead of examining each separately and independently, we al- ways have a special reference to its rela- tions and connexions with other parts, and its individual and aggregate importance in the region in which it is found. An accu- rate anatomical chart of the superficies of the body is the first object of our in- vestigations. We define all its promi- nences and depressions,—we subdivide it into regions or sections, by ideal or natural lines, and then taking each of these re- gions separately, we determine accurately vol. i. 38 the disposition and relations of its different parts, progressing from the periphery to- wards the centre, in order that by ascer- taining all their mutual bearings, we may be enabled to pronounce upon the probable injury sustained by any one or more of them, by an instrument traversing them in any direction; the manner in which they may be affected by diseases involving their structures; their importance in dis- placements; and the influence they are capable of exercising under all these cir- cumstances. In mapping out these re- gions, we are not governed by any natural limits presented by the organs themselves, or determined by their uses. We are merely governed by the importance of the parts, and their concurrence, as manifested in reference to any one or more patholo- gical conditions. The number of regions, therefore, may be very differently esti- mated, and their extent varied according to the object proposed. Thus, we may make a single region of the whole head, or it may be subdivided into parts of more limited extent, in order to constitute sepa- rate divisions of its frontal, parietal, and occipital portions. The same course may be adopted with the face, the neck, thorax, abdomen, &c. It will be best, however, as a general rule, merely to comprise, as far as possible, within each region, such parts only as possess a similarity of char- acter, or concur in the accomplishment of the same set of acts; thus avoiding, on the one hand, the unnecessary multiplication of regions, and on the other, the equally bad course of making them too extensive. Nature has, indeed, to a certain extent, laid the foundation for such a division. In a longitudinal direction, the trunk is di- vided by the linea alba into two lateral and symmetrical portions. In the opposite direction, it is likewise divided into seve- ral sections, consisting of the head, face, neck, thorax, abdomen, pelvis, and extrem- ities, all of which present clear and well defined limits. These, however, though useful to a considerable extent cannot be rigidly adhered to without further divi- sions, in the investigation of those details which appertain to topographical anatomy. Hence, some of them must not only be subdivided into anterior, posterior, and lat- eral, but likewise into transverse sections of variable dimensions and configuration. In pursuance of this course, we shall divide the whole superficies of the body into the following regions: 446 ANATOMY. {Pathological.) I. II. III. The Neck VI. VII. The Head ------ a Cranial region. The Face ------- a Facial region. " a Anterior Cervical region. - 6 Lateral Cervical region. k c Posterior Cervical region. * a Thoracico-axillary region b Sternal region. c Costal region. d Scapular region. ' a Epigastric region. b Umbilical region. Abdomen.......t c HyP°gastric region- i d Hypochondriac region. e Lumbar region. v New secretions \ Organizable. I Not Organizable i Formed in unusual situations. 1 situations. Situation \ £ormed in j"™™81 sitU£ (Transported to unusual 'Pneumatoma. Hydronoma. Pyonoma. Colloma. Steoma. Alsoma. Lithoma. Melanoma. Kirronoma. Ephaloma. Chloasoma. ANATOMY. {Pathological.) 455 Section V. Physical Lesions. "Physical Lesions of texture.—Wounds. {Dislocations. Hernia. Prolapsus. Retroversion, antiversion, invagi- SectionVL Living pro- ducts having no natural }• Entozoa. connexion with the organization. This classification will embrace all the lesions of the organization considered in a general manner, or viewed in their to- tality and as liable to affect any of its parts. But, as all, or at least most of them, may implicate every part of the system, it becomes necessary, in carrying out the details, in order to avoid endless repetitions, to consider the characters of each lesion, in the abstract, before it is de- scribed in its special relations with the or- gans which it may implicate. Hence, we divide pathological, like physiological an- atomy, into general and special; the first having for its object the consideration of the general characters of the elementary or primordial pathological states, in the abstract, and independent of the parts which they may affect; the second, the special consideration of these pathological states, as they are manifested in the vari- ous tissues and organs. Thus, after having determined the characters of each lesion, in advance, we are prepared to appreciate the phenomena and modifications which it presents in the several tissues and or- gans. Under the head of special pathological anatomy, we first examine the various le- sions as they occur in the widely diffused tissues; as, the cellular, osseous, carti- laginous, fibrous, muscular, vascular, nerv- ous, &c, and, afterwards, as they are manifested in the several systems or ap- paratus of organs, in the order of the functions which they execute. This course should not be pursued in relation to the perfect organization only, but also extend- ed to the products of conception, and the evolution of the fcetus. Estimate of the value of Pathological Anatomy. Some of the aids which pa- thological anatomy is capable of affording to healthy anatomy and physiology, have already been alluded to. We have now to speak of its importance in relation to med- ical and surgical pathology, and thera- peutics. It may be regarded as the only certain ] (^ nation, inversion, inflexion, &c. L Accidental distortions, &c. foundation of a correct diagnosis. To be convinced of this fact, it is only necessary to recur to the histories of disease given before pathological anatomy fertilized the science, and to compare them with those furnished by the best writers within the last twenty years, since the study of or- ganic medicine has been made to consti- tute the principal source of all patho- logical conclusions. Then, all was ob- scurity and conjecture;—now, much that could not formerly be explained, or which constituted a train of merely idle specu- lation, is rendered clear and intelligible. The seats of diseases not being known, their symptoms were comparatively of little value, because they could not be correctly interpreted; and it was impos- sible to determine the proper character of the morbid affection, since no concep- tion could be formed of the manner in which it affected the organization,—what tissue or organ was its seat,—what changes it induced in the texture and vitalism of the part, and the manner in which those symptoms were developed which consti- tute its outward manifestations. Not to go back to that period when catarrh was ab- surdly supposed to be a fluxion from the brain, rheumatism an acrid humour falling upon the muscles and joints, and phlegma- sia dolens a transfer of the milk from the mammas to the lower extremity, let us take some of the best works of even very modern times, and we shall see how de- fective was the science of diagnosis, for the want of a knowledge of organic le- sions, and how erroneous were the ideas entertained of the seat and characters of an infinity of diseases, which, owing to the assistance afforded by pathological an- atomy, are now well understood and suc- cessfully treated. Thus, by way of illus- tration, we may take what Cullen gives as the pathology of dysentery. He attri- butes all the phenomena of that disease to a state of constriction of the colon, which divides it more exactly into cells, giving occasion to the formation of hardened 456 ANATOMY. {Pathological.) feces. With this constriction, there is some effort at a peristaltic motion, which, however, only increases the spasm, and renders it more painful. This more violent spasmodic affection extending to the rec- tum, may emulge its mucous glands, and squeeze out blood from the superfidal blood-vessels, which is to explain the whole phenomena of the disease. Let any one who is the least sceptical, compare this pathology of dysentery with that which pathological anatomy has es- tablished, and if this does not convince him of the advantages to be derived from the study of organic lesions, let him take two cases of the disease as nearly alike as possible, and treat the one upon those prin- ciples suggested by the pathology of Cul- len ; the other, upon those dictated by the knowledge that dysentery is a violent in- flammation of the mucous membrane of the colon, exciting spasm of its muscular coat; and we think conviction cannot fail to follow. Let him take the whole range of the cachexies ofthe same author, and com- pare the explanations offered of their char- acters, with the clear and philosophical views of the same affections given by Broussais, in the " Phlegmasies Chron- iques;" or by any respectable modern writer who has stored his mind with the treasures of pathological anatomy, and he will find light where all was before dark- ness,—truth where before everything was shrouded in error,—and cannot fail to per- ceive the immense advantages which have resulted from the study of organic lesions in connexion with clinical observation. In investigating any disease, there are two problems to be solved: 1. the organ affected, and the kind and degree of its implication: 2. the modifications of the vital acts in which the morbid affection consists. These points are indispensable to enable us to form a correct diagnosis or prognosis, and are alone sufficient to found a correct and rational therapeutic indica- tion. The phenomena of the dynamic or vital modifications, consist, moreover, in every case, of two series: 1. those which precede the development of the morbid state of the organ, and which constitute what is called the prodromus of the dis- ease, or the proegoumenic symptoms: 2. those supervening upon the change which takes place in the organ, and hence de- nominated epigenetic phenomena. Taking these principles as the basis of pathological anatomy, and the rules by which it is to be applied to the science of diagnosis, it will be seen, that there are but few morbid affections in which it will not afford important illustrations. In a large proportion of diseases, a knowledge of organic lesions is indispensable to en- able us to determine their characters; and there are exceedingly few, except some of the neuroses, in which it will not assist in arriving at correct conclusions. What, for example, was known of pu- erperal fever, until dissections revealed that most of its phenomena are referrible to an inflammation of the serous mem- brane of the abdomen 1 and what know- ledge had we of croup, until we were taught by autopsic examinations that it consists in an inflammation of the lining membrane of the air passages, giving rise to the development of an adventitious plas- tic membrane, adhering to the internal surface of the tube, and impeding respira- tion ? To pathological anatomy, we are likewise indebted for nearly all we know of the whole range of the phlegmasia?. It reveals the difference between an inflam- mation affecting the membranous envelopes of an organ and its proper structures; it explains the successive changes which the structures undergo; the order in which they succeed each other; how far they may advance without destroying life; and the steps by which the parts return to their healthy condition. It demonstrates that an inflammation of the membranes of the brain is characterized by a different train of symptoms from those which attend an inflammation of the texture of that or- gan ; that an affection of this kind, merely attended with a slight effusion of serosity, will often occasion convulsions, and that a considerable quantity of fluid poured out by the same process, will sometimes pro- duce paralysis. What should we know of apoplexy, or of the symptoms which arise from softening of the brain, if dissec- tions did not explain to us, that in the one there is extravasation of blood, either within the substance or on the surface of the organ, embarrassing or annihilating its functions; and in the other, that there is a pulpy disorganization, disqualifying the organ for its office, or perverting its acts ? It has also taught us, that many cases of epilepsy are owing to tumours or spiculas of bone pressing upon the brain, or to le- sions developed within the substance of that organ; that cataract consists in an opacity of the crystalline lens, interrupt- ing the transit of the rays of light; that gutta serena is often dependent upon some organic modification of the retina; that deafness may proceed from a closure of the eustachian tube, or a change of struc- ture in the auditory nerve; that a lesion ANATOMY. of the olfactory nerve destroys the sense of smell; that when the third branch of the fifth pair is injured, taste is affected ; and that there will be paralysis of sensa- tion or motion, according as the posterior or anterior parts of the spinal chord, or the portions of the brain with which they are associated, are affected. In the diseases of the chest and abdo- men, pathological anatomy has not been less fertile in its illustrations. Pleurisy and pneumonia were confounded, until dissections taught that they were essen- tially distinct; and the pathology of hy- drothorax was not understood, until autop- sic examinations proved that it was owing to an effusion of serum and plastic lymph, resulting either from inflammation of the serous tissues of the thorax, or from an ob- stacle to the passage of the blood through the cavities of the heart. Nor did we know anything of the characters of those formations by which the surfaces of the organs are agglutinated, or their areolar texture consolidated, until pathological an- atomy demonstrated that they are pro- duced by a deposit of a plastic fluid, in which vessels are formed, and which thus becomes organized. How endless and visionary were the speculations offered in relation to the causes of the palpitations of the heart, of asthma, of angina pecto- ris, of cyanosis, and many other diseases of the chest, until autopsic investigations traced nearly all these affections satisfac- torily to various lesions of the heart and adjacent organs! Consumption was for- merly attributed to inflammation of the lungs, terminating in abscess; and chronic catarrh, or bronchitis, was confounded with it under the name of catarrhal phthisis. Pathological anatomy, in demonstrating that consumption is always owing to tu- berculous degeneration of the lungs, and the subsequent disorganization of the new product, has shown the error ofthe former opinions entertained of its character, and that it is essentially different from both pneumonia and catarrh. It has also explained many of the causes of jaundice, by demonstrating that any obstruction to the passage of the bile from the liver, will lead to its absorption and subsequent diffusion with the blood, and incorporation with the solids of the body. It has, likewise, explained the causes of dyspepsia, cholera, ileus, diar- rhoea, dysentery, and tabes mesenterica. It has shown that the primordial condition of all these diseases is an irritation of the mucous membrane of the stomach, giving rise to various changes of structure, and vol. i. 39 {Pathological.) 457 exciting various sympathetic phenomena. It has proved, that in the latter affection, the enlarged and degenerated state of the mesenteric glands has its origin in an irri- tation commencing in the mucous tissue, and radiating along the course of the lymphatic or chylous vessels to the glands. We are in like manner indebted to it for an illustration of the important truth, that in many of the diseases which have been mentioned, there is frequently very ex- tensive carcinomatous degeneration of the coats of the stomach,—ulceration, soften- ing, thickening and induration of the mu- cous membrane,—contraction of the diam- eter of the intestine, and even perforation of its 'walls. In like manner, we have been taught by it that a large proportion of those anomalous and distressing symp- toms which were formerly grouped under the heads of nervous and cachectic dis- eases,—which were considered states of pure debility, and treated as such,—derive their origin from a sub-inflammation of the mucous membrane of the first passages, propagating its influence through the gan- glionic nerves to the cerebro-spinal cen- tres, to be thence reflected upon the dif- ferent organs. The whole range of diseases which af- fect the liver, spleen, kidneys, ovaria, ute- rus, and the genital organs generally, have also been equally illustrated by patholo- gical anatomy; and it has likewise con- tributed much to elucidate the pathology of the fluids which are poured out by those that secrete. We are in like man- ner indebted to similar investigations for our knowledge of extra-uterine foetation, rupture of the uterus, displacements of that organ, as well as the various acci- dental developments which take place in its substance and in its appendages. In no respect, perhaps, have the advan- tages of pathological anatomy been more strikingly displayed than in the determina- tion of the characters of the various or- ganic transformations and heteroclite de- velopments. Of the true nature of tuber- cle, of the diversified conditions denomi- nated scirrhus and cancer,—pancreatic sarcoma, medullary sarcoma, encephaloid degeneration, fungus hematodes, &c, we possessed no definite information, until they were explained by the labours of modern pathological anatomists. It is true, that the lights thus acquired, have not contributed much to improve our success in the treatment of these formidable de- generations ; yet it is important to be ac- quainted with their characters, that we may be able to distinguish them from those 458 ANATOMY. {Pathological.) which are curable,—that we may form an accurate prognosis of the probable issue, and that we may know how far we can rely upon the resources of the art, as well as the extent to which our interference can be safely carried. Nor are these all the advantages which have been derived from the cultivation of pathological anatomy. It has completely reformed the doctrines of the essential or idiopathic fevers. They are no longer re- garded as diseases involving the whole or- ganization equally, and independent of any local affection. Whatever may be the mode of their origin, or the vital modifica- tions concerned in their development, re- iterated autopsic investigations, aided by careful clinical observation, have shown, that they are always accompanied with some local organic affection. Instead, therefore, of referring them to spasm and atony,—to bile and other vitiated humours, —to a deterioration of the blood,—or to morbific matter pervading every portion of the organization, and contaminating every element we know that the pheno- mena of the disease are always associated with a lesion of some organ. Our object, then, is to determine the seat and charac- ter of this lesion, the modifications of the vital acts which have been instrumental in producing it, and the disturbance or con- sequences to which it gives origin. We thus become possessed of the essence of the malady;—we are enabled to make a correct interpretation of all its phenomena, —trace them to their proper sources, form an accurate estimate of their collective and individual importance, and thus ac- quire positive data upon which to predi- cate all our therapeutic indications. Pathological anatomy cannot reveal to us the hidden essence of the exanthema- tous diseases; neither can its resources reach the mysterious character of the ve- nereal or hydrophobic virus, or the ele- ment of the scrofulous diathesis. Still, it can array before us the horrid effects of all these instruments of human destruction, by unravelling the formidable ravages which they commit upon the living struc- tures, and, in this way, not only explain how death is induced, but, in like manner, furnish suggestions calculated to lead to a rational and successful treatment. The whole range of cutaneous diseases has, moreover, been greatly illustrated through its agency. It has satisfactorily demon- strated that a great proportion of the vary- ing modifications of these affections are merely owing to the different parts of the dermoid structures that may be implicated, and that instead of considering every shade of form or physical aspect which an erup- tion may present, as constituting so many diseases differing in their element, many of them are referrible to one and the same condition, and should be treated upon the same principles. Aided by the collateral lights of chem- ical science, it has done much to elucidate the obscure and difficult pathology of the fluids. Upon this point, however, our knowledge is, unfortunately, as yet ex- ceedingly limited. Yet an impulse has been recently given to these investiga- tions, which cannot fail to lead to impor- tant results. But, in calculous disorders, its utility has been strikingly manifested. A careful study of these productions has led to the discovery of the condition ofthe system by which many of them are pro- duced, and in thus revealing their proper causes, has laid the foundation for a suc- cessful method of preventing their forma- tion. Pathological anatomy is in like manner identified with every part of surgical pa- thology. It lends its aid in explaining the complex phenomena induced by inflamma- tion,—how the tissues become softened or indurated by that process; how they are disorganized ; the characters of the new products which are formed ; the proper- ties of pus; how it becomes circumscribed in the substance of a tissue or organ, or travels through its parenchyma to some remote point; how it progresses to the sur- face to be discharged; and, finally, the process by which the ravages inflicted on the organization, either by vital or physical agencies, are repaired. To pathological anatomy is the surgeon also indebted for a knowledge of the characters of tumours and other morbid products requiring his interference;—for an explanation of the nature of hemorrhage, and the modes by which his means prove effectual in arrest- ing it; and for the process by which wounds and ulcers are healed,—fractured bones consolidated, and mutilated parts restored. Without its illustrations, what could he know of aneurism and the prin- ciples upon which its treatment should be conducted 1 How could he venture to ob- literate the main trunk of an artery, if he was not aware, that through the anasto- mosing vessels, a sufficient collateral cir- culation can be carried on to maintain the vitality of the limb? Or how could he explain the process by which a ligature applied to a vessel is capable of effecting a permanent obliteration of its calibre, without endangering the life of the indi- ANATOMY. {Pathological.) 459 vidual by hemorrhage? It explains the characters of hernia, the changes which take place in the protruded parts, and the consequences inflicted upon the strictured organ; it has laid the foundation for a ra- tional and successful method of treating artificial anus; and has illustrated the char- acters of hemorrhoids, of fistulas, and of prolapsus ani, and suggested appropriate treatment. The diseases of the bones and articulations have been rendered clear and intelligible by its illustrations; as have also the various displacements and distor- tions to which they are liable. In short, to represent its importance to the surgeon, would be to detail every disease and acci- dent which falls within the province of his art. The department of obstetrics is not less indebted to pathological anatomy. The distortions of the pelvis; the displacements of the uterus; the diseases to which it and the other female organs are liable; the anomalies in the development of the pro- ducts of conception, and the accidents to which they are subject all derive important illustrations from it; and he alone who is thoroughly enlightened by its principles, can be competent to meet successfully the emergencies of the parturient state, and surmount the numerous obstacles which impede delivery. Need we insist upon its importance to the medical jurist] There are many ques- tions connected with this important de- partment of the science, which derive their whole illustrations from pathological anatomy. The physician is often called upon to give evidence in relation to the causes of death. It is indispensably ne- cessary, therefore, that he should be en- abled to discriminate between those lesions which are the natural result of disease, and those which are produced by poisons, or other agents, administered for criminal or unlawful purposes. In questions of rape and incompetency; of infanticide; of death from violence; and under a variety of other circumstances, his opinions must be formed from that knowledge which is derived from the same fertile source; and upon no other data, unaided by pathological anato- my, can he place any positive reliance. Ignorance upon these points, has sent thou- sands of victims to the scaffold, for crimes which were never committed. Pathological anatomy furnishes the only data which can be safely relied upon m the classification of diseases. All attempts to arrange them according to their remote causes or their symptoms, are vain and nu- gatory. Of the former, we know com- paratively nothing; and the latter are so variable, and uncertain, that any scheme of nosology founded upon them, could only lead to inextricable confusion. The re- mote causes of disease, are, many of them, amongst the res recondita, and no human intelligence can ever scan them. We know not whence they come, or what are their attributes; but we know their effects, —we can take cognizance of the ravages inflicted by them upon the organization ; —the lesions they develop; and by deter- mining the character of these lesions, and the symptoms to which they give rise, we have a full-length picture of the malady placed before us. Inasmuch, therefore, as the mischief inflicted upon the organiza- tion, and the disturbance of the functions awakened by it, are the only parts of the process which present a tangible charac- ter, and are susceptible of being appre- ciated, they are the only characters which can be safely adopted in framing a noso- logical arrangement, intended to embrace the essential characteristics of disease. While pathological anatomy is thus fruitful in its illustrations,—while it thus fertilizes the whole range of etiology, symptomatology, diagnostics, prognostics, and even nosology, is it capable of render- ing essential aid to therapeutics ? Unless this question can be answered in the af- firmative, all these alleged advantages will be of no value; for what signifies the most accurate knowledge of a disease, if that knowledge aid us not in the application of remedies for its mitigation or removal 1 But if it be admitted, that to be conversant with the nature of a malady, and to be able to interpret accurately all its pheno- mena, constitute the first and necessary steps towards the adoption of a proper course of treatment, the advantages capa- ble of being extended to therapeutics by pathological anatomy, are incontestable. It is true, that it cannot be adopted as the only guide, and that in some diseases it cannot assist us;—it is true, that without its lights, Hippocrates, Aret^us, Syd- enham, Baillou, De Haen, Stoll, Cul- len, and others, merely directed by clin- ical observations, achieved important tri- umphs in the treatment of diseases, and enriched the science with works, which, although abounding in error, will hand down their names to the remotest posterity. Yet, for a want of a knowledge of organic lesions, how often were they misled in the application of their remedies! How often, influenced by the fallacious signs of de- bility, did they resort to active stimulation, or to perturbating remedies, where the 460 ANATOMY. {Pathological) organs were affected with an intense dis- organizing process; thus adding to the force of the malady, and hastening its fatal termination! To demonstrate the services which pathological anatomy is capable of rendering to therapeutics, let us take, by way of illustration, the physiologico-patho- logical conditions of one of the phlegma- sia?. In the inceptive period, the operation of the remote cause gives rise to a state of super-excitement of the affected tissue, which precipitates an inordinate quantity of blood upon the part, and a series of vital acts thus become instituted, which lead to the development of various changes of structure, new productions, or even to complete disorganization. What then is the object of the therapeutist'? Taking the lights of physiological pathology for his guide, and, consequently, pathological anatomy, for we have seen that they are inseparable, he knows that if he quiets the nervous erethism, which is the first link in the morbid concatenation, he will prevent the subsequent fluxion; that when an in- flux of blood has already taken place, an abstraction of it will avert the changes of structure which would otherwise ensue, reduce the actions of the part within those limits which are compatible with their physiological relations, and thus pre- vent the development of induration, soften- ing, suppuration, disorganization, trans- formations of tissue, new or heteroclite de- generations, which it is the natural ten- dency of inflammation to occasion. Being conversant with the organic and vital con- dition of the living structures, he knows that the whole of his efforts must be di- rected to invigorate their energies when they are languid, and restrain them when they threaten to surpass the proper bounds. He knows how to adapt the force of his remedies to the intensity of the disease ; he has clear conceptions of the modifica- tions of the vital acts which it will be ne- cessary to develop, in order to arrest the march of the malady; and, capable of dis- tinguishing between those affections which are incurable, and those which are within the controlling influence of the resources of the art, he knows when to limit his in- terference to a mere palliative course, and when it will be necessary to institute a more energetic treatment. All his efforts must, in short, be directed to second the conservative powers of nature; he should watch her salutary acts, and imitate them; and when he finds that she seeks relief by setting up a particular series of operations, his object should be to excite similar modi- fications by his remedial measures. If, then, this is to be his course; if he can only be prepared to act with advantage by an accurate knowledge of the condition of the diseased organ, and of the physiological modifications which are associated with it the important services which pathological anatomy is capable of rendering to thera- peutics are rendered indisputable, and both reason and experience demonstrate, that conjointly with clinical observation, it forms the whole foundation of the treat- ment of diseases. But in showing what it is capable of ac- complishing, should we not also advert to the errors which may arise from its misap- plication or abuse 1 We have only contended for the advan- tages which it is capable of furnishing, when fortified by clinical observation ;— we only insist upon it as one means of forming correct principles, and not as the only one; for he who supposes, that merely to know that an organ has its colour changed, its volume altered, its texture modified, and its relations deranged, will furnish all the indications necessary to di- rect him in the treatment of the morbid phenomena to which its diseased condition gives origin, deludes himself, and sad ex- perience must soon convict him of his error. Pathological anatomy has had such misguided votaries; and in their zeal to reduce everything to mere physical modi- fications of structure, they have abused the science, and attributed effects to causes altogether inadequate to their production. Every trivial and partial blush of redness; every appreciable modification of the size, form, or consistence of an organ; every insignificant tumour, excrescence, or ul- cer ; every accidental infiltration of a part with fluid,—is erected into a source of great and important disturbance of the healthy functions, and is appealed to in triumph as the fountain of all mischief, and the cause of death, when it had no participation in the phenomena of the dis- ease, and is frequently a mere accidental post-mortem phenomenon. It is certainly true that the changes which take place after death often annihilate all traces of morbid organic phenomena, which, during life, exhibited a character of great intensi- ty; yet it is equally incontestable, that mere cadaveric phenomena often similate so closely many organic lesions, as to ren- der it difficult to discriminate between them, and to cause them to be confounded by those who are not accustomed to make autopsic examinations. The mechanical obstacles presented to the passage of the blood through the heart and lungs, during ANATOMY. the last moments of life ; a similar condi- tion produced by the suspension of respira- tion, in the acts of hanging and drowning frequently occasions an extreme vascular injection, and consequent arborescent red- ness, which is apt to be mistaken for in- flammation. The extreme facility, more- over, with which the fluids percolate the parenchymatous arrangement of the tis- sues, and the tendencies which they have to become collected in the most dependent part of the organs and regions of the body after death, often give rise to phenomena which might be mistaken for evidences of disease. It should likewise be remarked, that so soon as life is extinct, a play of chemical affinities is brought into opera- tion; the solids and fluids are mutually acted upon by each other; the former lose their cohesiveness, and become softened and fragile; they are infiltrated by liquid and gaseous products, and have their pro- perties extensively modified. Sometimes, indeed, so powerful is the action of the fluids upon the solids, that the latter are completely broken down by them, or are resolved into a complete homogeneous, diffluent pulp. Hence, it is not uncommon to find after death, the whole of the mu- cous coat of the stomach dissolved, and even its entire walls, as well as those of the intestines, presenting extensive perfo- rations, when no evidences of disease of those parts were apparent during the life of the individual. While, therefore, pathological anatomy is calculated to render such important aid in the difficult task of determining the characters and conducting the treatment of diseases, we must disabuse ourselves of a too implicit reliance upon it to the ex- clusion of other considerations. It should be constantly borne in mind, that an in- finity of organic lesions may be found after death, which have had no participation in the destruction of the individual, and that we are liable to be imposed upon by ap- pearances, which only take place after death. We cannot have a better rule of conduct than the maxim laid down by Cruveilhier, " that every organic lesion which is not constantly observed as a con- sequence of any particular disease, should not be regarded as constituting an essen- tial part of it." Bibliography.—Thom. Bartholin. De An- atome pradica ex cadaveribus morbosis adornan- da consilium; &c. Hafh. 1674. 4to. Theoph. Bonetus. Sepulchretum, s. anatomui pract. ex cadav. morbo denatis, proponens histc- rias et observalimies, &c.: editio altera quam no- vis commentariis et observationibus, &c. illustra- vit J. J. Mangetus. Geneva?, 1700. 2 vols. Fol. 39* {Pathological.) 461 Peyer. Methodus historiarum anatomicc-me- dicarum. Paris, 1678. 12mo. Harder, (Jo. Jac) Apiarium observationibus medicis centum ac physicis experimentis plurimis refertum, &c. Basil, 1687. 4to. _ Blancard, (Steph.) Anatomia pradica ra- tionalis, s. variorum cadaverum morhs denatorum anatomica inspedio. Amst. 1688. 8vo. Hoffman, (Fred.) De Analome in praxi me- dica usu. In op. om. Halle, 1707. Hoffman, (C. L.) Disquisitio corporis hu- mani analomico-pathologica, &c. Altdorf, 1713. Cant, (A.) Impetus primi anatomici ex lus- tratis cadaveribus nati. Lugd. Batav. 1721. Fol. c. tab. Stenzel, (Chr.Godfr.) Anthropologia adpa- thdogiam applicant, prejudiciis liberata. Viteb. 1728. 4to. Haller. Opuscula pafhologica. Lausanne, 1755. 8vo. 1768. 4to. Morgagni. De sedibus et causis morbor.per anatomen indigatis. Venet. 1762. 2 vols. Fol. Nova editio curant. Chaussier et Adelon. Paris, 1822. 8 vols. 8vo. Lieutaud. Hisloria Anat. Med. Edit. ab. Ant. Portal. Parisiis, 1767. 2 vols. 4to. Baadek. Observations medica incisionibus cadaverum anatomicis illustrala. Friburg, 1762. 8vo. Camper. Demonstrationum Anatomic&paiholo- gicarum. Lib. I. II. Amst. 1760-62. In fol. fig. Clossy, (Sam.) Observations on some of the diseases of the parts of the human body, chiefly taken from the dissections of morbid bodies. Lond. 1763. 8vo. Benvenuti, (Jos.) Observationum medicinal. ?ua anatomia superstruda sunt, &c. Luc«, 764. 4to. Cheston, (Rich. Browne.) Pathological in- quiries and observations from the dissection of morbid bodies. Gloucester, 1766. 4to. c. tab. Sandifort, (E.) Thesaurus dissertationum, &c. Lugd. Bat. 1778. 4to. 3 vols. Ibid. Museum Anal. Acad. Lugd. Bat. Luffd. Bat. 1793-1827. 3 vols. Fol. Ludwig, (C. F.) Prima Linea Anatomia Pa- thologica, Sic. Lips. 1785. 8vo. Vicq. D'Azyr. Encyclopedic Methodique. Art. Anatomie Palhologique. Paris, 1789. Baillie. The Morbid Anatomy of some of the most important parts of the human body. Lond. 1791. 8vo. New edition, with prelimi- nary observations on diseased structures, and notes, by Wardrop. Lond. 1830. 8vo. Ibid. A series of engravings accompanied with explanations, which are intended to illustrate the morbid anatomy of some of the most important parts of the human body. Lond. 1799. gr. 4to. Conradi. Handbuch der pathologischen Ana- tomie. Hanover, 1796. 8vo. Flachsland. Observat. Anat. Path. Rastad, 1800. 8vo. Vetter. Aphorismen der pathologischen Ana- tomie. Wien, 1803. 8vo. Voigtel. Handbuch der Path. Anatomie, mil zusatzen von P. F. Meckel. 3 bde. Halle, 1804- 1805. 8vo. Herold, (Jo.) Observala quadam ad corporis humani portium struclura et conditionem abnor- mem. Marborg, 1812. 4to. Meckel, (Joh. Fred.) Handbuch der Path. Anat. 3 bde. Leipz. 1812-1818. 8vo. Ibid. Tabula Anatomico-pathologica Fate. I. II. m. IV. Lips. 1817-1826: Fol. Kelch, (Wilh. Gottl.) Beitrage der Pa- thologischen Anat. Berlin, 1813. 8vo. 462 ANCHILOPS. Bujalski. Dissert, de part corp. humani so- lidorum similarium aberrationibus. Berol. 1813. 8vo. Otto, (A. W.) Handbuch der pathologischen Anatomie des Menschen und der Thiere. Bres- lau, 1814. 8vo. Ibid. Lehrbuch der pathologischen Anatomie, &c. Erst bande. Berlin, 1830. In English, by South. Lond. 1831. Ibid. Seltene Beobachtungen zur Anatomie, Sec. Breslau, 1816-1826. Fleischmann. Leichenoffnungen. Erlangen, 1815. 8vo. mit 2 kpft. Farre, (J. R.) The Morbid Anatomy of the Liver. Parts I. II. Lond. 1812-15. In 4to. fig. Cruveilhier. Essai sur Vanatomie pathdo- gique en giniral. Sue. Paris, 1816. 2 vols. 8vo. Ibid. Anatomie pathologique du corps humain, ou description, avec figures lithographiies et co- lonies, des diverses allirations morbides, Sic. Pa- ris, 1828-33. To consist of 40 fasc. in fol. Howship, (John.) Practical observations in surgery and morbid anatomy, Sic. Lond. 1818. Biermayer, (Laurent.) Museum Anatomico- Patltologicum nosocomii universalis Vindobonen- sis. Vmdob. 1816. 8vo. Rayer, (P.) Sommaire d'une histoire abrigie de Vanatomie pathologique. Paris, 1818. 8vo. Lallemand. Observations Palhologiques pro- pre d iclairer plusieurs points de physiologic Paris, 1818. 4to. fig. 2d ed. 1825. 8vo. Ibid. Recherches Anatomico-Pathologiques sur VEncephale el ses dipcndanc.es. Paris, 1820-25. Cerutti, (Ludw.) Beschreibung der path. Preparat. des anat. Theat. zu Leipz. Leipz. 1819-21. Consbruch. Taschenbuch der path. Anat. &c. Leipz. 1820. 8vo. Rostan. Recherches sur le ramollissement du cerveau. Paris, 1823. 8vo. Paletta. Exercitaliones Palhologica. Me- diolani, 1820-26. 4to. 2 vols. Monro. The Morbid Anatomy of the Human Stomach and Gullet. Edinb. 1811. 2d ed. 1830. Bichat. Anatomie Pathologique: dernier cours de Bichat d'apris un manuscrit auto- graphe de P. A. Beclard, &c. Paris, 1825. Andral. Clinique Midicale, ou choix d'ob- servalions recueillies a la clinique de la Charili. 5 vols, in 8vo. Paris, 1823-1834. Ibid. Pricis d'Anatomie Pathologique. 2 tomes en 3. 8vo. Paris, 1829. In English, by Townsend and West. Lond. and New-York. Louis. Mimoires ou recherches anatomico- pathologiques sur plusieurs maladies. Paris, 1826. 8vo. Ibid. Recherches Anatomico-Pathologiques sur la Phthisic Paris, 1825. Ibid. Recherches Anatomiques, Palhologiques et Thirapeutiques sur la maladie connue sous les noms de gastro-enteri/e, &c. Paris, 1829. 2 vols. 8vo. Billard. Sur la membrane muqueuse gastro- intestinale. Paris, 1825. Bleuland, (J.) Descriptio musei anatomici Academia Rheno-Trajed. Utrecht, 1826. 4to. Ibid. Icones anatomico-pathdogica partium corporis humani, &c. Utrecht, 1826-28. Spitta. Die Leichen'uffnungen in Bezeihung auf Pathdogie, &c. Stendal, 1826. 8vo. Fasc. I.-IV. 4to. Gendrin. Histoire Anatomique des Inflam- mations. Paris, 1826-7. 2 vols. 8vo. Monro, (Alexr.) Morbid Anatomy of the Brain. Edinb. 1827. 8vo. Bright, (R.) Reports of Medical Cases. Lo - don, 1827. 2 vols. fig. col. 4to. Scho'n. Handbuch der Path. Anatomie des menschlichens Auges. Hamburg, 1828. 8vo. Craigie. Elements of General and Patho- logical Anatomy, adapted lo the present state of knowledge in that science. Edinb. 1828. Godman, (J. D.) Anatomical Investigations. Philad. 1824. Armstrong, (John.) Morbid Anatomy of the bowels, liver, and stomach, illustrated by a series of plates. Lond. 1828. Fasc. I.-III. 4to. fig. col. Hooper, (Robt.) TAe Morbid AwU. of die human brain. Lond. 1828. 4to. fig. col. Ibid. Morbid Anatomy of the uterus and its appendages, &c. Lond. 1832. 4to. fig. col. Ribes. De VAnatomie Pathologique considirie dans ses vrais rapports avec la science des mala- dies. Paris, 1828. Tome I. 8vo. Horner, (Wm. E.) Treatise on Pathological Anatomy. Philad. 1829. Lobstein, (J. F.) Traiti d' Anatomie Patho- logique. Tomes I. & II. 8vo. Paris, 1829-33. fig. col. in fol. Carswell. Illustrations of the elementary forms of disease. Lond. 1833-34. Fasc. I.-IV. 4to. fig. col. Hope. Principles and Illustrations of Morbid Anatomy, Szc. Parts I.-VII. Lond. 1833. Boivin et Duges. Traiti Pratique des mala- dies de Vutirus el de ses annexes. 2 vols. 8vo. et Atlas de 41 Planches coloriees in fol. Paris, 1833. Laennec and Bayle. Dictionnaire des Sci- ences Medicales. Art. Anat. Pathologique. Beclard. Dictionnaire de Medecine. Art. Anat. Pathologique. Paris, 1833. Cruveilhier. Dictionnaire de Medecine et de la Chirurgie Pratique. Art. Anat. Patholo- gique. Paris, 1829. Rudolphi. Encyclopaedisches Worterbuch der Medicinisch. Wissenschaften. Art. Patholo- gischen Anatomie. Berlin. Besides these numerous sources, we may refer for much important information, to several of the systematic Anatomical and Nosographical works, to all the Medical Journals, to the Memoirs and Transactions of Academies and Societies, and to a number of Essays and Monographs. E. Geddings. ANCHILOPS, Ankylops, or Ancilops. (Generally derived from ay^t, near, or ovyxvXfj, angle, and «4,, the eye; but the derivation is unsettled.) Ayxt,u>$, Gr.; Anchilops, Lat. There has been much useless discussion respecting the exact meaning and proper application of this term, which is now nearly obsolete. The ancients appear to have applied it to all tumours at the internal angle of the eye, whether caused by disease of the lachry- mal sac, or of the tissues covering this or- gan ; it is, however, to designate tumours in the cellular tissue over the lachrymal sac, that it is usually employed. These tumours present themselves under two forms. The first is termed inflammatory anchilops, and consists of a small phleg- monous tumour, which is red, painful, and sometimes even attended with considerable ANCHILOPS. 463 fever. The inflammation often extends to the eye-lids and conjunctiva; the puncta lachrymalia become completely closed, producing a constant stillicidium of the tears over the cheeks, and rendering the nostril of the affected side dry and so ex- ceedingly sensible that the slightest irrita- tion excites violent sneezing. The edges of the eye-lids and lachrymal caruncle se- crete a tough viscid mucus, which agglu- tinates the lids together during sleep. Suppuration often takes place, and an ab- scess forms which discharges externally; or the anterior portion of the lachrymal sac becomes implicated, and the matter passes into this cavity, constituting the false fistula lachrymalis of Beer. The second variety of anchilops is the encysted. This presents itself in the form of a round, hard, circumscribed, often in- dolent tumour, of variable size, situated above or below the tendon of the orbicu- laris muscle, rarely if ever immediately over it, and unattended at first with any redness of the skin. The development of this tumour is usually slow; and the im- pediment it offers to the free motions of the lids is the only inconvenience it occa- sions the patient. The tumour consists of a nbro-membranous envelope of variable thickness, inclosing a glairy ropy humour sometimes mixed with a yellowish pus. It often remains many years entirely indo- lent ; sometimes it ultimately inflames, the matter is evacuated, and a small ulcer re- mains {cegilops). Treatment. In inflammatory anchilops, an antiphlogistic treatment is to be em- ployed. Cold applications, as cold water or lead water, will generally suffice, with mild purgatives, restricted diet, and occa- sionally small doses of Tart, ant Unless the inflammation be very severe or ex- tensive, bleeding will not be necessary. When suppuration is about to take place, the cold applications must be exchanged for warm poultices, to hasten this event; and the abscess should never be allowed to open spontaneously; but as soon as fluc- tuation becomes sensible, the matter is to be evacuated by incision with a bistoury, to preserve the lachrymal sac from ero- sion. When this last accident occurs, the surgeon should avoid introducing probes into the sac, and content himself with washing out the abscess daily by means of an Anels syringe, with tepid water, to which a little laudanum may be added; and afterwards applying a piece of lint wet with this medicament over the wound. The abscess, instead of forming imme- diately above the lachrymal sac, some- times is seated still higher up; in which case, if it be not early opened, or the opening preserved until the cure is com- plete, the pus may make for itself a pas- sage above the sac and penetrate into the orbit producing serious accidents, as, ero- sion of the periosteum, followed by caries of one or more bones of the orbit. This may be detected by means of a silver probe, or by the presence of red, fleshy, very painful granulations, which bleed on the slightest touch, and are some- times developed at the opening of the fis- tulous canal. Such cases are usually of difficult management The deep situation of the caries, as well as the proximity of the globe of the eye and the smallness of the fistulous canal, present difficulties to the employment of topical applications. If the separation of the carious portions of bone be trusted to the slight suppuration which occurs, exfoliation will not be ef- fected in less than from six to ten months. In these cases, Weller recommends the external orifice to be enlarged, if possible, and the pus daily evacuated by carefully injecting a filtered infusion of rue {Ruta graveolens), with a little laudanum ; and by afterwards introducing to the bottom of the fistula a lint tent steeped in a mix- ture consisting of one part assafetida and two parts solution of myrrh. Exfoliation may still more promptly be obtained, ac- cording to the same surgeon, by introduc- ing to the bottom of the fistula a small quantity of the following mixture. R. Gum Assafetid.; Gum Myrr.; Terebinth. Venit.; aa 9j; 01. Sabin. gtt. v. ad viij. M. When the canal is contracted by fleshy granulations, they may be destroy- ed by the cautious use of nitrate of silver or of red precipitate. When, by these means, the caries is arrested, which may be determined by the probe, tents of lint wet with laudanum are to be for some time introduced a short distance within the fistula ; and usually this passage ulti- mately closes of itself, leaving a small de- pressed cicatrix. In encysted anchilops, if the cyst be small it should be extirpated; if it be large it must be laid open, which will sometimes suffice to effect a cure. If it should not, inflammation of the sac is to be excited to cause the adhesion of its parietes and its obliteration, by excising a portion of the cyst, or by touching its inner surface with mild caustics, or by filling its cavity with lint. The Anchilops erysipelatosa idiopathica of Beer, Anchilops erysipelatosa of Wel- ler, is an erysipelatous inflammation of 464 ANCHUS.—ANCHYL. the internal canthus of the eye. The tu- mefaction is at first equally diffused, no particular hardness exists, the affection does not differ from erysipelas in other parts of the body, and requires no particu- lar notice here. The inflammation, how- ever, sometimes extends to the anterior portion of the lachrymal sac; a painful, circumscribed tumour forms, which, if not dissipated, terminates in suppuration; and the treatment here is the same as that which we have recommended for inflam- matory anchilops, of which it is one of the forms. Bibliography.—St. Yves. Nouveau traiti des maladies des yeux. Amsterdam, 1767. This author confounds Anchilops with distension of the lachrymal sac, resulting from obstruction of this passage. Wenzel. Manuel de Voculiste. Paris, 1808. Cloquet. Art. Anchilops, in Diet de Med. Paris, 1821. Weller. Traiti thiorique et pratique des maladies des yeux. Traduit de l'Allemand, par F. J. Riester. Paris, 1832. I. H. ANCHUSA. {Botany.) Bugloss.— Buglosse, Fr.; Ochsenzunge, Germ. Sex. Syst. Pentandria Monogynia. Nat. Ord. Boragineae. Gen. Ch. Calyx five-cleft, persistent. Gorolla funnel-shaped, with a half five- cleft, spreading limb; orifice closed with five prominent scales. Anthers included. Stigma emarginate. Seeds gibbous, with a sculptured surface. Lindley. 1. A. Italica.—Italian bugloss.—Sp. Ch. " Leaves shining, strigose ; racemes bipartite, diphyllous; flowers subequal, bearded at the throat." Willd. Sp. Plant. —This species of Anchusa is a biennial, hairy plant, with a branching stem about two feet high; alternate, linear-lanceolate leaves; and five blue flowers, disposed in a loose panicle, formed of one-sided, twin racemes. It is a native of the south of Europe, and is abundant in France, where it is employed instead of the officinal bu- gloss, {A. officinalis,) which it closely re- sembles in properties, and which does not grow in that country. 2. A. officinalis,—Officinal bugloss.— Buglosse officinale, Fr.; qfficinelle Ochs- enzunge, Germ.—Sp. Ch. " Leaves lance- olate, strigose; spikes one-sided, imbri- cated ; calyx as long as tube of corolla." Lindley.—The root of the officinal bu- ■rloss is biennial or perennial; the stem, from one to three feet high, and branching at top; the radical leaves, petiolate, en- tire, often from six to ten inches long by an inch and a half broad; the cauline leaves, small and sessile; the flowers, at first violet-red, afterwards blue, and dis- posed in one-sided, recurved spikes or ra- cemes. The whole plant is rough and hairy. It is a native of Germany, Great Britain, and other parts of the north of Europe. It was formerly employed, to a considerable extent, in medicine. All parts of the plant were officinal. They are with- out odour, and nearly tasteless. The leaves are mucilaginous when chewed ; the root, sweetish and highly mucilaginous; the flowers, slightly bitterish. By the ancients the plant was deemed cordial and exhila- rating, and was used in hypochondriacal affections; but as it was taken in wine, its supposed effects were no doubt ascribable to the vehicle. The flowers were ranked among the four cordial flowers. In later times, bugloss has been considered aperi- ent and refrigerant, and has been used in complaints of the chest, cutaneous affec- tions, rheumatism, &c. At present, how- ever, it is believed to be nearly inert and no longer holds a place in the British pharmacopoeias. In this country, it is never employed in regular practice; though the plant is sometimes cultivated in gar- dens. The fresh expressed juice, or a de- coction of the plant may be given ad libitum. 3. A. tindoria.—Dyers' bugloss, Dy- ers' alkanet.—Buglosse tinctoriale, Or- canette, Fr. ; fdrbende Ochsenzunge, falsche Alkanne, Germ.—Sp. Ch." Leaves oblong; bractes longer than the five-parted calyx; valves of the corolla shorter than the stamens." Lindley.—This is a pe- rennial plant, with round, rough, hairy, branching, lax, herbaceous stems, from six inches to a foot or more in height, furnish- ed with lanceolate, obtuse, hairy, sessile leaves, and terminating in bracteate spikes bearing reddish-purple flowers. It grows in the Morea, Cyprus, and other parts of south-eastern Europe. The root is offi- cinal under the name of alkanet. CSee ANKYLOBLEPHARON, Ankylo- blepharon, or Ancyloblepharon. (From wyxiOoj, a hook, and f$te$ae;ov, an eye-lid.) Ayxvtoiii'kttyarov, Gr.; Ancyloblepharon, Lat. The cohesion of the margins of the eye-lids. This term has been also applied to the union of the lids to the globe of" the eye; an affection, of which we shall treat under its more appropriate title, Symble- pharon, (q. v.). Ankyloblepharon may be imperfect a portion only of the margins of the lids co- herent and this occurs generally at their temporal extremities; or perfect, the mar- ANCHYLOBLEPHARON. 465 gins of the lids united in their whole ex- tent. This last form is so infrequent, that Guthrie doubts its ever existing except as a congenital affection. The union be- tween the lids may be close and imme- diate, or lymph may be effused on their edges in considerable quantity, and be- come organized, forming a whitish firm membrane, occupying and obliterating the natural opening. Causes. Whatever produces excoria- tion or ulceration of the tarsi may occa- sion anchyloblepharon; for if the opposed lids, in this condition, be kept in apposi- tion, the process of union is apt to take place. The most common causes of this affection are traumatic lesions arising from burns, concentrated acids, quicklime, acrid substances, &c. Weller has seen it result from an ulcer of the internal an- gle, extending to both lids, and the mar- gins of which contracted close adhesions, having been kept in contact by a tight bandage. It also occasionally follows psorophthalmia, small-pox, &c. In very old persons the edges of the eye-lids sometimes gradually adhere from their ex- ternal towards their internal angle, so as to exceedingly contract the opening. Clo- quet and Rostan have each met with several examples of this, in which the opening was so small as scarcely to enable the patient to see sufficiently to find his way. {Did. de Med. I. 438.) In some rare cases anchyloblepharon is congenital, and it here no doubt results from inflam- mation of the lids during uterine life. Diagnosis. Anchyloblepharon cannot be confounded with any other disease, but it is important to ascertain whether or not it be complicated with symblepharon, and there be opacity of the cornea; for the pa- tient would yield little thanks to the sur- geon for exposing, by an operation, a dis- figured and useless eye. When the an- chyloblepharon is imperfect, the existence of symblepharon may be determined by introducing through the opening a flexible probe of silver or whalebone, and moving it between the eye and lids. A simpler method, and one which answers equally, whether the affection be partial or com- plete, consists in taking hold of the eye- lids with the thumb and fore finger, and raising them from the ball, at the same time instructing the patient to move his eye in different directions. If there be no adhesion between the eye and lids, the motion of the former is free; if, on the contrary, adhesions exist, the motions of the organ, and the separation of the lids from it are prevented. The patient being able to distinguish light, affords evidence of there being no adhesion between the cornea and palpebras; an entire insensi- bility to light, affords presumption of a dis- organized state of the cornea, and evi- dence of the inutility of an operation. Prognosis. When not complicated with symblepharon, the prognosis in this affec- tion is favourable; and especially so when the adhesions exist only at the middle of the palpebral margins, or when the union is by an intermediate membrane. The partial adhesions which exist at the com- missures of the lids, especially at the ex- ternal commissure, are readily renewed after the operation, requiring particular attention on the part of the surgeon, in the subsequent treatment. Treatment. The only means of cure consists in the operation of separating the lids with a cutting instrument This can be conveniently effected by various meth- ods. In imperfect anchyloblepharon, the lids may be separated with probe-pointed scissors, as performed by Maitre Jean ; or a flat probe may be introduced beneath the lids, and the adhesions divided upon it with a common scalpel, as recommended by Guthrie. The method most usually adopted is to pass through the interval in the lids, a small grooved sound, bent to accommodate it to the natural curvature of the eye, and then to separate the lids with a bistoury passed along this director, the whole extent of the adhesion. Beer's plan is as follows. He takes hold of a cross fold of skin, with the fore finger and thumb of his left or right hand, as the case requires, whilst an assistant draws the up- per lid outwards and upwards in the same manner. A small blunt-pointed bistoury is then introduced at the inner canthus, and made to cut its way slowly out to- wards the external angle, without injuring either eye-lid. If the adhesion be through the medium of a membrane, the inci- sion is to be carried along the edge of the upper lid, and the membrane attached to the lower lid must be cut away with scissors. In complete anchyloblepharon, the lids should be raised up into a fold, as just re- commended, and an opening made in the line of union, by an incision with a bis- toury transverse to this fold. Surgeons differ in opinion as to the best point for making this opening. Sanson selects the internal commissure: Cloquet prefers the external one on account of the puncta lachrymalia, which he thinks are then less liable to be injured ; and further, because the projection of the nose often renders 466 ANCHYLOG.—ANCHYLOS. the introduction of the sound at the in- ternal angle inconvenient: Mackenzie makes the opening at the centre of the commissure. The point selected appears to be of no great moment; that which is most convenient to the surgeon, and best adapted to the particular case, may be adopted. Advantage is then to be taken of this opening, to complete the operation by one of the methods just de- scribed. The operation being completed, it only remains to prevent readhesion. The best measures for this purpose consist in wash- ing the wound with an astringent liquid, as rose-water, with sugar of lead dissolved in it; or by slightly touching the wounds with sulphate of copper, and frequently washing them with warm water, and sub- sequently smearing them with some unc- tuous substance, as the ung. ox. zinc. Beer advises also, that the patient should sleep soundly the night before, so as to be able to remain awake the night after the operation; it may be sufficient however, to awake him frequently, and direct him to open widely his lids, so as to prevent their adhesion. When the adhesions are at the centre of the margins of the lids, these measures are usually entirely ef- fectual ; but when seated near either of the commissures, they often fail in part, rendering it necessary, for entire success, to repeat the operation several times. Bibliography.—Wenzel. Manuel de Vocu- liste. Paris, 1808. Beer. Lehre von den Augenkrankheiten. Wien. 1817. Demours. Pricis thiorique et pratique sur les maladies des yeux. Paris, 1821. Cloquet. Art. Ankyloblepharon, in Diet, de Med. Tom. II. Paris, 1821. Sanson. Art. Ankyloblepharon, in Diet, de Med. et de Chirurg. Prat. Tom. III. Paris, 1829. Mackenzie. A Practical Treatise on the Dis- eases ofthe Eye. Lond. 1830, and Boston, 1833. Weller. Traiii thiorique et pratique des maladies des yeux. Traduit de PAIlemand, par Riester. Paris, 1832. I. Hays. ANCHYLOGLOSSUM. (From 07*1*05, a hook, and ykaoaa, the tongue.) Abnor- mal connexion of the tongue and mouth, restricting the motions of that organ, and arising either from shortness of the fras- num,or from the presence of an adventitious membrane extending from this part to the tip ofthe tongue (see Tongue-tie); or from adhesions between the mucous membrane ofthe tongue and that lining the cavity of the mouth (see Mouth). I. H. ANCHYLOSIS. (From Ay*i*oj, crook- ed, bent.) A permanent immobility of joints naturally movable. The deriva- tion of the word would also imply an an- gular position of the bones, but the term is probably merely indicative of the fact that in the early observations of the Greek physicians, the bones were found in this relation; at least in the joints most subject to this affection, as the elbow and knee. Anchylosis is distinguished into com- plete and incomplete, according as the ar- ticulations have lost entirely their motion, or as a slight degree of it is preserved. Most commonly, anchylosis is the result of acute inflammation; but it also is produced by a joint being kept an undue length of time without motion, as in surgical dress- ings—in rheumatism—in paralysis—from cicatrices—contraction of muscles—orfrom choice, as among the fakirs of India, who, under certain ideas of devotion, hold a limb so long in the same position that it becomes permanently rigid. The diseases which give rise to this affection in most instances are complicated fractures of the joints, dislocations, sprains, hydrarthrosis, white swelling, rheumatic or gouty in- flammations, and a spontaneous ossification of the ligaments. In young persons, an- chylosis is for the most part the result of active arthrodial inflammation from some of the causes stated ; whereas the sponta- neous cases exist in persons of an age somewhat advanced; there is, however, no invariable rule depending merely on age. In anchylosis from mere immobility, the immediate cause is a cessation of the se- cretion ofthe synovial fluid, and a rigidity of the capsular and funicular ligaments, to which may be added, a dryness ofthe ten- dinous sheaths, and an inspissation of the surrounding cellular substance. Some of these cases present a fixedness of the joint as firm as that arising from the actual fusion of the contiguous bones into each other, and not susceptible of being distin- guished by external examination alone. The spontaneous ossification and disap- pearance of individual joints is by no means unusual, and prevails chiefly in those of the smaller toes: the writer has often observed it in negroes. The next in liability are the other joints of the foot and -then those of the hand. The verte- bral column may be considered as subject to this affection. There are also a few remarkable cases on record of this con- dition existing in all the movable joints ofthe same individual. An infant of twen- ty-three months, whose history is recorded by the Academy of Sciences of France, (anno 1716,) presented an instance of it Mr. Larrey, of Toulon, exhibited to the ANCHYLOSIS. 467 Faculty of Medicine of Paris, the skeleton of a fisherman in whom almost all the joints were in this state; and in the year 1802, an officer died at Metz, in whom it was universal. This last case, reported by Percy, resulted from an inflammatory rheumatism contracted by exposure during a campaign in a cold humid country. The skeleton, which is now deposited in the anatomical cabinet of the School of Medicine of Paris, is seen to con- stitute but a single piece. Even the ar- ticulation of the lower jaw has disap- peared, which rendered it necessary during the life of the individual, to extract two incisor teeth, with the view to an opening into the mouth, for the introduction of aliment. Diagnosis. The characters of anchy- losis are so well defined that there is but little difficulty in distinguishing it the complete or partial immobility of the joint being sufficiently indicative. Some de- gree of attention is, however, expedient in developing the diagnosis; because it occasionally occurs that joints are in a state of inflammation or sensibility, making the least motion painful, and where an in- stinctive tonic contraction of the surround- ing muscles follows any attempt on the part of the surgeon to make the joint exe- cute its natural movements. Though anchylosis may be readily dis- tinguished from other affections of the joints, yet if these be perfectly immovable it is difficult to determine whether the disease is a mere rigidity of the soft parts, or an absolute and perfect union of the contiguous bones. The attending circum- stances will assist the judgment; for in- stance, if they consist in a fracture of the joint, followed by violent inflammation— if the joint has been opened by a gun-shot wound—if the bones were carious for- merly—these several conditions present strong evidence of their complete fusion ; and especially if to them be added, a dry- ness ofthe joint—a sense of inequality on the surface of the new callus—and ab- sence of pain when an effort is made to bend forcibly the joint. On the contrary, if the anchylosis be incomplete, tumefac- tion and engorgement are perceptible, and severe pain follows a forcible effort to move the joint. It is of great importance to distinguish between these two species of anchylosis, since the complete is in- curable, and in many cases efforts at a cure may be highly inconvenient and even injurious; while, on the contrary, the in- complete or false anchylosis is, in its early stages, almost always susceptible of cure, though if neglected it becomes incurable. The following may be considered as the most common condition of joints in the various species of anchylosis. 1. Anchylosis from want of motion. Frequent motion being necessary to pre- serve the flexibility of every joint and to keep its ligaments of a proper length, size, and consistence, as well as to promote the proportionate discharge of synovial fluid, it happens that undue rest dries up this fluid or alters it into a simple serous ex- halation ; the contiguous surfaces of the synovial membrane lose their polish, be- come rough, and finally contract adhesions with each other, and in progress of time this membrane is converted indeed into a mere cellular substance, scarcely present- ing a vestige of its original character. The articular cartilages become thinner, and ul- timately wholly disappear. For a long time the spongy substance of the two bones is kept apart by a thin plate of cartilage and of compact substance ; but the final stage, which is that of complete ossification, re- sembles the junction of an epiphysis with the body of a bone, and scarcely a trace of the original separation remains. M. Cloquet, in the article on Anchylosis, in the new edition of the Dictionnaire de Medecine, informs us that he has repeat- edly verified the preceding stages on par- alyzed persons who had remained for a long time in bed in one position, and that he has never seen a trace of that inflam- mation in the synovial membranes, the existence of which is very commonly al- leged, but perhaps on hypothetical grounds. 2. Anchylosis from false membranes. When inflammation has assailed a joint especially the knee, the synovial mem- brane, like the pleura and peritoneum, de- posits a layer of coagulating lymph, which forms bridles through the joint, and occa- sions an adhesion of surfaces naturally free. These adhesions are at first soft and gelatinous, but they in progress of time acquire consistence, and are converted into cellular substance. The synovial fluid, which, in the early stage of the affection, was in excess, is afterwards entirely re- moved, and, as a final change, ossification invades the whole soft structure consti- tuting the joint, just as in anchylosis from immobility. 3. Anchylosis from softening and re- moval of the articular cartilages, in con- sequence of scrofulous inflammation and caries of the ends of the bones. This is the most common condition of a joint 468 ANCHYLOSIS. leading to anchylosis; and in this case when a sanative process succeeds the pre- ceding destruction of parts, the ends of the bones shoot fortii granulations which ad- here as in a common sore, and finally os- sify, so that the contiguous bones are con- tinued into one another, after a process very analogous to the union by granula- tions in a compound fracture. This pro- cess is, however, very much retarded in many instances, by fragments of detached bone, and by fistulous passages leading through the granulations. 4. Anchylosis from ossification of the interosseous cartilages. Wherever a fibro- cartilaginous junction exists naturally be- tween bones, as in those of the spine, there is a disposition to ossification, in advanced age; this is favoured both by the charac- ter of the tissue and by the small degree of motion. The ossification is seldom so perfect as to invade the whole interver- tebral matter, the pulpy part being com- monly left untouched, while bone invades the most fibrous portion which is in front. In some rare cases, the whole vertebral column has thus been converted into a single piece. M. Seraphin, the inventor of a celebrated pastime for children, in Paris, consisting in optical illusions, called the Chinese Shades, is said to have pre- sented this peculiarity. (Cloquet. Art. Ankylosis, in Diet de Med. 2d ed.) Treatment. Whatever may be the dis- ease tending to anchylosis, it should of course be treated by its appropriate reme- dies, which will be found under their pro- per heads. The preliminary affection be- ing ended, and the anchylosis itself estab- lished, the subsequent management must depend upon the latter being incomplete or complete. Incomplete anchylosis is almost always susceptible of cure, if it be taken in an early stage; its intractability is increased by duration, and is greater in the gingly- moid than in the orbicular joints. It is also more manageable when the conse- quence of protracted rest than when it re- sults from a morbid derangement of tissue. From the pliancy and succulency of the fibrous membranes in infancy, this may be considered as a favourable period of life for a cure. The rigidity of ligaments, and the re- traction ofthe muscles, being the common opponents to the relief of incomplete an- chylosis, the indications are, therefore, to restore flexibility to the former, and ex- tension to the muscles. These may be accomplished by making frequently gentle flexions and extensions of the limb, con- joined with simple or medicated frictions over its whole length. Among the appli- cations which experience has sanctioned are warm lotions, vapour baths, and streams of hot water from the mouth of a kettle. The hot springs of Virginia, which are used both as a bath and by suffering a stream to impinge on the body, are justly distinguished for their salubrious effects in stiffness of the joints from rheumatism and from incomplete anchylosis. Warm or hot bathing may be rendered more effi- cient by impregnating the water with common salt, muriate of ammonia, the al- kalies, and sulphur. Frictions with olive oil, plain or joined with camphor—with saponaceous liniment, or opodeldoc; fo- mentations of an emollient kind, as a de- coction of marsh mallows or flaxseed, or of the tripe of an animal, are very ser- viceable. The French surgeons place much reliance on a species of fomentation obtained by applying to the joint some por- tion of an animal just killed. Thus, M. Boyer {Malad. Chirurg. IV. 571.) re- commends the plunging of the affected part, if conveniently situated, into the body of an animal the moment it is opened; or else, taking the omentum or skin of a sheep just slaughtered, and wrapping it around the part for some hours. Two or more of these means may be used at once, and should be repeated for at least half an hour twice every day. When some relaxation is imparted to the joint its motions should then be sedulously attended to, by conforming them to the character ofthe articulation: thus, flexion and extension will answer for the hinge- like joints, while circumduction and rota- tion must in addition be used in the or- bicular. The motions ought to be very gentle at first, and extended gradually from time to time, to the greatest ampli- tude admitted by the form of the articula- tion. An abrupt force causes pain and may reproduce inflammation. In the early trials, a crepitation and grating will be heard, arising from the want of synovia and the friction ofthe rough articular sur- faces together, and also from the elonga- tion of the ligaments and the preternatural adhesions; but as the joint approaches the normal state, the increased secretion of synovia and the softening ofthe surround- ing parts make the motions smooth and without pain. These primary motions should be made by the surgeon himself, or by a skilful attendant. Where the anchylosis is very ancient and the retraction of the flexor muscles extreme, in addition to the above it is re- ANCHYLOSIS. 469 commended by the authority of Fabricius, Hildanus, Boyer, and others, to resort to a machine, the invention of the former, by which a constant extending force is main- tained upon the limb. A splint and bandage may be used to this end on the lower ex- tremity, and the frequent holding of a weight in the hand will answer for the upper extremity. In the progress of a malady, when it is obvious that complete anchylosis must fol- low, it is important to fix the limb in that position which is most favourable for its subsequent use: thus, the lower jaw should be a little depressed; the thigh and leg extended; the foot at right angles with the leg; the toes extended; the arm drawn downwards and some what out; the fore-arm flexed at right angles with the arm, and with its two bones parallel; the hand in a line with the fore-arm ; the fingers semi- flexed ; the thumb slightly out from the fore finger, with the second phalanx bent as in holding a pen. The head should be set at right angles on the vertebral column. Notwithstanding the general rule of complete anchylosis being incurable, some few cases have occurred in the surgical history of our own country, showing that it is not invariably so. The most remark- able exception, is the case of a patient in the Pennsylvania Hospital, affected with anchylosis of the hip joint, on the right side, attended with an inconvenient cross- ing ofthe os femoris to the other side, and who was operated on by Dr. J. Rhea Bar- ton, in 1826. In this instance the bone was sawed through a little below its neck, and the limb straightened. In twenty days after the operation, motion was instituted and kept up so as to make an artificial joint which at the end of four months seemed to have succeeded, the wound necessarily caused by the operation having previously got well. {North Am, Med. Journal. III. 279, and 400.) The following supplementary commu- nication from Dr. Barton to the Editor, will give the best idea of the consequences and condition of this case till within a short period: " Dear Sir,—In reply to your note of in- quiry on the subject of the case in which by an operation I had succeeded in remedying the distortion and lameness of a limb, and in establishing an artificial joint at the hip, as a substitute for the natural one, which had been destroyed by anchylosis, I can inform you, that for six years I kept a watchful eye on the individual operated on; and during this period had opportunities of inspecting the part. Within the first year the patient had vol. i. 40 been exposed to occasional attacks of inflam- mation; induced sometimes by contusions, and at other times by the undue and fatiguing use of the limb. The consequence of this early and repeated irritation of a part which had so recently undergone such treatment and alteration of structure, was, that much thickening at the hip, and a diminution of the latitude of motion in the joint, resulted. Nevertheless, when I last saw him, which is about two years ago, he walked surprisingly well, without a crutch or even a cane. There was to be observed in his movement scarcely anything indicative of the change which had taken place. But, though at this period the limb was straight; without any further short- ening, and was strong and useful; the mo- tion in the artificial joint had become much restricted by the thickening of the surround- ing ligaments, thus binding the articulating surfaces so closely together as to admit of but little motion on each other. Yet this, conjoined with the enlarged motion which he had acquired previous to the operation, be- tween the lumbar vertebras, and with the ac- commodating motions of the opposite side, gave to him the enjoyment of a limb free from contraction and firm, and useful enough for all ordinary purposes. Within the period of the six years, I fre- quently used to meet the patient in the streets, walking with a quick and easy pace. At one time he was engaged in soliciting subscriptions to some literary productions, but subsequently he returned to his trade. I regret that I have not been able to see him for the past two years, or to learn whither he has gone; that I might be able to inform you of the present condition of the joint. But my apprehensions were that ul- timately the motion of the joint, if not en- tirely lost, would not be of any material ex- tent ; though in the permanent value of the operation to him in all other respects, I had the fullest confidence. Should another case of a similar kind pre- sent itself, I would repeat the operation; but with such modifications as my experience in the first case, and my subsequent reflections on the subject, have warranted me in believ- ing would effectually prevent any final dimi- nution of the acquired motion; viz. by sub- stituting an oblique for a transverse section of the bone. Within the last three years I have suc- ceeded in re-establishing a joint at the ankle, in the case of a gentleman (Mr. B. Bullock) of this city, who, by an accident, had the mis- fortune to suffer a compound dislocation and fracture ofthe ankle joint, followed by the en- tire loss of full two and an half inches ofthe inferior extremity of the tibia, including its articulating surface. The fragment is pre- served in my collection—and the gentleman, who has not been under treatment for the last two years, has been, and is now, in the 470 ANCHYLOSIS.—ANDA. enjoyment of sound healtli, and of a good limb which he uses unaided even by a cane. In this case, a quantity of bony matter was secreted, as well from the inferior extremity of the fibula, as from the tibia itself, which would have terminated in true anchylosis, but for the motion to which I had subjected the part, as early as the state of the limb ad- mitted of it; thus applying the same princi- ple of practice to the re-establishing of the motions of a fractured joint, which had in- fluenced me in the formation of an artificial joint. With much respect, Yours, J. Rhea Barton. Dr. Hays. Philada. July 3,1834." Three cases of incomplete muscular an- chylosis of the articulation of the lower jaw have been successfully treated by Dr. Valentine Mott, of New-York. In the first case, {Am. Med. Journal. V. 102.) the individual had been in that situa- tion for ten or eleven years, the condition having been produced by the loss of the small and large grinding teeth on the left side of the lower jaw, together with a large piece of the jaw itself. A liga- mentous cicatrix, of an extremely firm character, had occurred between the cheek and the jaw bone in this region, so that only a little lateral motion could be im- parted to the jaw. The cheek was cut through to the coronoid process, and the adhesions to the upper and lower jaws de- tached; the jaw was then forced down by an ingenious lever, and the mouth kept open with it or a piece of wood, till the wound healed. The natural motions of the jaw were finally renewed, and the patient could masticate freely, and engage in conversation with a distinct articulation. The details of the second case are want- ing, but it is reported in general terms to have been similar to the first Dr. Mott's third case arose from a slough of the cheek, two inches in diameter, which, upon cicatrization, held the jaws immova- bly together, and caused the necessity of extracting a tooth from the other side of the mouth, for the introduction of food. As there was a considerable loss of substance here, the common method of cutting up the adhesions would not have been suffi- cient to provide for the opening of the mouth: the Doctor, therefore, by an ap- plication of skill the most creditable, re- moved the cicatrix, and by a Taliacotian operation brought a portion of the integu- ments of the lateral part of the lower jaw to supply the place ofthe destroyed cheek. The treatment seems to have succeeded most happily. (See Am. Med. Journal, IX. 47.) Dr. Mighels, of Maine, (Id. p. 50.) has also succeeded in restoring motion to the lower jaw, where it had been almost lost from an adhesion, of a ligamentous kind, extending from the cuspate tooth to the coronoid process on the left side. The ad- hesion was the result of mercurial ulcera- tion. The division of the adhesion, with- out cutting through the skin of the cheek, was sufficient in this case, the jaws having been forced asunder by a lever introduced between the teeth, and acting with great energy by means of a screw: a similar in- strument had been resorted to by Dr. Mott, in his cases. The preceding instances of immobility of the lower jaw do not come accurately under any of the ordinary scholastic divi- sions of anchylosis, but are cases apart, arising from the peculiar relations of the bone, and such as would not occur else- where. When the adhesions were re- moved, the main difficulty of putting the joint in motion appears to have arisen from the muscles not having their customary power, and not from any change in the joint itself; so that the term anchylosis is at least equivocal, meaning here rather a condition of the parts around the joint than of the joint itself. W. E. Horner. Bibliography.—Muller. De ancylosi. Ley- de, 1707. T. Van De Wympersse. Diss, de anchylo- seos pathologica et curatione. Leyde, 1783. J. Rhea Barton. On the treatment of An- chylosis, by the formation of artificial joints; in the North American Med. and Surg. Journ. III. 279, et seq. Philad. 1827. V. Mott. Case of immobility of the lower jaw successfully treated; in American Journ. Med. Sc. V. 102. Philad. 1829. Ibid. Case of immo- bility of the jaw, and Taliacotian operation; in same Journal, IX. 47. (1831.) J. W. Mighels. Case of immobility of lower jaw successfully treated by Prof. Mott's compli- cated lever, ana a modification of his operation; in same Journal, IX. 60. Art. Ankylosis, in Diet, de Med. et de Chirurg. Prat. Paris, 1829. Saml. Cooper. Art. Anchylosis, in Diet of Pract. Surgery. J. Cloquet. Art Ankylosis, in Diet, de Med. 2ded. Paris, 1833. I. H. ANCONEUS. (From ay*w, the el- bow.) An epithet formerly applied to all the muscles attached to the olecranon. (See Muscles.) I. H. ANDA. {Botany.) Sex. Syst. Moncecia Monadelphia. Nat. Ord. Euphorbiaceas. Gen. Ch. Calyx short, five-dentate. ANDA.—ANDIRA. 471 Corol. monopetalous, four times the length of the calyx. Fruit 2-celled, 2-seeded. This plant which is the only species of the genus, was first described by Piso, un- der its native name of Anda. It however remained unnoticed by succeeding botan- ists until Gomes (06s. bot. 1.) gave an ac- count of it, and erected it into a new ge- nus, on which he bestowed the name of Joannesia; this being, however, preoccu- pied, A. Jussieu restored its original ap- pellation of Anda, calling it A. brasilien- sis. The bark is lactescent and poisonous, and is used in Brazil for stupefying fish. The part used in medicine is the fruit, which is about the size of an apple, and of an ash colour. On removing the ex- ternal husk, a nut is presented to view, which is about two inches in diameter. It has a hard shell, which, on being broken, exhibits two cells, each containing one seed about the size of a chestnut. These Beeds are cathartic, in doses of from one to three, and are much used by the natives of Brazil. The external husk is employed as an astringent in diarrhoea, and also to moderate the effects of an over-dose of the kernels. By expression, these seeds fur- nish a clear, pale yellowish oil, which is destitute of taste and almost of smell; at common temperatures it is as fluid as olive oil, and is used in Brazil for burning, for painting, and, by the Indians, for anointing their bodies. From experiments made with it in the Pennsylvania Hospital, by Dr. Norris, it appears that in doses of 50 drops it generally induced one evacuation, and in larger quantities operated copiously. Like all other remedies furnished by the Euphorbiaceas, it will often act on the stomach, and cause nausea. Bibliography.—Piso. Hist. Nat. Brazil. Amstel. 1618. A. Jussieu. De Euphorbiacearum generibus, &c. Paris. 1824. B. Gomes. In Mem. de I'Acad. de Lisbonne. III. 5. A. St. Hilaire. Plantes usuelles des Bra- sHiens. Fas. XI. Paris, 1825. J. J. Virey. In Journ. de Pharmacie. XVII. 254. Paris, 1832. F. R. Smith. In Journ. Phil. Col. Pharm. IV. 25. Philad. 1832. R. E. Griffith. ANDIRA. {Botany and Mat. Med.) Sex. Syst. Diadelphia Decandria. Nat. Ord. Leguminoseas. Gen. Ch. Calyx urceolate, entire or five-dentate. Corolla two-petalled. Drupe fleshy, ovate, one-seeded. Gmelin. This genus was separated from Geof- froya, and includes those species included by Linn.eus in the latter, which have pa- pilionaceous flowers, and a fruit without valves. At the same time, as is justly ob- served by De Candolle, these two genera are scarcely distinct, and neither of them can strictly be con^'Jered as belonging to the Leguminoseas, on account of the char- acter of their fruit, which is analogous to that of the Amygdaleas. All the species of Andira are possessed of medicinal pro- perties of different kinds. 1. A. inermis. Cabbage-tree. Geoffroya de la Jamaique, Fr.; Wurmrinde, Germ. Sp. Ch. Unarmed; leaflets lanceolate. Willdenow. This species is found in many parts of South America and the West India islands. It is a tall tree, branching at the summit, with pinnate leaves, of four or five pairs of lanceolate, acute, smooth follicles; the flowers are in clusters, of a pale rose co- lour ; the fruit somewhat resembles a small plum; it is marked with a longitudinal furrow, and contains a hard stone or seed. The part used in medicine is the bark, which, as found in commerce, is in long, thick, fibrous pieces, externally of a brown- ish-ash colour and generally coated with lichens, internally yellowish; it has a resinous fracture, a disagreeable smell, and a sweetish, mucilaginous, bitterish taste. This bark was long employed in Jamaica and elsewhere, as an anthelmintic, before it was known in Europe, where the first account of it was published by Mr. Duguid {Phys. and Lit. Essays); after which it attracted considerable attention, and numerous testimonies in its favour ap- peared in the periodicals of the day; among others, Dr. Rush speaks of it in the high- est terms. " I have," says he, " used above thirty pounds of it, and have never found it to fad in one instance." The fullest ac- count that has been given of it is that of Dr. Wright. {Philos. Trans.) Notwith- standing these encomiums, it is now sel- dom or never employed, except in the West Indies. It was used in powder, de- coction, or extract; in all of which forms it was necessary to be cautious not to ad- minister an over-dose, as from its poisonous qualities it was liable to produce vomiting, superpurgation, fever, &c. The dose of the powder is from a scruple to half a drachm, of the extract 3 to 10 grains, and of the decoction a table-spoonfull two or three times a day, till the desired effect is produced. It is said that cold water should not be drunk during the operation of this medi- cine. The fruit, or rather the kernel of the nut, has also been recommended as a vermifuge, in doses of a scruple or more, and is said by Piso to be very active, though 472 ANDROG.—ANEMIA. experiments made at Paris have not con- firmed his assertion: this may have arisen from the nut having lost its active proper- ties by age. 2. A. surinamensis. Decan. A. relusa. Kunth. Sp. Ch. Unarmed, leaves ovate, obtuse or retuse ; carina two-petalled. Bondt. This species, which is also a native of South America, furnishes a bark possessed of the same qualities as the A. inermis, except that they are not quite so active\ As found in commerce, it is in flattened pieces, of about a foot long, and several inches wide, grayish externally, and red- dish-brown within, with brown strias and spots, between the layers. It is used in the same manner and in about the same doses as the last. Both these species have been analyzed by Dr. Huttenschid, who discovered in them two new substances of an alkaloid nature, to which he gave the names of Jamaicine and Surinamine. There are several other plants of this genus, which have also been used in medi- cine. The A. racemosa, found in South America, according to Dr. Hamel is al- most identical in its effects to the A. iner- mis, and, as in that species, the nut is ver- mifuge in doses of a scruple. The A. Horsfeildii, a native of Java, enjoys much reputation as an alexipharmic, and is also considered by the natives as an excellent stomachic. Bibliography—-N. Bondt. Diss. med. de cort. Geoffroya surinamensis. Leyde, 1782. G. F. Huttenschid. Diss, inaug. chem. sis- tens analysia chemicem cort. Geoffroya surinam- ensis. Heildeberg, 1824. Wright. In Transactions Royal Society. London. 67-507. B. Rush. In Medical Commentaries. Edin- burgh, 1773. N. Chapman. Elements of Therapeutics and Mat. Med. II. 25. 4th ed. Philad. 1825. Fee. Cours d'histoire naturdle Pharm. II. 770. Paris. A. Jourdan. Pharmacopie Universelle. I. 605. Paris, 1828. Merat et De Lens. In Diet Universel de Mat. Med. I. 287. Paris, 1829. R. E. Griffith. ANDROGYNOUS. (From ame, a man, and yw^, a woman.) avSgoywos, Gr.; An- drogynus, Lat. Hippocrates applied this term to effeminate men, but it has been most generally employed to designate the union of both sexes in the same individual, or hermaphrodism (q. v.). Some natural- ists make a distinction between hydrogy- nous and hermaphrodite, applying the for- mer to animals provided with the organs of both sexes, but who cannot fecundate themselves; and the latter to animals who unite both sexes, and are able to fe- cundate themselves, without uniting to an- other of their own species. Phytologists 1 term those plants androgynous, which pos- sess both sexes in the same individual, j though on separate and distinct flowers; and those hermaphrodite in which the or- gans of both sexes are united in the same flower. I. H. ANDROMANIA. (From avtle, a man, and pavia, madness. Passion for men. (See J Nymphomania.) I. H. ANEMIA, Anemia, AnhjEMI a, or Anai- mia. (From a, priv., and atflogico-clinico. Modena,l810. Desportes, (E. H.) Traiti de Vangine depoi- trine, ou nouvelles recherches sur une maladie de la poitrine, que Von apresque toujours confondue avec Vasthme, les maladies du caur, &c- °aTl9' 1811. Warren, (John.) Remarks on angina pecto- ris. New England Journ. of Med. and Surg- '• 1. Boston, 1812. , Blackall. 06s. on the nature and cure of dropsies, to which is added an appendix contain- ing several cases of angina pectoris, with dissec- tions. London, 1813. ,_ . Bogart, (Henry.) On angina pectoris. Thesis. New-York, 1813. Latham, (J.) Obs. on certain symptoms usu- ally, but not always, denoting angina pectoris. Med. Trans. IV. 278. London, 1813. aJ Testa. Malattie del cuore. III. 236. 2d ed. Kreysig. Die Krankheilen des Herzens, sys- lemalisch bearbeitet, &c. Berlin, 1814-1/- Zecchinelli. Sulla angina dell petto, e suite morti repenline. Padua, 1814. , . Horst. Geschichle und gerichdirhe Beurthei- lung eines angeblich durch einen Stoss auf die Brust pUitzlich gestorben Mannes, in Beziehung auf die Sogenannte Brustbraunne und organiscM Herzkrankheiten, &c. Hufeland's Joum. XU. 57. (1815.) Jurine. Mimoire sur Vangine de poitrine, qui a remporti le prix au concours ouvert sur ce sujet par ia Soc. Mid. de Paris. 1815. Averardi, (J.) De angina pectoris ejusque pracipua specie, sternocardia. Pavia, 1816. Black. History of two cases of angina pec- toris. Trans. Med. Chirurg. Soc: VU. 70 (1816.) Reid, (Rob.) On the use ofoxigengas, in an- gina pectoris. Trans, of Coll. of Phy* in Ireland. I. 101. Dublin, 1817. Nicholl. Case of angina pectoris. Ibid. n. 117. Dublin, 1818. Fontaine, (J. J.) Essai sur Vangine de poi- trine. Theses de Montpellier, 1819. Schramm. Commentatio pathol. de angina pectoris. Leipzig, 1822. Hosack, (David.) Remarks on sternalg' or angina pectoris. Essays QD various subjc .s of Med. Sc. II. 238^uSft*vJr"ork, lg24. Wolf. De angm^peAfif^heipag, 1825. Abercrombitt. Contributions lo the pathology of the heart. Traiii. of Med. Chirurg. Soc. of Edinburgh. I. 34. (1824.) Laennec. Traiti cPauscul/ation midiate. Pa- ris, 1826. Astes, (P. M.) Essai sur Vangine de poitrine ou sternalgia. Theses de Montpellier. 1828. Jolly. Art. Angina pectoris, in Diet, de Med. et de Chirurg. Prat. Paris, 1829. Adelmann. Bruslbriiune und Erweiterw des Herzens. Hufeland's Journal, August, 1830. Hope. A treatise on diseases of the heart and great vessels, p. 474. London, 1826. Chapman. Notes of cases of angina pectoris, with some remarks. American Journ. Med. Sc. VII. 67. Philad. 1830. Raige-Delorme. Art. Angina Pectoris, in Diet, dc Med. Paris, 1832. Copland. Art. Angina Pectoris, in Diet, of Pract. Med. London, 1832. Forbes. Art. Angina Pectoris, in Cyclopaedia of Pract. Med. London, 1832. I. H. END OF THE FIRST VOLUME. * V NLM023256400