'w. - 4 $8$ »'*Wftl 1 -*1-,* tet/V "• Vl ii .., >) V NATIONAL LIBRARY OF MEDICINE Washington Founded 1836 U. S. Department of Health, Education, and Welfare Public Health Service \ 3V- i MANUAL OP THE PRACTICE OE MEDICINE. * » A MANUAL PRACTICE OF MEDICINE. GEORGE HILARO BARLOW, M.A. & M.D. CANTAB. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS; PHYSICIAN TO GUY'S HOSPITAL ; TO THE MAGDALEN HOSPITAL; AND TO THE PHILANTHROPIC SOCIETY. WITH ADDITIONS, D. FEANCIS CONDIE, M. D., FELLOW OF THE COLLEGE OE PHYSICIANS; AUTHOR OF "' A PRACTICAL TREATISE ON THE DISEASE OF CHILDREN, ETC.' PHILADELPHIA: BLANCHARD & LEA 1856. 5.2 5*5lr> \8& Entered according to Act of Congress in the year 1856, BY BLANCHARD & LEA, In the Clerk's Office of the District Court, in and for the Eastern District of Pennsylvania. PHILADELPHIA: PRINTED BY KING & BAIRD, 9 SANSOM STREET. TO RICHARD BRIGHT, M.D., F.R.S., PHYSICIAN EXTRAORDINARY TO HER MAJESTY, FELLOW OP THE ROYAL COLLEGE OF PHYSICIANS, CONSULTING PHYSICIAN TO GUY'S HOSPITAL, ETC., ETC. TO THOMAS ADDISON, M.D., FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, SENIOR PHYSICIAN AND LECTURER ON THE PRACTICE OP MEDICINE TO GUY'S HOSPITAL, ETC., ETC. AND TO HENRY MARSHALL HUGHES, M.D., FELLOW AND CENSOR OF THE ROYAL COLLEGE OF PHYSICIANS, PHYSICIAN TO GUY'S HOSPITAL, ETC., ETC. SI]is Utorfe IS DEDICATED, AS A TOKEN OF ESTEEM, BY THEIR FAITHFUL FRIEND AND COLLEAGUE, THE AUTHOR. » ADVERTISEMENT OF THE AMERICAN EDITOR. We are pleased that an opportunity has been afforded us of presenting to the physicians of the United States an edition of Dr. Barlotv's "Manual of the Practice of Medicine." Of its favourable reception by them, we can entertain not the slightest doubt. We know, indeed, of none better adapted for the use of the student and young practitioner, and for oc- casional reference by those more advanced in the profession. Instead of a meagre and indistinct outline of the leading diseases which the physician may be called upon to treat, the author has, with great skill and accuracy, delineated their characteristic phenomena, their nature, causes, and remedial management, so as to give a clear and faithful representation of what may be denominated their natural history, as well as their proper treatment; in accordance with the latest ob- servations and the experience of the best medical authorities. By keeping constantly in view the recognized principles of general pathology and therapeutics, the reader is made aware of those varying circumstances which so frequently modify the character and progress of different cases of the same disease, as they present themselves in actual practice, de- manding, in consequence, a modification, also, in their treat- ment, or, the indications remaining the same, a change in the means by which those indications are to be fulfilled. 8 ADVERTISEMENT OF THE AMERICAN EDITOR. The practical portions of this manual are particularly excellent, as well for their clearness and precision, as for their conformity to the principles of a correct therapeutics. The position of Dr. Barlow as physician to one of the large London Hospitals, and his intimate association with some of the most distinguished practitioners of that metropolis, has enabled him very fully to compare the rules of treatment ad- vanced with the results of actual observation and experience. The present edition is an exact reprint of the work as issued from the London press. The only important deviation from the latter is the rendering into English the directions appended to the several formulae given by the author. The chief additions that have been made by the American editor are, a chapter on Cholera Infantum, one on Cerebro- spinal Meningitis, and a third, on Yellow Fever. The few notes introduced into the text are distinguished by being inclosed between brackets, [ ]. How far these additions enhance the value of the work must be left to the judgment of the medical public. It is hardly necessary to remind the intelligent reader, that the terms hydrargyri cMoridum, and hydrargyri biclilori- dum employed in the formulae given in the present work, are intended, the first for Calomel,—the hydrar. chlorid. mite of the U. S. Pharmacopoeia, and the second, for corrosive sublimate—the hydrar. chlor. corrosir. of the U. S. Pharm. Philadelphia, January, 1856. PREFACE. My object in the present work has been to lay before un- professional brethren, more particularly students and younger practitioners, a system of medicine based upon the etiology, or what I would venture to call—the natural history—of disease. I do not, indeed, mean to imply that others have not pre- ceded me in the same course, and with distinguished success. The profound and philosophical " Outlines of Pathology and Practice of Medicine," of Dr. Alison ; the elaborate work on the " Principles of Medicine," of Dr. Williams; the eloquent as well as logical and scientific lectures of Dr. Watson ; and the unfortunately as yet unfinished work of Doctors Bright and Addison, on the " Elements of Medicine," are more than sufficient evidence to the contrary. Without, however, in the slightest degree, detracting from the merits of these and similar works; it is, I believe, admitted that we are at present in need of a hand-book for students. It is hardly to be expected, and perhaps not to be desired, that a professedly elementary work should abound in origi- nality, and therefore much that appears in the following pages must have been borrowed from others; but it cannot fail to add weight to any doctrine, which I would inculcate, to be able to enforce it by other and better authority than mv own. At the same time I would add that, whatever 10 PREFACE. is here advanced upon points of practice is mine, in so far as that I have compared it with my own observation and experience. I cannot, however, forbear to express my gratitude to Doctors Bright and Addison, of whom I have had the advantage of being the pupil as well as the honour of being a colleague; and to my late colleague, Dr. Babing- ton, as well as to all my present colleagues, for much that I have acquired orally. I am aware of many omissions, others will, no doubt, detect many errors. I trust, however, that upon questions of practice, I have advanced* little that will not meet the concurrence of the enlightened members of our profession. Where, however, I have advocated opinions differing from those commonly entertained, I have stated my reasons for doing so. I fear that I have thus been occasionally led into discussions, which all must feel to be tedious, and some may reckon superfluous, but my excuse must be my anxiety, to the utmost of my ability, to connect not only practice, but diagnosis also, with principles; believing, as I do, that empirical diagnosis can lead only to empirical practice. I hope that I may not fall short of the expectations of my friends as much as I have disappointed my own, though in regard to the latter, I would fain console myself with the words of the great moralist, that " to rest short of his own aims is incident to every one whose views are comprehensive, and whose fancy is lively ; neither is any one satisfied with himself because he has done much, but because he can conceive little." Union Street, Southwark, October 23, 1855. CONTENTS. PAGE Preliminary Observations . . . . . . .17 I. Causes of Disease.......18 II. Modes of Death.......21 III. Elementary Changes......29 IV. Inflammation.......30 V. Signs of Inflammation, and of Disease in General........65 VI. Fatal Termination and Treatment of Inflam- mation ........82 VII. Typhous, Scrofulous, and Tuberculous Deposits 106 VIII. Rheumatic and Gouty Inflammation . . . 115 Gout.........121 IX. Auscultation.......129 X. Cynanche, Laryngitis, Croup .... 138 Laryngitis.......112 Croup........150 XI. Catarrh and Bronchitis.....161 Bronchitis.......168 XII. Pneumonia and Pleuritis.....186 Pleuritis........205 XIII. Phthisis........227 XIV. Diseases of the Heart and its Appendages . 255 XV. Diseases of the Liver and its Appendages . . 293 12 CONTENTS. PAGE XVI. Diseases of the Esophagus . . . . 313 XVII. Diseases of the Stomach.....**15 XVIII. Dyspepsia...... ... 326 XIX. Peritonitis......„ . 336 XX. Enteritis and Obstructed Bowel . . • 356 Obstructed Bowel......358 XXI. Muco-Enteritis, Tabes Mesenterica, Diarrhcea and Dysentery......365 [Cholera Infantum].....373 XXII. Diseases of the Kidneys.....378 Nephritis........383 Bright's Disease......386 XXIII. Urinary Deposits and Diabetes. . . .405 Diabetes........416 XXIV. Inflammatory Diseases of the Encephalon . 419 [Cerebro-spinal Meningitis . . . .433 XXV. Delirium Tremens and Mania .... 443 Mania........447 XXVI. Apoplexy and Paralysis.....450 Spasmodic Affections.....468 Asthma........481 XXVII. Intermittent and continued Fevers. . . 485 Intermittent Fever......488 Continued Fever......501 XXVIII. Eruptive Fevers.......530 [Yellow Fever]......554 XXIX. Epidemic Cholera......590 XXX. Influenza and Hooping-Cough . . . 596 Hooping-Cough......597 XXXI. Diseases of Adolescence and Puberty . . 598 MANUAL OF THE PRACTICE OF MEDICINE. PRELIMINARY OBSERVATIONS. Medicine, in its present state, may be defined to be the art of detecting and discriminating disease by the symptoms accessible to our investigations; and of removing, checking, or allaying it, by the different means, at our disposal, for influencing the vital actions of the living body. This art then presupposes a knowledge of health,—that is, of the functions of the body, and the forces by which it is actuated; of dis- ease,—that is, of the changes both structural and functional from the healthy state, and of the laws which regulate the sequences of those changes; and—of the action of external and internal agents and remedies, upon the system, both in health and disease. Now if the above sciences were perfect, medicine would consist in a collection of corollaries from the truths contained in them, since a knowledge of healthy structure and function would enable us at once to appreciate any departure from it, and a knowledge of the changes in structure and function, which constitute disease, and of the laws which regulate the sequences which those changes observe, which lead us at once to recognize the nature and origin of the disease; whilst a knowledge of the action of remedies would enable us at once to select and apply the most appropriate. But as at present these subsidiary sciences are by no means per- fect, there remains much which can only be learned by experience gained from the practice of medicine itself, and therefore medicine has its own truths and principles, which we cannot at present deduce from any other branch of knowledge. The theory of medicine must in fact still be regarded as an inductive science of itself, though we are at liberty to take for granted the established truths of those to which we have alluded, and in the following pages shall rarely enter into any examination of them. 2 18 causes of disease. I. CAUSES OF DISEASE. The term cause of disease is often used in too vague a sense, being sometimes employed to express the lesion which is supposed to give rise to the morbid phenomena, at others to indicate the cause or agent which has produced the lesion in question,—at others, again, to describe the condition of the system, when exposed to that agent, and which has rendered it more than ordinarily susceptible of its influence. Thus, when a person presents certain symptoms which, upon further investigation prove to be connected with inflammation of the lungs, that inflammation is said to be the immediate cause of the disease; and if, upon further inquiry, it is ascertained that these symptoms have come on after unusual exposure to cold; that ex- posure is said to be the exciting cause; and, if it further appear that the patient had before been of a feeble or delicate condition from previous illness, intemperance, or other causes, this state of system, and sometimes also the causes which had led to it, are called the predisposing causes. Now, upon a little reflection, it becomes obvious that the term cause of the disease, does not strictly apply to either the first or the last of these. The so-called immediate proximate cause is, in fact, nothing but the disease itself, and therefore cannot be said to be the cause. The last again indicates merely a passive susceptibility, a thing widely different from any correct notion of an active cause. Again, to take another instance, marsh miasma or poison is well known to be the cause of ague, but persons who have been exposed to this miasma with impunity, when in perfect health, have become powerfully affected by it, when suffering from weak- ness induced by excessive fatigue, intemperance, or other diseases. Now these, as Dr. Abercrombie remarks,* were never known of themselves to produce ague, and therefore cannot be said to be its cause; and although such a mode of speaking is not only admissible, but convenient in ordinary conversation, it is in the highest degree unphilosophical, and therefore inexpedient in the language of medi- cine, which though not strictly a science, is an art based upon science, and in which the meaning of the terms employed should be fixed with logical precision. We have then the disease itself, of which the symptoms are the effect, and of which some influence or agency, external or internal disturbing the natural functions, is the true cause, though what its real nature may be, we are not always able to ascertain • and lastly we have the system, upon which this force or cause acts and of which the condition must greatly modify the result produced • and if previous disease or other debilitating agencies have impaired those * On the "Intellectual Faculties." hereditary tendency to disease. 19 powers of the system, by which—injuries are repaired,—the de- pressing or other injurious influences of some poisons resisted, and others eliminated, we shall have a great susceptibility for various forms of disease, but not what can be called a cause of such disease. Although, however, we dissent from the propriety of calling, a susceptibility of being affected by morbific agents, a cause of disease, indiscriminately with those agents; we are by no means disposed to disregard such susceptibility in any of our reasonings concerning the origin of disease, since upon it, must in many instances depend whether any disease will be produced, when an individual has been exposed to any specific or other cause of disease, and we are also willing to admit that this very susceptibility is often itself a disease, and that the very causes of this susceptibility may of themselves be real causes of disease. Thus we have stated that intemperance will render a person more susceptible of the action of marsh miasma; but this susceptibility is often associated with a structural change in some of the depurating organs, as the liver or kidneys, if it do not consist in it, and of which intemperance is a cause, and we know also that such structural change may often constitute in itself a most formidable disease. _ The chief predisposing conditions which constitute a liability to disease, upon the application of the ordinary causes, are chiefly as follows:— (1.) An hereditary tendency to particular diseases, transmitted from parents to children. It is true, indeed, that all constitutional peculiarities in the parents, influence the off-spring in a greater or less degree; but this is more particularly the case with certain dis- eases, amongst which are scrofula and tuberculosis in all their varie- ties,—asthma,—diseases of the nervous system, especially epilepsy and mania,—gout,—gravel,—diabetes,—and several diseases of the skin. Now it is obvious that this congenital proclivity to particular dis- eases cannot be removed by art; but if we also know, and can by any means obviate, the agents which are the causes of these diseases, we may often do much towards their ultimate prevention. (2.) But besides the above, which may be said to be congenital liabilities to disease, there are others, which may be called the ac- cidents of the individual, such as casual occurrences, in the form of disease or otherwise, which, by impairing the power of the circula- tion, or depressing the nervous energy, render the system more sus- ceptible of any influence to which it may be subjected. Amongst these may be reckoned imperfect, unwholesome diet, especially during the period of infancy and youth;—the habitual want of the natural stimuli of muscular exercise, fresh air, and light;—previous de- bilitating diseases, and excessive and repeated evacuations, either of the blood or of the serous part of it;—habitual intemperance, which produces chronic change in the organs of circulation, digestion and secretion, besides depressing the nervous energy:—these, like here- ditary predisposition, impress upon the system a susceptibility which is more or less permanent and constitutional. 20 sporadic causes of disease. (3.) The same causes, when acting only for a short time, may pro- duce a temporary and transient proclivity to disease; as may also long-continued exposure to cold, depressing passions, excessive exer- tions, and privation of sleep, protracted fasting; also exposure to excessive and long-continued heat, to impure air, as that of crowded or ill-ventilated rooms, or emanations arising from imperfect drain- age ; though these latter may often prove a direct cause of disease; as also intemperance and excessive sexual indulgence, both which may induce disease without the intervention of any other morbific cause, as well as render the system more susceptible to the action of any such cause. Of the above agents, some affect more powerfully particular organs, and dispose them more than others to suffer from the application of any cause of disease; but, as Dr. Alison very justly observes, " there is no one organ or texture which is uniformly affected, nor any one kind of diseased action which is uniformly excited by these causes." Their general effect is to dispose the body to suffer from the exciting causes of inflammations, or other acute diseases, amongst which latter we may include the various morbific poisons which affect either particular individuals, or whole communities. AYe are thus led to a threefold division of the causes of disease; into, 1st, Sporadic, or those affecting particular individuals; 2nd, Endemic, that is to say, continually, or at repeated intervals, affecting the inhabitants of a certain fixed locality; 3rd, Epidemic, powerfully, and often fatally, affecting for a time the population of certain districts or countries, and disappearing from them, to reappear again in other districts, or in the same district at some future period. Of Sporadic diseases the chief causes are,— 1. Mechanical and chemical injury; which, however, fall mostly within the province of the surgeon. 2. Violent muscular exertions, hurrying the movements of the blood, and thus, by disordering the circulation, favouring local con- gestions, and sometimes injuring some portion of the circulatory apparatus. 3. Mental emotions, and intense sensations; which sometimes dis- turb the action of the heart, or the circulation through the brain, and at others derange the secretions. 4. Excesses of all kinds; which injure the secretions, and induce chronic disease of the secretory organs, and, by disordering the cir- culation, produce disease of the vascular system. 5. Suppressed evacuations; which induce plethora in any part of the system that may be predisposed to it: whilst excessive evacua- tions, by weakening the action of the heart, will sometimes produce the same result, and sometimes greatly influence the functions of the nervous and muscular systems. 6. External heat; which may either irritate the part exposed to it, indirectly affect the nervous system, or disorder the general circulation. 7. External cold-—which often powerfully affects the nervous sys- tem, and greatly disturbs the circulation, producing active conges- effects of heat and cold. 21 tions and inflammations, and, by repressing the action of the skin, producing disease of those secretory organs to which the former is auxiliary—is one of the most frequent, perhaps the most frequent, of all the causes of disease. The effect of cold upon the part to which it is immediately applied, is rather to render it susceptible of diseased action, than directly to excite it; this action evidently arising when the temperature is sub- sequently restored. It appears also, that the effect of heat or cold in producing intense sensation, or disturbance of the healthy action, is proportionate, not so much to the actual temperature, as to the rapidity with which change of temperature is induced. Thus, the application of the natural temperature of the body to a frost-bitten limb, will produce the same effect as a heat of 212° F., under ordinary circumstances; and the effect of cold in producing internal disease is increased by previously heating the body ;* and, for a similar reason, it is greater when applied by drafts or currents of air, or by wet clothes, which rapidly carry off the heat of the body. Though, as Dr. Alison adds, "in the circumstance of moisture, and, perhaps, other occasional qualities of cold air, there seems to be a peculiarity not yet understood, as to this power of exciting inflammation." A languid state of the circulation, with the consequent diminished power of generating heat, increasing and prolonging the sensation of cold applied to the surface, favours its action in producing internal congestions; and it is probable, on this account, that during sleep the system is much more prone than at other times to suffer from the effect of cold. The effect of cold, in producing internal inflammations, is very remarkable when it is applied to parts largely supplied with sentient nerves, and which are ordinarily protected by warm covering or otherwise, especially when compared with its effects upon other parts, similarly supplied with nerves, but not similarly protected; thus the sensation, produced by cold applied to the feet of those who are com- monly warmly shod, is most intense, and apt to produce internal congestions, although the same individual may expose his hands to great cold without any ill effect, or even inconvenience. The depressing effects of cold may be resisted or greatly mitigated by a vigorous state of the circulation, which quickly restores the heat that is lost, and by a tone or power of endurance in the nervous system, which we can best describe, by characterising it as opposite to that which is induced, by a too careful exclusion of cold, and ap- plication of artificial warmth. This vigorous state of the vascular and nervous systems is promoted by habitual exercise and the oc- * [Persons 'who have been exposed to a high degree of atmospheric temperature, for any length of time, are more liable, all other things being equal, to suffer from exposure to cold, than those who are habitually accustomed to a much lower atmospheric temperature. Thus a sudden change in the weather from warm to cold is almost invaria- bly productive of catarrh, pleurisy, and pneumonia. But by simply heating the body, short of inducing perspiration, in other words, by accumulating an amount of dry heat about the person, previously to exposure to cold, the effect of the latter in the produc- tion of disease will be diminished rather than increased.—Editor.] 22 ENDEMIC CAUSES OF DISEASE. casional prudent application of cold, and a moderate nourishing diet. Again: there are causes of diseases, which can hardly be said to be endemic, but which act on large numbers, and with great violence at certain times and in certain places only, (generally by the introduc- tion of a poison by the primce vice, or, in some instances, by the lungs,) though their action is so slow that they are commonly reckoned as instances of disease. Of these we have instances,—in scurvy which attacks whole ships' companies, and it may be bodies of men on shore, when restricted to the use of salt provisions, and deprived of suc- culent vegetables,^-in the palsy from lead, not only affecting painters, plumbers, and othersKbut also large portions of the community, when using water slightly impregnated with the salts of that mineral, de- rived from leaden pipes or cisterns.^1 Another instance is to be found in the pallid, doughy cachexia, so common in large towns, which is to be referred, in great measure, to the poison continually emanating from drains, cesspools, graveyards, and other sources of impurity abounding in such places, and which, probably, enters the system through the lungs; though, no doubt, the want of radiant solar light greatly enhances the effect of such exhalations. After all, however, these are but cases of slow poisoning. Again we have causes of disease, which are, in the strictest sense, endemic (sv Sj^w), that is to say, affecting only the population of par- ticular districts, and that without any great variation as to particular seasons. Of this class of causes of disease are, that of the Bron- chocele, affecting the population of parts of Switzerland and Derby- shire ; of the Cretinism of the Alps; of the Elephantiasis of Egypt. There is another class of causes of disease of great importance, at times extensively and fatally prevalent, affecting for a time, the population of certain districts; the disease thus produced being of a definite character, and, one which may with tolerable certainty be ascribed to a specific poison. Such diseases are said to prevail epidemically (iito 5^^), from their coming, for a time, upon the people of a certain country or district, which is at other times perfectly free from them. The causes of some of them are, however, in one sense of the word, strictly en- demic, that is to say, arising from the circumstances of the locality, so that although the disease in question may only prevail at certain times in a particular district, yet it is liable to recur epidemically in that district, and cannot affect other districts indiscriminately, but only such as resemble it. Of this form of epidemic disease, we have\ an instance in the agues which, at certain seasons, prevail in marshy ' districts, the cause of the disease being in such cases endemic, and consisting in a miasma produced by the emanations from decaying vegetable matter. Other diseases, again, affect whole populations with great rapidity, continuing their influence for a limited time and affecting, in rapid succession, different districts, between which there can be discerned no points of resemblance which can be as- signed as causes of the disease; their outbreak in any locality not being to be accounted for by communication with persons from EPIDEMIC CAUSES OF DISEASE. 23 infected districts. Of this form of endemic cause of disease, the in- fluenzas which have prevailed, at different times, without regard to place or season, form a good illustration. Other diseases again prevail epidemically, but which may be clearly traced to communication with infected persons; though there can be little doubt that in the majority of cases, their diffusion is promoted by some circumstance affecting the population generally. Such diseases are contagious. Though by the term contagion we do not imply exclusively immediate contact by touch, but also mediate communication, as by means of the clothes,—the excretions,—the breath, or other exhalations. 24 DEATH FROM SYNCOPE — COMA. II. MODES OF DEATH. There are few more important considerations in the treatment of diseases which threaten life, than that of the manner of their fatal termination when they end in death. The different modes of dying were first explained by Bichat, in his celebrated " Becherches sur la Vie et la Mort;" but the subject was first treated of in reference to disease by Dr. Alison, of Edinburgh, and has since been elaborated with much perspicuity and elegance by Dr. Watson, in his beautiful lectures. A few short and simple reflections will, however, be suf- ficient for our present purpose. The different modes in which life ceases are through the suspension of the two primary vital functions, circulation and respiration. Of these, the former cannot be suspended, in the human subject, for more than a few seconds, and the latter for more than three minutes, without life being extinguished. We perceive then that there are two simple modes of dying: I. Death from failure of the heart's action, or, to speak more com- prehensively, death from failure of the moving powers of the circula- tion, which is technically termed syncope; II. Death from impedi- ment to the aeration of the blood in the lungs, or death from apnoea. I. Death from syncope, or death from the heart, may be produced either (1) from a sudden shock to the nervous system arresting the heart's action; or the same effect may be produced by weakness of the organ itself. The anatomical characters of this form of death by syncope are full cavities of the heart, with the dark blood on the right side, and the crimson arterial blood on the left. (2), By sudden or gradual abstraction of the vital stimulus of the heart, as in the case of violent haemorrhage or its more gradual drain by slower ab- straction of the blood, from more gradual exhaustion or failure of nutrition, continued discharges, or failure of nutrition as in death from inanition; cases, too, occasionally occur which render it probable that death from failure of the heart's action may be induced by arrest of the extreme circulation cutting off the supply of blood from that organ, this may be termed peripheral syncope. The anatomical characters of this mode of death are, in extreme and rapid cases empty ventricles, pretty firmly contracted; and in cases where death has taken place more gradually, flaccid, but not emptf^dW II. The second mode of death may ensue, (1,) Xn i Wy to the nervous system paralyses the movements of respiration, causiL what is termed death by coma, or death beginning it ,' ^T.g wnaj (2), by obstruction to the circulation through the Ws coZU , what is more strictly termed death by asphyxia, or Sh bv an S The anatomical characters of death from impeded pulmonic ci 1? tion, are full cavities, those of the right side of the heart being more" I SYNCOPE. 25 particularly so, the blood being very dark in the latter, and in the former, of an almost venous hue. It is into these two modes of arrest of the vital functions, that all the different forms of death arising from injury or disease ultimately resolve themselves, although the manner of death, in many, or in most, may not be entirely simple; so that the two causes of death may both be more or less in operation. It will, however, almost always be found that one or other predominates. I. Death from syncope, produced by a sudden shock, may arise, though rarely, from injuries inflicted upon the substance of the nervous centres, although it has been found that the integrity or even existence of the latter is not essential to the functions of organic life, as these may be continued when the brain or spinal marrow have been gradually removed or destroyed. Still, if a violent injury is suddenly inflicted upon the cervical portion of the spinal marrow, or upon the medulla oblongata, immediate death by syncope is the result. It is also through the influence of the nervous system, that mental emotion, as the sudden announcement of distressing intel- ligence, has sometimes proved fatal. And, in the same way, a shock may be carried from the extremities of the incident nerves to the nervous centre, and be reflected to the heart, by violent extensive injuries, especially those which involve an extent of surface largely supplied with sentient extremities of nerves; and the same thing occurs from wounds or other injuries of the abdomen, as well as from spontaneous disease of great intensity occurring in the same region, particularly near the situation of the solar plexus; the depres- sion of the heart's action being in the case of disease less sudden, and the fatal syncope when it does take place, coming on gradually. Death from the heart may also take place from weakness of the organ itself, the walls of the heart having become attenuated or Otherwise weakened by disease, or its ventricles dilated to an extent greatly disproportionate to their thickness; or a sudden stress may be thrown upon one of them (the left ventricle most commonly) by some sudden injury, as happens sometimes when there is laceration of the sigmoid valves. It is probably through the impression produced upon the extremi- ties of the nerves, that certain poisonous substances, as the woorara or upas-tree poison, produce death by stoppage of the action of the heart. The heart's action may also fail with greater or less rapidity from the abstraction of its natural stimulus, the blood; as happens in violent haemorrhages: and more gradually in wasting discharges, in diseases of the organs of digestion impairing nutrition, and in death from starvation. Death from syncope includes the most sudden deaths, as when the life is extinguished by—violent concussion of the brain,—sudden extravasation of blood in the medulla oblongata,—sudden crushing of the medulla spinalis, from violence or from sudden dislocation, arising from disease of the ligaments of the cervical vertebras, those especially of the atlas and dentata. Death, also, produced by disease 26 APN(EA — COMA. of the heart is well known to be amongst the most sudden, and in such cases the death is by syncope. Death from failure of the heart's action is not, however, necessarily so sudden; for though very violent haemorrhage may produce very speedy death, the death, in most cases, even of severe hasmorrhage, is more gradual, and is preceded by pallor, clammy sweats, irregular pulse, and insensibility; with these symptoms are frequently conjoined others more directly refera- ble to the nervous system, arising from the diminished supply of blood to the brain: amongst which are nausea or vomiting, restless- ness, and jactitation or transient delirium, irregular sighing respira- tion, gasping, and convulsions. But death from failure of the heart's action may take place still more gradually, and it is then strictly termed death from asthenia; of this, the most perfect instance occurs, in death from inanition or starvation, which leaves both ventricles flaccid, but as nearly empty as after death from rapid haemorrhage; and the same thing happens when death supervenes upon diseases impairing digestion and nutri- tion, or upon others which obstruct the renewal of the blood as it is expended to supply the waste of tissues; or this kind of death may be brought about by destructive diseases causing exhausting dis- charges, or extensive suppuration. Certain poisons, of which we have specified that of the upas-tree, appear to produce sudden failure of the heart's action, that organ being found full, but, as it were, unable to contract upon its contents; but on the other hand, we have an instance in sudden death from digitalis, of the ventricles being found contracted and empty, which certainly seems to favour the notion of the blood being delayed in the extreme circulation, rather than of a loss of power in the heart to propel it. II. Death from obstructed respiration may, as already pointed out, be two-fold—(1) death from apnoea, properly so called; and (2) death from coma. (1.) The first of these takes place when an animal is killed by the exclusion of air from the chest, or by restraining the movements by which the respiration is carried on, or obstructing the passage of the blood through the lungs, by impediment to the circulation through the heart. Of the above we have evidences in drowning, strangling, suffocation, violent pressure upon the walls of the chest and abdomen, so as to stop both the expansion of the chest and the descent of the diaphragm; or when in disease these movements are stopped by para- lysis, which occurrence belongs more commonly to the next form, or death by coma, but which may occur without the stupor which characterizes the latter. This form of death may also arise when the access of the blood, in the lungs, to a sufficient supply of oxygen is prevented by other gases, such as hydrogen, which, though not poisonous, cannot support respiration, and it may be caused in dis- ease by closure of the larynx or trachea; and by those diseases, whether of the bronchial tubes or lungs, which prevent the free access either of the air to the air-cells, or of the blood to the vessels which ramify between and around them, as well as by those which EFFECT OF POISONS. 27 exclude both air and blood from the lungs, as is the case with large effusions of serum into the substance of the lungs, or into the pleural cavities. It may be produced also by stagnation or stoppage of the blood in the lungs by disease of the left side of the heart. The anatomical characters of this mode of death are, a very great engorgement of the cavities on the right side of the heart, and the presence of venous blood in those of the left side. The right side, it should be observed, is always the most engorged of the two, the left being in some instances comparatively empty, and that too in cases where there would appear to have been no mechanical obstruction to the pulmonic circulation, as when hydrogen or other gases have been inhaled which, though not poisonous, will not support respira- tion ; showing that by a want of the access of oxygen a congestion takes place in the capillaries of the lungs, even though the respira- tory movements and expansion of the lungs may be continued. (2.) Death from coma, or death from the brain, is in its ultimate result the same as death from apncea; but there is this difference, that in the former case aeration of blood in the lungs is impeded by a loss of its proper irritability in that part of the nervous system whence the nerves of respiration have their origin. The anatomical characters, therefore, as regards the lungs and heart are the same, the lungs being congested, the right side of the heart gorged with blood, and the left side circulating venous blood. It is in this way that effusion of blood or serum into the substance or the ventricles of the brain or upon its surface, causes death; and it is in this way that many poisons, whether taken into the system from without or generated within it (and which are denominated morbid poisons), induce the same result. Of the poisons, the true narcotic ones pro- duce death in this manner, and such poisons act more slowly than some which produce death by syncope, from a shock, as it were, or sudden impression upon the nerves. Morbid poisons, among which may be classed excrementitious substances, such as bile and urea, produce death generally by coma, that is to say, by their acting, as poisons, on the brain; but they may also, especially the latter, when in great quantities, act as sedatives to the heart. As regards the action of poisons, there has been a good deal of difference amongst physiologists, and a great many experiments, ap- parently contradictory, have been performed, mainly with a view of determining the question whether poisons,—by being taken into the circulation and conveyed to the brain, destroy life by extinguishing sensibility, in which case the mode of death ought necessarily to be by coma;—or whether they operate before they reach the nervous cen- tres upon the sentient extremities of the extreme nerves. Now, as we have seen that the modes of sudden or speedy death may be various, according as it takes place from the heart, the lungs, or the brain, so it is but reasonable to expect that the modes of death from poisons may be so likewise; and that as violent injuries will some- times produce death by syncope from a shock to the system, or violent impression upon the extreme nerves; so some very powerful poisons will act in the same way, and that, obviously without any 28 EFFECT OF POISONS. need for their being taken up into the general circulation; whereas others, amongst which are poisonous gases, may obstruct the circula- tion through the lungs, and produce death from apncea; whilst others again, like the narcotic poisons, produce death by coma, and must, therefore, in the generality of instances, act only after they have been absorbed. But further than this, these poisons, several of them at least, act differently according as the dose is great or small, and according to the susceptibilities of the individual. Thus some poi- sons, as opium or alcohol, which will, in certain doses, produce coma after excitement, will, in larger ones, produce instant death, either arresting the moving powers of the circulation by the powerful im- pression upon the nerves of the stomach, or producing immediate coma without excitement, so that we need be at no loss to account for the different results as regards the time and manner of death recorded by different observers when experimenting with different poisons. The necessary inference, however, appears to be, that as different injuries will produce death in different ways, by acting either upon the heart or the nervous system: and as the same difference may be observed in regard to injuries similar but differing in intensity, so different poisons may act either upon the nervous centres after ab- sorption, or more directly upon the moving powers of the circulation by the impression produced upon the sentient extremities of the nerves, and that the same difference may be observed in the mode of death from the same poison, according to the amount of the dose and the manner of application. ELEMENTARY CHANGES. 29 ni. ELEMENTAEY CHANGES. Certain changes or deviations from the healthy state may take place in the proper elements of a part, which although they may not be appreciable as disease, or become special objects of treatment, are nevertheless of importance as constituting the first steps towards those conditions which we more certainly recognise as such. Irritability, or the capability of contracting upon the application of a stimulus, is the distinctive property of muscular fibre, and may be regarded as one of the simplest manifestations of vitality in the living body. This irritability may become excessive: producing, 1, undue strength, or violence of muscular contraction; 2, over-readiness to contract, or susceptibility of being excited by too slight a stimulus; 3, unusual persistance of contraction, constituting tonic spasm or cramp. Irritability may be defective: 1, from a deficiency of strength of muscular contraction; 2, from a slowness or sluggishness of contrac- tion under the ordinary or appropriate stimulus. Tonicity, or the tendency to slow moderate contraction, not neces- sarily terminating in relaxation, is a property not only manifested by the obviously muscular structures, but also by some others not generally accounted so, as the air-tubes and the middle coat of the arteries, giving them a tendency to contract upon their contents. In many respects tonicity appears to be closely allied to irritability, and it is, in the main, excited by the same agent, but with this remarka- ble exception, that cold increases tonicity and impairs irritability, whilst heat, which diminishes tonicity, although it relaxes the muscles, renders them, at the same time, more irritable. Tonicity may be excessive: when this is the case the muscles are disposed to be rigid, the pulse hard, owing to the contraction of the cavities of the heart being vigorous, and the contractile or resisting power of the artery considerable; the capillary circulation also is active, and the secretions are scanty, especially that of the skin, which is dry and hot. Tonicity may be defective: when this is the case the muscles are lax and flabby, though their irritability may be in excess; there is tremulousness, and the heart's action is feeble, though irritable; owing to the diminished tonicity of the arteries, they readily yield to the injecting force of the left ventricle, and the pulse, though soft, is generally full: the extreme circulation is feeble; the secretions are irregular, being either deficient, through the languid circulation in the secreting organ, or profuse and watery, owing to the relaxed condition of the vessels. Another element of disease in the dynamical condition of a part, 30 ELEMENTARY CHANGES — BLOOD. appears to be an alteration in the relation between the tissues and the blood. That some such change is likely to take place, may be inferred from the analogy of health, since it is the condition of the part, rather than that of the artery supplying it, which _ determines the amount of blood which it receives as well as the activity of the circulation through it: the conditions upon which this mutual rela- tion depends, are not sufficiently understood, to enable us to explain its alterations; and we must therefore regard these alterations as ultimate facts. Disturbances of the nervous influences of the part, or as they are termed by Andral, lesions of innervation, constitute another primary element of disease. It is true, indeed, that, in by far the greater number of instances, these alterations of the nervous force originate in changes in the brain or spinal cord, or in the large nervous trunks; yet, in these cases the disturbance thus produced, may set up fresh morbid action in the parts to which the ultimate filaments of the nerves are distributed: but further than this, there is reason for be- lieving that, besides being propagated to them, morbid changes may commence in the nervous fibrils themselves, these changes producing in their turn, alterations in the circulation and nutrition of the nervous centres. The blood, again, may undergo changes in its physical, chemical, and vital properties, and these changes constitute another class of the primary elements of disease. Among the most important of these changes, are the alterations in the proportions of its healthy constituents. The red corpuscles of the blood may exceed the healthy standard in quantity; a circumstance which is generally observed in a state of the system, commonly described, as plethora. The proportion of these corpuscles, in health, is from 120 to 130 per 1000; but in this condition, they are found to amount to as much as 135 to 160 per 1000. The blood in such cases, is remarkable for its deep colour; the clot is large and of a very moderate firmness, and is never buffed, owing to the small relative proportion which the fibrine bears to the corpuscles; the serum also remains more or less coloured, after the coagulation has been completed. The red corpuscles may, on the other hand, be defective in quan- tity, this occurs in the state generally known by the term anaemia (want of blood, a and tu/*a), a word for which it has been proposed to substitute spansemia (poverty of blood, srtavo; and at^a) as more strictly expressing the real condition of the fluid; in this state, the red par- ticles only are affected, the fibrine and solid contents of the serum retaining their normal proportions; thus, in the earlier period of spontaneous anaemia, and in its milder forms, we find the quantity of red corpuscles to be about 100 per 1000, and in the more advanced or severer cases, as low as 65 or even 30. The physical properties of the blood are in accordance with what might be expected from the deficiency of the corpuscles. After it has been allowed to flow freely, and left to coagulate, we find a small clot floating in an abundant colourless serum; the clot is remarkably firm, and it is by CHANGES IN CONSTITUENTS OF BLOOD. 31 no means uncommon to find it covered by a distinct buffy coat, pro- duced, as we shall hereafter have occasion to explain, by the excess of fibrine relatively to the corpuscles, the effect being the same, whether this excess arises from the increase of the former, or the diminution of the latter. Besides the variation in quantity, the red particles are liable to structural change, in disease. Thus in scurvy and Walcheren fever, the blood has been described to be of a pitchy blackness, arising, no doubt, from change in the colouring matter of the corpuscles. There may also be a breaking up of these corpuscles, and solution of the colouring matter, shown by its staining, not only the blood vessels, but some of the surrounding textures into which the entire corpuscles could not have transuded. They also undergo alterations in form and size, which, however, most probably arise from alterations of the liquor sanguinis, or medium in which they are placed. It was observed by Hewson, that pure water caused them to swell, whilst they shrunk in strong saline solutions; changes which are now generally understood to be brought about by endosmosis and exos- mosis, the surrounding medium causing fluid to pass in or out of the cell, according as it is of less or greater density than the fluid which the cell contains, which fluid must, in health, necessarily be of the same density as the serum. The red particles may also under dis- ease, lose their capability of changing from the venous to the arterial hue, by the action of oxygen. Alterations in the fibrine occur both as to its quantity and its physical and vital properties. The mean proportion of fibrine in the blood is, according to Andral, 3 per 1000, though other observers have estimated it somewhat lower. The proportionate quantity of this principle undergoes extensive changes in disease; it may be increased, in inflammatory diseases, to as much as 6, or even 8 per 1000, whereas in some diseases of debility, as for instance, low typhoid fever, it may be reduced so low as one and a-half or one per thousand. Besides these changes in quantity there are others still more im- portant in the quantities of the fibrine. Of these qualities the most remarkable is its property of passing from the fluid to the solid form, by which the coagulation of the blood is produced; and the changes which occur in this process of coagulation in connection with diseased action are among the most interesting of morbid phe- nomena. " Within a few moments after emission, the blood, in the natural state, divides itself into a yellowish fluid called serum, and a dark red spongy mass called crassamentum* The time occupied by the separation of the clot, as well as the appearance which it presents when formed, varies in different conditions of the system. The time may be from 1J minute to 15 or even more, though the causes in- ducing this acceleration and retardation have not been very clearly ascertained. The coagulation appears to be hastened by the oxygen in the atmosphere, and it may be greatly retarded by its exclusion, as * Alison's "Outlines of Pathology." 32 CHANGES IN BLOOD — BUFFY COAT. when blood is drawn into a vessel of oil* Again, it is well known that the artificial addition of many salts to the blood retards its coagulation hence we may conclude that a slow coagulation may depend upon an increase of the salts. Independently, however, of these considerations, the time occupied by the coagulation appears to be influenced by the quantity of the fibrine, for if the amount of this principle be larger than ordinary, the time which elapses before coagulation is increased, and the co- agulum possesses an unusual degree of firmness: and in general when the fibrine is abundant the clot is firm, and the coagulation slow, and when the fibrine is scanty the clot is loose and the coagula- tion speedy, as is the case with the last portion of the blood which flows when an animal is bled to death.f Again, it is to be remembered also that the corpuscles of the blood are of greater specific gravity than its other ingradients, and conse- quently these bodies must, when the blood is at rest, have a tendency to sink towards the bottom of the vessel. This tendency is, in a great measure, counteracted in healthy blood by the corpuscles be- coming entangled in the meshes of the fibrillating fibrine forming the clot, and even then its lower portion is of a deeper colour than the upper. If, however, it happen that the blood is longer in coagu- lating, or the corpuscles subside more rapidly than in the healthy state, we shall have the upper part of the clot free from corpuscles or nearly so, to a greater or less depth, and forming what is familiary known as the buffy coat. This network of fibrine, free from red particles, frequently continues subsequently to its coagulation, to undergo a slow contraction, by which the edges of the clot are drawn towards each other, giving its upper surface the concave appearance commonly denominated " cupped." To sum up what has been said; the formation of the buffy coat is promoted, 1st, by an increase in the proportion borne by the fibrine to the red particles, whether that increase depend upon an excess of the former, or a defect of the latter; 2, by the time occupied in the coagulation of the blood, which time is increased by an increase in the salts, and an increase in the quantity of the fibrine; 3, by the rapidity with which the red particles subside through the coagulating liquid, which may be increased by a diminution of the specific gravity of the serum, and also by an arrangement which they seem under some circumstances to affect, viz., a coalescence in considerable num- bers, having their flattened discs opposed to each other, like rouleaus of coin, which force their way through the semiviscid fluid by their aggregate weight more quickly than they could do singly. The size of the clot is in the inverse proportion to its firmness and in the direct proportion to the quantity of fibrine; so that when the clot is loose, it may be apparently large; although the quantity of fibrine may not be great: a large and firm clot, however indicates a large proportion of fibrine, and a great amount of fibrillating or * Dr. Babington in Med. Chir. Trans., vol. xvi. f Carpenter's " Manual of Physiology." COAGULATION OF BLOOD. 33 contractile force, and when this force is in excess, depending pro- bably upon increased tonicity, the continued contraction of the fibrine forming the buffy coat gives it the cupped appearance. An important practical inference may be drawn from the above statements, viz.,—that the buffy coat is not of itself a certain sign of any particular condition of the blood, since it may be produced by several different, and, in some respects, opposite causes. The proportion of dry albumen in healthy blood is about 70 or 80 per 1000; under some circumstances of disease, probably in inflam- matory fever, it may be increased; and the same may happen (pro- portionately to the fluid constituents of the blood) when a large quantity of water is carried rapidly out of the system, as in spas- modic cholera. This principle is reduced in quantity sometimes as low as 60 or 50 per 1000, or even lower, when a considerable amount is carried off by the urine, or repeated haemorrhages, or other ex- hausting discharges. It is possible that it is also deficient in cases of imperfect digestion or sanguification. The proportion of oily or fatty matter in the blood has not been accurately ascertained, and it probably undergoes great variations in health; being generally the greatest about four or five hours after a full meal, its presence being indicated by an oily or milky appear- ance of the serum. The proportion of the salts of the blood is also liable to increase or diminution, and this variation, no doubt, plays an important part in many pathological phenomena. An excess of the salt retards, as we have already seen, the coagulation of the fibrine, and when very great prevents it altogether. A decrease in the quantity of these substances tends, according to Henle, to favour the adhesion of the corpuscles to each other; and is stated by him to exist in inflamma- tory affections. The same deficiency is said by Stevens and others to be present in pestilential fevers and cholera. Independently of the variations in its natural ingredients, the blood may also undergo morbid alterations, from the presence of excretory matters not belonging to it in health, or, if so, not in ap- preciable quantities. Now we know, from physiology, that there are various matters, the products of the interaction of the tissues and the blood, which are in health speedily eliminated, and we also learn, from observa- tion of disease, that if these matters are not thus removed, they re- main in the blood, and act as poisons. The most important substances of this character, and those with which we are most concerned; in the treatment of disease, are the principles of the secretions of the great depurating organs, the lungs, the liver, and the kidneys, to which may, perhaps, be added the skin (which is, in a great measure, vicarious of the latter), and the glandulae of the large intestines. Now the depurating action of these organs may be suspended or 3 34 RETAINED SECRETIONS. interrupted chiefly in three different ways: 1st, the depurating organ may itself be unsound; 2, the circulation of the blood through it may be obstructed; or, 3, the matter to be eliminated may not be brought to the depurating organ in the particular form suited for removal by that organ. The first of these conditions will be specially noticed in respect to each secretion, in treating of the diseases of the corresponding organ, when the particular consequences of the retention will also be described. In order to the due appreciation of the second and third circum- stances just mentioned, as interfering with the action of the depurat- ing organs, it is necessary to understand the general conditions essential to their full operation. We know from physiology, that in the course of the circulation carbonic acid gas is formed and received into the blood, and that, if retained, it acts as a poison to the system; and we also know that the removal of this gas is effected in the cells of the lungs, where it is exposed to the action of another gaseous fluid, the atmospheric air, which acts as a solvent of the carbonic acid, and, according to Dr. Stevens, exercises some attraction for it. It may here be remarked that, though water and carbonic acid are the only excretions or exhalations from the membranes of the air- cells in the perfectly normal state, yet, as is remarked by Dr. Alison, it is certain that many volatile matters taken into the stomach, are excreted unchanged or but little changed, with the breath, and pro- bably the body is thereby saved from their injurious effects. It must therefore follow, that if the free access of air to the cells or the free circulation of the blood through the lungs be impeded, there must ensue an inquination of the blood by carbonic acid and perhaps other gaseous excretions. As regards the bile and the urine, the former of these secretions is a liquid consisting of water holding in solution certain principles containing a large proportion of carbon and hydrogen, which are uniformly present in health, and are in part, though probably not wholly, excrementitious. These principles, moreover, exist in healthy blood in very minute quantities, and it is the office of the liver to remove them; their secretions taking place, as there is every reason to believe, from the minute branches of the portal vein, by means of the hepatic cells, and consequently an inquination of the blood, by these substances, must ensue, if the function of the liver be suspended, or the circulation of the blood through that organ be impeded. The presence of the bile pigment gives to the serum a yellow hue, which is another instance of change of colour in the blood • which change is also imparted to the surface, constituting the well-known jaundiced tint. The urine, again, is a liquid consisting of water, holding in solution various solid matters, which may be divided into two classes: 1 those lower organic products abundant in nitrogen, formed probably in the extreme circulation by the reciprocal action of the arterial blood and the organs of the body on each other, as the urea, uric acid and RETAINED SECRETIONS. 35 water; and 2, those soluble substances which are taken with the ingesta, and which do not undergo decomposition in passing through the system, as for instance, neutral salts formed by inorganic acids. The matters of both classes, when allowed to accumulate in the system, producing injurious effects; the former probably as direct poisons, and the latter, by giving rise to changes of the blood already noticed (pp. 33, 34;) and both are carried off by the kidneys. Of the diseases of the liver and kidneys interfering with their secreting functions, we shall speak hereafter; but it may here be remarked, although the proposition is almost self-evident, that—if there be not a free passage of blood through these organs, the con- tinual abstraction from that fluid of excrementitious matters cannot proceed; whether this impediment arise from venous obstruction distal to the organ, or pressure upon the afferent vessel tergal to it. Thus, in the case of the liver, obstruction to the return of the blood through the cava, or to the passage into the gland from the vena portae, would alike interfere with the due secretion of bile. It is not, however, sufficient that the excreting organ be healthy, and that there be no impediment to the passage of the blood through it, but since the liver, and the kidneys, and also the skin, are adapted to secrete only liquids, it follows that the elements of the bile and also of the urine, cannot be removed unless they are brought to their respective secreting organs in a state of solution; therefore a con- tinual supply of water is necessary for the depuration of the blood, and obstruction to that supply must give rise to the inquination of the latter by the elements of, the secretions of these organs. The course of the water fulfilling this office is as follows. That which is received into the stomach is, with such soluble matters contained in it as are not decomposed in the primes vice, taken up by the capillary branches of the veins, which converge to form the vena portai, carried onwards with the blood through the trunk of that vein, and again dispersed by its ramifications through the liver; here a portion of it is again separated from the blood, in order to form a solvent for the solid contents of the bile. Passing onwards through the pulmonic and systemic circulations, the redundant water of the blood carries with it those inorganic soluble matters which it con- tained at first, and receives, or rather acts as a solvent to those pro- ducts of the interaction of the blood and the tissues which have been already noticed as poisonous when retained in the system, and which are therefore expelled from it, or at least from the nourishing fluid. Holding these substances in solution, it is carried on with the current of the blood to the other great excretory organs, the skin and the kidneys, whence it passes out of the system, carrying with it, through those organs, the substances which each is designed to eliminate, but which it cannot remove unless brought to it in solution. The entrance of the water may be opposed as it were, in limine, by obstruction high up in the intestinal canal; or, again, its passage into the circulation may be intercepted in the portal system, or by disease in the liver or, even, further on, in the heart and lungs; all which obstructions may be so great as to prevent there being such a 36 FOREIGN INGREDIENTS. supply of redundant water in the blood as is required for the solu- tion of the excretory matters, and from this cause there may arise inquination of the blood by those substances. Besides the above substances, which are continually formed in the course of circulation, and which are as continually removed by the deputary organs, others, foreign to the blood in a healthy state, may be present in it in disease; thus we know that .the blood in health has an alkaline reaction: in some forms of disease, as stated by Vog^l, the blood is neutral, or at times even acid. This depends probably upon the presence of free lactic acid, and occurs in diseased conditions in which a tendency to decomposition in the blood may be suspected. Sugar, again, is a substance foreign to healthy blood; but in dia- betes (in which disease there is probably a defect in that action of the liver by which the sugar formed in the stomach is rendered susceptible of the normal changes in the lungs) it is present in the general circulation, from which it is carried off by the kidneys, not however before the blood had become so far impregnated with it as to allow of its detection by a chemical analysis. Pus in the blood is not a very rare occurrence in several morbid conditions of the system to be noticed hereafter. In some cases it is formed within the vessels, more frequently the veins; in others it enters from without. Having now given a brief statement of the changes to which the blood considered, by itself, is liable, we proceed to speak of the derangements of the blood in circulation. The conditions of general plethora and general hyperaamia con- stitute in themselves determinate diseases, which may become objects of special treatment, and will be best considered hereafter. Local plethora, however, or, as it is more commonly termed congestion, or hyperaemia according to the French authors, besides that it is in itself not unfrequently an immediate object of treatment, occurs, either as cause or effect, in the greater number of diseases of which the living body is susceptible. It is true, indeed, that many organs and vessels admit of a considerable range in the quantity of blood circulating through them in a state of health, this variation depend- ing upon the varying activity of the organ; but it is equally true that, when long-sustained or excessive in quantity, these accumula- tions give rise directly to derangement of function, and often consti- tute the first step towards structural changes. The consideration of the subject of congestion is essential to the right understanding of those important affections, inflammation dropsy, and haemorrhage. Congestion or hyperasmia may arise, 1, from the increase of the flow of blood to the part; 2 from an increase of the capacity of the part for blood; and, 3, from a diminished flow of blood from the part. (1.) The first of these constitutes the active congestion of most authors, and the active or sthenic Iryperaemia of Andral, sometimes CONGESTION. 37 called also "engorgement. It is not inflammation, neither does it necessarily lead to it, though it bears a most important relation to that complex process, since, when the latter does occur, active or sthenic hyperaemia is the first step that leads to it. In order to the right understanding of the nature of congestion, and also of the right application of the means for its removal, it is necessary to bear in mind that an increase in the quantity of blood sent to a part is not necessarily dependent upon, or even always as- sociated with, an increased quantity in the system at large, or even upon an increase of the injecting force of the heart. To explain this we may recur to some physiological considerations respecting the moving powers of the circulation. The first propel- ling power of either circulation is the systole of the ventricle, by which the artery is filled and its elasticity overcome. As soon, however, as the systole is completed, the sigmoid valves being closed, the pressure which the large arteries exert upon the blood by their contractility can act only in propelling it in a continuous current, so that we may regard the large arteries and sigmoid valves as an ap- paratus for converting an intermitting motion into a continuous one, such as the fly-wheel of a steam engine: or, to use the more appro- priate comparison of Sir Charles Bell, the elasticity of the artery acts like the compressed air in a fire-engine to produce a continuous current from a force acting at intervals. It has been shown that, in addition to its yellow elastic tissue, the middle fibrous coat of the arteries contains nonstriated muscular fibre, giving to it a degree of real muscular contractility in addition to the mere physical property of elasticity; yet there is no reason for concluding that these fibres produce any peristaltic movement which would exert a propelling force upon the contents of the ves- sels, though they probably have the power of regulating the calibre of the artery, for purposes to be hereafter explained. The movement of the blood in the capillaries, however, appears to be greatly assisted by a different power, viz., an attractive force, arising from the mutual affinity of the blood in the capillaries, and the tissues surrounding those vessels. In a word, the systole of the ventricle, acting mediately through the elasticity of the arteries, is the propelling force by which the blood is conveyed through the arteries to supply the capillary vessels, whereas the circulation in the latter is maintained by the same force, aided by the mutual interaction of the blood and the surrounding tissues. It is a physiological fact scarcely needing demonstration, that various stimuli, whether—mechanical, as rubbing, or scratching, or the agency of the imponderables, as heat and electricity, or—chemical, as mustard, cantharides, ammonia, &c, or—vital, as the special stimulus of any particular organ, for instance, the application of any excretory matters to the kidneys by the blood, or the presence of an impreg- nated ovum in the uterus, increase the flow of blood through that part, antecedently to any increase in the force or frequency of the pulsations of the heart, and therefore independently of it; and 38 CONGESTION. further, that when this hyperaemia is long maintained, there ensues an enlargement in the artery supplying the part, unattended with any corresponding enlargement of the other arteries of the body, and therefore not to be accounted for by a general cause, such as increase in the injecting force of the heart, which must alike affect all the arteries of the system. This connexion between the activity of the circulation in a particular part, and the diameter of the artery supplying that part, is probably maintained by the branches of the sympathetic nerve so freely distributed along the arteries acting upon the muscular fibre before mentioned, (p. 44.) This increase of the calibre of the arteries may be propagated still further backwards along the course of those vessels, so as eventually to influence the general circulation, and through it the action of the heart itself. Before proceeding further, it may be well to state briefly the phe- nomena which are observed in the progress of local congestion, as well those which from their minuteness can be seen only in the transparent parts of animals by the aid of the microscope, as those which are appreciable by the unassisted senses, and may be observed in all the tissues when irritation has been applied to any tissue, as in pricking the web of a frog's foot under the microscope, or the ap- plication of alcohol to a membrane: after a time varying from a few minutes to some hours, a change in the condition of the small blood vessels is observed; they become enlarged and distended,* the blood also passing through them with increased velocity; at the same time that new vessels appear to be produced, most probably from those which before did not allow of the passage of the red corpuscles, or which admitted them in a quantity insufficient to render their colour apparent, now permitting them to enter them freely; the globules also manifest a tendency to cohere into irregular masses, which some- times pass through the capillaries, and may be observed in the veins. This is active congestion, or the sthenic hyperaemia of Andral. This state of things cannot, however, continue long without leading to further change; if it have not been intense, the increased quantity of blood and rapidity of its movement may gradually subside, and the vessels return to their original condition, or it may pass into in- flammation, to be described hereafter, or it may be relieved by effu- sion of the whole blood, giving rise to haemorrhage, or of'the liquor sanguinis, as in fibrinous dropsy, or of serum, as in serous dropsy, or it may pass into the next form of congestion. (2.) This form of congestion is spoken of by authors in this country under the name of passive congestion, and by Andral and the French pathologists as asthenic, or passive hyperozmia, in which the capillaries become distended with blood, and the motion of that fluid impeded. Passive congestion may also occur without any previous acceleration of blood in the arteries or capillaries, of which we may often see instances when the lower or depending parts of aged or debilitated subjects become livid or purplish, owing to the contractility of the * Alison's Pathology, p. 99. CONGESTION. 39 capillaries not being sufficient, as in health, to overcome the dis- tending force arising from the gravitation of the blood. It also suc- ceeds to active congestion, the increased energy of contractility in the small vessels being followed by a corresponding deficiency, so that, becoming dilated under the force of the active congestion, they have not sufficient contractility to resume their original size, but remain permanently distended with blood. _ (3.) Allusion has been made to impediments in the course of the circulation causing accumulation of the blood which is following the obstructed portion, or, as it is termed, tergal to it. This form of congestion, which is termed mechanical, exists exclusively in the first instance in the veins, though it may be propagated from them to the capillaries:—it is instanced by the effects of compression upon the venous trunks of an extremity;—by obstruction to the passage of the blood through the right side of the heart, which gives rise to venous congestion of the whole system, by opposing the return of the blood through the ascending and descending cava; though this congestion, however, affects chiefly the parts nearest to the heart;— and by disease of the liver obstructing the passage of the blood through the portal system, and inducing congestion in the capillaries of all those parts, from which the blood is conveyed by the veins converging to form the vena portas. Although many of the phenomena which have been described as constituting the state of congestion, can only be observed in the superficial textures of the body, yet we have reason, not only from the considerations already adduced, but from the evidence afforded by inspection after death, for knowing that the internal organs are equally liable to the different forms of congestion. The part thus affected is to the eye redder than natural; this redness is observed under the microscope not to be general, but to follow the course of the capillaries, the interstices remaining colourless; when the part is cut into a more than ordinary quantity of blood flows from it, the corpuscles in which have undergone little or no alteration. The affected part is also denser than usual, but the consistence is normal. A sudden or intense congestion of blood may in some instances prove immediately fatal, as when it occurs in the brain, or in congestive fever; though this is, comparatively, a rare occurrence. In the treatment of congestion or hyperaamia, it is necessary to bear in mind the different forms which it assumes, and the excess or defect of the vital affinities upon which it depends. This is more especially true of the two first forms, which result from very different or even opposite conditions, but which, nevertheless, as has been just observed, merge into each other by almost insensible degrees; so that when either of these conditions exists singly, the most applica- ble treatment is, in the case of the second, almost opposite to what it would be in the first. Of this we have a ready illustration in the case of the eye, the transparency of whose textures allows us to see the variations in the fulness of their vessels. Thus, after the applica- tion of cold, or any irritating cause, the vessels of the conjunctiva, which in health do not admit the red corpuscles, may be seen travers- 40 CONGESTION. ing tnat membrane in all directions, and carrying red blood; and we know that at first this condition is best relieved by remedies which depress vascular action, and is aggravated by the application of any stimulant. We also know that, when this congestion has passed into its second or passive state, a change may be often de- tected in the vessels, which appear in a more distended state than at first, having lost their vivid colour and assumed a dusky hue; and then, stimulating or almost irritating applications will often speedily restore the natural paleness of the part, by re-exciting the contrac- tility of the capillaries. We cannot, indeed, actually see the same thing going on in in- ternal parts, and, although inspection after death may give evidence of the existence of congestion, it gives us none as to its stage or character; an instance, if any were required, that morbid anatomy is a part only of pathology. It furnishes us, indeed, with much knowledge respecting the changes produced by disease, but it is not conversant with disease itself; that is, with the deranged action upon which disease depends, and of which structural changes are the effects, and not the causes. We may, however, by comparing the revelations of morbid anatomy with the symptoms observed during life, and by again correcting the deductions thus obtained by the known effects of remedies, arrive at pretty certain conclusions as to the existence of one or other of these forms of congestion in internal organs. Of the importance of the distinction thus observed, we shall presently have a remarkable instance in the bronchial membrane. The details of the particular mode of treatment best adapted to each form of congestion will be most conveniently considered when we come to speak of special diseases; there are, however, a few general principles, which will be best appreciated when regarding congestion simply as such, without embarrassing ourselves with the more complex phenomena with which it is commonly associated. The most obvious means of relieving any congestion would, at first sight, appear to be the abstraction of blood from the system, which, by diminishing the whole volume of the circulating fluid, might be expected to lessen, in the same proportion, the quantity supplied to each particular organ. Experience, however, has not shown this to be the case; since not only are those apparently the most ex-sanguine equally liable with others to local congestions, or even more so, but also, in many instances, where a congestion has been established, it would appear as if the system might almost be drained of its blood, and yet, the portion which remains, as if obedient to the local stimulus, will still rush in a redundant quantity to that part. One reason of this may be that, by abstracting blood from a vein, or a branch of an artery, we diminish, though only for a time, the volume of the blood in the larger vessels, and at the same time depress the action of the heart, without materially affecting the move- ment of the blood in the capillaries, which, as we have already seen, though not independent of the former, is yet greatly influenced by forces affecting wholly the capillary system. The influence of blood- letting is, perhaps, fairly stated by Andral, in the following words: CONGESTION. 41 " By the employment of bloodletting, the organ congested is relieved of a part of its superabundant fluid; the general mass of blood in circulation is diminished; and a powerful cause of irritation thus withdrawn from the system; but neither by local nor general bleed- ings can we remove the unknown cause, under the influence of which the hyperaemia was originally developed. If, however, this cause be not particularly active or violent in its operation, its influence may be considerably diminished, or even completely paralyzed by sanguine- ous abstraction, as the blood is thus withdrawn from the seat of irri- tation as often as it tends to accumulate there, and the hyperaemia is thus prevented from establishing itself in the part: but if the exciting cause of the congestion be more violent in its action, we shall in vain attempt to remove it by bloodletting.....It is, therefore, the ex- citing cause which we should endeavour to investigate and coun- teract, and not exclusively confine our attention to the local conges- tion, which is merely an effect; an elementary part of a very complex phenomenon." According to the above view, which is, to say the least, not too unfavourable to the use of bloodletting, it is not merely the consideration of whether the congestion be active or passive that is to guide us in the use of that remedy, as even, in the case of the former, it may aggravate the mischief, since a local hyperaemia, in an anaemic state of the system is a greater evil than where there is a normal condition of the general circulation. That a local congestion may be accompanied by increased action of the heart and large vessels, and may even excite such increased action, has been already explained, and it is evident that the effect must be to maintain, or even to aggravate congestion; and it is under these circumstances that benefit may be expected from the general abstraction of blood. It is then by the force of the heart's action that we are mainly to be guided, such force being measured, not so much by the impulse which seems to be given to the blood in the artery, as by the power with which it resists the pressure of the fingers. Even these indica- tions, however, must be received with the greatest caution, if not altogether disregarded, in cases of congestion arising in the course of exanthems, or other diseases of the general system excited by morbid poisons. Local depletion, when it can be applied, presents a better prospect of relieving local congestion, since by it we may hope to unload directly the distended capillaries, and this too by the abstraction of a quantity of blood far less than could be expected to produce any relief by general bleeding. It unfortunately happens that, in the greater number of cases, we cannot remove blood directly from the part affected; when, for instance, we suspect an internal congestion we may indeed have recourse to leeching or cupping over its proba- ble seat, by which means we may relieve neighbouring vessels; but these are often supplied by different arteries from those distributed to the part affected, and, consequently, we cannot expect the same result as would be produced by emptying the gorged capillaries of the part. Still we have reason to believe from experience that we may, even in this way, check or control the disease. Though the 42 TREATMENT — BLEEDING, SEDATIVES. mode by which this result is produced is not very easily explained, much indeed may be the revulsive action of the leeches or cupping- glasses, especially of the latter, though this is hardly sufficient to account for the effects produced. General bleeding, then, is applicable in active congestion when there is considerable increase in the force and frequency of the heart's action, as indicated by the arterial pulse, this being generally the condition when such congestion is merging into inflammation. Local depletion, from a part near the seat of the congestion, is bene- ficial when we have reason for believing that the congestion is of an active character, although there be no great increase of the heart's action. It must, however, here be urged that regard should be had to the general condition of the system before venturing upon this less powerful mode of depletion; for it must be borne in mind that by the means ordinarily employed blood is removed from the smaller arteries and veins as well as from the capillaries, and therefore that the effects of the depletion are not solely confined to the latter vessels, but in some states of the system they show themselves strongly upon the action of the heart and large vessels. The advantage of the truly local bleeding, that is, of relieving directly the capillaries of the part affected, where it can be done, as when the congestion is situated on the surface, applies to the passive equally with the active form; since the blood thus removed flows almost entirely from the distended capillaries, where it was in a state of stasis, entirely removed from the pale of the general circulation, and, therefore, unlikely, by its abstraction, to produce any depressing effect upon its moving powers. There are various medicines and applications which are reckoned as sedatives to the circulation; of these the former are chiefly of the nauseating kind, as tartar-emetic, digitalis, and colchicum; and although it is doubted by many whether this sedative agency can be exerted unless nausea be also induced, that they do exert such an agency is certain, though they do not appear to act each on the same class of vessels. Of the agency of colchicum we know but little, though its sedative effect seems to be produced mainly through the heart and large vessels. Digitalis, again, is undoubtedly a sedative to the heart. The tartarised antimony, on the other hand, though it unquestionably exercises some depressing influence on the heart, has certainly as great, if not greater, influence upon the capillaries, and is therefore one of the most efficient means we possess of combating active hyperaemia. A very important means of producing a sedative effect on the whole system, including the capillaries, and therefore advantageous, or rather essential, in the treatment of active congestion, is what is termed the antiphlogistic regimen, by which is meant low diet, the avoidance of muscular exertion and mental emotion. The external application of cold, as by effusion, or by its more continued local application, is a powerful sedative, and sometimes very useful, though unless it be carried beyond the limits consistent with perfect safety its effects are but transient: applied locally for any considerable time' as when cold applications are used to erysipelas of the scalp, it is apt MECHANICAL CONGESTION. 43 to set up secondary hyperaemia, often more dangerous than the pri- mary disease. It has been already observed that, when a hyperaemia or conges- tion has passed into the asthenic or passive state, the depressing or sedative remedies are productive of harm rather than benefit, whereas stimulant, tonic, or astringent remedies become serviceable. The indi- cations^ which the latter remedies are here calculated to fulfil are, 1, to excite the action of the heart and large vessels, and thereby increase the vis a tergo, by which the blood is to be removed from the distended capillaries; 2, to enable the latter vessels to relieve themselves by increasing their contractility; and, 3, it may be that, by acting upon the nervous system, and through the organic nerves, they increase the vital activity, upon which depends the interaction between the tissues and the blood in the capillaries. The most direct stimulants to the action of the heart are alcohol and aether taken into the system, and their judicious employment is often followed by the best results in passive congestion. It must be remembered, however, that their action is not only transient but apt to be followed by a corresponding depression; this may be in some measure counteracted by administering them in small doses fre- quently repeated. Ammonia probably acts more upon the nervous system than immediately upon the heart; it has, however, a secondary and stimulating influence upon the organs of circulation. The effect of internal medicine in directly increasing the contractility of the extreme or capillary arteries may perhaps be doubted, though when a passive congestion is within reach, astringent and stimulating sub- stances locally applied restore the tonicity of these vessels. The benefit moreover of a tonic regimen, aided by medicines of the same character, as cinchona, quinine, and the other vegetable tonics, or (when the state of the system seems to call for it) by mineral tonics, as iron or zinc, cannot be doubted. The third form of congestion depending mainly upon mechanical obstructions to the return of the blood through the veins, must be combated mainly by endeavoring to remove these obstructions, or, when this cannot be effected, by regulating the circulation so as to adjust it as nearly as possible to the altered condition of the system. Local depletion may sometimes be called in to aid in fulfilling this latter indication, and it may even become necessary to abstract blood generally, though this latter must be regarded only as a measure adapted to a passing emergency, since congestion of this character is, in the greater number of instances, mainly dependent upon a defect in the moving powers of the circulation, and therefore the probability of its recurrence is increased by whatever tends to lessen the force of the heart's action. 44 INFLAMMATION. IV. INFLAMMATION. Having now briefly considered the more simple dynamical or functional derangements of the solids, as well as of the blood, we pro- ceed to that more complex, and most important affection—Inflamma- tion,—a process into which enter nearly all the elementary morbid changes which we have been considering, since we have—changes in the irritability and in the contractility of the vessels of the part,— changes in the blood and in its attraction for the tissues,—changes in the nervous force, and—changes in the nutrition of the part. The word inflammation, derived from infiammo, I burn, was pro- bably suggested in the first instance from fanciful and erroneous notions respecting the disorder which it was used to denote. _ The word is however now retained as a conventional term, used, without reference to its literal and original meaning, to express a certain pro- cess, or series of phenomena, about which medical men are in the main agreed; and so used it is preferable to many words by which it has been proposed to replace it, since it is not easy to disentangle such words from the theories upon which they have been founded, and which may eventually prove to be erroneous. Pain, swelling, heat, and redness, have been from the earliest ages of medicine recognised as the indications of inflammation in any part in which they are combined. These conditions are not, however, all of them invariably present in any great degree, thus the degree of pain will vary much according to the structure and sensitiveness of the part affected. It is much less in inflammations of the mucous membranes, and of the parenchymata of the several viscera than in those of denser structures, as the serous membranes; or of parts more abundantly supplied with nerves of common sensation, as the skin. The swelling and redness vary according to the texture of the part and intensity of the inflammation. The heat, again, belongs almost entirely to the commencement of the inflammation, and is most mani- fest in those parts which are the furthest from the centre of the circulation, and of which the ordinary temperature is consequently the lowest; since, in the most intense inflammations, the heat seldom rises above the healthy standard of the blood at the heart. In order to complete the description of inflammation, we must add to the pain, swelling, heat, and redness, a tendency to the effusion from the blood-vessels of fresh matter, generally liquor sanguinis, speedily assuming the form of coagulated lymph, or pus. It is true, indeed, that these consequences may sometimes not ensue, owing to the slight degree or short duration of the inflammation. Still we may fairly argue, from precisely similar instances, that they would have done so but for the above circumstances. "A peculiar perver- sion of nutrition or secretion," to use the words of Dr. Alison " we DESCRIPTION OF INFLAMMATION. 45 may hold to be essential to the very existence of inflammation;" and in this, it may be observed, consists the difference between inflamma- tion and active congestion; the latter, indeed, may be induced by stimuli external to the vessels, but the phenomena of congestion, as such, are confined to the vessels; whereas inflammation, being extra- vascular, and implying a perversion of nutrition, implies also a dis- turbance in all the tissues concerned in nutrition. Now, as is observed by Professor Paget,* " The conditions of the healthy maintenance of any part by nutrition, are, 1, a regular and not far distant supply of blood; 2, a right state and composition of that blood; 3, (at least in most cases,) a certain influence of the nervous force; and, 4, a normal state of the part in which nutrition is to be effected. All these are usually altered in inflammation." It is not therefore to the blood and blood-vessels alone that we are to look for an explanation of the phe- nomena of inflammation. In the first commencement of inflammation, as observed imme- diately after the application of a stimulus capable of exciting it, the minute vessels of the part become contracted, and the movement of the blood in them is quickened, according to many authors, though very accurate observers, and amongst them Professor Paget, maintain, and probably with truth, that there is no quickening, but rather a retardation of the flow of blood simultaneously with the contraction. After a time, however, an opposite condition of the capillaries may be observed, they become distended and dilated, and the movement of the blood in the focus of the inflammation is retarded, and in some capillaries it stops entirely, whilst around this focus the blood runs quickly in tortuous and distended vessels, and still further off it runs, still quickly, but through less distended vessels. Over the whole surface of the inflamed part, a number of small vessels become apparent, which could not be seen before; this is, no doubt, owing to capillaries allowing the passage of the red;'corpus- cles, which could before admit only the liquor sanguinis, or colourless liquid of the blood. Besides being enlarged, the blood-vessels are otherwise changed in shape; they are elongated, and consequently rendered more tortuous, and they also, as stated by Professor Paget, from observations by Kolliker and Hasse, have a tendency to become aneurismal or varicose. The movement of the blood is further affected by the arrangement of the red corpuscles, which cohere into irregu- lar masses, distending the blood-vessels, which often appear regularly crammed with them, "and often," says Professor Paget, "when there is stagnation in a considerable artery, one may see the blood above or behind it pulsating with every action of the heart, driven, up to the seat of stagnation, and thence carried off by the collateral branches; while in the corresponding vein it may oscillate less regularly, delay- ing till an accumulated force propels it forward, and as it were, flushes the channel." It is to be observed that the increased calibre of the vessels and the accelerated flow of blood through those around the part where * Lectures on Inflammation. 46 B L 0 0 D I N I N F L A M M A f I 0 N. the inflammation is the greatest, appear to do more than compensate for the retardation and stagnation at the central parts of the inflam- mation, so that the quantity of blood circulating through an inflamed part exceeds the quantity in health, for it has been ascertained that the blood returned by the veins from an inflamed limb, is at least three times as much as that returned by the corresponding veins on the opposite side. \ Thus far the changes which have been described in the blood- vessels coincide pretty closely with those which have been pointed out as occurring in congestion; but congestion and inflammation are not therefore to be confounded. Congestion is in many instances a strictly natural and healthy process—the afflux of blood in obedience to natural and healthy stimuli, to a part where an increased supply is wanted for physiological purposes. Of this we see instances in the impregnated uterus, and in the increased vascularity of the tissue whence the horns are nourished, when they are reproduced after having been shed. Congestion, indeed, almost always accompanies inflammation, but it is rather to be considered as a consequence of that excitement or irritation whereby the inflammation is set up, than as itself forming the first stage of the inflammation. Whilst the above changes are taking place in the capillaries, and the surrounding textures, which are the seat of the inflammation, the blood in the vessels of the part likewise undergoes alteration. This alteration includes not only changes in its chemical and physical, but also in its vital properties, by which latter is meant its adaption to the nourishment of the tissues to which it is distributed. We have before spoken of the tendency sometimes manifested by the red corpuscles, to arrange themselves in rows like rouleaus of coin; this tendency, which was first distinctly pointed out by Mr. Wharton Jones, and which is so efficient a cause of the buffy coat, is one of the changes which take place in the blood in inflammation. Much of their colouring matter has also been observed to escape from them, diffusing itself through the liquor sanguinis, and giving to the blood the appearance of a uniform red mass, interspersed throughout with colorless globules. These globules have been by some supposed to be the nuclei of those red corpuscles from the investing mem- branes of which coloring matter has escaped; an opinion which is at variance with the views now entertained respecting the structure of the corpuscles. It is more probable, therefore, that the corpuscles alluded to, are the white or rudimental corpuscles of the blood. The red corpuscles are, throughout the system, diminished in inflamed blood, though they may be present in an increased proportion at the seat of the inflammation. The fibrine and white corpuscles are in excess in inflamed blood, though from the difficulty of separating these two principles, it is by no means certain whether this excess is to be attributed chiefly to one or the other. It is probable however that when the inflammation occurs in healthy subjects, the increase takes place almost entirely in the fibrine, but that, in debilitated subjects, it is due mainly to the corpuscles. Andral states that in strong subjects the proportion of fibrine during inflammation may NERVES IN INFLAMMATION. 47 reach as high as from five to seven or even eight per thousand of the whole blood. Besides the increase in its quantity, the fibrine of the blood under- goes a no less remarkable change in its power of fibrilation or coagu- lation, a circumstance which materially facilitates the formation of the buffy coat in inflamed blood. It has already been shown (p. 41) that the slower coagulation of the blood, the more rapid subsidence of the red corpuscles, and increased proportion of the fibrine (all which conditions are present in a greater or less degree), promote the formation of the buffy coat; but that there is some other cause, tending to produce it, is evident from the facts, that the separation of the liquor sanguinis from the red corpuscles may often be-observed in inflamed blood before the time that coagulation would have com- menced in the healty state; and that this separation may take place in films of blood so thin as not to allow of a stratum of liquor san- guinis being laid above one of red corpuscles. The conditions which concur for producing the buffed and cupped clot of inflammation, appear on the whole to be as follows—relative diminution in the number of red corpuscles, and proportionate increase in the quantity of fibrine or white corpuscles:—more rapid and closer aggregation of the red corpuscles into rolls, and of these again into masses having large intervening spaces filled with liquor sanguinis. To the above may be added a continued slow coagulation of the fibrine, after the separation of the clot; the effect of which is, that the upper layer of the clot being disengaged from the red corpuscles its edges are drawn towards each other, and thus is given to the surface that concave form which is commonly called "cupped." Two other changes of the blood in inflammation—the diminution of red corpuscles, and increase of water; which, as we have already seen, favor also the formation of the buffy coat; although they are but little adapted to explain " any of the phenomena of the local process," nevertheless furnish us with a resemblance between the condition of the blood in inflammation, and in several states of the system which are commonly believed to be the most opposed to it; but in which the accurate clinical observer is well aware that it frequently arises—viz., spontaneous anasmia and that state of the system which is induced towards the close of many protracted dis- eases. It is very true, as is observed by Professor Paget, that none of the conditions, the existence of which has been ascertained, either by chemistry or by microscopical observation, are sufficient to explain the local phenomena upon any known principles. But as it is known that many instances occur, in which inflammations have their origin in a morbid condition of the blood, we are compelled to believe that such morbid condition may exist, though it elude both chemical and microscopical observation, and must, in the present state of our knowledge, be described as a loss of adaptation to the purposes of nourishment, and, consequently, of the mutual affinity between the blood in the capillaries and the surrounding tissues. 48 CONSEQUENCES OF INFLAMMATION. Of the condition of the nerves during inflammation nothing can be known by actual demonstration. That disturbance of the nervous influence may of itself excite inflammation, we know from the effect upon the tissues of the eye produced by disease or injury of the fifth nerve, and also from the kind of sympathetic inflammation which is communicated through the nerves of an inflamed part to those of another part. That irritation applied to the sentient extre- mities of the nerves will produce a certain degree of inflammation, is apparent from the eruption upon the surface produced by electric sparks. The pain felt in an inflamed part also suggests the idea that the nerves of that part are in what is termed a highly " excited" state, and of this there is further evidence in the extreme tenderness and susceptibility to every stimulus. That pain, and that very intense, may often exist without inflammation we know; still it is not to be overlooked, that in very severe paroxysms of pain, as in facial neuralgia, there arises an inflammatory oedema and redness of the part. It may, perhaps, be too much to assert that disturbance of the nervous system is as much an essential part of inflammation as is that of the vascular system; yet we have seen that congestion or excitement of the vascular system may exist without inflammation, as well as pain or excitement of the nervous system. We know also that congestion, long continued, is apt to result in inflammation, and so also is long continued pain or excitement of the nervous system; and if it be said that inflammation may exist in parts which are scantily if at all supplied with nerves, so also, it may be answered, will it arise, as in the cornea, in parts which have no vessels. That inflammation may be induced, by an altered condition of the part, independently both of the blood-vessels and nerves, is apparent from the instance just cited of the cornea, which has neither; and as regards the increased afflux of blood to an inflamed part, we will again repeat what has been before insisted upon, viz., that it is the condition of the part which determines the supply of blood rather than the supply of blood the condition of the part. It is not therefore to be inferred that inflammation may not arise from disturbance either in the blood-vessels, the blood, the nerves, or in the proper elements of the part itself, but that the state com- monly recognised as inflammation cannot be fully established without involving them all; and as it may begin in any one of these disturb- ances, so is it impossible to ascribe to either the precedence in the order of sequence, and therefore they should be studied as contem- poraneous events, rather than as following each other in any neces- sary series. The local changes now described are followed by certain conse- quences which have been treated of by many authors as the termi- nations of inflammation; thus we read of inflammation terminating by resolution, by effusion, by adhesion, by suppuration, by ulcera° METASTASIS. 49 tion, and by gangrene: strictly speaking, however, the first and last, viz., resolution and gangrene, are the only true terminations, since the different effusions may take place at any period of inflammation, and are not necessarily attended by its subsidence, although the term abscess, applied to a circumscribed suppuration, from abcedo, would seem to imply the notion of a departure of the inflammation. Eesolution, which is in reality a subsidence of the inflammation, takes place when the state which we have just been describing passes away without leaving any permanent change in the part which was the seat of the inflammation. This subsidence takes place by just the same steps as those by which the inflammation had been established, but in an inverted order. The swelling diminishes, the rapid motion of the blood in the vessels surrounding the seat of the inflammation abates, whilst, at the focus of the inflammation, where stagnation had been established, the agglomerated corpuscles may be seen to separate and pass off in different channels, and the blood resumes its motion; the vessels gradually return to their former calibre, and recover their contractility, the redness and heat of the part disappear, and it is at length restored to its former con- dition. This termination is the most favorable result that can ensue in inflammation, provided it be not followed by diseased action else- where. Sometimes, however, inflammation undergoes resolution, and that very rapidly, in one part, to be set up again as rapidly in another, continuous with that in which it commenced. This disposi- tion to a continuous transference of inflammation by which it appears to creep along from one part of the same membrane to another, is more frequent in some textures than in others, as in the skin and the mucous membrane of the bronchi, and also in some varieties of inflammation than in others. It happens also, not unfrequently, that the inflammation suddenly subsides in one part and reappears immediately, and with the same intensity, in others remote from it, though generally in a structure similar to that which it has left. This sudden removal of inflamma- tion from one part to another is particularly liable to recur in acute rheumatism and some other inflammations of a specific character, and it is termed metastasis. This transference of inflammation from one part to another is a circumstance of which we often avail ourselves, and endeavor to imitate by setting up an inflammation on an external part in the hope of withdrawing or subduing a more serious and dangerous one within. This mode of treatment is called counter-irritation; the terms derivation and revulsion are also used to express it. It is not improbable that the subsidence of an inflammation after what have been called critical discharges or evacuations, are instances of fortunate or beneficial metastasis, as they proceed from a congestion connected either in the way of cause or effect, with the subsidence of the primary inflammation. When, however, resolution does not take place, the characteristic effusions of inflammation begin to make their appear- ance as soon as it is at its height. 4 50 EFFUSIONS OF INFLAMMATION. The first of these products or effusions is the so-called serous effusion, from its apparent similarity to the serum of blood. When the inflammation is at its height a colorless liquid exudes from the capillaries, either infiltrating the surrounding tissues, or if the seat of inflammation be a secreting surface, increasing the secretion of the part. When, for instance, the inflammation is in the areolar tissue, we have from this cause a great increase of the swelling, and if it be a closed cavity we have dropsy of that cavity. It however rarely happens that this is the true serum of blood; it is, in fact, as was long ago pointed out by Dr. Babington, in the paper already alluded to, liquor sanguinis, or blood deprived of its red corpuscles. This effusion has been described by Paget, under the term fibrinous dropsy, and differs from the true serous dropsy in that it contains fibrine, and is capable of coagulating after it is removed from the body. Another form of liquid effusion is pointed out by Professor Paget as happening from serous inflammatory matter capable of organization into cells. The fluid containing fibrine has generally the appearance of serum, from the circumstance of its retaining its fluidity, which it will do for a considerable time within the body, and that too after death. The reason of this delay in the coagulation is by no means obvious, though it is a propitious event; for so long as the effusion is liquid, absorption may ensue on the subsidence of the inflamma- tion.* It may sometimes happen that serum is effused in inflammation, but this is only in the lowest forms, and the serum is very rich in water; but, as a general rule, it is exceedingly rare as an inflamma- tory product. The same may be also said of blood, which, though it has been reck- oned among the effusions of inflammation, never occurs unless it be from the rupture, either of some of the highly congested capillaries, or of those delicate vessels which are formed in recently coagulated lymph. In the former case the haemorrhage is termed primary, and in the latter secondary; but in either it is to be regarded rather as an accident than as one of the natural results of inflammation. It not unfrequently happens that the coloring matter of the corpuscles is dissolved in the effused fluid, giving it the appearance of blood, which no doubt has led to the belief in the red corpuscles transuding through the walls of the vessels. We have already seen that true serum rarely occurs as an inflam- matory effusion, the characteristic product of inflammation being the blood-plasma, or as it is commonly termed, lymph, and which we will designate inflammatory lymph, to distinguish it from other sub- stances to which this term is applied. Of this inflammatory lymph the so-called serous effusions are merely modifications and like them, it occurs under two varieties, the fibrinous and the corpuscular. The fibrinous variety occurs when the liquor sanguinis, which is poured out as before stated, becomes of a thicker and more gelatinous * Paget, opus citat. EFFUSIONS OF INFLAMMATION. 51 character, and at last assumes a form closely resembling, in appear- ance and composition, the buffy coat of the blood,—the adhesive inflammation of surgeons. This product of inflammation may be seen most plainly in the formation of adventitious deposits, which are frequently found upon serous membranes, sometimes gluing together their opposed surfaces, as the pleura pulmonalis and pleura costalis, or the free and attached surfaces of the pericardium, after an attack of inflammation of either of these membranes. The lymph is sometimes effused with the serum, the latter remaining unabsorbed in the cavity, whilst the former adheres to its serous lining, or in cases of less active inflam- mation remains in loose shreds, which subside to the lower part. At other times the lymph or fibrine alone is effused, or, what is more probable, the serum is absorbed almost as fast as it is poured out, and the result is, the deposition of lymph alone upon the surface of the membrane, little or no serum remaining in the cavity. Now it being one of the properties of inflammation, of which no satisfactory explanation has as yet been given, to propagate itself from one surface to another in contact with it, especially when these surfaces are similar structures, the consequence must be, that since the opposite surfaces of serous membranes, when not separated by effusion, are always in contact with each other, the inflammation of one portion of such membrane, the pleura pulmonalis, for instance, must, in the absence of such fluid, give rise to inflammation of the corresponding part of the pleura costalis, and the lymph, poured forth by each, forms, as it were, a cement by which these parts are united, the union becoming firmer by its subsequent organization. A very similar process takes place in the inflammation of the areolar tissue of the body, of the spongy texture of the lungs, and other parenchymatous viscera, the lymph effused into the interstices as- suming the solid form, sometimes almost immediately, at others not till after a considerable time. In the former case the result is a hardening almost from the first, in the latter there is first a swelling or distension of the part, which pits under the pressure of the finger owing to the infiltration of the texture by the liquor sanguinis; afterwards, the serum being absorbed, the part becomes hardened by the coagulation of the lymph or fibrine. The exudation of lymph or fibrine does not very often happen upon the free surfaces of mucous membranes, though it does some- times occur when the inflammation is very intense, as in the case of the exudations in the larynx, trachea, and bronchi, in croup, and in patches in the larger intestines in dysentery. It also not uncommonly takes place in the areolar tissue beneath such membranes, giving rise to a thickening, that encroaches upon the tube which it lines, and causes a diminution of its calibre, as in stricture of the urethra. "In the corpuscular variety of lymph," says Professor Paget,* " no coagulation, in the ordinary sense of the word, takes place, but * Lectures on Inflammation. 52 VARIETIES OF INFLAMMATORY LYMPH. corpuscles form and float free in the liquid part. Typical examples of this form are found in the early-formed contents of the vesicles of herpes, eczema, and vaccinia, in the fluids of blisters raised in cach- ectic patients, in some instances of pneumonia, and in some forms of inflammation of serous membranes." These corpuscles, exudation corpuscles, or exudation cells, resemble, in their first appearance, the white corpuscles of the blood, though they admit of many varieties in their subsequent changes. These two varieties, namely, the fibrinous and the cellular, con- stitute the typical forms of inflammatory lymph, but it will very commonly happen that the effusion is of a compound character, the fibrine and the corpuscles being mixed in various proportions, and accordingly, as the former or the latter preponderates, will be the probability of the lymph being organized into tissue, or degenerating into pus, or some other inorganizable product; the probability, in short, of adhesive or suppurative inflammation. It becomes, therefore, a matter of great practical importance to ascertain what are the conditions upon which depend the effusion of one or the other form of lymph. It has generally been stated that this is determined mainly by the character of the tissue in which the inflammation is seated, and it is undoubtedly true that cceteris paribus, adhesive inflammation is more likely to take place in some tissues, and suppurative in others. Thus, in serous membranes the inflammatory lymph is commonly fibrinous, and, having a great tendency to form adhesions; whilst that effused in inflammations of mucous membranes, is prone to assume the form of pus. But it is also true that the same tissue, even when excited to inflammation by the same cause, may pour out either fibrinous or corpuscular lymph; thus the fluid of the vesica- tion of a blister applied to a healthy subject, deposits shreds of fibrine, whereas, as we have already seen, the same fluid, in a cachectic subject, contains merely exudation corpuscles, and has no power of spontaneous coagulation; again, the fluid effused in inflammation of the pleura, occurring in a person of previously good health, is highly plastic, whereas the fluid effused under the same circumstances in a debilitated subject, contains little or no fibrine, but becomes speedily puriform; it follows from this, that independently of the nature of the tissue affected, the character of the effusion is greatly influenced by the state of the blood, of the nervous force, or general health of the patient. Besides these conditions, the character or intensity of the inflam- mation will often determine the nature of the effusion; thus we know that the skin, under inflammation of what is termed a specific character, as eczema, herpes, small-pox, and erysipelas, effuses the corpuscular lymph alone, though that tissue, in its normal state, pours out fibrinous lymph in common inflammation; whereas the mucous membrane of the trachea will, on the other hand, pour out plastic fibrinous lymph under the intense inflammation of croup. There are then three conditions influencing the character of the in- flammatory exudation:— VARIETIES OF INFLAMMATORY LYMPH. 53 (1.) The nature of the part or tissue that is the seat of the inflam- mation. (2.) The state of the blood and general health. (3.) The character and intensity of the inflammation. Mucus is another substance which has been reckoned among the products of inflammation, though there is little doubt that, in the ma- jority of instances, the apparently increased quantity of mucus poured forth from a mucous membrane, in which inflammation has been established, is owing mainly to the inflammatory lymph mixing with the natural secretion of the part, though, no doubt, the secretion of proper mucus is often increased likewise, and with it the quantity of epithelium, with which are mixed immature epithelial cells. It appears probable that too much stress has been laid by sys- tematic authors, upon the essential difference between the product of inflammation in a serous and a mucous membrane; for in an established inflammation of one of the latter, there appear the ordi- nary products of inflammation of serous membranes and other parts; the difference consisting only in the fluid in which they lie. Their increased proneness to degeneration, and consequent diminished susceptibility of development when so mixed, produce a greater tendency to puriform effusions from mucous surfaces than from other textures. The inflammatory lymph, in its progress towards degeneration or development, undergoes changes, the history of which constitutes a most important part of the doctrine of inflammation. The inflammatory lymph, like the blood from which it is separated, has a life of its own, and is capable of acting as a blastema, originat- ing new formations independently of the blood-vessels, although the presence of the latter constitutes one of the conditions without which that life cannot be indefinitely prolonged. It is also necessary to bear in mind that the progress of the inflammatory lymph towards more complete organization cannot commence until the inflamma- tion subsides, as before that happens, fresh lymph will be continually poured out, and that already effused may undergo degeneration but never development. The fibrine of the effused lymph, after its first coagulation, is of a soft, flocculent, or semigelatinous consistence; it soon, however, evinces a remarkable tendency to shrinking, or rather contracting in bulk, owing to which we find not only an increased hardness of different structures as one of the consequences of inflammation, but a remarkable drawing together of the parts into which the effusion has taken place, or shrinking of the surface upon which it has been deposited. After some time red striae may be observed in the new product, appearing like continuation into it of the vessels of the tissue from which the lymph had been effused. It has been much ques- tioned whether these vessels are really prolongations of those of the original tissue, or whether they are formed de novo from the effused cytoblast. The latter is the opinion of Vogel, who states that he has arrived at it through a large number of observations, and adds that it is only at a later period that they connect themselves with the 54 ITS SUBSEQUENT CHANGES. previously existing normal vessels; the blood which they contain before uniting with the latter vessels being probably produced anew in the same manner with themselves. Professor Paget, on the other hand, maintains that all the vessels in inflammatory lymph are formed by outgrowth of adjacent vessels, in which opinion he is supported by Mr. Travers, Mr. Quekett, and others, and it cannot be denied that there are many sources of fallacy in the observations by which the opposite opinion is supposed to have been established. At the same time that these vessels are being formed, the fibrinous lymph passing through the stage of a nucleated blastema, assumes the cha- racters of the fibro-cellular or areolar tissue of the body, and its organization may be said to be completed. The corpuscular lymph, though more prone to degeneration than the fibrinous, is also capable of organization, which is generally effected, according to Professor Paget, through the elongation of its cells, and it is through the development of these cells that granula- tions, hereafter to be described, are produced. Besides the fibro- 'ellular tissues, there are two other structures which may be formed from lymph, namely, epithelial cells, and bone; the first of these are formed in the skinning of superficial wounds and sores, and on membraneous inflammations; the latter is formed from lymph effused in inflammations occurring in or near the periosteum; the earthy amor- phous deposits occurring in false membranes formed by the organiza- tion of inflammatory lymph, and which are the result of the subse- quent degeneration of such tissues, are to be distinguished from the products of the ossific inflammation. Besides these changes, which constitute the development of inflam- matory lymph into organized tissues, constituting integrant parts of the living body, others may occur, by which it retrogrades into sub- stances of a lower degree of vitality less removed, that is, from in- organic matter, and consequently, more prone to disintegration, but, at the same time, more susceptible of absorption. A brief enumera- tion of these changes will greatly aid the explanation of several of the consequents of inflammation; though for a more complete account of them the reader is referred to the admirable lectures of Professor Paget, already quoted. (1.) It may undergo a simple wasting or drying; the fibrine showing no tendency to organization, but becoming merely closer and firmer. (2.) A very important degeneration to which the fibrine of the effused lymph is liable, is a change closely resembling the fatty de- generation in muscular fibre, which has been long known to patho- logists as a simple lesion of nutrition, and one to which the last named tissue is peculiarly liable in old age. In the lymph poured out in the lower forms of inflammation, or in very unhealthy sub- jects, minute drops of oil may not unfrequently be detected; while the fibrine of the lymph is very soft, and easily broken. This oily, or fatty matter, with the ill-formed fibrine by the degeneration of which it is produced, is the principal constituent of the " aplastic INFLAMMATORY DEGENERATIONS. 55 lymph" effused in inflammations of serous membranes in unhealthy subjects, and " to the same source," as observed by Professor Paget, "we may trace most of that molecular and granular matter which is usually mingled—with pus formed by the suppuration of inflamma- tory indurations,—with the variously-changed corpuscles of scro- fulous matter,—or with the granule-cells, and other corpuscles of pneumonia and the like inflammations; at least, this disintegration of fibrine is probably a frequent origin of such molecular matter; while the quantity of fatty matter present in pus and the products of pneumonia, and its gradual increase while pus is retained in an abscess, confirm the view that the changes here described are of the nature of fatty degeneration." It is very probable, and, moreover, important to be remembered in practice, that this degeneration of fibrine into a lower organic product, fat, is highly beneficial, bring- ing the lymph into a state more susceptible of absorption, and thereby facilitating resolution, the most favourable termination of inflam- mation. Another change is the calcareous degeneration, of which we see traces on the valves of the heart and on the surface of the pericar- dium, though this change is less frequent in the fibrine, than in more advanced products of inflammation. Another degeneration is the pigmental. The corpuscular lymph is also liable to undergo degenerations similar to those which have been already described as occurring in the fibrinous exudations; thus the corpuscles may wither and dry in any stage of their development, as in the cheesy, ochre-coloured scrofulous matter. The fatty degeneration of corpuscles is shown in their transition into granule-cells, and may appear at almost any period of their de- velopment ; and it is probable too that, as in the case of fibrine, this change is a step towards the absorption of the lymph. We pass on, however, from these, to speak of the most important and most fre- quent degeneration of lymph-cells, viz., the puriform, or in fact of the process of suppuration. It may be well to state, first, that pus is an opaque and homo- geneous fluid, of a creamy consistence, pale-yellow, or rather yel- lowish-drab colour; it has a greasy feel when rubbed between the fingers, and when fresh and warm, it has a very slight, mawkish odour (i*affrations upon which its clearness depends. These precajjflns being observed, the percussion may be practised, com- mencMMwith the space immediately under the clavicle on either side, a^rthen proceeding in the same manner Avith the corresponding space Wa the other side, so as to institute a comparison between the resonance£f the two. In addition, hoAvever, to these precautions, it should befen^mbered that independently of disease, there are several circumstances Avhich tend to increase or diminish the resonances of the chest, anrl that in health the resonance varies in different parts of the same chest. Thus the resonance of the chest is grenter in lean than in fat per- sons. In the old, again, the increased rigidity of the cartilages, from the greater quantity of ossific matter contained in them, has the effect of diminishing the elasticity of the skeleton, and, to a certain extent, diminishes the resonance; though this effect is often more than counterbalanced by the less quantity of fat, and even muscles on OF THE RESPIRATION. 133 the walls of the chest, and by the enlargement of the air-cells, whereby the resonance is increased. Again, the resonance of differ- ent parts of the chest \-aries according to the quantity of muscle overlaying each. Thus the regions of the scapula and the pectoral muscles are duller on percussion, and the axilla and margin of the middle portion of the sternum (on the right side) are the most resonant. There are, hoAve\rer, differences as regards the contents of the different parts of the thorax Avhich materially affect the reso- nance, and Avhich it is still more important to remember; thus the chest contains, besides the lungs, the heart and large vessels, the former of which is in contact Avith the interior surface of the chest through a space of nearly an inch in diameter. Over the correspond- ing portion of the chest, and some way beyond it, owing to there being only a thin layer of lung interposed between the heart and ribs, that is to say, over the cartilages of the fifth and sixth rib, in the space betAveen them, and from the middle bone of the sternum for about an inch and a half leftwards, the sound is dull. The reso- nance is also defectiA*e over the false ribs on"the right side, owing to the proximity of the liver; and in children, owing to the liver being proportionately larger: and sometimes in females, owing to the per- nicious habit of tight lacing, this dulness extends as high as the sixth or even the fifth rib. On the left side, again, in the same situation, we have often a great variation in the resonance, and that taking place in a short time in the same individual; thus the stomach may be distended by gas, and rise higher than usual, the effect of which is to give rise to a peculiar ringing sound, or, on the other hand, it may be filled Avith liquid, and thus diminish the resonance in the same situation; as a general rule, hoA\rever, the loAver part of the chest is duller on the right than on the left side. The exploration by means of the sounds elicited by percussion is, in fact, a species of auscultation or listening; Dut|fchere is another mode of listening of perhaps even greater importance than the former, which is termed, par excellence, auscultation, and that is, by listening to the action of the various viscera of the chest. It needs hardly a moment's reflection to perceive that if a large bronchial tube be closed, the respiratory murmur will cease in the corresponding portion of the lung; and that the same thing must happen if the lung, or a portion of it, be rendered irrespirable by the filling of its cells by morbid deposits, or by its being compressed, by air, by fluid, or by solid tumours. But, Avithout being silenced, the sounds of respiration are apt to be very much altered by disease; they may be rendered louder than natural OAving to undue activity of a portion of the lung, in which case the respiration is said to be puerile, from its resemblance to the breathing of children. Again, they may be too faint, as is the case Avhen the cells are over-dilated, or Avhen there is partial obstruction of a large bronchus. Again, the respiratory murmur may be altered in character rather than in inten- sity, as when the breathing becomes hissing, or, as it is termed, sibi- lant, by narrowing of .the extreme ramifications of the bronchi from SAvelling of their lining membrane; or the soft whispering murmur 134 A S C U L T A TI 0 N. may be converted, by change in the walls of the cells, into a fine crackling sound termed a dry crepitation. Again, in the case of the heart, if there be any great change in the size of its cavities or the thickness of its walls, the sounds which accompany their contraction and the discharge of their contents will be likewise changed; and if the valves be much altered in structure there Avill be some modifica- tion of the sounds which attend their closure. The above, hoAvever, is not all, for disease may occasion new sounds as Avell as the alteration of the natural ones; it, in fact, has its oAvn proper sounds as well as health. Thus the secretion Avhich lines the bronchial tubes is not, in health, of sufficient quantity to cause any sound by its being disturbed by the passage of air through them; but Avhen this secretion becomes excessive in disease, its agitation, both in inspiration and expiration, gives rise to a sound resembling that Avhich would be produced by bloAving through a tube partly filled Avith fluid, as Avater thickened with mucilage, which sound wil), of course, be modified according to the size of the tube, and the quantity, and thickness or viscidity of the fluid. In this manner are produced the different sounds termed rattles, to be hereafter specially described. Again, there are sounds termed ronchi, which may be sibilous or hissing—sonorous—cooing—the result of contraction or dilatation of the tubes; as well as a modification of these, termed cavernous res- piration, from the air passing in and out of a large cavern or hollow, hoAvever formed. These caverns, Avhen partially filled Avith pus or mucous, give rise to a species of rattle termed gurgling. The passage of air through the bronchial tubes is not to be heard in health, except just below the sterno-clavicular articulation; but Avhen the lung is condensed by disease, or pressed upon by fluid, it becomes audible, and we hear Avhat is termed bronchial respiration. Mucous crepita- tion, again, is a modification, by fluid in the smaller tubes of the affected portion of* lung, of the crackling or crepitation already described. These sounds, and others which are varieties or exag- gerations of them, will be more clearly understood hereafter, when we come to treat of the diseases in which they are produced, so that an analysis of them in this place would be premature. AVe may, hoAvever, here remark that Ave have— (1.) Sounds of respiration, modified by disease of the part Avhere it is heard, as coarse or harsh respiration—or by that of other parts, as puerile respiration. (2.) Sounds Avhich may exist in health, but only become audible on the surface of the chest by change in the conducting poAver of the surrounding tissues, as bronchial or tubular breathing, and perhaps also the expiratory murmur. (3.)_ Sound produced by changes in the Avails of the tubes, as ronchi. (4.) Sounds produced by changes in the contents of the tubes, as rattles. (5.) Sounds produced by the formation of new holloAVS accessible to the air, as cavernous sounds. OF THE VOICE. 135 (6.) Sounds produced by changes in the structure of the cells, as dry crepitation and wheezing. (7.) Lastly, we have the sound produced by the motion of two surfaces of the pleura upon each Avhere the smoothness of the mem- brane has been impaired by disease. _ Again, many of the structural changes produced by disease, give rise to certain alterations in the sounds heard at the surface of the chest in speaking or coughing, which alterations are valuable signs of these particular changes. Now the morbid phenomena observed on the surface of the chest when the patient speaks are similar to spme Avhich may be observed in health, but only in particular situa- tions. Thus, Avhen the stethoscope is applied over the larynx of a person Avhilst he is speaking, the sound appears to proceed along the instrument to the ear of the listener, much as if the mouth of the speaker were applied to that of the instrument. This is termed laryngophony. But Avhen a similar phenomenon is observed on the surface of the chest (Avhile it is not in health) it is called pectoriloquy. Again, Avhen the ear of the stethoscope is placed between the scapulae, in many persons the voice seems not so much to proceed from the part upon which it rests as to traverse it; it is, in fact, heard at that spot, but seems to be crossing, as if some one were speaking through a quill laid across the bell of the instrument or the ear of the listener. This is bronchophony, which is also observed as a morbid phenome- non on the surface of the chest. These sounds are audible on the surface of the chest, and become morbid phenomena under the following conditions:—Pectoriloquy occurs when there is a large holloAV having each diameter as large at least as that of the trachea, surrounded by a substance more homo- geneous than healthy inflated lung, and of greater density. Bron- chophony, again, takes place when there is interposed between the surface Avhere the ear or the stethoscope is applied, and a bronchial tube, a substance of greater density than healthy lung, such as con- solidated lung, or lung compressed by fluid, with the fluid itself. It.Avould be out of place here to enter minutely into the examina- tion of the causes of these phenomena upon acoustic principles; but as some confusion appears to have arisen from the views put forward some years ago by Professor Skoda, it may be well to submit the following brief explanation:—In the healthy condition of the lungs and air passages, the vibrations of the vocal chords upon which the voice depends, are propagated downwards along the trachea and large bronchi—these vibrations being communicated both to the walls of the trachea and large bronchi, and to the column of air contained within them;* but the bronchi become divided into innumerable branches and twigs, which are again surrounded by the spongy lung, * According to the views of Dr. Skoda, this sound is produced by the occurrence of what is termed consonance; but it must be obv'o is to those acquainted with the subject, that, for the production of this latter phenomenon, there is required a relation between the note or tone of the tubes and that produced at the vocal chords, which would not, according to all ordinary probability, be so uniformly present as it must be to produce the common occurrence of bronchophony. 136 A U S C U L A T I O N. so that not only are the vocal vibrations broken and obstructed by being thus diverted into innumerable directions, or in other words, their poAver of consonating destroyed, but they are also muffled, and, as it Avere, smothered, by the heterogeneous substance Avhich sur- rounds them, which also prevents any sounds which may be excited in them being propagated to the surface of the chest. AVhen, how- ever, instead of spongy lung and the minute ramifications of the bronchi, a larger tube is surrounded by a more dense or homo- geneous structure, its poAver of transmitting the sonorous vibrations Avill be increased, and if the consolidation be extensive those vibra- tions which are excited in the walls of the tube, as well as the air contained in it, will be propagated directly to the surface. Thus, lung consolidated by inflammation affords the most favourable con- dition for the phenomena, provided the consolidation extends to the surface of the organ. Effused fluid, again, will propagate these sounds better than the non-homogeneous lung, but by no means so poAverfully as air and solids. The opinion of Dr. Skoda that bronchophony is wholly produced by a consonance between the air in the tubes and the voice, is opposed to the explanation Avhich has just been given, and appears to be based upon some confusion between consonance and propagation of sound, though it is conceded that the power of consonating must be much increased in the tubes by their being surrounded and sup- ported by condensed lung. The diagnostic import of the various sounds observed in the aus- cultation of the voice, as well as their various modifications, will be best considered in connection with the diseases in which they occur. The signs observed in coughing agree both as to the principles upon Avhich they may be explained, and their diagnostic significance, so closely with those of the voice as scarcely to require a separate notice in this place. Another mode in which sound is available for the detection of dis- ease is the applying the ear to the chest of the patient and giving him a sudden jerk; this is termed succussion, and under certain dis- eased conditions a splashing may be heard like that of a small cask partly filled with water. This sound, in fact, depends upon the presence of air and fluid in the same cavity. Of the sounds of the heart, both in health and disease, it will be most convenient to speak when we come to treat of the affections of that organ. AYe may now say a few words about the practice of auscultation. Auscultation, like percussion, is of two kinds, immediate and mediate. The former consists in the direct application of the ear of the listener to the chest of the patient; the latter in the use of an instrument termed a stethoscope, to convey the sound from the one to the other. Each of these methods has its advantages, for there can be no doubt that Avhere the ear can be applied closely to the surface of the chest, it must receive the sounds which are present there more accurately than if they Avere exposed to being modified by transmission through some other substance. But the ear cannot well be applied to the sur- ASCULTATION. 137 face of the chest in all situations and under all circumstances, and therefore it often becomes necessary to have recourse to the sthethos- cope. This instrument has also the further advantage, that although by its assistance we can hardly hear so plainly as with the naked ear, we can locate the sounds more accurately. It is, however, quite in- dispensable that the operator should be Avell practised in both methods. There has been a difference of opinion as to the mode in which the sound is transmitted from the chest to the ear, some believing that it is conveyed by the Avails of the instrument, Avhere a hollow one is used; others, that it is propagated by the column of confined air within it. JNToav if the former opinion be correct—and the fact that the sonorous vibrations with which we have to do are those existing on the surface of the chest, and consequently taking place on a solid, would lead us to believe that it is so—a solid instrument should be preferred to a hollow one. Accordingly solid stethoscopes have been constructed, and several practitioners have believed that they heard better with them than with the ordinary holloAV ones. Practically, however, there is little if any real difference, and the rules which it is most important to observe in the choice of a stethoscope are, that the ear-piece should upon trial be found well-suited to the ear of him who is to use it; that the base of the bell should not be too large, that is to say, not more than from an inch to an inch and a quarter in diameter, as if it be larger than this it cannot be so accurately applied. It is also desirable that the stethoscope should be of the same material throughout, or at least that there should be a con- tinuity of the fibres of the wood from the base to the centre of the ear-piece. 138 CYNANCIIE, LARYNGITIS, CROUP. X. CYNANCHE, LARYNGITIS, CEOUP. In treating of the diseases of the different regions of the body, it is expedient to begin Avith those of the viscera of the trunk, since these may be considered as the rudimentary, being more often the cause of disease in other parts than the consequence of them; and the reason of this is obvious, for in one or other of the great cavities of the trunk, reside the organs which form, elaborate, move, and purify, the blood. AAre therefore at once proceed to inflammation of the lungs and air-passages. Of the inflammation of the organs of respiration, that Avhich natu- rally presents itself to our notice is cynanche tonsillaris, or inflamma- tion of the tonsils. This disease is one, about the diagnosis of which there is no great difficulty, as the symptoms are apparent, and the part immediately affected is accessible to inspection. It has been characterized by Cullen as affecting the mucous membrane of the fauces, and more especially of the tonsils ; Avith SAvelling and redness, the accompany- ing fever being a synocha. The disease often commences with strong pains in the limbs, and general lassitude, folloAved by flushings of heat and thirst, Avith increased frequency and sharpness of the pulse, and a furred and somewhat coated tongue, and severe headache— with the symptoms, in short, of the commencement of inflammatory fever; though it not uncommonly happens, on the other hand, that the local signs are the first to manifest themselves. These consist, in the first instance, in a feeling of soreness and constriction in the throat, Avith painful deglutition, and a difficulty in speaking, attended with a peculiar character of the voice, which may be readily recog- nized, though not very easily described; but may, perhaps, be com- pared to an attempt at speaking whilst a morsel of food is in the fauces. The respiration is at first but little affected. Upon looking into the mouth, we see the membrane covering the fauces, the velum, the uvula, and the tonsils very red, and the latter much swollen. Thus far we have the redness and tension proceeding from the congestive stage of inflammation, with diminution of the secre- tion of the part, but, as the disease proceeds, one of its consequences, the increase of the secretion, takes place in the form of a copious and transparent, rather viscid frothy mucus, which, as the patient is unable to swallow Avithout pain, produces continual annoyance from his efforts to expel it. Small opaque Avhitish spots now begin to show themselves; these might be, by careless observers, mistaken for incipient sloughs or ulcers ; but are in reality effusions chiefly from the follicles—fibrin- ous shreds or globules, giving the appearance of films of lymph to the exuded mucus. There is now great difficulty in opening the C Y N A N C n E — PROGRESS. 139 mouth, it being often impossible to separate the jaws far enough to admit one finger betA\reen the teeth, or sufficiently to allow the pas- sage of the tongue, which, independently of this, is protruded Avith much pain and difficulty, on account of the inflammation about the pharynx. When seen, the tongue is perceived to be covered Avith a thick creamy mucus, and streaming with the increased secretion from the fauces, and the pulse is thick and sharp, but rarely hard. The inflammation may noAv be said to be at its height, and may commonly be expected, unless any great extension to the neighbor- ing parts takes place, either speedily to subside, or to proceed to suppuration. Sometimes the inflammation extends along the mucous lining of the Eustachian tube, producing pain in the ear; this pain, indeed, is said to indicate approaching suppuration, and certainly it often precedes it. The disease may be, indeed, attended with still more urgent symptoms, apparently more deeply seated, or involving to a greater extent the submucous areolar tissue; but these more severe cases are generally of a specific character, as diffuse erysipela- tous inflammation, or that of scarlatina, constituting the cynanche maligna, to be described hereafter. If resolution of the inflammation do not take place, suppuration commonly ensues, in which case the fever is protracted for a feAV days longer, or even a fresh accession takes place, ushered in by rigors. The tonsils become more SAVollen and distended Avith pus, Avhich may often be seen through the attenuated membrane. • This abscess at length bursts, discharges a small quantity of highly offen- sive puriform matter, and the patient is instantly relieved. This disease, though very painful, and often attended Avith much distress to the patient, is, in its simple form, rarely a dangerous one ; it for the most part yields in the commencement to prompt treat- ment, by which suppuration is arrested; and where it does take place, and Avhere great obstruction to the breathing follows, this may almost always be instantaneously relieved by opening the abscess. Perhaps the only cases in Avhich cynanche proves fatal, are those of a specific character already mentioned, and that spoken of as extend- ing doAvn into the areolar tissue. There is, indeed, another form of this disease, to Avhich the term diphtherite has been applied by French authors, and which is more dangerous than the ordinary cynanche, and is probably of specific character, since it has occasionally prevailed epidemically; in this, small patches of flocculent lymph appear upon the surface of the tonsils and fauces, and extend into the pharynx, and sometimes doAvn the oesophagus or into the larynx, in Avhich latter case it may produce suffocation, as in croup. This form is also dangerous from the depressing character of the typhoid fever which attends it, threat- ening death from sinking. This disease may, hoAvever, assume a tedious and protracted form (1) in persons of a sluggish circulation, in Avhom the inflamed part becomes of a purplish colour, with a loose condition of the velum, and perhaps elongated uvula, constituting what is commonly known as relaxed sore throat. (2.) In those of a scrofulous habit, especially 140 PROGNOSIS — TREATMENT. children, the tonsils are apt to remain swollen and indurated, and sometimes after repeated causes of irritation, pass into a state of chronic ulceration. (3.) In those whose constitutions have been tainted by syphilis or mercury. In the cases of simple cynanche, the object at the commencement of the inflammation should be to cut it short, or, in other words, to induce its resolution. For this purpose, decided and vigorous, though not violent, antiphlogistic measures, should _ be pursued. These should consist of evacuants, derivatives, sedatives, and the antiphlogistic regimen. It is not often that general bleeding is required in this disease; in robust subjects, however, when the inflammatory symptoms threaten to be very severe, it may be resorted to, and must then be carried to such an extent as to produce a decided impression upon the system; such cases are, however, rare, but when they do occur, general bleed- ing is to be preferred to local. Another evacuant Avhich is often of signal service in the commencement of cynanche, is an emetic; indeed, it very commonly happens that a full emetic, followed by pretty free purging, arrests the disease, and the patient becomes con- valescent in the course of twenty-four hours.(16)* When the disease is too far advanced to render it probable that it will be cut short by these means, but the inflammation is still in its active stage, as shoAvn by the redness of the tonsils, and some degree of sharpness in the pulse ; diaphoretic and even nauseating medicines may be given, and the patient kept upon a light diet, care being also taken to secure a free action of the boAvels.(17)f *(16) R Antim. pot. tart. gr. j. Pulv. Ipecac. Q j- Misce. Ft. Pulv. ; for a dose. R Hydr. Chlor. gr. ij. Ext. Coloc. co. gr viij. Misce. Ft. Pil. ij. ; to be taken after an interval of three hours. Or the emetic and purgative may be given in combination, as in the following mix- ture : — R. Mag. Sulphat. 3 vj. Antim. Pot. tart. gr. iij. Aq. puree, 3* iij. A large spoonful to be taken every half hour until full vomiting is induced. The common effect of this mixture will be, after a few doses, to excite full vomiting, which will generally be quickly followed by a free action of the bowels. f(17) R. Vin. Antim. Pot. tart. 3 ii. Sp. ^Eth. nit. ^i. Tinct. Hyoscyami, g i. Mist. Acaciaa. Syrupi Aurant. aa 5 ss. Liq. Ammon. acet. 3 jss. Mist. Camphorre, q s. To make a 5* vi. mixture, of which the fourth part is to be taken every fourth hour. R. Pulv. Ipecac, co. gr. iv. Ext. Coloc. co. gr. vj. Misce. Ft. Pil. ij. ; to be taken at bed-time. CYNANCHE — TREATMENT. 141 AVhere the bowels are irritable, Avhich, however, is not generally the case, the Avine of ipecacuanha may be substituted for that of the antimony ; or the same may be done when the pulse is so compres- sible as to justify the apprehension that the latter medicine may be too depressing ; still, as a general rule, cynanche is a disease to which in its earlier stages antimony is especially applicable. At the com- mencement of cynanche, astringent gargles aggravate rather than relieve the suffering of the patient, but the gargling Avith warm barley Avater is often productive of much comfort, and probably relieves the tension of the vessels by favouring the secretion from the part. The inhalation of the steam of Avarm Avater is, perhaps, still better, as it is unattended Avith the action of the muscles of deglutition requisite for gargling. When the inflammation has not been treated with sufficient activity, or Avhen, as it sometimes will do, it proceeds in defiance of the most prompt measures, a change of treatment will generally be advisable; all depressing remedies should be laid aside, and moderate support given to the patient; and if the pulse have become feeble, and there is much prostration (oAving partly to the abstinence from food, Avhich the difficulty in SAvalloAving often compels), stimulants, as Avine, Avill relieve the depression, and forward the progress of the abscess. If the abscess do not speedily empty itself, or the accumulation of matter opposes great impediment to deglutition and respiration, it will become necessary to give vent to the pus, Avhich generally affords instant relief to the patient. After this has been done, tonics, and even stimulants, may be employed, in the form of bark or quinia, animal diet, and a moderate alloAA^ance of Avine. AArhen the inflammation has not proceeded to suppuration, but has yielded to the remedies employed at once, there frequently remains a considerable degree of depression, Avhich will be best relieved by moderate doses of quinia, care being taken to secure a regular action of the boAvels; for this purpose the disulphate of quinia, Avith a little sulphate of magnesia, in a bitter infusion acidulated Avith sulphuric acid, will be the most eligible; (18)* at the same time an astringent gargle (19)f may be used Avith benefit, as the tonsils and uvula often con- tinue enlarged and of a purplish colour, constituting the relaxed sore throat already alluded to. This latter affection, hoAvever, often comes on Avithout being preceded by a decided attack of acute cynanche; but in such cases the treatment should be the same as in the chronic * (18.) R. Quiniae Disulph. gr. vj. Mag. Sulphat. 5j iij. Acid Sulphat. dil. 3 ss. Syrup. Aurant. ^ ss. lnfus. Aurant. co. 5 iijss. Misce. Of this mixture one-fourth part is to be taken three times a day. f (19.) R- Aluminis, 3 ss. Meilis Rosae, 3 ss. Tinct. Myrrhae, 3 ss. Decoct, (inchon. 3 vii. Misce. For a gargle. 142 ACUTE LARYNGITIS — SYMPTOMS. form AA'hich has folloAved the acute disease, though the gargle may be rendered more stimulating by the addition of about half a drachm of tincture of capsicum; or one of a solution of nitrate of silver may be used instead. A pure air and moderate exercise, with nutritious diet, will do much to aid the cure; but not less important than all, is the negative precaution of avoiding those circumstances which are liable to excite a fresh attack, to Avhich the patient will commonly continue for some time liable ; amongst the most active of these may be reckoned exposure to an atmosphere Avhich is at once cold and damp; the going from a warm and crowded place, Avhether church, theatre, ball-room, public meeting, or private party, into a cold air; and the perhaps no less dangerous transition from a cold, frosty air, to the front of a blazing fire. LARYNGITIS. Nearly allied to cynanche tonsillaris, but of a far more formidable character, is the cynanche laryngea, or laryngitis: indeed, it is to its tendency to run into this disease, that the first-named malady owes its principal, if not its only, danger. Laryngitis is, as its name im- ports, an inflammation of the larynx, especially of the cartilages, and affords an instance of inflammation exciting danger not so much from the constitutional disturbance, or the exhaustion consequent upon it, as by its arresting the function of a part essential to life. This formidable disease is mostly sudden in its inA'asion and rapid in its progress. The first complaint made by the patient is of a sore throat, but this is generally attended Avith an unusual degree of anxiety, and upon looking into the throat Ave may perceive an in- creased redness of the fauces, but not inflammation sufficient to account for the general distress. The next symptom is difficulty of deglutition, and when this superA'enes upon those mentioned above it ought abvays to excite alarm; at the same time the voice becomes husky or croaking, or perhaps more often it degenerates into a Avhisper; there is also great dyspnoea, the respiration becoming almost of a croAving character, and there is a harsh, discordant, half-metallic- sounding cough, but for neither of these symptoms can any adequate cause be discovered upon exploration of the chest by auscultation. The patient also complains of a most painful sense of constriction, which he refers to the situation of the pomum Adami, and of tender- ness about the situation of the point of the os hyoides. About this period of the disease there takes place an abundant glairy secretion of rather stringy mucus; and if its progress be not noAV arrested it runs speedily on to a fatal termination. The distress of the patient becomes greater and greater, and there is increased difficulty in speaking and dread of making the attempt either to speak or to swalloAV. The efforts in respiration are truly distressing, especially during inspiration, each attempt at which is attended by a hissing and sometimes almost croAving sound; the only words uttered are expressive of a desire for air and a sense of suffocation, the shoulders PATHOLOGY — DIAGNOSIS. 143 and clavicles are drawn up, the neck straightened, the head being throAvn somewhat backwards, and the accessory muscles of respira- tion throavn into violent action, by which the cartilages of the larynx are draAvn down tOAvards the sternum; the dyspnoea is liable to paroxysms of intense aggravation, during which the patient is nearly suffocated; after a time the countenance becomes dusky, the skin moist and clammy, the pulse very feeble at the wrist, the impulse of the heart remains considerable, and the patient dies of apnoea. The pathology of this disease is exceedingly simple, and the symp- toms during life are pretty clearly explained by the morbid changes displayed by inspection after death. The seat of the inflammation is, as has been already stated, the mucous covering of the larynx and its cartilages, including the rima-glottidis, the epiglottis, and some- times the sacculi laryngis. The first effect of inflammation of the mucous membrane is engorgement of the minute vessels by Avhich it is abundantly supplied, attended with increased nervous sensibility; the consequences of this are the pain, swelling, heat, and redness of the part affected, and there is also in this stage of the inflammation diminution of the secretions of the membrane. Hence the redness observed in the fauces at the commencement of the disease; the pain and tenderness, with difficult deglutition—the "sore throat,"—the hoarseness of the voice, and the pain on speaking. The next stage in the process of mucous inflammation is that in Avhich the inflam- matory products are effused, and accordingly there ensues an effusion of serum or liquor sanguinis into the areolar tissue underneath the mucous membrane, which effusion sometimes becomes of a puriform character; at the same time there is often an increase in the secretion of the surface. Noav the danger of this effusion in the part indicated must be apparent, and it will satisfactorily account for the distressing symptoms which have been described: it, of course, greatly adds to the SAvelling, and not only is the larynx much encroached upon and its canal narrowed, but the little crevice in the glottis by which the air passes into it is rendered less and less, and sometimes entirely closed by the continual SAvelling of the membrane and its subjacent areolar tissue. The morbid change Avhich essentially belongs to this disease, and which is constantly found upon inspection after death, is infiltration of the areolar tissue in the part just pointed out; the mucous mem- brane is also reddened, thickened, and occasionally smeared Avith a puriform mucus; it is also sometimes ulcerated; the epiglottis is thickened and often erect. There are, commonly, venous congestion throughout the body—extensive engorgement of the lungs, and com- monly of the right side of the heart—signs characteristic of the mode in Avhich' this disease proves fatal, by apnoea. The diagnosis of laryngitis is fortunately not very difficult, as it is of the greatest consequence that the disease should be early recognized in order that it may be promptly treated. The loss of voice, and spasmodic breathing of hysterical females may be distinguished from it, by the ordinary signs of hysteria, and by the absence of the signs of inflammation. A common sore throat or hoarseness may indeed be mistaken for this 144 ACUTE LARYNGITIS. disease, or what Avould be worse, the latter may be regarded as a case only of the former. Now, although the common sore throat, Avhich is a disease of no danger, does no doubt depend upon inflammation of the mucous membrane of the larynx, it is unattended by either the inflammatory fever, the general restlessness and anxiety, and the early occurrence of spasmodic breathing, Avhich characterize laryn- gitis. Where the two former of these occur in sore throat the case should be carefully watched, and the first appearance of the latter ought to excite great alarm. From cynanche trachealis, or croup, laryngitis may be distinguished partly by its affecting generally adults, whereas the former disease is almost exclusively one of in- fancy or childhood; and partly from there being no difficulty of SAvalloAving in croup; in cynanche pharyngea, on the other hand, there is difficulty of swallowing as well as of respiration. Tumours, again, whether produced by abscess, aneurism, SAVollen glands, or other morbid groA-vth or enlargement, may by pressing either upon the larynx or trachea, or upon the nerves by Avhich those parts are supplied (as when the recurrent nerve is pressed upon by an aneurism of the arch of the aorta), give rise to symptoms resembling those of laryngitis, and hence have been mistaken for it. The possibility of the existence of any of these should always be borne in mind; and a careful examination of the throat and of the condition of the heart and large arteries as far as the state of the patient will alloAV, should always be instituted. The causes of acute laryngitis are exposure to cold or damp, or to both together; it may also be excited by mechanical or chemical irritation of the larynx or glottis ; and a not unfrequent cause amongst children is the inflammation set up about that part by the SAvalloAving of scalding water. It may also be induced, as has been already noticed, from the extension of the inflammation of cynanche tonsil- laris to the larynx, or arise in the course or at the termination of scarlatina, measles, small-pox, erysipelas, and sometimes of rheu- matism. The prognosis is generally unfavorable in acute laryngitis, the disease proving fatal in a great number of instances. AVe must not, indeed, despair under favourable circumstances, and in good con- stitutions, of saving our patient, notwithstanding the severity of the disease; especially when remedies can be promptly applied at its commencement; but if much time has been lost, and the patient is of a feeble constitution, apparently of a cachectic habit, or the sub- ject of visceral disease,—circumstances which favour the effusion of serum into the areolar tissue, the probability of recovery is exceed- ingly small. It must have been inferred, from what has been already said, that the treatment of acute laryngitis should be prompt and decisive. The disease is an acute inflammation, and therefore calling for anti- phlogistic measures, which from its dangerous position, it is most desirable to subdue, if possible, before it reaches that stage in Avhich the truly inflammatory effusions take place; since it is from these that the chief danger arises. It is, hoAvever, an inflammation of a TREATMENT. 145 mucous membrane, and consequently one less directly amenable to the effect of blood-letting than those of some of the other tissues; it is, on the other hand, to be remembered, that blood-letting, when applied at too late a period, or when there exists an ansemic, or rather spansemic state of the system, favours the effusion of serum, by ren- dering the blood still poorer, and thus inducing the form of the disease to be presently noticed under the term of oedema glottidis. When, therefore, the patient is of temperate habits, apparently of good constitution, with no tendency to leucophlegmasia or anaemia, and the pulse is firm as Avell as sharp, and the tongue white, bleed- ing in a full stream, until some decided impression has been produced upon the heart, and repeated in a feAV hours if the pulse and the general condition of the patient are such as to justify it, has often appeared to cut short the inflammation: and there can be no doubt, that under such circumstances, it is the most efficient remedy at our disposal; but on the other hand, it more frequently happens that the persons in whom this disease occurs, are of previously unsound con- stitution, or weakened by previous disease, as when the laryngitis supervenes upon measles, scarlatina, or erysipelas, and in Avhom the use of the lancet would consequently be dangerous; or if this be not the case, the disease may be so far advanced as to have greatly depressed the system by the obstructed respiration, and consequent circulation of carbonized blood: or if it have already existed some hours, or has been fully established, experience teaches that blood-letting is nearly inefficacious. It has been recommended by some authors to apply leeches to the throat, more or less, according to the state of the sys- tem or activity of the disease, in those cases, where, for the reasons assigned above, it might not be considered safe to bleed from the arm; or where, bleeding having been already performed, it might not be justifiable to repeat it; but there is one great objection to the use of leeches in this situation, namely, that it is apt to be followed by the effusion of serum into the subjacent cellular tissue, the occurrence of which, in that situation, is one of the dangers to be apprehended in this disease. Cupping at the back of the neck, as recommended by Dr. Watson, is certainly a preferable expedient. Although blood-letting, Avhether general or topical, is not to be neglected in this disease, Avhen it can be performed with safety, we are not to overlook other remedies which we possess as efficacious, and perhaps less dangerous. Amongst these, as applicable at the very nearly stages of the disease, must be mentioned an efficient emetic; indeed, a moderately-full dose of antimony and ipecacuanha in the form already recommended (p. 140) will sometimes arrest at the outset attacks of a very threatening character. Our attention should next be turned to fulfilling those indications presented by the nature and symptoms of the disease, and these are to reduce the action of the heart and large vessels, to reduce, too, the increased action of the capillaries of the part and determination of blood to them, and to allay the excessive nervous excitement of the part. These three indications are admirably fulfilled by the combination of antimony, calomel, and opium, already recommended in speaking of 10 146 ACUTE LARYNGITIS. the treatment of inflammation. It should be observed, however, that as it is in the highest degree desirable to make an early impression upon the heart, and to maintain it, the antimony may be given in somewhat larger doses than there recommended, whereas the ten- dency of calomel to set up inflammation about the fauces, and to induce ulceration of the larynx itself, suggests the prudence of a more limited use of that remedy; for the opium again there is a special indication in the restlessness and anxiety of the patient, as well as the frequent paroxysms of spasmodic constriction of the larynx, and it may accordingly be more freely used, provided there be not much lividity arising from the impeded aeration of the blood, as it ought always to be remembered in this, as well as in several other diseases, that Avhere this is the case, there is a diminished tolerance of opium. The best plan generally will be to give every three hours a pill com- posed according to (F. 3, p. 103); in the interval to administer a draught, containing from half a drachm to a drachm of antimonial wine, with or without a feAV drops of tincture of opium, and the addi- tion, if necessary, of a little sulphate of magnesia: the antimony in the pills, or in the draughts, should also be gradually increased, until it produce a decided tendency to nausea. The early application of blisters, which is objectionable in all inflammatory diseases, is in this case especially so, from the danger of producing infiltration of serum into the subjacent areolar tissue; indeed it is more than doubtful if they ought to be applied to the throat at any period of acute laryn- gitis, though when the more active symptoms have subsided, a blister may be put upon the back of the neck. Flannel well wrung out in water so hot as almost to produce vesication, and applied to the throat when the paroxysms of dyspnoea are most urgent, often affords very marked relief. In the treatment of acute laryngitis, it is indis- pensable that the temperature of the apartment should be kept uni- formly at a moderately high standard; 65b of Fahrenheit is about the best, and from this it should never, if possible, deviate by more than one or two degrees; and perhaps it ought never to fall below it. By a steady perseverance in these means we may often succeed in carrying the patient safely through this most dangerous disease, which not uncommonly recedes just as the signs of the action of mercury upon the system are beginning to show themselves; but it must be admitted that the chances of doing so, where the inflamma- tion has been fully established, are less than the chances against us; and when the disease is in its latter stages but little can be effected by medicine. Under these circumstances, it has been proposed, and the operation has sometimes succeeded, to perform tracheotomy. But though the operation has succeeded, it has often failed, the inflamma- tion extending down the trachea; still the question as to its expedi- ency in any particular instance is not to be lost sight of. In simple acute laryngitis, the disease is situated, as already de- scribed, in the neighbourhood of the glottis and chordae vocales; and, consequently, when it is threatening to be fatal by suffocation, it is here that the obstruction to the admission of air to the lungs takes place, and therefore if an opening be made below it in the CHRONIC LARYNGITIS. 147 trachea, air may pass into the lungs, and thus, the immediate cause of death being obviated, time is gained for combating the primary disease. It is, however, necessary to ascertain that the obstruction is limited to the above situation, and therefore, before deciding upon the operation, the greatest care must be used to ascertain that the disease is not simulated by any of those which have been mentioned as liable to be confounded with it, and also that it is not complicated with inflammation of the trachea, in which case the operation would be productive rather of harm than benefit; or with such mischief in the lungs as would render it useless. It may, however, be stated in recapitulation, that when the disease, upon most cautious examina- tion, is found to be really laryngitis, and further that it is solely laryngitis, so far as to be free from any complication which would either add to the danger of tracheotomy, or render the operation futile, and if it seems to gain ground in defiance of the steady use of the means Avhich have been recommended, the operation may be per- formed with a justifying chance of success. Sound discretion is also required in deciding when it is to be per- formed, for intractable as this disease often is, it is not so certainly so as to justify so formidable an operation before the trial of every treatment, but if it have resisted such treatment, and shows no sign of subsidence after about forty-eight houite, the operation may be performed without waiting for the signs of impending suffocation; but should such signs appear before then, of course it ought to be done without delay; and it may be added, that under such, the operation ought not to be abandoned because it appears too late, since cases have occurred, both of what may be termed spontaneous laryngitis, and also of those supervening upon swallowing hot water, or other local irritation, in which the pulse had ceased at the wrist, and the countenance become perfectly livid, where the pulse has returned, and the lividity vanished, when air was admitted through the opening made by the surgeon in the trachea. The inflammation of the larynx, which is excited by the attempt to swalloAV boiling water, not an uncommon occurrence amongst children, as it is intense, and apt to prove fatal very speedily, is a case in which tracheotomy is generally expedient; as it often is also in that form of the disease which occurs in the course of erysipelas, and other eruptive fevers, where the active antiphlogistic measures required to subdue the inflammation cannot be tolerated in the weakened state of the system. (Edema of the glottis, which is to be distinguished from acute laryngitis, by the absence of the signs of active inflammation, and is characterized by a loud hissing respiration, happens, and that not very rarely, as a secondary consequence of other and sometimes remote affections. Thus it may take place from tumors pressing upon the large veins in the neck, as in aneurism of the thoracic aorta; and again in dropsy, arising from disease of the kidneys, it sometimes occurs very suddenly, and is one of the recognized modes in which that disease proves fatal. In such cases also we can have 148 PROGNOSIS — TREATMENT. little hope from any other measure than tracheotomy, though this of course can only save life for a time. The larynx is also liable to chronic inflammation, which renders the membrane injected, thickened, corrugated, and ultimately ulcer- ated ; the perichondrium of the cartilages becoming also implicated, and leading to necrosis of the cartilages themselves. The same thing also happens to the epiglottis, which is occasionally partly destroyed, and thus rendered inadequate to the closure of the rima. The lining membrane of the sacculi laryngis also becomes inflamed and ulcer- ated. This chronic form of the disease, Avhich is more certainly, though less speedily fatal, than the acute, sometimes supervenes upon it. It also arises from syphilis, from the abuse of mercury, and sometimes from a common sore throat induced by the ordinary causes, occurring in a patient whose constitution has been much im- paired by the above or other causes. The chief symptoms are first of all hoarseness, subsequently loss of voice (the patient speaking in a whisper), owing to the injury of the parts about the larynx, wherein the voice, as distinguished from a whisper, is formed. There is also a ringing cough, with generally a copious puriform expectoration, and considerable emaciation; this frequently continues to increase, hectic supervenes, and the patient dies with all the symptoms of phthisis pulmonalis, constituting what in fact is frequently spoken of as phthisis laryngea. This last form of the disease, however, is rarely an uncomplicated or even primary one; the primary affection being generally in the lungs, and the laryngeal one is little more than a complication, or rather consequence, though often a very distressing one, of disease in those organs. AVhen the chronic laryngitis, as a primary affection, proceeds to a fatal termination, there is increasing dyspnoea, total loss of laryngeal sounds, and ultimately of the power of articulation even in a Avhisper, difficulty of swallowing, the attempt at which often threatens to induce suffocation, owing to the continually open state of the glottis, and the patient dies, either suffocated from the closure of the rima or of the larynx, by the thickened membrane, or exhausted by the protracted ulceration and the difficulty of swalloAvino-. The only morbid appearances necessarily present in such cases, are the thickening and ulceration of the lining membrane of the larynx, and the ossification and necrosis of the cartilages already described. The prognosis in this disease is, as has been already stated, unfa- vourable; when indeed it is merely a consequence of the acute disease, there is a reasonable hope of effecting a cure. When, how- ever, it occurs in a previously broken constitution, especially one which has been impaired by syphilis or mercury, or, which is equally common, by both combined, and ulceration of the cartilages has taken place, little can be hoped for beyond palliation; and in those cases which are merely complications of phthisis, the prospect is altogether desperate. The treatment as well as the prognosis of chronic laryngitis must be guided mainly by the nature of the exciting cause; in those cases which are the consequence of the acute disease, gentle antiphlogistic CHRONIC LARYNGITIS. 149 measures will still, no doubt, be occasionally required, but these must, both in kind and in degree, be such as are not likely to lower the strength of the patient. A few leeches may sometimes be applied to the throat, and blistering is not so objectionable here as in the acute disease, but it is far better to apply it to the back of the neck. Hot fomentations, however, and poultices are generally to be pre- ferred as external applications, unless there be signs of fresh excite- ment indicating a return of acute or sub-acute inflammation. A mild mercurial alterative (20*) will be of service for a short time, provided its action be carefully watched, and it be Avithdrawn as soon as the least effect is produced upon the gums. A soothing anodyne mix- ture (21f) should also be employed at the same time. A useful remedy in the treatment of chronic laryngitis, is the application of a strong solution of nitrate of silver to the glottis, in the mode Avhich has not inaptly been termed swabbing by Mr. Vance, who introduced it.:}: This is performed by passing a piece of sponge saturated with a strong solution of nitrate of silver down the throat (if no violent spasmodic action be excited), and pressing it against the upper surface of the larynx. In what may be termed the cachectic form of chronic laryngitis, our chief reliance must be placed upon restoring the strength of the constitution; and perhaps the best means for this end will be country air, or the sea-side, in a tolerably sheltered situation; and the bene- ficial effect of these may be aided by the iodide of potassium, with sarsaparilla or cinchona, or mineral acids with one of the latter: the action of the skin also, which is of great importance, may be improved by an occasional warm bath. When there is increasing dyspnoea, and threatened suffocation from the thickening of the lining membrane, the operation of trache- otomy affords the only prospect of prolonging life, though but for a short time. Still, the present relief, and addition of a few days, or it , may be a few weeks, or even months, to life are not to be disregarded. * (20) R. Pil. Hydr. Chlor. co. gr. iv. Pulv. Ipecac, gr. v. Ft. Pil.; to be taken at bed time f (21) R. Pot. Nitrat. £ ij. Tinct. Camph. co. 5 ss. Oxymel simplicis, 3 iiss. Aq. purse, ^ iij. Misce. A large spoonful to be taken four times a day. J Watson's Lectures. The strength of the solution may be five grains to a drachm. 150 CROUP — PREMONITORY SYMPTOMS. CROUP. Nearly related to laryngitis, is the croup, cynanche trachealis, or tracheitis. This disease is to children much what the former is to adults, though it differs from it in many important respects. Like laryngitis, it is sudden in its attacks, and often speedily fatal; like it, too, it produces death by opposing the passage of the air to the bron- chi, but it differs from it in producing this obstruction not by swelling of the lining membrane, but by the effusion of a plastic deposit upon it; it also differs in its seat, as it occurs in the trachea, and, which renders it doubly formidable, it is very apt to extend down into the bronchi. It is, too, a disease of children, occurring almost exclu- sively between the periods of weaning and puberty, whereas laryn- gitis, though it may occasionally happen to children, is almost entirely a disease of adults. The croup consists essentially in intense inflammation of the mucous lining of the trachea, leading, if unchecked, to the effusion of a layer of solid albuminous matter, which obstructs the trachea, and causes death by suffocation. The course of the disease has been variously divided by authors into steps or stages. It is, however, important for practical purposes to recognise three only, viz., the premonitory stage, the stage of con- firmed inflammation, and the stage of impending suffocation. The premonitory stage, though generally present, may sometimes be so slightly marked as to escape observation; or at others it is very transient, being only of a few hours' duration, but in most cases it occupies a period of nearly two days. The child is commonly attacked with the ordinary symptoms of common catarrh, with per- haps a greater degree of febrile disturbance than attends the latter disease; thus we have chills, followed by heat of skin, lassitude, loss of appetite, a rather flushed countenance, and increased hardness of pulse, with headache, sneezing, coryza; and, in addition to these, a short cough and a hoarseness, which, even at this period of the dis- ease, gives to the voice a peculiarly harsh and metallic character. This latter symptom is, however, often wanting, and as to the rest, they at times present no distinctive characters by which the croup can at this period be distinguished from a common catarrh. In very young children the only premonitory symptoms may be restlessness, flushing of heat on the surface, a short, frequent cough, sleeplessness at night, and uneasiness about the throat, manifested by the frequent application of the hand to the part. We have seen that there are no very decided signs, certainly no distinctly diagnostic ones, by which the premonitory stage of croup may be recognised; at the same time, we may generally be enabled, by the aggregate of the symptoms, to suspect its approach, and take measures for its prevention; and it may be well to bear in mind that in young children catarrh seldom causes hoarseness, and therefore, that where the latter is superadded to catarrhal symptoms, in the SYMPTOMS. 151 absence of any difficulty of swallowing, or distinct tumefaction about the throat, we should never omit to warn the parents or friends of what may be apprehended, and this the more, if it occur in a child who has evinced a tendency to the disease, or even in a family, or a district, in which it is prevalent. It generally happens, however, that medical aid is not obtained until the disease is nearly fully developed; when we have hoarseness, if it have not been present before; or the previously existing hoarse- ness has assumed a peculiar thrill, or cracked sound, or the voice dis- appears altogether; this last, however, would indicate that the disease has extended to the larynx. The characteristic cough of croup now begins to be heard; this cough is perhaps most aptly described by the expression "tussis clangosa" of Cullen; it has been compared to the barking of a puppy, or coughing through a brass tube; it is not, however, very readily described, though it may be easily recognised by any one who has heard it. The inspirations following the cough are slow and hissing, or accompanied by a crowing sound. The respiration between the fits of coughing is much obstructed, and each inspiration is attended Avith the hissing or crowing sound just noticed; the expiration is quick, but less difficult than the inspira- tion; the head is thrown back, and, at each act of inspiration, the pomum Adami is forcibly drawn down towards the sternum; the countenance is congested and turgid, and sometimes bedewed with perspiration; the skin is hot, the pulse sharp, and the tongue white; there is little or no expectoration. The boAvels are constipated, and the urine scanty. The above symptoms generally come on towards evening: often when the patient has been affected during the previous day with the signs of the premonitory stage, he is attacked by them in the night on waking from sleep; they often subside towards morn- ing, and the remission continues through the day, but towards evening, or again upon awaking from sleep, they return with greater severity than ever; the dyspnoea is aggravated, and the croupy cough and breathing more marked;—the countenance congested, the cheeks more livid, and the eyes more turgid—the pulse, which continues sharp, becomes very frequent, small, and contracted;—the voice becomes feebler, and more whispering;—the cough, up to this time dry, or attended with scanty mucous or sanguineous expectoration, becomes husky, with frequent efforts to expel what is felt to be in the trachea; if, however, vomiting follow, and especially if it give rise to the excretion of albuminous or membranous matter, a con- siderable relief is often obtained; this relief may, indeed, be only momentary, but sometimes it is the commencement of a gradual sub- sidence of all the symptoms. The signs afforded by auscultation are, a louder sound over the trachea; diminished respiratory murmur over the chest, but good resonance on percussion. When, however, the disease has extended down the bronchi, there is, in addition to the above, bronchial or tubular respiration. The above symptoms are rarely continued, but present remissions, as above stated; if, however, the disease do not subside, or is unchecked by remedies, these remissions become less and less; and 152 CROUP. their disappearing altogether may be said to characterize the stage of impending suffocation, which is also marked by increased frequency and difficulty of respiration, and failure of the moving poAvers of the circulation—the voice and articulation becoming nearly lost, the laborious action of the muscles of respiration, and expansion of the alse nasi more marked, and the pulse feeble, irregular, and even inter- mittent. The eyes are now sunk and glassy; the head thrown back; the countenance dusky; the skin cold, and bedewed with a clammy perspiration; the tongue loaded and congested; the tips of the fingers livid; the veins deeply marked, and those about the neck distended. It may happen that, even in this apparently hopeless stage of the disease, a copious expectoration takes place, in which some mem- branous matter is excreted, and the breathing is relieved, and the other urgent symptoms subside; it more commonly happens, how- ever, either that the child sinks exhausted, or is suffocated in a violent paroxysm of dyspnoea; or it may be that he is carried off by convulsions arising from the congestion of the brain. The most remarkable, and indeed the essential morbid appear- ance upon dissection after death, is an albuminous or fibro-albuminous layer, which occurs either in separate patches, or, in the best marked cases, as an uniform membrane lining the whole of the trachea, and sometimes extending far down the bronchial tubes: this membranous layer must not, however, be confounded with the layers of plastic lymph, which occur upon the surfaces of inflamed serous membranes, since it is incapable of organization, and may be readily detached from the surface on which it is poured out. Such are the symptoms and progress of the disease, in what may be termed its most acute and perfect form; in such cases the patho- logy may be readily understood. Croup in this form is, as was stated at the commencement, essentially an intense inflammation of the trachea. This inflammation, like others, is at the commencement attended with congestion and consequent turgescence of the part, and diminution of its secretions; during this condition we have the beginning of the dyspnoea, the harsh, husky voice, and dry cough; or the larynx is often more or less involved in the inflammation, and when this is not the case, it is apt to be spasmodically affected by the irritation existing in the trachea. This congestion may be for a time relieved by the occasional increase in the secretion of the part; and with it the dyspnoea will be relieved also; as the disease proceeds, however, the peculiar effusion of the inflammation begins to' show itself; this, in the present instance, where the inflammation is intense, and involving the submucous areolar tissue, contains a considerable portion of fibrine, which gives it a filamentous or membranous appearance, and this prevails to so great an extent as to line the trachea with a continuous layer. Now the effect of the presence of this membranous matter in the trachea, must be much the same as that of a foreign body (which indeed it is) in the same situation; and hence the frequent paroxysmal and suffocating efforts to clear the tube of what is felt to be lodged there; these efforts being always attended by spasmodic contractions of the muscles of the larynx. VARIETIES. 153 The effects of this mechanical obstruction of the trachea, and frequent spasmodic closure of the glottis, are too obvious to require to be minutely detailed. They may be summed up as, imperfect aeration of the blood, and engorgement of the lungs, of the right side of the heart, of the portal system, and of those organs Avhich return their blood by the ascending cava,—hence the lividity, the dark stools, and scanty urine—also venous engorgement of those parts which return their blood by the descending cava—hence the livid counte- nance, the venous congestion of the brain, particularly at the base and medulla oblongata, and occasional occurrence of convulsions towards the close of the disease,—death by apncea. As the true croup sometimes makes its attack very suddenly, and gives rise to membranous effusion very quickly, it may prove fatal in the course of twenty-four hours; the most common time, however, for a fatal termination, is on the fourth day. It varies also in other cases from two or three to eight or even nine days, the inflammation not subsiding immediately after the expulsion of the membranous effusion; sometimes, too, it exists in a less active state, and, according to some authors, gives rise to ulceration; from this chronic form the patient may recover by judicious management, though he often sinks after a period of some weeks. In the explanation of the various modifications of croup, it is necessary to keep in mind the nervous sympathy which exists between the trachea and the larynx, the exquisite sensibility of these parts, and also the abundant supply of nervous influence to the larynx, and its consequent liability to spasmodic excitement. This spasm may be excited not only when the larynx itself is the seat of inflammation or irritation, but when those parts with which it is connected by the reflex nervous action, are so affected; and also when any cause of irritation exists, either at the extremities, or along the course, of the incident or reflected nerves, or at the convergence of both in the nervous centre. These facts, duly considered, may do much towards removing the confusion that has arisen between the acute and severe croup of which we have just been treating, and other diseases which, in respect at least to some of the most obvious symptoms, are very nearly allied to it. In the disease which has just been described, there exists a double cause of spasmodic action of the parts about the larynx,—1st, the in- flammation in the trachea; and, 2ndly, the membranous effusion which is the product of that inflammation, which acts as a foreign body, both opposing the access of air to the lungs and exciting efforts for its own dislodgment, which efforts are attended by strong spasm of the muscles about the larynx, and are from that circumstance often inef- fectual. , We should, however, expect a priori that there would some- times occur inflammation of the lining membrane of the trachea, not proceeding to the membranous effusion, but exciting considerable spasm about the glottis and neighbouring parts, resembling what occurs in the earlier stages of croup; and also, that there would occur such spasm, arising from some cause of irritation—other than inflam- mation at the extremities either of the incident or reflected nerves— 154 CROUP. existing elsewhere along the course of those nerves, or in the nervous centre from which they proceed. Accordingly, we do meet with a form of disease in which there are the inflammation of the trachea and the spasm, but without the mem- branous effusion; this is the mucous [or catarrhal] croup of some authors, though others have confounded it with the .true spasmodic croup, " laryngismus stridulus," or child-crowing of Dr. Gooch, which is essentially a non-inflammatory disease, being the result, in its purest form, not of disease of the larynx or trachea, but of irritation either in the brain or medulla oblongata, or along the course of the nerves supplying the former parts. The mucous croup commonly affects very young children, that is, those who have been lately weaned, and is most frequently observed in those of apparently a leucophlegmatic temperament; its attack is rapid and seA^ere, but not so sudden and violent as is that of the true croup; it is preceded by coryza and other symptoms of catarrh, but with little fever, and generally comes on in the evening, or in the night, with the invasion of a shrill, ringing cough, and sibilant and very hurried respiration; there does not appear to be much redness of the fauces, and the inflammation does not at the commencement extend down the bronchial tubes; these attacks generally recur on the following evening or night, but after the first or second day the cough is attended by a mucous rattle, and the fits terminate more speedily in the expectoration of a glairy mucus. The disease gene- rally terminates in bronchitis. This form has been by some authors regarded as a bastard or spurious croup, but it is with much more justice considered as a milder form of inflammation by Dr. Copland and others. It is, in truth, an inflammation of the trachea, occurring in children in whom the nervous system is highly irritable, which cir- cumstance, combined with the natural irritability of the parts affected, accounts for the disproportionate excess of nervous excitement. In the true spasmodic croup, or child-crowing, we have no inflam- mation, and the spasm is to be explained upon the principle of con- vulsive action of a particular part, being frequently excited, not only by irritation—at the extremities of the nerves supplying that part— of which inflammation of the part itself is one instance—or in the course or at the origin of those nerves, as in the cases of morbid growths on the skull or vertebras—or disease in the nervous centres themselves; but also—when it is seated at the extremities, or in the course of nerves supplying parts whose action is associated with that of the part in question by a reflex action; as when the diaphragm and other muscles of respiration are excited by irritation of the nares, or the former muscle thrown into spasmodic contractions by irrita- tion of the extremities of the pneumogastric nerve, in the case of hic- cough, where the offending cause is in the stomach: but further than this, we know from experience, that in irritable subjects, and in cer- tain morbid conditions of the system, convulsive or spasmodic move- ments may be excited in different parts of the system, by irritation propagated to the nervous centres from the parts where the irritation is set up, but thence reflected to parts not associated with the latter CROUP. 155 by any normal reflex functions, as in the convulsions of children from teething or gastric irritation, and in tetanus. Hence we have ample ground for the explanation of the phenomena of the "child-croAving," "laryngismus stridulus," or "spasmodic croup." The crowing respi- ration and its accompanying dyspnoea, which are the most obvious phenomena of this disease, occur in paroxysms between which there are intervals of tranquil respiration. The best description of this affection is that given by Dr. Ley. " When the closure of the chink of the glottis is not perfect (says he), the child struggles for breath, the respiration is hurried, the countenance generally bluish or livid, the eyes staring, and each inspiration is attended with a crowing noise. When the closure is more complete, the function of respiration is entirely suspended for a while; there is an effectual obstacle to the admission of air. The child makes vehement struggles, by some termed convulsive, to recover its breath. At varied intervals, from a few seconds up to a minute, or upon some occasions nearly two minutes, air is at length admitted through the glottis, now partially open, and this rush of air passing through a very narroAV chink, pro- duces the peculiar sound. To these symptoms not unfrequently succeeds a fit of coughing or crying, which terminates the scene; or if the glottis be not thus partially open, the child at the end of from tAvo to three minutes at the utmost will be suffocated. Pallid and exhausted, it falls lifeless upon its nurse's arms, and it is then that the child is generally said to have died in a fit." It very often hap- pens that the above symptoms are attended by convulsion of the extremities, especially of that form often associated with gastric irri- tation in children, namely, the contraction of the muscles of the wrist, thumb, and fingers, and of the ankles and toes, the thumb being strongly contracted upon the palm, and the foot so distorted as to have almost the appearance of club-foot. The distinctive characteristics of this disease are the occurrence of the above symptoms, with the absence of fever and the perfect tran- quillity of the respiration between the paroxysms. The explanation of these phenomena need not detain us long as it is included in what has already been said of reflex nervous irritation, and, indeed, all the most satisfactory, which have been given, resolve themselves into this. That of Dr. Ley, for instance, wherein the temporary closure of the glottis is accounted for by pressure upon the recurrent, or some branch of the pneumogastric nerve, from enlarged glands in the neck, or within the chest, is but a particular instance of the general fact of pressure or irritation in the course of the eighth or fifth pair of nerves, inducing spasm of the glottis; the same Avould apply to its being excited by offending matters in the stomach, or by the irrita- tion of teething; and its arising from disease within the cranium, is but an instance of the cause of irritation existing at or near the origin of either of the same nerves. The presence, however, of enlarged glands in the neck may assist us much in the diagnosis of cases of this description, since not only may it be in itself the cause of dis- ease, but shows the probability of" strumous disease either in the glands of the chest or abdomen, or within the brain itself; it also 156 CROUP. indicates that state of nervous atony, in which irritation so produced upon these nerves would be most likely to excite the spasm of which we are speaking. The last mentioned variety of croup does not strictly belong to in- flammations of the larynx or trachea; neither is it for the most part a disease of those parts at all: we have, however, spoken of it in this place from its liability to be confounded with the true croup, and in order the better to consider the diagnosis of these affections. If it be borne in mind that croup is essentially an inflammation of the trachea, and that consequently the obstruction which it excites is to the breathing, and not to the deglutition, we shall have no great difficulty in distinguishing it from the cynanche tonsillaris, the cy- nanche maligna, and the cynanche pharyngea; not to mention that the latter diseases may be recognized at once by an inspection of the throat, unless indeed, they are of sufficient severity to prevent the opening of the mouth, which would of itself be a sufficient sign of the existence of one of these rather than croup. The eruptive fevers (more particularly measles), and whooping-cough, sometimes commence with a degree of inflammation about the trachea, which excites a spasmodic cough, and is attended with a husky voice, not unlike that of croup, especially of the mucous kind; in the case of the measles, the Avatery eye, the coryza, and the sneezing, soon point out the true nature of the case; in whooping-cough the distinction is not at first so easily made, but the diagnosis is of no great importance, since the tracheal inflammation which really does exist, will require to be treated according to its severity; and when the latter disease is really established, the character of the cough, so unlike that of croup, will at once mark the difference. The diagnosis from laryngitis is, per- haps, not easily made with certainty, though it is fortunately one of no great practical importance, since the treatment would be nearly the same in either case. It will assist us, however to remember that laryngitis is mostly a disease of adult life, whereas croup is one affecting almost exclusively infants and children. The fixed burning pain of laryngitis, Avhich is always referred to the situation of the pomum Adami, will also assist us at the commencement of the latter disease; and its further progress, unlike that of croup, leading to ulceration and suppuration, and scarcely ever to the effusion of false membrane, will enable us to recognise it in its more advanced stages. The chronic affections of the larynx and glottis, though they some- times produce the croupy cough, voice, and respiration, may never- theless be distinguished by their slower progress, and by their rare occurrence amongst children. (Edema of the glottis may indeed suddenly occur even amongst them, when there exists disease of the kidney with a tendency to dropsy; but the presence of this latter disease ought at once to suggest the true nature of the affection. It is of the first importance not to mistake the earlier symptoms of croup for those of ordinary catarrh, but of this we have already spoken in describing the invasion of the former. Croup may super- vene upon bronchitis, when its presence may be detected by its cha- racteristic symptoms presenting themselves in addition to those of DIAGNOSIS. 157 the latter disease; but there can be very little danger of mistaking between the two, as we shall perceive when we come to treat of bronchitis. Symptoms not unlike those of croup may be induced by the presence of foreign bodies in the larynx or trachea, the sudden- ness of the pain and suffocation, the change in the situation of the latter, the dryness of the cough, the violence and irregularity of strangulation, as well as the history of the case, will generally lead to the discovery of its true cause. The greatest practical difficulty in the diagnosis of croup used to be, that between the different forms of the disease, especially that betAveen the plastic croup and the child-crowing. The more correct knoAvledge of the latter disease which we now possess, and the recol- lection of its characteristic symptoms as already described, will now remove all serious difficulty. It may, in fact, be distinguished from the true croup by the age of the patient, generally from nine to fifteen months, but never, according to Dr. Clarke, beyond the ex- piration of the third year of the child's life—Avhereas the true croup is the most common after that age;—by the history of the case, and condition of the patient, generally presenting some cause of nervous irritation, as teething, gastric irritation, enlarged glands in the neck, a strumous diathesis, or a large or ill-formed head;—by the sudden- ness of the attack, and by its sudden departure;—and by the ab- sence of fever, cough, and dyspnoea in the intervals between the paroxysms. The difference between the first and second varieties of croup is one rather of degree than of kind—the fever in the latter is slight; it generally, too, attacks younger children than does the membranous croup, especially those who have lately been weaned. It should be remembered, however, that those children who have suffered from the true croup in early life are very liable to have such symptoms recur when they become the subject of a slight catarrh; but it is equally true that such symptoms may run on to an attack of the real croup, and therefore require watching, and, if necessary, prompt but not violent treatment. As to the circumstances AA'hich conduce to a liability to true croup, it is pretty generally agreed that the greatest tendency to it exists in cold and damp situations, and particularly such as are liable to rapid changes of temperature; those seasons of the year in Avhich such Aveather may be expected are also those in which, in this climate, it most frequently happens, viz., from November to April. There is, how- ever, more difference as regards the character of constitution of the individual which is most liable to it, whence we may infer that but little is certainly known respecting it. Some consider that florid and irritable children are most liable to it; thus Dr. Copland says, " the nervous and sanguine temperaments, or a mixture of them—the spas- modic characters predominating in the former, the inflammatory in the latter—with a tendency to a fulness of habit, seem to predispose to croup." It should, hoAvever, be recollected that there is not neces- sarily a greater tendency to inflammation in those inclined to plethora than in others; although those of a nervous temperament are un- i' 158 croup. doubtedly more liable to nervine affections. It is certain, too, that in some families there exists a peculiar proneness to the disease, and that in certain seasons it prevails almost epidemically, though there is no ground for believing that it is ever contagious. Those children who have once suffered from croup have a greater tendency to the disease than others, in addition to the liability to croupy symptoms upon the occurrence of trifling irritation. The mucous form of croup is influenced by the same external cir- cumstances as the more severe form of the disease; it more com- monly, however, attacks children of a leuco-phlegmatic temperament, and languid circulation. The external circumstances which seem the most to favour the attacks of the child-crowing or true spasmodic croup, are damp and low situations, the want of pure air, of light, and of wholesome diet; whatever, in fact, interferes with healthy nutrition, and the perfect elaboration of the blood, the disease being, in truth, one that particularly affects scrofulous children. It is by no means improbable that exposure to cold and damp, or to any of the causes which in stronger children induce the ordinary croup, may bring on an attack of child-crowing in those in Avhom, owing to a state of constitution of the character just described, there exists a pre- disposition to it; but the common exciting causes of the disease are those mentioned in the description of it, namely, irritation existing either at or near the base of the brain, or along the course, or at the extremities of the fifth or eighth nerves. As croup is at ah times a very dangerous disease, the general prog- nosis must be unfavourable, or at the best extremely doubtful; though in a child of good constitution, and in the early stages, we have a fair chance of success from a well-directed and persevering plan of treat- ment. The danger, however, is always very great, when from a sibilant respiration over the larger bronchial tubes, we have reason to believe that the inflammation has extended to them. AVe must also be exceedingly cautious in pronouncing our little patient out of danger, for as long as there exists any false membrane in the trachea, or even that excessive sensibility and irritability of the part which are the consequences of this inflammation, there is a possibility of obstruction, or of spasm of the glottis. The expulsion of a mem- branous substance, if followed by a warm healthy perspiration, and relief to the respiration, is at all times a favourable symptom; whereas, the increased length of the paroxysms of dyspnoea, with diminution of the interval between them, the failing pulse, lividity of counten- ance, and clammy perspiration, with the other symptoms already mentioned as indicative of the last stage of the disease, can be re- garded in no other light than as signs of the greatest danger, if not of impending death. The mucous croup, as long as it continues such, is not a disease of much danger; but even here our prognosis must be very guarded, as it may speedily pass into the severer form of the disease, and it is upon its tendency to do so that its danger depends. The child-croAving, though merely a spasmodic disease, is not upon that account to be regarded as free from danger, for not only may death, as Ave have seen, take place by suffocation during the paroxysm, TREATMENT. 159 but the long suspension of the respiration may give rise to conges- tion, leading to serious disease in the brain, lungs, or heart. The first object in the treatment of croup should be to check the inflammation, and thus, if possible, arrest the disease, and prevent the formation of the inflammatory product, constituting the false mem- brane, or albuminous deposit obstructing the air-passages. If, how- ever, we are too late, or unable to effect this, we must endeavour to induce the removal of these inflammatory products; and thirdly, we must endeavour to allay the nervous irritability upon which the spasm attends. The most effective means at the commencement of the disease for fulfilling the first of these indications, is an emetic sufficient to pro- duce full vomiting; for this purpose the tartar emetic is to be pre- ferred to ipecacuanha, though, perhaps, it may be better to use a combination of both: thus from a quarter of a grain to a half a grain of the former, with from three to tAvelve or fifteen of the latter, ac- cording to the age of the child, will generally produce full vomiting, the consequence of which will often be the expulsion of thick glairy mucus, and in some cases of shreds of false membrane, followed by free diaphoresis, and great relief to the respiration. The relief fol- loAving the exhibition of the emetic is sometimes so great as to lead to the belief that the affection has been entirely spasmodic; but the effect of an emetic, even at an advanced period of the disease, is some- times so striking as to leave no doubt of its efficiency in cases un- questionably inflammatory. It is only in the commencement, and Avhen it is somewhat doubtful AA'hether the attack will prove one of the more severe membranous form of the disease, or of the second and milder one, that an emetic should be trusted to as the primary remedy, and before bleeding has been performed either locally or generally. When, however, the patient is seen thus early we may have recourse to it in the first instance with a fair chance of success. It should be observed, moreover, that there is generally a great tolerance of emetics, and that much difficulty is often experienced in effecting vomiting; and when this is the case, it will be well to repeat the emetic, though in a smaller dose, perhaps half that administered in the first instance, at the end of an hour's time. The vomiting, Avhen it has been obtained, will commonly be followed by free action of the bowels. When, however, this does not take place, measures should be taken to ensure it, as most marked relief often follows free purgation; a very good practice will often be to keep up a slight degree of nausea, and moderate action of the bowels by a combina- tion of tartar emetic and sulphate of magnesia; after the disease has yielded to these measures, slighter spasms will frequently occur, and these will be best met by the application of flannel cloths wrung out in hot water, so hot as to produce great redness, or even a slight degree of vesication. When, however, as most commonly happens, the patient is not visited for many hours after the attack, and there are reasons from the symptoms to believe that the second stage, that, namely, of mem- branous effusion, has already commenced, or is upon the point of 160 CROUP. doing so, we must not delay to abstract blood in such quantities as the degree of fever, the sharpness of the pulse, and the age and con- stitution of the patient seem to call for or to justify. In children above the age of four, or sometimes even younger, we may often practice venesection with tolerable ease and success, sometimes by opening a vein in the back of the hand, and where this mode of ab- stracting blood is practicable it is to be preferred at this stage of the disease in its severer forms, as the effect produced upon the system is more speedy and more certain, and the quantity of blood drawn can be more accurately estimated; for a child of three years four ounces will be a pretty full bleeding, and an ounce may be added for every additional year. In older children, or where it is not practica- ble to open a vein, cupping betAveen the shoulders may be practised with advantage, the same rule as to the quantity of blood taken being observed as in venesection. In speaking, however, of these rules, we ought to premise that they are only approximations or averages, and that much must be determined by the fever, and appa- rent strength of the individual child. In infants and very young children, where we are obliged to have recourse to leeches, Ave may observe nearly the same rule; thus Dr. AAratson recommends "the application of a couple of leeches to an infant in its first year, and an additional leech may be employed for every additional year." These leeches should also be applied over the first bone of the sternum (not above it, and along the course of the trachea, as is recommended in some works); since independently of the objection stated in speaking of the use of leeches in laryngitis, we ought in no case to apply leeches in children where we should be unable to apply pressure to stop the bleeding Avhen necessary, in fact we ought not wantonly to neglect this precaution in patients of any age. After the bleeding as recommended above, we should, before re- peating it, have recourse to emetics and purgatives, which may be employed much in the manner already described Avhen speaking of their employment in the first instance, and here, as before, it will be expedient to administer a purgative, in the form perhaps of calomel and jalap, if the same effect have not been produced by the emetic. It will be afterwards desirable to keep up the nauseating and depres- sing effect of the antimony upon the s}rstem; as by so doing we diminish the force of the heart's action, and probably also the activity of the capillary circulation, and thereby, the supply of blood to those vessels Avhence the effusion of the membranous matter takes place; the best mode of affecting this is to administer the tartar emetic at moderately short intervals. About a quarter of a grain in a desert- spoonfull of water may be given every hour to a child of six years, and the frequency and quantity increased or diminished according to the effect produced both as regards the nausea, and the force and frequency of the pulse. The failure of the strength of the pulse will generally be attended with relief to the difficulty of bleeding, but if with the returning force of the former the latter return also, recourse must again be had to the antimony; the collapse induced by Avhich remedy is often so great as to threaten extinction of life, in which TREATMENT. 161 case a little brandy, or a feAV drops of sp. ammon. co. should be admi- nistered. About a grain of calomel may at the same time be given every three or four hours. It may be well to remark, hoAvever, that many of the best authors recommend the exhibition of this remedy in larger doses, and some the combination of it Avith the antimony in the form of poAvders, but the antimony appears to be the remedy, Avhich, of all others, has the most poAverful effect upon inflammations of the mucous membranes, and therefore it is better to administer it in the form which will be most readily and certainly taken: and this it Avill be in solution, since from being tasteless it may be given to a child of any age as a drink, Avithout his being aware that he is SAval- lowing medicine, whereas there is often much difficulty in the admi- nistration of powders, and the struggling which attends the forcing them doAvn is injurious. We would not, however, be understood as setting no value by the use of calomel, it probably diminishes the tendency to the effusion of the membranous matter, and perhaps, where it has taken place, it faA-ours its separation. It is therefore best to rely mainly upon the known beneficial effects of the tartar emetic, and at the same time, where it can be done, to administer the calomel as an auxilliary remedy. In older children, the Dover's poAvder, in doses of about a grain, or a grain and a half, may be combined with the calomel, and in younger, a little extract of conium, or of hyoscyamus may be given in the mixture, disguised with a little syrup, provided only it can be readily administered, as any excitement in swalloAving it Avould more than counteract the good effect of the anodyne. An admirable sedative, however, in the paroxysm of dyspnoea Avill be the use of the hot fomentations already recommended. Blisters are on every account objectionable. A most important adjuvant in the treatment of croup is the keeping the apartment at a steady temperature, about 65° Fahr.; the child should also be kept as quiet as possible, and Avhen he is sufficiently old or intelligent should be urged to refrain-from speaking. Av'hen the symptoms are those of impending suffocation, the pros- pect maybe inferred, from Avhat has been stated already, as nearly hopeless. Cases of this kind, have, however, sometimes, though rarely, recovered under the use of squills and ammonia, Avith conium or henbane, and a little wine ; but the symptoms are, most generally fatal. The question remains then, are Ave in such cases to endeavour to save the life of the patient by the operation of tracheotomy ? : not only theory but experience also is against the probability of success from such an operation, and Avere it not for its having succeeded in tAvo or three well authenticated cases, it might be pronounced an unjustifiable operation. It has, hoAvever, succeeded in this very small number of cases, but it has failed in numberless others. The reason of the very small success Avhich has attended this operation in croup, compared with that which has resulted from it in laryngitis, is not to be found in the greater difficulty of the operation in children than in adults (though that is not to be altogether disregarded), since it has been performed with safety and success in cases of inflammation of the larynx caused by boiling Avater or irritating fluids, and also with- 11 162 CROUP. out any serious result in cases of supposed membranous croiq> but upon the fact of the membranous effusion most commonly taking place in the trachea, and along the course of the bronchial tubes, reaching even to their finer ramifications. The only cases in which it can succeed are the very rare ones where the false membrane does not extend more than half an inch beloAV the cricoid cartilage ; and those in which there is little or no false membrane, but the impedi- ment to the breathing has arisen from thickening of the mucous membrane, and accumulation of viscid, reddish mucus, (which often occurs in the mucus form of croup) about the narrowest part of the trachea, AA'hich accumulation cannot perhaps in some cases be ex- pelled from the impossibility of getting air enough behind it to force it out. These are conditions the existence of which it is unfortu- nately next to impossible to ascertain. AArhere, however, mucous croup comes on very suddenly, characterized by the croupy voice and speedy threatening of suffocation, it is probable that the disease does not extend far doAvn the larynx, and the operation may be per- formed, the best excuse for which is that if it afford but a bad chance, it is almost the only chance. It may be well again briefly to recapitulate the chief points in the treatment of this formidable disease. At the commencement, in children who are not very robust, endeavour at once to arrest its progress by emetics of potassio-tartrate of antimony, followed by nauseating and depressing doses of the same medicine, and if neces- sary by a purgative. In more robust children in the country, and Avhen the disease is A'erging on the second stage, bleed and then adopt the same plan, adding the calomel, and if the disease continue to resist this mode of treatment, and the antimony appears to depress more than is consistent with safety, push the calomel. If all other remedies fail, and suffocation appear imminent, tracheotomy is admis- sible or rather justifiable, though only AA'hen there is no apparent hope from any other course, not that the operation is in itself a very dangerous one in skilful hands, but for the reasons assigned above, and also because in cases Avhere it is not called for by the imminent suffocation, the irritation of the trachea which must attend it, as well as the direct admission of cold air into that tube, cannot but aggra- vate the existing inflammation ; it is on this account essential, Avhen the operation is resorted to, that the temperature of the room should be raised to 80° or 85° Fahr., and the air kept tolerably moist by the presence of vessels of warm water, exposing a considerable surface for evaporation. The treatment of the spurious or spasmodic variety may be inferred from Avhat has been said of its cause; it will, however, be more fully understood when we have spoken of those diseases of which it is in reality but one of the symptoms; attention to the gums is the first consideration, and if they are swollen, or if there are any teeth nearly through, they should be freely lanced. The state of the alimentary canal should also be carefully investigated, and moderate doses of castor oil or of rhubarb and magnesia administered if there be reason to ap- prehend the presence of irritating matter, purging is, however, to be TREATMENT. 163 carefully abstained from. The cervical glands must next be attentively examined, and if enlargement be found Ave have not only detected a condition which may, of itself, be an exciting cause of the spasm, but Avhich also points to the probable existence of other causes in enlarged bronchial or mesenteric glands, as also to a strumous condition of the system, Avhich is one highly susceptible of this affection. Lastly, Ave must carefully examine the head, and inquire diligently into all cir- cumstances Avhich would indicate disease of the brain or of its mem- branes. We see, then, that the treatment of this disease involves not only that of dentition and gastric irritation, but also that of the strumous diathesis, and of the diseases of the viscera of the head, heart, and abdomen. During the paroxysm a warm bath will often prove serviceable, or what is still better, the application of a sponge from which hot Avater has first been squeezed, or of flannels wrung out in hot water. It may be well too here to suggest, in addition, the treatment applicable to the particular lesion which is supposed to be at the root of the mischief, that nervine tonics and anti-spasmodics are specially indi- cated, and for this purpose the sulphate of zinc with a feAV drops of tincture of valerian, or the valerianate of zinc, are particularly appro- priate. It may be Avell also to reiterate Avhat has before been observed, that a certain amount of inflammation about the larynx or trachea may be the cause of the spasm, and therefore that we are not hastily to discard all antiphlogistic remedies merely because the dis- ease does not present the unequivocal symptoms of membranous or even mucous croup. 104 CATARRH AND BRONCHITIS. XL CATARRH AND BRONCHITIS. The catarrh, common cold, or "cold in the head," is a disease so frequent in this country, that there can be very feAV, if any, Avho have escaped it altogether, and no great number Avho ever pass through a year, Avithout suffering an attack of greater or less severity. Any lengthened notice of it must, therefore, be superfluous, although the mention of it cannot be altc - ^ther omitted, since it is intimately con- nected with important disc* -, from Avhich it is not at all easy to distinguish it. Catarrh is essentially an inflammation of the Schneiderian mem- brane, and the mucous lining of the nares, extending thence upwards to that of the frontal sinuses, and through the lachrymal ducts to the conjunctiva; posteriorly to the posterior fauces, and along the Eustachian tubes; and doAvnwards to the trar-hea and large bronchi. It is commonly preceded by lassitude, and pains or aching in the back and limbs; not, indeed, often of sufficient severity to excite the apprehension of severe illness, but a general feeling of malaise. These are quickly folloAved by a sense of weight and tightness across the forehead, soreness or weakness in the eyes, stuffiness, or obstruc- tion in the nares, an uneasy feeling about the situation of the Eustachian tubes, and some soreness about the throat, and hoarse- ness or loss of voice, often with pain about the muscles of the neck; the tongue is also someAvhat furred; there is thirst, and increased sharpness and frequency of the pulse. As yet there is no coryza or increased secretion from any part of the inflamed mucous membrane; we have, in fact, the signs of engorgement or acti\7e congestion which constitutes the first stage of inflammation, and in which, as we have already observed, there is swelling, at the same time that the natural secretion of the part is generally arrested or diminished; hence we have the feeling of tightness and obstruction in the various passages lined by this membrane, and frequently, a Avish to expel something from the nares, although the sensation indicating its presence is attributable solely to the turgescence of the inflamed membrane; one consequence of this state of things is repeated sneezing. In pure catarrh, as distinguished from bronchitis, the inflammation does not extend into the bronchial tubes, and, therefore, there are no abnormal respiratory sounds belonging to it as such, Ave consequently reserve our remarks upon the stethescopic signs of inflammation of the bronchial membrane till Ave come to treat of those diseases of AA'hich it properly forms a part. The symptoms above described, which are those of what may be termed the first stage of catarrh, generally continue about two days, Avhen the characteristic effusion of inflammation begins to shoAv itself; this, in the case of a mucous membrane, consists in an SYMPTOMS — CAUSES. 165 increase in its secretion, but there is at the same time an altera- tion in its character; it is not of the bland nature which belongs to it in health, it is serous, transparent, and glairy, and, from its acrid character, often excoriating the upper lip, constituting the coryza or excessive discharge from the nostrils, attended Avith frequent sneezing. There is often at the same time profuse lachrymation, Avhilst the fauces, velum, and uvula pour forth a like discharge, Avhich irritates the glottis, and produces a short quick cough. During this period of the disorder, there remains more or less thirst and fever, and the appetite is commonly impaired. This condition generally continues about forty-eight hours, and is the period during which the "cold" is most annoying to the patient; at the end of that time, if allowed to run its course, it passes into the third and last stage. The characteristics of this are a subsidence of the uneasy feelings dependent upon the turgid state of the mem-* brane, and the irritating discharge from it, a cessation of the fever, and the pouring out of a secretion, of a thicker consistence, as well as more copious, than occurs in the healthy state. It consists, in this instance, of a bland, opaque, tenacious mucus, Avhich is freely excreted from the nostrils, and often collects in the posterior nares and fauces, whence it is expelled in lumps of tough tenacious phlegm of a green- ish or yelloAvish colour; as this proceeds the inflammation and irri- tation subside, and if the patient be not exposed to any cause likely to produce it afresh, the disease disappears in a feAV days. " There is another form of catarrhal complaint, Avhich has hitherto excited little notiee, but Avhich merits attention, not because it is in itself of a character to inspire the least alarm, but because it may be, and probably often has been, a source'of much uneasiness, in conse- quence of being mistaken for something else. In this instance, the inflammation appears to be chiefly confined to the internal mouth, constituting Avhat may be called catarrhus stomatitis. The Avhole of the mucous membrane appears highly injected, and sometimes slightly aphthous, the gums are red, swollen, and tender; there is occasionally a slight fulness about the parotids, and not unfrequently a greater or less degree of salivation; indeed, in some instances, the salivation has been profuse, and has been accompanied by a foetor exactly re- sembling that arising from mercury. There is some, but seldom much, constitutional disturbance, and the patient generally gets Avell in a feAV days."* The circumstances which are commonly said to predispose to ca- tarrh, but which, speaking more correctly, render the individual more than ordinarily susceptible of its usual causes, are a peculiar idiosyncrasy, the nature of Avhich is not accurately understood—a delicacy and irritability of habit, often induced by overmuch indulg- ence, living in overheated apartments, and neglecting the bracing effects of fresh air, from a dread of the very evil which is thus ren- dered more probable, and perhaps more than all preceding attacks. The most common of the so-called exciting, or really direct causes, * Bright and Addison, " Elements of the Practice of Medicine," vol. i., p. 172. 166 CATARRH. are, sudden exposure to cold, as to draughts of cold air, sudden changes of temperature, either from heat to cold, as in going from a heated drawing-room into the cold outer air, or coming in from a cold drive and sitting before a fire in a warm room; getting Avet through, or wet-footed. Some persons are liable in the hay season to a modification of catarrh, knoAvn as hay-fever, and which is ascribed to something emanating from the floAvering grass. A disease of which one of the most prominent symptoms is catarrh, has, on several occasions, prevailed epidemically over a large portion of the globe, under the name of influenza, or epidemic catarrh; it is, hoAvever, as the experience of 1833, 1837, and above all of 1847-8, must have taught us, too formidable and fatal a malady to be thus lightly passed over, and must be reserved for a separate notice. The prognosis of catarrh, as such, is of course generally favourable: the symptoms of catarrh are, as we have seen, sometimes the only ones AA'hich present themselves at the commencement of that formida- ble disease, the croup; and a neglected catarrh often extends along the bronchial membrane, till it becomes a severe bronchitis; but the prognosis is in that case the prognosis of the latter disease. It is also to be borne in mind, that, in persons disposed to phthisis or asthma, neglected or repeated attacks of catarrh are often the means of calling the morbid tendency into activity. As regards the treatment of catarrh: it is not very often that this disease becomes the subject of our remedies. In almost every family there is some faArourite preparation or regimen Avhich is put in prac- tice on such occasions. In general, rest in an equable temperature, with a light diet, and abstinence from stimulants, and the avoidance of the circumstances AArhich excite the disease, AArill prove sufficient for a cure, or, at all events, allow of recovery in a few days. A catarrh may, hoAvever, be often cut short, or its duration greatly shortened, by appropriate measures at the commencement; although the means which have been recommended are very different, and may seem opposite to each other. The safest and best plan, perhaps, when Ave are consulted early, is to advise a foot-bath, and going early to bed, a feAV grains of comp. ext. of colocynth, with a sixth of a grain of tartar emetic, and three of ext. of hyoscy., A\'ith a moderate saline aperient in the morning; and a mild diaphoretic draught, as three drachms of liq. am. acetat., with about a half a drachm of sp. seth. nit. and ten or tAA'elve minims of vin. ant. pot. tart, or vin. ipecac, in cam- phor mixture, three or four times daily. A continuance of this plan for tAvo or three days, the drink being slops, the diet boiled mutton, with a light bread pudding, will generally effect a cure. A mode of cure, not perhaps more agreeable, but having the ad- vantage of not confining the patient to the house, is recommended by Dr. AAratson upon the authority of Dr. Williams; it has been termed the dry plan of cure. It consists in abstinence from every kind of drink. " No liquid, or next to none, is to be SAvallowed until the disorder is gone. The principle here concerned is that of cutting off the supply of the watery materials to the blood." Dr. Williams " allows, without recommending, a table-spoonful of tea or milk for T R E A T M E N T. 167 the morning and evening meals, and a wine-glass of water at bed- time." This plan has certainly the merit of simplicity, its novelty is not so certain. " In gravedine autem," says Celsus, " primo die qui- escere neque esse neque bibere, caput velare, fauces lana circumdare: postero die surgere, abstinere a potione, aut si res coegerit non ultra heminam aquae assumere."* Opposed to this is the more grateful moist cure, viz., about four glasses of sherry Avith sugar in a large quantity of Avarm water, light reading on the sofa for the evening, a foot-bath and early to bed; or the still more agreeable one of a good dinner and an extra glass or tAvo of Avine. The first of the two latter expedients Avill often prove effectual in the commencement of the disorder, but should never be put in practice when much fever is • present; the latter should only be ventured upon in the more ad- vanced stage, when the mucous excretion is thick and readily ex- pelled. A most important matter in connection with catarrh, is prevention. Noav there are various means attempted for this; one is to heap flannel jacket upon chest-warmer, and outer garment upon outer gar- ment over this, till the patient perspires freely under the Aveight of artificial integuments, and thus a free action of the skin, the best relief to the internal mucous membrane, is kept up; but if in an un- guarded moment he expose himself to a draught of air, or keen east wind, with a greatcoat too little, his enemy is sure to seize the op- portunity. A more rational mode of prevention, is that of enabling the system to withstand the impressions of cold, by inducing such a vigorous state of the circulation as may counteract its effect on the temperature of the surface, or quickly restore the heat that is lost. The habitual exposure to variations of temperature, as in exercise in the open air, blunts someAvhat the sensibility of the surface, and ex- cites and strengthens the capillary circulation there; and the same end is attained by the exposure of the surface to a temperature loAver than it is likely to be called upon ordinarily to encounter, but for so short a time as to avoid the danger of any ill effects from it. This may be done by cold bathing or sponging, or the use of the shoAver- bath. The latter of these has no doubt an excellent effect in ena- bling the system to resist impressions of cold, but it is liable to grave objections in many cases. In the first place there is not in all per- sons sufficient strength to withstand the shock, or, in other words, sufficient power in the moving forces of the circulation, to restore activity in the capillaries of the surface, when it has been thus sud- denly arrested, and in such cases there is no reaction or " glow" after the effusion, but, on the contrary, a chilliness, Avhich is a certain sign that harm rather than benefit is the consequence. But we must also remember, that even where, to all appearance, a healthy reaction in the superficial capillaries foUoAvs the use of the shoAver bath, there is a considerable stress throAvn upon the ventricles of the heart, andthat in persons of lax fibre, there is danger of some injury being inflicted upon this organ or its valves. Those too Avho are liable to any undue * Lib. iv., cap. ii. » 168 BRONCHITIS. flow of blood toAvards the head, as indicated by head-ache with in- creased heat of the scalp, ought not to use the shower-bath, since the first and most poAverful shock takes place upon the surface of the head, and the subsequent reaction there is consequently greatest. Persons, therefore, of languid circulation, of feeble muscles, or dis- posed to determination towards the head, ought not to use the shoAver- bath. The slipper bath may be begun to be used with tepid Avater, in summer, and afterwards, by degrees, with cold; and thus many persons' may be inured to its use, Avho would shudder at the very mention of cold water. There is, however, much trouble attending the use of this bath, and therefore it cannot be very generally em- ployed ; but there are feAV Avho cannot procure the luxury of a large tub or pan, in Avhich they may sponge themselves, beginning with the extremities, then freely sponging the abdomen, chest and back, and last the head, a practice which will have the prophylatic ad- vantages of the shower-bath, Avithout the risk either to the heart or the head. BRONCHITIS. ATe have dAvelt somewhat at length upon catarrh, not so much on account of its importance considered by itself, as from its liability, if neglected, to lead to the more formidable disease bronchitis, or in- flammation of the mucous membrane of the bronchi and their rami- fications through the lungs. This disease is one of such frequent occurrence in this climate, that but few persons pass through life without one or more attacks of greater or less severity, and although, in ordinary cases, it is attended with little or no danger, in those of its greatest severity it is one of the most formidable diseases Avhich we are called upon to treat; as, besides the more imminent peril of this latter class of cases, the remote consequences are to be carefully guarded against in all, since they include some of the most dangerous lesions, not only of the bronchial tubes and lungs, but also of the heart and liver, and through them of the kidneys and brain. Bronchitis usually commences Avith the ordinary symptoms of in- flammatory fever. There is considerable lassitude, pain in the limbs and back; the tongue is furred and rather disposed to be red at the edges; nearly at the same time, or very shortly aftenvards, the character of the disease is announced by a feeling of irritation about the throat, with a sense of oppression AA'hich is mostly referred to the situation of the sternum, and gradually assumes the character of a rawness or even sharp pain, aggravated by coughing or taking a deep inspiration: the cough is short and frequent, and there is com- monly at this period of the disease no expectoration, but the respira- tion is hurried, and performed with increased effort. As the disease advances, there is more decided febrile reaction, which in some cases is of great severity; the skin becomes hot, often dry, especially in the commencement, though sometimes it is moist throughout, the tongue is furred on the dorsum, but red at the tip and edges, and the papillae SYMPTOMS. 169 commonly elongated; there is thirst and often headache, scanty urine, a frequent, full, but compressible pulse. AVith the increase of the fever there is commonly an aggravation of the cough and dyspnoea; the cough being frequent and sometimes violent; and the respiration not only hurried, but accompanied Avith wheezing, and causing pain often of a sharp character, referred chiefly to the sternum, though often extending to different parts of the chest; but there is not as yet, necessarily, any expectoration. The disease may noAv be said to have completed its first stage, and it may be well to consider for a moment the pathology of this period of bronchitis, both for the explanation of the symptoms and the right understanding of the changes which may be expected to follow. Bronchitis consists, as has been already stated, of an inflammation of the mucous membrane Avhich lines the bronchi, and their ramifica- tions in the lungs; and the first effect of inflammation of a mucous membrane is an increase in the quantity of blood in the vessels ramifying immediately beneath the surface, Avith often some serous effusion into the areolar tissue, but a diminution rather than increase in the secretions of the surface itself. Now the effect of this state of things upon the bronchial tubes must be a swelling and dryness of the lining membrane, accompanied Avith heat and pain; conditions which fully account for the sensations which have been described as felt in the chest; at the same time that the tenderness of this mem- brane, which must render the inflation of the lungs painful, explains the distress with which the inspiration is accompanied. There is, hoAvever, another aspect in which it is of practical im- portance to vieAV this change in the mucous lining of the bronchi, and that is in its effects upon the physical or auscultatory phenomena of the chest. Noav as regards the sounds elicited by percussing the chest, Ave know that the quantity of air in the cells of the lungs is not necessarily affected by this condition of the mucous membrane of the tubes, and consequently Ave should not anticipate that any great alteration would take place in the resonance; and experience shows the same thing, for Ave find, cceteris paribus, that the resonance of the chest does not vary from Avhat it is in health. Let us now examine the effect Avhich the above change in the tubes must produce upon the sounds of respiration. AVe have already (p. 130) described the sound produced by the air entering the cells of the lungs, and have pointed out that in health no sound is to be heard at the surface of the chest, from the passage of the air along the tubes, except in certain situations, namely, over the first bone of the sternum, and on the space between the scapulas (p. 134); but if the tubes undergo the changes which have just been described, and their calibre is narroAved, and that irregularly, we shall have them converted into musical instruments, and hissing, Avhistling, cooing or snoring sounds may be expected to arise according to the degree in Avhich the canal may be diminished, and to its diameter on each side of the obstruction, and this is what we actually find to be the case. AVe hear on listening to the respiration in this stage of bronchitis tAVO classes of sounds, the one which might be supposed to arise from 170 BRONCHITIS. the propelling air through small tubes, and includes the hissing, whistling, wheezing noises Avhich are included in the technical term sibilus; and the other comprising the cooing, snoring, croaking sounds AA'hich are denominated by the term ronchus. These are the bronchial dry sounds of respiration; and it is very important to become familiarly acquainted with them by experience, and to have correct ideas as to their cause. The various modifications of ronchus are such as would be produced by blowing through a cylindrical tube of some size, the bore of which is narrowed at any particular part, the note or tone depending upon the size of the tube, and the degree of obstruction. Ronchus thus belongs to the larger tubes, and is produced by partial narrowing of those tubes, either from the thickening of the lining membrane above described, or from the pressure of a tumour, or other morbid enlargement external to the tubes, or, Avhich is very common, from the partial clogging of a tube by a piece of tough phlegm, such as might readily lodge in one of them when the moisture on the surface of the lining membrane is diminished. The first and last only of these conditions indeed belong to bronchitis; it is, however, necessary to remember that they may all equally produce a sound which has been too often stated to be peculiar to the latter disease. AVhen again air is forcibly bloAvn through a very small tube, we have a hissing sound, especially if there is any narrowing or con- striction in its course; noAV this is precisely what accurs Avhen the inflammation has reached the lining of the smaller bronchial tubes, and rendered it tumid; the occurrence, then, of a sibilant noise in bronchitis, shows that the disease has extended to the minuter bron- chi; and Avhen it is heard over a very large portion of the surface of the chest, it indicates disease of a very formidable character. We have, then, two classes of dry sounds, the ronchus and sibilus, the former produced in the large, the latter in the minute tubes com- municating with the vesicles: noAV the ronchus, Avhich is produced in the larger tubes, cannot very materially interfere Avith the production of the respiratory murmur, but Avhen it is present to a great degree, it may prevent our hearing it by its own louder noise; it outroars it, as Dr. Watson well observes; where indeed ronchus has been pro- duced in a large tube, by a piece of tough mucus partially obstruct- ing it, this obstruction may sometimes become complete, and then the ronchus and the respiratory murmur in the part of the lung to which the tube leads, will cease together; we shall then have silence over that portion of the chest, but without any diminution of the resonance on percussion. This phenomenon, however, is not perma- nent, and may commonly be removed by coughing, and in this Avay it may be distinguished by its transitoriness from the same condition produced by emphysema. With the sibilant noises, however, the case is somewhat different; for when the mucous lining of the minuter tubes is swollen, the ordinary murmur of the air passing from them into the cells must be converted into a hissing noise, so that the morbid sound supersedes rather than masks the natural one, whereas the sibilus which, under this condition of the small tubes, PHYSICAL SIGNS. 171 attends the respiration, is altogether a neAV sound. Such, then, are the dry sounds indicating the first stage of inflammation of the large and small tubes respectively: Ave have described them separately, in order to their better explanation; but Ave as frequently meet with them combined as singly. It is more common, hoAvever, to have ronchus without sibilus than the latter Avithout the former. AArhen they coexist, we have every possible combination of groaning, snor- ing, cooing, hissing, and Avhistling. After a time, varying from one or two to several days, or even a week, but generally a very short time, the inflammatory secretion begins to shoAV itself, first of all in the form of a glairy mucus, of considerable viscidity and tenacity, and whilst this continues the fever remains intense, and the dyspnoea, where a great extent of the membrane is involved, distressing; the disease being, in fact, at its height. The presence, hoAvever, of this secretion in the tubes causes a considerable alteration in the stethoscopic signs, the sounds AA'hich attend the respiration being noAV of the moist kind, which we pro- pose to designate rattles. It may, however, here be remarked, that though there is much force in the ojection urged by Dr. Watson against the term mucous rattle, adopted from the French, as descrip- tive of the moist sounds of bronchitis, viz., that we cannot tell by the sound itself that it proceeds from mucus rather than any other liquid in the air-passages, still the term rattle has been retained, as distinc- tive from the dry sounds of the tubes ronchus and sibilus, and as preferable to the term "crepitation," with which Dr. AVatson pro- posed to replace it, and Avhich appears best fitted to express another class of sounds to be described hereafter. By this term rattle, then, we mean the sound produced by the rapid formation and bursting of air-bubbles, caused by the passing to and fro of the air through the bronchial tubes loaded Avith fluid, whether this fluid be the glairy, viscid secretion of the first stage of bronchitis, of which we are now speaking, or, more fully formed mucus, puriform fluid, serous exuda- tion, or even blood. Corresponding to the ronchus, or dry sound in the large tubes, we have the large rattle, formed, apparently, by the greater size of the bubbles {i-ale musqueux cl grosse bulles of Laennec); and, to the sibilus, the small rattle, arising from the smaller size of the bubbles formed in the minuter tubes. These sounds have been described separately, as it is of practical importance to attend to the difference betAveen them, as Avell as the almost opposite conditions of the mucous membrane, which they indicate. It generally happens, hoAvever, in practice, that the dry stage of the inflammation does not continue long throughout its whole extent, but is in many parts speedily succeeded by that of increased secretion, giving rise to the various rattles, so that, in fact, we most commonly hear the dry sounds, ronchus and sibilus, coexisting in the same lung Avith the large and small rattles. Here, too, it may be observed, that we have described these rattles once for all; we shall have occasion to recur to them hereafter in other diseases, in Avhich, though their patholo- gical import may be different, their mechanical or physical cause is the same. 172 BRONCHITIS. The glairy transparent mucus, Avhich is the first secretion poured out in acute bronchitis, marks, as Ave have said, the height of the inflammation, and it is important to watch the changes in the expec- torated matter, as from it we may learn the probable progress of this disease: AArhen this is favourable, the sputa lose their transparent cha- racter, become of an opaque white, Avithout, hoAvever, losing their stringy mucous character (but, on the contrary, rather increasing in consistency than diminishing in adhesiveness); and subsequently they often acquire a greenish colour, showing that the inflammation is terminating in resolution. The difference in the sputa, at the dif- ferent periods of bronchitis, Avas observed by the earliest Avriters in medicine, the glairy mucus first excreted having been by them deno- minated crude, and that in latter stages, ripe, or concocted; indeed, before the introduction of auscultation, the character of the expec- toration afforded one of the most important signs, not only of the progress of the inflammation but also of the seat of the disease itself. It may and often does happen, that after the sputa have passed into the concocted form, there is a recurrence of the crude, Avhich indicates that there has been also a recurrence of the active inflam- mation ; the appearance of the expectoration thus furnishing an important guide to our treatment. It may happen, too, that there is a partial recurrence or extension of the inflammation in one part, Avhilst the resolution is proceeding in others, in which case there Avill be a mixture of the two kinds of sputa, the opaque mucus generally floating in the thinner and more transparent fluid. AVhen, hoAvever, there is no relapse of this kind, the fever subsides upon appearance of the concocted sputa, the tongue becomes cleaner from the edges towards the centre, the expectoration is looser, as it is commonly termed, that is to say, the sputa are excreted Avith less difficulty, the respiration becomes more tranquil, and the pulse returns to its natural standard. Such is the progress of bronchitis Avhen it terminates favourably; but as this is a disease not always unattended with danger, it is very important to have right notions of the modes in Avhich it may prove fatal, in order that Ave may be enabled to counteract the fatal tend- ency, in each particular case. Noav, in all inflammations we may have —1, Death from the direct effect of the inflammation, the excitement terminating in exhaustion or failure of the moving poAvers of the circulation, ending in death by syncope, or death from the heart; or we may have death from exhaustion produced by the excessive secre- tion, puriform or othenvise, consequent upon the inflammation. The former of these is in bronchitis a possible rather than a probable occurrence; the second occurs more commonly Avhen the disease has degenerated into a chronic form, and seldom occurs except in those Avho have suffered from previous attacks of the acute. 2. Inflamma- tion of a part, the performance of Avhose functions are necessary to life, may prove fatal by its arresting the functions of that part, either directly or by means of the products of the inflammation. This is the most common mode in which bronchitis destroys life, leading to death by apnoea. MODES OF FATAL TERMINATION. 173 It sometimes occurs where the inflammation is very intense and very extensive, that the swelling of the bronchial membrane Avhich occurs at its commencement, is sufficient to arrest the access of air to the minute vessels ramifying in the cells of the lungs, and thus speedily cause death by apncea, before any secretion has been poured out into the tubes. Instances of this are not common, and Avhen they do occur it is most often in those who have suffered; from re- peated previous attacks, and in Avhom the bronchial membrane is consequently not in a healthy state, and Avho are never perfectly free from dyspnoea, or in those whose lungs are studded Avith miliary tubercles, and in whom a severe and extensive bronchitis has been suddenly set up by exposure to some of its exciting causes. AVhere this has been the case, the dyspnoea becomes rapidly more and more urgent, tongue, lips, countenance and hands, especially under the nails, livid, the patient restless, anxious, and gasping for breath, the pulse very feeble, though the heart's action may be strong and heav- ing—all Avhich circumstances show great obstruction to the transit of blood through the lungs ; wandering delirium often supervenes, from the carbonized blood circulating through the brain, and the patient dies suffocated, the right side of heart, lungs, liver, and venous system generally, being gorged Avith blood. These cases, I repeat, are not very common, but they do happen, and it is necessary to be acquainted with them, and to understand them, as they present one illustration of death from apnoea, or death from the lungs. The most common mode, however, of the fatal termination of bronchitis, is by obstruction to the respiration, and consequent death from apnoea, caused by the inflammatory effusion in the tubes pre- venting the access of air to the pulmonary cells. This may take place at any period of the disease, and arises either from the intensity of the inflammation and its rapid extension to the minuter tubes, causing a profuse secretion to be poured into them more quickly than it can be excreted; or from inability of excretion, arising partly from its quantity and partly from the failure of the poAvers of life; in Avhich latter case the cause of death is more complex, as the fatal result is brought about partly by failure of the moving poAvers of the blood, and partly by apnea. AVhen there is danger of the disease terminating fatally by exces- sive secretion in its earlier stage, the dyspnoea, the lividity, and in fact the general symptoms presented by the patient, are the same as in the case of threatened apnoea from turgescence of the lining mem- brane of the tubes, with the exception perhaps that in the latter there is more heat and less moisture of the skin; the true distinctive cha- racters, hoAvever, are to be found in the signs furnished by ausculta- tion. In the dry condition of the membrane there is, as avc have seen, sibilus, but no rattle ; in the present instance, on the contrary, there are rattles to be heard over the Avhole surface of the chest, and the more extensive these are, and " the smaller" they appear, the greater is the danger. It is, hoAveA'er, in the latter stage of the disease, where the poAvers of the constitution are naturally feeble, or where they have been 174 BRONCHITIS — PROGNOSIS. exhausted by former diseases, especially by previous attacks of bron- chitis, or by injudicious treatment at the commencement, that the greatest number of cases prove fatal, and that from the combined agency of exhaustion and excessive secretion; constituting the suffo- cative catarrh of the French authors, more properly termed suffoca- tive bronchitis. The tendency to this mode of fatal termination, is a circumstance Avhich it is extremely important to keep constantly in view in severe cases of bronchitis. The signs which threaten this result are, increase of the dyspnoea, generally with a concomitant increase of the lividity ; a failure of the circulation evinced by the pulse becoming very soft, irregular, and sometimes intermittent; coldness of the extremities, Avith delirium or stupor. Auscultation discovers large and small rattles over the AA'hole of the chest, Avith more or less wheezing, the resonance of the chest, upon percussion, remaining unaltered. Such is the ordinary progress of acute bron- chitis, either to recovery or a fatal termination; it very frequently, however, runs on to the chronic form, which requires a separate notice. The diagnosis of bronchitis, which is a matter of some practical importance, has become comparatively easy, since the general adop- tion of auscultation. From inflammation of the substance of the lung it may be distinguished by the moist rattles Avhich we have already described; by the resonance upon percussion remaining unal- tered, and by the absence of those auscultatory signs which will be presently pointed out as indicative of pneumonia ; by the expectora- tion being more decidedly mucous, and not tinged by blood inti- mately mixed Avith it, as in the latter disease; and by the general symptoms of a less heat of skin and a softer pulse. From pleurisy it may also be distinguished, by the absence of the stitch, and the dif- ference between the stethoscopic sounds. It is true, indeed, that Ave may have either of these last-named diseases concurring with bron- chitis ; in which case they may be distinguished by their character- istic symptoms, a diagnosis which certainly requires some tact and experience in auscultation; though it may be observed, that there is not often much danger of overlooking the bronchitis under such circumstances, since its peculiar sounds are more likely to mask, than to be masked, by those of the other diseases. Perhaps the most diffi- cult point in the diagnosis of bronchitis is the distinction betAveen the primary idiopathic form of the disease, and that which occurs as a complication or concomitant of continued fever; it is, however, a difficulty that may readily be avoided by those who are familiar with the latter disease, and the error is perhaps to be the most carefully shunned, by those who are prone to rely too exclusively upon the local signs furnished by auscultation. There is, again, often a diffi- culty as to bronchitis and phthisis, but this, also, is a question belong- ing rather to the diagnosis of the latter disease, and the same may be said of its concurrence with diseases of the heart or large vessels. The truth is, that though bronchitis occurs as a primary disease, and a formidable one too; it often is also a symptom only, or a conse- quence, of some other lesion; so that the presence of its local signs, DIAGNOSIS. 175 particularly when unattended with the fever that belongs to it/in its acute form, ought never to satisfy us that we have ascertained the Avhole extent of the disorder. The causes of bronchitis, like those of most other diseases, have been divided into predisposing and exciting; in the more correct language AArhich Ave propose to adopt, they may be classed as—1, conditions which induce a susceptibility to the disease, or an inability to Avithstand its direct causes: and 2, the direct causes themselves. Now as to the predisposing conditions: there is no age which is exempt from its attacks, although the very old and the very young suffer the most severely from it; it affects alike, cceteris paribus, males and females. As regards habits of life, those are the least liable to its attacks who live temperately, and expose themselves moderately and cautiously to the tonic effects of cold; whilst, on the other hand, those who are enervated either by intemperance or other excesses, or AArho live in confined dwellings, or pass their time in overheated rooms, or inhale the carbonised air of croAvded assemblies, or are employed in heated work-rooms, Avhere the atmosphere is often vitiated, are most liable. Amongst the predisposing conditions too must be reckoned, previous attacks of the disease, and also diseases of the kidneys and the heart, if, indeed, the two latter are not to be reckoned amongst the direct causes. The direct cause of bronchitis is commonly exposure to cold, or still more to cold and damp combined; especially after having been subjected to the influence of those conditions Avhich have been pointed out as weakening the poAver of resisting the impression of such agencies. In infants, the disease is often excited by the process of dentition. The inhalation of irritating gases or of minute par- ticles of dust, sand, or filings suspended in the air, also produces the disease amongst the different classes of artisans who are exposed to them in their respective operations. As has been already observed, bronchitis accompanies several other diseases, as measles, continued fever, phthisis, pneumonia, disease of the heart and of the kidneys, &c, either as a consequence, an accidental complication, or a cause. It is also a very frequent accompaniment of that extensive epidemic the influenza, so much so, that many, or rather most, authors have regarded that disease as an epidemic bronchitis; the experience, hoAvever, of late years, has taught us that bronchitis is not essential to influenza. Notwithstanding the apparently trivial nature of bronchitis in many instances, it is, nevertheless, one of the most fatal, as well as most frequent diseases in this, and perhaps in all variable climates. Our prognosis, therefore, ought to be very guarded in all severe cases, and in many it must be exceedingly doubtful, if not unfavour- able. The circumstances AA'hich influence the amount of danger, are the age and constitution of the patient—the attack being a first one, or a repetition of a disease from AA'hich the patient has frequently suffered before—the extent and severity of the attack—the season of the year and perhaps also the locality. AVhen the disease attacks infants and young children, it is fre- 176 ACUTE BRONCHITIS. quently very little amenable to remedies, and is fatal in great num- bers of instances, more so than is perhaps commonly believed; since by far too many of such cases are set down as inflammation of the lungs, or pneumonia, In old people, again, there is a great suscepti- bility of the disease, Avhich though inflammatory in the first instance, is very little amenable to such means as it Avould be safe to employ, and in the more adAranced stage, there is a tendency to sinking, the danger of Avhich is aggravated by the debility of age. Independently, however, of the age of the patient, the cachectic state of body induced by intemperance, or organic disease of any kind, greatly lessens the probability of recovery. This is especially applicable to disease of the heart and kidneys, the former of Avhich, by impeding the return of the blood from the lungs, is an additional cause of that obstruction to the pulmonic circulation Avhich is so dangerous in bronchitis; and disease of the latter organs, which is at all times apt to induce rapid effusion into the areolar tissue, is still more apt to do so in any part which is the seat of inflammation, and consequently Avhen bronchitis attacks such subjects there is danger of a sudden and rapid anasarca of the submucous areolar tissue, threatening death from apnoea. Of all previous diseases, however, that which most increases the risk of an unfavourable termination, is a succession of previous attacks of the same disease, or a pre-existing chronic bronchitis, especially if it have been of long duration. Bronchitis is also more dangerous in the Avinter and spring than at other seasons of the year, especially if there haA^e been cold and damp weather. Independently, however, of all these considerations, a severe attack of bronchitis, affecting extensively the minuter tubes, (the capillary bronchitis of some authors,) is at all times to be dreaded. AVhen, with much febrile excitement, rapid, hurried, and distressed breathing, and quick and sharp pulse, there are small sibilant sounds, or small rattles, over the Avhole of the chest, there is always reason for apprehension, Avhich is increased by lividity of the lips or fingers. When, hoAvever, although the case be severe, the expectoration becomes more free and is performed Avithout pain, and the sputa gradually change from the crude and transparent to the bland, opaque, and Avhitish or greenish; there is reason to hope that resolu- tion is taking place; and still more, if at the same the tongue begins to clean from the edges toAvards the centre, and the pulse and respi- ration becomes less hurried. On the other hand, a recurrence of the transparent sputa is a sign of a fresh attack, or extension of the inflammation, and is of course, as far as it goes, an unfavourable sign. The sudden suppression of the expectoration, again, especially if it be attended by increased dyspnoea, or lividity, or Ioav delirium, por- tends the most urgent danger. Delirium is in itself at all times a dangerous symptom, especially in old persons and in those who have been previously subject to the same disease. There are few diseases in AA'hich the pulse requires more careful watching than in bronchitis. It is from the commencement generally more compressible than in inflammation either of the lungs or pleura, but Avhen the dyspnoea becomes urgent, and there is much lividity, TREATMENT. 177 it often becomes exceedingly small, although the impulse of the heart may remain poAverful; this indicates great obstruction to the passage of the blood from the right to the left side of the heart, and, therefore, urgent danger: sometimes, too, under these circumstances, it becomes intermittent, though at others, OAving to the difficulty of propelling the carbonized blood through the extreme circulation, the pulse is throbbing and even large, Avith a feeling as if of a back stroke. A very scanty secretion of urine is also, if it continue obstinately, and independently of profuse perspiration, an unfavourable symptom, as it shoAvs sufficient obstruction to the pulmonic circulation to cause engorgement of the liver, and thus, upon principles already explained (p. 35), to diminish the secretion from the kidneys. From what has been said of the nature and danger of bronchitis, it Avill be at once apparent that the indications are seemingly opposite and inconsistent, but to an experienced and rational practitioner by no means incompatible: they are—to subdue inflammatory action, Avithout exhausting the patient's strength—to facilitate expectoration Avithout stimulating the bronchial membrane—to allay irritation, without oppressing the brain by anodynes—and subsequently to sup- port the strength of the patient, Avithout rekindling the inflammation; to Avhich may be added, the relieving the lungs by keeping up a free action of the other excreting organs. The first and most obvious means of reducing the inflammatory action is the abstraetion of blood, but in the use of this we must be restrained by the risk of exhausting the strength of the patient, and therefore it must be practised Avith the greatest caution. In young and strong subjects, in the country, blood may often be drawn with advantage in the commencement of the disease, particularly before the dry sibilus has been superseded by the moist rattle; but as a general rule, in large toAvns and in elderly persons, or those of infirm constitutions, general bleeding ought not to be attempted. AYhen, hoAvever, the above conditions being in its favour—the pulse having some degree of firmness, the skin being dry and hot, the dry sibilus not having yet given place to the moist rattle, or the secretion, if any, being still of the glairy transparent character—there is much febrile action and dyspnoea, Avith evidence upon auscultation of the smaller tubes being involved to a greater extent, and the urgency of the case is such as to render it important to make a speedy impres- sion upon the system, venesection may be performed. For this pur- pose the patient may be raised into a sitting posture, and the blood allowed to Aoav from a pretty large orifice until signs of fainting shoAV themselves; provided, as a general rule, that not more than a pint be taken. The blood when draAvn under these circumstances Avill be buffed and someAvhat cupped. In most cases, however, it will be more prudent to have recourse to local, in preference to general, bleeding, and in adults, the best mode is by cupping, Avhich has the double advantage of reducing the vascular excitement, and acting as a revulsive; in nervous females and children, when depletion is necessary, leeches may be employed. It is not, hoAvever, to be supposed, that in all cases, even of consider- 12 178 ACUTE BRONCHITIS. able severity, depletion in any form is necessary; and in large towns, where the loss of blood is so generally, though not perhaps imme- diately, folloAved by exhaustion, we should not practise it, unless the indications in its favour are decided. Emetics at the commencement of an attack of bronchitis often prove of excellent service: as already explained, they have a tendency to relieve that state of active congestion of the vessels of the mucous membranes Avhich exists in a marked degree in the first stage of this disease; they should therefore be exhibited before the moist sounds begin to prevail: they are especially useful in the bronchitis of in- fants. The best form for administering them is, for adults, the com- bination of antimony and ipecacuanha (F. 16, p. 140), and for infants and young children the safest is the ipecacuanha alone, a few grains of which may be given in some watery vehicle. The next remedies Avhich require consideration, with a vieAV to subduing inflammatory action, are antimony and mercury. The former of these, where it is not contraindicated by irritability of the stomach or boAvels, is a remedy of which Ave have already spoken as exerting a special power over inflammations of mucous membranes, and is on this account particularly applicable in bronchitis; indeed, in the generality of cases of simple acute bronchitis it may form the staple of our treatment. Mercury has been much recommended by several Avriters of high authority; and as an adjuvant to other remedies, and in cases of great severity, in Avhich it is necessary to use every means of subduing the inflammation, it may be used with some freedom; but as a general rule it ought only to be a secondary remedy, and we must not rely for fulfilling the primary indication upon the in- ducing of ptyalism; since, in cases of capillary bronchitis, which are the most urgent and dangerous, we can never feel confident that the disease has not a tuberculous origin, and in such cases, the use of mercury, in any considerable quantity, Avould tend to aggravate the mischief. The best practice will in general be found to be, to give the antimony in solution combined Avith an anodyne and diaphoretic (as in the mixture F. 17, p. 140); the antimony may, hoAvever, be increased or diminished according to the circumstances of the case. In general the first dose of the antimony may be about half a drachm of the Avine of the potassio-tartrate, or one-eighth of a grain of the salt itself, to be repeated every four hours in solution: this may be gradually raised Avhen necessary to half a grain of the latter, or tAVO drachms of the former, beyond which it will seldom be necessary to increase the dose; where it is thought expedient, however, to push the drug still further, it may be Avell to lessen the intervals betAveen its being taken, as from four to three hours. It must, however, be regulated by its effects upon the disease and upon the system ge- nerally, rather than by weight and measure. The dose should be increased to such an extent as to keep up a slight nausea, and so maintained till the skin is moist and cool, and the pulse soft and less frequent. In conjunction, or in combination, with the antimony, mercury in some form may be given in moderate doses; in the more severe cases the combination of calomel, antimony, and opium (F. 3, TREATMENT. 179 p. 102), may be given two or three times a-day, the mixture being continued at the same time. In general, however, and particularly Avhere the pulse is small as well as quick, a combination of Dover's powder and the mercury Avith chalk is to be preferred. (22)* When the skin is less dry and hot, and there are moist rattles of various sizes to be heard over the surface of the chest, the antimony may be diminished or discontinued, and ipecacuanha employed as the safest and least irritating of expectorants. For this purpose ipe- cacuanha wine may be added to the mixture instead of the anti- monial, and at the same time about five grains of Pil. Conii co. of the Pharmacopoeia administered two or three times a day, or the mixture (23)f may be employed, and the pill of Dover's poAvder and mercury with chalk exhibited night and morning. Another admirable ex- pectorant is the inhalation of the steam of warm water. This is the period of bronchitis at which counter-irritation may be most advantageously employed, or at least commenced; as before the skin has become soft and moist, and the pulse less sharp, it only ag- gravates the disease, as has been already explained in speaking of the treatment of inflammation in general (p. 105). It is, hoAvever, neces- sary here to inisist again upon this point of practice, there being no disease in which blisters are so much abused as in bronchitis, and there is no popular error more pernicious than the very prevalent one that in a " cold upon the chest" a blister is a very safe remedy. The best mode of counter-irritation is generally the common blister, Avhich may be applied over the chest, and allowed to remain on from twelve to sixteen hours or more in the case of adults; in children under a year old a good plan is to apply the blister for an hour, and then remove it for an hour, and if there be no vesication at the end of the second hour, to replace it; for the inflammation of the skin having been excited, it will very often go on to vesication, that is, effusion of serum, after the irritating cause has been withdrawn; Avhen there is urgent dyspnoea, and we are anxious to produce coun- ter-irritation as speedily as possible, a mustard-poultice to the chest or between the shoulders is to be preferred to a blister, or the acetum lyttae may be painted on the chest. It commonly happens in a sound subject, not too much advanced in life, that bronchitis thus treated terminates favourably, and little further treatment is required beyond, perhaps, the application of an additional blister, and the continuous use of the anodyne and ex- * (22) R. Pulv. Ipecac, co. gr. vi.—x. Hydr. cum Cret. gr. iij.—vi. Mucilag. quant, suf. Ft. Pil. ij. vel iv.; of which one or two are to be taken twice a-day. f (23) R. Ext. Conii, gr. xv.—xx. Ext. Glycyrruiz. gr. xxiv. Sodte Sesquicarb. ^ j. Sp. Pimentpe, 3 i. Vin. Ipecac, n^ xl.—£j. Sp. JEth. nit. 3 i.—3'ij. Aq. distillat. q. s. To make a 5 iv. mixture, of which the one-fourth is to be taken every sixth hour. 180 ACUTE BRONCHITIS. pectorant draught, the vessels of the mucous lining of the bronchi returning to their natural condition without any tonic or stimulating measures beyond a gradual return to the patient's usual diet. It may occur, however, either from neglect at the commencement of this dis- ease, or from the loss of contractility in the capillaries, arising from previous attacks of inflammation, or from visceral disease, or a con- stitution impaired by time or excesses, that although there may be no very alarming symptoms, yet there appears to be little attempt at a return to the natural condition of the membrane, as shown by the continuance of the dyspnoea, the wheezing, or the moist rattles, just as we often see the vessels of the conjunctiva remain injected after inflammation of that membrane; in this state of things some rather more stimulating expectorants will be of service. If the pulse be soft, the tongue moist, and the skin perspirable, and there are mucous rattles in the chest, but no great amount of expectoration, the am- moniacum may be given with advantage, in combination Avith about twenty minims of tincture, or about a drachm of the oxymel of squills, with the addition, where the urine is scanty, of about half a drachm of sp. oeth. nit.; and a repetition of the blister will, at the same time, be advisable. When there appears to be little secretion from the tubes, as shoAvn by the diminished rattles but increased sibilus, especially if the urine be loaded or high coloured, and the dejections deficient in bile, the pill (24)* may be used. It may hap- pen, however, that as the activity of the inflammation subsides, a still more alarming condition ensues, the patient becoming nearly pros- trate, the pulse feeble, and the signs of sinking already described presenting themselves. In this state, stimulating expectorants, as well as general stimulants, must be freely administered. The best medicine under these circumstances is the combination of ether, am- monia, and senega (25)f; but a most important adjunct, if not the most essential part of the treatment is the liberal but regulated use of wine or brandy; the former is generally to be preferred, and, in those who have been accustomed to its use, should be allowed to the extent of about four ounces a-day, as soon as the signs of exhaustion begin to shoAV themselves, and it may be gradually increased to eight, twelve, or more according to the condition of the patient. AVhen these measures become necessary, the situation of the patient is in the highest degree perilous, and the prognosis very unfavourable; still, by their persevering application many such cases may be saved. * (24) R. Pil. Hydr. Pulv. Ipecac. Pulv. Scillse, aa gr. i. Ext. Conii, gr. ij. Ft. Pil.; to be repeated three times a-day. f (25) R. Ammon. Sesquicarb. gr. v. Sp. JEth. co. Tinct. Scilla?, Tinct. Hyoscy. iia n^ xx. Decoct. Senegse ^ i. Misce. Ft. Haust.; to be repeated every fourth hour. About two or three drachms of the Liq. Ammon. Acet. may be added when the ekin is dry. CHRONIC BRONCHITIS. 181 The difficult question to decide at this stage of the disease is '"he expediency of an opiate: the restlessness, which arises in great measure from the incessant cough, is often most distressing, and tends greatly to wear out the strength of the patient; to procure sleep, then, is highly desirable; but on the other hand, we know that there is generally imperfect decarbonization of the blood, and, there- fore, with one narcotic poison in the system, we must be cautious about introducing another. The suppression of the expectoration, too, if it take place very suddenly or completely, is also attended Avith danger, and often has a tendency to increase the oppression of the brain: great care is, therefore, to be used in the exhibition of opium in bronchitis attended Avith much dyspnoea, and as a general rule, it ought never to be used when the countenance is dusky or the lips livid; but when the cheeks remain florid and there is a free expectoration, an opiate, given at bed time in combination with an expectorant, often acts almost magically (26*). The treatment of bronchitis has been described at some length, not that it is possible, by the most detailed plan, to include that which shall be applicable to every particular case of this varying disease, but because it is of the greatest importance to understand the different indications, and the principles upon which they are to be fulfilled, for the very fre- quency of the disease is too apt to induce a routine of practice, and therefore one in Avhich little regard is paid to the distinction between the different phases, which require such different and even opposite remedies. It has already been remarked, that after an attack of acute bron- chitis there may be little or no attempt at a return in the bronchial membrane to its natural condition, its vessels remaining injected, apparently from a want of contractility, the part being, in fact, in a state of asthenic hyperaemia, or passive congestion, the blood circu- lating very slowly in the capillaries. The immediate effects of this condition of the bronchial membrane will be turgescence, probably oedema of the submucous areolar tissue, and altered secretion, the latter being generally increased, the neces- sary symptoms of which will be dyspnoea, cough, and sometimes expectoration. This state of things may, however, come on to all appearance spontaneously, and without any previous acute disease; in either case it is termed chronic bronchitis. The above constitute what may be termed the essential and neces- sary conditions of chronic bronchitis, but others are often superadded to them, or rather follow as their consequences, which are the causes of the distress and danger often attendant upon the disease. The continued hyperaemia of the mucous membrane may lead to permanent thickening from the effusion of fibrinous matter into the * (26) R. Opii, gr. i. Antim. Pot. tart. gr. J. Confect. Ros. q. s. Ft. Pil.; to be taken at bed time. Or, R. Morphiae liydroclilor. gr. J. Pil Scillse co. gr. iv. Ft. Pil.; to be taken at bed time. 182 ITS PATHOLOGY. areolar tissue; this will at once impede the respiration, and interfere Avith the aeration of the blood; hence there may arise increased dysp- noea, wheezing, and lividity: or, again, the puriform secretion from the mucous surface may be so excessive as not only to give rise to cough and dyspnoea, but also, by the continual drain upon the sys- tem, to lead to pallor, hectic, and emaciation. We perceive from this, that when the above structural changes have supervened upon chronic bronchitis—and they are such as that disease is continually tending to induce—the affection assumes a highly dangerous character, and a fatal termination may be appre- hended in one of two modes. 1. Where there is dyspnoea and wheezing, from the Avails of the tubes being thickened, and their calibre thereby diminished, the ten- dency is to death by apncea. 2. When, on the other hand, there is excessive puriform secretion, death from gradual sinking—death, that is to say, from asthenia, is to be dreaded. The cases of these two different classes, though consequences of the same disease, present remarkable contrasts; in the former, where there is obstruction to the functions of the bronchial tubes by change in their structure, the chief ausculatory sign is wheezing; in the latter, where the chief mischief is the great muco-puriform secretion, there are rattles: in the former there is great li\ddity, the countenance will be often dusky, and the lips and ends of the fingers blue; in the latter there is indeed a slight livor of the lips, though it requires a practised eye to recognise it, but otherwise there is pallor: in the former there is a bloated countenance, and sometimes general oedema; in the latter there is emaciation. In the former the patient dies suffocated; in the latter exhausted. These are the tAVO simple forms of chronic bronchitis, though neither is often presented to our notice uncomplicated by the other, and it is perhaps from their joint effect that another change takes place in the bronchial tubes, of great importance in connection with the subject of chronic bronchitis. It appears to be a law in pathology, that when a membrane overlaying muscular fibre is inflamed, the lat- ter loses in some measure its contractility; and the proposition may perhaps be extended to include fibrous tissues generally: if the in- flamed membrane be a mucous one, the contractility of the muscular fibre is at first increased, and subsequently diminished; as we see in the diarrhcea and subsequent constipation which occurs in inflam- mation of the mucous membrane of the intestines. Now, according to this, not only should we expect some increase in the action of the non-striated muscular fibres of the bronchial tubes, which it is by no means improbable does actually take place, aggravating the dyspnoea, and aiding the swelling of the membrane in producing the sibilus; but also that there would subsequently be a diminished power of expelling any accumulated secretion, and also a tendency to dilate, or become enlarged, under the slightest increased distending force; such a force is often supplied by this very secretion, as well as, in the opinion of some, by the convulsive efforts of coughing. Accordingly, CHRONIC BRONCHITIS. 183 we do find every variety of dilatation of the bronchial tubes; some- times a single pouch like an aneurism in an artery; sometimes a series of dilatations in the same tube; sometimes a cylindrical dilata- tion affecting a congeries of tubes, branches of an entire bronchial tree. The section of a cluster of tubes of this kind may be compared to the fingers of a glove.* Before quitting this subject, we would remark, that though we have sometimes the accumulated secretion as the cause of this dilata- tion, and the changed condition of the walls of the bronchial tube as the reason of their susceptibility of the change, Ave would not limit the mechanical cause to the former; indeed, it is not improbable that where the contractility of the Avails has been destroyed by inflamma- tion, the atmospheric pressure in inspiration Avill be a sufficient cause: and besides this, as we shall hereafter see, the instances of greatest dilatation do not generally occur in cases of simple bronchitis, but in those which are complicated with pneumonia, or pleurisy, or both, where the subsequent changes in the surrounding textures have often a considerable influence in promoting the dilatation of the tubes. AVhen dilated tubes are added to the other changes produced by chronic bronchitis, there will of course be considerable aggravation of the dyspnoea, and the lividity consequent upon the obstructed function of the lungs. If the dilatation is in the small tubes there will be sibilus and Avheezing, Avith deficiency of respiratory murmur; the presence or absence of rattles depending upon the amount of secretion; if in the larger, there will be ronchus, Avith or without large rattles. It may be remarked, hoAvever, that there seems to be scarcely any limit to Avhich the tubes, especially those of the third or fourth dimensions, may dilate; so that they often present the physical signs of cavities produced in the lungs in other ways. The expectoration in chronic bronchitis may, as we have observed, be very scanty, and sometimes transparent: often it is abundant, and of a muco-puriform character; but where there is the latter associated with dilatation of the tubes, the puriform mucus from remaining in these pouches, is coughed up in roundish lumps, looking, when seen floating in a fluid, like coins, and thence called nummular sputa. AAre have" already pointed out the different modes of fatal termina- tion in chronic bronchitis, and the different symptoms Avhich charac- terise the tendency to one or the other; still, the two forms of the disease may exist in the same subject, and in the worst cases they commonly do so. In such there will be wheezing, ronchus, and rat- tles ; there will be lividity of the tongue, lips, and fingers, with pallor of the surface generally; there will be emaciation, but with a bloated, and often oedematous condition of the face and extremities; in these cases, too, we often have the hands emaciated, but the tips of the fingers swollen from the long continuance of venous congestion, and the nails liAud and curved; there is orthopnoea; the skin is sometimes dry and harsh, at others, especially over the extremities, bedewed * See a good representation in Drs. Handfield Jones and Sieveking's Pathological Anatomy, Philadelphia ed. p 389. 184 PROGNOSIS. with a clammy perspiration. The signs of obstructed pulmonic cir- culation being added to those of exhaustion from excessive secretion, we have palpitations from dilated right ventricle, defective secretion of bile from gorged liver; and scanty urine. It must be apparent from what has been said, that chronic bron- chitis is a disease continually tending to a fatal termination, and that even when it is present in its simplest and mildest form, there is danger of those additional lesions Avhich bring about this result. Whilst there are dyspnoea, cough, and expectoration, there is occa- sion for the greatest caution. AVhen there are orthopnoea, Avheezing, and lividity, puriform expectoration, hectic, and emaciation, there are grounds for the most serious apprehensions. The urgency of the disease is liable to great variations; many persons are affected by it only in the winter, and are nearly if not entirely free from it in the summer months; this form of complaint being popularly known as Avinter cough; but after some years it generally happens that the disease does not altogether cease, but merely becomes less severe in summer, Avhilst the Avinter attacks become longer and more violent. The persistence of the symptoms during the summer is a sign that structural changes are going on, or, in other words, that the disease is proceeding, though it may be but slowly, to a fatal termination. The treatment of chronic bronchitis must be partly preventive, and partly directed to meet the more urgent symptoms as they arise. When a person has been the subject of a winter cough, the great object should be, if possible, to take advantage of the summer inter- mission, or even remission, if it be no more, to correct the morbid habit or tendency, so to speak, of the bronchial membrane. Now as this appears to consist mainly in a state of passive congestion of that membrane, (p. 29), to which there is often added deficient tonicity of the tubes, the best means for correcting it will be a moderately tonic regimen, and mode of living. Of these a pure and moderately bracing atmosphere, is a most essential part. Generally the sea will be found to agree well Avith such patients during the summer; and that often in situations where it might be supposed to be too keen, as on the eastern coast, for instance, at Margate or Eamsgate, or even at Lowestoft or Cromer. It is generally, however, for those in whom there is considerable expectoration that such situations will be found best suited; for those in whom there is wheezing, with little or no expectoration, the rather more relaxing atmosphere of the coasts of Devonshire and Cornwall is to be preferred. If the patient be ordi- narily resident in a large toAvn, he will often derive much benefit from a pure and moderately bracing inland air. The diet should be nutritious; about tAvo glasses of port wine, if it agree Avith the patient's stomach, should be recommended where there is much secretion. At this period too tonic medicines may be of service; in cases of profuse expectoration the sulphate of iron is often very use- ful. What perhaps is a still better remedy is the sulphate of zinc, which will be at once a moderate astringent and a tonic. This, with a little conium, will be very applicable to the more common class of TREATMENT OF CHRONIC BRONCHITIS. 185 cases, in Avhich though there is some cough and expectoration, the latter is not excessive (27).* AT hen slight attacks of an acute or sub-acute character supervene during the summer they must be treated as ordinary bronchitis. In those in whom the disease has not been confirmed, the attempt may be made during the summer to inure the patient to the use of cold, in the form of bath sponging or effusion, as recommended against catarrh. Having taken precautions in the summer to brace the patient against the attacks Avhich are to be expected in the Avinter, equal pre- caution must be used to mitigate the attack AA'hen the first symptoms begin to shoAV themselves. This, hoAvever, is not to be done by too soon confining the patient to the house, as in general he should be encouraged to go out in fine weather to the last, carefully avoiding night or evening air. The clothing should be uniformly Avarm; light Avoollen being Avorn next the skin, but heaA-y clothing avoided. In severe and threatening cases the patient should be confined to the house in the Avinter, and if there be much cough, and it appear easily excited by the admission of cool air, he should even be kept in apartments of Avhich the temperature should not be alloAved to fall beloAV 60°; and Avhen, as they often Avill do, acute attacks supervene, they must be treated upon the principles already recommended for acute bronchitis, it being always borne in mind that in such cases there is an earlier tendency to sinking, and therefore that support and even stimulants must not be long Avithheld. * (27) R. Zinci Sulphat. gr j. Ext. Conii, gr. iv. Ft. Pil; to be repeated twice or thrice a- day. 186 PNEUMONIA — PLEURITIS. XII. PNEUMONIA—PLEUEITIS. Pneumonia may be defined to be inflammation of the air-cells of the lungs, though this inflammation may give rise to different products, and consequently different results. It sometimes happens, indeed, that inflammation of the bronchial membrane extends to the air- cells, and so involves the substance of the lung, and more commonly the disease of the air-cells implicates the bronchial tubes; still we have many instances of its commencing in the former, and confining itself solely to them; and therefore it is desirable to consider it singly. There has been a good deal of difference of opinion as to the exact seat of the inflammation—as to Avhether, in fact, it is in the wall of the cell comprising the vessels, or Avhether it is in the mere lining or internal surface of the cell; a right application, howeA'er, of the laws of inflammation, in connection with the structure of the part, Avill be sufficient to show that these different views are rather partial and defective, than involving any real error. Now, we have seen that the first step in the process of inflamma- tion is that of engorgement or active hyperaemia, and as the inter- stices between the cells consist almost entirely of a plexus of minute vessels, the result must be a SAvelling of the Avails of the cells, with a diminution of their cavities, giving to the lung apparently a closer texture, and one more largely supplied with blood—this is Avhat is termed the stage of engorgement. At this period of inflammation, hoAvever, the true inflammatory products have hardly made their appearance, and we have merely the tumescence Resulting from the increased supply of blood. When a lung in this stage of inflamma- tion is examined after death, it is found not to have lost its property of crepitating when squeezed between the fingers, although it does not collapse so readily under the pressure of the atmosphere as healthy lung; it is of a florid red colour, and the blood Aoavs freely from it Avhen it is cut into. The next step in the process, if the inflammation do not subside by resolution, is the effusion of some of its characteristic products. Now, although in the case of the disease under consideration these products vary in their subsequent results, they in the first instance occur in the form of lymph, either fibrinous or corpuscular, or in the compound form in Avhich the fibrine and corpuscles are mixed (pp. 50, et seq), the former, or the latter preponderating, according to the greater or less constitutional power of the patient. AVhen there is active inflammation in a subject of tolerably good poAver, we have the greatest proportion of fibrine, which almost immediately assumes the solid form, giving rise to consolidation of the lung, which, OAving to the large supply of blood, retains the red PATHOLOGY OF PNEUMONIA. 187 colour Avhich it had acquired in the first stage of the inflammation. The highly-vascular inflamed lung, thus consolidated, resembles the liver in appearance, and is said to be " hepatized ;" and its condition in this stage of the inflammation is called red hepatization. It should, hoAvever, here be remarked, that there is a difference of opinion amongst authors as to the exact situation in which this deposit takes place. Ljennec and others were of opinion that it took place into the cells, filling them up, and, as it Avere, obliterating them; and certainly the finely granulated structure, Avhich the lung in this stage of inflammation commonly exhibits, AA'hen lacerated or cut into, seems to favour this supposition ; and that this is really so, in some cases at least, of acute pneumonia, has been demonstrated by Reynaud. Others again, amongst Avhom may be mentioned Andral and Stokes, have maintained that the red hepatization of acute pneumonia de- pends not on any deposits in the vesicles, but by the walls of these vesicles being so thickened or SAvollen by the excessive congestion of blood in their vessels, that their surfaces are approximated, and sometimes so closely as to obliterate the cavities; and they further account for the red hepatization presenting in some cases a granular, and in others a smooth surface, by supposing the latter to arise from the more intense congestion and perfect obliteration of the cells; and it cannot be denied that the inference to be drawn from the examina- tion of dried specimens of hepatized lung is, that in some cases this hepatization results from congestion and probably coagulation of blood in the vessels. This view of the matter overlooks, hoAvever, the true products of inflammation, and merely shows that the condition termed hepatization, or one closely resembling it, may be produced independently of them ; it does not, however, invalidate the observa- tion of Reynaud, of the actual presence of the inflammatory products in the air-cells ; nor, on the other hand, do the latter observations prove that in all cases AA'here plastic lymph is poured out, it is neces- sarily effused into the cells, and into the cells alone. It is not of great practical importance, and therefore not consistent with the object of the present work, to pursue this question further; we may, therefore, briefly state, as the result of these seemingly opposite observations, that engorgement of the lung, without plastic effusion, may exist to such an extent as to give rise to a condition apparently the same as that commonly described as red hepatization; but that this engorgement, if it do not terminate by resolution, is most fre- quently folloAved by the extra-vascular product of inflammation, i. e., the effusion of inflammatory lymph ; this taking place into the air- cells, and so filling them Avith plastic lymph, and giving the hepa- tized iung the granular appearance, or, according to the supposition of Dr. Williams, into the other tissues constituting the substance of the lung, when we have the smooth surface. Such are the steps by which the lung is brought to the state of red hepatization. Here, however, it may be well to remark, that instead of the plastic form of effusion which we have described as producing this state, we may have the effusion of the compound or corpuscular lymph, or lymph in which there is a great excess of serum, constitu- 188 PATHOLOGY OF PNEUMONIA. ting what may be termed serous pneumonia, or inflammatory oedema of the lung, a condition not generally recognized by authors^ but of the existence and danger of Avhich there can be no doubt; this state supervenes sometimes very suddenly upon the first stage of pneumo- nia, generally in persons of impaired constitutions and unsound vis- cera ; at others, indeed, the previous stage may have been so short as almost to have escaped detection; it is possible, too, that the lymph may in some cases be reabsorbed, if the inflammation subside imme- diately after its effusion. When a portion of lung has been brought to the state of gran- ular hepatization, it may subsequently undergo various changes. (1.) Resolution and absorption of the effused lymph may take place, and thus the lung may be restored to the healthy state; or— (2.) The lymph effused into the air-cells may take the form of pus, and thus the whole of the inflamed part become infiltrated with pus, resembling, as has been observed, a sponge soaked Avith that fluid, without any circumscribed abscess being formed; or if the effused lymph haA-e been of the corpuscular form in the first instance this infiltration Avith pus may take place Avithout any previous consolida- tion. Under these circumstances sloughing of the lung may follow: or if this do not happen, and the patient do not sink during the pro- cess, the lung may be restored to its healthy condition by the lique- faction of the effused lymph, and its subsequent expectoration; or— (3.) The portion of lung which has been condensed and hepatized becomes harder and dryer, with a uniformly grey colour; and if the patient survive, it remains impervious to air, and of a very dark colour, from the black pulmonary matter, constituting the iron-grey induration. Lung in this state sometimes becomes the seat of the deposition of tubercles, or sometimes it passes into ulceration without any such deposit. Having noAV described the different changes produced in the lungs by pneumonia, Ave shall be better able to understand and appreciate the different symptoms by Avhich they are characterized. It may be well to bear in mind that they are of a three-fold character—1, those of the inflammatory fever resulting from the inflammation of a parenchymatous viscus; 2, the disturbance in the functions of the lungs themselves, as Avell as of other organs, resulting from the lesion of the former; 3, the changes in the auscultatory phenomena of the chest, resulting from the altered condition of the lungs. Pneumonia in the first stage is attended by inflammatory fever of an active character : this fever commences Avith rigors and oppression, followed, in most cases, by strongly marked symptoms of febrile reaction,—giddiness, — sometimes severe headache, Avith now and then delirium, especially towards night,—heat of skin, Avhich is almost ahvays of a pungent character,—a full and strong, though sometimes rather labouring pulse; the tongue is furred and somewhat congested, urine scanty and rather high coloured ; and there are thirst and loss of appetite, with an anxious expression and dusky hue of, countenance. PNEUMONIA — ITS SYMPTOMS. 189 With these symptoms of general fever there are those arising from the disturbance of the particular organ; there is dyspnoea; not neces- sarily any pain in the chest, though this is often present, from the frequency of bronchitis of the small tubes ; upon the same circum- stance, too, depend the frequency of .the cough, and the quantity and quality of the expectoration ; so that when this complication is absent, all these symptoms may be Avanting. Generally, however, in persons of tolerably sound constitution, and not very far advanced in life, there will be more or less inflammation of the smaller tubes in the part of the lung affected, and there will be pain, or rather a feeling of soreness in the chest, cough, and expectoration of a remarkably viscid mucus, Avhich is of the consistence of thick mucilage, contain- ing numerous minute air-bubbles, and adhering so firmly to the sides of the vessel containing it, that it may be inverted Avithout its escap- ing. This matter may be of every possible colour, sometimes almost like white of egg, more frequently of a rust colour, and sometimes tinged Avith blood ; but it is also not unfrequently of a bright gam- boge yellow colour, or even bluish or greenish. At this period of the disease, we do not commonly have any very marked disturbance in the functions of other organs beyond what might be supposed to arise from the general febrile disturbance, Avith the exception of (1.) the heat of skin, which is hardly to be ascribed to the latter cause, since it is far more frequent than is observed in ordinary inflammatory fever, or indeed in any disease, with the exception of the early stage of continued fever in young subjects, and in the commencement of the exanthems, and in some cases of albu- minous urine* The relation, however, in Avhich this state of skin stands to the disease in the lungs, has not yet been explained; Avhether it depends upon an increased evolution of carbonic acid, calling for an increased generation of it, and consequent increased evolution of heat in the extreme circulation , or Avhether the inflamed lung, excreting less than its usual quantity of this gas, there is less heat rendered latent by its evolution in the air-passages, has not been shown; the latter supposition is, hoAvever, more in accordance with the analogy of other organs. (2.) The derangement in the functions of the liver often giving rise to some degree of jaundice; this, pro- bably, arises from engorgement of the hepatic cava?, and consequently of the portal vessels, from the impediment to the pulmonic circula- tion ; it is said, indeed, to belong more especially to pneumonia of the right side; and if this be true, it must be the result rather of contiguity than functional relationship. The local or auscultatory sign Avhich characterizes this stage of the disease, is a dry crackling sound accompanying each act of respira- tion, but heard most distinctly at the termination of the inspiration. Various similitudes have been found for this sound, it has been com- pared to the noise produced by throwing salt upon red-hot coals; but it is best imitated, as observed by Dr. AVilliams, by the sound which any one makes by rubbing a lock of his own hair near the ear * This symptom was first pointed out in its true importance by Dr. Addison. 190 PNEUMONIA. between his thumb and fingers. Several causes have been assigned for this phenomenon: some have supposed it to arise from the pas- sage of the air through the viscid secretion in the cells, and the formation of very minute air-bubbles in them; others, with certainly not less probability, have ascribed it to the expanding of the cells, the walls of which have been renderd more stiff by the tumescence, and more adhesive by the small quantity of viscid secretion upon their surface. Be this as it may, it is certain then that this sound (which we shall denominate generally a crepitation, and distinguish particularly, as dry crepitation, or pneumonic crepitation) belongs especially to the state of lung which we have already spoken of under the name of engorgement, Avhether that engorgement be the commencement of inflammation, or whether it belong to a portion of lung that has been hepatized, and is in process of return to its natural condition. It may here be observed that this introduces us to a fresh class of sounds, which we shall speak of generally by the name of crepita* tion, or crackling. We have already described the ronchus and sibilus, which are produced by air in cylinders without liquid, the rales or rattles which are produced by air and liquids in tubes ; and Ave now have to do with crepitations, or crackling, which arise from the separation or unfolding of membranes AA'hich are either rendered more unyielding by congestion, or their surfaces more adherent by altered secretion. These crepitations may be dry or moist, hard or soft; in the present case we have a dry crepitation, which, Avhen not masked by other sounds, cannot fail to be recognised when once it has been heard. It generally happens that this crepitation is as- sociated with more or less of the sounds arising from bronchitis of the smaller tubes; these, however, do not in ordinary cases prevent our hearing the dry crepitation. Up to this time there is no diminution in the resonance of the chest on percussion, the cells not being sufficiently closed to prevent their containing a considerable quantity of air. The signs then Avhich belong essentially to the first stage of pneumonia are—inflammatory fever,—pungent heat of skin,—dry crepitation Avithout loss of reson- ance on percussion: with these are commonly associated pain in the chest, cough, and viscid expectoration. In the second stage, or that of hepatization, there is for the most part a continuance of the fever; the heat of skin is not necessarily present, though it is generally so in practice, since when one part of this inflamed mass is in a state of consolidation, there is probably some other part in a state of engorgement, either progressing towards consolidation or retrograding from it. The disturbance of the func- tions of the lungs and other organs, however, becomes greater, there is more duskiness of the countenance, owing to the greater impedi- ment to the aeration of the blood, the functions of the liver and kidneys are also more disturbed. The disease also sometimes proves fatal in this stage, and signs of failure of the powers of life may mani- fest themselves by the pulse becoming quicker and unequal, or the tongue brown and dry; or there may be threatened death from SYMPTOMS. 191 apnoea, evinced by hurried and laborious breathing, livid counten- ance, Avandering delirium, very small pulse, and clammy sweats. The signs furnished by auscultation are very different: the lung having now become consolidated, the air is excluded from the vesicles, and we have dulness on percussion, the sound of the air passing along the tubes becomes audible, and we hear tubular breath- ing, and, in the manner already explained (p. 135). The intensity with which these sounds may be heard must depend evidently upon the continuity of the consolidated portion, and upon its being near the surface; if the consolidation be confined to separate lobules, here and there, through the substance of the lungs (a rare occurrence), there may be neither tubular breathing nor bronchophony; or if there be a consolidated mass of some size toAvards the centre of the lung, distant tubular breathing may be heard without bronchophony, though the latter is scarcely ever audible without the former. In ordinary acute pneumonia, hoAvever, it almost ahvays happens that the inflammation extends to the surface; thus we have in its second stage both tubular breathing and bronchophony. As, hoAvever, the consolidation of the lung renders audible the passage of the air along the bronchial tubes, Avhich could not be heard independently of it, so in the same Avay it gives an increased distinctness to the bronchial rattles, Avhich often become under these circumstances remarkably characteristic signs. AVe have noticed, already, that lymph effused into the substance of the lung may be either of the fibrinous or corpuscular kind, and also that it may vary as regards the proportion betAveen its different constituents. And there is good reason for believing that effusion of serum containing but a small proportion of fibrine or corpuscles, sometimes takes place suddenly into the cells, as a consequence of inflammatory engorgement of the lungs, and in the place, if we may be allowed the expression, of the plastic fibrinous lymph which con- stitutes hepatization. This is distinguishable from simple oedema or serous dropsy, by its being consequent upon engorgement, and preceded by the general symptoms of pneumonia: there are not, perhaps, any well-marked signs by Avhich its approach may be antici- pated, but it is most to be apprehended in those Avho are the subjects of any visceral disease, especially of the heart or kidneys, and in whom, from previous illness, or other circumstances, a deficiency in the fibrine and red corpuscles, or a want of constitutional poAver, may be apprehended. Its occurrence is generally attended by increased dyspnoea and lividity, often by orthopnoea—a feeble, quick, and sometimes intermittent pulse, by much the same symptoms, in short, as indicate suffocative bronchitis, from which it is to be distinguished by the previous history, and by the signs furnished by ausculation. Its stethoscopic signs are dulness on percussion, bronchophony, and tubular breathing, not, however, so well marked as in consolidation; and a moist or soft crepitation. AVhen consolidation has taken place, the next step in the progress of the change in the lungs is, commonly, the grey hepatization or puriform infiltration. The general symptoms which attend this stage 192 P N E U M 0 N I A. of the disease are principally those of diminished poAver, and activity in the fever; the latter of which assumes more of a remittent or hectic character; the pulse becomes soft and the skin generally cooler, though there are at times flushings of heat, and often profuse perspiration; the tongue is coated, red, and sometimes glazed, and the Avhole condition of the patient betokens a tendency to exhaustion. There is a frequent cough, with generally copious expectoration of a puriform character, commonly presenting the nummular appearance, though sometimes it looks like uniform pus: this expectoration has generally either a very offensive foetid odour, or a peculiar earthy one. The stethoscopic signs are just what might be expected from the nature of the changes going on in the lung; namely, a moist crepitation, with dulness, tubular breathing, and bronchophony,—the three latter, hoAvever, being much less distinct than in consolidation. When the disease goes on favourably, and the cells of the affected portion of the lung become emptied of their adventitious contents without injury to the tissue of the organ, the respiration becomes less embarrassed, and the tongue more natural; the hectic subsides, the expectoration decreases and gradually loses its unpleasant odour, and has less the character of pus and more that of mucus; the dulness, tubular breathing, and bronchophony, as Avell as the moist crepita- tion gradually disappear, and are either succeeded by healthy respira- tory murmur, or there is the recurrence of the dry crepitation (rale crepitant redux) before the healthy action of the lung is restored. It very often happens, hoAvever, that the disease takes an opposite course, the tissue of the lung becoming disorganized, or the patient sinking, without such actual destruction, from the exhaustion attend- ing the extensive suppuration: in this case the expectoration con- tinues of the puriform character, sometimes becoming intolerably foetid, or assuming a pinkish colour from the admixture of blood; the powers of the patient fail, the tongue becomes broAvn, and the pulse more feeble, the stethoscopic signs remaining little altered, unless an abscess form from the softening down of a portion of the infiltrated lung, in which case there will be gurgling cavernous re- spiration, and pectoriloquy. The passing of the lung into the state of iron-grey induration is not distinctly marked by any characteristic signs: when it takes place, the general symptoms of disease subside, but the resonance and respiratory murmurs are not restored at the part affected, and bron- chophony or even pectoriloquy may remain: the latter is generally the result of induration of the lung, which is attended by contraction, taking place when the pneumonia has been complicated Avith pleuritis and bronchitis: this contraction of the lung which has been rendered adherent to the ribs by the pleuritis, draAvs asunder and consequently dilates any large tube Avhich may pass through it; at the same time that the occurrence of the bronchitis renders the tube more suscepti- ble of such dilatation. The symptoms most commonly observed when the lung passes into a state of gangrene are a greenish colour of the expectoration, Avhich has a most intolerably foetid odour, at the same time that DIAGNOSIS. 193 there is a rapid failure of the powers of life in the patient, the fever assuming a Ioav typhoid form. Having already given the principal symptoms, both local and general, by which pneumonia is accompanied, we may confine our remarks upon the diagnosis of this disease to the means of distin- guishing it from those with AA'hich it is most likely to be confounded; and here it may be observed that pneumonia in its most ordinary form is not pneumonia in its most simple form, and that the cough, expectoration, and pain in the chest AA'hich commonly accompany it, and Avhich are generally the symptoms by which the attention of the practitioner is directed to the chest, but which, in reality, belong more to the capillary bronchitis which accompanies the pneumonia, than to the pneumonia itself, are consequently absent when the disease appears in its most simple form; in which case it can only be detected by a careful exploration of the chest by auscultation. The important point then to be borne in mind is, that pneumonia may occur without those more obvious signs which are commonly received as indicative of its presence, and that we are not to be diverted from our examination of the chest by their absence. The diseases for which pneumonia is most likely to be mistaken under these circumstances are continued fever and certain cerebral affections.—From fever it may be distinguished by the greater anxiety of the countenance, Avhich, though congested, presents an appearance very different from the stupid apathy of the latter dis- ease; and although the patient may be confused in intellect and even delirious, yet the delirium is different from that of fever, and more resembles that which we have noticed as occurring in exten- sive bronchitis, the patient being capable of being roused, and rationally ansAvering questions for a time, though soon becoming confused again. The tongue also presents an important difference, being covered with a Avhitish fur, unlike Avhat is observed in the com- mencement of fever. A most important aid in this often difficult diagnosis is that furnished by the pungent heat of skin, which we have already noticed as belonging to pneumonia in its earlier stages; for this we are indebted to Dr. Addison. It ought not indeed to be affirmed that pneumonia is present in all cases in which this peculiar heat of skin is found, for it may occur, as we have before said, in some other diseases, but where it is present it ought always to direct the most careful attention to the condition of the lungs. As regards the cerebral symptoms, pneumonia sometimes com- mences, especially in the young subject, with intense pain of the head, Avhich is very likely, if there be no cough or pain in the chest, to divert our attention from the lungs to the brain. In old persons again the same error may arise from the disease commencing with active delirium, or a threatening of delirium tremens; in children again we may have no obvious symptoms of disease, but such as seem to belong rather to hydrocephalus than pneumonia; though Ave must bear in mind that in the latter class of subjects the two dis- eases may often be associated. In all these difficulties the pungent heat of skin is a great aid, and should suggest a most careful exami- 13 194 PNEUMONIA. nation of the chest; but it must be remembered that in the com- mencement of simple pneumonia, when from the period of the dis- ease there is no loss of resonance to guide us, the crepitation is often not readily heard, and therefore it is necessary to make the patient take a very deep inspiration, at the termination of Avhich it may generally be detected; or to ask him to cough, the doing which is generally preceded by such an inspiration. In the commencement of ordinary pneumonia, which is the only stage in Avhich it can be mistaken for bronchitis, the state of skin above noticed will be an important guide, to which may be added the dry crepitation, and the character of the expectoration already described. In the more advanced stages of the disease, the charac- teristic signs of pneumonic consolidation should render such a mis- take improbable. The pneumonic crepitation, and the absence of the stitch in the side, will distinguish early pneumonia from early pleu- risy; but the diagnosis betAveen pneumonia that has advanced to con- solidation and pleurisy that has gone on to effusion is not so easy; there is, hoAvever, more probability of mistaking pleuritic effusion for pneumonic consolidation than the converse, and therefore the diagnostic signs belong more appropriately to the former, and will be explained hereafter. [A peculiar form of pneumonic inflammation is liable to occur in young children—of a strictly lobular character. It is in all cases consequent upon bronchitis or pulmonary catarrh;' and is hence de- nominated by Trousseau, who has given a very excellent account of the disease, pneumonic catarrh. The infant, after having suffered, at short intervals, repeated at- tacks of catarrh or bronchitis, often of apparently so slight a character as to excite little or no uneasiness, becomes suddenly attacked with fever; its face becomes congested; its cheeks and lips livid, and its skin hot and dry. The alae of the nose are widely, and almost con- stantly dilated, and the epigastrium is retracted toAvards the spinal column, causing a deep depression in the region of the diaphragm. The orthopnoea rapidly increases, and the pulse acquires an extreme frequency; rising often to 120,110, or 160 in a minute. If the hand be applied flat upon the thorax while the child is crying, the vibra- tion of the voice will be felt much more distinctly on the diseased than on the healthy side. In proceeding to auscultate the chest care must be taken not to alarm the child. Placed upon the lap of its nurse, the ear of the physician can be applied to the posterior and lateral regions of the thorax. Most frequently, a sub-crepitant ronchus is heard, pre- ceded, sometimes, by a mucous or sibilant ronchus—it is not rare to hear crepitation as fine as in the adult. Bronchial respiration is heard during expiration; but it has neither the dryness nor clearness observed in the adult. It is most frequently detected towards the upper part of the inferior lobe of the lung. The respiratory murmur may be heard at several portions of the chest; it is often absent, after the lapse of a few hours, in a part where it had before been distinctly heard. This results from the principal bronchial tube leading there PROGNOSIS. 195 having become blocked up with mucus, so as to prevent the passage of the air through it. In many cases, this form of pneumonia is of long duration, and liable to frequent relapses. It may continue for fifteen to thirty days, or even for several months. Acute attacks of it may occur five or six times in quick succession; or the diseases may go on, merely intermitting in intensity at irregular intervals, until it assumes a chronic form and thus continue for six months and even longer. This forms an important differential character betAveen it and the pneumonia of adults. The anatomical lesions are well marked. With inflammation and tumefaction of the bronchial mucous membrane, there are pre- sent a number of small indurated lobules, between which, the tissue of the lungs is healthy. The surface of the lung presents a marbled appearance. Besides these indurated lobules, AArhich are confined, sometimes, to a portion of one of the lobes, and sometimes invade the whole lobe, other lobules are of a violet colour, indicating pneumonic inflammation of the first degree; while, here and there, these masses are harder, and form projections Avhen the lung is collapsed. In these red lobules, by the aid of the microscope, globules of pus may be detected. In addition to lobules in the first and second degrees of pneumonic inflammation, there are still others of a yelloAvish colour, in the third stage of inflammation. Pneumonic catarrhal inflammation is followed by a special lesion; namely, disseminated abscesses, or small cavities—the air vesicles of the lung dilated, or several of these vesicles broken down—filled with pus. The number of those minute abscesses will, in some cases, amount to one hundred, or even many hundreds, in a single lung. It is often difficult to distinguish between this condition of the lungs in the third stage of pneumonic catarrh in children, and a condition of these organs, in young subjects, resulting from pulmonary tuber- culosis.—Editor.] In forming a prognosis in a case of pneumonia, as of every other disease attended with danger, Ave must keep steadily in view the modes of fatal termination, as, by so doing, we shall more readily detect the signs Avhich indicate such a result. Pneumonia is not often fatal in the first stage; it may happen, no doubt, that even at this period of the disease the extent of the lung involved may be such as to cause death by apncea, or the intensity of the inflammation such as to be fatal by syncope. We have also stated a belief, in which, perhaps, all may not concur, that inflammation of the lungs sometimes proves rapidly fatal by the state of engorgement passing, almost suddenly, into one of effusion into the substance of the lung; constituting an inflammatory dropsy of the organ, and causing death by apnoea. It more commonly happens, however, that pneumonia does not prove fatal before hepatization commences; when, if the portion of lung affected be large, and the disease attended by exten- sive bronchitis, there often appear symptoms indicating failure of the strength, with increasing difficulty of breathing, and death takes place from apncea. This change in the lungs sometimes ensues very 196 PNEUMONIA. rapidly, especially in a subject previously in a feeble state of health, and the patient may die in this manner within a week. When, however, the danger arising from a tendency to apncea has been escaped, the affected portion of lung frequently passes into the state of puriform infiltration, in which case death from sinking, or a tendency to failure of the heart's action, is to be apprehended. The prognosis, then, of pneumonia is to be founded upon a careful consideration of the severity of the attack, upon the presence or absence of the signs of the fatal termination which we have described, and upon the constitution, age, or other circumstances in the condi- tion of the patient, amongst Avhich are to be included complications with other diseases. When the patient is seen at the commencement of the disease, and is of moderately good constitution, and the inflammation not very extensive, especially if only one lung be involved; we may entertain a good hope of a favourable termination. If, hoAvever, the patient be advanced in life, or of generally unsound constitution, if the inflam- mation appear to affect a great portion of the lung, and still more, if both lungs are involved, or if there exist extensive bronchitis, or dis- ease of any other important organs, the danger is great. And even in the first stage of pneumonia, if there be delirium or great oppres- sion of the nervous system, and if the respiration be hurried, the countenance livid, the pulse very frequent and small, and the tongue disposed to become brown and dry, we may apprehend death by sinking or apnoea, or rather by a complication of both. When hepa- tization has taken place, the danger (besides the previous condition of the patient which bears upon all stages of the disease) depends chiefly upon the extent to which this change has taken place, and when that is great, if at the same time there be any of the signs already mentioned as indicating much impediment to the respiration and tendency to sinking, the prognosis is most unfavourable. At this period of the disease a moist and warm perspiration, with a some- what increased fulness, but at the same time diminished hardness, of the pulse, is a favourable sign, as is also the appearance of a lateri- tious deposit in the urine, and may be expected to be followed by the further favourable symptoms of a diminution in the dyspnoea and a recurrence of a crepitation in the portion of the lung which had been rendered irrespirable by the consolidation; and this sound, which has been denominated the urdle crepitant redux," is regarded as a sign of retrogression of the inflammation, and of the progress of the part affected to its normal condition. A good deal of stress has been laid upon the appearance of the expectoration in regard to the prognosis; though perhaps, as Dr. Addison observes, more is due to the ease and freedom with Avhich it is excreted: the sputa losing their very viscid and tenacious character, when there are other signs of the retrocession of the dis- ease, show that but little remains but the bronchitis; the appearance of a little blood in the expectorated matter is by no means an unfavourable sign; but the sudden suppression of the expectoration is a very alarming circumstance, and indicates either great exhaus- PNEUMONIA — CAUSES. 197 tion or complete closure of the air-cells through a great extent of the lungs. At a more advanced period of the disease the presence of pus, which has often a most offensive earthy odour, is a circumstance that ought to excite great anxiety, though it is not necessarily an unfavourable sign. It indicates, in conjunction with the symptoms which have been already pointed out (p. 191), the probable occur- rence of grey hepatization, or in other words, the softening down into pus of the lymph which has closed the air-cells. This change may, as we have seen, lead to the ultimate recovery of the part; but as there is great danger of the substance of the lung becoming impli- cated in the suppuration, and breaking down at the same time, or, what is even more probable, of the patient's powers giving way during the process, it bespeaks a very critical condition. In this state of things our prognosis must depend mainly upon the powers of the patient. If the tongue be tolerably healthy in appearance, the pulse of good power, and if there be none of the stethoscopic signs of disorganization, but on the contrary, some return of resonance on percussion, without any gurgling, though the soft crepitation may remain, and still more if the latter give place to the dry crepitation, Ave may hope that the process of cure is going on safely. Here, however, we cannot but watch the expectoration with considerable interest; the diminution of the foetor, and of the proportion of pus in the expectoration, and subsequently of the quantity of the sputa themselves, are favourable signs; but if they become more and more offensive, and assume a pinkish or greenish hue, and have not the nummulated appearance, but run into one homogeneous mass, we may infer that disorganization or even sloughing of the lungs is going on; and if at the same time the tongue become brown or red and glazed, the pulse quick and feeble, and if there be decided hectic, with rapid emaciation, and increasing dyspnoea, the prognosis is all but desperate. Dr. Alison remarks, and not without reason, that when the hectic, which in a greater or less degree attends the suppu- ration consequent upon pneumonia, is protracted beyond three weeks, ulceration of the lungs commonly with tubercular deposit may be apprehended. There can be little doubt, that the greater number of cases of active plastic pneumonia in previously healthy subjects are the direct result of severe exposure to cold, though in some, and those, too, of the most intractable character, there is every reason for believing that the disease is set up by the presence of a poison in the blood; thus it often occurs to all appearance spontaneously when the depurating action of the kidneys is arrested by disease of those organs; as well as in persons in whom there may be supposed to be an unhealthy condition of the blood from other causes; it occurs also in the progress of disease depending upon a morbid poison, as measles, influenza, and typhus fever. Pneumonia may also be set up by an irritation of a more direct character, as when it supervenes upon tubercles, or is set up by the accidental admission into the lungs of substances which irritate mechanically, or of acrid gases. 198 PNEUMONIA — TREATMENT. As an instance of the supervention of pneumonia upon the pre- sence of a morbid poison in the blood, wre must not omit to notice that Avhich occurs apparently in consequence of inflamed veins, or suppuration in other parts of the body, in which case the inflamma- tion in the lungs rapidly and certainly assumes the suppurative character; these cases are generally fatal, though there may have been instances of recovery. From what has been said of the various results of pneumonia, and the different modes in which it may prove fatal, it must at once be evident that there must be great difference, or even contrariety, in the means required for combating the disease. In acute pneumonia in tolerably healthy subjects, the treatment must be decidedly anti- phlogistic; that is to say, the recumbent position must be enjoined, and the patient restricted to the use of farinaceous diet; in addition to this, the temperature of his apartment should be uniform, and moderately warm, from 60° to 65° Fahrenheit. At the same time the easy action of the lungs should be insured by careful ventilation, so arranged as not to expose the patient to the least current of air. The next step should be, in the first stage of pneumonia, to bleed the patient in pro- portion to his strength and the activity of the disease. Bleeding has an undoubted power in controlling pneumonia in the first stage; and in healthy subjects, therefore, where Ave have good proof of its presence, and where there is no disease of the heart, blood-A'essels, or kidneys, the patient should be placed in a sitting posture, and blood allowed to flow from a vein in a full stream, until the patient feels signs of fainting, or until the pulse becomes softer, or if it have before been contracted, fuller, or until the sense of oppression about the chest is diminished. The abstraction of blood in this stage of the inflammation has, in all probability, a double action; in the first instance, it has the direct sedative effect upon the heart, and larger vessels, which we have already (p. 87) pointed out, as applicable to inflammation in general, but also, in the present case, it diminishes the quantity of blood sent to the lungs, and thereby lessens the amount of function which they have to perform. The relief afforded by a full bleeding, thus opportunely timed, is often very striking. Sometimes, however, although the breathing has been relieved, and the pulse rendered softer, or fuller, the symptoms will again become aggravated after some hours, when the venesection may be repeated with great effect; and in some instances there Avill be little need of further treatment. It may be observed here, however, that some- times syncope ensues, without any mitigation of the symptoms; a circumstance which is generally to be regarded as unfavourable, since it shows either a want of power in the system, or else that the extent of the inflammation is very great. After the bleeding has been performed, and repeated if necessary, the next object is to secure a free evacuation of the bowels; for which purpose the combination of rhubarb and calomel, followed, if neces- sary > by a cathartic draught, or half an ounce of castor-oil, will be well fitted. When we have any doubts of the bleeding being well ANTIMONY — MERCURY — OPIUM. 199 borne, it will be a safer practice to cup the patient on the surface of the chest, corresponding to the seat of the inflammation, to six or eight ounces—a measure which can be repeated if the inflammation should continue to extend. Before quitting the subject of the use of venesection in pneumonia, we would again call attention to the cautions which Ave have already given as to the abstraction of blood, in speaking of treatment of inflammation in general, (pp. 90—97,) and more particularly to opinions expressed that a partial subsidence of the inflammation having taken place after blood-letting, in those cases where it has afterwards extended, and given rise to effusions of an unfavourable character, is no proof that the bleeding has had no ill effect, since it may have disposed to an unfavourable termination. The remedies Avhich, next in order, demand our consideration are antimony, calomel, and opium. The former of these has been much recommended by practitioners in various parts of the Continent, more particlarly by the French physicians, many of Avhom are in the habit of relying mainly upon it for the cure of pneumonia. The practice which they recommend is to give it, in doses, commencing at about half a grain, and rapidly increased till irritation of the stomach and boAvels ensue, after AA'hich, if it be persisted in, what is commonly termed a tolerance will be established. The late Dr. Thomas Davis, however, Avas in the habit of administering the antimony in doses, commencing with one-third of a grain every hour, guarded by a few minims of tincture of opium at first,, which last was omitted if no signs of vomiting ensued, and the dose of the antimony gradually increased till it reached two grains. Now, from the explanation which has already been given (p. 98) of the action of antimony on inflammation, it might be inferred that in this, the first stage of pneu- monia, before the lung has gone into a state of consolidation, the antimony would be a most efficient remedy; and such is found to be the case in practice. In the ordinary acute pneumonia of sound sub- jects, provided the patient be seen in the commencement of the first stage, one or two bleedings, and the continuance of the antimony, in doses not exceeding tAVO grains every hour, or hour and a half, will often be sufficient to check the disease. In general, the antimony acts best when it does not excite vomiting; and, indeed, the tolerance which is found to exist in these doses, which may be called moderate when compared with those of the French physicians, is of itself a suf- ficient evidence of the propriety of its exhibition. It may, however, happen that the antimony will not be borne, or that the disease proceeds to the second stage in defiance of it; and, therefore, it is necessary to be provided with another remedy less irritating, and of which the operation will be appropriate to any con- solidation which may have taken place. Such a remedy we find in mercury. Accordingly, it will be generally found the best practice to administer the calomel and opium in the form of the pill already recommended, (F. 3 or 4,) twice or thrice a-day, at the same time that the antimony is being taken, and subsequently to increase the quan- 200 PNEUMONIA. tity of the calomel according to the progress of disease; that is to say, if the antimony is not borne it may be diminished and the calomel carefully increased until some effect is produced upon the system, or the disease is manifestly subsiding. Even in this stage the disease may, as has been already pointed out, prove fatal by apnoea, owing to the great extent of lung involved in the inflammation. When there is a threatening of such an event, a repetition of the bleeding, if the patient can bear it, affords the best chance of safety: after the skin has become soft, a large blister should be applied to the sternum. Signs of sinking from the extent and intensity of the inflammation may also manifest themselves; in which case it will be necessary to administer wine and stimulants, the mer- cury and opium being continued, and a blister applied over the inflamed portion of lung. In most cases we do not see our patients who are the subjects of pneumonia, until after the inflammation has proceeded to consolida- tion, Avhen the difficulty of combating the disease becomes much greater. In this stage our object must still be to check the progress of the inflammation, and bring about, if possible, resolution, and pro- mote the absorption of the inflammatory effusion; and in so doing, we must endeavour to prevent the occurrence of the third stage, or at least to guard against its disorganising consequences; in other words. we must be careful to spare the strength of the patient. Now, here bleeding will not exert the same influence OA^er the disease as in the stage of engorgement, and there is danger of its too far exhausting the powers of life; where, however, there is still considerable heat of skin, with a hard pulse, it may be ventured on, especially if there be dry crepitation still to be heard. As a general rule, hoAvever, it will be a safer and not less efficacious practice, to take a few ounces of blood by cupping from over the inflamed part of the lungs, and repeat the operation should the disease continue to extend; but even this is not to be done, if the pulse be compressible. Our next object should be to promote the absorption of the effused lymph, which has caused the consolidation. Now, for this purpose, we cannot look for much assistance from the antimony, but accord- ing to the principles already laid down (pp. 101-103), Ave may hope a great deal from the use of mercury. The French physicians, indeed, recommend the tartar-emetic even in this stage, but the prac- tice is not generally adopted by those of this country. As in the first we recommended the combination of calomel in moderate doses with the antimony, so in the second stage the combination of a little antimony with the calomel is found to be the most successful treat- ment, and to these opium is to be added, to allay irritation, and to prevent the calomel from running off by the boAvels. The best mode of proceeding then is to administer the pill (F. 3 or 4) every three or four hours, and in the interval about fifteen minims of antimonial wine in a mixture (F. 5). At this period of the disease, a blister may be applied with good effect, and repeated in the course of a few days. This treatment should be continued until there is evidence of TREATMENT OF SECOND STAGE. 201 the subsidence of the disease, in the diminution of the dyspnoea, and in the occurrence of the crepitation before mentioned over the seat of the consolidation; or until a decided effect is produced upon the gums ; unless there be signs of the remedy disagreeing. When amendment takes place, it will generally be best to diminish the quantity of the calomel, or to substitute for it two or three grains of blue pill, care being taken not to affect the system powerfully by the remedy ; which ought also to be withdrawn when there is pus in the expectoration, or any of the signs of the presence of puriform infiltration or grey hepatization of the lung. Should the remedy be well borne after the occurrence of the crepitation of returning respiration, it may be. cautiously persevered in till that crepitation is succeeded by the respiratory murmur of health. When, however, it happens that the gums become affected without any decided impression being produced upon the disease, the case becomes one of greater difficulty. Under these circumstances, if there be no signs of the medicine disagreeing, and no hectic or other sign of puriform infiltration, keep up a slight effect upon the mouth by small doses of some mild preparation for a few days, when, if there be no symptoms of any return of the consolidated lung, towards its healthy condition, the mercury should be discontinued, in which case the counter-irritation should be repeated; and the mixture of extract of conium (F. 23) be employed, to which, if there be little cough about a grain and a-half of iodide of potassium may be added; and at the same time a grain of sulphate of quinia may be given three times daily. It must be remembered that in this stage we may have the iron-grey induration supervene—a result which, although not amounting to a perfect cure, places the patient in com- parative safety, as no fresh disorganization is likely to ensue until he is exposed to some fresh exciting cause of the disease; and, conse- quently, it will be more desirable to favour this result by avoiding every cause of irritation, and gently supporting the patient's strength, than to run any risk of inducing suppuration by efforts to procure absorption, especially by the excessive use of mercury. Patients, who have undergone this permanent change in a portion of lung, have uncommonly a pale, doughy, and rather anaemic appearance. In the stage of puriform infiltration, our object must be to carry, if possible, the patient through a process of cure, which, as has been already pointed out, is attended with considerable danger; this danger arising from the texture of the lung becoming involved in the softening which is going on in the effused lymph, and the whole mass breaking doAvn together. The object of the practitioner then, in such cases, should be to allay irritation, and support the strength of the patient; for this purpose a bland nutritious diet is essential; good beef-tea and fish, or poultry or game when procurable, are good articles of diet; and where there is not great heat of skin, and the appetite tolerably good, a little mutton. Beer, or wine and Avater, or wine may also be allowed, their effects being carefully watched. The bowels must be regulated, and if the skin be moist, and there- be no 202 PNEUMONIA — TREATMENT. diarrhoea, the mixture (F. 28)* will be of use. When, hoAvever, there is a tendency to irritability of the boAvels, the acid must be omitted, and about five or six grains of sesqui-carbonate of soda may be added. If there be much flushing at night, with perspirations tOAvards morning, the bark or quinine may be of service, provided there be no great heat of skin in the intervals. A good form in such cases is the pill (F. 29).f The recovery of the patient may be forwarded, Avhen his strength admits of it, by a removal into a pure, but mild air; he must also continue every precaution as to his mode of living and the avoidance of exposure to cold, for some time after the disease has apparently ceased, which may be knoAvn by the pus disappearing from the expectoration, and the return of the sounds of healthy respiration in the inflamed part, by the patient getting flesh, strength, and his natural complexion, and the pulse resuming its ordinary frequency. AVhen the tissue of the lung with the effused lymph breaks down into suppuration, the case approaches very closely to one of phthisis, and must be treated accordingly. When a portion of inflamed lung becomes grangrenous, which may generally be known by the intolerably foetid smell of the breath and expectoration, the case is nearly hopeless ; though there is reason to believe that recovery does sometimes take place under the free use of stimulants, as wine, bark, ammonia, and aether. After all that has been said respecting pneumonia and its treat- ment, it should be remarked that the details of the latter are not strictly applicable in every particular to the greater number of cases in which we have to do with pneumonia of some form or other. The fact being that simple acute sthenic pneumonia is by no means a com- mon disease. Dr. Watson states that he rarely meets with more than five or six cases in a year, and in a vast amount of disease the author of the present work rarely finds more. Pneumonia is, nevertheless, a disease the consideration of which is of the utmost importance, since inflammation of the lungs supervening upon some pre-existing lesion is an affair of everyday occurrence. It is set up by the extension of the inflammation along the tubes in bronchitis, and by the irritation of the tubercles in phthisis, in the progress of which disease it plays a very important part. It is brought on by the pulmonic symptoms arising from disease of the heart, and it is excited by the state of the blood in diseases of the various depurating organs, especially of the kidneys. In all these different cases the directions which have been given for the treatment of pneumonia Avill require to be modified according to the general condition of the patient. * (28) R. Acid. nit. n^ iv. Acid. Hydrochlorici, n^ viij. Ext. Conii, gr. xij.—xv. Ext. Sarzte. ^ ss. Syrup. Aurant. 3 ss. Aq. purse, ^ iiiss. Misce. ; of which a third part is to be taken three times a-day; or infusion of bark may be used as a vehicle instead of water. f (29) R. Quinire Disulphat. gr. iss.—ij. Pulv. Ipecac, gr. ss. Bxt. Conii, gr. ij. ss. Ft. Pil. ; three or more to be taken daily. TYPHOID PNEUMONIA. 203 There is one form of pneumonia which may be regarded as the extreme instance of that condition in Avhich the active antiphlogistic measures applicable to the acute sthenic affection are not admissible, and in which the very opposite mode of treatment is found the most successful; this is commonly known as Typhoid Pneumonia. This form of the disease is often more insidious in its attack than is the sthenic; in some cases it is ushered in by rigors; but these are as frequently wanting, or so slight as to be overlooked, the patient merely having complained at times of being cold; there is commonly little or no pain in the chest; but the respiration is hurried, and the patient complains of an oppression of his breath; there is generally headache, and frequently early delirium. The tongue very soon becomes brown, and the teeth covered with sordes; the pulse also is very quick and feeble. The skin in the commencement of the dis- ease has the pungent heat of pneumonia; but it is afterwards dry, but not very hot; the expectoration has in the earlier stages of the disease the characteristic viscidity; it is generally of darkish yellow, dusky brown, or sepia colour; it often, however, becomes mixed with pus, and not uncommonly assumes a dingy colour, and in a great measure loses its viscidity; the sputa running, as it were, together, and being of a uniform opaque dirty green, or brown character, of the consistency of thick gruel, with not uncommonly of a foetid odour. The changes which are meanwhile going on in the lungs are, in the commencement, not very unlike those of acute pneumonia. There is first engorgement, but this engorgement is rather that of conges- tion than of inflammation; at all events, it does not give rise to the characteristic effusions of the latter, and possibly it is on this account that little or no crepitation is to be heard; what there is, is of a softer or moister character. In the next stage, the inflamed lung, instead of becoming consolidated by the effusion of plastic lymph, presents more of a soft pulpy consistence, not unlike that of the spleen. If, hoAvever, the inflammation be not at the very base of the lung, there will be bronchial respiration and bronchophony. The tendency of this form of inflammation is to disorganisation, generally in the form of purulent infiltration, and breaking down of the tissue of the lung; it more often happens, however, if the disease be not arrested, that the patient dies with symptoms of exhaustion before those changes can take place. Typhoid pneumonia is very apt to assume the lobular form, affecting many separate lobules through the lung. When this is so, there will rarely be crepitation audible in the first stage, or bronchophony in the second, and the diagnosis is consequently very obscure. When, however, the patient is seen early, the viscid ex- pectoration, and still more the pungent heat of skin, will enable us pretty surely to suspect what is going on; but where this is not the case, it is often next to impossible to distinguish the disease from low continued fever. It is fortunate, however, that the confounding this disease Avith fever, and treating it accordingly, is an error of far less practical consequence as regards the life of the patient than that to Avhich those are liable who are guided solely by physical signs, and having by these detected pneumonia, would proceed to treat the 204 TREATMENT. typhoid as the acute. It is rarely, if ever, that depletion can be borne in any stage of typhoid pneumonia, and it is only at the commence- ment that milder antiphlogistic measures are admissible; but it is very desirable to induce a gentle action of the skin and kidneys, and to allay irritation at the same time; care being taken not to depress the strength of the patient. It has been recommended to administer the tartar-emetic in pretty full doses, and bark or quinine in the in- tervals. In general, however, the bark will not be well borne while the tonge is coated and the skin hot, and the best practice will be found to be the exhibition of acetate of ammonia (F. 30),* with a diuretic and light tonic or diffusible stimulant; small doses of ipecacuanha or antimony may be combined with it at the commencement of the attack. Owing to the disorganising tendency of the disease, mer- curials must be used with great caution. A grain of calomel may be given twice or thrice a day, with a quarter of a grain of tartar-emetic, and a grain or half a grain of opium, according to the state of the bowels and the tendency to delirium; but the mercury should be carefully Avatched and withdraAvn so soon as there is the least appear- ance of any action upon the mouth, or there is reason to apprehend any suppuration in the lungs. Care should be taken from the first to support the patient by light nourishment, such as good animal broths and nutritious farinaceous food; but when the pulse begins to get more feeble, and the skin less hot, a little wine may be allowed, and if the circulation be not very feeble, a blister may be applied over the inflamed part, and at this period of the disease, also, ammonia may be added to the medicine, and the ipecacuanha or antimony withdraAvn; and if the circulation continues to fail, the compound- sulphuric aether may be substituted for the nitric; the wine also may require to be largely increased as the typhoid symptoms become more urgent; and it not very rarely happens that the patient in this apparently-hopeless condition recovers under the free use of stimulants. The form in which pneumonia most commonly presents itself in large towns, is one which we should be inclined to regard as inter- mediate between the sthenic and the typhoid. It has not the hard pulse and white tongue of the sthenic, though it has not the signs of prostration which attend the typhoid. The auscultatory signs are however those of active pneumonia. These cases might no doubt be made typhoid by the use of the lancet; but they generally do well with moderate doses of calomel with antimony and opium, or even hydrarg. c. cret. and Dover's powder, aided by a saline and anti- monial draught; a blister being applied after the skin has become perspirable. * (30) R. Sp. ^th. nit. 3 ss. Tinct. Hyosc. r^ xx. Liq. Ammon. Acet. 3 iij. Mist. Carnphorse, vel. Infus Serpentarise, ^ j. Ft. haust.; to be taken every fourth hour. To this the sesquicarb. ammon may be added, in doses of from two to five grains. PLEURITIS. 205 PLEURITIS. As pleurisy or pleuritis consists essentially in inflammation of the pleura or serous membrane which invests the lungs and lines the walls and floor of the chest, and as the symptoms are for the most part directly connected with the changes resulting from that inflam- mation, it will be best, in treating of this disease, to commence with the description of the latter. The first stage of inflammation, of this, as of every other serous membrane, is that of congestion or hyperaemia, in Avhich the membrane assumes a red colour, in consequence of the apparently-increased number of vessels ramifying immediately un- derneath its surface, this appearance depending, as has already been explained, upon the enlargement of the minuter capillaries, enabling them to admit the red corpuscles of the blood. It is not often, except in the case of accidents, or when the patient is cut off' by some other disease at the commencement of an attack of pleurisy, that we have an opportunity of seeing the membrane in this condition. Such ap- pearances have, however, under such circumstances, been ascertained to exist, and when an animal has been opened very soon after inflam- mation has been artificially excited in the pleura. At this time, so far from there being any effusion, the membrane is dryer than in health. This condition may either continue only a few hours, or may endure for several days, according to the greater or less intensity of the inflammation, or the greater or less strength of the constitution of the patient. The characteristic effusions of the inflammation then begin to show themselves. Now, it may be as well to bear in mind that these consist essentially in the first place of inflammatory lymph; though this lymph admits of every possible gradation, from plastic fibrinous lymph to corpuscular lymph with abundance of fluid. The plastic effusion generally first makes its appearance in thin layers or flakes upon the surface of the pleura, of a gelatinous consistency, these gradually becomes firmer, the fluid part either becoming absorbed or subsiding to the more depending part of the cavity. The more solid portion Avhich is thus left adherent to the surface of the pleura is at first of a greyish-white colour, and somewhat pasty consistency. The layers or flakes of this substance have at this period a soft villous appearance, and may be readily peeled off from the inflamed mem- brane, leaving it red with stellated vessels. The serum is of a pale straAV colour, at times transparent, and at others rendered turbid by the admixture of minute shreds of fibrine, and in some rare instances is coloured with blood. This then constitutes what may be termed the second stage of the disease, in which we have the soft villous layers of lymph adhering to the pleura, and the serous fluid above described gravitating in a greater or less quantity to the lower part of the cavity. From this stage the disease may follow several dif- ferent courses. In tolerably good constitutions the lymph becomes organised ac- cording to the process already described (pp. 53 et seq). Now, we 206 ITS PATHOLOGY. have already seen that if two surfaces of serous membrane, one of which is the seat of inflammation, are in contact, as would ordinarily be the case with regard to the costal or diaphragmatic, and pulmonic pleura, the inflammation extends by contiguity, and where there is a layer of lymph poured out upon one surface, the same takes place upon the opposed, and the minute vessels of each, which are formed in the process of organisation, inosculate Avith each other and thus adhesion is established. If, however, there is a large proportion of serum effused with the lymph, or in other words, if the effused liquor sanguinis contains a large proportion of fluid, the tAVO surfaces will be kept asunder, and the adhesion prevented; in which case the soft villous coat already mentioned as adhering to the pleura undergoes the ordinary changes of effused lymph, becomes firm, and assumes the properties of areolar tissue, and thus a new or adventitious layer of false membrane (as it is frequently termed), is formed either upon the surface of the lining of the chest, or of the coating of the lung. The time required for the formation of these coverings of new areolar tissue is exceedingly various; in some cases they are formed in a few days, and in others not within several weeks. Generally speak- ing, the plastic power is the greatest, and therefore early organisation is more to be expected, in young and robust, than in debilitated sub- jects. There is also a great variety in the extent to Avhich these membranes may be effused; sometimes they cover the whole lung, and line the Avhole of the walls and floor of the cavity. There is also a great variety in -the thickness of these membranes: sometimes they are scarcely thicker than the serous membrane itself; at others they consist of several layers, amounting to two or three or more lines in depth. One remarkable property of these membranes, to which allusion has already been made, is their tendency to contract; and when the costal pleura is lined by a tolerably thick layer of lymph, whether that layer be adherent to the corresponding portion of the pulmonic pleura or othenvise, there Avill often be a drawing together of the ribs on that side, causing flattening of the chest and some amount of lateral curvature of the spine. AA nen there is a large quantity effused, separating the lung from the ribs, absorption may take place, and the contact between them being restored, the contraction above spoken of will ensue. Sometimes, hoAvever, this absorption is sus- pended, and the side, instead of contracting, bulges out from the great accumulation of fluid ; one effect of Avhich is, that the lung is compressed against the bodies of the vertebrae, so as in some cases entirely to exclude the air, and( give it the appearance of a dense fleshy mass, which, however, unless constricted by the false mem- brane, is capable of being again inflated ; in this condition it is said to be earn fed. AVhen this effusion is upon the left side of the chest it often presses so strongly upon the mediastinum as to thrust it, and the heart Avith it, to the right side, so that the latter may be felt beating to the right of the sternum; sometimes, when it is on the right, the dislocation towards the left is perceptible; in the latter case, too, it often thrusts ITS GENERAL SYMPTOMS. 207 doAvn the liver, so as to give the appearance of enlargement of that organ. AYnen the fluid remains in the cavity of the chest for a con- siderable time, or when it occurs in an unsound constitution, it com- monly assumes a puriform character, presenting every possible gradation betAveen serum rendered turbid by the presence of a few pus globules, and perfect pus; this is termed empyema. When an empyema is thus established, the false membrane by which it is lined assumes the characters and properties of pyogenic membrane, and continues to secrete pus. This pus is commonly free from offen- sive odour as long as the air is excluded: but Avhen any has been admitted, the fluid generally becomes intolerably foetid. Both these statements, however, admit of exceptions. AYnen the cavity of the pleura is thus filled with pus, it often happens, that, after a time, there is a bulging in one of the intercostal spaces, generally rather Ioav in the chest, as between the sixth and seventh, or seventh and eighth ribs; which soon fluctuates upon being handled, and has all the appearance of an abscess pointing, as it is termed. If this be not opened by the knife, the pus makes a Avay for itself by ulceration, and thus escapes (a portion of it at least), spontaneously. Unless, however, the lung expand sufficiently to fill up the cavity of the pleura, Avhich is rarely the case, the pus cannot all Aoav out, unless its place is refilled by air, and this is one Avay in Avhich air is admitted into the cavity of the pleura, constituting what is termed a pneumo- thorax. Sometimes, again, but not so frequently, ulceration takes place through the pleura covering the lung, and thus the pus finds its Avay into the substance of that organ, and occasionally produces death by suffocation; at others a communication is established with a bronchial tube, and thus a large portion of the pus is got rid of by expectoration; at the same time that a pneumothorax is established by the admission of air through the opening. The fluid does not ahvays move freely in the cavity of the pleura, as it is not uncommon for adhesions to form around an effusion either of serum or pus, con- stituting Avhat is termed a circumscribed empyema. AVhen an empyema of this kind points outAvardly, or is opened by the surgeon, or Avhen it opens by ulceration into the lung, there can be no exten- sive admission of air into the cavity of the pleura, and the lung is prevented from collapsing by the circumscribing adhesions. Such are the principal structural changes in the pleura caused by inflammation of that membrane. It Avill be Avell next to connect these changes with the symptoms observed in the course of the dis- ease. Pleuritis then commonly is ushered in by the ordinary signs of inflammatory fever, as pain in the limbs, rigors followed by heats, head-ache, scanty and high-coloured urine; the tongue is white and furred^the pulse rather hard and frequent, the skin hot but disposed to be moist, and differing much from the pungent heat of pneumonia. With these signs of constitutional disturbance there is first felt in the chest, and most commonly at the seat of the inflammation, a sharp pungent pain which often seems to shoot in various directions. This pain is always increased by drawing a deep inspiration, whence it is familiarly known as a stitch; by coughing, and often, though not 208 PLEURITIS. always, by pressure upon the part affected. The pain gradually increases in severity; it is most severe in persons of vigorous consti- tution, but in some leucophlegmatic- subjects the disease often creeps on insidiously, and with so little pain, that it is at first nearly over- looked. When the inflammation is near the apex, the pain is often very slight, but when near the angle between the ribs and the dia- phragm, or upon the diaphragm itself, it is commonly most intense. There is sometimes considerable tenderness upon external pressure, in which case the patient lies most easily upon the sound side, gene- rally Avith the shoulders rather raised so as to cause a curvature of the spine with the concavity towards the affected side. Often, how- ever, there is no tenderness, in Avhich case the easiest position is on the affected side, as the pressure thus produced, helps to keep the ribs at rest, and in some degree prevents the pain which is caused by the respiratory movements. The expression of the countenance is very remarkable, being that of a peculiar smile or grin, to which the term risus Sardonicus has been applied ; it arises no doubt from the constrained mode of breathing and the continued apprehension of taking an inspiration, sufficiently deep to cause the sharp lancin- ating pain which commonly attends it. The constrained movement of the ribs and diaphragm which is thus produced furnishes one of the most interesting signs of this disease, though one Avhich has not till lately, received the attention which it deserves, and for the elucidation of which the profession is mainly indebted to Drs. Hutchinson and Sibson, though its importance in connection with the aetiology of disease was noticed in the Guy's Hospital Peport of the year 1-11,* and subsequently in the Guls- tonian Lectures. AYnen the inflammation affects the pleura costalis, or a corresponding part of the pleura pulmonalis, the ribs on that side are nearly fixed, but the movement of the diaphragm is not impeded, and the respiration is abdominal; when, on the other hand, inflammation affects chiefly the pleura covering the diaphragm and that over the base of the lung, the respiration is, for similar reasons, thoracic, or more commonly carried on almost entirely by the upper ribs; often, however, the respiratory movement of either part is rather diminished than altogether arrested, and for the purpose of measuring the diminution a very ingenious instrument has been contrived by Dr. Sibson. The next condition to be investigated is the respiratory sound: noAV, as has been already observed, the two surfaces of the pleura glide, in health, so smoothly over each other that no sound is elicited. In the earliest stage of the inflammation, before any effusion is pro- duced, the natural secretion of the part being diminished or arrested, it is reasonable to expect that there may be some slight friction sound; and such a sound is stated by some authors to be one of the diagnostic signs of this stage of the disease; it may, no doubt, be sometimes heard, but it is very faint, and owing to the diminished * Vide Guy's Hospital Report, vol. vi., p. 235, et seq., and Gulstonian Lectures, by G. H. Barlow, M. D., in Med. Gazette for 1844. SIGNS OF EFFUSION OF LYMPH. 209 motion of the part it is but rarely heard, and therefore but little value is to be attached to it in practice. It is, however, in the next stage, that of effusion of liquor san- guinis, or inflammatory lymph, when the general or constitutional symptoms are but little altered, that the auscultatory, or one might say the physical signs generally, are of value; and we need merely revert to the statements already made, respecting the different forms which the inflammatory lymph may assume, to make it at once appa- rent that we shall have corresponding differences in the physical phenomena. Let us take first the case of the effusion of fibrinous lymph with a small quantity of serum, which is quickly absorbed. As the pain and tenderness of the membrane remain as at the commencement, the diminished mobility of the part will also continue, and the resonance will be but little affected; but Ave shall have the first unequivocal instance of those friction sounds to which allusion has already been made. In the earliest condition of the plastic lymph, as already described, it is soft and villous, not indeed moving Avith the ease and noiselessness of the healthy membrane, but not yet capable of pro- ducing any rough or grating sound. AA7hen, therefore, the ear or stethoscope is applied to the surface of the chest near the part which is in this stage of inflammation, we hear a very soft sound, which indeed can only with difficulty be distinguished from a moist crepita- tion or a fine bronchial rattle; when, hoAArever, the new membrane becomes firmer from the further absorption of the serum, the friction sound becomes rougher, and, as it were, dryer, sometimes resembling the rubbing of the cuff's of the coat together, and sometimes having quite a rasping sound. In the latter instances, Avhere in fact we have the friction produced by the tougher and nearly organised membrane, a vibration, or " fremissement," may be distinctly felt by laying the fingers in the intercostal spaces over the part affected. When the inflammation is situated in the diaphragmatic pleura, and that, part of the pulmonic pleura which is in apposition to it, there will of course be but little if any friction sound to be heard; and, unless it extend up the side of the chest, or there be effusion of fluid in sufficient quan- tity to make its presence apparent by the characteristic physical signs, we can derive but little aid from the stethoscope, and consequently the diagnosis becomes much more difficult. Under these circum- stances, however, we may obtain much assistance from the general symptoms of serous inflammation, with the exception, however, that the pulse is often very small, contracted, or, as it is termed, wiry; and the general distress and expression of anxiety more intense; indeed, there appears to be a remarkable tendency in inflammation of the diaphragmatic pleura to depress the moving powers of the circulation, not unlike that which we shall hereafter have occasion to notice as accompanying inflammation of parts immediately beloAV the diaphragm. Another important aid to the diagnosis in such cases is to be found in the altered mobility of the ribs; the diaphragm on the side affected (and it is not uncommon for this form of pleurisy to attack both sides) is nearly fixed, as are also the four inferior ribs, 14 210 PLEURITIS. termed by Dr. Sibson the diaphragmatic ribs. After all, however, it will remain very difficult, and in some cases next to impossible to distinguish between diaphragmatic pleurisy and other inflammations in the same region of the body, or immediately below the diaphragm; especially inflammatory affections of the peritoneum covering neigh- bouring structures, since the immobility of the lower ribs and dia- phragm and the depression of the circulation will often be the same. When the effused lymph has formed adhesions between the two apposed surfaces of the pleura, the friction sounds will generally cease, but there will commonly, for a short time afterwards, be a creaking or leathery sound accompanying a deep inspiration; this will often continue with greater or less intensity till the new mem- brane has become organised, when the inflammation may be said to have ceased, and we have to do only with its permanent effects. There will also be immobility, or diminished mobility, of the ribs or diaphragm, according to the part affected; and where the lymph is very thick betAveen the two surfaces of the pleura there will be defective resonance, owing to the diminished elasticity of the walls of the chest, but not the almost perfect dulness of large serous effu- sion, or extensive pneumonic consolidation. AYnen, however, as very often happens, the serum is not absorbed, and remains in considerable quantities in the cavity of the pleura, we have a different set of phenomena. If it be not circumscribed by adhesion it subsides to the lower part of the chest, raising in some measure the lung, which, Avhen not consolidated by disease, is speci- fically lighter than the fluid; when the latter is not in any large quantity, there is no great impediment to the function of the lung, and consequently the pulse and respiration are but little affected; as, hoAvever, the quantity of the fluid increases, the respiration becomes much embarrassed; and since owing to the compression of one lung, the quantity of blood in the pulmonic circulation is much diminished, the quantity returned to the left side of the heart must be so like- wise ; and consequently the pulse becomes either very small, irregu- lar, or intermitting. Another effect of the diminished function of respiration and impeded pulmonic circulation is the imperfect aera- tion of the blood, and consequent lividity of the lips and tongue, with congestion of the countenance. This obstruction of the pulmo- nic circulation also produces its ordinary results—obstruction to the return of the blood in the veins, and, when long continued, anasarca, generally of the most depending parts, engorgement of the right heart and portal circulation, scanty urine, and general derangement of the secretions. The position also of the patient may assist us in detecting pleuritic effusion; respecting this a good deal has been written, though not always very clearly. When there is much fluid in either cavity, it must necessarily happen that the pressure, not only upon the lung on the side affected, but also upon the mediasti- num and through it upon the opposite lung, must be increased by the recumbent position, and consequently there is most commonly orthopnoea, or if not that, a necessity for a semi-erect position. AVhen, hoAvever, the quantity of the fluid is not very great it is rea- SIGNS OF EFFUSION. 211 sonable to expect that the pressure upon the opposite lung will be the least, and consequently the respiration the easiest when the patient lies on the affected side. Generally, however, owing pro- bably to the larger hollow which is formed between the bodies of the vertebrae and the angles of the ribs, the patient lies easiest not exactly upon, but towards the affected side, in a diagonal posture, as Andral has termed it, resting in fact mostly upon the angles of the ribs of the affected side. Still there are many exceptions to this rule, depending partly, no doubt, upon the presence of adhesions, and partly upon the condition of the opposite lung; so that cases are not very uncom- mon in Avhich the patient may lie indifferently on either side, although one pleura may be quite full of fluid, and in some the patient even lies the. most easily on the sound side. It is true, indeed, that all the above symptoms may arise from other causes than effusion, and therefore to these must be added the signs arising from the physical changes, which may be detected by inspection, manipulation, and auscultation. Now, effusion into the pleura in large quantities almost always causes a fulness of the ribs on that side, Avhich may generally be per- ceived by inspection. It must not be forgotten, however, that it has been stated that the contraction of false membrane, formed by pleu- ritis, causes a draAving in of that side or bending of the spine towards it, the effect of Avhich is to give an appearance of a bulging of the ribs on the opposite side; and it is no imaginary case for the contrac- tion of the plastic effusion of a pleuritis on one side to have given rise to the suspicion of a large effusion of fluid on the opposite. Not only is there this bulging of several of the ribs together, but there is often a degree of protrusion of the intercostal spaces beyond them, producing an appearance, especially in the lean subject, the very opposite of that which is commonly observed^ namely, of these spaces being more prominent than the ribs; this is accounted for, by Dr. Stokes, upon the principle that the intercostal muscles lose their con- tractility, and consequently the poAver of resisting the pressure of the fluid Avithin the chest, by their being overlaid by an inflamed mem- brane. And there is, no doubt, much truth in this explanation, but it is to be regarded rather as an illustration of an interesting patholo- gical law, than as an aid to diagnosis; since the fluid effusion may be present, but it may have been poured forth by a part different from that at Avhich it produces the greatest lateral pressure; as, for instance, the inflammation may have been in the pleura covering the diaphragm, but the effusion, if abundant, may ascend up the sides of the chest, and the pressure would be in the same situation as if the fluid had been poured out by inflammation.of the costal pleura, but the inter- costal muscles would not in this case have lost their contractility, and consequently no protrusion of these spaces would ensue. The bulging of the ribs may be more satisfactorily determined by com- paring the corresponding measurements of the two sides, though it may be observed that this requires the greatest caution in adjusting the tape or whatever is used. Considerable aid in the diagnosis of effusion may also be obtained 212 PLEURITIS. by manipulation or manual examination of the chest and hypochon- dria. AVhen the hand is placed upon the ribs of a person in health, while speaking, a peculiar thrill or vibration may be felt which has been termed the tactile vibration of the voice. This vibration is no doubt greater in some persons than in others, as in thin than in corpulent subjects; it is less also in old than in young subjects, and is diminished by thick and firm adhesions, but in none of these cases is it obliterated, which hoAvever it is completely Avhen there is any considerable quantity of fluid in the pleura. AVhen this is the case, and the palm of the hand is laid upon the loAver ribs, vibration will not be felt in the slightest degree, and its absence may be rendered more striking by contrasting it with the opposite side; and it will be more or less extensive according to the amount of effusion, and may generally be most plainly perceived over the angles of the inferior ribs. By manual examination the position of the heart may also be ascer- tained, and the presence of fluid in the left side often detected by its being thrust to the right; the dislocation of the heart towards the left side by fluid in the right pleura is not so obvious, and can only be observed when the fluid is in great quantity. The motion of the abdominal parietes in respiration should also be explored by the hand for the reasons already explained; though it should be remem- bered that other diseases will interfere Avith the descent of the dia- phragm. Percussion affords most important aid in detecting the presence of fluid in the pleura; as the resonance of the chest is diminished or impaired according to the amount of the effusion. It must be remem- bered, hoAvever, that a considerable quantity may be present at the base of the cavity Avithout its being detected, in this manner, espe- cially on the right side, where the neighbourhood of the liver always causes a greater or less degree of dulness. AVhen the quantity of the fluid is great, but not sufficiently so perfectly to destroy the reso- nance of that side of the chest, the dulness is commonly at the lower part, when the patient is sitting up, and may be traced in nearly a horizontal direction to the anterior. When the patient lies on his back the fluid will of course gravitate toAvards the posterior part of the cavity, and the dulness may be observed ascending more or less towards the anterior part of the chest, Avhich, Avhen the fluid is not in very great quantity, will have become resonant, and this will aid in distinguishing it from the fixed dulness resulting from pneumonic consolidation; this sign, obtained from the shifting of the fluid, is not of universal application, and although its presence may be looked upon as conclusive in support of the question of effusion, its absence is not so against it. The most important of the physical signs of pleuritic effusion are those derived from auscultation. The principles which give rise to these characteristic phenomena are, that the effused fluid compresses the lung so as in some parts to prevent altogether its inflation in in- spiration, and in others to modify the sounds of respiration ; secondly, that the effused liquid is a far better conductor of sound than the spongy texture of healthy lung; and lastly, that the vibrations of SIGNS OF EFFUSION. 213 the fluid give a peculiar character to the sounds of the voice and respiration. According to the first of these principles, we find that the respira- tory murmur is commonly absolutely silenced in the part most com- pressed by large effusion, as in the lower lobe when the patient is in the erect posture; whereas in the upper part of the lung, which is pressed against the walls of the chest, the vesicular murmur of re- spiration is more or less diminished, at the same time that the con- ducting power of the lung is increased; the effect of which is to render the respiratory sound coarse and rather hissing. The sound of the air passing through the bronchi is also rendered more audible from the same cause: this, however, can only be the case where the lung is but little compressed, since the greater the compression, the less must be the amount of air passing through the tubes; therefore, when the patient is in the erect position, bronchial respiration is to be heard only at that portion of the chest Avhich lies near the upper boundary of the fluid (as indicated by dulness on percussion), and that not with the same degree of intensity with which it may be heard in consolidation of the lung. It should be remembered that as the lung is connected with the walls of the chest, near the bodies of the vertebrae, it must, when there are no adhesions, recede from the ribs Avhen pressed upon by fluid, but as this" pressure will be the greatest at the lowest part, it will be more compressed, and also recede further from the parties at the base in the erect position, and will approach more closely to them higher up; and, except in cases of very great effusion, such as are rare Avhen it is of an inflammatory character, there will be contact between the surfaces of the pleura above the fifth or fourth rib, the result of Avhich must be a layer of fluid between the lung and the ribs, diminishing in width from below upwards: the effect of this is to give a coarse and rather hissing sound to the respiration above the highest line of the fluid: below this there will be little, if any, vesicular murmur, but the respiration will be tubular or bronchial, and at the same time distant, that is to say, not appearing to proceed to the ear from a point immediately beloAV the ribs, but some distance beyond them; but lower still, where the stratum of fluid is of the greatest Avidth, there is scarcely any respiratory sound to be heard. It is well here to point out, that as the compression, and conse- quently the diminution of the respiration, is the greatest at the lowest part of the lung, there can be little air passing through the bronchial tubes above; which is one reason of the bronchial respiration not being so distinctly heard as in the case of pneumonic consolidation, where there is respirable lung beyond the consolidated part, and therefore air passing freely along the tubes Avhich traverse it. As regards the voice, however, the case is different, for, as was remarked when we spoke of pneumonia, its sounds are not rendered audible at the surface of the chest by the transit of the air through the tubes, but by the propagation of the sonorous vibrations along the tubes; which vibrations, though they are not sufficiently intense to be heard through the healthy lung, become audible Avhen there is condensed 214 PLEURITIS. lung interposed between the liquid effusion and, the tubes and the walls of the chest, and thus it is that the vocal sound already de- scribed by the term bronchophony, is produced; the bronchophony being the most distinct some little way below the highest line of the fluid, where there is sufficient compression to condense the lung around some of the tubes nearest the surface of the pleura, but not sufficient to obliterate the tubes, or greatly to obstruct the sound. We have stated that the effused fluid has a peculiar effect in modify- ing the sound produced by the voice in the tubes: this consists in giving it a remarkable vibrating or tremulous sound, Avhich Ave pro- pose to term tremulous bronchophony. Laennec compared the sound sometimes heard under these circumstances, to the bleating of a goat, and called it cegophony; but this is a sound which we can very rarely hear, though when heard, it is most striking, and may be re- garded as pathognomonic. Its rarity is probably owing to a definite depth in the layer of fluid, and perhaps also a fixed size of the tube being required for its production. The more ordinary tremulous bronchophony, or, as some have termed it cegophonic bronchophony, is a sound which may almost always be heard where there is a mo- derately thin layer of fluid betAveen the ribs and the lung; it is generally discoverable from the line where the resonance begins to diminish, to where the respiratory sound is altogether lost, and is one of the most constant and distinctive signs of pleuritic effusion, if not the most so. Such are the principal signs of fluid in the pleura, by which such effusion can commonly be recognised. As, however, the diagnosis between this and the dulness arising from pneumonic consolidation is one of considerable practical importance, it will be well briefly to recapitulate the points of difference. 1. In the first place, the previous cause of the disease, as far as it can be ascertained, is of some assistance. In pneumonia there is not necessarily pain in the side affected, and Avhen present, it is not severe, whereas that of pleuritis is sharp and pungent; in the pro- gress of pneumonia there will generally have been the rust-coloured viscid expectoration, in pleurisy there is little or none; the occurrence of this expectoration does not, however, prove that the dulness in question arises from pneumonia, since, though this disease may be present, the probability is rather in favour of its being complicated with pleuritis. 2k Pleuritic effusion often distends the cavity, and either causes elevation of the intercostal depressions, displacement of the heart, or depression of the liver, none of which occur in pneumonic con- solidation. > 3. When the quantity of effusion is not so great as to render the whole side of the chest dull upon percussion, there will be a tremulous bronchophony a little below the upper line of dulness; and in the same situation tubular breathing may be heard likewise, but beloAV this line the sounds of the voice and respiration are silenced alto- gether ; in pneumonic consolidation, on the other hand, the dulness, and bronchial voice and respiration are generally coextensive. When ITS CAUSES. 215 the quantity of fluid is such as to cause universal dulness, the sounds of respiration will be altogether silenced, although those of the voice may still be heard over the upper part of the lung, and we shall have' the further distinction, in the case of effusion, of— •1. The absence of the tactile vibration, which, on the other hand, is not at all diminished by pneumonic consolidation. It must be remembered, however, that although in the majority of cases, the diagnosis betAveen pleuritic effusion and pneumonic con- solidation is comparatively easy, yet in some instances, amongst which may be reckoned effusion circumscribed by adhesion, the dis- tinction is next to impossible. Under these circumstances, too, there is some difficulty in distinguishing the former disease from enlarged liver, and from malignant disease of the lung or pleura. The causes of pleurisy are— 1. Exposure to cold. This is perhaps the most common, if not the alone, cause of pleurisy as a primary affection. Even when thus pro- duced, however, it is very often associated with pneumonia; the dis- eases under such circumstances are not to be regarded as cause and effect, but as the joint effects of a common cause. 2. It may arise from disorders of remote organs, as when disease of the liver or kidneys, but especially the latter, impedes the depura- tion of the blood by those organs, in which case, as we shall have further occasion to observe, inflammation is very apt to arise sud- denly in some serous membrance; again, cases of pleurisy sometimes occur which depend on the presence of suppuration in other parts of the body, and also in specific inflammations of the skin, as erysipelas; these are of a peculiarly dangerous and intractable character. The presence of other morbid poisons in the system may also excite inflammation of the pleura, as well as of other serous mem- branes; of this we have a familiar instance in the frequency and intensity of pleuritis occurring in influenza. Pleurisy may also be excited by extension of disease in a neigh- bouring organ, the most common instance of which is, the inflamma- tion of a part of this membrane covering a tuberculous portion of lung; it is also set up over a diseased rib; and sometimes, though not so frequently, by extension of disease below the diaphragm, as when intense inflammation occurs in the peritoneal covering of the latter. The same thing likewise happens occasionally in inflamma- tion of the pericardium. Pleurisy may also be the effect of mechanical injury, as of the splintered ends of a fractured rib; and sometimes of a severe blow, independently of any such fracture. The admission of air into the cavity of the pleura will almost ahvays, though perhaps not universally, excite inflammation of that membrane; and thus it may be induced not only by accidental injuries, or surgical operations, in which the air enters from without, but also by the extension of disease in the lung to the surface, in which case the air enters from within. In this way, a tuberculous cavity may, by opening into the pleura, establish a. communication between a bronchial tube and the cavity of that membrane. It ordinarily happens, that, as the inflammation extends towards the 216 PLEURITIS. surface of the lung, the pleura covering it becomes inflamed, and this inflammation, extending by contiguity to the costal pleura in appo- sition to the part, adhesion ensues, and thus the escape either of air or matter is stopped, and the great extension of the pleuritis is pre- vented. Sometimes, nevertheless, the ulceration reaches the pleura without any such adhesion, and the consequence is an escape of air, and perhaps matter, into the cavity. A pulmonary vesicle, distended by emphysema of the lung, and lying immediately beloAV the pleura, may give way during some strong exertion, and thus an escape of air takes place into the pleura. In almost, if not entirely, all cases in which air thus finds it way into the pleural cavity, inflammation of the membrane ensues, and the product of such inflammation is almost certainly puriform. Instances sometimes occur indeed, in which, from the latter of the causes mentioned, namely, the sudden giving way of a dilated vesicle, there appears to be very little, if any inflam- mation or effusion in the pleura for a considerable time. There is, again, another way in which a communication may arise between the pleura and the bronchi, and that is, when a circumscribed pleuritic effusion ulcerates through the pleura pulmonalis; though its taking this course is far less common than its making its way through the intercostal spaces. The presence of air in the pleura has been designated by the term pneumothorax; when, however, as generally happens, there is like- wise fluid in the cavity, it is termed pneumothorax with effusion, and sometimes empyema with pneumothorax, or hydro-pneumothorax, which last term, however, is objectionable. The invasion and presence of pneumothorax are characterised by remarkable symptoms, with which it is very necessary to be acquainted, and Avhich are the result of the sudden admission of air between the two surfaces of the pleura, of the more or less rapid collapse of the lung, consequent upon it, and of the inflammation of greater or less intensity, which nearly always attends it. We here speak more especially of those cases in which the pneumothorax is the result of admission of air through the lungs, since, in those cases in which it finds its way from without, the nature of the wound or operation renders the disease sufficiently obvious. When a pneumo- thorax is caused by perforation of the pleura from a vomical cavity, there will most commonly have been previous signs of phthisis, though not necessarily far advanced: the patient is suddenly seized with intense lancinating pain in the side, urgent dyspnoea, and fre- quently a great depression of the heart's action, threatening death from syncope, which sometimes actually ensues. It most commonly happens, however, that after a time reaction takes place, and there are the symptoms of severe pleuritis, though generally with con- siderable depression of the vital powers, the pulse being small and wiry; the patient breathes laboriously; generally reclines in a semi- recumbent attitude, with the shoulders raised, not turning, most commonly, entirely to either side, but assuming a sort of diagonal position, and supporting himself as it were upon the scapula; the side towards which he turns being either the sound or affected side, PNEUMOTHORAX. 217 according to circumstances: most commonly, however, it is the affected side. At the first escape, indeed, of the air into the pleural cavity, the quantity of matter which accompanies it being for the most part small; the pressure of the sound lung, as well as the heart, when the pneumothorax is on the right side, upon the mediastinum stretched over an empty cavity, might be supposed to cause some inconvenience, though this is very doubtful; but after a time, when the fluid has increased, there is far more inconvenience felt by the pressure of that fluid, or by its gravitating, through the opening in the lung into the trachea; and the patient then lies on the affected side. The dyspnoea almost ahvays continues, in a greater or less degree; and when the quantity of air, or the subsequent effusion is very great, there will also be displacement of the heart, as in hydro- thorax ; sometimes also there is protrusion of the intercostal spaces. The air, of course, escapes into the cavity, with greater or less rapidity, according to the size of the opening; and the distending force of the air in the lung being counterbalanced by that between it and the walls of the chest, the lung collapses by its natural elas- ticity, and, when not prevented by adhesions, is compressed into a small space against the vertebrae and mediastinum. Sometimes the opening in the pleura is valvular; and the air, entering the pleura at each inspiration, is unable to escape, owing to the closure of the valve by the greater pressure exerted upon the inner surface when the ribs descend in expiration; and the result is an enormous accumulation of air in the pleura, threatening suffocation;. which, if it be not allowed to escape, sometimes ensues. It occasionally happens that a person subject to emphysema of the lung, is suddenly seized with urgent dyspnoea during exertion, or in a fit of coughing; this is fol- lowed by signs of pleurisy, not commonly of equal severity with those in the former case: here a dilated vesicle has given way, and allowed the escape of air into the pleural cavity; the same thing may also be brought about in gangrene, or sloughing of the lung. In the case in which an opening is made from the pleura into the lung, by an accumulation of pus in the former making its way into a bron- chial tube, the collapse of the lung will generally be prevented by the surrounding adhesion, and the dyspnoea will rarely be urgent, unless the quantity of matter be so great as to be incapable of being expectorated with sufficient rapidity to prevent a considerable por- tion regurgitating through the tubes into the rest of the lung. These cases too are characterised from the first by a copious discharge of pus, which soon becomes foetid. The physical signs of pneumothorax are highly characteristic, pre- cisely, in fact, what might be expected from one side of the chest containing air with some liquid, and the lung being collapsed. When the affected side of the chest is percussed, it emits, over a considerable extent, a sound far exceeding in resonance that of the same region when filled with ordinary inflated lung, and more resem- bling the drum-like sound of a flatulent stomach, at the same time that the natural sounds of respiration are perfectly silenced; thus presenting a contrast to the opposite side, Avhere the resonance is 218 PLEURITIS. somewhat diminished, and the respiratory sounds increased. When, however, the patient speaks or coughs, there will be heard a remark- able ringing metallic sound, which, from its resemblance to the ringing of a nearly empty cask, has been termed amphoric, and which may be imitated by applying a child's india-rubber ball to the ear and gently striking it. A similar sound may be elicited by gently tap- ping a chest in this condition, provided it be not done too near the part where the stethoscope is applied. These sounds receive a strik- ing addition from the presence of fluid, the least agitation of which, from the movements of the patient, give a tinkling sound, the tinte- ment metallique of French authors. The fluid, of course, occupies the lower portion of the chest, and the air the upper, and, therefore, when the patient sits upright, the upper portion of the chest will be reso- nant, and the lower perfectly dull; the depth of the non-resonant .portion depending upon the quantity of the fluid. The metallic sounds will generally be best heard a little below the nipple, and at the base of the scapula; and the relative situations of the dulness, and excessive resonance, may be changed by altering the position of the patient, just as in a barrel half full of liquid. Another remark- able sign is obtained by placing the patient in an erect position, and giving him a shake rather sharply, when a splashing sound may be heard, which can be compared to nothing better than the sound of shaking water in a barrel. It may be as well here to remark, that the condition necessary for these amphoric or metallic sounds, is a large hollow, containg air and liquid; and that a communication between the external air and this cavity are not so; and, therefore, we may have those metallic sounds should that opening become plugged up; and, in the hypothetical cases of air being secreted by the pleura, or of a cavity formed by the absorption of effused fluid more rapidly than the walls of the chest could collapse or the lung expand to close the vacuum, we should still have these metallic sounds; and the same sounds may often be heard over the stomach, and in that situation have actually been mis- taken, by experienced auscultators, for those of a pneumothorax, in a case where there was at the same time extensive pleuritic effusion. But when there exists a fistulous opening between the lung and the pleura, which is most commonly the case in pneumothorax, or when it continues unclosed, we have the additional sound of an amphoric voice and respiration, resembling that which might be produced by blowing into the mouth of a bottle. The prognosis of pleurisy is generally favourable in the early stages, but must be modified, in a great measure, by the extent of the disease and the constitution of the subject; it is rarely, if ever, fatal before the effusion of any inflammatory product has taken place; but if a large surface of the membrane be suddenly affected, or if both pleurae become inflamed at the same time, especially that portion which covers the diaphragm, the inflammation exerts a remarkably depressing effect on the heart's action, the pulse becoming feeble and contracted, and death from syncope may ensue in the stage of plastic effusion. It most frequently happens, hoAvever, that the inflamma- PROGNOSIS. 219 tion yields to ordinary remedies, but permanent adhesion is the result; so common indeed, is this, that in the majority of persons, some portion of the pleura is found adherent after death. AVhen, hoAvever, the layer of plastic lymph causing the adhesion has been of considerable thickness, there will be some contraction, producing often more or less deformity. These adhesions are a very frequent cause of pleurodynia. When there is a considerable amount of serum effused, producing compression of the lung, in the manner already described, the pro- spect of recovery Avill depend much upon the quantity and character of the former: when it is not very great in quantity, nor of a puri- form character, its resorption may pretty confidently be expected; but, if the quantity be very great, which may be ascertained from the signs already stated, there is danger of suffocation from the rapid compression of the lung : if this do not take place, the absorption of the fluid will probably be very slow, and if it be of a puriform cha- racter, which may generally be suspected from the occurrence of chills, followed by flushings of heat, the danger of suffocation will be still greater; or the fluid may assume still more the character of pus, and degenerate into chronic empyema, which may empty itself either through the lung or the wall of the chest, or may continue a source of constitutional irritation; and, in either case, there is much reason to apprehend that the patient will sink under hectic. Such, then, being the modes of fatal termination of pleurisy, it is evident that where the disease attacks both sides of the chest, or where the effu- sion takes place very rapidly, and to a great extent, our prognosis must be very guarded, if not unfavourable, and the danger must be considered as still greater when there is the slightest appearance of hectic. In any individual case, a subsidence of the fever, and correspond- ing relief of the pain and dyspnoea, with the absence of all symptoms of increasing effusion, are to be considered as favourable omens. Whilst aggravation of the pain, increased difficulty of breathing, and still accumulating effusion, especially if the pulse become rapid and feeble, whilst there is an appearance of lividity in the countenance, are indicative of most imminent danger; and in double pleurisy about the diaphragm, even if there be little or no liquid effusion, any sign of the failure of the heart's action must be viewed with the greatest apprehension. It has been already stated that inflammation of the pleura may be excited by morbid poisons, as in the case of influenza or eruptive fever, and may arise from non-depuration of the blood, as in disease of the liver and kidneys, especially of. the latter. In these cases the prognosis is more unfavourable^ and must depend principally upon the character of the primary disease. There are also, undoubtedly, instances of pleurisy (as observed by Dr. Alison) of peculiar fatality, and little influenced by treatment, which depend upon the presence of suppuration in other parts of the body, and of puriform matter in the circulation; in both these the effusion is puriform probably from the commencement; and there are cases, seen chiefly in hospitals, in 220 PLEURITIS. convalescents from febrile diseases, and especially from small-pox, which would seem to be of the same specific and peculiarly intracta- ble character. Pleurisy, arising from perforation of the pleura pul- monalis, is almost always fatal, though the time which a patient may survive is much longer than used generally to be supposed. Andral states that death almost certainly takes place within a few days; this, however, is at variance Avith the experience of British practitioners, as many cases are on record, in which life has been protracted for a considerable time; instances of this kind are men- tioned by Dr. Watson; one is related by Dr. Houghton, in which the patient survived thirteen months; and one occurred to the author of this work, in which the patient lived three years after the estab- lishment of a fistulous communication between the lung and the pleura* It is moreoA^er remarkable how little distress is occasioned by this state of things, persons having been known often to take active exercise, and even to hunt without complaining of any incon- venience beyond the annoyance of the splashing of the fluid in the chest. In childhood and early youth, however, the prognosis of pneumothorax with effusion, though certainly unfavourable, is not so desperate as in persons more advanced in life. A patient of the author's, a lad ten years old, was the subject of a pneumothorax, with abundant foetid puriform effusion into the left pleura. Suffoca- tion impending, the fluid was let out by a puncture between the ribs, the patient slowly but steadily regaining flesh, and losing the dysp- noea, and after some months, the left lung was perfectly inflated, though by what means nature closed, in the pulmonic pleura, the orifice is not very apparent. The treatment of simple pleurisy in its early stages, and in patients of tolerably good constitution, should be decidedly antiphlogistic. It has been already observed, that bleeding is better borne in inflamma- tions of serous membranes than of almost any other tissue of the body. When, therefore, a patient is seen while the stitch is severe, the tongue furred, the pulse sharp, and before there is any consider- able amount of effusion, it will generally be not only safe, but highly expedient, to bleed him, in an erect posture, to a pint, or to the first signs of fainting; and this may sometimes be repeated with advan- tage within twelve hours; and it is to be remembered that the bleed- ing so timed, tells more upon the inflammation, and less upon the strength of the patient, than at a later period of the disease. Even here, however, it is necessary that Avhat has been stated, respecting the depressing influence of acute inflammation in the neighbourhood of the diaphragm, should not be forgotten, and, therefore, in such cases, when the pulse is wiry, the effects of loss of blood should be carefully watched, and the vein closed upon the slightest approach of syncope, and if the pulse do not increase in volume, after the first bleeding, a second should on no account be ventured upon. AVhen the state of the pulse or the constitution of the patient is such as not to warrant general bleeding, from twelve to tAventy leeches may be Vide Guy's Hospital Reports, vol. iv. p. 339. TREATMENT. 221 applied to the side; or, what is still better, blood may be taken from the same part by cupping, to the amount of ten or twelve ounces; and even in cases A\'here there is very considerable depression, cup- ping to a small amount is very beneficial, as much perhaps from the revulsive effects of the glasses, as from the actual abstraction of the blood. The combination of tartar-emetic, calomel, and opium, which has been already recommended, Avill here also be highly beneficial; indeed if the inflammation be not at once arrested by the bleeding, the disease will rarely be subdued until some effect has been pro- duced upon the mouth by the mercury.. For this purpose it Avill be Avell to give from two to four grains of the calomel with half a grain of opium and one-fourth of a grain of the tartar emetic; the latter of these medicines has not indeed the same poAverful effect in this dis- ease as in inflammations of some other structures, but thus given it is a useful adjunct. The opium is serviceable as a sedative, and in preventing the mercury from running off by the bowels; and should there be any tendency to diarrhoea, it may be increased to as much as a grain. AVhen the pain is in some degree subdued, the skin cool and moist, and the pulse softened, the application of a blister to the side will greatly accelerate the cure. Sometimes, howeA'er, notwithstanding the use of these means, the difficulty of breathing and of lying down is increased, although the pain and fever may have subsided, and we have unmistakable signs of accumulation of fluid in the pleura, namely, dulness, broncho- phony, and, perhaps, bulging of the ribs: and the removal of this fluid Avill often be a Avork of coifciderable difficulty. To promote this, the patient should be kept on as low diet as his strength will justify; a slight mercurial action should be maintained, blisters re- peatedly applied to the side, and diuretics administered. The best form of mercurial in this condition of the patient, is the combination of the blue pill, or, Avhat is still better, the grey oxide of mercury, with compound squill pill, which, Avhile it maintains the mercurial action, aids that of other diuretics. As regards the effect of the latter remedies, there is at all times considerable uncertainty, which is mainly to be attributed to the condition of the other viscera ; yet, as recent inflammatory effusion into the pleura does not necessarily imply previous disease, either of the heart, lungs, liver, or kidneys, we shall commonly succeed in obtaining a free action by a judicious combination of diuretic medicines. Saline diuretics, as nitrate or acetate of potass, in combination with infusion of digitalis, and nitric ether, will often succeed, the latter medicine rendering the action of the digitalis much more certain and more safe. The infusion of the digitalis is to be preferred, as being the most diuretic form for its exhibition, and being the least likely dangerously to depress the action of the heart. Should these remedies fail in their effect, or should they appear too much to reduce the strength of the patient, the iodide of potassium may be substituted for a time; purgatives should be at the same time freely employed, of which the compound jalap powder is generally to be preferred. By perseverance in this plan of treatment, the absorption of the 222 DIURETICS. fluid may often be brought about, and the lung restored to its healthy state. Sometimes even after the fluid has been absorbed, the affected side does not return to its natural condition, but becomes contracted or shrunk, owing in this case to the lung, which has been tied down by adhesions, not expanding to meet the ribs as the fluid diminishes; whilst the consequent pressure of the atmosphere, often, no doubt, aided by the contraction of the false membrane, thrown out upon the costal pleura, compresses the ribs inwards towards the mediastinum. It has been supposed, indeed, by some, that the fluid absorbed under these circumstances is replaced by a secretion of air from the pleura, thus giving rise to a pneumothorax; but this is very doubtful. In most cases of this kind, the lung never fully expands again, and the flattening of the chest, and the curvature of the spine which gene- rally attend it, remain for life, though this is not attended with any serious inconvenience, beyond the deformity, except in the cases of young persons Avhose groAvth is not complete, in whom, as we shall hereafter explain, everything Avhich diminishes the capacity of the chest is a serious evil. In such persons, hoAvever, there is reason to believe that the configuration of the chest may sometimes be in a great measure, if not entirely, restored: the same thing sometimes happens where the effusion has been almost entirely plastic lymph, but little serum having been poured out. In this case, after the pain and fever have subsided, the shrinking sometimes continues, and the side remains dull on percussion, owing to the thickness of the new membrane, and to its impeding the vibration of the ribs. Besides the deformity, this new membrane is sometimes an additional source of mischief, since it may itself become the seat of fresh disease, as by going into suppuration, or becoming a nidus for tubercles. If after the means which have been recommended for bringing about the absorption of fluid in the pleura have been persever- ingly used, there is no apparent diminution in its quantity, or if it should suddenly increase so as to threaten to destroy the patient by suffocation, the important question arises, as to whether it should be got rid of by making an opening into the pleura, that is to say, by tapping the chest. Although this operation is neither difficult nor, generally speaking, immediately dangerous, it may be well here to protest against its indiscriminate or too early employment, not only on account of the danger of admitting air into the pleura, which would, according to the principles already laid down, convert a serous effusion into a puriform fluid, but also because experience has taught us that, independently of such an accident, its repetition would produce the same result, and we have already seen that in the majority of cases such an effusion may be got rid of by other means. In short, the objections to the operation may be thus summed up,—Avhere it is safe and likely to be successful, it is unne- cessary, but where it seems to be called for by the permanence of the effusion, it is more dangerous, and generally unsuccessful. As long then as we believe the fluid to be serum,'the operation ought not to be had recourse to, except to avert impending suffoca- tion. It is true, indeed, that eclat often results to the practitioner PARACENTISIS. 223 from its performance, but it is no less true that in the majority of instances the safety of the patient is compromised. When, however, we know, no matter by what means, that there is a large quantity of pus in the cavity of the pleura, the reasons in favor of its with- draAval are apparently stronger; nevertheless it may well be doubted, whether the results of experience will show that it has more fre- quently been productive of good than harm; for, though it is con- tended by many that pus cannot be wholly absorbed, yet the familiar instance of hypopion proves that it may be, in a great measure, if not entirely; and there is every reason to believe that in the cases under consideration, the serous part of the pus may be removed by absorption, leaving the pus globules in the form of a cheesy mass, which produces no serious inconvenience; and where this is not the case, the process adopted by nature, of finding an exit for the matter by slow absorption, going on in one of the intercostal spaces, and causing a pointing externally, will generally be found to give more safe and certain relief than the apparently more expeditious, but pos- sibly premature, interference of the surgeon. It is, however, but fair to admit, that there is considerable difference of opinion on this subject, and that some writers of deservedly high authority recom- mend the withdraAval of pus whenever it is known to exist in the pleura. AVhen the urgency of the case calls for the performance of the operation, the next thing to be determined is, where the operation is to be performed. Now it seems superfluous to say, " be careful not to tap the wrong side of the chest;" yet such a thing has happened, and the respirable lung having collapsed from the admission of air into the chest, the result was, as may be expected, the instant death of the patient. A blunder of this kind, arising from ignorance as to which pleura is the seat of the effusion, would be little less than criminal with our present means of diagnosis. The best point to select in the side will generally be between the angles of the sixth and seventh rib, but here, before proceeding to introduce a trochar, it wiU be well to place the presence of the fluid beyond a doubt by the introduction of the grooved exploring needle of Dr. Davis, or what is still better the small exploring trochar and canula first used by Dr. Babington, which has the advantage, not only of deciding upon the presence of fluid, and its serous or puriform character, as well and as safely as the needle, but also of admitting the introduc- tion of a small silver probe, by Avhich the distance between the lung and the ribs may be ascertained, and the quantity of the fluid, as Avell as the presence or absence of adhesions, inferred. When the fluid that flows through the canula is serum, it will be best to allow it to run as long as it will continue to do so without the admis- sion of air into the chest, and then the orifice should be closed; but Avhen it is puriform, the fluid, may be allowed to run as long as any can be obtained, and the orifice may be left open. For some excel- lent directions as to the best mode of performing the operation, as well as valuable suggestions respecting the diagnosis of empyema, the reader is recommended to consult an able article by Dr. Hughes and Mr. Edward Cook, in the Guy's Hospital Eeports, Second Series, vol. ii. pp. 48, et seq. 224 BRONCHO-PNEUMONIA. Whatever opinion we may form as to the expediency of tapping the chest—and it is not to be concealed that many physicians enter- tain opinions far more favourable to it than those expressed above, -r-there are objections to it in cases Avhere the pleuritis is complicated with extensive consolidation, which appear to us to be of peculiar force, though we are not aware of these being stated by any previous writer; but before entering into them, we proceed to make a feAV remarks upon the complications of pleurisy, pneumonia, and bron- chitis with each other. In treating of pneumonia, we alluded to the frequent coexistence of bronchitis; noAV it is needless to do more than repeat this to make it apparent, that a large number—the larger number—of cases of pneumonia, which we meet with in practice, must present symptoms different from those which have been described as belonging to pneumonia simply as such. If, however, the above fact be borne in mind, the bronchitic complication need not embarrass us much; since the symptoms are such as might be expected from the coexistence of the two diseases. The rattle may indeed mask the bronchitic crepi- tation, as the rattles and ronchus in the larger tubes Avere stated to have obscured those in the smaller; but generally there will be crepi- tation to be heard over a greater or less extent, and, if the pneumonia proceed, the occurrence of dulness on percussion Avill at once decide the matter. The expectoration will often be of a mixed character, being more fluid than that of simple pneumonia, but possessing a degree of viscidity that does' not belong to the sputa of uncompli- cated bronchitis. The constitutional symptoms again Avill be of an intermediate character; the skin will always at some period present the characteristic pungent heat of pneumonia; but this Avill not be of so long duration, and even Avhile it lasts there will be a tendency to coolness, or even moisture, about the extremities. The pulse again will be softer, and the tongue redder at the edges. As regards the prognosis of the disease, it must be regulated upon the principles already laid down in treating of each of these diseases singly; but in the expectation of perfect and permanent recovery we must not OArerlook the effect of pneumonic consolidation in promoting dilatation of the bronchial tubes; the contraction of the fibrinous effusion constituting the consolidation, by drawing the Avails of the tubes asunder, aids the other causes which have been mentioned (182) in producing that lesion. The treatment of this complication must be regarded upon the same principles; if what has been stated respecting the indications for bleeding in pneumonia be applied to the case in point, the exist- ence of this affection will not lead to its adoption merely upon the grounds of the presence of pneumonia, though the existence of bron- chitis should always act as a caution to dissuade from its too ready adoption, unless the indications are very decided. Closely connected with the complication of pneumonia with bron- chitis is the peripneumonia notha, or catarrhus senilis of the older authors. These cases are in fact little more than instances of asthe- nic bronchitis occurring in persons generally advanced in life, who PERIPNEUMONIA NOTHA. 225 have been subject to long continued congestion of the lungs, the consequence either of repeated bronchitis or disease of the heart; but, besides this, the inflammation in the smaller tubes is very apt to extend to the air-cells, and pneumonia of an adynamic type is rapidly or almost suddenly excited. The symptoms of the disease are gene- rally those of severe and extensive bronchitis, .threatening death, sometimes from apnoea, at others from asthenia, either from the depressing effects of the inflammation upon a feeble constitution, or from the exhaustion consequent upon a profuse puriform secretion. It not uncommonly happens, however, that there is great relief from a copious expectoration. * The pulse is commonly feeble, though it may appear hard from the condition of artery so common in advanced life. The tongue is red at the edges, but coated in the centre, and soon evinces a ten- dency to become brown and dry; the skin is often hot, especially over the surface of the trunk, though the extremities will soon become cool and clammy. Dr. Watson remarks that the nicety of treatment required in cer- tain stages of acute bronchitis is still more apparent and necessary here. But it may well be doubted whether we are often called upon to take blood in any way, though the assumption, from the age of the patient, that the disease is peripneumonia notha, and not acute bronchitis, ought not to deter us from moderate antiphlogistic meas- ures, when called for by the symptoms and powers of the patient. At the same time we must be very cautious not to mistake the hard artery (p. 70), for a hard pulse, and be misled by it into the belief that the patient can bear bleeding. The treatment, then, must be that of bronchitis, with the anticipa- tion of a failing of the constitutional powers. The liquor ammon: acet. with a little vinum ipecac, may be used at the commencement, and ammonia added in excess, when signs of debility appear. When the skin becomes perspirable a blister may be applied to the chest. The intercurrence of pneumonia rarely calls for active antiphlogistic measures, and should the sputa assume the " plum-juice" appearance, it is rather an additional reason for support, or even stimulants. The combination of senega with ammonia and squills (F. 25) is often of the greatest service in the advanced stages of peripneumonia notha. In the scarcely less common complication of pneumonia with pleu- ritis, generally known as pleuro-peripneumony or pleura-pneumonia, there will be a blending of symptoms, which, hoAvever, will not mask them so as to occasion any real difficulty; neither is there any reason for supposing that the complication increases the danger. AVhen large effusion takes place, the stethoscopic signs of the pneu- monia will be, in a great measure, silenced by the compression of the lung; but in the commencement, the crepitation may generally be distinctly heard; and after slight effusion, it may sometimes be detected above the bronchophony, or above the line of dulness. The treatment of pleuro-pneumonia, must, in general, be conducted upon the same principles as those laid down for pneumonia and pleu- ritis. There is, however, a form of complication which is worthy a 15 226 BR0NCH0-PLEUR0-PNEUM0NIA. short consideration, and that is the coexistence of extensive bronchi- tis, pneumonia, and pleuritic effusion in the same side of the chest. AVhen this takes place, the lung will not collapse so readily as when it has been unaffected, and universal dulness of that side will be caused by a less amount of effusion than would have been otherwise necessary to produce the same effect, the anatomical condition being an uncollapsed, because consolidated, lung, surrounded by serous or sero-puriform effusion, the bronchial tubes being also more or less inflamed. But though the lung is, from the change in its physical condition, not susceptible, of being collapsed, it is nevertheless com- pressed sufficiently to arrest the progress of the disease, or, at all events, to retard it, so that the effusion may be looked upon, as, to a certain extent, conservative. Suppose now that the effusion were suddenly withdrawn—the consequences would be that the inflammatory changes would again proceed, and, if the subject were one of feeble constitutional power (and it is in such that we most commonly meet with the above con- dition), it is highly probable that disorganisation would be the re- sult, and the patient sink under its exhausting effects. If, however, the fluid were to be sloAvly removed, we might expect that the lung would either return to the healthy condition, or go into the state of permanent induration ; in which case the contraction of the pulmo- nary tissue would draw asunder the walls of the bronchial tubes. But as bronchitis already exists, it is probable that as the lung begins to be again inflated, it will resume its activity, and a consider- able puriform secretion will ensue, which will tend to increase the distension Avhich sometimes becomes so great that the sounds of cavities are produced in the tubes. From this we would infer, that,, under such circumstances, it would be highly inexpedient to draw off the fluid, and further, that when such cases go on favourably, the progress would be, considerable puriform expectoration, contemporaneously with the diminution of the fluid; the first signs of respiration to be detected in the lung being of a cavernous character, resembling those heard in vomica?, though sometimes these pseudo-cavities may be so large as to simu- late amphoric sounds. Such cases do not uncommonly occur, and the pre-existence of pleuritic effusion, the subsequent copious puri- form expectoration, and the cavernous or even amphoric sounds, have led to the belief that there had been perforation of the pleura, and that the patient Avas bringing up the contents of an empyema with pneumothorax. They may, however, be accurately distin- guished from the latter, by the previous history,—by the stethosco- pic signs during the effusion, since (though there is universal dulness and absence of respiratory sound) bronchial breathing and bronchial voice, though distant, may still be heard, which they would not be in cases of perfect compression of the lung,—by the absence of any history of a sudden perforation, and lastly,—by the nummular character of the sputa. These cases will often do well with the treatment recommended for that of pneumonia in the state of grey hepatisation, with diur- etics, repeated blisters, and good nourishment. PHTHISIS. 227 XIII. PHTHISIS. The word phthisis is derived from the Greek verb $#»'" (corrumpo) and therefore strictly means a wasting disease. It has, however, been generally used in medicine, and that from the earliest times, to signify a Avasting dependent upon disorganising disease of the lungs : and the term has been still further restricted by most modern patho- logists to those cases only in which this disorganisation is the result of tuberculous deposit. It will, however, be more convenient as well as more in accordance with what has been already stated in speaking of the effects of inflammation and of scrofulous and tuber- culous deposits, to include under the term phthisis all those cases in AA'hich there is strumous deposit in the lungs, although it may not be of that character which strictly belongs to Avhat we have already described as tubercle: the course and symptoms of the disease are, however, in either case so nearly the same, that, for practical pur- poses, the distinction is perhaps rather nominal than real. As pulmonary phthisis is one of those diseases, the chief symptoms and fatal termination of Avhich are dependent upon a series of morbid changes effected in certain organs, Ave first describe those changes and afterwards the symptoms resulting therefrom. These changes are, in fact, precisely those AAmich have been described as brought about by tuberculous deposits in general. Thesepare at first the small grey semi-transparent tubercles of the size of millet-seeds, or the larger crude yellow tubercles (p. 107) deposited in clusters in the lungs, the latter being often, though not necessarily, a more advanced stage of the former. These tubercles then begin to soften, with greater or less rapidity, as already pointed out (p. 108), involving in their disorganisation the portion of lung in which they have been deposited; the product of which joint disorganisation is a thick, apparently puriform fluid, contained in a cavity often lined, like an abscess, by a layer of fibrinous matter ; or several of these clusters or centres of disorganisation running together enclose an isolated por- tion of comparatively healthy lung, and thus a larger cavity or vomica is formed. This disorganised mass generally makes its Avay by ulceration to the nearest mucous surface, i. e., a bronchial tube, and thus the contents of the cavity may be expelled. Fresh tuber- cles are in the mean time deposited in the neighboring parts of the lung, and in this way the greater part of the organ is destroyed. The tuberculous deposit, unless its seat is previously determined by some local irritation, as pneumonia, almost always commences in the apex of the lung; and as the tubercles in this situation proceed soonest to enlargement, softening, suppuration, and expulsion, and as fresh deposits of the same matter are continually taking place, loAver and lower down in the organ, and following the same course, Ave 228 PHTHISIS. commonly find after death that the disorganisation is most perfect in the apex, as shown by cavities of varying size, but generally large; whilst lower doAvn Ave see cavities generally smaller or less close together than above, the intervening space consisting in great mea- sure of lung apparently in a state of pneumonic consolidation, more or less thickly studded with tubercles. Still nearer the base there may be the above condition of lung Avithout cavities, and loAvest of all, there will commonly be respirable lung, nearly or entirely free - from tuberculous deposit. It is an important fact, and one bearing most closely upon the pathology of pulmonary phthisis, that with the traces of disorganisa- tion, such as have been described as taking place generally in any tissue Avhich is the seat of tuberculous deposit, Ave almost ahvays find evidence of inflammatory action of greater or less activity. The lung surrounding a cavity is almost ahvays condensed and solid; and the cavity itself, Avhen the tubercles are first expelled, is soft and ragged on its inner surface. It afterAvards either extends by the softening of other tubercles in the immediate neighbourhood, Avhich form fresh vomica? that open it, so that an irregular, or, as it is some- times termed, multilocular cavity is produced; or, if there are no tubercles very near, a layer of fibrinous matter is deposited, AA'hich becomes organised, forming a species of lining membrane to the cavity, the vessels of which sometimes pour out pus; but at others the fresh membrane contracts as in ordinary inflammation, and the cavity cicatrises, as it Avere, and is ultimately obliterated, giving rise to a puckering of the pleura on the corresponding surface of the lung. When this happens, the disease is arrested in the particular part, and a cure Avould take place if there were no fresh deposits in other parts of the same or corresponding organ; but this, unfortunately, is very rarely the case, for, on the contrary, fresh deposits of tuberculous matter are, in by far the greater number of instances, continually taking place, and in this manner the disease is incessantly advancing by the repeated deposition of tuberculous matter, and not, as in the case of many malignant growths, by the continual assimilation of the adjacent tissues to their OAvn structure. We see, then, that the process of disorganisation of the lung in the ordinary progress of phthisis is in a manner twofold, for Ave have the deposition of the tuberculous matter enlarging and softening, and involving in this softening and disorganisation, the tissue in which it has been deposited, and besides this, another induration and subse- quent softening and ulceration, closely resembling, or rather identical with that which takes place in common inflammation. Here then we are met by two questions which have been much agitated, and which it is impossible altogether to evade, though a lengthened discussion of them would be foreign to the object of the present work: 1. What is the particular tissue of the lung in which the tuberculous deposits take place? 2. Are they the product or the cause of the inflammatory action with which they are associated ? (1.) As regards the seat of the deposit, it is probable that the ITS CONNECTION WITH INFLAMMATION. 229 opaque crude or yellow tubercle is deposited on, or rather in the lining membrane of the smaller tubes (as pointed out by Dr. Cars- Avell), and in the air-cells with which they communicate, thus giving rise to the little clusters of crude tubercles, like bunches of grapes, Avhich may be often seen on making an incision into a phthisical lung; Avhereas the grey semi-transparent tubercle is deposited in the cell, or in the cell wall, as in the case of the product of common in- flammation of the lung, and gives rise to the appearance commonly described as miliary tubercle. (2.) As regards the connexion of tubercle with inflammation,— although we have no proof that this deposit occurs as an immediate product of inflammation, yet there can be no doubt that the Ivyper- aemia, or local determination of blood (p. 46) attendant upon inflam- mation may so greatly favour the deposition of tubercle, that it may in a number of instances, practically be regarded as its proximate cause, or, in the Avords of Dr. Alison, " Phthisis pulmonalis very frequently appears in practice as a consequence of inflammatory dis- eases ; usually of repeated attacks of them in their milder and more chronic form." This statement, which regards inflammation as the most prominent cause of that impaired nutrition of which tubercle rnay be the result, is not necessarily opposed to the belief that such derangement may arise independently of inflammation, and therefore Ave are willing to admit, in the Avords of the distinguished physician already quoted, that " phthisis sometimes shows itself and makes progress, chiefly in those most strongly predisposed, without any indications of inflammation preceding or attending it." There is, however, every reason to believe that such cases are very rare. It has been already stated, in treating of common inflammation, that Ave may have, as its products, inflammatory lymph or pus, the former of which, though capable of becoming organised and forming a permanent tissue, is nevertheless liable at any period of its progress to break down into the second, and in so doing to involve the tissue in Avhich it has been deposited in the same process of disorganisation; and also that, after it has become perfectly organised, this new tissue may become the seat of a fresh inflammation, which will generally be of a suppurative or disorganising character. Accordingly, as Avas specified in treating of pneumonia, the product of inflammation in the lung is, in sound subjects, almost always plastic, tending, if the inflammatory process be not arrested, to permanent induration of the organ; but under unfavourable conditions, and in cachectic subjects, pus may be poured forth in the first instance (or corpuscular lymph which quickly becomes pus), or even if the product have been in the first instance of the plastic kind, it may, before it is completely orga- nised, break down into pus, involving (like tuberculous matter) the pulmonary tissue in which it has been deposited in a like disorganisa- tion ; and even when induration of the lung has actually taken place, and possibly when it has existed for months or even years, the part so affected may, under a fresh attack of inflammation, break down into suppuration, and form a cavity closely resembling one which has been formed by the softening down of the tuberculous deposit. 230 VARIETIES OF PHTHISIS. The above description includes the various forms of phthisical dis- organisation of the lung, which may be classed under three heads: 1, The truly tuberculous, in which the deposition of tubercles takes place without being preceded, attended, or followed by pneumonia, and in which the disorganisation is the result of the softening doAvn of the tuberculous matter, involving in its disorganisation the tissue in Avhich it has been deposited; 2, That in which inflammation, if it have not preceded and given rise to the formation of tubercles, arises in the course of their development, and is the main instrument by which the disorganisation of the lung is effected; and 3, That in which the disorganisation of the lung and the formation of vomical cavities have their origin in pneumonia, and are brought about in- dependently of any true tuberculous deposit. So that we may have three classes of phthisis: (1), The tuberculous; (2), The tuberculo- pneumonic; and (3), The pneumonic. This classification of the varieties of phthisis was introduced by Dr. Addison, to whom also we are indebted for the description of the third or pneumonic variety. Of these varieties of phthisis, the first is very rarely, if ever, met with in practice in its perfect form, since inflammation, though it may not have originated the tubercles, is almost sure to affect some portion of the organ in the process of softening. Still, as this inflammation is rather an accident than essentially necessary, we cannot altogether disregard the theoretical possibility of the first variety. The second variety is by far the most common, and may be said to include nearly all the cases of phthisis in early life, occurring in subjects not previously injured by great exposure or intemperance. The third variety belongs more to the middle period of life, and it is probable that the greater number of cases of phthisis occuring near or after the age of forty are of this character. Phthisis is also divided by many authors into acute and chronic, as it sometimes runs an acute course, but much more frequently a chronic one. As therefore the latter may be considered the more typical form of the disease we shall speak first of it. Chronic phthisis has been commonly divided into three stages, depending upon the anatomical changes which take place in the lung, which stages are pretty well marked by certain physical signs, as those of deposition, softening, and ulceration or excavation. It is, hoAvever, worth the inquiry whether there be not another stage ante- cedent to the first of these, which might be termed the premonitory, since if such be found to exist, and if it can be recognised, or even conjectured by any appreciable signs, we may be enabled to apply our remedies at the time at which there is the greatest, or rather, the only, probability of their producing a satisfactory result. The stage of deposition, which is often regarded as the first, is that in which tubercles are first present in the lungs, and as they are generally considered as essential to phthisis, it may perhaps appear illogical _ to speak of any previous stage of the disease; but setting aside this difficulty as rather formal than real, it must be obvious that since tubercle is itself a pathological epigenesis or morbid pro- duct, there must have been some antecedent diseased action, preced- ITS PREMONITORY STAGE. 231 ing or even causing this product. This previous morbid condition is of a twofold character, the one generally affecting the whole system, constituting what has been already described as the tuberculous dia- thesis, and the other local, depending often upon a determination of blood to the lungs, or, in other words, active congestion of those organs, a condition which is very likely to occur, as already pointed out, at the age Avhen the general development of the sj'stem is com- pleted ; though it is not denied that in extreme cases of tuberculous diathesis tubercle may be deposited, as a simple perversion of nutri- tion, and without any appreciable amount of such congestion. In this first or premonitory stage of phthisis, the symptoms are not very marked, and we have often not very distinctive physical signs; still there are often such symptoms preceding those of deposition. These signs are perhaps more of a general and physiological, than of a local and physical character, and are such as might be expected to arise from some embarrassment of the pulmonic circulation, in addi- tion to those of the tuberculous diathesis. Thus there will often be a fixed colour in the cheeks, with a very slight tendency to lividity there, as well as in the lips; the pulse will generally be quick and small, although the impulse of the heart may be considerable, owing to increased fulness of the right ventricle; the hands and feet will often, from the same cause, be cooler than natural, with sometimes a slight clammy perspiration: the impeded circulation through the lungs will also affect that through the portal vessels, whence we have some signs of hepatic congestion, as dyspeptic symptoms, and scanty, and often turbid urine. The respiration, under such circum- stances, is generally quickened, though hardly in the same proportion as the pulse, and there is no dyspnoea so long as the patient remains quiet; but the breathing becomes hurried and laborious upon very slight exertion, which also causes palpitation, owing to the blood, when hurried to the right side of the heart, not finding a free passage through the lungs. There is seldom much cough or expectoration in this stage of the disease. These symptoms, it may be observed, are merely those of obstructed pulmonic circulation, which might arise from several causes; but when observed about the time at which phthisis most commonly makes its appearance, they are suf- ficient to excite apprehension; and if to these there be superadded expectoration of blood in any amount whatever, the grounds for apprehension will be still greater, and the chest should be carefully explored. Such examination will, at this stage, detect little or no diminution of the natural resonance of the chest; but when there is any.it is under the clavicle or in the supra-spinous and clavicular regions, and more commonly on the left side than the right. There will as yet be no flattening of the ribs beneath the clavicles, but on the contrary, the affected side may be slightly more prominent than the other; neither is the mobility of the ribs at all impaired. Auscultation, again, declares little that is conclusive. The inspiratory murmur may be good over the whole of the lungs, but the expiratory is too distinctly audible under the clavicles. There may also be a fine 232 PHTHISIS. mucous rattle in this situation, depending probably on the congested condition of the bronchial membrane in the capillary tubes. The sounds of the heart will be natural over the surface of the organ, which surface, however, seems to occupy a greater space than in health, owing to the fulness of the right ventricle; and, conse- quently, the prsecordial dulness will be increased; there will also sometimes be a soft systolic murmur, depending probably upon the same cause: the cardiac sounds are, however, at this stage of the disease more distinctly audible than in health in other parts of the chest; and this is particularly the case over the apices of the lungs, and arises probably from the increased density of the lung rendering it a better conductor of sound than is the healthy organ, and which is the effect of the increased amount of blood in that condition Avhich attends, or immediately precedes, the first deposition of tubercles. This state of the upper lobes of the lungs often gives rise to another phenomenon, which though not constantly present, or at least not always observed, is amongst the earliest premonitory signs of phthisis; namely, a soft systolic murmur (bruit de soujflet) under the clavicles, generally heard about the situation of the bifurcation of the inno- minata on the right side, and of the subclavian on the left. It is not, however, so distinctly traceable over the course of the vessel as to be obviously produced by the current of blood through it, and it may be a question whether this murmur is really produced by the lung pressing upon the innominata or subclavian, or whether it be that the pulmonic circulation actually becomes audible owing to the increased vascularity and density of the lung, and thus a sound is produced analogous to the placental souffle. In the second stage of phthisis, that of deposition (the first stage of most authors), the symptoms, so called to distinguish them from the physical signs, begin more decidedly to manifest themselves. It should, however, be premised that, as has been correctly stated by Dr. Walshe, these symptoms do not admit of such systematic division, according to the stages of the disease, as do the physical signs. The cough is now almost always present—in a small proportion of cases, dry—but in far the greater number attended with a frothy expec- toration, or, what is a more unfavourable symptom, it may have a mucilaginous appearance. The sputa may also be streaked with blood, and even profuse haemoptysis is not uncommon at this period of the disease; and it is perhaps from its frequently occurring at its very commencement, that an attack of haemoptysis has often been assigned as the cause of the subsequent phthisis; though it is more correct to _ regard it as one of the accidents liable to occur in that disease, arising, at this period more especially, from the hyperaemia Avhich exists in the lungs; and although it is to be looked upon with apprehension as a precursor of impending mischief, it may be so far from a cause of that mischief, as to be a means employed by nature for its mitigation. Dyspnoea is not a more urgent symptom than in the premonitory stage; indeed, in ordinary chronic phthisis, it is rarely so at all; the ITS SECOND STAGE. 233 respiration even upon moderate exertion, never being quickened more in proportion than the pulse, rarely so much so. Pain in the region of the chest, often of an acute, but seldom of a very severe kind, is of common occurrence; these pains may be merely of a neuralgic character, but are more commonly the effect of partial pleurisies excited by the presence of clusters of tubercles, either on the serous membrane or immediately beneath it. Febrile symptoms are rarely well developed at this stage of the disease; there is, however, during a great part of the day, an increased heat of the surface, excepting at the extremities, which are generally cold, often clammy, with a tendency to duskiness or lividity: at night, or rather during sleep, there will be an increased, but not an exces- sive perspiration, chiefly affecting the head and chest. The pulse is generally, though not invariably, frequent, small, and compressible; it is in fact the pulse of pulmonic congestion (pp. 72 and 75), though it is, no doubt, accelerated likeAvise by the nervous irritability almost constantly attendant upon the tuberculous diathesis. Exceptions to this rule no doubt occur, but they will generally be found in subjects in whom there has been some degree of dilatation of the left ventri- cle, or some other circumstance modifying the effect of the disturbed circulation through the lungs upon that of the system at large. There may, however, be great differences in the degree of acceleration, not only in different individuals, but in the same individual upon different, and even consecutive days. It has been stated that the difference between the pulse in the erect and recumbent postures, is less in the early stages of phthisis, than in other diseases attended with debility. The. glandular system in the abdomen will rarely be perfectly healthy in persons of the tuberculous diathesis, and consequently its mucous surfaces will be prone to disorder; but in addition to this, it is to be observed that one of the first effects of pulmonic obstruction must be venous congestion of the liver, and consequently of the mucous membrane of the stomach and small intestines, uneasiness in the epigastrium, with tenderness below the ensiform cartilage as Avell as nausea; irregular appetite and occasional vomiting are therefore of frequent occurrence, though the latter may sometimes be induced merely as the mechanical results of fits of coughing. Thirst is rarely absent at this or the subsequent periods of the disease. The intellectual faculties are rarely much disturbed at this stage of phthisis, except in those cases in which there is also tuberculous deposit in the membranes of the brain, when active delirium may Gome on at any period. There is, however, in most cases, a good deal of nervous excitement, with restlessness, or irritability of temper. Emaciation, which is one of the most prominent features of this disease throughout its whole progress, is generally very apparent in this stage, and is greater than can fairly be accounted for by the vomiting or loss of appetite; so much so, that it has generally been regarded as the direct and necessary consequences of the presence of tubercles, though it would perhaps be more correct to attribute it to that defect or perversion of nutrition of AA'hich the deposition of these 234 PHTHISIS. bodies is one of the results; though it is certain that in many cases in which their presence could not be questioned, not only have the patients ceased to lose flesh when the other symptoms of their pro- gress have been for a time arrested, but they have actually increased in weight. In the female the uterine functions are more or less disturbed in this as well as in the preceding period of the disease, it being by no means uncommon for monorrhagia to be the precursor of the invasion of phthisis; in some subjects, however, there will be a sudden sup- pression, which is always an unfavourable symptom, since in ordi- nary amenorrhoea or chlorosis there is generally a gradual diminution of the discharge for several successive periods; neither is it uncom- mon for its sudden cessation to have been preceded by its excess. Upon examination of the chest, after the deposition of tubercles has commenced, there will generally be found a slight flattening of the infra-clavicular region of the more affected side. The mobility of the superior ribs, or, to speak more correctly, the expansion of the chest during inspiration is diminished; these ribs being simply raised and not gently protruded as in health. The diminished expansion of the apex of the lung is a more important sign in the female than in the male, since in health this expansion is less in the latter than in the former. In some cases the expansive movement is altogether wanting, or there may even be an actual sinking of the infra-clavicu- lar regions during inspiration; this is generally the effect of pleuritic adhesion. The tactile vibration of the voice, is in general absolutely increased in this region; but it should be remembered that it is in health greater on the right side than on the left, and in the male subject than in the female. There is generally, but not always, in this stage of the disease, diminished resonance on percussion. This may of course be almost invariably at first detected in the infra-clavicular region, and more frequently on the left side than on the right. It is most marked upon the inner side of this region immediately over the apex of the lung. At the commencement of tuberculisation, and when the tubercles may be supposed to be least thickly aggregated, the dimi- nution of the resonance may escape observation when percussion is made upon a single point, though it may be detected by percussing upon a larger surface. The increase in the resonance produced by a full inspiration, which is considerable in health, will be scarcely per- ceptible where tubercles exist in any considerable numbers. As the deposition and consolidation increase, the sound becomes duller, and so as to be even woody. This, however, indicates that there is at the same time agglutination of the surfaces of the pleura. The dulness on percussion is of course most obvious in the infra-clavicular and superior scapular regions, but as the deposition and its consequent changes extend, the dulness does so likewise. The respiratory sounds are in this stage considerably affected, being in some parts defective, in others increased, and in some tubular or bronchial. They are for the most part attended Avith mucous rattles; though these are rather to be regarded as one of the THIRD AND FOURTH STAGES. 235 accidents than the necessary effects of the disease: and here and there about the parts where the signs of consolidation are most appa- rent, the dry crepitation from intercurrent pneumonia may not unfre- quently be heard. Perhaps the most important sign at this stage is harshness of respiration; though it is doubtful Avhether it do not belong more to the preceding, since there is good evidence for believing, and the same thing is affirmed pretty confidently by Dr. Stokes, that it may frequently be removed by treatment. In the third stage, or that of softening, the constitutional symptoms become more decidedly those of considerable suppuration, and we have generally confirmed hectic. There is now a remarkable bright- ness of the eyes, Avith pearly conjunctivae; the tongue is generally red towards the edges, and furred towards the centre; the bowels, too, are irregular, and apt to be disordered by slight causes, and it is probably in this stage that there commences that irritation of the lower part of the ileum and of the large intestines, which terminates in ulceration. The pulse continues frequent, or if it have not been so before, it now becomes so; the cough, which may have been but slight before, becomes troublesome, especially in the morning; and there is expectoration of puriform mucus, in which tubercular matter may sometimes be detected, and the voice assumes the well- known hoarsenes of phthisis, which is by some referred to ulceration near the glottis, but is by others ascribed to a reflex irritation of that part, arising through the medium of the pneumogastric nerve from the disorganisation going on in the substance of the lung. The characteristic symptoms of this stage are, however, the development of the hectic, and the puriform expectoration. The physical signs of softening, are flattening of the chest, increased dulness, and moist crepitation; the respiration being often tubular, but rarely bronchophonic, and the resonance of voice increased; the impulse of the heart is generally feeble from incipient atrophy of that organ; to this, however, there are exceptions, especially in the more rapid cases. The characteristic sign is the moist crepitation— the mucous crepitation, or muco-crepitant ronchus, of some authors. In the fourth or last stage, that, namely, of excavation, the consti- tutional symptoms are still further aggravated; the hectic fever is severe, the emaciation generally extreme, colliquative diarrhcea may be apprehended as the disease draws near to its fatal termination. The pulse is exceedingly small and frequent, the tongue is red and sometimes dry, the cheeks hollow, and the eyes sunken from the absorption of the fat contained in the orbits. The skin, though it may be at intervals hot and dry, is generally bedewed with a clammy perspiration. It may here again be observed that these symptoms are such as indicate the advanced disorganisation of the lungs, and belong to extensive suppurative disease, and, therefore, that they generally occur when the disorganisation of the lungs is far advanced; but that they are not invariably absent in the preceding stages of the disease of which we are treating; nor, on the other hand, does it necessarily folloAV that they will supervene as soon as excavation has commenced; since, in the former case, the tuberculisation and con- 236 SIGNS OF EXCAVATION. sequent softening may have been so extensive and rapid as to give rise to the constitutional symptoms which more commonly belong to the stage of excavation; and, on the other hand, the disease may have been so limited as that a cavity may have formed before exten- sive softening has taken place elsewhere, and consequently without the hectic and other general disturbance, such as ordinarily belong to that stage of the local disease. The physical signs of a cavity are increased flattening and dimin- ished mobility. Contrary, however, to what might have been expected, the resonance on percussion is almost ahvays diminished over a cavity; this is generally owing to the consolidated lung which surrounds the excavation as well as the dense adhesions in the cor- responding part of the pleura: sometimes, however, when the cavity is large and simple, and near the surface, a pretty sharp percussion elicits a ringing or almost amphoric sound, and now and then a sound is produced resembling that arising from a cracked iron vessel (bruit de pot fele); a multilocular cavity on the other hand always diminishes the resonance. The natural respiratory murmur is of course wanting, and in its place may be heard an omphoric sound, like that produced by blowing in a bottle or an empty cask; this sound, commonly called cavernous, has not unfrequently a metallic ring, and the respiration is generally attended by a gurgling sound like that of air passing through a considerable quantity of liquid. The character of this sound, ,even in the same cavity, will vary according to the quantity of the fluid which may be present, and may therefore change greatly from day to day, sometimes ceasing altogether, and then returning after a longer or shorter interval. Such is the general course of the constitutional and physical signs of this disease; but, superadded to them, there frequently arise cer- tain complications affecting either the lungs or other organs, and which may be termed the accidents of phthisis: several of these are of importance as they materially influence the duration of life. One of the first of these, connected with the lungs, is haemoptysis. This at the very commencement of phthisis has been already shown to be of importance merely as a symptom, and to retard rather than accele- rate its progress; but when it takes place after softening has com- menced, the haemorrhage proceeds in all probability from a vessel of some size which has been opened in the course of the ulceration, and becomes dangerous from its tendency to produce death from asthenia. The extravasation of blood may sometimes take place so rapidly as to obstruct the bronchi and larger tubes, and so cause death from apnoea or suffocation. The haemorrhage, when it occurs to this alarming extent, is not uncommonly produced by sloughing and gangrene, arising from the strangulation of the nutrient arteries by the pressure of the tubercles. But besides this, gangrene of the lung, when it supervenes in the progress of phthisis, may of itself cause death by asthenia. The first of these accidents, the haemoptysis, sometimes occurs without any previous symptoms; at others, however, it is preceded by a fine moist crepitation and increased sharpness and frequency of * ACCIDENTS OF PHTHISIS. 237 the pulse. The symptoms of gangrene will be the same as those with Avhich it is accompanied when it occurs as a primary affection, or as the result of pneumonia (p. 193); but it should be remembered that there may be an intolerable foetor both of the breath and of the expectoration towards the close of phthisis, without any gangrene being found after death. Pneumonia is of such common or rather universal occurrence in phthisis, that it can hardly be regarded as one of the accidents of the disease; unless, as it sometimes happens, it suddenly makes pro- gress from imprudent exposure, change of temperature, or it may be without any assignable cause. Under such circumstances its pre- sence is indicated by increased febrile excitement, pungent heat of skin, crepitation, and the other symptoms which ordinarily attend it: unless, hoAvever, it be quickly arrested by the most careful manage- ment, it hastens the disorganisation of the lung, and consequently the termination of the disease in the ordinary manner. In some cases it has been still more speedily fatal, where a considerable por- tion of the lung, having been previously blocked up by tubercles, the greater portion of the remainder has been consolidated by the pneumonia, and death from apncea has been the consequence. Inflammation of the pleura is so common in the progress of phthi- sis that M. Louis states, he never, in a single instance, inspected the body of a patient Avho had died of phthisis, in Avhich the lungs were not attached to the ribs by a greater or lesser extent of pleuri- tic adhesion. These inflammations of the pleura are often associated Avith tubercles on the surface of that membrane, though it may not be always easy to say, whether the tubercle is the cause of the inflam- mation, or the inflammation of the tubercle. These pleurisies are, for the most part, partial, and though for the time they may cause considerable pain to the patient, they are not often attended with the active febrile symptoms of simple pleurisy. They may be early recognised by the pleuritic friction sound, Avhich hoAvever disappears Avhen adhesion takes place. The occurrence of these partial pleurisies may be regarded as a confirmatory sign of tuberculisation of the lungs, when, from other circumstances, we have reason to suspect its commencement. Another, and very com- mon affection of the appendages of the lungs in this disease is ulcer- ation of the larynx ; and this too is so frequent an accompaniment of phthisis, and so rarely present without it (except in syphilitic cases), that it may be regarded as symptomatic. These ulcers occur mostly in the upper part of the larynx, and often extend to the rima glotti- dis and the epiglottis, but affect the under surface of the latter much more than the upper. It is a remarkable fact, too, that they are in much greater numbers on that side on which the disease in the lungs is the most extensive; thus it may happen, for instance, that the left luno- being extensively disorganised by tubercular disease, and the right comparatively little affected, the left side of the larynx will be found studded Avith ulcers, and the right almost entirely free from them. Another cause of sudden inflammation of the pleura, in the progress of phthisis, is perforation of that membrane by a vomical p 238 COMPLICATIONS. cavity ulcerating into it, and the consequent escape of its contents as well as of air into the serous lining of the chest; the effect of this is generally an empyema, with pneumothorax, which is not difficult of detection, and of which the symptoms have been already described. The occurrence of this accident sometimes cuts short the life of the patient by death from exhaustion, owing to the depression caused by sudden inflammation; but if this do not happen, the lung becoming collapsed, and consequently inactive, the disease is for a time arrested, and, if the other lung be but little implicated, life may be prolonged for as long a time as if the perforation had not taken place, or even longer; in a case which occurred to Dr. Houghton, of Dublin, the patient survived thirteen months, and in one related in the Guy's Hospital Reports as long as three years. Tuberculous disease in the brain or its membranes sometimes manifests itself in the progress of phthisis; the tubercles being de- posited in the arachnoid or on the cerebral surface of the pia mater. The symptoms of this complication may present themselves at any period of the disease, and generally commence with Aveight across the forehead, Avhich gradually increases to most intense pain over the Avhole of the cranium, often attended Avith considerable stupor, but seldom with violent or active delirium; the patient will sometimes look you most steadily in the face when speaking, and then de- liberately turn aAvay his head without the slightest expression of displeasure. Tubercular meningitis, when it supervenes under these circumstances, is generally fatal in a few days. The serous membrane of the abdomen is often the seat of tuber- culous deposit in the progress of phthisis; its symptoms are those of chronic peritonitis, to be more particularly noticed hereafter; to ulceration of the boAvels allusion has been already made, and also to the diarrhoea which commonly attends it; though this latter symp- tom may be present when there is no ulceration. Sometimes the ulceration gives rise to perforation, which is followed of course by intense peritonitis and speedy death. Sometimes the ulcers cicatrise, and in so doing cause contraction and consequent obstruction. Another very remarkable, though perhaps practically not very important abdominal complication is fatty degeneration of the liver: this morbid change does not, however, appear to be nearly so frequent an attendant upon phthisis in this country as the observations of M. Louis show it to be in France. It presents no symptoms, besides an enlargement of the organ and a peculiar satin-like condition of the skin, first noticed by Dr. Addison. Fistula in ano is a frequent oc- currence ; and its presence in early life should excite a suspicion of a liability to phthisis, if not of the existence of that disease, although it seems, like many other discharges, sometimes to keep the other symptoms in abeyance. Before proceeding to consider the important questions of the diag- nosis, the causes, and the treatment of phthisis in general, it is desira- ble briefly to notice its rarer form, namely acute phthisis. This disease has been by most authors considered under three forms: the first differing from the chronic merely in its greater rapidity; the ACUTE PHTHISIS. 239 second, which is perhaps the most exquisite form of acute phthisis, consists of a universal deposition of the grey semi-transparent tuber- cles throughout both lungs; and the third presenting crude and softening tubercles throughout both lungs, with here and there small vomicae. In the first form we have the same symptoms as in chronic phthisis; but they follow each other with greater rapidity, sometimes running their course in tAvo or three months, or even less. In these cases, however, there is often greater dyspnoea, and a greater tendency to A'enous congestion, than in the chronic; OAving to the emaciation and diminution of the amount of the circulating fluid not keeping pace Avith the disorganisation of the lung, and to the consequent obstruc- tion to the function of respiration, and the pulmonic circulation; there is also a greater liability to pulmonary haemorrhage from the more rapid ulceration of the lungs, and consequently the less time for the somewhat sIoav process of obliteration of the vessels which may become implicated; the appearances presented after death are also the same as in chronic phthisis. In the second form the lungs are thickly studded throughout AArith miliary tubercles, the tissue of the organs presenting the appearance of pneumonic engorgement, with here and there consolidation or hepatisation. The disease makes its attack with well-marked febrile symptoms, often resembling those of acute and intense bronchitis. In some cases the patients may previously have been in apparently good health; though we shall most commonly learn, upon closer inquiry, that there has been some tendency to phthisis in the family, or even that the patient may have had one or two slight attacks of haemop- tysis, or has been very susceptible to cold; it will generally also be found, where any evidence upon the subject can be obtained, that the patient has had a quick and small pulse, with some signs of venous congestion. The final attack, however, generally commences with the ordinary signs of bronchitis; but the dyspnoea rapidly becomes more urgent, the countenance dusky or livid, the pulse very frequent and small, but the impulse of the heart in most cases disproportionately strong. The tongue is furred and much congested; the surface is warm, and often moist, but the extremities are of a clammy coldness. The urine, too, is scanty and high coloured, and there is often a Avandering, but sometimes active delirium. The symptoms may be summed up as those of extensive bronchitis of the small tubes, with a greater amount of obstruction to the pulmonic circulation than even this disease is sufficient to account for, and fever of a typhoid character. Upon examination of the chest, we may find diminished mobility of the ribs, and perhaps of the diaphragm likeAvise; but the former appear to remain somewhat elevated as if inflated, the difficulty seeming to be in expiration rather than inspiration. Percussion generally reveals but little, if any diminution of resonance. Upon auscultation, the sounds heard are commonly preternaturally loud over the Avhole of the chest. The inspiratory murmur is loud and 240 FATAL TERMINATION OF PHTHISIS. coarse, with generally a fine mucous rattle, and the expiratory loud and wheezing. An attack of this kind may prove fatal in a few days; in Avhich case the lungs are found not to collapse, or to do so but little Avhen the chest is opened, and Avhen cut into to be in a state of excessive engorgement, and to be thickly studded throughout with miliary tubercles. The right side of the heart is gorged, and the portion of auricular septum occupied by the foramen ovale convex toAvards the left auricle; the liver Avill also be in a state of hepatic venous congestion. If^ however, the disease do not prove fatal in this stage, it passes on into the third form of acute phthisis, that, namely, of softening tuber- cles diffused through the substance of the lung. This form may, however, present itself without having obviously passed through the previous one, the attack commencing when the patient has been in apparent health. The general symptoms are much the same as in the previous form, but not so rapid in their progress, and the dyspnoea and lividity, though considerable, are less urgent, and the commence- ment of the febrile symptoms not so strongly marked. The rigors are often repeated for several days, and are generally followed by heat and perspiration; but there Avill commonly, as in the former case, be a coldness and clamminess of the extremities, Avith a feeble pulse at the wrist, but considerable impulse of the heart. The cough will generally be attended with expectoration of mucus, which soon be- comes opalescent and puriform. Pain Avill not unfrequently be felt across the epigastrium and along the margin of the ribs, especially on the right side, the effects of engorgement of the liver and spleen from obstructed pulmonic circulation; and the urine Avill be scanty and loaded, and not unfrequently there will be diarrhcea, with tenesmus. Hectic and emaciation now rapidly come on, the expectoration becomes more and more puriform, and the patient dies mainly of exhaustion, but still Avith a considerable tendency to apnoea, gene- rally within ten or twelve weeks of the commencement of the illness. Upon exploration of the chest we find that there is slightly-dimin- ished mobility, and the general resonance of the chest is impaired. At the commencement there is dry ronchus, but soon there is fine mucous rattle, which gradually becomes larger, or assumes the charac- ter of mucous crepitation, which passes on to gurgling. Phthisis, it is well known, is a most frequent disease in all climates; but in this more especially: it is also a most fatal one, though not, perhaps, so certainly or necessarily as is generally believed: the modes in which it proves fatal are various. In the chronic form, and when the fatal termination is not hurried on by any of what have been spoken of as the accidents of phthisis, the patient dies from asthenia or protracted syncope; owing to the great extent of suppura- tion in the lungs, aided in most cases by the diarrhcea; just as would be the case from similar disorganisation in any other part. Death in this form of the disease rarely, if ever, is the direct result of apncea, neither do we find in the heart or liver the ordinary results of obstruc- tion to the pulmonic circulation, OAving to the volume of blood being DIAGNOSIS. 241 greatly diminished by the protracted suppuration; and accordingly the heart is generally found to be small, and neither ventricle immo- derately distended; the liver also is not usually congested. The modes of death from the various accidents of phthisis have been already described. In the acute forms they are altogether different, being more or less owing to the obstruction of the function of the lungs. In the case of rapid excavation the mode of death is less widely different from that in chronic phthisis ; there being consider- able emaciation and exhaustion ; but nevertheless, urgent dyspnoea, and after death the right side of the heart is distended, and the liver congested. In the case of miliary tubercles, on the other hand, the mode of death is purely apnoea, the patient being often perfectly livid, and there then being every sign after death of the greatest obstruction to the pulmonic circulation, the subject being - but little emaciated, or even in full flesh. The diagnosis of phthisis is, as must be obvious, a matter of the greatest importance, not only as regards treatment, but, which is of hardly less moment where so fatal a malady is in question, as regards prognosis. It must also be apparent that it is of no less importance to detect the disease at its commencement; and it is at this time that it is also the most difficult. It may be that even before its com- mencement, or at all events before there have been any cough or expectoration, or any of those symptoms AA'hich peculiarly belong to it, the question of the danger impending phthisis is submitted to us. The premonitory symptoms having been already described, it re- mains to notice a few of the disorders Avhich may be mistaken for early phthisis. The first of these in point of order, is, perhaps, dyspepsia, the diagnosis betAveen which and early phthisis, will generally arise only in persons in Avhom there is supposed to exist some previous tendency to the latter; and in such subjects, or, in other words, in young adults of phthisical families, or in Avhom the general symp- toms of tuberculous diathesis are present, obstinate dyspepsia is to be watched with anxiety; and if to this there be added a furred and red tongue, not to be accounted for by any transitory febrile disturb- ance, the danger is greater; or if such a subject, not being a dissi- ■pated person, steadily lose flesh without any assignable cause, there is a strong probability of his becoming phthisical. A most important question arises in young females, from amenor- rhoea. In ordinary amenorrhoea, or in chlorosis, there is generally a gradual diminution in the menstrual discharge before its entire sup- pression; in phthisis, on the other hand, the cessation is almost sudden. Still, amenorrhoea has been mistaken for phthisis, and, what is of more serious consequence, the latter for the former; there may be amenorrhoea, with haemoptysis, without phthisis; but sudden amenorrhoea, Avith cough, and expectoration streaked with blood, is probably the beginning of phthisis, and if with this there is obstinate bronchitis of one or both apices, the symptoms are still more unfa- vourable. Closely connected with the above is the diagnosis from hemoptysis Avithout tubercle; in the female, haemoptysis with amen- orrhoea is more alarming when occurring in small quantities, and 16 242 PHTHISES. mixed Avith mucus, than when the blood is pure and in larger quan- tities. In the young adult male, where there is no disease of the heart, or aneurism, if there be haemoptysis, there is probably phthi- sis, and the diagnosis becomes almost positive if there be obstinate bronchitis of the upper lobe. Malignant disease of the lung may form an exception, but this is rare in such subjects; and when it is present, the character of the expectoration resembling red-currant jelly, as well as the general and local symptoms, will enable us to recognize it. The discrimination of simple bronchitis from early phthisis is the question that we are perhaps most frequently called upon to decide in regard to the diagnosis of the latter. If to bronchitis of the small tubes there be added diminished mobility of the upper ribs—im- paired resonance over the apices—increased loudness of the sounds of the heart in the same situation—irregular or jerking respiration —haemoptysis or raucedo—there is probably phthisis, and this pro- bability is still greater if the pulse be persistently more than 100. Emaciation is also an important symptom under these circumstances; but it must be remembered that tubercles and even cavities may be present in the lungs, and the patient recover flesh, Avhen the progress of the disease is merely checked for a time. Pleurisy has an important bearing upon the diagnosis of phthisis. Frequent attacks of limited and apparently erratic pleurisy are ahvays unfavourable, and still more if subacute or chronic peritonitis be also present. It is stated by Louis, that when the latter disease exists in a person of more than fifteen years .of age, provided cancer be not present, there is also phthisis; to this exception there has been added that of Bright's disease ; but even thus qualified, the law, though generally, is not universally true. Double pleurisy, with effusion, has been stated to be almost certainly indicative of phthisis; but besides the common exception of Bright's disease, and the rarer ones of malignant disease, and puriform infection, there may be (pos- sibly from rheumatism) double pleurisy with effusion, without phthi- 'sis, though almost always in an acute form. Sometimes there is a great depth of solid matter effused on the surface of the pleura; this, when it occurs near the apex, will produce diminished resonance, tubular breathing, and flattening, which may be supposed to arise from phthisis. This state of things is, however, much more common with the latter affection than without it, and if there be signs of dis- ease in the corresponding part on the other side, though these signs be almost entirely referable to the pleura, the diagnosis of phthisis becomes almost positive. The diagnosis between phthisis and pneumonia is often difficult, and in many cases we must be satisfied with a merely conjectural one, since pneumonia supervenes upon tubercular disease ; and may be folloAved by it, if it be not its cause. It is impossible, therefore, as long as pneumonia exists in either apex, to say, that there may not be phthisis; and so much more common is this disease than simple pneumonia in that part of the lung, that the probability is always in favour of phthisis; though the diagnosis must be consid- DIAGNOSIS. 243 ered doubtful, until mucous crepitation or some unequivocal symp- tom is detected, either in the other apex, or in the neighbouring portion of the same lung ; or some of the more characteristic consti- tutional symptoms make their appearance; or, on the other hand, until the subsidence of the former, and the continued absence of the latter, lead to the belief that the consolidation is dependent upon a disease confined to that part, a conclusion strongly at variance with the apprehension of phthisis. There may also be a difficulty in the diagnosis betAveen the more advanced stages of phthisis and pneumonia. " If," observes Dr. Addison, "acute pneumonia have already proceeded to complete hepatization, when Ave first examine the patient, the physical signs are not unfrequently insufficient to distinguish the morbid change from phthisical disease, or from ancient pneumonic induration, with or without dilated bronchial tubes. This is more especially the case when acute pneumonia assails the apex of a lung, which is by no means very uncommon." It will generally be—by the previous history of the case,—by the disease having come on more slowly and insidiously,—by the greater amount of emaciation,—the greater tendency to hectic,—the less pungent heat of the skin, that we may often be able to distinguish the chronic tuberculous phthisis. The acute phthisis is not so likely to be mistaken for pneumonia of the apex, OAving to its more diffused character, except in the case of the first form, in which, no doubt, the difficulty is the greatest; but even here the state of the opposite lung—the character of the fever—the previous history of the case, will generally enable us to solve the difficulty; still the diagnosis is a difficult one, and the difficulty must be borne in mind in the treat- ment of the case, by carefully watching its progress and the effects of remedies. It is not very often that a question arises between fever and phthisis, still, as Avas first pointed out by M. Louis, the acute miliary phthisis (form 3) often closely simulates typhus fever of the congestive character; the eruption of fever when it occurs, and is observed, of course decides the question. When there is chronic peritonitis, if bronchitis, or diminished resonance of the apices arise, or even if there be increased resonance of the voice, or loudness of the sound of the heart in that situation, there is probably phthisis. Persistent, or frequently-recurrent diarrhcea is always a premoni- tory sign, in a young adult of tuberculous diathesis, and if to this there be added any of the topical signs, the case is almost certainly one of phthisis.* The treatment of phthisis has generally been considered either as prophylactive or palliative; the former applying chiefly to those cases in which, from family predisposition, or other causes, the dis- ease may be apprehended ; the latter to those in which there is satis- factory evidence of its existence; this distinction being based upon the assumption that when the disease is once established, its removal is a thing quite beyond the reach of art. * Dr. Walshe's " Diseases of Lungs and Heart." 244 PHTHISIS. The question as to whether we are to regard the treatment of inci- pient phthisis as curative or prophylactic, is not of very great prac- tical value, though it is not entirely without its influence upon our views of the principles according to which the management of the disease is to be conducted. Since, if according to the opinions already expressed (p. 230) there must be a lesion antecedent to the deposition of tubercles, we have, at this period, a disease to treat,— and one from which there are good grounds for believing that many have recovered,—and, Avhether that recovery be regarded as sponta- neous, or as the effect of art, it cannot be supposed that it would have taken place under other than favourable circumstances, both external and internal; and, therefore, the rational mode of proceed- ing must be to endeavour to ascertain those circumstances, and as far as possible to imitate them ; and the same reasoning holds good of the far less frequent instances of recovery in more advanced stages, the cessation of the disease in the manner described (p. 228) being a result more opposed to experience than to any known laws of pathology. As regards the strictly preventive or prophylactic treatment of phthisis, it consists in measures calculated to prevent the develop- ment of the tuberculous diathesis, where it is to be apprehended; and Avhere it exists, to obviate all circumstances tending to promote irritation, excitement, or even undue activity of the respiratory organs; and where such irritation has arisen, to endeavour to subdue it as speedily as possible, without having resource to such measures, as, by lowering the reparative powers, would favour the general tendency to tuberculous disease. As to the first of these indications, namely, the preventing the development of the tuberculous diathesis, precautions should be most strictly enjoined for the avoidance of all those circumstances (under our control) which have been already pointed out (pp. 110 et seq.) as favouring it, and the cautious use of such means as may be expected to have a contrary tendency. As to the prevention of the determination of the tuberculous diathesis to the lungs, we must again recur to what has been stated, when treating of the circumstances influencing the location of tubercle (pp. 112 et seq.). It is about the age of puberty that the greater expansion of the respiratory organs, arising from a greater need for the activity of their functions, suggests the necessity for increased precaution against their becoming the seat of tubercle; for, although the deaths from phthisis between the ages of fifteen and twenty are many less than those between tAventy and twenty-five; there can be little doubt that, in by far the greater number of instances, the disease has its origin during the former period. It becomes then a matter of great importance, in the management of young persons in whom a tendency to phthisis may be apprehended, to use every possible precaution to obviate determination of blood to the lungs, as well as undue excitement of those organs. In the first place, the obvious and ordinary rules of diet, clothing, air, and exercise, Avhich are, however, but too commonly neglected. PROPHYLACTIC TREATMENT. 245 cannot be too carefully followed; though, as regards diet, it must of course be nutritious, but not stimulating; in moderate quantities, and at reasonable intervals, so as to avoid the extremes of exhaustion and repletion, and prevent the undue afflux to the digestive organs, and consequent languid circulation of the extremities. Determination to internal organs, and especially to the lungs, must also be guarded against by a careful attention to the temperature and circulation of the surface. Uniform, but not very warm clothing, is an important means to this end; and it must be used in subservience to the principle of preventing the sudden or too rapid abstraction of the animal heat, but not employed to such an extent as to diminish the activity of those functions upon which the evolution of this heat depends. Light Avoollen clothing should be employed in some form, for the Avhole of the body below the clavicles, and where there is a tendency to irritation about the larynx, a thin layer of flannel or woollen gauze may be Avorn round the throat: where a uniform system of under-clothing of this kind is adhered to, there will be no occasion for oppressing the body with a load of outer-garments. The same remarks apply to night-covering, though it will not generally be desirable that the patient should sleep in flannel. The night-dress should be calico, and if there is much coldness of the feet, woollen socks may be worn. Before quitting the subject of clothing, we must not omit to notice the mischiefs which may arise from undue pressure or constraint. The apices are the parts first attacked, and, therefore, whatever causes increased activity of that part of the lung, promotes the disease, and this cannot be done more effectually than by compressing the lower lobes by tight stays or waistbands. The questions of air and exercise—in the former of which we may, for the sake of brevity, include climate—are at this period particularly important. In the case of a young person in danger of phthisis, whose growth is not completed, we must not only avoid circumstances likely to cause too great determination to the chest, but, as far as we can, prevent such a development of the system as would call for more than an average amount of respiratory function. It is a common observation, that young persons of a phthisical tendency have narrow chests, their lungs not being sufficiently developed; and, therefore, it is inferred, somewhat hastily, that the narrowness of the chest is the cause, or rather the essence of the phthisical tendency; the converse, however, is more nearly the truth, namely,—that, when the tendency to tuberculous deposit in the lungs is present, there is an instinctive avoidance of that exercise which would promote the morbid change; and, therefore, the lungs being less active are less developed. It must be borne in mind, then, that whilst a defective expansion of the lungs is of itself a source of most serious and even fatal lesion, though not of tubercle, their full or even moderate development, may call the tuberculous diathesis into activity; and, in the management of the class of patients we are now considering, the regulation of air and exercise must be conducted with a view to favouring the gradual expansion of the lungs, without inducing that amount of respiratory function which is excited by a cold atmosphere, and without such 246 PHTHISIS. vigorous exercise as stimulates the rapid development of the muscular system. With this view, a mild and uniform climate, but, as a general rule, one free from humidity, should be selected; and for this purpose many parts of the southern shores of this island are well adapted, as Hastings, the AArest Cliff of Brighton (during the autumnal and winter months), Bournemouth or Clifton. Though for those in whom, to use the words of Dr. Walshe, there is a greater tendency to the strictum in the constitution, Ventnor, Torquay, Budleigh, Salterton, Sidmouth, or the coast of Cornwall, as Penzance or Flushing near Falmouth, and the Cove of Cork, will be better adapted as Avinter residences. One great advantage of a mild climate is, that there need be less difference in temperature betAveen the external and internal air, and that, consequently, exercise may be taken out of doors Avithout the risk arising from changes of temperature; and that such exercise may be sufficient to keep up the warmth of the surface, and excite a moderate action of the lungs, without so far exciting them as to promote the determination of the disease to them. Walking, when it does not embarrass the respiration, is upon the whole the best exercise; but where the patient's strength is soon exhausted, or where the breathing is easily hurried, riding [on horseback] is to be preferred, provided that it does not cause coldness of the extremities. In warm weather carriage exercise is beneficial, as is also sailing, or being rowed in a boat, where it does not induce sickness. It is at this period that irreparable injury has often been inflicted by the use, or rather abuse, of athletic games or exercise, pursued sometimes even under medical sanction, from the mistaken notion of obviating the tendency to contraction of the chest so common in subjects of this class; whereas, from what has been already stated, the expansion of the lungs, and the development of the muscular system, must be most undesirable; and for the same reason the greatest caution is necessary, in alloAving the use of such exercises as rowing, cricket, &c, in youths in Avhom there is a narrow chest and suspected tendency to phthisis; though where this contraction arises from causes to be hereafter noticed their moderate use is admissible. Another important question often asked in such cases is, the expediency of bathing; now where, as it often does, the arterial system seems disproportionately defective as compared with the venous, the pulse being in such cases small and feeble, sea-bathing is seldom safe; as, under such circumstances, there would probably not be sufficient power in the left ventricle to drive the blood again to the surface, and internal congestion, probably of the lungs, would ensue. When, however, as we now assume to be the case, there is no evidence of present lesion of the lungs, and the pulse is moderately full, and there are no signs of venous congestion, or of engorgement of the right heart, or other circumstances contra-indicating its use, careful bathing in the sea may be allowed. Such bathing should generally be about an hour and a half after breakfast, and the patient should not remain long in the sea, neither will it be generally desirable that he should plunge suddenly in, but he should step from a machine feet foremost, immerse the Avhole body and head, and return. He TREATMENT OF IMPENDING PHTHISIS. 247 should on no account go cold into the water; but, on the contrary, a slight increase of temperature induced by exercise is rather desirable. AVhere bathing is not admissible, sponging the chest both in front and behind with cold water can generally be borne, and where it is followed by a moderate glow it is a most valuable aid in promoting the activity of the circulation in the superficial capillaries. The period of impending phthisis is of course not a time for active medical treatment, though it is one for very careful medical superin- tendence. In regard to medicine the same principle must be carried out as in the hygienic management; the general strength and nutri- tion must be cared for, and undue excitement of the respiratory function guarded against: as a means to these ends attention to the digestive organs is indispensable. AVith this object in view, it will be necessary, in addition to the careful attention to diet enjoined above, to insure a regular action of the bowels; the irritating purga- tives must be avoided; as, besides their other ill effects, they depress and derange the circulation; but an occasional dose of rhubarb and sulphate of potass will be of service: or, if the bowels be habitually costive, a dessert spoonful of olive oil, taken early in the morning, will have the effect of relieving them without risk of irritation, or sometimes about half a drachm of the extract of taraxacum taken early will have the same affect. This last has also another advantage, if, as Dr. Baillie used to assert (and as there is reason to believe to be the case), it may be regarded as a vegetable mercury, exciting the action of the liver; for that organ being, in regard both to circulation and function, closely connected with the lungs, affords a ready channel through which to relieve them. The maintaining the action of those organs which may be regarded as in any way supplementary to the lungs, should never be lost sight of; and as this applies especially to the liver, the state of the stools and urine should be watched; and when the secretion of bile appears defective, it should be promoted, not by mercurials (except sometimes a moderate dose of hydrarg. cum. cret. Avith rhubarb) but by taraxacum or the laxative just recommended. Besides the liver and bowels, the kidneys afford a means by which to relieve the circulation of the system generally, and consequently in the chest, and therefore the state of the urine should be regularly observed, and as its becoming turbid will generally depend upon partial obstruction, arising probably from incipient pulmonic conges- tion, the aperient should be given, and for a time moderate diuretics. The extract of taraxacum with about ten grains of bicarbonate of potass and tAventy minims of sp. aeth. nit. in bitter infusion, will often have a good effect in this way. The earliest symptoms of bronchitis, or any other thoracic inflam- mation, should of course be promptly met by decided but not over- active treatment; all needless depression of the powers of the system only aggravating the tuberculous tendency. In case of bronchitis, Avhich is the more ordinary form of disease, salines, with small doses of antimonial or ipecacuanha Avine, about five grains of extract of conium every night, or night and morning; and, after a few days, 248 PHTHISIS. the application of a blister, if the irritation continue after the febrile symptoms have subsided, will generally be sufficient. The conium mixture will also be found a most useful medicine under such circum- stances. AVhere pneumonia or pleurisy occur, they must be treated upon the principles already laid down, but with a more cautious use of depletion, and. a no less scrupulous one of mercurials. The local abstraction of a small quantity of blood by cupping or leeches, over the inflamed part, will in either case be generally well borne, and expedite the resolution of the inflammation with the least loss of strength to the patient. Dr. Graves, indeed, as well as several other Irish pathologists, and Dr. Munk in this country, have strongly recommended rapid mercu- rialisation in such cases; but it is not a practice which has extensively obtained the confidence of British physicians. [In all cases such a practice, we are persuaded, would be rather calculated to accelerate than retard tuberculous disease of the lungs.] It is not generally desirable, in the absence of any decided symp- toms of disease, to put such patients under a course of medicine. Where, however, there is emaciation, a course of the cod-liver oil, continued for three or four weeks, and resumed, if necessary, about the same time after its discontinuance may be of service; and where there is an exsanguine appearance, iron, in the form of small doses of the citrate, or of the syrup of the iodide, should be employed. The use of iron is often specially applicable to females (it being observed that we are now speaking of young persons just about, or past the age of puberty, in whom there is a tuberculous diathesis but no apparent pulmonary affection), as the delay or arrest of menstruation is, in young females prone to phthisis, not only an unfavourable symptom, but may be in itself a cause of pulmonic irritation; for the connection, elsewhere pointed out, betAveen the uterine functions and the evolu- tion of carbonic acid, renders it highly probable that the suppression of the catamenia must promote the development of tubercle in the lungs. When a young subject of this class is affected Avith any strumous ulcer, diseased bone, or fistula in ano, it is doubtful whether the healing of these is desirable. It is certain that, in some cases, the more active symptoms of phthisis have supervened upon the healing of such ulcers, and have subsided upon their reappearance in the same or some other part. It appears, then, most expedient to use no active measures to heal them, except in so far as that result can be brought about by improving the general health. When, as in case of very unsightly strumous ulceration of the skin, any application is used for that purpose, it would be well to establish some compensating dis- charge, as an issue or seton on the surface of the chest. The best internal remedy under such circumstances is the iodide of iron. With regard to fistula in ano, experience is strongly opposed to the expediency of the operation for its cure; unless the amount of dis- charge, and the consequent drain upon the system, be so great as to become almost a greater evil than phthisis. In speaking of the prophylactic management of young persons in TREATMENT OF FIRST STAGE. 249 whom phthisis may be apprehended, Ave have said nothing of removal to a distant climate, as it is a question which belongs more to the treatment of the first stage, in which the premonitory symptoms of phthisis begin to show themselves locally; indeed it may well be doubted Avhether it is expedient to send young persons in whom the development of the system is complete, to an intertropical climate, or even to a Ioav latitude, since it is highly probable that the return to this country would be attended with a double danger. In the treatment of Avhat we have styled the first stage of phthisis, that, namely, Avhich immediately precedes tuberculisation, the prin- ciples above laid doAvn must still be acted upon, namely, to avert irritation or inflammation in the lungs, and to maintain the nutritive powers of the system. But at this period, when the disease may be said to be impending, if not already existing in the lungs, we may lay greater stress upon the fprmer clause, and direct our remedies more particularly to the lungs. It is now that the greatest benefit may be hoped for from change of climate; but this change must be made for a sufficient time; and, if a removal from this to another country be decided upon, it should be to one climate decidedly different from that in which the patient has been hitherto residing. Dr. Graves observes, and with reason, that it is needless to send a patient from these islands to the south of France, or to the Mediterranean;* and that a change beyond the limits of Europe should be made. Madeira is, perhaps, the nearest place, and the convenience of access to that island is certainly a recommendation; but the greatest benefit, probably, is to be obtained- by a residence at the Cape, or in the West Indies, or a voyage to the East Indies. Of course it is of the first importance to prevent any inflammation of the lungs or their appendages, but where such does occur, it must be treated upon the principles already laid down (p. 248), and any more trifling irritation, as catarrh or slight bronchitis, by light diet, and the conium mixture with a little ipecacuanha wine. When the symptoms, general or local, indicate an increased determination to the lungs, a very small amount of blood may be taken, by leeches or cupping, from under the clavicles; or dry cupping may be used. Occasional blisters may also be applied, when there is not too much heat of skin; or the tartar-emetic ointment employed. A valuable method of counter-irritation is the application to the chest of the plaster recommended by Dr. Hughes (F. 31).f The pulse in this stage of the disease is generally rapid, and it is important, in some measure, to control the heart's action; for this purpose digitalis will sometimes be useful, and the infusion will be the best form for its exhibition, as, although it does not so directly depress the heart's * Malaga, however, presents many of the advantages of a more southern climate- See Dr. Francis on Change of Climate. f (31) R. Emplast. Picis co. sjiss. Anti. Pot. Tart. gr. x. Dissolve and mix. 250 PHTHISIS — HAEMOPTYSIS. action as the tincture its more diuretic properties are serviceable (F. 32).* AVhere there is no active irritation of the lungs or bronchi, the digitalis may be advantageously combined Avith iron or quinia, or both, as in the pills (F. 33) :f where the quinia or steel may be too stimulating, the sulphate of zinc will be found a most useful tonic (F. 34)4 and this more especially in those cases where the skin is generally moist. Another useful medicine will be the conium in combination Avith sarsaparilla, in the form of the conium mixture, with about fifteen grains of the solid extract, or 3i. to 3ij. of the liquid. If there be emaciation, the cod-liver oil will be of service, but otherwise it is rarely so in this stage of the disease. It is not unfrequently at this period that haemoptysis occurs, and when it does so, it must be treated accordingly; but it must be borne in mind that when not very great, it is to be regarded rather as a bad symptom than as in itself a cause of mischief, since it is by no means impossible that it may give relief, by diminishing the hyperaemia, which is its cause. It is rarely, if ever, expedient, under these circumstances, to take blood from the arm, but cupping under the clavicles to two or three ounces is generally admissible. Where it is obA'ious that one lung is much more affected than the other, that side may be selected; if the pulse be quick, digitalis with acid may be employed, as in (F. 32); and should the haemorrhage be of such an amount as to become of itself a source of weakness, about ten grains of alum, or five of gallic acid may be added. Lead has certainly considerable power over haemorrhage from the lungs, but the other astringents are to be pre- ferred to it when there is much tendency to anaemia. When, hoAvever, the haemorrhage is A'ery great, threatening death from exhaustion, the stronger styptics, as turpentine, may be employed, and cold applied to the surface of the chest. The latter, however, is a remedy to be used with the utmost care, as Ave have seen more than one instance in which there was too much reason to believe that, by the applica- tion of ice to the chest, and the neglect of cautions to prevent the * (32) R. Infus. Digitalis, 3 iij. Tinct Hyoscyam. 55 ij. Sp. JEth. Nit. 3 iij. Syrupi Rhsead, 3 iiiss. AcidSulph. dil. z ss. Infus. Rosae co. 3 iij. M. A third part to be taken three times a day; add, if indicated, Quinise Disulph. gr. j., to each dose. t (33) R. Pulv. Digitalis, Quinise Disulph. aa gr. j, Ferri Sulphat. gr. ss. Ext. Conii. gr. iiss. M. Ft. Pil ; to be taken three times a-day. X (34) K Zinci Sulphatis, gr. i. Ext Conii, gr. iv. M. Ft. 1'il.; to be taken three time a-day. TREATMENT OF LATER STAGES. 251 patient being wet with ice-cold water, congestion, pneumonia, and speedy death, were the consequences of over-much zeal in checking haemoptysis in this manner. When ice is applied, it should be care- fully tied up in a bladder, and the effects upon the general tempera- ture of the surface carefully watched. There is good reason for believing that, in many cases of this description tending, under unfavourable circumstances, to tuberculi- sation and softening of the lung, the disease has been arrested by measures such as we have been recommending, and that, too, in cases where a removal from this country has not been practicable. The treatment of the next two stages, those, namely, of tuberculi- sation and softening, must be nearly the same, if, indeed, these stages can often be separated: but the object in either case is to allay irritation, and at the same time maintain the powers of the system, and to treat any of the accidents or complications of the dis- ease, which may now be expected to present themselves, as they arise. It will be of great importance to allow the lungs as great a degree of repose as is consistent with the general health, and particu- larly to preclude all those circumstances Avhich might be expected to call upon them for any sudden or hurried increase of action. This is mainly to be effected by a uniformly-warm temperature. At the same time, however, in the absence of all the accidents above alluded to, we must not lose sight of the principle of maintaining to the utmost the healthy nutrition of the system. The selection, where it is possible, of such a climate as will allow of the patient passing some time in the open air, or even taking moderate out-door exercise without incurring any considerable change of temperature, or indeed of at any time breathing an atmosphere below 60° F., is a most important means to this end; and therefore, where the disease is not far advanced, or likely to be very rapid in its progress, a removal to a warmer climate, as the Cape, or to Madeira, may yet be attempted; but it should not be encouraged by the medical attendant without an express intimation to the friends of the patient of the doubtfulness of his living to return; and, therefore, one of the places in this country already alluded to will often be preferred. Even in these, for many months in the year, it Avill be possible to obtain fresh air without violating the above conditions; and when the external temperature is not beloAV 60°, artificial warming of rooms should be dispensed Avith, and the windows freely opened. The diet should be nutritious, but unstimulating: mutton, or Avhite fish, or game, being allowed once, and when there is much debility, twice in the day. The clothing should still be uniform, but not oppressive, and composed of materials that are the worst conductors of heat. As regards medi- cine, the conium mixture, with the sarsaparilla, or two or three minims of the dilute hydrocyanic acid, will still be found useful, especially if the cough be troublesome, and even at the same time the cod-liver oil may be used, adding to it, as Dr. AValshe recommends, a little mineral acid if it offend the stomach, and, when the bowels are irritable, a feAV drops of laudanum. It may sometimes be con- 252 PHTHISIS. veniently given, in such cases, floating on the draught (F. 35).* The conium mixture may be given night and morning, and the oil about an hour after each meal. Where the cough is not a troublesome symptom, it will be best to discontinue all medicines except the oil, though it will often be found, after a time, that patients who have been taking it without repugnance, suddenly conceive an unsur- mountable antipathy to it; in which case it must of course be with- held; after some time, however, the patient will express a willingness to resume its use, and it will then be found to be as serviceable as before; indeed, the alternation of the conium and sarsaparilla with the cod-liver oil, appears to be a very beneficial course of medicine. Another important-consideration at this period of the disease is the obtaining sleep; indeed, sleep is one of the best remedies in _ con- sumption, as it is the most effective and most natural means of giving rest to the respiratory organs. The extract of hyoscyamus, in combination with that of lettuce, will often be a useful anodyne, but when this fails, opium or morphia may be employed (F. 36).f Morphia with henbane is a very useful combination. It ought perhaps to have been first stated, that the best of soporifics is fresh air, and that, when the patient can be much out of doors, there will not often be occasion for any other. The treatment of the last stage, or that of excavation, can of course be but palliative; but even here it must be remembered that cases do occur in which there has been a cavity, and that too of conside- rable size, but where the rest of the lung having been free from dis- ease, the cavity has emptied itself, and ultimately, by the contraction of the lining membranfe, been nearly obliterated; or in which the symptoms, both topical and general, have so closely resembled this state of things, that it has been next to impossible to distinguish them: so that we are still called upon to omit no precaution to avoid irritation of the lungs, or any means to maintain the nutrition of the system; for which purpose the same measures must be pursued as heretofore, and to this end the cod-liver oil will still be found most serviceable. A nutritious, but unstimulating system of diet must still be pursued, though, where there is much exhaustion, the mode- rate use of wine or malt liquor may be allowed; of the latter the best is, perhaps, pure single stout of the London brewers. When there is any increase of cough or expectoration, the conium, with a little ipecacuanha, may be again employed, and counter-irrita- tion may be established over the cavity by a small blister, or the tartar-emetic ointment. It is in this stage that the night-sweats are * (35) R. Acid Nit. dil. ni, x. Tinct. Opii, tt^ ij. Syrupi Aurant. ^ i. Infus. Aurant. co. 3 vj. Misce. Ft. haust. f (36) R. Morphise Hydrochlor. gr. i. Ext. Hyoscami, gr. xvi. Misce. Ft. Pil. iv. of which one is to be taken at bed-time. TREATMENT OF LATTER STAGES. 253 most troublesome, and against them there is no remedy equal to the combination of zinc and hyoscyamus (F. 37).* It is often in the latter stages of phthisis that the irritation from the laryngeal ulceration is the most troublesome. Where this is the case, the solution of nitrate of silver should be applied in the manner recommended for chronic laryngitis. Where, however, there is any irritation from this cause in the commencement of the disease, the strong solution may be employed, not only with advantage to the affection of the throat, but apparently -with benefit to that of the lungs as well. The complications or accidents of phthisis may be treated upon ordinary principles. The partial and erratic pleurisies which so fre- quently occur may be combated by the application of small blisters, occasionally mustard poultices; the intercurrent pneumonias in this disease may be treated upon the- principles already laid down, although the details given for the management of active pneumonia would of course be inapplicable here; for we must remember that the pneumonia Avhich we have now to do with is of a disorganising character, and, therefore, that mercury in considerable quantities, and other lowering measures, should be abstained from. Antimony, Avhere there is much heat of skin, and the boAvels are not irritable, may be administered in small doses, and a little Dover's powder and hydrarg. cum cret. given at night, or night and morning. AVhen the inflammation is of a decidedly active character, a few leeches may be applied over the inflamed portion of lung, or two or three ounces of blood removed by cupping. Haemoptysis, when it occurs, as also pneumothorax, must be treated in the manner already recommended. Sickness is often, though not very often, a distressing incident in phthisis; it generally, however, is the effect of some abdominal com- plication, as strumous disease of the glands about Glisson's capsule; it may frequently be combated by effervescing draughts, to Avhich may be added small doses of prussic acid; or by soda or Seltzer water, given in small quantities at a time; or, where there is much irritability of the mucous membrane, as shown by redness of the tongue, by restricting the patient, for a time at least, to the use of milk and lime-Avater in about equal proportions, applying at the same time blisters or sinapism. Diarrhoea is another very troublesome symptom, and particularly toAvards the termination of phthisis; it occurs, however, not uncom- monly (as Ave have seen) in the earlier stages, Avhen it is probably excited by irritating matters in the alimentary canal, under Avhich circumstances gentle laxatives may be employed, as castor oil and laudanum, castor oil and tincture of rhubarb (F. 38),f or the combi- * (37) R. Zinci Sulphat. gr. i. Ext. Hyoscyam. gr. iv. Misce. Ft. Pil.; to be taken each night, at bed-time. f (38) R. Olei Ricini Tinct. Rhei, lili 3 ij. Tinct. Opii, rr^ iv. Aq. Cinnam. ij ss. Mix, and intimately diffuse the ingredients. 254 PHTHISIS. nation of rhubarb and chalk and opium (F. 39).* In the latter stages of phthisis, when there is probably ulceration of the boAvels, the diarrhoea is best combated by astringents, as copper and opium, compound kino powder, nitrate of silver, logwood, &c. A very use- ful astringent or tonic is the combination of nitric acid and tincture of opium (F. 40).f Enemata of starch and laudanum are also appli- cable. Pain and tenderness in the abdomen, arising from chronic, i. e., tuberculous peritonitis, may occur at any period, though it is sometimes itself the older disease, and, with its treatment, must be considered hereafter. We have before spoken of the pneumonic phthisis, in which the excavation of the lung appears to be brought about by the softening of those parts of the organ Avhich had been the subject of pneumonic consolidation ; this form of the affection—the pneumonic phthisis of Dr. Addison—appears to be that alluded to by Dr. Graves, under the term scrofulous pneumonia. There is again another form of disease which is closely allied to phthisis, and that is the chronic bronchitis, with profuse puriform expectoration, of which also we have before spoken—probably the scrofulous bronchitis of Graves. These affec- tions are to be met with—(1) In those who have inherited no ten- dency to tuberculosis, but whose constitutions have been impaired by exposure, illness, or irregularities, or by repeated attacks of the acute forms of the above diseases. (2) In persons of strumous constitu- tions, who have escaped the dangers of phthisis in early life, but in whom the tendency again manifests itself, though in this altered shape, when their strength has become impaired by age. These forms of disease constitute, in fact, the phthisis of impaired constitu- tions and of advanced life. The treatment of these affections must be conducted upon the principles already laid doAvn when speaking of pneumonia and bronchitis. * (39) R. Pulv. Rhei, gr. xv. Pulv. Cretse co. c. Opio, gr. x. Misce. Ft. Pulv.; to be taken in any suitable vehicle. • f (40) R. Acid. Nit. dil. n^ xij. Tinct. Opii, tt^ v.—x. Syrupi 5 i. Aq. Cinnam. 3 x. Misce. Ft. haust.; to be taken every sixth or fourth hour. DISEASES OF THE HEART. 255 XIV. DISEASES OF THE HEART AND ITS APPENDAGES. Like all serous membranes, the capsule of the heart is liable to inflammation from various causes. This inflammation constitutes pericarditis. Pericarditis may be acute or chronic; it may be idio- pathic, that is to say, arising to all appearance spontaneously, or excited only by the ordinary causes of inflammation; it may also be secondary, that is, the consequence of some anterior disease affecting either the Avhole system or particular organs. Acute pericarditis in its perfect form, passes through the stages of engorgement or congestion, effusion of lymph or serum, absorption, and adhesion. In the first of these stages, the surface of the membrane is gene- rally dryer than in health, and if the disease be arrested in this stage (i. e. if resolution takes place), no permanent effect is produced. In the second stage, the effusion may assume various forms, according as the fibrinous lymph, molecular lymph, or serum predominate. When the effusion consists almost entirely of fibrinous lymph, it is deposited in layers of varying thickness, which often speedily form a bond of union between the cardiac and reflected surfaces of this membrane ; though, AA'hen very thin, they remain in flakes upon its surface. AVhen the molecular lymph predominates, the solid deposit will be less firm, and there will be (especially if the powers of the system be enfeebled) a tendency to puriform degeneration, pus being sometimes formed in the cavity of the membrane, which produces speedy death by its pressure on the heart; a large quantity of pus being found in the cavity after death, and the surface of the heart covered by soft villous lymph. It more commonly happens, how- ever, that an intermediate condition exists, in which the effusion being but imperfectly plastic, the solid matter is softer than the true fibrinous lymph, and after death the apposed surfaces of the pericar- dium are found to have been but feebly agglutinated, and present, when separated, a villous appearance; it is this form of effusion, pro- bably, which has been not unaptly compared by Dr. Watson to the rough sides of pieces of tripe which may be seen in butcher's shops. Sometimes, again, the serum is poured out in large quantities, and if not speedily reabsorbed, is fatal in the same manner as the puriform effusion; it is, however, much more susceptible of absorption, as well as of much more frequent occurrence. The next stage is the absorption of fluid; this often takes place very rapidly, or, Avhat is the same thing, the quantity poured out having been very small, the lymph is left either giving rise to a greater or less extent of adhesion, merely covering portions of the membrane. The next step in the history of ordinary inflammatory exudations is, the organization of the lymph; and when this takes place without 256 pericarditis. connecting the two surfaces of the pericardium, the membrane be- comes in parts roughened by layers of areolar tissue. AVhen the two surfaces are glued together, the organisation of the effused lymph takes place with greater or less rapidity, and different effects may be produced on the surface of the heart. There may be simple adhesion, with scarce any areolar tissue between the surfaces, an occurrence Avhich has no doubt given rise to the fables of the peri- cardium having been found wanting altogether; or, there may be only partial adhesion, or, the fibrinous lymph may have been so thick, that, by the contraction which accompanies its organisation, it, in a measure, strangulates the heart, and greatly embarrasses the circulation. It has been a matter of some doubt, whether the fibrinous effusion is ever removed by absorption; that it sometimes is, though after a long interval, and probably through the intervention of fatty de- generation, has been shown by Professor Paget. The general symptoms of pericarditis, independently of its physical signs, are alone insufficient for the purposes of diagnosis; but so, in some instances, are the physical signs themselves, and therefore neither one or the other are to be disregarded. The disease sometimes comes on insidiously; often, in the course of an ordinary attack of acute rheumatism. There may have been no symptoms to mark the origin of pericarditis, yet, upon careful ex- amination, there may be found evidence of changes which would imply a duration of some days: there may have been rigors, but these are by no means necessary; and the pain, in the region of the heart, though a symptom upon which much stress has been laid by several authors, is so often absent Avhen the inflammation is confined to the pericardium, that it may well be questioned, Avhether, in all cases in which it occurs, it is not an accident produced by the pleuritis which so frequently attends this disease, rather than one of its essential symptoms. When in pericarditis there is pain in the region of the heart, it is generally increased by pressure made upwards against the diaphragm by means of the'fingers placed under the margin of the ribs ; often there is also a sense of weight or stiffness about the left shoulder, extending down the arm to the elbow or wrist. Though there may be no pain, there are always, in acute pericar- ditis, great distress and anxiety, Avhich are plainly expressed in the shrunken features and contracted countenance: the position too is often peculiar; the patient sitting up in his bed with the shoulders bent forwards, and the elboAvs resting upon the knees, or some other support. Sometimes he will recline upon the left elbow, or against some support placed by the bedside, as he rarely, if ever, lies fairly upon that side, or, indeed, upon either, though he may upon his back. The occasional presence of orthopnoea has induced some authors to state that its occurrence is a sign of effusion into the paricardium; this is certainly not the case, as it is often wanting when there is effusion, and as often present, and indeed urgent, when there can be ITS PHYSICAL SIGNS. 257 none; it probably depends more upon the situation and extent of the inflammation than upon any other circumstance. As a general rule, the descent of the diaphragm increases the uneasiness, and therefore the patient endeavours to place himself in the position most likely to keep it at rest. This is sometimes the case to such an extent, that a patient has been known to tie a belt or bandage round the Avaist, finding relief by restraining the motion of the diaphragm in this manner; the respiration is almost always hurried, and the alae nasa expand perceptibly; the number of respirations, too, is increased in a greater proportion than the frequency of the pulse. The free motion of the heart is no doubt in some degree interfered with, and so far we have the Icesa partis functio to aid us in our diag- nosis ; but as there are so many other disorders that render the heart's action hurried or irregular, no great reliance is to be placed upon this symptom. As a general rule, however, the pulse is frequent, sometimes full and hard at the commencement, but becoming, as the disease advances, feeble, sometimes wiry, and often unequal both in force and rhythm; the frequency of the pulse is also very liable to great and sudden variations, especially upon change of posture, some- times even from the slightest movement; the tongue is in the more acute and sthenic cases generally covered Avith a Avhite fur, but it presents no characteristic appearance; there is often, especially in rheumatic cases, a profuse perspiration, and the urine is generally scanty, high-coloured, and loaded with urates. AVhen effusion has taken place, the action of the heart becomes heaving, the dyspnoea urgent, and the pulse very feeble and ir- regular. Another important, though not very common symptom of peri- carditis, and one that may occur at any period of the disease, is delirium, Avhich is sometimes of a furious character; this distressing complication is most liable to arise when the cardiac inflammation supervenes upon an attack of acute rheumatism. The topical signs of pericarditis are, in the majority of cases, pretty distinct, though in some rarer ones they are either altogether Avanting, or so feebly marked that the disease is not easy of de- tection. In nearly all cases of this disease, and through all its stages, the mobility of the walls of the chest, over the region of the heart, is obviously diminished: in the greater number, the breathing is thoracic, for the reasons already stated; but in some few, in Avhich the inflammation affects mainly or entirely the base of the heart, it may be abdominal. In the first stage, or that of engorgement, the irritability of the organ being increased, the impulse is most obvious to the eye; and when the hand is placed over the heart, this impulse is felt to be stronger, as Avell as sharper than in health; the area of the precordial dulness upon percussion is not increased; auscultation gives a faint friction-sound generally with the first beat, but this is by no means constant. AVhen the exudation of lymph has commenced, there is not un- 17 258 ENDOCARDITIS. commonly a thrill to be felt over the region of the heart, and when the lymph effused is very thick, there is increased precordial dul- ness ; but the characteristic sign of this stage is the friction-sound, AA'hich is produced by the attrition of the surfaces of the pericardium roughened by fresh lymph. This sound is heard Avith most distinct- ness Avhen the lymph which produces it is situated near the base of the heart, and it then commonly accompanies both sounds, constitut- ing'the to-and-fro murmur, which can often be traced to the origin of the aorta, but no higher. AVhen the friction-sound is produced more towards the apex of the heart, it is not so constantly double, and generally follows immediately upon the first sound, so as to appear like a continuation of it; it is generally soft in its character, approaching to the bellows murmur, though sometimes it has more of a harsh or rasping tone. It should be remembered that the sounds produced by the attrition of the surface of the pericardium are in themselves morbid or preternatural; and not, as may be the case Avith valvular murmurs, modifications of the natural sounds; and, therefore, although they may be obscure, they do not, as in the case of the latter, supersede them. The natural sounds are therefore still present, though it may be difficult at all times to separate them from the new ones introduced by disease. Allusion has already been made to the occasional absence or obscurity of the stethoscopic sounds of pericarditis, and this remark is, perhaps, more applicable to the friction sounds of the stage of exudation; for cases certainly have occurred in which effusion of fresh lymph has been found after death, and in which no friction-sound could be detected during life, though sought for at so short a period before death as to preclude the possibility of effused serum having prevented the friction, and having been subsequently absorbed. In such cases the lymph is of the soft villous character, and the powers of the system and action of the heart have been feeble. In the case of effusion of fluid, the area of the precordial dulness is considerably increased, and occupies a triangular space correspond- ing to the situation of the pericardium; the impulse of the heart though feeble is diffused and heaving, and the rhythm sometimes irregular (the pulse at the wrist being very feeble and often inter- mitting) : an undulating motion may also be sometimes felt by the hand, and some authors mention a protrusion of the intercostal spaces in the precordial region; though it is doubtful if this ever occurs independently of pleuritis. The apex of the heart is raised higher than its natural position. The sounds are distinct and feeble; in most cases the friction-sounds which had been previously heard are observed to have ceased; and Avhere the process of their obliteration has been carefully Avatched, they Avill be found to have disappeared from below upAvards. AVhen absorption of the effused fluid takes place, the friction- sounds gradually return, extending from the base of the heart doAvnAvards toAvards its apex, and the charcteristic signs of effusion gradually disappear. When adhesion is established the friction- sounds are much diminished, and in some cases again disappear FIRST STAGE. 259 altogether, but there often remains a rolling and trembling motion of the heart. The consideration of further changes in the products of the inflammation belong more to the subject of chronic inflamma- tion of the pericardium. The internal, like the external lining of the heart, is liable to inflammation, constituting endocarditis, which, like pericarditis, may be either acute or chronic, primary or secondary, and is liable to be excited by the same causes. The anatomical changes of endocarditis are, at the commencement, engorgement, Avith more or less consequent, tumefaction of the mem- brane and subjacent tissues, next, effusion of lymph or pure fibrine upon its surface or immediately beneath it, subsequently, thickening, granulation, contraction, and puckering, sometimes adhesion, softening and laceration; the functional effect throughout is increased excita- bility of the organ, Avith impaired action of its valvular apparatus. As the effect of the functional derangement, we have palpitation and uneasiness at the region of the heart, but not necessarily pain or tenderness in the precordial region. As the effect of the anatomical changes, Ave have more or less turgescence of the organ itself, with alterations in the sounds accompanying its action, and disturbances in the current of the blood. The constitutional symptoms of endocarditis differ but little from those of pericarditis. There is much the same anxiety of countenance, but less dyspnoea; the attitude is less constrained, though the patient generally lies on his back; and sometimes there is considerable rest- lessness : the skin is hot, but not remarkably so; the pulse quick, sometimes unequal or irregular, not intermittent at the commence- ment of the disease, though the late Dr. J. Taylor stated that it was slow at that period, a remark which applies only to its very beginning. The anatomical changes in the heart and the valves, produce cor- responding alterations in the physical signs which accompany the movements of this organ, and in its action as an hydraulic machine; in which latter Ave include the systemic and pulmonic circulations. These changes Avill best be understood by tracing them from the heart through the system in the different stages of the disease. In the first stage,—that of hyperemia or engorgement,—AAre have more or less turgescence of the organ itself, and this is attended by some increase in the area of the precordial dulness; the impulse of the heart is, at the same time, rather duller and more forcible than in health, as Avell as sharper or quicker. There being as yet merely turgescence of the valves, Ave have no great amount of imperfection in their action, and, therefore, although the sounds accompanying it may be modified, the current of the circulation is not much disturbed; accordingly, a Aralvular murmur may be heard at this period. This murmur, Avhich accompanies the first or systolic beat of the heart, is most distinct in the mid-sternum, and may be traced along the course of the aorta nearly to the top of the first bone of the sternum; it is produced by the turgescence of the aortic valves, causing them to obstruct the current through the aortic orifice more than they do in health. There is also frequently a murmur to be heard more toAvards 260 ENDOCARDITIS. the axilla in the situation of the mitral valve, also accompanying the first sound. This murmur is generally of the soft blowing character, and is by some authors referred to regurgitation through the mitral Aralve; the difficulty of this explanation lies in the want of proof that such regurgitation does take place, neither is there any reason for supposing it, unless it be owing to imperfect closure of the valve, arising from the action of the columne carne being impaired by the inflammation of their investing membrane. Others have supposed it to arise from the ventricular surface of the right curtain of the swol- len valve disturbing the current of blood toAvards the aorta, though, if this Avere true, the murmur would be traceable along the ascending aorta, which it is not. May not the explanation of this murmur, which is a modification of the first sound, be found in the considera- tion that this sound is a complex phenomenon, in the production of which the closure of the auriculo-ventricular valves is not the sole agent, whilst an important one in producing it, namely, the muscular contraction, may be considerably affected? After all, it is probable that the only murmur properly belonging to the first stage of endo- carditis is the soft systolic aortic murmur described above. The pulse, as before mentioned, is quick (except, perhaps, at the very commencement of the attack), and its sharpness is someAvhat increased, but we have as yet none of the conditions of the pulse characteristic of imperfect action of the valves (p. 69); in fact, the absence of such conditions may be cited as additional evidence against the murmur above referred to being produced by mitral regurgitation. In the second stage, or that of exudation, the lymph may exude either upon the free surface of the endocardium or underneath it; in the former case it is often throAvn out upon the ventricular surfaces of the aortic sigmoids, rarely upon those of the pulmonic: being soft, it probably yields to the pressure where the surfaces are apposed in closing the orifice, and, accumulating along the edge of those sur- faces, forms a sort of fringe along the margin of the two crescent- shaped segments which constitute the surfaces of apposition; that is to say, along the crescentic margins of the opaque scutiform portion of the valve, or else along the free margin of the valve itself, in the manner described by Dr. AVatson. The same thing may occur along the margins of the apposed surfaces of the mitral valve, and some- times of the bicuspid, though the same exact regularity of arrange- ment is not observed. These fringes of lymph generally increase, either by fresh exudations, or by the deposition upon them of the fibrine from the blood itself, so as to form excrescences of sufficient size to disturb the current passing through the orifices of the heart, and sometimes to prevent the accurate closure of the valves them- selves. Similar deposits may also take place upon other parts of the internal surface of the heart, as upon the Avails of the cavities, or upon the surfaces of the fleshy columns, or amongst the chorde ten- dine. It is also a possible, though not very frequent occurrence, that these deposits of fibrine may become detached and form loose coagula in one of the cavities, generally in the left ventricle; and these are sometimes of sufficient size to cause sudden death by obstructing the SECOND STAGE. 261 orifice, or, undergoing degeneration, to set up pyhemia and its dis- astrous consequences. AVhen the lymph exudes underneath the endocardium, there will ensue an opacity of the membrane Avhere it lines the cavities, and Avhen between the layers which form the valves, the latter Avill, in this stage of the disease, be SAvollen and thickened; thus they may, more than in health, encroach upon the space alloAved for the current of the blood, and by their becoming less flexible the freedom of their action may be impeded. The signs by which these changes may be recognized will be best understood by considering their effects upon the action of the heart, and the current of the blood. When there is exudation upon the surface, or between the layers of the aortic valves, there Avill be more or less narrowing of the orifice, and consequently, upon auscultation, there will be heard the systolic blowing murmur, traceable from the situation of the aortic valves along the course of the artery, as in the first stage of the disease. But it may happen, besides, that the closure of the valve is imperfect, and in this case a murmur, produced by a reflux of blood through the orifice, will be heard in the same situation, but accompanying the second sound. In this stage of endocarditis affecting the aortic orifice and its valves, there may be a double, or, as it has been called, a see-saw murmur. This is not by any means a constant effect, as the murmur may re- main a single one in this stage, and even in the next, but when it is present it proves that the disease has gone beyond the first stage. Lesion of these valves has, as has been pointed out (p. 69), a cha- racteristic influence upon the pulse at the Avrist. When there is simply obstruction, the pulse will be rather sharp, compressible, and of small volume compared to the impulse of the heart; Avhen, how- ever, there is regurgitation through the sigmoid valves, there is the splashing or " water-hammer" pulse. It has been remarked, and with much reason, by Dr. Chevers (on Diseases of the Heart, p. 17), that it is important to distinguish be- tween effusion upon the surface and between the layers of the valves. AVhen there is a very harsh or musical murmur with the first sound, but none (indicating regurgitation) with the second, the probability is in favour of deposit upon the surface of the valve, particularly if this occur early in the disease, and in a subject of previously good health. AVhen the exudation takes place upon the surface of the mitral valve, or between its layers, there may occur one or both of tAvo things, the current from the auricle into the ventricle may be ob- structed, or there may be regurgitation into the auricle. It is very doubtful AArhether the former occurrence ever produces a murmur, though some authors have described such; if it do occur, it must just precede the natural first sound; it is, hoAvever, to say the least, very rare. When there is regurgitation, there is a murmur accom- panying the first sound, and heard more distinctly towards the axilla; but for the reasons already adduced, there is much more obscurity attaching to the sounds ascribed to this valve, than to those of the sigmoids. The pulse, however, affords us great assistance, especially 262 ENDOCARDITIS. if there be no disease of the aortic Aralves, which would, of course, materially disguise any character that it Avould receive from the con- dition of the mitral; but Avhere these are free, the pulse at the Avrist will be either very small and intermittent or both, the latter condi- tion belonging more especially to those cases in Avhich the orifice is contracted. And even in cases AAdiere there is obvious disease of the aortic valves, the pulse Avill be much smaller and less splashing than it would have been had the mitral disease not been present also. Throughout this stage the constitutional signs of endocardial inflammation continue as before. In the more advanced stage of the disease are found the changes which ordinarily take place in inflammatory exudations, producing in the valves and orifices of the heart thickening, granulation, con- traction, puckering, adhesion, and, sometimes, softening and lacera- tion. These processes seldom occur singly; and therefore, we commonly find the characteristic signs of two or more of them occur- ring at the same time: to begin Avith the aortic valves—there may be thickening of the valves, and often Avith this there will be granu- lations or Avarty excrescences on their surface, arising from the orga- nisation of the lymph Avhich has been deposited as already described (p. 260) ;. and to these may be added fresh deposits of fibrine from the blood. There will then be increased impulse of the heart, whilst the pulse at the wrist will not be proportionately strong, and a hoarse systolic murmur traceable along the ascending aorta : but in addition to this, the effect of the granulations may be to impair the closure of the valves, and cause, in addition to the above signs, a diastolic murmur in the same situation, Avith a splashing or " water-hammer" pulse. Again, there may be adhesion between the contiguous extremities or angles of tAVO valves, and Avith it a tearing away, from their inser- tions, of the angle, close to Avhich the adhesion takes place; so that the two valves are formed into one imperfect one ; or, owing to the contraction of the fibrinous lymph effused between their layers, the valves may become puckered. In either case, there may be present the signs of obstruction combined with those of regurgitation, in a much more marked degree than in the earlier stages of the disease. The same changes may occur in the mitral valve, from exudation upon the surface of its curtains, or between the folds of endocardium of which they are formed ; and Ave then find the signs of obstruction and regurgitation the same as when the valves are thickened or ob- structed in the commencement of the exudation ; but, as in the case of the aortic, in a more marked degree, both in the sounds of the heart and in the character of the pulse; though it must still be borne in mind that there is a greater obscurity in the diagnosis of disease of the mitral, than of that of the aortic valves, arising, as has been pointed out, from the complicated character of the first sound, and from the effect upon the pulse, of disease of the former valve, being liable to be modified by that of the latter, as well as simulated by other conditions of the circulation. There is another effect of inflammation upon the mitral valves CARDITIS — CAUSES. 263 which deserves notice, though not of very frequent occurrence, namely,—softening and consequent laceration of the chorde tendi- nee. After death several of these may be found separated, and the extremities shrivelled up upon the free edge of the valve, and covered with clusters of vegetations. The necessary and immediate conse- quence of this accident is considerable regurgitation into the left auricle, diminished supply to the sj-stemic circulation, and great engorgement of the lungs, causing imminent danger from the com- bined effects of syncope and apnoea. The further changes which occur in the lining membrane and orifices of the heart, and the effects upon the extreme circulation and other parts of the system, belong more appropriately to chronic endocarditis and its consequences. The pathological changes, as Avell as the immediate effects and symptoms of pericarditis and of endocarditis, have been separately described to enable the student to analyze more accurately the vari- ous cases which present themselves in practice rather than with the vieAV of describing diseases which often occur in a simple and uncom- plicated form, as it is far more common to meet Avith the two affec- tions combined than with either singly. This will be apparent, by considering the causes of pericarditis and endocarditis. Like pericarditis, endocarditis may arise, to all appearance, sponta- neously and as a primary affection, depending upon no assignable cause beyond those of ordinary inflammation; but like the former, it is more commonly the effect of some antecedent disease. In estimating the frequency of primary or idiopathic pericarditis, as well as endocarditis, some allowance must be made for the chance of both one and the other being overlooked, especially AArhen they do not terminate fatally; still neither of them is probably of frequent occurrence. Of the idiopathic inflammations of the serous mem- branes, those affecting the heart are less frequent than idiopathic pleuritis or arachnitis, but more so than idiopathic peritonitis; and as regards their frequency relatively to each other, idiopathic peri- carditis is more common than idiopathic endocarditis. Both these diseases are, however, almost universally blood dis- eases, that is to say, arising from some morbid poison or—from retained secretion in the blood. Of the former class of causes, by far the most frequent is acute rheumatism. So much is this the case that we may safely affirm that by far the greater number of cases of acute pericarditis, and also of acute endocarditis, are rheumatic. Next to acute rheumatism as a specific disease, acting as a cause of acute pericarditis or endocarditis, is influenza, and next to it, but far less frequent as a cause of cardiac inflammation, is scarlatina; and it is probable that all the eruptive fevers may occasionally induce inflammation of these membranes. Of the latter class of causes, namely, retained secretion, by far the most common is uremia, from disease of the kidneys, which next to rheumatism is the most frequent of all the causes of acute cardiac 264 CARDITIS — CAUSES. inflammation, and is the most frequent cause of subacute inflamma- tory action terminating in organic disease. The same thing may occur, though much more rarely, from retained biliary secretion; and it is not improbable that a large proportion of cases of so-called idiopathic inflammation of either surface of the heart arise from a similar condition of the blood, induced by repression of the cutaneous exhalation. Such being the causes common to both pericarditis and endocarditis, it might be expected, as, in fact, is ordinarily the case in practice, that the one will almost always be more or less complicated with the other; especially in the more common case of their occurring as secondary diseases; and therefore we may speak of them under the common term of carditis as regards their general diagnosis, prognosis, and treatment. The diagnosis of pericarditis is only to be considered certain, Avhen we have the characteristic friction-sound, of the rather crackling char- acter, which belongs to recent exudation; and this is most distinctly heard when the inflammation involves the base of the heart, and con- sequently the sound is double. It is very true, as observed by Dr. AValshe, that this friction-sound may be mistaken for other things; but it must also be remembered that the sound may be wanting under certain conditions; and then we are left to conjecture the pre- sence of the disease by the previous history, the character of the pulse, the position of the patient, and the diminished mobility of the loAver ribs and diaphragm; though nearly the same symptoms Avould be presented by pleurisy on the left side, confined to the diaphragm. Fortunately, in acute stages of either disease, the diagnosis between them Avould be of no practical importance. The diagnosis between pericarditis with a friction-sound, and pleuritis of that part of the membrane Avhich overlaps the heart, will generally be effected by observing the difference between the cardiac and respiratory rhythm; but there is one source of fallacy, in pleuritic friction-sound some- times effecting a cardiac rhythm: Avhen this is the case, hoAvever, the sound is not to be heard over so large an extent of the cardiac region, but is more confined to the edge of that region; the pleural sound too is not heard Avith every beat of the heart, especially when the patient holds his breath* The diagnosis of endocarditis, before it has produced the charac- teristic sounds of valvular disease, is perhaps more doubtful than that of pericarditis; though Avhere these are absent the probability is in favour of the existence of the former disease rather than the latter, particularly if the patient do not exhibit the characteristic attitude and countenance of pericarditis. There is another form of disease which presents many of the symp- toms of both pericarditis and endocarditis, namely, pleuritis on the left side, and nearly confined to that portion of the membrane which is connected Avith the diaphragm. The diagnosis will, however, soon become clear in the majority of cases, either by the appearance of the * Drs. Addison and Walshe. CARDITIS — MODES OF DEATH. 265 friction-sounds or murmurs; or, by their continued absence, render- ing it highly probable that there is no cardiac lesion. It is important to bear this distinction in mind, in order to be able more clearly to foresee the subsequent progress of the disease; though, as regards the immediate treatment, it is of no great practical moment. Neither pericarditis nor endocarditis, nor the two combined in the more common disease which, for the sake of brevity, Ave term carditis, is so often fatal in the acute stage, as by the remote effects to Avhich they very frequently lead, the consideration of Avhich belongs more properly to chronic carditis. Death does, however, not very rarely occur in pericarditis, either from the sudden and rapid effusion of serum or puriform fluid between the surfaces of the membrane, which by its pressure upon the heart produces death from syncope, particularly in pericarditis from diseased kidney and uremia; or the disease; may terminate by sinking or gradual syncope from the depressing effect upon the heart's action, of the continuance of the inflammation Avithout any effusion sufficient to account for such a result. This mode of death may also occur in the manner just men- tioned, from endocarditis, as may also sudden syncope from the sudden occlusion of one of the orifices of the left side of the heart, by a coagulum of fibrine, which has formed about the lymph effused upon the inflamed portion of endocardium, and become detached from thence by the current of the blood. Cardiac inflammation may also prove fatal by exhaustion conse- quent upon sudden and often violent delirium supervening in the course of the disease; sometimes, too, when it appears to be sub- siding, and this without a trace of any lesion being found within the cranium. This occurrence is most to be apprehended in rheumatic carditis. The treatment of carditis will be much the same whether it affect the external or internal surface of the heart. The great principle of keeping the part affected in perfect rest in all acute inflammations, cannot be applied, except to a very limited extent; still much may be done towards removing all causes of excitement of the circulation, and something towards producing a directly sedative effect upon the heart. AVith this end, in all cases of cardiac inflammation it is neces- sary not only to confine the patient strictly to his bed, but to enjoin the most careful avoidance of every movement that can possibly be prevented, a precaution which in cases of this kind is too often neglected, or, rather, not enforced with the earnestness it deserves. Another important preventive is the removal, as far as lies in our power, of every mental excitement. Upon this account, as well as of the physical exertion which attends it, no conversation should be alloAved; not only should the diet be most strictly antiphlogistic, in the commencement of all acute cases occurring in any but the most asthenic conditions of the system; but Ave should also endeavour, by regulating the quantity of fluid taken, and by maintaining regular and copious discharges from the bowels, the kidneys, and the skin, to render the volume of the circulation as moderate and uniform as possible. 266 CARDITIS. As regards more direct remedial measures, the first question Avhich suggests itself is the expediency of general bleeding. The expecta- tion of thoroughly annihilating an attack of carditis by free and repeated venesection, as recommended by M. Bouilland, has been long abandoned in this country; both on account of the improbability that where fibrinous exudation has taken place it can be speedily removed, and also because bleeding pushed to such an extent as greatly to retard the movement of the circulation is not the most likely means of effecting this result. Still it is not impossible, as remarked by Dr. AVatson, that, if the general symptoms teach that pericarditis exists, but no attrition-sound is to be heard, we may hope to arrest the disease by a full and copious bleeding. And the same applies to endocarditis, Avith the qualification that there may exist a faint valvular murmur from the mere vascular turgescence of the valves before any truly inflammatory exudation has taken place. As a general rule, the venesection is admissible and desirable in the very commencement of inflammation of either surface of the heart, though care must be taken that the absence of the pericardial friction is not attributed to the early period of the disease, when, in reality, it is the effect of the exudation being of the flocculent, almost puri- form character, together Avith the very feeble action of the heart, both resulting from an asthenic condition. Unless, however, the indications of bleeding are decided, a safer plan, and not less beneficial, will be the abstraction of a moderate quantity of blood from the region of the heart by cupping or leeches (the former being generally to be preferred): this remedy, though it cannot annihilate the disease after the second stage has been estab- lished, will do much toAvards checking its further progress; and the measure may be repeated Avithout danger to the patient. The next object is to get the patient under the influence of mercury, which will be best affected by the combination of calomel, antimony, and opium already recommended (F. 3 & 4); the antimony will also fulfil the important indication of depressing the force of the heart's action. When in the course of the disease, or even after its apparent sub- sidence, effusion appears to be taking place rapidly into the pericar- dium, a large blister applied to the region of the heart will often have the effect of arresting it. It has been observed above, that carditis may at almost any period terminate by rapid sinking, and then it may sometimes become neces- sary to have recourse to stimulants. When the pulse becomes very feeble, the skin cold and clammy, and there are general signs of prostration, especially in an advanced stage of the disease, ammonia, wine, or even brandy may be administered, even although from the probable continuance of the inflammation it is necessary still to repeat the calomel. The above remarks apply to the treatment of carditis generally, and more particularly to its simplest, though rarest form, namely, the idiopathic. When, however, it occurs in its more common form of a secondary disease, the treatment must be regulated in a great mea- sure by the primary one. TREATMENT. 267 It has been of late a question amongst physicians whether rheu- matic carditis should be treated as a common inflammation, or by the means Avhich are found most applicable to the specific one. Till very lately the former has been the plan most generally followed; and perhaps in an acute inflammation, attacking so important a'part, it is hardly safe to Avait till the secondary disease can be overcome by eradicating the primary one; it becomes, therefore, necessary to direct our treatment immediately to the latter; though it Avill be most reasonable and generally most successful to select the remedies with some reference to the former. The lemon juice recommended by Dr. Rees, and Avhich is undoubtedly efficacious in acute rheuma- tism of the joints, is hardly admissible at the same time with the calomel, and therefore it is best to use some other remedy of known efficacy in rheumatic inflammation Avhich can be administered at the same time with the mercurial. AVhen either surface of the heart becomes implicated in the course of an attack of acute rheumatism, apply tAvelve leeches to the region of the heart, or Avhat is better, let about eight ounces of blood be taken from thence by cupping, and let the patient take the calomel, antimony, and opium; two grains of the former, one ©f the opium, and a quarter of a grain of the anti- mony being given to an adult three times a day, and in the intervals let him take the acetate and nitrate of potass (F. 11). AVhen the pulse becomes less sharp a blister may be applied to the region of the heart; and as soon as there is the least effect produced upon the gums by the mercury, the quantity must be diminished, generally to about one grain night and morning, the opium and anti- mony being administered Avith it, or else from five to ten grains of the compound ipecacuanha poAvder, and the acetate and nitrate of potass Avith about half a drachm of nitric ether, and the same quantity of tincture of hyoscyamus. Digitalis has been recommended on account of its lowering the action of the heart; but in a disease which may terminate suddenly by syncope, it cannot be considered a safe remedy. Colchicum is also used in rheumatic inflammation of the heart; but it is not altogether free from the same objections as digitalis, and the sedative effect of the saline above recommended Avill in a great measure fulfil the same indication. AVhen, hoAvever, a purgative is required, the addition of from twenty to thirty minims of the compound tincture to a senna draught is admissible. It sometimes happens that when the patient appears to be going on favourably, sudden effusion takes place into the pericardium: under such circumstances the application of large blisters will, as in the case of primary pericarditis, often speedily effect its absorption. AVhen the disease appears to be assuming a subacute form, in which case there is often more or less of subacute rheumatism affect- ing the joints, the iodide of potassium with liquor potasse may be administered in infusion of bark, and counter-irritation must be continued by means either of repeated blisters, or the tartar-emetic ointment. The tendency to syncope will sometimes be so great as apparently to require stimulants: these, hoAvever, should be cautiously given, the safest, perhaps, being about ten or fifteen minims of sp. 268 CARDITIS. eth. co., with tAventy of sp. ammon. aromat. The sudden invasion of delirium is a very alarming symptom, and, if not checked, the excitement sometimes terminates by death from exhaustion: this delirium is not generally to be regarded as arising from active inflammation of the brain or its membranes, but appears to be a secondary effect of the cardiac inflammation, occurring Avhen the nervous system is in an asthenic condition, and therefore it is best met by opiates and stimulants. There are, no doubt, exceptions to this rule, and therefore caution is requisite in the exhibition of these remedies; and if there be dry skin, scanty urine, or contracted pupil, calomel should be combined with the opium, or when the signs of active irritation of the brain are strongly marked, the opium should be withheld, and the hyoscyamus, camphor, and calomel administered (F. 41).* Another class of cases of inflammation of one or both surfaces of the heart are those Avhich present themselves in connection Avith specific febrile diseases. Of these, perhaps the most common are those occurring in influenza. Scarlatina also is sometimes followed by inflammation of the heart, and the same thing may occur as an effect of small-pox, typhus, or any other specific fever. AVhen we haAre to do Avith pericarditis or endocarditis occurring as a complication of influenza, the leading principle in the treatment of the primary disease, namely, its intolerance of loss of blood, must be kept steadily in view; even the ajDplication of any considerable number of leeches will sometimes cause furious delirium, and if the the abstraction of blood is attended by no apparent ill effects, or even when the inflammation appears to be mitigated, the amendment is, in most instances, only temporary (pp. 89-90). In such cases, a blister should be applied to the region of the heart, calomel administered, in combination Avith antimony and opium, so as to induce a decided mercurial action, and in the intervals, acetate of ammonia, to which should be added an excess of the carbonate, as soon as symptoms of exhaustion supervene, which they commonly Avill in all inflammatory complications of influenza; and, as a general rule, it Avill be safer to anticipate them. AVine and ether may also become necessary in such cases. Nearly the same rules apply to the treatment of cardiac inflammation occurring as an effect of the scarlatinous poison, though probably the necessity for stimulants will not present itself so early. When urea or bile are retained in the system, Ave have, especially in the case of the former, a liability to inflammation of the pericardium and endocardium as of all serous membranes. In carditis from uremia mercury must be sparingly used; and therefore when the disease arises from this cause, we must have recourse to local bleeding by cupping or leeches, the former being generally to be preferred, blisters, purgatives, and diuretics, the mercury being administered in * (41) R. Hydrarg. chlorid. Camphorae, aa gr. j. Ext. Hyos^yami, gr. iij. M. Ft. Pil.; to be taken every third or fourth hour. TREATMENT. 269 small quantities, and immediately withdrawn upon the first appear- ance of its specific effects. It may be observed, before quitting the subject of acute inflamma- tion of the surfaces of the heart, that the term carditis has been by some authors restricted to inflammation of the substance, or muscular structure of the organ, a disease which, though it may be theoretically possible, is one of Avhich Ave have no experience in its simple form. It is indeed highly probable that in the greater number of instances of inflammation, both of the pericardium and endocardium, the un- derlying muscular structure is involved, the subsequent effects being degeneration, generally in the form of fatty change, which, by dimin- ishing the contractility of the muscular fibre, impedes the action of the organ, and gives a tendency to dilatation. When pericarditis assumes a chronic form, there is either a thick layer of fibrinous lymph, or a considerable quantity of fluid in the pericardium, which remains nearly stationary in quantity. In the former case the solid lymph undergoes various transforma- tions in its progress to organisation; in AArhich process it is liable to fresh attacks of inflammation. AVhen the layer of lymph is thin, there will often, for a length of time, be little or no disturbance of the action of the heart, provided the valves be sound and the subject an adult; if, on the contrary, the layer of lymph between the tAvo surfaces of the pericardium be very thick, the contraction described in speaking of the consequences of inflammation ensues; and this sometimes to such an extent as in some measure to cripple or stran- gulate the heart. The subsequent progress of the disease may be various; in some cases an adhesion and organisation may be followed by the deposition' of earthy matter: there is a specimen in the museum of Guy's Hospital, Avhere the effused lymph connecting the tAvo sur- faces of the pericardium, near the base of the heart, has thus been converted into a bony ring; the patient from Avhom this preparation was taken having suffered from rheumatism, with probably pericar- ditis, twenty years' previously, and having subsequently enjoyed tolerable health until a short time before his death, which Avas brought about by ascites, resulting from disease of the liA^er, Avhich Avas, to all appearance, primary, rather than the effect of the cardiac affection. It is also important to bear in mind that after there has once been inflammation of the pericardium, followed by adhesion, the patient is liable to a recurrence of the inflammation upon any fresh attack of rheumatism, though the symptoms will be much masked by the pre- existent disease. There is scarcely a more difficult diagnosis in the whole range of chest diseases than that of adherent pericardium, where we have not had the advantage of Avatching the case at the time of the formation of the adhesion. AVhen the adhesion is universal, and the lymph not A'ery thick, the action of the heart will not be much disturbed ; there Avill be no friction-sound, and unless there be hypertrophy, Avhich is a common though not necessary attendant upon such an affection, there will be no decrease of resonance. AVhen also the adhesion is near or 270 i CARDITIS. around the base of the heart, the same thing will be the case, though here the beat of the apex will be generally high and fixedly so* When the adhesion is near the apex the beat will be low, and the respiratory movements of the diaphragm and lower ribs diminished; and as in this case there will generally be hypertrophy, we shall have the area of the precordial dulness increased, and a rolling or tumbling action of the heart. When, too, as in the last instances, the adhesion is only partial, Ave may, and generally shall have a friction-sound; and Avhen there is adherent pericardium associated, as is often the case, Avith pleural adhesion overlying the heart, depression of the loAver part of the sternum, Avith a dimpling inwards of the scrobiculus cordis. When the lymph which has glued the surfaces together is near the diaphragm, there will generally be considerable dyspnoea, some flat- tening of the precordia, Avith diminished mobility of the ribs, feeble pulse, orthopnoea, and symptoms affecting the remote circulation, to be hereafter described among the sequele of cardiac inflammation. AVhen a fresh attack of inflammation occurs in a previously adhe- rent pericardium, there will be pain, dyspnoea, and palpitation, with general febrile symptoms; but if the adhesion have been universal, there Avill be no friction-sound. If, however, there have been partial adhesion, there will often be a soft friction-sound, either single or double, according to the situation; and if there have been old friction- sounds, these Avill sometimes disappear, owing to the adhesion, which before had been partial, becoming general. In the rare case of a stationary effusion into the pericardium, we have the same physical symptoms as in the stage of effusion in acute pericarditis, but persistent. The treatment of chronic pericarditis should consist of very gentle mercurials, as the pil. ipecac, cum scille, gr. iv. hydrarg. cum cret. gr. j. night and morning, with iodide of potass, in doses of about two grains three or four times a-day, combined Avith about ten minims of liquor potasse, and half a drachm of nitric ether." Eepeated blisters, or an inunction of tartar-emetic ointment, should also be persevered in. In regard to the treatment of chronic endocarditis, Ave would recur to what has been stated at p. 261, respecting the importance of dis- tinguishing between the effusion of lymph upon the surface of a valve, and its deposition betAveen its layers; and the ground of the desirableness of this distinction consists in the greater probability of bringing about the absorption of the latter than the former; and our being therefore justified in pushing our remedies, Avith that object, to a greater extent in the one case than in the other. These remedies are essentially the same as those just recommended in the case of chronic pericarditis, and it is obvious that, to employ mercurials, however gently, or even iodine, without a reasonable chance of effect- ing our purpose, must, in such a case, be to waste the strength of the patient. The diagnosis is indeed a difficult one, and also one in Avhich, except in the case of the aortic valves, the physical signs can give us but Walshe, Diseases of Lung9 and Heart. HYPERTROPHY. 271 little assistance ;* but even here the general condition of the patient Avill aid us greatly, since the same state which has been pointed out as contraindicating the use of mercury, is precisely that in which it is most probable the effusion would be on the free surface of the valve, and, therefore, the remedy powerless in promoting absorption. The sequele of inflammation of either surface of the heart are highly important, as being in their ultimate effects more destructive of life than is the primary disease: the fatal result is, however, in a number of instances, brought about by gradual changes, which are often more obvious in other organs than the heart: in other cases, again, the final and fatal lesion may be in the heart, but not in that part of it which had been the seat of the primary disease, the part least affected having become the most so, as a remote effect, through the intervention of some secondary lesion. Before proceeding to the consideration of the secondary and remote consequences of cardiac inflammation, or even to that of chronic dis- ease of the heart in any form, it is necessary to premise a few remarks upon hypertrophy and dilatation of that organ. Hypertrophy of the heart may be true or false. By true hypertrophy is meant an excessive development of the muscular tissue of the organ. The term false hypertrophy, on the other hand, is here introduced to express an increase in the volume of the heart without a corresponding one in that tissue Avhich consti- tutes almost its entire substance in health, and upon the strength of which its action depends. This hypertrophy is, therefore, termed false, because it arises, not from an excessive nutrition of the original structure, but from the deposition of a new one in the substance of the organ—a state of things obviously not incompatible with even a deficiency or atrophy of the former. Dilatation is an enlargement of one or more of the cavities of the heart. When this takes place, Avithout any corresponding increase in the absolute quantities of the muscular walls of the cavity, it is obvious that there must be a corresponding diminution in their thick- ness. Thus, if we suppose, by Avay of illustration, that owing to some cause the cavities of the ventricles of the heart Avere to be increased to tAvice their longitudinal axes, the proportions to the other dimen- sions remaining the same; the Avhole area of the surface of each cavity Avould be multiplied by four, and consequently, (if the quantity of muscular tissue remained the same,) its thickness at any part must be changed in the inverse proportion—that is to say, it must be reduced to one quarter. It may be here observed, also, that as the outAvard pressure, or resistance to contraction, increases in the same propor- tion as the area of the internal surface—then, supposing the change to take place Avhich has just been assumed, we should have, cceteris paribus, four times the resistance with one-fourth the thickness of muscle. In some rare instances it happens that the diminution of the thickness of the Avails is seen in a still greater proportion, the actual quantity of muscular structure being diminished. In the * See Dr. Chevers "Ou Diseases of the Heart," in loco citat. 272 DILATATION. majority of cases, however, with the dilatation there is an increase in the absolute quantity of muscle, nearly sufficient to maintain its thick- ness at the original standard, though not sufficient fully to compen- sate for the increased size of the cavity. This condition is the most common of all forms of enlargement of the heart, and is generally known as hypertrophy. AVith dilatation it is also sometimes termed excentric hypertrophy, to distinguish it from Avhat has been termed concentric hypertrophy, in which there is increase in the thickness of the muscular walls without any enlargement of the cavity, or even with a diminution of it from the encroachment of the thickened muscle; it is doubtful, however, if this latter ever really exists during life, its presence having been probably suggested after death by the strong contraction of the hypertrophied muscle. The alone cause of true hypertrophy of the heart is an increase to the force opposed to the contraction of the muscle or any portion of it. This may arise in various ways: thus there may be increased difficulty in the passage of the blood through either the systemic or pulmonic circulation, the effect of abnormal conditions either of the blood, the tissues, or the vessels; or there may be causes of obstruc- tion in the different orifices of the heart, all of which will tend to produce dilatation and hypertrophy;—first, in that cavity which lies immediately tergal to it in the course of the circulation, and subse- quently in the one lying next behind that, and so on, it may be, to all the cavities of the organ. It is conceivable again that a certain portion, or certain layers of muscular fibre should have their con- tractile powers destroyed or impaired by disease, and if this be so, it must happen that, a greater stress being thrown upon the remainder, a partial hypertrophy would ensue. Now, we know that other mus- cles underlying inflamed membranes lose their contractility, as is seen in the bulging of the intercostal spaces in pleuritic effusion, and the distension of the intestines arising from loss of contractility of the circular muscles in enteritis; and, therefore, it is but reasonable to believe, that there may be loss of contractility of the superficial fibres, and consequent hypertrophy of those nearer the endocardium, as a consequence of pericarditis; and loss of power in the portion of the muscle underlying the endocardium, and consequent hypertrophy of those nearer the pericardium, as a consequence of inflammation of the former membrane. The above are not the only modes in AAmich there may be an in- crease in the force opposed to the contraction of the ventricle giving rise to some form of hypertrophy or dilatation, although there may not be found an obvious mechanical cause for such obstruction. Thus the cause may not very uncommonly exist in the blood itself, which may be so changed in its physical and chemical or vital properties as not to pass freely through the extreme circulation. This state of the blood may arise in disease of the depurative organs, and when long continued induces hypertrophy and dilatation. The same condition of the blood often produces, or, to say the least, is associated Avith thickening and diminished elasticity of the coats of the arteries, • CAUSES. 273 extending even to the smaller branches; and thus it may increase the antagonist force to the stystole of the left ventricle. It is not improbable that the physical condition of the blood may materially influence the facility with which it is transmitted through the capillaries; since it has been ascertained that a fluid which is very thin and perfectly liquid, as water, does not pass through capillary tubes so easily as one which has been rendered rather viscid by some mucilaginous substance: this may be one reason why blood that has been deprived of a considerable portion of its albumen, as is the case after repeated hemorrhage or serous discharges, appears to circulate with more difficulty than healthy blood; and Avhy such a condition is often followed by excentric hypertrophy of the heart. It is true, indeed, that with such a state of blood the heart is imperfectly nourished, and this *may tend to promote dilatation; but it is a fact, the importance of which is perhaps not sufficiently recognised, that repeated losses of blood, or long-continued serous discharges, or protracted anemia, are often followed by excentric hypertrophy of the heart. Muscular exertion is one of the causes which have been assigned for hypertrophy, and there can be no doubt that where strong exer- cise is habitually used, the heart, like other muscles, becomes more fully nourished; this is perhaps the nearest approach to true concen- tric hypertrophy that is often met with. AVhen unusual or excessive exercise is persevered in by one not accustomed to it, or in whom the poAvers of nutrition are feeble, there is obviously a danger of the heart becoming dilated rather than hypertrophic, and the most com- mon result is excentric hypertrophy; the proportion betAveen the hypertrophy and dilatation varying according to the powers of nutrition of the patient. It is true, indeed, that inordinate exercise endangers the integrity of the valves (but of that more hereafter), but there can be no doubt that when such exertion is used, by one whose muscles are but indifferently developed (as from generally sedentary habits, for instance), a greater or less amount of dilatation may ensue, which may be followed by more or less compensatory hypertrophy. For instance, in London, a medical practitioner, whose mode of life is not that which is most conducive to the perfect nutrition of the muscular tissue, goes through an unusual amount of professional exertion; or a gentleman of the same state of system goes, by way of improving his health, upon a tour on the continent, or to the lakes of England or Scotland ; and finding his health and spirits invigorated, he walks long distances and ascends mountains; he afterwards finds that he is troubled with a little palpitation, and that the action of the heart is at times irregular or intermittent; this is often the effect of dilatation of the left ventricle. The same thing may ensue, from great exertion in hunting, roAving, cricket-playing, by one who is not in " good-condition," or even in a young lady of rather anemic system, or becoming so towards the close of a season, from some more than ordinary fatigue in dancing, or other exciting amusement. Mental emotion, if violent or long continued, is also reckoned amongst the causes of heart disease, and there can be no doubt that 18 274 HYPERTROPHY AND DILATATION. it may, in states of the system above described, produce dilatation, and perhaps hypertrophy. The above remarks may appear more applicable to the left than to the right side of the heart, but the same principle applies to both: and muscular exertion, which drives the blood onward to the right side of the heart, has no doubt a tendency to produce excentric hypertrophy of its cavities, though the consequence is, in a great measure, obviated by the safety-valve action of the tricuspid valve, explained by the late Mr. T. W. King. The chief cause, however, of enlargement of this side is obstruction to the pulmonic circula- tion, whether arising from disease or defect of the lungs or air- passages, or of the left side of the heart. The diagnosis of hypertrophy and dilatation will often follow as a corollary from that of theTesion which has caused it; though at other times it may aid in that of the latter. AVhen there is hyper- trophy of the left ventricle, the radial pulse will be full and hard, the impulse of the heart strong and heaAnng, and the first sound deep. AVhen there is dilatation the pulse will be soft (often sharp, owing to the character of the disease Avhich has produced the dilatation), the impulse of the heart heaving, but not forcible—both sounds loud and sharp. As in both hypertrophy and dilatation there is increased precordial dulness, the inference wilf be in favour of one or the other condition, according as the symptoms of either preponderate, ahvays remembering that the most common occurrence is the coinci- dence of the two. When there is hypertrophy of the right side, the precordial dulness extends more in that direction, the radial pulse is almost always feeble, absolutely,—and remarkably so, comparatively to the force of impulse of the heart, which is strong and heaving. There are also signs of venous congestion, with enlarged liver and scanty and high-coloured urine. Hypertrophy of the right heart scarcely ever occurs Avithout dilatation ; and the extent of the latter is marked by increased feebleness of pulse, engorgement of the liver, and diminution of urinary secretion. Of the false hypertrophy, the immediate cause is to be found in fatty change, with so very few exceptions that we may, for practical purposes, regard this change or degeneration, in one or-other of its forms, as constituting the anatomical condition essential to that lesion. In one form of false hypertrophy, there is an increase in the volume of the organ (the cavities being enlarged and their parietes thickened), but the latter do not consist of firm muscle, but are flabby and very lacerable, and are discovered, upon closer examination, to be undergoing a process of fatty degeneration. There is a strong probability that in many cases this degeneration is a sequela of inflammation, though it may no doubt arise under any other condi- tion of impaired nutritive energy; and as this defect may first shoAV itself in the heart, the lesion may, in one sense, be regarded as pri- mary. Again, it is very probable that some large fatty hearts may previously have been the subject of true hypertrophy, but the in- creased action necessary to its maintenance has been folloAved, as its necessary consequence, by a loAver grade of nutrition (i. e. fatty de- THEIR CONSEQUENCES. 275 generation), promoted possibly by a failure of the powers of the system at large.* It is also very conceivable, on the other hand, that fatty degeneration may become the cause of some amount of true hypertrophy, OAving to the, as yet, healthy layers becoming more active, in order to compensate for the diminished poAver of those which have undergone degeneration. Another form of false hypertrophy is the deposition of fat upon the surface of the heart, described by Dr. E. Quain, in an excellent paper upon fatty degeneration of the heart, published in the 33rd volume of the Medico-chirurgical Transactions, as fatty growth upon the heart. This is generally accompanied by a wasting of the mus- cular structure of the organ, and, from the Aveakness caused thereby, with more or less of dilatation. This apparent enlargement of the heart is commonly associated Avith a general tendency to the deposi- tion of fat in different parts of the system, as the omentum, appen- dices epiploice, &c, and a corresponding defect in the powers of nutrition as regards the muscular fibre. The consequences of true hypertrophy, are generally difficult to distinguish from those of the previous lesion, of Avhich it is itself the consequence; the hypertrophy being, in fact, a provision for over- coming some obstacle to the performance of a function essential to the continuance of life, is, in by far the greater number of cases, originally conservative. It may, however, become secondarily destructive, from the injury which the contraction of a too powerful cavity may inflict upon parts lying between that cavity and the seat of the obstruction, which is the cause of the hypertrophy, or even in some diverging currents of the circulation; or the preternaturally thick and strong walls of the cavity may oppose too great an obstruc- tion to the current from behind, and thus give rise to congestion and hemorrhage. For instance, disease in the descending aorta may cause hypertrophy of the left ventricle, which, by its preternaturally forcible contraction, may injure the ascending aorta or its valves; again, as the force of the systole of the left ventricle is transmitted equally along all the arterial branches, this hypertrophy, which is merely compensating as regards the descending aorta and its branches, becomes excessive and injurious as regards those arteries which proceed from the arch, especially the carotids and the branches, and the con- sequence may be disease and even rupture of the vessels of the brain. The consequences of dilatation are of an almost opposite character; they are, in fact, those of insufficient force in the central-moving power of the circulation. The dilatation and consequent increase of the force opposed to the ventricular systole, with diminution of the force by which that systole is effected, may go on increasing to such a degree that under any (even the slightest) additional exertion or obstruction, death may ensue from sudden failure of the circulation. For instance, a person labouring under dilatation of the left ventricle * Upon referring to Dr. R. Quain's paper upon this subject, I find that this is one of the explanations given by that author of the large fatty hearts ; and moreover, that he regards it as the most frequent cause of that condition. It may, no doubt, be received as such when there has been any apparent cause for previous hypertrophy. 276 DIAGNOSIS OF TRUE HYPERTROPHY. has, not uncommonly, died of syncope induced by the exertion of getting out of bed or straining at stool, and where the dilatation is mainly of the right ventricle, death from apncea, or obstructed pul- monic circulation has been brought on by a slight attack of bronchi- tis, or even sudden depression of temperature. The more gradual results—obstructed circulation and consequent venous engorgement, are, however, the most frequent effects of dilatation; thus, dilatation of the right ventricle gives rise successively to engorgement of the liver, ascites, and subsequently, to obstruction through the whole venous, and ultimately the arterial system; whilst a dilated left ven- tricle, if the patient is not suddenly cut off by syncope, leads even- tually to the same result, by causing obstruction in the lungs, and consequently engorgement of the right ventricle and its results. The physiological consequences of false hypertrophy or fatty de- generation being essentially those of debility of the heart, are nearly identical with those of dilatation; there is, therefore, the same lia- bility to death by failure of the moving power of the circulation, and perhaps a greater tendency to congestion, from the thickened though weak cavity not yielding so readily to the distending force from behind, and to irregular action, from its not contracting so readily when distended by the blood. The diagnosis of true hypertrophy, simply as such, consists in a heaving and strong impulse of the heart, with palpitation upon mode- rate exertion, a full and hard pulse, which is regular and not frequent, appearance of congestion of the vessels of the face, giddiness or ver- tigo, scanty urine, and in many cases torpidity of bowels, amounting almost to constipation. When the hypertrophy, as is most com- monly the case, affects mainly the left ventricle, the precordial dulness extends towards the axilla; the impulse of the heart, besides being very forcible, is diffused, the first sound is deeper than natural. In dilatation, there is also dyspnoea, and palpitation upon exertion, with a tendency to syncope; the pulse is sharp, and sometimes full, but always very compressible; in some instances, particularly under exhaustion, intermittent; the countenance is congested, with more or less hvidity, in severe cases, and the extremities cold, sometimes livid, Avith a clammy moisure; the urine is apt to be scanty and high coloured, and the liver often to be felt below the margin of the ribs. There is extended dulness upon percussion, a diffused and rather heaving but feeble impulse of the heart; the sounds, both first and second, are loud and sharp, but there is not necessarily any murmur with either; though sometimes there is a soft systolic one, the effect probably of distension. In the more common case of hypertrophy Avith dilatation or eccen- tric hypertrophy, the symptoms will be modified according as the greater tendency to one or the other condition prevails. There will be dyspnoea with palpitation upon moderate exertion; there will be injection of the countenance and prolabia, with more or less lividity, according to the extent of the dilatation; the urine will be scanty and high coloured, the more so in more advanced cases; the impulse of the heart will be heaving, and the pulse will not be pro- FALSE HYPERTROPHY. 277 portionably full; the latter may be sharp, but then it will be com- pressible in proportion to the dilatation. AAHien the dilatation of the left ventricle is considerable, there wiU sometimes be intermission, increased by whatever diminishes the volume of the circulating fluid, or depresses the nervous powers, as free purgation or diuresis; the tendency to syncope will also depend upon the extent of dilatation; in severe cases there is also orthopnoea; there will be extended pre- cordial dulness, and the impulse of the heart will be diffused and heaving, but not forcible, unless there is thickening of the muscular Avails. The first sound will be loud—dull when there is much thick- ening—sharp in proportion as the walls are thin. There is not necessarily any abnormal sound, though there is sometimes a soft systolic murmur or bruit de soujfiet (distension murmur); and there may be slight murmur, with the second sound, in old cases where long-continued distension has caused some degree of attrition, and consequent opacity and thickening. The diagnosis of false hypertrophy, or enlargement with fatty degeneration, will depend much upon the general aspect and condi- tion of the patient; it is more common in advanced life than in early manhood; but to this the exceptions are not very rare; and young females in whom there is a tendency to obesity are liable to it. In early life it is certainly more common in the female than the male; it is also observed most frequently in those who are disposed 'to be fat, and in whom there is a degree of sallowness, with a silky and sometimes unctuous condition of the surface; the minute veins over the whole surface are often injected; it is perhaps more common in those who live in large towns and pursue their callings in a confined and impure atmosphere than in those who live in the country, and are much in the open air. The symptoms are thus described in the paper of Dr. E. Quain before alluded to: " A patient complains in the earliest stages of being exhausted, particularly by ascending heights; he feels, he says, faint when he gets to the top of the stairs; though not giddy, he feels as if he must fall; and though not breathless or panting, sighs and seeks for air." Any unusual excitement, a heated or close atmosphere, produce the same effects, at the same time there is often experienced an uncomfortable feeling of choking or fulness in the chest. In the intervals the individual is pretty well. As the disease advances, the attacks become more frequent and severe, and often disturb and distress the patient at night; the temper has been observed to be irritable; in several cases the expression of the features appears anxious, and frequently the countenance is sallow; oedema of the legs and copious perspirations from very slight causes appear amongst the associates of the disease; the pulse is generally affected, but the mode in which it is so depends, no doubt, on the part of the heart affected, and on the extent and degree of the dis- ease. Irregularity is one of the most frequent alterations, weakness is another, slowness a third. "In general, weakness, irregularity, and sloAvness of the pulse are the characters which we most frequently find." As the disease advances the symptoms become more marked, the various effects of languid and feeble circulation show themselves, 278 HYPERTROPHY AND DILATATION. angina pectoris is perhaps fully developed, or the patient is cut off suddenly by some of the effects connected either immediately or remotely with the lesion itself. The physical signs are, extended precordial dulness when (as is generally the case) the heart is enlarged, a very feeble, though some- times diffused impulse of the heart; the first sound very feeble, it is doubtful if any murmur is necessarily present; when a systolic mur- mur is heard it is probably the effect of distension. In tAvo out of eighty-three cases in Dr. Quain's paper, the second sound Avas feeble or imperfect; this was ascribed by him to fulness and dilatation of the ventricle preventing perfect closure of the semilunar valves. As regards the treatment of simple or primary hypertrophy, it is, as has been shoAvn, so rare a disease that it will seldom, if ever, be necessary to direct our remedies especially to it. The cases Avhich approach most nearly to this form of hypertrophy, are those in which there is a tendency to an excessive development of the muscular system, increased, it may be, by great muscular exercise; the danger being that either the valves or the arteries will be injured by the too forcible contractions of the ventricle. The obvious indications in this case are the avoidance of the causes which may have led to the hypertrophy, and the use of a moderate unstimulating diet. Dieuretics, with alkalies or alkaline carbonates, may be occasionally employed, and all tendency to congestion coun- teracted by maintaining a steady and rather free action of the bowels. It is only, however, in extreme cases, as when, for instance, there is reason to apprehend hyperemia of the brain, that bleeding is to be resorted to; since whatever impairs the nutrition of the body may favour fatty degeneration, which is probably one of the remote con- sequences of hypertrophy. The treatment of the false hypertrophy, or fatty change of the heart, can be little more than prophylactic, since as Dr. R. Quain very justly observes, "AVe have no evidence to show that we can restore muscular fibres which have been destroyed; all, therefore, that we can hope for, and that not always, is to arrrest or suspend for a time, the progress of the disease by improving the quality of the blood, and thus supporting the vigour of those portions of the heart still uninjured." Nevertheless there is good reason for believing that, in cases not very far advanced, much may be effected by measures of this description; and by so regulating the circulation as to prevent all unusual distension of any of the cavities of the heart. When a tendency to this disease exists in young subjects, a mode of treat- ment, such as would be applicable in cases of obesity, must be pur- sued; accordingly, a spare diet of lean meat, and a moderate allow- ance of bread or biscuit, but little vegetables, and no fermented liquors; active exercise being at the same time perseveringly followed, much after the plan recommended by Dr. T. K. Chambers; liquor potasse may be taken in milk, in doses from half a drachm to a drachm: and, above all things, a pure bracing atmosphere should be sought. In this manner great relief has been obtained in several instances which have occurred to the author. TREATMENT. 279 The greatest danger from this disease, however, arises in more advanced life, when active exercise cannot be borne, owing to the general weakness, and when any considerable exertion, by hurrying the blood to the heart, might involve the danger of over-distension of that organ; but even under these circumstances, we may gain much from a system of diet similar to that which has been recom- mended above; and we may hope for equal benefit from a pure atmosphere, since this form of degeneration is much accelerated, if not induced, by the want of that essential depurating agent, without a sufficient supply of which, the consumption of the redundant car- bon in the extreme circulation, and the excretion of the carbonaceous compounds by the lungs, cannot proceed. The liver, it is true, may often, under these circumstances, be stimulated to supply, to a limited extent, the defect of the action of the lungs, and so may also the skin: these ends may be promoted by the frequent use of aperients, Avhich must not be of a depressing character; for instance, the compound decoction of aloes with the addition of a few grains of rhubarb and acetate or tartrate of potass (F. 42):* should this draught not prove sufficiently active, its use may be preceded by some colocynth pills with calomel. The liquor potasse and extract of taraxacum may also be administered in these cases alternately with saline diapho- retics. These measures, however, can be regarded only as palliative, and as from the debility of the heart there is a tendency to engorge- ment of the liver, the difficulty of maintaining a free action of that organ will generally increase. Some relief may also be given to the pulmonic circulation, and through it to the right side of the heart and the liver, by expectorants, which should generally be rather of a stimulating character, such as the combination of squills and ammonia. The great object, however, being, if possible, to arrest the tendency. to fatty change, the chief reliance must still be placed (in conjunction with a rigid adherence to the prescribed regimen) upon such exercise as can be taken (without inducing palpitation or ^intness) in the open air, in the country, or by the sea-side. Where the patient is able to ride, gentle horse-exercise will be most desirable; otherwise he should drive in an open carriage, or walk moderately. Before proceeding to consider the treatment of the more common cases of hypertrophy with dilatation, it will be well to trace the effects of its most frequent cause, namely, lesion of the orifices, pro- ducing either regurgitation, or obstructions, or both; as we then shall * (42) R. Pulv. Rhei, gr. xii. Pot. tart. 3 ij. Decoct. Aloes co. % ss. Sp. Ammon. arom. n^ xx. Aq. Pimentae, 3 vj. Misce. Ft. Haust. ; to be taken in the early part of the morning. Or, R. Sodae bicarb. Pulv. Rhei, aa gr. xii. Decoct. Aloes co. ^ ss. Aq. Pimentae, 3 vj. Misce. Ft. Haust. 230 HYPERTROPHY AND DILATATION. be in a position to take a more rational view of the management of chronic disease of the heart in general. Noav, as has been remarked, the essential cause of hypertrophy of any portion of the muscular tissue of the heart, is an increased stress thrown upon those fibres; and as among the most frequent causes of such increase is obstruction in the orifices, or defect in the valves, we will commence with the ventriculo-aortic orifice. When there is thickening of the valves and contraction of the orifice of the aorta, it is obvious that there must be an increase in the resistance to the exit of the blood, and consequently that hyper- trophy of the left ventricle Avith dilatation may be expected to ensue; and such is almost always the case; but it may not be at first so obvious that the same result will follow regurgitation through these valves with little or no obstruction. Supposing that the orifice is clear, but that the valves remain open, there will be a full jet into the aorta, but as soon as the systole is complete, a portion of the blood will return into the ventricle, which is in the mean time receiving fresh blood from the auricle, and thus becomes over-distended, and called upon for an increased amount of contractile effort. Having, in fact, besides maintaining the systemic circulation, to keep up a to- and-fro motion of a certain quantity of blood, which is continually passing backwards and forwards through the valves (without, as it were, the pale of the circulation), the left ventricle must either become hypertrophic, to sustain this additional effort, or must yield under it, and become dilated. When the impediment to the circulation is not very great, and the hypertrophy is nearly sufficient to compensate for the increased dif- ficulty, the patient may live for months and years, under favourable circumstances, with comparatively but little inconvenience; when, however, the dilatation continues to increase in a greater proportion than the hypertrophy; or, which is the same thing, when there is not hypertrophy sufficient to prevent the dilatation, it happens either —that the patient dies suddenly from syncope, or—that owing to the inability of the left ventricle to empty itself, there is an obstruction to the entrance of blood into it from the auricle, and the effect is engorgement of the lungs and the right side of the heart, engorge- ment of the liver, ascites, anasarca, and death from apncea, in the manner to be presently described as occurring in disease of the mitral valve. The symptoms of lesion of these valves have been already pointed out; but it may be here remarked, that as long as there is no other disease obstructing the circulation, the pulse, though splashing, or having the other characteristic conditions, continues regular; but if any cause arise to obstruct the pulmonic circulation, as, for instance, an attack of bronchitis, then it will become irregular, for the reason that the cavity of the ventricle being enlarged by dilatation, the diminished supply of blood will not be sufficient to stimulate it to regular contraction. When there is chronic change in the left auriculo-ventricular orifice, the effect upon the circulation will differ little, whether that DISEASED MITRAL VALVE. 281 change takes place in the way of thickening of the valves and con- traction of the orifice, or of imperfect closure, arising either—from puckering of the valves,—from vegetations upon their edges,—from rupture of the chorde tendine,—from dilatation of the ventricle draAving away the origins of the columne carnee, or—from dilatation of the orifice itself. The immediate effects, however, upon the heart will be somewhat different; if, for instance, there be contraction of the orifice, the current of blood into the ventricle being small, it will be but feebly excited to contract, and OAving to this comparative inactivity, the cavity will be small, and the walls rather thin; and since the current into the ventricle is small, that which flows from it must be so likeAvise; and, if there be no other counteracting disease, the aorta Avill be small also; since, as has been already explained (p. 37), the size of an artery is regulated by that of the current of blood passing through it. This state of things does not, perhaps, ahvays continue, as owing to the obstruction being propagated backwards through the pulmonic and venous systems, it at length reaches the left ventricle, which then begins to dilate, and becomes more or less hypertrophic. When there is regurgitation through the mitral valve, the orifice being not contracted, or, as is not uncommonly the case, being dilated, there will not be the same want of stimulus to the left ventricle, which will then be not diminished, or what is more likely even increased in capacity and thickness. The effect upon the pulse will, in either case, be nearly the same, as it will be frequent, very small, and often intermitting; as a general rule, if there be intermission, the lesion of the mitral valve is, pro- bably, contraction rather than regurgitation. The most serious consequences of this lesion, however, take place in the direction opposite to the course of the circulation. The first result is dilatation of the left auricle, which sometimes becomes so much enlarged as to press upon and flatten the left bronchus; not, indeed, so as materially to embarrass the respiration, but sometimes sufficiently to cause a bronchial respiration to be heard in that situa- tion. Whether this sound can be made available for diagnosis is, at present, questionable. From the left auricle, the obstruction extends to the pulmonic veins and arteries, causing great delay in the circu- lation through the lungs, and thereby preventing the aeration of the blood, and giving rise to general venous congestion, with lividity of the lips, cheeks, and extremities. The bronchial membrane also becomes much congested, and the capillary circulation is sometimes relieved by the effusion of serum into the cells and bronchial tubes; this, sometimes, occurs to such an extent as to become dangerous by threatening death from apnoea. From the lungs, the obstruction extends to the right ventricle and auricle, producing, in the first instance, over-distension of the former; this, however, brings the safety-valve action of the tricuspid valve into play, thereby allowing much of the blood to be thrown back into the former, and delaying and diminishing the engorgement of the lungs that would ' otherwise speedily ensue. It has been sug- 282 HYPERTROPHY AND DILATATION. gested by Dr. Chevers, in one of a most interesting series of papers originally published in the London Medical Gazette, that the venous circulation may also sometimes be relieved by the bronchial artery taking on the functions of a vein, though this can hardly be expected to happen except in young subjects. The immediate consequence of this is engorgement of the right auricle and accumulation of blood in those great reservoirs the li\'er and spleen. In the former, hepatic venous congestion takes place, and the organ becomes rapidly en- larged. This is followed by portal congestion, and engorgement of the veins converging to form the vena porta, and hyperaemia of the gastro-intestinal mucous membrane, Avhich often give rise to much irritability of the stomach, and sometimes to diarrhoea; from the same cause ascites is also produced, whilst the congestion of the systemic veins produces general anasarca. The disease is terminated sooner or later by apnoea, either from the direct effect upon the lungs, or from that cause aided by the pressure upon the diaphragm, arising from the enlargement of the liver, and the accumulation of fluid in the abdomen. Such is the least speedy termination of this most serious lesion of the heart, though it may prove fatal at any period, either in the manner ahpve pointed out—by a very extensive pulmonary apoplexy, —by a combination of apnoea and syncope, arising from inability of the right ventricle to propel the accumulated blood by Avhich it is distended,—or, it may be, by coma, the effect of venous congestion in the brain. As regards the diagnosis of lesion of the valves of the left side of the heart, there is no great difficulty, in the earlier stages especially, in distinguishing between disease of the aortic, and that of the mitral valve, though there is often much, in distinguishing the latter from other affections of the pulmonic circulation. Before the obstruction produced by disease of the aortic valves has extended far back along the course of the circulation, there will be little general distress, and the patient may be scarcely aware that he is labouring under any disorder of importance. It is then only to be recognised by the characteristic murmur traceable along the course of the ascending aorta, and by the almost equally characteristic pulse (p. 69-70). In the more advanced stages, AA-hen the effects upon the circulation more closely resemble those arising from disease of the mitral valve; the same means of diagnosis will distinguish betAveen this and any other cardiac lesion, except, perhaps, disease of the ascending aorta itself. When there is disease of the mitral valve, whether obstructive or regurgitant, the earliest symptoms will be those of obstruction to the circulation through the lungs, which may sometimes be sufficient to give rise to hemoptysis; this, Avith the very small, or intermittent pulse, will be sufficient to direct attention to the investigation of the condition of the organs concerned in the pulmonic circulation; and, if to these symptoms there be added those of venous obstruction already described, there can be little doubt of the existence of disease in some portion of this circuit; and if there be besides a bellows' murmur with the first sound, increasing in distinctness towards the DISEASED VALVES — PROGNOSIS. 283 axilla, the probability of disease of the mitral valve will be further increased; and this murmur will generally indicate regurgitation. NarroAving of the orifice of the mitral valve is also generally at- tended with a systolic murmur, though this murmur is rather more to the right than in the case of regurgitation, that is to say, a little to the left of the origin of the aorta; this latter murmur may be dis- tinguished from that of disease of the valves of the aorta, by its not following the course of that vessel. The presence or absence of these murmurs is not, however, to be regarded as deciding the question of the presence or absence of disease of the mitral valve, since their immediate connection Avith such disease is, to say the least, doubtful. The prognosis of val\rular disease of the heart may be inferred from Avhat has been said of its ordinary progress—it is, in the main, unfavourable; at the same time, it must have been apparent, that there is a great difference betAveen the rapidity Avith which a fatal termination may ensue in one form of disease or in another. Thus the prognosis is much less unfavourable in disease of the aortic Aralves than in that of the mitral. AAHien there is evidence solely of disease of the aortic valves, as obtained by the state of the pulse, and the stethoscopic signs, we may reasonably hope that, under careful management, life may be pro- longed in comfort for many years; and, in the case of young persons, we may even go further, and, judging from experience, assert that it is at least possible that the injury may be so far repaired, or the state of the orifice may be so adapted to the condition of the valves, that a considerable degree of Arigour and activity may be maintained, and the patient grow, up to perform the duties of any but a very laborious station in life. Disease of the mitral valve, on the other hand, leads to death, as it were, by a shorter route; though, even here, much may be done to delay its termination, when the narrowing or regurgitation, and con- sequent pulmonic obstruction, are not very great. In women, too, the establishment and maintenance of the catamenial discharge may afford great relief, though a fatal termination may be expected when this function ceases. It has been pointed out, however, that there is much obscurity about the state of the mitral valve, Avhen the sigmoids also are dis- eased ; and therefore we must be guided rather by the effects upon the circulation generally, particularly upon that through the right heart, than by any stethoscopic signs of the local affection. As a general rule, therefore, when we have the signs merely of disease, whether obstructive or regurgitant, of the aortic valves, and no evidence of obstructed circulation elsewhere, without dyspnoea, venous conges- tion, or scanty urine, our prognosis, though not favourable as regards the ultimate result, may be such as to give a hope of years of comfort and usefulness. But where there are signs of obstructed pulmonic circulation, engorgement of the liver, or the urine is scanty, Ave must apprehend, either—that the obstruction caused by the disease at the orifice of the aorta is extending itself to the left auricle and the lungs —or that mitral disease exists, though masked by that of the aorta; 284 TREATMENT. and in this case the prognosis is bad. Disease of the mitral, again, is essentially unfavourable, but even here we must judge rather by its results than by the topical proofs of its existence, and when the pulmonic circulation remains tolerably free, and there are but little or no dyspnoea, lividity, or oedema, and the urine is not very scanty, we must not entirely destroy the hopes of the patient and his friends. The general principles of the treatment of the sequele of inflam- mation of the heart, Avhether of the pericardium, the muscular tissue, or the endocardium, folloAV pretty directly from the explanation which has been given of their origin, and tendency to a fatal result. The first indication in the treatment of such disease is to prevent, if possible, any farther injury being inflicted upon the weakened struc- ture by the forcible action of the ventricle, the next to counteract that tendency to excessive dilatation which is one of the steps lead- ing to a fatal issue, and, thirdly, where this dilatation has become such as to impair materially the moving power, to obviate the effects of such weakness, Avhether manifesting itself in the form of a tend- ency to syncope, or of venous congestion. In applying these principles to the aortic orifice and its valves, we may remark' that the most frequent cause of disease of this orifice is endocarditis, and of that endocarditis the most frequent cause is rheumatism, and next to it, uremia, as in albuminuria, besides which various morbid poisons, as those of scarlatina, influenza, &c, may produce the same effect; but besides that, excessive muscular exer- tion may giAre rise to a local endocarditis, which causes thickening or adhesion of the valves, or, when very great, to direct injury in the way of laceration or retroversion; and exertion of the arms, especially when raised above the head, as is seen in sawyers and sailors, rowing, when violent or long sustained, is apt to produce the same injury. It is to be remembered, however, that such efforts are more especially dangerous to those who are not in the habit of making them. Thus a gentleman runs a "much greater risk by a rowing match than does a waterman. Mental emotion is another cause, and to these may be added excesses of all kinds, as at once exciting and debilitating. Whenever, then, we have reason to suspect that there has been at any time endocarditis (and the very fact of a previous attack of rheu- matism should arouse such a suspicion), we should lay down the strictest injunctions for the avoidance of all these exciting causes, and the necessity for such restrictions becomes tenfold when we have the slightest auscultatory sign of any lesion of the valves. It may be said, indeed, that in regard to mental emotion, but little can be done, yet where we have to do with young subjects, and such cases are not uncommon, we may explain to parents the possibility of strengthening or acquiring habits of self-possession, which will do much to counteract the effects of circumstances in exciting mental emotion ; and in all we can enjoin the necessity for avoiding scenes and places where they are likely to be exposed to such excitement. In arresting further injury to these valves, much is to be done by DISEASED AORTIC VALVES. 285 dietetics. The diet should be carefully regulated as to quantity and quality, of both solids and liquids. As regards food, it should be nutritious, unstimulating, and not great in point of bulk. Thus a moderate meal of meat should be allowed once a-day, and with about half-a-pint of liquid ; this may be either light malt liquor, as bitter beer or ale, or water, Avith a glass or tAvo of wine, according to the habit and general condition of the patient. For breakfast, cocoa where it agrees, will be a good beverage, or otherwise, "cafo au lait;" both these are to be preferred to tea, but of none should more than half-a-pint be taken ; an early dinner, about four hours after break- fast, is generally to be preferred, and about four hours after that, a little tea (not more than two tea-cups), and at night a very light sup- per, as a small basin of arrow-root, sago, or tapioca, or a sandAvich, Avith a little Avine and Avater, where there is any tendency to exhaus- tion ; but except during sleep, nourishment should be taken at inter- A*als of about four hours. Exercise must be regulated upon the the same principles; walking, but not against any steep ascent, and gentle riding, as being conduciA*e to healthy nutrition, serve to obvi- ate the tendency to dilatation ; ahvays provided that they are neither attended or followed by uncomfortable palpitation. A pure and moderately-bracing air is also desirable, and upon much the same grounds. Cold bathing is inadmissible, but where the affection is but slight, tepid sponging may be used Avith safety. The great object being to keep the circulation as uniform and tranquil as possible, an equable temperature must be carefully main- tained ; for this purpose, the clothing should be uniformly Avarm over the body, and Avhile heat is to be shunned as stimulating to the heart, sudden exposure to chills must be as carefully avoided, lest by driving the blood from the surface, it should call for too great an effort to return it, or failing this, endanger the life of the patient by syncope. In the period of the disease of Avhich we are now speaking, that, namely, in which there is opportunity for preventive management, there is not occasion for much therapeutic treatment; but the occa- sional employment of remedies tending to regulate the amount of the circulating fluid and allay palpitation, will promote the comfort and prolong the life of the patient. Eepeated small bleedings have been proposed Avith this view, but their employment is most mis- chievous. Blood should not be drawn except to relieve some alarm- ing congestion in the brain or lungs, and then its abstraction can only be regarded as an unavoidable evil. Where any tendency to congestion, manifesting itself in vertigo, congestion of the counte- nance, or even increased excitement of the heart, seems to indicate the expediency of sonie reduction in the volume of the blood; the best means of effecting it will be by moderate hydrogogues and diuretics. For this purpose, two scruples of the pulv. jal. co. may be administered. The folloAving formula will perhaps be a convenient one* (F. 43.) * (43) R. Pulv. Jalapae co ►) iv. Syrupi Zingiberis, 3 ss. Misce. One-half to be taken early in the morning. 286 TREATMENT. In promoting the action of the kidneys, and at the same time re- lieving the palpitation, a combination of senega with some diuretic will be eminently serviceable. The modus operandi of the senega under such circumstances is not quite obvious, but it certainly is specially useful in palpitation arising from aortic disease, though it has not the same good effect in disease of the mitral valve. The accompanying formula may be useful* (F. 44.) AVhen there are any symptoms indicating the supervention of inflammatory action, as increased sharpness of pulse, with furred tongue, and other signs of pyrexia, without any other assignable cause for such excitement, we must, of course, apply the ordinary means of subduing such inflammation; but this must be done Avith every consideration for the strength of the patient. If necessary, a small quantity of blood may be taken, or, what is better, the patient may be cupped over the region of the heart to from four to six ounces, and if the skin is not hot a blister may be applied, and calomel, antimony, and opium, with salines, may be given. As re- gards the mercury, however, salivation is to be avoided, since it promotes spanemia, which favours dilatation. It is to be remembered that in treating of the early period of dis- ease of the aortic orifice, Ave are speaking of the most hopeful form of heart disease, and that in which most may be done by judicious management, but in which, on the other hand, irremediable mis- chief may be inflicted by a single false step. A needless abstraction of blood, though it may even seem for the time to afford relief, or the wanton use of any lowering remedies, or even too much absti- nence from nutritious diet, may lead to dilatation without hyper- trophy, and its disastrous consequences ; whereas over-stimulation or over-exertion may aggravate the primary mischief. For the latter reason iron will not generally be admissible as a tonic, but zinc in the form of sulphate, or where there is irritability of stomach, of oxide, will be useful (F. 45) ;f where there is much palpitation it may be combined with camphor (F. 46)4 In the next period we have to do with increased dilatation and consequent delay in the passage of blood through the left heart, manifesting itself by symptoms of obstruction to the circulation * (44) R. Sp. iEth. nit. 3 ij. Tinct. Hyoscy. 5 iss. Decoct. Senegas, 3 iij - Mist. Camphorae, quant, suf. To make a 5 iv. mixture, of which the one-fourth part is to be taken three times a-day. t (45) R. Zinci Sulphat. (vel Oxidi), gr. iij. Ext. Lupuli, gr. vj. Misce. Ft. Pil. vj.; to be taken three times a-day; increase gradually the dose of the zinc, gr. iij. X (46) R. Zinci Sulphat. (vel Oxidi), gr. i—iii. Camphorse purse, gr. i. Ext. Hyos. gr. ii. Misce. Ft. Pil.; to be taken three times a-day. DISEASE OF THE MITRAL VALVE. 287 through the lungs and liver, as dyspnoea, sometimes slight icteric tinge, scanty and turbid urine, &c. There is now less to be done in the way of prevention, but rest must be most rigidly enforced. The bowels must be kept freely opened by moderately warm aperients and occasional doses of colo- cynth and calomel, or blue pill; or, where there is much oedema, the compound jalap powder may be employed. Diuretics will also be of service, and amongst these the combination of senega and nitric ether, recommended above. There is noAV more tendency to palpitation, and the camphor, henbane, and zinc may be used, though where the palpitation is very troublesome the zinc should be omitted. In the still more advanced cases, when palpitation and dyspnoea with orthopnoea become urgent, and signs of venous congestion begin to shoAV themselves, the disease is evidently draAving to its termina- tion, and the treatment must be mostly palliative, or similar to that employed in disease of the mitral valve. / The treatment of disease of the left auriculo-ventricular orifice is, for the reasons already adduced, less promising than that of the aortic, and we have to deal almost from the first with obstructed pulmonic circulation and venous engorgement, with their consequent evils. The chief indications here Avill be to relieve the pulmonic circulation by expectorants, which must not, however, be of a very stimulating character, and the portal and general circulation by purgatives and diuretics; though from the latter we often obtain but little effect, owing to the engorgement of the liver. AVhen there is no albumi- nuria, the combination of squills and blue pill or grey oxide (F. 47),* may be continued till the gums are slightly affected, or till there is an obvious improvement in the secretion of urine. A diuretic mixture may be administered in the course of the day, and a moderate but effective purgative alternate mornings (for this purpose F. 13, without the colchicum, Avill be applicable). The combination of senega with nitric ether, recommended above, may also be administered, but we cannot expect the same benefit from it as in disease o£ fhe aortic valves. The addition of tincture, or oxymel, or vinegar of squills Avill render it more expectorant, and therefore more applicable to this form of disease, which, both in its symptoms, its consequences, and the treatment required, closely resembles pulmonic congestion, caused by long-continued chronic bronchitis. Upon these grounds great temporary relief may often be obtained by large blisters applied upon the sternum or between the shoulders: and as our object should be to induce free serous discharge rather than irrita- tion, the blister should be removed at the end of eight hours, and a large linseed poultice applied in its place. * (47) R. Pil. Hydrarg. gr. iij, Pil. Scillse co. gr. vij. Ft. Pil. ij.; to be taken at bed time. Or, R. Hydrarg. Oxidi, gr. iss. Pil. Scillce co. gr. x. Ft Pil. iij ; to be taken at bed time. 288 ACUTE AORTITIS. The remarks which have been made upon the treatment of the effects of disease of these two sets of valves apply, with but little alteration, to the direct and palliative treatment of hypertrophy and dilatation arising from other causes. Where the enlargement is merely of the left ventricle, the effects upon the circulation Avill be much the same as those arising from the second stage of disease of the aortic valves; and the treatment, as regards regulating the volume of the blood and the activity of the excretory organs, must also be the same; in like manner, where the enlargement is mainly on the right side, the treatment will be the same as that most applicable to disease of the mitral valve. As regards our efforts at producing some permanent relief, we must be guided by what insight we can gain into the probable cause of the enlargement. AVhen, for instance, hypertrophy of the left heart is the effect of thickening of the sys- temic arteries, Ave must regard the left ventricle as suffering over- distension, arising from an increase in the force which opposes its systole, and endeavour to regulate the circulation much as in early disease of the sigmoid valves. Where, again, we have to do with cases in which there has been dilatation of the left ventricle, from over-exertion under unfavourable circumstances (as pointed out p. 273), tranquillity, moderately good living, and regular exercise will go far to obviate the mischief. Where the dilatation is the effect of weakness induced by carditis (p. 280), gentle alterative remedies, as iodide of potassium, or, per- haps, iodide of zinc, which will combine the advantage of an alterative and tonic, should be used, and we must pursue, in other respects, the same plan as in the last case, but with greater restriction as to exer- cise and less hope of radical amendment. Acute inflammation of the aorta, or acute aortitis, is a very rare disease, and one of which the signs are very obscure. Dr. Chevers, to whom we are indebted for most of our knowledge respecting it, states that it proves fatal by esthenia, complicated with comatose symptoms.» The pulse is exceedingly rapid, often indistinct, though somewhat wiry; there being at the same time much obstructed pulmonic circulation, stertorous breathing, venous congestion, and swollen extremities. For the anatomical changes produced by acute inflammation of the arteries, we Avould refer the reader to the work of Doctors Jones and Sieveking. The diagnosis of acute aortitis is very obscure; the difficulty is, no doubt, in great measure, owing to the rarity of the affection, particu- larly as a primary lesion; and where it has supervened upon other diseases, it has, as Dr. Walshe observes, produced no additional symp- toms besides increased irritability or distress. AVhere hoAvever we have, in addition to the latter symptoms, pain, thrilling pulsation, and arterial murmur along the course of the aorta, Ave may suspect this disease, though we can hardly venture further than a surmise in our diagnosis. Chronic inflammation of the aorta and large arteries is a much more common occurrence, producing fibrinous deposit, atheroma, ossi- fication, aneurism, and, sometimes, ulceration. For a description of CHRONIC AORTITIS. 289 these changes, we would again refer to the work of Drs. Jones and Sieveking. The importance of these affections in regard to the prac- tice of medicine, consists in their destroying the elasticity of the artery, rendering it in some parts unable to recover its proper size under distension, and in others, preventing its yielding sufficiently to the injecting force of the heart. Hence there will arise an irregu- larity in the calibre of the artery. It becomes in some parts dilated, and in others narrowed. One result of this loss of their proper contractility on the part of the aorta and large arteries is, that the machinery whereby the uniform current of blood is maintained being impaired, the pulse becomes splashing, or of the water-hammer character, much resembling that produced by disease of the aortic valves (p. 70). The effect of this condition of the aorta upon the heart must likewise be nearly the same as that resulting from disease of the above-named valves, and there will in course of time ensue hypertrophy and dilatation, with their consequences, the tendency to fatal termination being the same. The physical signs of this form of the disease of the thoracic aorta also closely resemble that of disease of the valves: there will be a systolic murmur traceable up the course of the ascending aorta, and the same Avill be heard along the spine; the pulsation of the aorta will also be frequently felt above the sternum; and as the disease generally more or less implicates the arteries, we shall have similar murmurs in the course of the innominata, the sub-clavian, or the carotids. These murmurs must of course be carefully distinguished from anemic ones; but besides this history of the case, and in most in- stances the absence of anemia sufficient to produce the murmur, there will be the characteristic pulse, with the hard artery (p. 70). Disease of the arch of the aorta is often accompanied by great dysp- noea, liable to serve paroxj^smal aggravations, arising probably from irritation of the recurrent nerves. AVhere we have strong reason for believing in the existence of acute inflammation of the aorta, our treatment should be decidedly antiphlogistic; not indeed that general bleeding will be tolerated in the majority of instances, since the moving powers of the circulation are sometimes so much depressed as to threaten to destroy life by apnoea; cupping at the sternum or in the course of the spine Avill, however, generally be borne. Where the depression is very great, Ave must be content to employ dry cupping; and where there is no great heat of skin, a blister may be applied along the side of the spine; calomel, opium, and antimony should also be employed, and saline diaphoretics administered in the intervals. The effects of chronic aortitis, are those of alteration in the calibre of the aorta, or of loss of its contractility, are, for reasons already explained, the same as those of obstruction to the circulation from coarctation or thickening of the aortic orifice, and must be treated accordingly. Aneurism is a most important form of disease of the aorta. Into the varieties and anatomical conditions of aortic aneurism we do not now enter, our business being mainly with its symptoms and manage- 19 290 ANEURISM. ment. Chronic changes in the aorta of the character above alluded to are more frequent in its ascending portion and the arch, than at a greater distance from the heart, and it is probably upon this account that aneurism also is more frequent in the same situation, not to men- tion that this part of the artery is more than any other exposed to the direct impetus of the blood thrown from the left ventricle. Sometimes these aneurismal pouches form so near the origin that they have been known to burst into the pericardium, causing instant death to the patient; though the lesion has manifested itself by no appreciable symptoms during life. When the aneurism forms higher up in the ascending aorta or in the arch, it generally increases so as to form a considerable tumour, and then its presence becomes apparent, by the signs of the pressure upon the neighbouring structures, by the effects upon the circula- tion generally, and by physicial changes presented in the aneurism itself. The effects upon the neighbouring parts may not manifest them- selves for some time. AVhen the tumour is in the ascending aorta these symptoms are for a long time very obscure; but if the patient's life be not early destroyed by the giving way of the sac, a pul- sating tumour shows itself in the course of the vessel. Sometimes again the nature of the eftection becomes apparent from a sudden gush of arterial blood from the mouth. We noticed, when speaking of phthisis, that the arteries are the structures which, of all others, are the slowest to become involved in the destruction of the surrounding lung, and, it would appear, that even when they do get morbidly enlarged, the neighbouring tissues become absorbed, rather than the artery itself, under the pressure; so that the sternum or cartilages of the ribs, or the trachea, or bronchi, disappear before it; or, if it be seated more posteriorly, the oesophagus or bodies of the vertebre are similarly destroyed. AA'hen the aneurism is in the arch of the aorta, one of the earliest signs is not unfrequently a peculiar huskiness of voice, Avith difficult respiration, attended with some distress, the effect probably of pressure upon the recurrent nerve: vague lancinating pains in the chest and back, sometimes extending into the back of the head, are also amongst the earliest symptoms, produced probably by pressure upon the nervous trunks. Difficulty in swallowing, again, is often produced by pressure upon the oesophagus; and another remarkable effect of the pressure of aneurismal tumour is that upon the large veins, producing distension of the veins of the chest, neck, face, or even the upper extremities, sometimes giving rise to oedema of these parts. In other cases, again, there is atrophy, from the pressure reaching the thoracic duct. The above effects might, in the greater number of instances, be produced by any other tumour in the same situation, though it is one in which none is so likely to occur as aneurism. But besides these there are the effects produced upon the circulation generally, and more especially upon the arterial system. The first and most obvious impression must be upon the left ventricle, the svstole of Avhich is more or less impeded by the obstruction in the aorta; for ANEURISM. 291 even if there have not been sufficient coagula to obstruct the channel, the very fact of disease in the artery destroys that elasticity by Avhich it assists in forwarding the current of the circulation, and conse- quently induces more or less hypertrophy and dilatation. The cur- rent along the arteries must also be disturbed by obstruction so near its commencement, and consequently we have a degree of thrill or splashing not unlike that produced by disease of the aortic valves, though in a less degree. In short, the effect upon the circulation is in general not unlike that of the latter affection. Besides this, hoAv- ever, Ave may have great obstruction to the current either through the aorta, the innominata, the subclavian; or common carotids. This may arise either internally from the clot, or from the aneurismal sac pressing upon the artery from without. When the aorta itself is thus obstructed the pulse at each wrist will be similarly affected, so that it may be very small, and in some rare instances it has been wholly obliterated. AVhen, however, the pressure is upon the large arteries, there will be a difference according to the side affected, and consequently the pulse at one wrist may be almost imperceptible, whilst that at the other remains nearly natural. The physical signs presented by the aneurismal tumour itself are generally pulsation and sound. The pulsation is, in most cases, expansile, that is to say, extending itself laterally as well as ante- riorly, and sychronous with the systole of the heart. There are, no doubt, exceptions to this rule, since the clot may be so large that the current which passes through the sac may not be sufficient to cause any perceptible expansion, and, in some cases, even any movement which can be detected by the hand. The sounds which may be heard by placing the stethoscope on the projecting part of the surface are in the majority of instances double, consisting of a first sound, which we call systolic, as accompanying the systole of the heart, though it in reality attends what might be termed the diastole of the aneurismal sac; and a second or diastolic sound, synchronous Avith the diastole of the heart, though with the systole of the aneurism. The first of the above murmurs is produced by the roughened condition of the artery, and the agitation of the current produced by the change in size Avhich the current undergoes in passing from the artery into the *■ sac. The diastolic, or second murmur, is to be referred to the exit of the blood produced by what may be termed the systole of the sac. The above are the sounds which are commonly heard, and which are obviously to be explained by this aneurismal condition; but it is evident that they must be liable to great modifications, and that many circumstances may interfere with their production. Thus the first, which is ordinarily the loudest, may be very feeble or altogether wanting, owing to the entrance to the orifice being very smooth; and if, on the other hand, the exit be disturbed by moveable fibrine, the second or diastolic murmur will be rendered the loudest. If the action of the heart be very feeble, the orifices of the aneurism very free, the channel through the aneurism very smooth, or the pouch rendered incapable of distension by the deposition of fibrine, one or both murmurs may be absent. 292 ANEURISM — ITS TREATMENT. From what has been said, it must be inferred that the diagnosis of aneurism is often exceedingly obscure, as many of the signs often regarded as diagnostic may be absent, and, on the other hand, several may be simulated by other tumours. The early diagnosis of this affection has been admirably given by Dr. Addison:—"When the aneurismal swelling is such as to cause injurious pressure upon neighbouring parts, and interrupt the functions of particular organs, our apprehensions are likely to be awakened; and if we find the heart's action greatly disturbed, without our being able to trace it to any decided disease of the organ itself, or to sympathy with disease in other parts—if we observe the flow of blood passing to the descend- ing cava to be much obstructed—if we have indications of pressure upon the trachea and bronchi or upon the pneumogastric or recurrent nerve, producing hoarseness and feebleness of the voice, croupy cough and respiration, or symptoms of spasmodic asthma, or of spasm of the glottis—if there be anomalous symptoms of bronchitis, pneumonia, or hemoptysis—if deglutition be painful or so difficult that the patient is under the necessity of making a double effort before the meal will descend into the stomach—and if he complain of vague or severe rheumatic, lancinating, or grinding pains about the back of the neck, in the upper extremities, or shooting from the sternum to the sides, and towards the back, the existence of an aneurism becomes more than probable." In the management of aneurism our chief object should be to maintain the current of the circulation at the lowest possible volume; but at the same time the power of the circulation must not be much depressed; for if the latter effect be produced, there will,,in the case of aneurismal dilatation, be a danger of promoting dilatation of the left ventricle, and it may be also of rendering the pouched artery more yielding; and, in the case of a sacculated aneurism, of rendering the coagulum so loose as to be ineffective as a support to the weak- ened parietes of the sac. When there is much tenderness over the tumour a few leeches may be from time to time applied. Repeated very small venesections are not, as Dr. Chevers observes, so objec- tionable in the case of aortic aneurism as in that of ordinary heart disease; but Avhen these are employed mild tonics should be at the same time exhibited. The important object, however, of obtaining* the conditions most favourable for the relief of the disease, namely, a moderate volume of circulating fluid with a good proportion of fibrine, will be best obtained by a scanty use of fluids, a nutritious diet, the employment of purgatives, and occasionally diuretics (the former being to be preferred as less likely to promote a spanemic condition), and by the use of gentle tonics. Of the other class of medicines zinc is one of the most eligible, from its not producing any stimulating effect upon the heart, which is sometimes the case with iron. The senega also, which we have already recommended in dis- ease of the aortic orifice, will often be of great service; allaying excitement without depressing the vital powers, it may be combined with a diuretic, thus (F. 44). A pure air is of the greatest import- ance, since, under the necessity for rest, it presents the means of maintaining the plastic power of the blood. DISEASES OF THE LIVER. 293 XV. DISEASES OF THE LIVER AND ITS APPENDAGES. Before proceeding to the consideration of the diseases of the alimentary canal, we pass, as it were, along the course of the circula- tion to those of the liver; the condition and activity of which are so intimately connected with those of the thoracic viscera. Congestion of the liver is among the most frequent of its morbid conditions. This may arise in various ways; and as the probable course of the disease will depend mainly upon the cause from which it has arisen, and our treatment must also be in a great measure regulated by our knowledge of it, we may speak of the different forms of congestion in the order of their causes. The most common cause of congestion of the liver is, obstruction to the exit of the blood from the vene cave hepatice, arising, in the majority of instances, from disease within the chest inducing obstruc- tion to the circulation through the right heart; though it may also be produced by other causes, as obstruction in the vein itself. The first consequence of this is engorgement and congestion of the branches of the vene cave hepatice, constituting what was termed by Dr. Kiernan hepatic-venous congestion, giving to the liver a mottled appearance (the earliest presented in the so-called nutmeg change or degeneration), the centre of the lobules only, becoming red from congestion of the hepatic twigs originating from them, whilst their margins remain pale. This congestion must, of course, spread itself in a direction contrary to that of the circulation, that is to say, from the heart, or into the capillaries communicating with the tAvigs of the branches of the portal vein, by which the dark-red colour spreads towards the circumference of the lobules: so that where the twigs of one lobule are continuous with those of a contiguous one, the dark colour extends from one to the other. The liver will still present a mottled appearance; though the deep-red colour will preponderate more than in the former stage. When this congestion has been long continued, the liver becomes sensibly enlarged, its margin descending two or three inches below that of the ribs. The second stage of the mechanical or hepatic-venous congestion is rarely attained unless there be a persistent cause of obstruction to the return of the blood through the cava. The branches of the portal vein likeAvise become congested, and the secretion of bile impeded, the effect of which is that those parts which are not reddened by the congestion become tinged with yellow by the retention of bile. When this is the case, the liver becomes still more enlarged, often descending as low as the crest of the ilium, and the complexion of the patient becomes dusky, and the conjunctive tinged; the urine also is high-coloured, loaded with lithates and purpurine, and scanty. The alvine evacuations are sometimes pale, but more frequently dark 294 SECONDARY CONGESTION — TREATMENT. or green. This state of the hepatic circulation will often give rise to effusion into the peritoneum; oedema of the loAver extremities is a frequent concomitant, though it is produced directly by the disease in the chest, rather than through the medium of the liver. It is stated by Dr. Budd, that this condition of liver is attended by little or no pain beyond the feeling of weight and distension in the right hypochondrium; and it is probable that such is in most in- stances the case; though it not uncommonly happens, that where, as in cases of acute bronchitis supervening upon chronic, or upon valvular disease of the heart, .the liver becomes rapidly vcongested, there is intense pain across the epigastrium, especially upon the right side; this can hardly be explained otherwise than by the tension of the proper and peritoneal coats of the liver, from the sudden enlarge- ment of the organ. The diagnosis of this form of congestion,—the hepatic-venous congestion of the liver,—must rest mainly upon our knowledge of the state of the circulation within the chest. When, therefore, there is enlargement of the liver (to be detected by percussion or manipula- tion), with scanty urine, of high specific gravity, or depositing pur- purine or urates; and when at the same time there is disease of the heart, or of the bronchial tubes, or such as has been already shown to produce engorgement of the liver, we may infer that there is the mechanical or hepatic-venous congestion: if also we have reason to suspect that obstruction exists in the ascending cava itself3 extending as high as the entrance of the hepatic veins, we may expect a similar result. We lay some stress upon the diagnosis of this form of liver disease, and upon the necessity of referring it to its true cause; be- cause, when the enlargement of this organ is detected during life, or the changed appearance produced by the congestion noticed after death, there is still, in the minds of many practitioners, a tendency to regard the secondary and often more palpable lesion as the primary and causative, and not, as it really is, as the secondary one. The prognosis of this disease, like the diagnosis, must depend upon that of the primary lesion; but at the same time it must be remem- bered that its existence is a proof of the serious nature of the latter, and tends to render the prognosis more unfavourable. When the cause of the venous obstruction is capable of subsidence or removal, as in the case of bronchitis, the congested liver will, with the repara- tion of the original lesion, diminish in size, and return to its natural condition. The treatment of the hepatic, in addition to that which is directed to the primary affection, must consist of cupping at the margin of the liver, diuretics, and purgatives. The latter are the most im- portant ; since, for reasons already explained (p. 242), the former class of medicines, when the circulation through the liver is impeded, will often, and that too in the severest cases, fail in their operation. Where there is nothing to forbid it in the general condition of the patient, about eight ounces of blood may be taken from the margin of the ribs, and the bowels freely relieved by a few grains of calomel with jalap, folloAved either after a few hours, or the next morning, PRIMARY CONGESTION. 295 by the aperient draught of tartrate of potass and manna (F. 13); and subsequently one of the diuretic mixtures may be regularly ad- ministered. By these means we may frequently relieve the congestion of the liver, and diminish the obstruction in the chest from which it originated. There is, as pointed out by Dr. Budd, another form of congestion of the liver, which, though it may be produced in extreme cases of that just described, is essentially of a more active character, and arises from over-stimulation of the secreting structure. It is not improbable that this form patakes more of the " portal-venous-con- gestion" of Mr. Kiernan, though this in its simplest condition is stated by that gentleman to be extremely rare. Certain, however, it is, that congestion of the liver does occur in persons in whom there is not mechanical obstruction sufficient to account for its presence, and in Avhom its probable exciting cause is in the blood of the portal vein, which is overcharged with alcohol or with the products of imperfect digestion. The anatomical change produced in the liver by the portal-venous congestion consists (according to Mr. Kiernan) in an increased injec- tion of the twigs of the portal vein ramifying around the lobules, and of the capillaries in the margin of the lobules, leaving the central parts pale and uninjected; thus we have a pale mottling upon a red ground, as in the second stage of hepatic-venous congestion, though, according to Air. Kiernan, the red is not of so deep a tint. Another cause of active congestion is the absorption of unwhole- some exhalation, of which the marsh or ague poison has notoriously the effect of producing congestion and enlargement of the liver. The diagnosis of this form of congestion of the liver is more obscure than of the other, which depends upon mechanical causes: in the absence of such cause, Avhere there is enlargement of the liver, scanty and dark-coloured urine, a jaundiced complexion and conjunctive, evacuations rather pale, or wanting the bright colour of healthy bile; and Avhere there is a dull weight without acute pain in the region of the liver, with pain in the right shoulder or between the scapule, we may infer this form of disease of the liver. The prognosis of primary congestion of the liver is doubtful; since, owing to the state of constitution in which it ordinarily occurs there is but little tolerance of the means recommended above for relieving the venous congestion of the organ; and there is much danger of typhoid symptoms with extreme exhaustion supervening, as well as of coma from the retained secretion in the blood. The unfavourable symptoms are, a continuance of the icterode appearance, especially if purpura or oedema be superadded, stupor, jactitation, delirium, scanty urine, rapid and feeble pulse, with a brownish or dry tongue. The subsidence of the jaundiced appearance, the absence of cerebral dis- turbance, and an abundance of urine, with a reappearance of healthy bile in the evacuations, are favourable. It is possible that the un- favourable symptoms may arise in this disease from the obliteration or destruction of the secreting cells, giving rise to the fatal form of 296 ITS TREATMENT. jaundice attributed by Dr. Budd to that cause, and which will be hereafter described. The treatment of primary congestion of the liver must consist, in cases Avhere the condition of the patient does not forbid it, of local depletion, mercurial and saline purgatives, and diuretics. Where we have reason to suspect the disease to have arisen from the too copious use of alcoholic drinks, we must be very guarded in the abstraction of blood, and when the pulse is very compressible, or there is any tremor of the tongue or limbs, we must not venture upon it. Otherwise, about six or eight ounces from the region of the liver will materially promote the cure of the disease. If, as is sometimes the case, the bowels are irritable, we must, of course, abstain from active purgation; but even when such is the case, about four grains of hydr. cum cret., followed by two or three drachms of castor oil, guarded, if necessary, by as many minims of laudanum, will generally be borne, and may have the effect of removing irrita- ting matter from the alimentary canal. When this is not the case, a combination of Pil. Hydr. and Pil. Coloc. co. may be administered every night or every other night, according to circumstances, and the sulphate of magnesia, with the carbonate once or twice a-day. It may be well here to insist upon not giving mercury otherwise than as a purgative, and always so to combine it as to insure its purga- tive action; for there is no more pernicious practice than that of administering it indiscriminately in all diseases of the liver. If mercury have a direct cholagogue action when absorbed into the circulation, it cannot fail, when so absorbed, to increase the hyper- amia Avhich Ave wish to subdue: but as it certainly has a tendency to diminish the cohesion of the tissues, a tendency which already exists in the majority of instances of retained secretion, Ave have a still stronger reason against its use, except as a purgative. When, how- ever, it is so employed, it excites the secretion from the lining mem- brane of the small intestines, and by^ stimulating the part into which the bile is to be poured, affords the only safe means of relieving congestion of the secreting organ. After the action of the bowels has been well established, or even in the intervals between the aperients, we may give the citrate of potass draught in effervescene, with about 3ss. of sp. eth. nit.; to which may be added, when there is no sickness or great prostration, about fifteen minims of antimonial wine. AVhen the symptoms begin to assume a more chronic character, the taraxacum may be used in combination with some diuretic (F. 48).* Should delirium * (48) R. Ext. Taraxaci, Q i. Sp. iEth. nit. £ ss. Infus. Scoparii, 5 xss. Ft. Haust. ; to be taken three times a-day. To this there may be added, when the urine is not highly acid, Acid. Nit. dil. £ ss. Or, R. Pot. Acetat. ►) j. Sp. JEth. nit. 3 ss. Decoct. Scoparii co. ^ j. Ft. Haust.; to be taken three times a-day. INFLAMMATION OF THE LIVER. 297 or coma supervene, a blister may be applied to the neck; and Avhen, as will sometimes be the case, the tongue becomes brown, or the pulse very feeble, or there are other signs of sinking, wine and stimu- lants must be freely administered ; and this must be done earlier in those cases Avhere they have previously been too largely used. From the congestive Ave pass to the inflammatory diseases of the liver: of this we cannot adopt a better division than that given in the admirable work of Dr. Budd, into the— I. Suppurative inflammation, or that AArhich tends to suppuration and abscess. II. Gangrenous inflammation. III. Adhesive inflammation, or that which causes effusion of coagulable lymph. IV. Inflammation of the veins of the liver. V. Inflammation of the gall-bladder and ducts. I. Suppurative inflammation of the liver :— Of this form of inflammation, the causes appear to be (1) mechani- cal injury; (2) suppurative, inflammation of a vein, and consequent infection of the blood Avith pus ; these abscesses are not, as used to be supposed, deposits of pus from the blood transuding through the Avails of a vessel; but the product of a suppuration induced in the first instance by the lodgement of a pus globule in one of the capil- laries of the part. From the above cause of suppuration, the liver becomes affected only in common with other structures of the body; and is so affected next, in point of frequency, to the lungs, as being the next in regard to the quantity of venous blood passing through it, and the slowness of its progress; there is, however, another cause of suppuration Avhich appears specially to affect the liver, and that is, ulceration of those parts the veins of Avhich return their blood to the portal vein, to be thence transmitted through the capillaries of the liver : as, for instance, the intestines, stomach, gall-bladder, or gall-ducts. Of these conditions, that which is most commonly associated with abscess of the liver, and is in fact its most frequent cause, is dysentery. The anatomical changes produced by suppurative inflammation of the liver, are, first, redness and softening; next, puriform infiltration, which is, however, of very short duration ; and, thirdly, suppuration, or abscess. This inflammation, in the words of Dr. Budd, " com- mences in the lobular substance of the liver, and is often confined to it; the capsule of the liver, the trunks, the vessels, and of the ducts being perfectly healthy. But if the inflamed part reach the surface of the liver, adhesive inflammation is generally set up in the portion of the capsule immediately above it, and coagulable lymph is poured out, which causes permanent adhesion between that portion of the liver, and the parts with which it is in contact." Abscesses in the liver vary in size from that of a pea to that of a cavity containing several pints; the contents of these abscesses are most commonly like those of ordinary phlegmonous abscesses, unless, as Dr. Budd observes, when, from communication Avith the lung, it 298 SUPPURATIVE INFLAMMATION becomes decomposed and foetid from the admission of air. In ab- scesses occurring in subjects Avith but little plastic power, and in whom the disease is for the most part quickly fatal, there is no stroma or fibrinous lining to the cavity; but in the majority of cases, it is lined by a layer of false membrane, like a phlegmonous abscess. An abscess of this kind may remain for a long time stationary ; but in most cases it folioavs the usual course, making its way towards the surface, ultimately emptying itself—it may be into the peritoneal cavity, and producing speedy death from peritonitis, though this seldoms happens—more commonly adhesion is established between the liver and some adjoining viscus, as the stomach or colon, with Avhich the abscess ultimately communicates by ulceration, or it finds its way through the diaphragm in a similar manner into the lungs, after Avhich its contents are expectorated—or it reaches the surface, and points externally. It may be very easy to lay down symptoms as diagnostic of ab- scess of the liver; but actual clinical experience teaches us that the diagnosis of this disease which, to say the least, is not common in this climate, is obscure in the highest degree. Dr. Budd, and we need cite no higher authority, says that " physicians who have had most experience in this disease confess their inability, in many cases, to distinguish it from other diseases of the liver; and in some cases even to pronounce that the liver is the seat of disease at all."* The cases in which the symptoms are most closely marked, are those in which the suppuration is the effect of a blow, or other direct injury. This usually takes place on the convex surface. " There is pain and tenderness in the region of the liver, and a sense of fulness and resistance under the false ribs, from increased size of the organ. The liver becomes enlarged, and if the abdomen be flaccid, and the intestines empty, its edge can be felt some inches below its natural limit. The secretion of bile may be suppressed or deficient, and the patient jaundiced. In addition to these symptoms, which may be called special, from their pointing to the liver as the seat of disease, there soon appear, as in simple inflammation of other organs, the general symptoms of inflammatory fever; the pulse is frequent and full, the skin hot, the tongue furred and yellowish; appetite is alto- gether absent, or much diminished; the patient is thirsty, and there is occasionally vomiting of bilious matter ; while the urine is scanty, high-coloured, and deposits a red sediment."f AVhen the above special and general symptoms concur after injury over the region of the liver, and there is no evidence of disease of the lung or pleura, we may infer suppurative inflammation of the liver. But, as Dr. Budd very justly adds, the liver is so well shielded by the ribs, that the disease is seldom caused in this way. When, as is more frequently the case, suppurative inflammation occurs as the effect of puriform infection of the blood from remote injuries, surgical operations, or phlebitis, we can receive no assistance from the constitutional symptoms, since they exist beforehand, * Budd on Diseases of the Liver. f Ibid. OF THE LIVER. 299 owing to the primary lesion ; and Ave can only infer the existence of this affection from the special symptoms, pain in the region of the liver, and jaundice occurring in the midst of the general disorder. But even these may be absent, and then, as Dr. Budd says, " the abscesses in the liver can be discovered only after the death of the patient." The diagnosis is not much more obvious in the case of abscess of the liver occurring during dysentery; it must rest mainly upon the special symptoms, pain and tenderness in the region of the liver, ten- sion in the right hypochondrium, and jaundice; these symptoms may all arise under other circumstances, as from obstruction or inflamma- tion of the gall-ducts, but when they arise in the course of an attack of acute dysentery, or in acute supervening upon chronic, the suspicion should be entertained of suppurative inflammation and abscess of the liver. It may happen, however, that suppuration occurs without any of these symptoms, since this form of inflammation causes but little enlargement, at least before the formation of pus, and if there be no great extent of the organ involved, the enlargement will be scarcely perceptible. And as regards jaundice, we know that a portion only of the liver (as is also the case with the lungs and kidneys) is often sufficient for the depuration of the blood, and consequently when the inflammation is partial, there need be no jaundice. Again, we know that the parenchymata generally are not sensitive structures, and that Avhen inflammation is deep-seated, it may go on to suppuration with- out being attended by any considerable amount of pain. Besides the above general and special symptoms, there are others occasionally observed, and AA'hich when they do occur, often continue after the feverish symptoms have passed; these symptoms are pain in the right shoulder, vomiting, a short dry cough, and permanent rigidity of the muscles of the abdominal parietes, but especially of the right rectus muscle.* Pain in the right shoulder occurred to Dr. Budd in five cases out of fifteen; of three which occurred to the author, it was absent in two, and present in the other. In one of Dr. Budd's cases, Avhere the abscess was upon the convex surface of the liver, the pain in the right shoulder, which was intense, was relieved when the abscess was opened. Dr. Budd also confirms the statement of Dr. Annesley, that pain in the right shoulder is a sure sign of the abscess being in the right lobe. AVhen hepatic abscess is the result of phlebitis, the more urgent symptoms are those of puriform infection generally, and the suppura tion is as extensive in the lungs as in the liver, or more so; the patient passes rapidly into a typhoid state, and there is no oppor- tunity for active treatment. Under such circumstances, the best that can be clone is to support the powers with the liberal use of wine, and serpentary and ammonia, and sedulously to apply hot fomentations to the affected part. AVhen the suppurative inflammation arises either from an ulcer, * Budd, op. citat. 300 GANGRENOUS INFLAMMATION. or from ulceration in those parts from which the blood is returned through the portal vein, the suppuration being confined to the liver, and the system generally not infected Avith the poison, there is oppor- tunity at the commencement for more active measures: blood-letting may even be ventured upon when the pulse is full and hard, but, as a general rule, cupping at the margin of the ribs on the right side is to be preferred. There will always, no doubt, be some difficulty, from the obscurity of the diagnosis, but the same measures will be, to say the least, harmless, Avhen the same symptoms arise from inflamma- tion in any neighbouring organ. As regards the use of mercury, there can be little doubt that, except as an adjunct to an aperient, its exhibition in any stage of this disease must be positively injurious, since, in so far as it acts as a stimulant to the organ, its use is con- trary to that most important rule in practice, of avoiding all excite- ment of an inflamed part, and AArhen suppuration has taken place, it must have the same ill effect as in all suppurative diseases. In reply to the question of the expediency of opening an abscess of the liver, Dr. Budd very justly condemns the practice, except when it is evi- dent from circumscribed oedema, or a slight blush on the skin, that union has taken place between the integument and the abscess. In more chronic cases, the best practice to pursue is the use of gentle laxatives, as decot. aloes co. with rhubarb (F. 42), and Avhen there is a tinge on the skin and conjunctive, the use of nitro-muriatic acid which taraxacum. II. Gangrene of the liver is an exceedingly rare affection, so much so as to be of but little importance in a practical point of view; and is chiefly deserving of notice from the circumstance of portions of the organ of a dark-green colour, with a very putrid offensive odour, being observed near the margin of the abscesses that have not be- come encysted, being frequently regarded as gangrenous; though the appearance is in reality the defect of decomposition, and also that gangrene does sometimes affect this organ. It never, according to the best authorities, occurs without gangrene of some other part. III. We have already seen that adhesive inflammation may take place in the portion of the liver contiguous to an abscess, and the soft albuminous matter Avhich lines the latter be again enclosed by a deeper layer of fibrinous lymph, which acquires a greater degree of hardness according to the age of the abscess; the adhesive inflamma- tion in this case being confined to the neighbourhood of the abscess which excited it, though it may extend to the capsule, and to the peritoneal coat of the organ, and to neighbouring viscera. And Ave have already alluded to the fact of fibrinous lymph effused on the surface of the liver, falling down into the abdomen or pelvis, and setting up adhesions between other viscera. Adhesive inflammation of the liver may also be excited around hydatid tumours, and some- times, though rarely, around cancerous groAvths. The capsule of the liver may, however, be extensively inflamed in connection Avith deep-seated adhesive inflammation occurring, to a greater or less extent, in the substance of the organ, the lymph being effused almost entirely in the areolar tissue Avhich accompanies the ADHESIVE INFLAMMATION. 301 portal veins. Sometimes, according to Dr. Budd, the effusion is limited to larger branches, Avhich are surrounded by it to the distance in some parts of half an inch; these branches, however, remaining pervious, but some of the twigs Avhich arise from them are obliter- ated, and the parts of the liver supplied by them atrophied, though the other portions of the liver are apparently not affected: the neigh- bouring portion of the capsules is also puckered, and there are generally adhesions to neighbouring organs. It more commonly happens, hoAvever, that the effusion of fibrinous lymph extends to the areolar tissue forming the nidus of the small twigs between the lobules. The subsequent contraction of the lymph strangulates the vessels and ducts, puckers the capsule, giving to the surface of the liver the uneven appearance commonly known as hobnailed. The organ throughout is rendered paler than natural by the white fib- rinous matter, and by the diminished quantity of blood caused by the strangulation of the vessels, whilst it is rendered yellowish by biliary matter detained in the cells. This condition gives to the organ the appearance of impure bees-wax, Avhence the disease in question has received the name of cirrhosis, from the French authors. In other cases the contrast betAveen the yellow biliary matter in the cells and the surrounding fibrous tissues is more marked, owing to the quantity of the latter being much greater, and by its stronger contraction drawing the liver in nodules, which appear like peas dispersed through the surface of the organ. Sometimes there is, in addition to this change, the deposition of oil-globules in the lobules, swelling out the latter, and rendering the organ more nudular at the same time that it makes the lobular tissue softer. The anatomical condition upon which this cirrhosis of the liver depends being in the first instance the effusion of lymph—of which the serum is absorbed, and the fibrine ultimately contracts—it fol- lows, that the size of this organ so affected must undergo considerable variations, being in the first instance somewhat enlarged, and when fatty degeneration coincides with the cirrhosis, considerably so; but as the contraction of the fibrinous effusion goes on it becomes smaller, and is at last reduced considerably below the natural size and weight. The cause of the inflammation inducing the changes above described is over-stimulation of the organ, this over-stimulation being in most instances produced by the character of the blood in the portal vein. The most palpable, as well as frequent examples of this, are found in the spirit-drinkers, unfortunately too numerous in our large towns; and it is remarkable that spirit-drinking produces the disease more speedily and certainly than does the use of alcohol in any other form, as Avine or beer; but hot climates, or even long-continued exposure to heat in the pursuit of various occupations, will greatly promote, if not induce, the same result, probably by calling into requisition the supplementary function of the liver by diminished activity of the lungs. A stimulating diet, confined air, and want of exercise, pro- mote the same result. This was remarkably exemplified in two faAvns Avho were kept for some time at the back of Guy's Hospital, often getting fed upon linseed meal and other matters readily under- 302 CIRRHOSIS OF THE LIVER. going fermentation, and of course using (for them) but little exercise, and living in an impure atmosphere. These creatures both died of ascites from cirrhosis of the liver. Cirrhosis of the liver usually comes on insidiously, and the patient seldom comes under treatment so much for the disease in the liver itself as for the effects produced upon the rest of the system. In some cases, hoAvever, there is a more rapid onset, and there are symptoms indicative of active inflammation, combined Avith those of rapid diminution of the secretion of bile. There is loss of appetite, nausea, and, it may be, sickness, pains in the limbs, and other symp- toms of pyrexia, the skin and conjunctive become more or less tinged with bile, the urine high-coloured and loaded with lithates; there are pain and tenderness in the region of the liver, and the organ may be felt below the margin of the ribs. When these acute symptoms do not present themselves at first, or when they have been subdued by treatment, or have spontaneously subsided, the patient makes no very distinct complaint, but gradu- ally loses flesh and strength, and his skin becomes salloAV and dry, the countenance sunken and dingy. After some time, generally several Aveeks or months, the effused lymph contracting, the circula- tion through the portal vessels is obstructed, and the escape of bile is probably at the same time impeded; the effect of which must be both scanty secretion and delayed excretion. In the mean time the fibrinous lymph goes on contracting, and the liver from being larger than natural, becomes smaller, in some cases exceedingly so, and the obstruction to the passage both of blood and bile through their proper vessels is almost closed. The effect of the closure of the portal ves- sels is obvious in A'arious Avays. There is a general exudation of serum from the extreme branches of the veins converging to form the vena porte, and the consequence is effusion into the peritoneal cavity. This goes on increasing, generally AA-ithout pain or tender- ness. The amount to Avhich this fluid increases is often such as to press up the diaphragm and impede the respiration, and also by pressure upon the ascending cava, to divert the returning blood into the superficial veins, and cause great enlargement of those on the surface of the abdomen; these are still further distended, owing to a portion of the portal blood finding its Avay by this course to the right side of the heart, having access to these veins from the hemorrhoidal branches of the superior mesenteric vein, through the branches of the internal iliac which anastomose freely with the former. From the same cause the loAver extremities become anasarcous, but not the upper or the face, which remains shrunken throughout. The portal obstruction likewise causes engorgement of the venous branches in the mucous membrane of the alimentary canal, resulting in hemor- rhage from the stomach and bowels. The obstructed circulation through the portal system also prevents the absorption of fluid into the general circulation, and consequently the urine becomes scanty. This diminished absorption must, no doubt, induce a scanty supply to the whole system, and render the process of waste and repair much less, which may account for there CIRRHOSIS OF THE LIVER. 303 not being more obvious ill effects from the diminished secretion of bile and urine. The blood is, however, materially disordered, as may be seen by the general tendency to hemorrhage, spots of purpura or ecchymosis being rarely absent sooner or later, and besides the hemorrhage above noticed, which are due merely to mechanical obstruction, epistaxis, and bleeding from the mouth or gums, or from leech-bites, or the wounds of scarificators in cupping, are of common occurrence. The diagnosis of this disease may be, in the onset, somewhat obscure, but the sallowness, feverishness, dull pain in the region of the liver, Avith a history of the use of spirits, where a correct account can be obtained, are pretty conclusiA^e evidence of this disease, even before any of its more characteristic signs have begun to show them- selves. But Avhen, by the progress of the disease, we have the known results of obstructed circulation through the liver, such as ascites, scanty urine, and subsequent anasarca of the lower extremities, the diagnosis, especially in male subjects, is comparatively easy, espe- cially Avhen we can get an insight into the history of the patient. The only diseases with which it can be confounded are enlargement of the spleen, chronic peritonitis, malignant disease of the liver or omentum, or malignant groAVths obstructing the portal circulation; and in the female ovarian dropsy. From enlargement of the spleen it may be distinguished by the previous history, by the absence of tumour under the left hypochon- drium, aided by the persistence of the ascites, which often in enlarge- ment of the spleen, subsides, leaving the tumour, which may be recognised by its shape and the notch at its anterior edge. In chronic peritonitis there is often more tenseness of the abdominal walls, and the fluctuation is not so distinct. This disease often occurs in con- nexion with tuberculosis, of which we may find symptoms in other parts of the body. The hollow viscera, too, in hepatic ascites, will ahvays float to the portion of the abdomen which is uppermost, according to the position of the patient, so that we have this part resonant and the rest of the belly dull upon percussion. This free movement cannot take place in peritonitis, OAving to adhesions of the viscera to each other, and contraction of the mesentery; and con- sequently, there will not be the circumscribed area of resonance which avc find in simple ascites, though the general resonance may be greater. In cancer, of the liver or peritoneum, the effusion is rarely so great, the complexion has more of a dingy whiteness than of the sallowness of hepatic disease. In most forms of cancer of the liver we can feel the enlarged organ; it is nodulous, and the enlargement generally increases as the disease advances. The emaciation too, and general progress of the disease is more rapid; and there is generally evidence of the same disease elseAvhere; and cancer is not a disease induced by intemperance. Very similar constitutional signs, with more dif- fused pain and tenderness in the abdomen, and a nodulous tumour in the epigastrium, Avhich may be mistaken for a cancerous, but not 304 CIRRHOSIS OF THE LIVER. very readily for a cirrhose liver, will enable us to distinguish cancer of the omentum from the latter disease. There is a form of probably malignant disease existing in the ascending cava, involving the kidney, and extending almost into the right auricle, described in the second volume of the second series of Guy's Hospital Reports, which also produces great ascites, and even greater enlargement of the superficial abdominal veins, than does cirrhosis, from which it is with difficulty distinguished; but the diag- nosis has been, effected, and may be so by carefully considering all the effects which would ensue from simultaneous obstruction of the ascending and hepatic cave. Ovarian dropsy is another source of difficulty, especially when there is a very large cyst; the previous history Avill, however, do much to guide us; added to which that, the swelling is generally said to have commenced rather more on one side than the other, and the dropsy being encysted, the intestines are pushed on one side, and do not float up, and give a hollow sound in the centre of the abdomen, as when the fluid is in the general cavity. Hydatids, though fre- quently producing great abdominal enlargement, need never be mistaken for ascites. In the treatment of cirrhosis we must act upon the knowledge that it is primarily an inflammatory affection of the liver; that until the effused fibrinous lymph has become organised and begun to contract, the indications are to arrest the inflammation, and, if possi- ble, promote the absorption of the inflammatory effusion; but that subsequently the organ is spoiled, although the disease may be at an end; and therefore we can only palliate its effects, namely, obstructed portal circulation and diminished or almost obliterated function of the liver. In the commencement local depletion may be employed, but with great care, for we have to do Avith those who, from previous intem- perance, are intolerant of loss of blood, and liable to delirium tremens from its being carried too far. Cupping, however, of the liver to about eight ounces may be tried, and repeated once or twice if Avell borne. Saline purgatives, as the sulphate with the carbonate of magnesia, may be used at the same time, and a grain of calomel with half a grain of opium and one-sixth of a grain of tartar emetic, night and morning; but the mercury is to be used at first only in small doses, and with a view to arresting plastic inflammation, not as a stimulant to the liver, for in so far as it has this effect it is mis- chievous. When, however, the febrile symptoms have subsided, Ave may use the mercury a little more, Avith a view to its specific effects, but still very guardedly; and iodide of potassium is to be preferred in broken constitutions. The conium and blue pill (F. 52) may be used three times a-day. The saline aperients, if necessary, and iodide of potassium in tAvo-grain doses, should be substituted for the blue pill as soon as the gums are the least affected, and iodine ointment may be rubbed into the right hypochondrium. IV. The veins of the liver are liable to inflammation both of the suppurative and plastic kind: of the former, the symptoms are not INFLAMMATION OF THE GALL-DUCTS. 305 unlike those of hepatic abscess; of the latter, they are even still more obscure and uncertain. V. The mucous membrane of the hepatic system, like that in other regions of the body, is liable to different varieties of inflamma- tion : these are divided by Dr. Budd, in accordance with the analogy • of the same membrane in other organs, into 1, catarrhal; 2, suppura- tive ; 3, croupal or plastic; and 4, ulcerative or mucous inflammation: and it is not improbable that this " bronchitis of the liver" may play as important a part in the diseases of the biliary apparatus, as does bronchitis in those of the respiration. 1. Catarrhal inflammation is, if we may judge from the analogy of other mucous membranes, most probably not an uncommon occur- rence, and may perhaps account for many of the cases of simple jaundice which Ave meet with in practice; and the symptoms which Ave might expect to arise from such an affection would be slight pyrexia, dull pain in the right hypochondrium, and jaundice. 2. In severe cases the secretion of the mucous lining of the ducts becomes puriform, the matter secreted being often of a greasy cha- racter, like pus AArhich has been treated with an alkali, at the same time that it may be coloured by the bile. The symptoms are not very unlike what might be supposed to arise from an abscess in the liver. The inflammation of the ducts may, by the turgescence of the sub- mucous areolar tissue to which it gives rise, cause obstruction of the canal, as may readily be supposed Avhen the narrowness of the canal is considered. AVhen this obstruction affects the common duct there will be pain in that situation; the liver Avill be gorged Avith bile, and jaundice will ensue. It will also not uncommonly happen that a pyriform tumour presents itself in the right hypochondrium, Avhich is the distended gall-bladder. If the inflammation imrolve only the hepatic duct, the symptoms Avould be much the same, but there Avould be no enlargement of the gall-bladder; but it does not neces- sarily follow that if the cystic duct be obstructed there need be none, since if, as is not unlikely, there be at the same time mucous inflam- mation of that sac, or if it be subjected to any other cause of irrita- tion, its own secretion Avill be very considerable, and having no outlet will go on accumulating to an amount scarcely credible. In a patient of Dr. Babington's, at Guy's Hospital, the cystic duct had become obstructed, and the gall-bladder contained a quantity of thin mucus, Avhich nearly filled a Avashhand-basin. The fact of the gall- bladder being capable of distension by its own secretion should be remembered as aiding diagnosis, and as tending to correct some erroneous inferences which may be drawn when it is found full upon examination after death. 3. Plastic inflammation of the mucous lining of the biliary pas- sages is a \-ery rare occurrence, and one with the clinical history of which we are unacquainted. 4. Ulceration of the gall-bladder and biliary ducts is perhaps among the most common forms of inflammation of those structures, and may be induced by various causes, though the symptoms especi- 20 306 INFLAMMATION OF THE GALL-DUCTS. ally referable to the lesion itself are, as might have been anticipated, by no means Avell defined.. Dr. Budd remarks that it has been noticed by several observers as one of the anatomical changes observed after death from remittent fever; and Ave have ourselves noticed it on more than one occasion in subjects AA'ho had died Avith typhus fever; in one instance the peritoneal coat, Avhich had been laid bare by the ulceration, gave Avay in gently lifting the gall-blad- der. It is also very apt to be excited in those AA'ho have previously suffered from disease in the same situation. Ulceration of the gall-bladder or ducts may, by perforating the peritoneum, allow the escape of the contents into the caArity of that membrane, giving rise to puriform peritonitis, which is speedily fatal. If indeed there have been closure of the cystic duct, and the gall-bladder, as before noticed, contain only the mucus secreted by its lining membrane, the escape being more gradual, and the extra- A\nsated matter not so intensely irritating, the extraA*asation may be circumscribed by adhesion. And the same Avill happen Avhen the ulceration is set up by gall-stones, in which case the adhesion com- monly precedes the perforation, the bladder or duct becoming adhe- rent to some adjacent part, often the duodenum or colon, by which means the gall-stone passes into the intestinal canal. An ulcer in a large duct may find its Avay into a neighbouring branch of the portal vein, and then the consequences are most disastrous—bile as Avell as pus becoming mixed Avith the blood. The symptoms Avhich precede the ulceration are probably pain, loss of appetite, thirst, and some degree of fever, with weight and heat at the epigastrium, and, Avhen the inflammation has given rise to occlusion of the hepatic or common duct, intense jaundice. The treatment of inflammation of the mucous membrane of the biliary apparatus must be in the main antiphlogistic—our object being to subdue the local inflammation, to remove the unhealthy secretion, and restore the health of the organ. The inflammation, hoAvever, is one affecting a mucous surface, and therefore depletion must be used with caution. AVith this end, leeches or cupping to the margin of the ribs have been recommended; but Avhen, as is most commonly the case, there is jaundice (and in fact our diagnosis cannot be complete Avithout it), the latter should be employed; indeed it may Avell be questioned Avhether it is ever justifiable to use leeches when there is jaundice, OAving to the great difficulty in stopping the hemorrhage Avhich under such circumstances often floAVS from the leech-bites, and has been known in some instances to prove fatal. For promoting the expulsion of the accumulated mucus, Ave do not perhaps possess any remedies which can be strictly compared to expectorants as applied to the bronchial membrane; but certainly there is no more effectual method of promoting the flow of its secretion from the liver, than by exciting the action of the part into Avhich it should be poured; for this purpose saline purgatives are well adapted, and there is no combination better than the sul- phate with the carbonate of magnesia; Avhen there is heat of skin, diaphoretics should be employed, and Avith them antimonials, if there JAUNDICE. 307 be no sickness (F. 5). Mercury is a much-abused remedy in all biliary derangements; and Avhen there are any signs of pyrexia it should not be employed except so combined as to insure its purga- tive action ; though it may be remarked that its employment in this disease is not directly in opposition to all rational principles of thera- peutics, as it is Avhen the substance of the organ is the seat of disease. The pills of blue pill and colocynth, may, hoAvever, be given Avith safety Avhen the bowels do not respond to the saline aperients. When all inflammatory action is at an end, moderate doses of pil. hydrarg. or hydr. cum cret. may be used at intervals, much on the same principle as Ave Avould employ stimulating expectorants in chronic bronchitis. Soda again, Avhich is one of the constituents of the bile, and therefore likely to pass out of the system by the liver, is Avell fitted for such cases, since it is probable that it also corrects the character of the secretion in the ducts, by rendering it less viscid; an effect similar to that Avhich is known to be produced by this and other alkalies in similar affections of the bronchial tubes. Taraxa- cum is another remedy Avhich appears to modify the quality of the bile, and in affections of the biliary passages, which have assumed a chronic form, it is peculiarly applicable. It may, under these cir- cumstances, be combined Avith the soda or liq. potasse. In some chronic cases, it seems also to exert an admirable cholagogue influ- ence when combined wtth nitric acid.* Hydrochlorate of ammonia also is a cholagogue, the importance of AA'hich is hardly sufficiently appreciated in this country: after the boAvels haA'e been freely re- lieved by saline and mercurial purgatives,'it may be administered in doses of about ten grains (F. 49). AVe have already frequently alluded to jaundice as a S3rmptom of various affections of the liver, Avhence it must be apparent that it is in reality nothing more than an effect, we might even say a symp- tom, which may arise from various causes; yet, as it is often spoken of as a disease per se, and in the present state of our knowledge, we are also sometimes compelled to recognise it as such, and as, although it may be a secondary lesion, yet it may ghre rise to subsequent ones, and those of no mean importance, it is expedient to give it a separate notice. Jaundice, then, is to be recognised by the yelloAV skin and eyes, white stools, and deep saffron-coloured urine which stains the linen. The diagnosis of the disease is, therefore, almost obvious at first sight, the question being as to its cause ; but even before pronounc- ing the disease to be jaundice, we must look carefully in the pati- ent's face, since some persons have a sallow complexion not unlike the hue of jaundice; and the tinge in some chlorotic females is nearly of the same cast, as is also that in the remarkable discoloration to AA'hich Dr. Addison has lately called the attention of the profession * (49) R. Ammonite Hydroch. gr. x. Pulv. Tragacanth. co. gr. x. Aq. Cinnam. 3 iss. Ft. Haust. ; to be taken three times a-day. 308 JAUNDICE — ITS SYMPTOMS. in connection with the renal capsules. A careful examination of the conjunctive, which are pearly in the latter affections, will soon remove all doubt. The stools again are not. necessarily white in jaundice, as Ave shall presently have occasion to notice; and there may be Avhite mucous stools Avithout jaundice. The urine is, hoAv- ever, ahvays dark, sometimes nearly resembling London porter, Avith a yellow margin, and giving a deep-green colour with hydrochloric acid. The jaundiced appearance then is produced by the presence of the bile in the serum of the blood, Avhence a portion of it, and at all events its colouring matter, is carried off by the kidneys, giving rise to the dark urine ; whilst, the pale colour of the feces arises from the bile not finding its way into the alimentary canal. There has long been a question as to the manner in Avhich the bile finds its way into the circulation, and in this is involved a preliminary question, as to the orgin or formation of the bile itself. The earlier opinion was that the bile Avas formed in the liver, and when its exit through the ducts was obstructed, it was reabsorbed into the system, and gave its characteristic colour to the tissues. The discovery, hoAvever, that the urine Avas not formed by the kidneys, but in the extreme circulation, led to the belief that the bile was so likewise. The cases are not hoAvever strictly analogous, since the bile must be regarded as not entirely excrementitious, like the urine, but also as a secretion having important uses to fulfil before it is finally expelled from the system. There can hoAvever be little doubt that ingredients which are noxious enter into its composition, and that these may, when the secreting' organ is diseased, remain in it and produce in- jurious effects. AVe may thus have tAvo classes of phenomena presenting them- selves in jaundice. First, those arising from the non-performance of the proper office of the bile; and secondly, those AA'hich may be pro- duced by its action, or that of some of its ingredients when not eliminated from the system. Amongst the first class of symptoms may be reckoned the colour of the skin and conjunctive, the dark colour of the urine, and the absence of colour in the stools, the stools being rarely paler than natural; but besides these, and more important, there is impediment to the natural conversion of the food after it has passed from the stomach, and a liability to speedy decomposition and fermentation; the consequences of which are that nutrition is checked, and the patient becomes emaciated and languid, and also that the stools, besides being pale, are offensive, sourish, and apparently in a state of fermentation. Of the latter class of phenomena are the stupor, delirium, coma, and other signs of cerebral derangement not uncom- monly observed in jaundice; and perhaps Ave may add the occasional excitement of serous inflammation. NoAv it is a fact which must be familiar to every practitioner, that in many, or rather in the greater number of cases of jaundice, Ave have the first elass of symptoms Avithout any of the latter and more alarming ones, unless it be torpor or apathy, not amounting to stupor, which often attends simple jaun- GALL-STONES. 309 dice, though it is not unlikely that this is to he accounted for by the impaired nutrition and: consequent languid circulation through the brain. Another effect of jaundice in all its forms is the tendency to hemorrhage, not only from those organs which discharge their venous blood into the portal vein, but from all parts of the system, sometimes giving rise to purpura, and ahvays rendering every solu- tion of continuity more than ordinarily dangerous. The above include the essential symptoms of jaundice, the others which frequently accompany it belong more properly to the lesion of which the jaundice itself is an effect or symptom. Jaundice, as we have seen, may be induced by mechanical venous congestion of the liver of the passive character, as well as in the more active congestion, arising probably from over-stimulation (p. 295). In the former case the jaundice probably first commences in the liver; when the bile is re-absorbed into the circulation it shows itself mainly by the yellowness of the conjunctive, and by the colour of the urine, which is also at the same time loaded with urates and pur- purine. In the jaundice from the more active form of congestion, we have a greater tendency to the more formidable symptoms of suppressed secretion. Such cases are not common. The folloAving is an illustrative one:—A young married woman, during the absence of her husband at sea, indulged too freely in the use of spirits; her conjunctive and complexion became yellow and her urine of a deep saffron; the pulse Avas not at first accelerated, but afterwards became very rapid and feeble; her tongue was coated, with rather red edges: there was at first sickness. The stools Avere dark. Her countenance was dusky as well as turgid, and there Avas an appearance of venous congestion over the whole surface. There Avas no pain, though much tenderness, in the right hypochondrium, and the liver could be felt > below the ribs. She was at first relieved by purgatives, but subse- quently became delirious, the delirium assuming more and more of a low muttering character; and she ultimately sunk in a state between coma and exhaustion. Here then was evidently toxemia arising from a suppression of the secretion, or from decomposition of the retained principles of the bile. It may be suggested that this case partook of the nature of the destruction of the hepatic cells to be presently noticed, but the enlargement of the liver is at variance with this opinion. Catarrhal inflammation of the ducts is probably the most frequent cause of simple jaundice: this jaundice may be of varying intensity, both as regards the colour of the skin and the urine, and the paleness of the stools. When there is thickened mucus obstructing the com- mon duct, the jaundice becomes complete, and the same must occur when the ducts become obstructed from thickening or adhesion. There is, again, another cause of jaundice from obstruction in the ducts, which deserves especial notice from the severity of the suffer- ing Avhich ordinarily attends it, and that is gall-stone. Gall-stones are concretions in the ducts or gall-bladder, consisting commonly of cholesterine with colouring matter of bile. These concretions are 310 JAUNDICE. sometimes solitary, sometimes in great numbers, and may form either in the gall-bladder or in the ducts; they may be of various sizes, sometimes as large as a filbert: these concretions are often found in the gall-bladder, and it may be by their escape thence that they first make themselves felt either in the cystic or the common duct, though they may be present and cause obstruction in the hepatic duct or any of its branches. The symptoms attending passage of a gall-stone are—intense pain in the region of the liver, extending to the scapula. It is sometimes of a dull aching kind, though more frequently it is acute, and appears to be the most agonising that can be inflicted; it comes on in paroxysms, and is attended with vomiting of sour matter, and sometimes hiccough, with a frequent catching inspiration. The intense pain, aided it may be by irritation so near the solar plexus, brings on a state of the greatest exhaustion, either reducing the pulse below the natural frequency, or else rendering it very quick and feeble. In a case Avhich occurred to the author, the patient appeared to have died from the depressing effect of a large gall-stone in the common duct, since the symptoms had not been of an hour's dura- tion, and there was no jaundice, though the duct was completely obstructed. There are often rigors, sometimes recurring periodically. If the obstruction do not give way, the urine becomes high coloured, and in most cases the patient brightly jaundiced. This will not, of course, be always the case, since Avhilst the concretion is in the cystic duct there need be no jaundice, and if from its angular shape it only partially obstructs the common duct, the jaundice may be slight, or only transient, appearing and disappearing with great rapidity. Should the gall-stone not be expelled, the patient either dies from the depressing effect just noticed; or, OAving to the effect of the con- tinued obstruction upon the tissue of the liver, the secreting cells become disintegrated, giving rise to a fatal form of jaundice to be presently noticed. The most satisfactory evidence of the cause of the jaundice is the detection of the calculus in the evacuations. If the feces be mixed with water, it is probable that the gall-stone, Avhich is specifically lighter, wili rise to the surface. It is, as Dr. Watson observes, a great gratification to the patient to see that his enemy has been ex- pelled. There may, hoAvever, be more lurking behind. When the gall-stone has one or more flat polished faces, it has probably been in contact with several others in the gall-bladder. Besides the obstructions within the ducts, there may be causes of pressure from without, as from malignant disease in the neighbour- hood of Glisson's capsule, in the small lobes of the liver, in the pylorus, the head of the pancreas, or the duodenum. Under these circumstances the jaundice will commonly come on very gradually, and there will be emaciation, often enlarged and hardened glands in the axillae, groins, or elseAvherc, or other signs of malignant disease. Malignant growths in the liver may produce jaundice by pressing upon the ducts, but it may as frequently happen that there is exten- sive disease of this kind in the liver without jaundice, the fact being that such disease is in the organ, not of it, and therefore unless the TREATMENT OF JAUNDICE. 311 groAvth act mechanically the function of the organ is not interfered with. AVe have already alluded to disintegration of the secreting cells of the organ, and to this cause Dr. Budd has, Avith much apparent reason, referred a fatal form of jaundice which is occasionally met with, and sometimes appears almost epidemic, though Dr. Bright considers it as resulting from diffused inflammation of the liver. This formidable disease is not at its commencement unlike ordinary simple jaundice. The skin and conjunctive are bright, the urine dark. Dr. Budd states that the stools are pale; but this is at variance Avith the experience of the author, who in tAvo cases Avhich occurred in his OAvn practice, found the evacuation dark broAvn, not indeed of a Avarm ginger-bread colour, but a dark dirty broAvn which might be compared to the mud in the streets of London. Indeed he would almost be inclined to regard this appearance as symptomatic but for the counter-statement of so careful an observer as Dr. Budd. Dr. Graves, on the other hand, who Avas the first specially to describe these cases, speaks of dark stools as an unfavourable sign. In the course of an attack of what appears to be ordinary jaundice, either considerable irritability or excessiAre drowsiness supervene, the stomach becomes irritable, and there is A'omiting sometimes of bilous matter; after a short time violent delirium, with pain in the head, supervenes, which ultimately subsides into coma, in which the patient expires. In the course of this affection the pulse, which may haA'e been in the first instance sIoav, becomes quick with the excitement, but again becomes sIoav toAvards the close. According to the author's observation, the characteristic signs are, in the course of an attack of jaundice, stupor or irritability, a diminu- tion in the deep colour of the urine, and a darkness in the stools, without any sign of amendment, delirium, and coma. Dr. Bright, Avho refers the change in the liver to inflammatory action, states that the surface of the lh'er appears variegated, of a light yelloAV and dark red or purple, in patches; and certain portions pro- ject above the rest, which, Avhen cut through, sometimes prove of a softer texture, and even undergoing a procees of change or disor- ganisation. It is remarkable that the liver is always smaller than natural. Dr. Budd, who refers the affection to disintegration of the hepatic cells, states that it may result from long retention of the secreted bile from closure of the common duct; but adds that, "destruction of the hepatic cells may take place rapidly without any obstruction of the gall-ducts, and instead of being consequent on protracted jaundice, the impaired nutrition of the cells may be the cause of jaundice that proves rapidly fatal." The small size of the liver is certainly opposed to the notion of inflammation. It is not impossible that there may be several causes for this disin- tegration. In some instances it may be a primary lesion, and the fact of this alarming disease having been knoAvn to attack several members of a family in rapid succession, would suggest the idea of a miasmatic origin. In others, obstruction of the common duct is the cause, and Ave would suggest that the smaller duct may be closed by 312 TREATMENT OF JAUNDICE. catarrhal inflammation, as in the case of capillary bronchitis, and ma}- give rise to disorganisation, as when the common duct is closed. The treatment of jaundice must be regulated in great measure by our knoAvledge of its cause. Of that arising from congestion and catarrhal inflammation Ave have already spoken. In the case of gall- stones, we must endeavour to favour the passage of the calculus. For this purpose opiates should be combined AArith purgatives and antimonials, provided there be not much sickness. Thus, a grain of opium Avith a quarter of a grain of tartar-emetic may be given tAvo or three times daily, and the draught of sulphate of magnesia with the carbonate in the interval. Warm baths and hot fomentations are valuable adjuvants. Many recommend mercury; but if it increase the secretion Avithout removing the obstruction, it must damage the liver. In regard to the treatment of the dangerous form of jaundice from disorganisation of the liver, steady purgation, we believe, holds out the best hope. Dr. Budd recommends the annexed formula (F. 50).* Mercury is decidedly objectionable upon the grounds just stated. AVhen the excitement is great cold may be applied to the scalp, and, if the heat is diminished, a blister may be placed upon the back of the neck. Jaundice sometimes appears to be the result of impeded functions of the liver, from a lesion of innervation, as in the instances, not uncommon, of simple jaundice coming on after anxiety or depression of mind. In these cases the stools are white, the urine dark, and the countenance slightly jaundiced, the pulse slow, the patient languid. For this the best treatment is at first the blue pill and colocynth, Avith saline aperients; subsequently, change of air and scene, moderate exercise, and compound decoction of aloes, with taraxacum. In cases of torpid liver, or jaundice from chronic change, the nitro- muriatic bath (F. 51), f recommended by Mr. E. Martin, is useful. * (50) R. Mag. Sulph. gss.—gj. Mag. Carl), gs. xv. Sp. Ammon. Arom. 3 ss. Aq. Purse, 3 x. F. Haust ; to be taken three times a-day. f (51)R. Acidi Nitrici, It. ij. Acidi Hydrochloric!, H> ij. Aquse ferventis, conj. xl. Misce. DISEASES OF THE (ESOPHAGUS. 313 XVI. DISEASES OF THE (ESOPHAGUS. Acute inflammation of the oesophagus rarely occurs except as the effect of chemical or mechanical irritation. The symptoms are, pain, with inability to swallow either solids or liquids, but especially the former, the attempt being attended with great suffering, and the matters immediately rejected. The most appropriate treatment for this inflammation is local depletion as near the situation of the affected part as it can be applied, and what is of more importance, rest of the inflamed structure; this is obtained by almost total absti- nence, nothing being taken except a very little thin barley water, or milk and lime water. These last may be used in equal parts, of which mixture a tablespoonful may be administered about every two hours; the abstinence itself will be a means of subduing the inflam- matory action, and where the irritation is very severe, the rest alloAvs it opportunity to subside. When, however, the irritation and conse- quent inability to swallow continues so long as to endanger the life of the patient by inanition, enemata of beef-tea must be administered. After inflammation of the oesophagus, the part involved is liable, as in the case of the urethra, to contract, and thus obstruct the passage through the canal: under these circumstances surgical aid maybe employed to pass bougies down the tube, by which, however, only temporary benefit is often obtained, and the patient ultimately dies of inanition. Here also life may be prolonged by the diligent use of nutritive enemata. When there is stricture of the oesophagus, the portion of the tube above it is apt to become dilated, from distension by its accumulated contents. But the same dilatation sometimes takes place Avithout such stricture, (possibly as an effect of inflammation, as we shall observe in other parts of the canal,) and, what is somewhat remark- able, Ave have an effect similar to that which is produced by stricture, namely, difficulty in swallowing. Ulceration is sometimes the effect of the obstruction; in which case the contents of the oesophagus may be extravasated into neighbour- ing parts. This ulceration may, though rarely, take place sponta- neously. In a case which occurred to the author, a gentleman of not very temperate habits, after taking a considerable quantity of wine, became sick, and soon after vomiting, or in the act, was seized with severe pain in the side, with symptoms of sudden effusion, either into the chest or upper part of the abdomen. He sunk rapidly, and died in about eighteen hours. Upon examination after death, a consider- able quantity of port Avine Avas found in the right pleural cavity. In the pleura Avas a small rent near the vertebre, and corresponding to it was a perforation in the oesophagus, produced apparently by a cir- cular ulcer, without any elevation of the edges, and resembling those 31-1 OBSTRUCTION OF THE (ESOPHAGUS. which occasionally occur in the stomach, and which will be noticed hereafter. Obstruction of the oesophagus may also be produced by malignant disease in any part of its course; this most often occurs about its ter- mination in the cardiac orifice of the stomach, in which case the pain, and rejection of the food, are as violent and as immediate after the attempt to swallow as when the stricture is high up in the tube. The same symptoms may also arise from the pressure of aneurismal or other tumors of neighbouring parts. The oesophagus, like every canal surrounded by muscular tissue, is liable to have the passage of its contents obstructed by irregular contraction of these fibres, causing the food, as soon as it has passed into the gullet, to stop, occasioning a sense of pain either between the shoulders or in the passage itself. The symptoms are, as Dr. AVatson observes, "the same as those which result from permanent stricture of the gullet, except that they are not permanent. When the stric- ture is organic and abiding, the symptoms occur during or after every meal. AArhen it is simply spasmodic, they come and go capri- ciously." Spasmodic stricture may be independent of any disease of structure in any part of the body, but it is of some importance to be aware that it may also be s}rmptomatic of very serious organic changes,* as, for instance, ulceration in the larynx or even at the cardiac orifice of the stomach. True spasmodic stricture most com- monly occurs in persons of a highly-irritable state of the system, as, for instance, in hysterical females, or persons reduced by hemor- rhages, or excessive discharges of any'hind^and is best relieved by checking or removing the weakening cause, and administering iron or zinc. In hysterical subjects the same remedies are applicable, the iron being preferred Avhen there is evidence of anemia, the zinc in the more purely hysterical subjects, in whom anemia is not neces- sarily present; the tincture of valerian may also be. advantageously given at the same time with the mineral tonics. * Dr. Watson's Lectures on the Practice of Physio. ' 7 DISEASES OF THE STOMACH. 315 XVII. DISEASES OF THE STOMACH. Acute gastritis, by which is meant inflammation of the mucous membrane of the stomach, is a rare disease in adults, except as a con- sequence of some irritant or acrid poison; though it is not uncom- monly met with in young children. The anatomical changes pro- duced by it are a vivid redness of the mucous membrane, from injection of the minute blood-vessels, eccymosis into the sub-mucous areolar tissue, Avith softening of the membrane, so that it may be readily peeled off; the mucous follicles are rendered prominent, and here and there there are minute ulcers; sometimes portions of the organ are found thickened, probably from tumescence of the areolar tissue, at other times the parieties are much attenuated, though this is probably a post-mortem effect of the gastric juice. It should be remembered, however, that the degree of injection of the minute vessels of the mucous membrane of the stomach, is a very fallacious sign of inflammation having existed before death; since not only will these vessels become injected from mechanical causes at or soon after it, but also their mucous surface, in which there has been unques- tionably much irritation during life, becomes pale after death. The characteristic symptoms of this disease are great irritability of the stomach, with pain, and extreme tenderness in the region of that organ; the pain as Avell as sickness being excited by taking any- thing but the blandest liquids, and sometimes even by these. This pain extends round the hypochondria, and is particularly com- plained of between the shoulder-blades; there is urgent thirst, the tongue is white and furred, or brownish, and rather dry towards the centre; it is almost ahvays red at the tip and edges. The pulse is small, soft, and frequent, and there is excessive prostration. The skin is generally hot, the bowels confined, and the urine scanty and high-coloured. As, however, we have observed, it is in children that Ave are most frequently to expect this disease, and here we often find some spasmodic affection associated with it, generally a chronic spasm of the flexors of the fore-arm, wrist, and fingers on one or both sides, often a similar affection of the loAver extremity. The subsequent progress of acute gastritis, if not relieved, coincides with what might be anticipated from the combined effect of irritation near the solar plexus, and continued inanition; the pulse becomes more and more feeble, the eyes sunk and hollow, there is AArandering delirium, or stupor, pallor of the countenance, with cold, shrunken extremities, and the patient dies of gradual syncope. The causes of the disease are very obscure: as before stated, it is rare in adults, unless induced by irritant poisoning, though it may be excited by the irritation of indigestible food in a system rendered susceptible of such irritation by protracted mental anxiety. In 316 ACUTE GASTRITIS. children, gastritis may be set up by the irritation produced by teething, and probably, also, by improper articles of diet, alloAved through carelessness or ignorance, and possibly by substances actually poisonous, taken in the same Avay, and by SAvalloAving hot liquids. It may also arise from the retrocession of gout, erysipelas, or rheumatism, but more especially the former. Gastritis may also occur in connection with the exanthemata, and continued fever; though these cases are more rare and less violent than they are com- monly described. The ordinary causes of inflammation, such as exposure to cold or damp, may excite inflammation of this as of other mucous surfaces. Symptoms resembling gastritis may arise from disease obstructing the circulation through the right side of the heart, though they are rather the effect of mechanical congestion than of acute inflammation. Violent sickness may arise from inflam- mation or irritation of the kidneys, though in the latter case the injection of the mucous membrane of the stomach, which may be found after death, occurs rather as the effect than the cause of the A'omiting; and the same remarks apply to sickness from intestinal obstruction. The diagnosis of acute gastritis is of considerable importance, from the fact of its being most commonly induced by irritant poisoning; and therefore, where the symptoms just pointed out are present, a most careful investigation must be instituted, as well by chemical examination of the contents of the stomach, as by the search for other kinds of evidence bearing upon this point. For information upon this head we Avould refer the reader to the works of Dr. A. Taylor, and other medical jurists. Care also must be taken to ascer- tain that there is no hernia or other intestinal obstruction, and, which is perhaps more difficult, that the disease is not inflammation of the peritoneal coat of the stomach: from this it may be distinguished by the redder tongue, by the tenderness being less intense and less diffused, and by the pulse being softer. From nephritis, or the irri- tation of a calculus in the kidney, gastritis may generally be distin- guished by the absence of the pain described as belonging to the former, as well as by the burning pain in the epigastrium, and between the shoulders; examination of the urine will also assist the diagnosis, though it must be remembered that that secretion may be extremely scanty in both cases. The seat and character of the pain, even when there is no jaundice, will prevent the passage of gall- stones for being mistaken for gastritis, not to mention the greater frequency of the former affection. The prognosis of gastritis is ahvays doubtful. AVhen it arises from irritant poisoning, the degree of danger must depend much upon the nature and amount of the poison sAvallowed; and even Avhen it has arisen without such a cause, there is much danger from the depression produced directly by inflammation in this region, as well as by protracted inability to retain any nourishment. Continued sickness, failing pulse, cold extremities, and collapsed features are unfavourable symptoms. On the other hand, ability even to take the least nourishment, warmth in the extremities, and continued steadiness of the pulse may be TREATMENT. 317 regarded as favourable. The more frequent disease of infantile gas- tritis is also dangerous, though in such subjects the prognosis is per- haps more hopeful than in adults. The treatment of gastritis is to be conducted mainly upon the principle of obviating the least excitement of the inflamed organ. Scarcely any medicines can be tolerated; and the practice too fre- quently adopted of administering repeated doses of calomel, is more likely to aggravate than relieve the symptoms. [In children, minute doses of calomel—from an eighth to a twelfth of a grain— repeated at short intervals, will be found the very best means in many cases to allay the excessive irritability of the stomach.] AVhen the tenderness is great, and the prostration not excessive, a few leeches may be applied to the region of the stomach; and sinapisms applied in the same situation are at all times admissible, and gene- rally beneficial. Equal parts of milk and lime-water, to the amount of about half a tablespoonful of the tAvo combined, may be adminis- tered about every hour, though, should even this excite sickness, it must not be persisted in; in which case the lime-water alone may be tried. Impatience as regards the action of the bowels is to be depre- cated, though, should they not act for several days, a simple* injection of gruel and salt may be administered; the patient may also be sup- ported by injections of beef-tea, administered twice or thrice in twenty-four hours. A similar plan of treatment may be pursued with children, and if it can be retained, a little hydrocyanic acid, with two or three grains of bicarbonate of soda with mucilage. Though acute inflammation of the stomach is very rare, Ave cannot but expect that the lining membrane of that organ, which is exposed to so many sources of irritation, both mechanical and chemical, should become the subject of chronic or of subacute inflammation. This inflammation, Avhen long continued, produces thickening of the coats of the organ, and sometimes ulceration. In many cases the mucous membrane is roughened, thickened, and slate-coloured; this latter appearance proceeding, probably, from the gastric juice dis- colouring the blood detained in the smaller vessels. Sometimes, with apparently increased vascularity, the surface of the membrane is thickened, and covered with a tenacious mucus ; at others, especially in hysterical females, in whom the symptoms often assume a charac- ter seemingly more acute, this mucus is bloody ; these appearances are most remarkable about the large curvature. AVhen ulceration occurs, the ulcers may be of every variety of size; in some instances they are less in circumference than a pea, with smooth and but slightly elevated edges; sometimes, though this is not so common, there may be one large ulcer, with irregular, or thickened edges. These ulcers are often about the small curvature, sometimes perfora- ting the Avhole of the coats, and producing fatal peritonitis ; at others, they may be seen to have been prevented by adhesion to neighbour- ing viscera; sometimes the extravasated contents of the stomach have been found enclosed in a sac composed of the walls of adjacent viscera and false membrane, so that life has continued a considerable time after the escape of the contents of the stomach. 318 CHRONIC GASTRITIS. Caution is requisite in deciding upon the appearances of the inner surface of the stomach after death, as it is particularly liable to undergo changes in vascularity, from position, and, what is more deceptive still, changes in consistency, from the action of the gastric juice: these latter may even go to the extent of inducing solutions of continuity, that may by careless observers be mistaken for ulcera- tion; and as these solutions of continuity occur most readily in those who die rapidly, and after little previous disease, they have given rise to the question of irritant poisoning. A specimen was once brought to the author for his opinion as to AArhether the death of a child had been caused by poison; the reasons for the suspicion being, that the child had been attacked with sickness, tenesmus, without any evacuation from the boAvels, except a little blood, col- lapse, and death in a feAV hours; and that after death a large ragged perforation, surrounded by softening, was found in the large curva- ture ; and further, that a portion of the intestines Avas in a state of intense inflammation. Upon being asked his opinion, the author immediately inquired if the part so said to be affected was not near the ileo-colic valve, and upon further examination it turned out that there was an intus-susception in this situation, and that the affection of the stomach Avas a post-mortem solution by the gastric fluid. The symptoms of ordinary chronic gastritis are, pain in the epi- gastrium and between the shoulder-blades, increased by pressure at the scrobiculus cordis, and by taking food into the stomach; this latter feeling continuing for some time afterwards, or else not com- mencing till sometime has elapsed, being referrable, in fact, to the process of digestion then going on. There is also in most cases nausea, vomiting of mucus or of the ingesta, languor and restless- ness, the bowels are irregular; the evacuations sometimes pale and at others dark; the tongue is generally coated with a drab-coloured fur, and red at the tip and edges; or it may be red throughout, or glazed and chapped ; the pulse often quickened and sharp, the urine frequently scanty and high-coloured. There is, hoAvever, a great want of uniformity in the symptoms of chronic gastritis, the pain being in some cases wanting, there being only a feeling of acidity in the region of the stomach, the vomiting too is often absent, especially at the outset; indeed, this symptom depends much upon the seat of the irritation, being more urgent the nearer the latter is to the pylorus : and it would seem that the seve- rity of the symptoms depends rather upon the extent than the depth of the irritation, since many cases have gone on to a fatal termination by a perforating ulcer, with scarcely any signs during life, the most common in such cases being a sense of heat and burning at the epi- gastrium, and betAveen the shoulders. Chronic gastritis may terminate by resolution, and the patient may very gradually recover his appetite, powers of digestion, and general health; in less favourable cases the disease may pass on to the still more chronic form of dyspepsia. In still more unfavourable cases, even of ulceration, there is reason for believing that the ulcers occa- TREATMENT. 319 sionally heal, but at other times they perforate the Avhole of the coats of the organs, causing death from peritonitis. Sometimes, before the perforation takes place, adhesion is established to a neighbouring viscus: but the ulceration rarely stops there; if the viscus be a hollow one, the ulceration goes on till it penetrates its walls; and thus an opening may be made, for instance, from the stomach into the colon. The adhesion may, however, be to a solid viscus, as, for instance, the liver, spleen or pancreas; in Avhich case there is great danger that, the ulceration proceeding, some considerable vessel, or a large number of smaller ones being laid open, fatal hemorrhage will ensue ; or the same thing may happen from the ulceration open- ing an artery in the stomach itself. When the contents of the stomach escape into the general peritoneal cavity, death usually takes place at the end of between twenty-four and forty-eight hours. The causes of chronic gastritis are, a preceding attack of acute gastritis from any chemical or mechanical irritant, the habitual or frequent use of stimulating articles of diet or medicines, excessive indulgence in the pleasures of the table. Blows upon the region of the stomach may produce it, as will also leaning forwards so as to press the epigastrium against any solid body, as is obserA'ed in clerks at the desk, and still more in curriers and leather-dressers. It may also be induced by AA'hatever excites a congestion of the lining mem- brane of the stomach or determines a flow of blood there; sometimes, for instance, it is a troublesome complication of those forms of dis- ease of the heart or lungs which impede the circulation through the right side of the former. In young females, it may occur as a sequel of the hematemesis which often attends uterine derangement, more particularly amenorrhoea, and this is, perhaps, of all others, the form of chronic gastritis Avhich is most apt to lead to ulceration: and it is a fact to be borne in mind that young-females are, more than others, liable to perforating ulcers of the stomach, often Avithout any previ- ous sign of inflammation beyond a sense of heat or acidity in the stomach so slight as to have attracted but little attention. These ulcers are, hoAve\'er, not confined to such subjects, as they have been several times met Avith in elderly men, Avith the same absence of previously Avell-marked sj-mptoms. The treatment of chronic gastritis depends mainly upon the prin- ciple of removing as much as possible every source of irritation from the inflamed surface; the most obvious and most effectual mode of fulfilling this indication is the keeping the patient strictly to the blandest and most easily assimilated diet. For this purpose, milk, as an article of food, is most eligible for those persons Avhose stomachs are not readily offended by it, and there are feAV with whom it will not be found to agree when combined with lime-Avater, and Avhen but little or no other food is taken except bread. AVhen there is tenderness Ave must haAre resource to more active measures, in the Avay of local depletion and counter-irritation. AVith this view six or eight leeches may be applied to the scrobiculus cordis, and in a short time afterAvards a blister. In those cases in which there is much congestion about the liver and spleen, and in Avhich the stools are 320 MALIGNANT DISEASE OF THE STOMACH. very dark, small doses of blue pill are very useful. This is best given in the accompanying form (F. 52),* and unless the boAvels act freely, the draught of sulphate of magnesia Avith the carbonate should be given every morning. AVhen the pain and tenderness have been subdued, and the tongue has become cleaner and the pulse more tranquil, resource may be had to gentle tonics ; amongst these is the infusion of columba, to Avhich may be added fifteen grains of bicar- bonate of soda, and Avhen the bowels are torpid, about half an ounce of infusion of rhubarb. Care will for a long time be required to avoid every source of irritation in the way of diet. AVhen the patient has been used to stimulants, a little bitter ale may be allowed or light Avine; about a dessert-spoonful of brandy in three parts of a tumbler of water is often recommended: but care should be taken that the proportion of the former is not gradually increased. AVe should not neglect to remind our patients that attention to the state of the skin in the way of frequent ablutions and moderate friction, is as essential to a healthy condition of the gastric as of the other mucous membranes. In addition to the changes produced directly by inflammatory action, the stomach is one of the organs most prone to specific ma- lignant disease; that is to say, to cancer in its various forms. The anatomical distinctions of these belong more to the province of the morbid anatomist, since, as far as our present experience teaches, the difference in the species of malignant disease affects but little the difference in the symptoms or result of the disease; though, as regards the symptoms, there is a very great difference according to the part of the organ affected. The most sensitive portions of the stomach are, as we might almost have anticipated, its tAvo extremities or orifices. These ostia both for ingress and egress, are also guarded by sphincters, for the purpose not only of preventing regurgitation, but also of opposing the passage of matters Avhich are unfit to be transmitted through them. They become, Avhen organically diseased, sometimes mechanically closed, sometimes exceedingly irritable, and sometimes permanently open; and, when there is excessive irrita- bility or sensitiveness, the parts of the canal leading to them become excited to contraction, to prevent the approach of offending substances. Thus, when the cardiac orifice of the stomach is the seat of cancerous disease, we have, in the earlier stages, great pain in the act of sAvallowing, at first referred commonly to the region of the heart, or to the left hypochondrium, and (which is the case Avith nearly all painful sensa- tion connected with diseases of the stomach) to the space between the scapule. In more advanced stages of the disease, and Avhen there is considerable ulceration or excoriation, there is almost an inability to swallow, so much so that the patient often refers the seat of this obstruction to the throat. AVhen the pylorous is the seat of the dis- ease, there is little or no uneasiness in the act of swalloAving; but * (52) R. Pil. Hydr. gr. iss.—iij. Ext. Conii, gr. xij. Ft. Pil. iij. ; one to be taken three times a-day. CAUSES AND TREATMENT. 321 after some time, usually about half an hour, there is considerable pain, generally described as a feeling of great distension, folloAved by vomitino-. AVhen, on the other hand, the large curvature is the seat of carcinoma, we have, for a long time, scarce any symptoms refera- ble to the stomach, there being commonly no sickness or pain in taking food. From Avhat has been said, it may be inferred that the diagnosis of carcinoma of the stomach is often very obscure. AVhen Ave have great pain in the region of the cardiac orifice, connected with the act of swallowing, and subsiding after the food has apparently entered the stomach, we may, in the absence of any assignable cause, suspect malignant disease of that ostium, which suspicion will be confirmed if there is vomiting of mucus coloured Avith a coffee-ground looking substance* and if added to this there be hardened glands in any part of the body. AVhen again there is pain about half an hour after taking food, followed by sickness and vomiting of coffee-ground matter, with general emaciation, and pains betAveen the scapule, Ave may suspect similar disease of the pylorus; and we ought carefully to examine the epigastric region, where, if the disease exist, Ave shall, sooner or later, detect a tumor occupying the situation of the pylorus; and we shall also often find enlarged and scirrhous glands in the groins or axille. AVhen the disease is in the large curvature of the stomach, there will, from the absence of symptoms, be still greater obscurity, the first sign being often a tumor in that situation, and we shall be driven to form our diagnosis mainly by a method of ex- clusion ; that is to say, from the absence of the symptoms of disease of any other organ in that situation. There is another form of disease of the stomach which has been by many authors included amongst the malignant affections of that organ, namely, the so-called scirrhus of the pylorus; this consists in thicken- ing of the mucous and areolar tissues, Avith hypertrophy of the mus- lar, occasioned probably Avith its being thrown into more continuous action by the irritability of the overlying membranes, and thus in- ducing an induration and thickening, Avhich may be compared to permanent stricture of the urethra. The symptoms of this stricture of the pylorus differ little or nothing from those of malignant disease in the same situation. It differs, however, in this, that it is not gene- rally associated Avith malignant disease in other parts. Obstruction in this situation is often (though not constantly) attended by great enlargement of the stomach, with pain at an interval of from half an hour to two or three hours after taking food. This pain extends between the scapule, and terminates with a copious vomiting of yeasty matter, generally containing vibriones and sarcine. The causes of the true carcinomatous disease of the stomach are no doubt the various irritations Avhich would, in ordinary subjects, produce chronic gastritis; but in those in whom there exists the constitutional liability to those heterologous formations, these causes excite them in this particular part. They are more likely, too, to occur in advanced life; that is to say, when the poAvers of healthy nutrition begin to decline; thus they most frequently occur after 21 322 H .E M A T E M E S I S. the age of fifty in men, and after the cessation of menstruation in females. The stricture of the pylorus, on the other hand, though no doubt more common in elderly persons, is by no means confined to such subjects, but is sometimes met with in persons betAveen twenty and thirty. The general termination of these diseases is from inanition, OAving to the stomach being unable either to receive or to retain nourishment; but in the truly carcinomatous affections, the fatal termination by asthenia is accelerated by the effect of the malignant infection upon the Avhole system. Malignant disease of the stomach sometimes terminates suddenly by perforation and con- sequent extravasation into the peritoneal cavity. ' In those cases of stricture of the pylorus, Avhich are of very questionable malignancy, death is caused solely by inanition. The treatment of these diseases when detected can, at the best, be only palliative; much, however, may be done by obviating all causes of irritation, towards relieving the sufferings of the patient and pro- longing his life to the utmost. In the first place, the food Avhich is taken should be very small in quantity, and of the quality least likely to be either chemically or mechanically irritating; and in the earlier cases, nearly the same dietetic rules must be observed as will be laid down when treating of dyspepsia. In the more advanced cases, much suffering Avill often be avoided, and the patient may obtain tolerable nourishment, by restricting him entirely to a diet of lime-water and milk, with a little stale bread, which should be softened in the liquid. The lime-water may be mixed with the milk, either in equal parts, or in the proportion of two parts of the latter to one of the former, and the mixture may be taken either warm or cold, as may be most grateful to the patient; but it should never be used hot, that is to say warmer than 120° Fahrt The patient should never take more than three ounces at a time, but otherwise there need be little restriction as to quantity beyond his own feelings: nearly a quart of milk is sometimes taken in this way in the course of twenty-four hours. When even this or any other bland nourishment causes much pain or sickness, we must endeavour still further to spare the stomach by helping the nutrition of the body by enemata of animal broths. As regards internal remedies Ave cannot do much. In the less advanced stages bismuth in small doses often relieves the pain and sickness (the solid form either of pill or poAvder is to be preferred); another remedy, which often allays the sickness, is the ext. of nux vomica, made into a pill, with ext. of conium (F. 58).* When the boAvels do not act, which is often the case, we must not run the risk of offending the stomach by aperients taken by the mouth, unless it be the addition of about one-third of a grain of ext. of aloes to each pill, but relieve them by aperient enemata. Haemorrhage from the stomach is not an uncommon occurrence, and may arise from various causes. (1). It may proceed from ulceration, caused either by chronic gas- * (53) rjt- Ext. Nucis vomicae, gr. i. Ext. Conii, gr. xii. Ft. Pil. vj.; one to be taken three times a-day. ITS DIAGNOSIS. 323 tritis or malignant disease. In cases of ulceration the hemorrhage may proceed either from a number of minute vessels exposed by the ulceration, or from a large vessel either of the stomach or some other viscus to which it has become adherent; or from a considerable extent of the internal surface of the organ, which has become to such a degree congested that the capillaries have given way. This con- gestion is generally the effect of mechanical obstruction to the return of the blood through the portal vein arising from the disease in the heart, lungs, or liver. (2). it may arise from similar congestion, though perhaps of a more active character, arising from the suppression of other san- guineous discharges, as hemorrhoids or the catamenia: of the latter it is often vicarious. (3). Hemorrhage from the stomach may also occur from changes in the blood itself by the disintegration of the corpuscles, by 'which the hematosine is dissolved in the serum, and in this condition is susceptible of transudation without any rupture of the Avails of the vessels. It is important to bear in mind the probable causes of gastric hemorrhage as a guide to diagnosis. The diseases, or diseased con- ditions which may be mistaken for it, are hemoptysis or hemorrhage from the lungs, and vomiting of blood which has been swallowed from any other source. Ordinary hemoptysis, Avhen there is con- siderable cough, and the blood florid and not in very large quantities, and mixed as it generally is with the mucous expectoration from the lungs, cannot readily be mistaken for gastric hemorrhage; but when the blood is in very large quantities, it is apt to be SAvallowed, and thus rendered black in the stomach, and afterwards vomited, in which case Ave shall really have hematemesis or vomiting of blood, but not gastric hemorrhage; "and on the other hand, when the hemorrhage from the stomach is abundant, it may produce irritation about the glottis, and some of it passing into the larynx will excite coughing. Hemop- tysis, hoAvever, is generally preceded by dyspnoea and cough, and frequently by pain referred to the sternum; whereas hematemesis is generally ushered in by weight and pain at the epigastrium, and as the hemorrhage into the stomach generally takes place some time before the rejection of the blood by vomiting, we have pallor and a tendency to fainting preceding ejection, which, though they may attend or follow hemoptysis, rarely precede it by any considerable interval. In hematemesis the blood is commonly expelled in a large quantity at once, after which the discharge ceases, for a time at least: whereas, at the close of the most profuse hemoptysis even, blood almost always continues to be coughed up in small quantities for some time. Blood may also be swallowed from the nares or fauces, espe- cially during sleep, and being vomited afterwards, may simulate hematemesis; but a careful examination of the parts will generally detect the source of fallacy. An inquiry into the previous symptoms will also aid us, not only in forming our opinion as to Avhether the hemorrhage is really gas- tric, but also as to its character, if it be such. Thus the history of 324 HEMATEMESIS AND HELENA. previous chronic gastritis, or of the burning sensation in the epigastrium which has been stated to accompany ulceration of the stomach, may suggest the belief that the bleeding is from an ulcer. Of the causes which produce mechanical venous congestion of the mucous mem- brane of the stomach, some, such as disease of the heart, may produce also engorgement of the lungs and hemoptysis; but in such cases the dyspnoea is urgent, and we have the signs of pulmonic apoplex}^ nor do we often have copious hemoptysis from this cause. Obstruction to the portal circulation from cirrhosis of the liver is a very common cause of hematemesis, which, Avhen not very profuse, may be con- sidered as a salutary relief under such circumstances, and we may he guided in our diagnosis by the previous history and present symp- toms of that disease. The hematemesis may ahvays be suspected to be vicarious of menstruation when it occurs in young females, without any other lesion, which may account for it, and may be pretty cer- tainly inferred to be so when Ave have a history of uterine irregularity. The prognosis of hematemesis must depend much upon its probable cause. AVhen we have reason to believe that it proceeds from ulcera- tion, the prognosis is unfavourable, and it is so in the highest degree if that ulceration be malignant. When the hemorrhage is from mechanical venous congestion, the prognosis will depend mainly upon the disease Avhich produces that congestion; and, amongst such diseases, if we believe the case before us to be one of cirrhosis, although there is the highest probability of an ultimate fatal ter- mination, yet with respect to the hematemesis, we may regard it in a great measure as conservative, and give a favourable opinion as to the more immediate consequences. Hematemesis as vicarious of menstruation need occasion no immediate apprehension beyond that of the possibility of it arising from ulceration, or being likely to lead to it. Connected with gastric hemorrhage, and generally a consequence of it, is the passing of the copious, dark, pitchy stools, commonly known by the name of melena, consisting of blood, partly digested, and changed by its passage through the intestines; sometimes, but rarely, the blood which is poured out into the stomach is not vomited, and the whole of it makes its appearance in this form. Melena may also arise from hemorrhage taking place into the small intestines, either from congestion near the stomach, and produced by nearly the same causes as gastric hemorrhage, or into the ileum, as a conse- quence of ulceration of that part of the canal. The treatment of intestinal hemorrhage must be regulated mainly by our own knowledge of its cause. When it is of an alarming and dangerous character from malignant disease, and even from simple ulceration,—and upon the latter point there must always be some uncertainty,—we may have recourse to powerful astringents, of Avhich the gallic acid is perhaps the most to be relied upon (F. 51).* Tur- * (54) R. Acidi Gallici, gr. iv.—v. Or, it may be given in solution, thus— Ext. Gentian, gr. ii.—iv. £. Acid. Gallici. gr. v. Ft. Pil. i. vel. ij. ; to be taken Acid Aceiici dil. 5 ss. every third or fourth hour. Syr. Aurant. 3 ss. Aq. Purse, 3 x M. For a dose. TREATMENT. 325 pentine has also been much recommended; it may be given in doses of from fifteen to tAventy minims every three or four hours, or oftener. In cases of hemorrhage from congestion, the hasty use of astringents is not only useless, but mischievous; we must, in such cases, first endeavour to remove the accumulated blood from the intestines, and at the same time aid the attempt which nature is making to relieve the portal congestion; for this purpose purgatives may be employed; indeed, in cases of hematemesis and melena of this character (and they include a very large proportion, especially amongst the intem- perate), we can do nothing by any other means until the bowels have been well cleared out. For this purpose we may, in the first instance, give a moderate dose of colocyuth and calomel, and aid its operation by a terbinthinate enema; and after these have operated freely, a steady action must be kept upon the bowels by sulphate of magnesia Avith sulphuric acid (F. 55),* to which may be added a little alum; cold drinks should be used, and soft and light nourishment must be employed, and taken cold. ATe must remember, also, in the majority of such cases, that Ave have to deal Avith those who have used stimu- lants largely; therefore, Avhen there is much exhaustion, we must alloAV wine or brandy; port Avine is generally to be preferred. The cases Avhich occur in connection Avith suppressed menstruation will be best treated by aloetic purgatives and iron (F. 56),f or after the boAvels have been relieved, the tinct. ferri. sesquichlor. may be employed in doses of about fifteen minims. The hemorrhage from the stomach arising from disorganisation of the blood corpuscles, commonly occurs in connection with purpura, and must be treated accordingly. As a consequence sometimes of chronic gastritis, but often to all appearance independently of it or of any structural disease of the stomach, we meet Avith the troublesome train of symptoms knoAvn by the term dyspepsia. Now, although digestion is a complicated process, it is in reality not so mysterious a one as used to be supposed before it was elucidated by the labours of organic chemists, amongst Avhom in this country we are especially indebted to Dr. Prout and Dr. Bence Jones. * (55) H- Mag. Sulph. 3 i.—ii. Acid. Sulph. dil. n^ x. Aluminis, gr. v. Syrupi Papav. 3 ss. Infus. Rosae co. 3 xiss. Ft. Haust.; to be taken every four hours. t (56) R. Ferri Sulphat. gr. iv. Extracti Aloes, gr. iv.—vj. Saponis mollis, gr. iv. 01. Alenth. pip. n^ j. Ft. Pil. iv.; of which one is to be taken four times a-day. 326 DYSPEPSIA. XVIII. DYSPEPSIA Dyspepsia is a somewhat vague term, used to express the multi- farious and often distressing symptoms produced by an imperfect performance of the functions of digestion. The symptoms of this affection are so variable and so uncertain in their combinations, that the more prominent ones appear each to require a separate notice. Anorexia, or loss of appetite, may arise from a variety of causes, the nature of which must be as obscure as is that of the appetite itself, which has given rise to so much speculation amongst physio- logists. But whatever may be the immediate cause of hunger, it no doubt arises primarily from a want in the system of those materials which are necessary to repair the Avaste, or rather consumption that attends every operation in the living body. These materials may be divided into two great classes—the nitrogenized substances, for the supply of the consumption of albumen and fibrine resulting from the waste of tissues,—and the non-nitrogenized, which supply the materials for the combustion of carbon by union Avith the oxygen, by which combustion the animal heat is maintained. AArhen the aliments that have been taken into the stomach have been dissolved and distributed throughout the system, there will, before they are entirely consumed, arise the feeling of hunger, if the stomach be empty, and the organs of digestion healthy. We have used the termed " dissolved" advisedly, since, as Dr. Bence Jones has well remarked, there is no such thing as chemical transubstantiation in the process of digestion; that is to say, the nitrogenized or albumi- nous substances cannot be supplied without an injection of such sub- stances ready made in our food: neither can the stomach from carbonic acid and water, which exist everyAvhere around us, so put together the carbon, oxygen, and hydrogen as to form fatty matters, starch, and sugar—the non-nitrogenized alimentary substances. All that the digestive apparatus has to do, in the animal, is to dissolve them, together with the requisite earthy and saline matters, and send them through the lacteals, the lungs, the heart, and the blood-vessels, to the different parts of the system. Now, as the non-nitrogenized substances are intended mainly for the supply of carbon and hydrogen to support the eremakausis by which carbonic acid and Avater are being continually formed and exhaled by the lungs; it must folloAV that when this process is greatly impeded,—as when the pulmonary circulation is obstructed, for instance, by disease of the mitral valve, or old capillary bronchitis, or when there is general venous congestion from feeble circulation— we have loss of appetite. And the same thing occurs in respect to the nitrogenized substances when there is a disturbance of the capil- SYMPTOMS — NAUSEA — FLATULENCE. 327 lary circulation, and consequent suspension of the vital functions, in fevers. Whatever, therefore, materially embarrasses either the pul- monic or systemic circulation, will destroy the appetite. For similar reasons, if the different excretory organs, especially the skin and the kidneys, be disordered, the same result will ensue: or if there be not loss of appetite, there will be delayed solution and absorption, and consequently pain from distension, when the first stage of diges- tion has been completed. In addition to these causes of vitiated appetite, we may also have lesion of innervation. The nervous communication between the brain and the stomach, or, Avhat is more common, the brain itself, may be so disordered in its action that it does not correctly indicate the impression which it should receive from these nerves: and there- fore, there may be loss of inclination for food, arid even aversion to it, from slight cerebral disturbance; and it is an old remark that mental emotion, as grief or anxiety, immediately destroy the appe- tite. On the other hand, irritation at the roots of the nerves com- municating with the stomach, will often excite a craving or a ravenous hunger, and this is not uncommon in chronic disease of the brain. Excessive appetite may also exist when the stomach is able to digest well, and the chyle is taken up by the lacteals, but its pro- gress arrested by disease of the mesenteric glands, pressure upon the thoracic duct or in the course of the lacteals. Nausea and vomiting are very common and very troublesome symptoms in dyspepsia. These may occur at various intervals after the taking of food, and sometimes there is a sudden vomiting or rejection of the food without any previous nausea; in other cases, again, there is continual nausea without vomiting, and this may be almost incessant, even though little or no food be taken. Sometimes there is continual nausea and retching, mucous and afterwards yellow bile being expelled by the inverted action of the stomach and duode- num. This vomiting is generally connected with a morbid irritabil- ity, the cause of which is very obscure: setting aside structural disease of the organ itself, it sometimes arises from hyperemia of the stomach from obstructed circulation through the heart, lungs, or liver. It is also in some instances the effect of a lesion of innerva- tion produced by slight cerebral disturbance; and, in some cases, again, we are unable to assign any antecedent cause for this condi- tion, and are obliged to regard it as primary lesion. Flatulence with eructation, or belching, is another consequence, and a most unpleasant one, of impaired digestion ; in many instances it is produced by the evolution of gases generated by the fermenta- tion of the food in the stomach, which, by being detained there, undergoes much the same changes which a similar mass of organic matters would do if placed in any bag, and kept moist, at the same temperature. Sometimes, however, this gas appears to be secreted by the stomach itself, for some persons suffer from it when that organ is empty, and are particularly liable to be troubled by it Avhen a meal is delayed beyond the accustomed hour. AVhen the eructa- tions are produced by the decomposition of the food in the stomach, 328 DYSPEPSIA. they will often be most offensive, even to the patient himself, some- times suggesting to him the idea of rotten eggs or foul drains, from the amount of hydrosulphuric acid evolved. In this case too the gas often brings Avith it fluid, or a portion of the solid matters in the stomach, as though the patient Avere ruminating. These matters which are thus belched up are often intensely acid, partly so from the acetic acid generated by the fermentation, partly perhaps by the irritated stomach secreting more than a usual amount of hydrochloric acid. Pain, in or about the region of the stomach, is a common though not constant symptom of indigestion. A common form in which it often presents itself is that popularly known as cardialgia, or heart- burn. In other cases, again, there is a more severe and violent pain coming on in paroxysms, which has been termed by nosologists gastrodynia, and, popularly, cramp in the stomach. The heart-burn is a sense of heat in the region of the stomach, generally toAvards the left side, often attended with eructation of acid matter. When it occurs, as it frequently does, soon after meals, it is probably the result of acid, either acetic or lactic, produced by fermentation; but sometimes it occurs when the stomachy is empty, and the uneasy feeling is often relieved by taking food; this, in all probability, depends upon an excessive acrimony of the fluids of the stomach itself. Sometimes, again, there is pain in the stomach immediately after taking food, which continues until it is relieved by vomiting. This in the majority of cases arises from chronic inflammation of the stomach, or undue irritability about the pylorus or duodenum, gene- rally of a subacute inflammatory character. In some instances, hoAV- ever, there is continued increasing uneasiness, until at last vomiting takes place without any apparent irritability, but' rather from a loss of tone of the stomach combined with the arrest of the natural changes of the food, the ingesta consequently remaining nearly un- changed, except by fermentation, until expelled by the combined efforts of the diaphragm and abdominal muscles. These cases are most frequent in females. A very frequent complaint, but one which seems not to have been much noticed by authors, is of pain coming on about tAventy minutes or half-an-hour after a meal; the pain is of a dull aching character, often extending through between the scapule, and accompanied with a very uneasy feeling of distension, and sometimes flatulent eructa- tion. The tongue in this case is generally clean, though it may be indented at the sides by the teeth; the appetite is not generally much impaired, the patient sometimes saying that he could eat if he were not afraid of the subsequent pain. The uneasiness in this case appears to depend upon delay of the food in the stomach, owing perhaps to a want of the proper solvent; and it may be also from a want of nervous power. In other instances the pain does not begin till two or three hours after a meal; but continues for several hours. Dr. Abercrombie was of opinion that the cause of this pain was excessive irritability or P Y E O S I S. 329 subacute inflammation of the duodenum. Dr. Watson, however, holds, and with apparent reason, that the seat of the pain cannot be so near the stomach as the duodenum ; since, in that . case, it Avould commence earlier, and believes it to arise from excessive secretion of acid in the small intestines. Pain again attacks the region of the stomach, in some instances, in violent paroxysms, accompanied Avith great flatulent distension. This form of pain, to Avhich the term gastrodynia has been applied, is most common in hysterical females, often shooting betAveen the shoulders, and sometimes extending over the Avhole abdomen; it' may, hoAvever, occur in all subjects, especially those Avhose boAArels are apt to be constipated. In such cases it is produced in all probability rather in the colon than the stomach. Sometimes again we have spasm of the stomach, as it is termed, perhaps correctly, in persons of a gouty diathesis; this so-called spasm is no doubt in many instances nothing less than incipient gouty inflammation, Avhich, if it be not arrested, may speedily prove fatal. Pyrosis, or ivater-brash, is another troublesome concomitant of dys- pepsia, though it is said sometimes to occur without any derange- ment of the digestive functions. It consists of pain and contraction across the scrobiculus cordis, generally reaching through betAveen the shoulders, and increased by raising the body to a perfectly erect attitude. This pain generally comes on when the stomach is empty, and after it has lasted some time there is an eructation of a thin Avatery fluid, which is often brought up in very great quantities. There is generally much derangement of the digestion in pyrosis, which is perhaps no more than might be expected from the quantity of the fluid diluting the natural gastric juice, and rendering it no longer a fit solvent for the food. The cause of the pain is not so obvious, but it is possible that it may be produced by distension from hyperemia, which is eventually relieved by the exhalation, from the mucous membrane, of this excessive secretion. Sometimes the secretion takes place in great quantity, just as the patient is about to commence a meal. In one instance an elderly gentleman was unable to commence his dinner till he rejected a large quantity of this fluid. Pyrosis may be symptomatic of organic disease of the stomach; it may also be produced by pressure from neighbouring viscera, as in a case mentioned by Dr. Watson, where it was caused by the pressure of an enormous liver; and Abater-brash, with severe dyspeptic symptoms, is one of the forms of disorder to which the curriers, who in their work are exposed to great pressure on the epigastrium, are exceedingly liable. Constipation, or rather costiveness, is at once a frequent con- comitant, and cause of dyspepsia; in some instances, no doubt, the liver may be at fault here, and the diminished flow of bile into the duodenum may be one cause of diminished peristaltic action of the intestines, which may also delay the contents of the canal above, and thereby disturb the action of the stomach. Besides these disorders, directly referable to the digestive organs, there are others which more affect distant parts. There is almost 330 DYSPEPSIA. always, to a greater or less extent, a loss of vigour both of body and mind, the muscles wasting, and becoming flabby from defective power of repair, and the brain losing its Avonted energy, from a Avant of its accustomed supply of healthy blood; but, as is generally the case when the tonicity of the system is impaired, there is an excess of excitability, though the functions of the- nervous matter may not be so steadily and uniformly performed. Accordingly, there is fre- quently irritability of temper, great restlessness, and no steadiness of purpose; or there may be that lamentable condition approaching almost to insanity, commonly known as hypochondriasis, in Avhich the patient is in a state of incessant despondency respecting either his health or his affairs; or it may be about his family, or the safety and prosperity of his country; but whatever be the object of his interest, it is also that of his most unfounded apprehensions—the metus ex causis non ozquis of Cullen. The nerves of sensation are also easily excited, and Ave often meet with pains in the thorax, or across the epigastrium. Headache is also a common symptom, as are also vertigo and confusion of sight. The tongue is generally coated, the bowels irregular, and flatulence is commonly a troublesome symptom. The pulse is often irregular, and frequently there is palpitation. These symptoms, together with the pain in the left side of the chest, excite great apprehension of disease of the heart. As dyspepsia consists essentially of defective performance of the, functions of the stomach and parts immediately connected with it, it may be induced by structural diseases of these parts, and therefore the diagnosis between such diseases and simple dyspepsia must de- pend upon the presence or absence of the signs of the structural changes alluded to. Besides this, it closely resembles subacute gas- tritis in many of its symptoms; but from this it may be distinguished by the pain, when it occurs, not coming on immediately upon taking food, but after an interval of twenty minutes or more. The causes of dyspepsia are very various. A common one is anxiety, or, great mental occupation, with little exercise and seden- tary habits, especially if the latter be attended by confinement in close rooms or offices. Indulging too freely at table,—eating too quickly,—and resuming active occupation of body or mind too soon after a full meal, allowing too short as well as too long an interval to elapse between meals—an imperfect performance of the functions of the skin, for the connection between the mucous membranes and the skin, of which the latter is but a continuation, is so close, that the former cannot reasonably be expected to continue in healthy action unless the latter be so likeAvise—an injudicious selection of articles of diet, both as regards their chemical and physical properties. In the treatment of dyspepsia the first object must be to obviate, if possible, the circumstances or conditions which have induced the disturbance of the functions of digestion; and secondarily to palliate or counteract the ill effects and inconveniences arising from this dis- turbance. Now, the first principle in the management of disease of all kinds is to give as much rest as possible to any irritable, inflamed, or feeble » DIET. 331 organ; and this applies to the stomach as much, at least, as to any other. The first rule then must be to insure the stomach not having too much food put into it at a meal. Dr. Abercrombie well remarked that we are apt to err quite as much in the quantity as in the quality of our food, or even more. Another important rule is to give time for the stomach to rest after digesting a meal. As a general rule, from four to six hours should intervene between one meal and another. When a person in good health has taken a hearty though moderate meal, including animal food, he can well go on for six hours or more, and even though actively engaged, he will hardly be ready for another within that time. AVhen, indeed, the food has been of a light simple kind, bread, or bread and milk, or bread and butter Avith tea, or coffee, the stomach Avill have sooner emptied itself, and be sooner ready for the reception of more food; and, therefore, Mr. Abernethy's rule of six hours, which allowed from four to five for digestion, and one for rest of the stomach, was a very fair one for the interval after a full meal: but Avith feeble persons, and after a meal of soluble food, the stomach Avould be empty, and after a time exhaustion will succeed much within this period. For persons who take very light and very soluble food, four hours is perhaps a suf- ficient interval. Nothing, however, can be more obviously absurd, than putting one meal into the stomach before the former one can have been converted into chyme, and have passed the pylorus, and thereby requiring the stomach to supply gastric juice for substances in different stages of solution. For similar reasons a variety in the articles of food must be bad, and also, because the use of several dishes affords a series of fresh stimuli to the appetite and induces the taking too much. Persons Avho are politely said "to be fond of the pleasures of the table," are almost ahvays dyspeptic. It is next to impossible to lay down particular directions for the diet of persons in health; still more so for those who are the subjects of dyspepsia, since some persons are made exceedingly ill by articles of food which are for the generality of people wholesome, and others can best use those which are to most persons the reverse. Thus one lady could never, without undergoing the greatest inconvenience, eat any of the rhomboideal fishes, and another of apparently very irrita- ble stomach could live comfortably upon salmon. When the dyspepsia is dependent upon chronic inflammation of the stomach, there can be no doubt that butcher's meat should be abstained from, and that the diet should consist of a little white meat, as chicken or white-fleshed fish, and farinaceous food; and where the irritability is great, of the latter entirely, with the addition of milk, which, hoAvever, does not suit all stomachs. Of butcher's meat, mutton is the most readily digested, and fur- nishes perhaps the greatest amount of nourishment in the least bulk. Bread again, it should be remembered, is the true pabulum vital, as it contains all the materials, both non-nitrogenised and nitrogenised, required for nutrition; but in an undissolved state, and therefore requiring the trituration of mastication and the addition of some 332 DYSPEPSIA. solvent in the way of drink, so that bread is the normal solid nourish- ment. Milk, on the other hand, contains the same materials ready dissolved, so that it is the normal liquid nourishment, and is that provided by nature for infants, who take no additional liquid for a solvent. Bread, therefore, is the substance-which of all others is best suited for Aveak digestive powers; but if it remain too long in the stomach it is prone to fermentation, whereby acids are generated and gases evolved. Animal food, Avhich should consist of welf- roasted or boiled flesh, fowl, or fish, is perhaps as readily chymified as any; but there certainly appears to be required a certain amount of activity in the powers of life, and free action of the excretory organs, especially the skin, that meat may be well digested,_ and which is only compatible Avith a considerable amount of exercise in the open air; as otherwise the tongue becomes loaded, the breath offensive, the urine foul from urates, and if there be not headache or sickness, the appetite fails and offensive eructations take place; the mixed diet is, therefore, most suitable for the generality even of dyspeptic persons, provided there are not many ingredients in the mixture. Vegetables again, such as potatoes and green vegetables, are liable to acetic fermentation in the stomach, and thereby cause acidity and flatulence, when not taken in very great moderation by dyspeptic persons; but when omitted altogether, a state kindred to purpura is induced, in which the stomach eventually suffers with other organs from the diseased state of the blood. It appears, then, that though a person could live better upon bread than upon any one single article of 'food, that a mixed diet is, in the general, to be preferred, provided that the mixture be not too complex. In all articles of diet the physical condition should be considered, and therefore those which are soft and in a state ready for solution are the most eligible for Aveak stomachs; those, on the other hand, which are rendered hard by artificial processes, as preserved and pickled meats, ham, &c, are to be shunned. Meat is as well, or better, roasted than dressed in any other way, as boiling produces a hardness on the outside which may be irritating to dyspeptic stomachs, particularly when the affection is dependent upon subacute gastritis. As regards liquids, it is probable that most dyspeptic persons take too much of fermented drinks, and the majority of such should abstain as much as possible; though there are cases in which a moderate use of wine, beer, or spirits, acts as a wholesome stimulus to the feeble stomach. As Dr. AVatson well remarks, it is impossible to lay down any specific rules upon this subject, but that liquid should be selected which causes the least heat and irritation. AVhere there is a tongue with red edges, most alcoholic drinks will have this effect, and then it is better to abstain altogether. Next to the excessive use of ardent spirits, there are few things in regard to which people make so free with their stomachs as in the matter of tea and coffee; that they are most grateful nervine stimu- lants cannot be doubted, and also that they are of great service by obviating the use of more pernicious beverages, but the large quan- TREATMENT. 333 tities vrhich some persons take must, by diluting the fluids of the stomach, impede the process of digestion, and certainly those who are liable to painful distension of the stomach after meals, have this, much aggravated by tea in any considerable quantity. The proper quantity of fluid to be taken can hardly be defined by any certain rule; but for most persons about three pints in the day are neces- sary, and more than that is injurious. As regards liquid, or dissolved nourishment, it is not best suited for most dyspeptic subjects: but on this point we must be guided mainly by experience in each indi- vidual case; and some very irritable stomachs are offended by any solid food. AVhen this is the case, lime-Avater and milk in propor- tions varying from equal parts of each to two of the latter to one of the former, will often be found soothing, and at the same time nutritious. In the selection of medicines as well as of diatetic remedies we must be guided, in great measure, by the symptoms Avhich are most prominent among those which we have already described. In the sickness of dyspepsia Ave find a great uncertainty in the effect of remedies. In many cases, carbonic acid, either in the form of effervescing draughts or soda-water, have a very marked effect; in others, the mineral acids, especially the sulphuric, in infusion of green mint. But in a still greater number of cases, the alkalies, as liquor potasse, or carbonate of soda, are more effectual, and the combina- tion of the latter, in a draught, Avith three or four minims of the dilute hydrocyanic acid of the pharmacopoeia. Creosote is a doubtful remedy, and is nauseous to swalloAV, and still more nauseous to vomit up again. A very efficacious remedy is strychnia (F. 57),* in closes of from a 32nd to a 24th part of a grain. Bismuth is often service- able in allaying sickness: to this remedy, however, Ave shall again revert. AVhat is, hoAvever, of most importance, is a careful restriction of the quantity put into the stomach, and more particularly the avoid- ance of taking food too frequently. AATiere the irritability is great, a good plan is to limit the patient to a large coffee-cup of milk and lime-water about every three hours; and when the irritability diminishes, to allow a small quantity of meat (roast mutton, or a chop,) in the middle of the day. The boAvels should also be kept open by the aloetic pill. Dr. AVatson relates a case of chronic vomiting successfully treated in this manner; and a similar case in Guy's Hospital was as speedily relieved by a careful, though not so strict regulation of the diet, and the use of the aloetic pill thrice a-day, with the addition of a quarter of a grain of extract of nux vomica. The loss of appetite, Avhen the tongue is foul, Avill first re- quire the clearance of the intestinal canal by a dose or two of rhubarb and blue pill, followed, if necessary, by a gentle aperient draught. If, hoAvever, the bowels are irritable, a combination of rhubarb Avith * (57) R- Strychnise, gr. \—£• Acid. Acet. dil. 3 ij. Aq. distillat ^ iv. Misce. Dose, a large spoonful every four hours. 334 DYSPEPSIA. an opiate is preferable (F. 58);* after this, the diet should for a time be of the simplest and least irritating kind, and it is a great mistake to solicit it by highly-seasoned dishes; on the contrary, we may more frequently starve persons to an appetite by a very sparing diet. AVhere there is simply defect of .appetite, the bitter tonics, with the addition of the mineral acids; or, Avhen the bowels areVather torpid, one of these bitters with compound decoction of aloes, may be administered, and, what is far better Avhen attainable, a good A-valk or ride in the open country, and occasional relaxation of mind, with change of air and scene. Flatulence, again, is another symptom requiring careful diet, as it is often the consequence of errors in this respect, either as regards quantity or quality. When the flatulence is attended by the "rotten- egg" eructation, there is probably undigested animal matter in the stomach or duodenum, and whilst this occurs the diet should consist of light farinaceous substances. Flatulent eructations and disten- sions will, however, sometimes occur spontaneously, or when, in weak stomachs, the interval betAveen meals has been unusually long. When this is the case, a careful regulation of the times of taking food is necessary. This flatulence is often speedily removed by some aroma- tic Avater, as peppermint or dill, or a few grains of calcined magnesia, with about half a drachm of tincture of cardomums in water: that which follows meals will generally be best obviated by SAvallowing, about half an hour before each meal, a pill composed of two grains of extract of rhubarb, with four of nitrate of bismuth. The pain in the stomach which precedes meals, and is sometimes relieved by taking food, is often removed by a small quantity of cal- cined magnesia; but that which immediately follows taking food is less tractable, as it commonly depends either upon subacute inflamma- tion of the mucous membrane or organic disease of the stomach, and must be combated by the means best adapted for those affections. Small doses of the nitrate of bismuth, either in pill or in combination Avith hydrocyanic acid, will, however, often palliate it, as will also the nitrate or oxide of silver, in doses of about one-third of a grain. The pain, again, which follows taking food after a short interval, and is often unattended by any other manifest gastric derangement, the tongue being generally clean, is best relieved by the nitrate of bismuth, taken about half an hour before meal times. It may be taken either in the form of pill with the extract of rhubarb, or sus- pended with mucilage in a draught, and a few minims of dilute hydrocyanic acid may be added. The pain, again, which follows taking food at a longer interval, will often be prevented, when it does not depend upon any organic cause, by taking a small quantity of an alkali immediately after a meal (as recommended by Dr. Watson), and of these a fixed alkali, in the form of liquor potasse, or liq. calcis, is the most effective, perhaps, from its not causing the evolution of * (58) R. Pulv. Rhei, gr. xv. Pulv. Cretae co. cum Opio, gr. x. Aq. Menth. pip. 3 x. Misce. For a dose. 3 TREATMENT. 335 any gases, and sometimes fixing any acid ones that may have been generated. The mineral tonics, as sulphate of iron and zinc, are also not unfrequently useful; and here too, as in several other painful affec- tions in the abdomen, the bismuth Avill be found eminently useful. The paroxysms of pain which have been described under the term gastrodynia, are sometimes greatly relieved, or even prevented, by the action of a brisk purgative; it is, no doubt, most effectual in those cases in Avhich there is distention in the arch of the colon, and in all affections of this description we should make sure of the free evacua- tion of the bowels. In many cases, however, these pains appear to be purely neuralgic, and are very common in hysterical females. They are then often relieved by mustard poultices applied to the pit of the stomach, by the combination of ether and opium, provided the bowels have been satisfactorily emptied, and by prussic acid. Water brash is often a very troublesome complaint, and, in some constitutions the secretion of an enormous quantity of fluid has become such a habit of the mucous membrane of the stomach, that it is next to impossible to arrest it. Astringents combined with opium will, however, often check it, and amongst these, the pulv. kino comp. of the Pharmacopoeia is extolled by Dr. Watson. The mineral astringents, as bismuth, nitate or oxide of silver, and oxide of zinc, are also very serviceable, and still more so when combined with extract of nux vomica, or very minute doses of strychnia (F. 59).* The opium will often have the effect at first of increasing the tendency to constipation which ordinarily exists, though, after a time, this effect of the drug will often cease. When, however, there is occa- sion for an aperient, the compound rhubarb pill may be employed, or equal parts of compound colocynth pill and soap. The same reme- dies will be found effective when costiveness is the prominent symp- tom of dyspepsia; or a mild dinner-pill may be employed. * (59) R. Ext. Nucis Vomicae, gr. jss. Argenti Nitrat. gr. ij. Ext. Lupuli, gr. xii. Ft. Pil. vj.; one to be taken three times a-day. Or R. Bismuth Nitrat. 5 ss. Strychniae, gr. \. Ext. Papaveris, gr. xii. Ft. Pil. vj.; one to be taken three times a-day. 336 PERITONITIS. ,XIX. PEEITONITIS. Like all other serous membranes, the peritoneum is liable to inflam- mation. This inflammation may be acute or chronic; it may also be idiopathic or secondary, common, specific, or tuberculous. Acute, primary, or idiopathic peritonitis is by no means so common a disease as it Avas formerly, or perhaps still is ordinarily believed to be; yet, as this may be regarded as the primary or typical form, a description of it is necessary Avith a vieAV to the right understanding of the dis- ease under the different conditions in AA'hich we more commonly meet with it. Peritonitis, then, as its name imports, consists in inflammation of the serous membrane lining the parietes and investing the viscera of the abdomen. In its acute and simple form it presents the ordinary phases of inflammation of such a structure. At first, the membrane is dryer than in health, and the minute vessels more injected; next there is effusion of liquor sanguinis, of the fibrinous or molecular form, according to the vital powers of the patient. When this lymph is of the fibrinous character, it is generally speedily deposited upon the surface of the peritoneum in thin layers or flakes, the serum becoming quickly reabsorbed; these layers of lymph generally increase by fresh depositions as long as the inflammation continues, attaining every variety of extent and thickness, and forming adhe- sions between the contiguous portions of the membrane; so as to connect the different viscera, or portions of viscera, with one another and with the Avails of the abdomen. The next stage of inflammatory effusion then takes place, and the lymph becomes organised, and the adhesions cellular and permanent; the lymph in the process of organi- sation evincing the same tendency to contraction as in other situa- tions. AAThen, hoAvever, the disease occurs in subjects of less plastic power, or in Avhom there is a deficiency in the solid contents of the blood, the serous effusion greatly predominates; and, whilst the layers of fibrine may be deposited upon the surface of the membrane, the cavity itself becomes distended by serum, constituting one form of ascites. In some cases, again, of still feebler poAver, and where the lymph has been in the first instance entirely molecular, it may degene- rate into pus. Such is a brief sketch of the anatomical changes pro- duced by acute inflammation of the peritoneum in its more active form; these changes, however, may assume every variety of extent and situation. Sometimes the omentum is the part of the membrane chiefly affected, and it becomes adherent either to the Avails of the abdomen or the intestines; in some cases, by its subsequent contrac- tion, dniAving them together and partially strangulating them. Some- times the intestines become adherent amongst themselves or to the other viscera of the abdomen, as the stomach, liver, spleen, bladder, ACUTE PERITONITIS — SYMPTOMS. 337 ovaries, or uterus; and it need hardly be remarked that the functions of these organs may thereby be seriously impeded. As we have before observed that peritonitis is more commonly a secondary than a primary affection, it appears that, in the majority of cases, this dis- ease is to be regarded as a most important intermediate link in a series of morbid action, being a very grave consequence of antece- dent diseases, (those of the blood, amongst others,) and the antecedent or cause of others of no less importance. The invasion of acute peritonitis is, for the most part, sudden, from whatever cause it arises; though, under some circumstances, it is almost instantaneous. It is characterised chiefly by severe pain and tenderness of the abdomen. The pain being scarcely a more promi- nent feature than the tenderness; so great, indeed, is the latter, that the pressure of the bed-clothes is hardly endured. The legs are drawn up to remove the pressure arising from the tension of the abdominal muscles; the breathing is extremely hurried, and is also thoracic, as the descent of the diaphragm, by disturbing the abdomi- nal viscera, and causing a slight motion of one surface of the perito- neum upon the other, would aggravate the pain; and the suffering caused by coughing amounts at times to perfect agony. The pain, too, is often increased or induced by assuming the erect posture, or by turning from side to side. It is truly observed by Dr. Watson, that though in true peritonitis there is generally occasional remission of pain, the tenderness is constant. It would appear from this that the tenderness is the essential symptom, and that the pain is the effect of circumstances which excite this tenderness; thus, as the intestines are at times nearly qui- escent; Ave have an explanation of the absence of pain; but as they are liable to be disturbed, and to have their peristaltic action excited by the passage of aliment, of flatus, or even of their own secretion, or of that of the organs Avhose ducts pass into them, we can account for the frequent, and apparently spontaneous accessions of pain. The varying states of distension of the urinary bladder must also produce exacerbations in the pubic region. The pain which attends all the movements of the abdominal viscera may be regarded as the lesa partis functio, which is almost a pathog- nomonic sign of the disease, since the essential function of the peri- toneum may be said to be the providing a smooth, well-lubricated surface, to insure the painless movement upon each other of the con- tents of the abdominal cavity, and which is frustrated by the effects of the inflammation. Again, in an inflammation of the membrane, which constitutes one of the coats of the greatest portion of the intes- tinal tube, we naturally look to the state of the bowels; and here we find uncertain and opposite statements amongst different authors;— thus, Dr. Alison says that the boAvels are obstinately costive; Dr. Abercrombie, that they are not generally affected either by constipa- tion or the contrary; and Dr. Addison, that they are generally cos- tive. The statement of the last-named physician will, in the main, prove to be the correct one. Inflammation of the peritoneum does not per se affect the functions of the alimentary canal; if, however, 22 338 PERITONITIS — PULSE — URINE. the peritoneal coat of the intestine becomes implicated, there is no fresh excitement to action as in the case of inflammation of the mucous membrane, nor any diminution in the power of acting, as in the case of inflammation of the muscular coat; but there will be diminished action in order to alloAV of the natural reparative process; and, therefore, the bowels are generally costive, but not necessarily in the early stage of the acute disease obstinately constipated. AVhen, hoAvever, the inflammation in this situation has lasted some time, then, as Ave have frequently occasion to remark, the muscular tissue underlying the inflamed membrane loses its contractility, and constipation ensues. The same must necessarily become the case when the muscular coat itself is involved. Sickness, Avhich is not an uncommon symptom, is generally ascribed to inflammation of that part of the membrane which covers the stomach; but it may occur when the inflammation is in other parts of the peritoneum, owing most probably either to nervous irritation, or to the inflammation involving the small intestines, and thereby causing obstruction in that part of the alimentary canal. The pulse, another important sign in all inflammatory diseases, presents great differences in peritonitis : thus, Dr. Addison describes it as " frequent, sometimes contracted, but nevertheless hard and resisting to the finger;" and this is about the most accurate general description that can be given of it; but it varies very much under the different circumstances of the disease, and in accordance with the principles laid doAvn in speaking of the pulse generally (p. 74 et seq.) Thus in the onset of peritonitis it is hard, and generally full; there being intense inflammation, increasing at the same time the tonicity of the artery, and the force of the ventricular contraction; but cir- cumstances may arise to obviate the latter condition; thus there may be exhaustion and shock to the system produced by the agent which excited the inflammation, by the nearness of the part affected to the expansion of the solar plexus, or even by its rapid develop- ment—and, consequently, the hardness only remaining, whilst the injecting force of the heart is feeble, the pulse may become small and hard, that is to say, wiry and even thready. The fulness and hardness of the pulse both belong only to the active stage and fibri- nous form, which are typical of inflammation of a serous membrane; but when the effusion is molecular, and, still more, when it has degenerated into puriform fluid, the pulse likewise loses in some measure its characteristic peculiarities, and becomes softer, approach- ing more nearly to the pulse of mucous inflammation ; and in extreme cases of suppurative inflammation of the peritoneum it is rapid, very small, and compressible. The state of the urine is also important in all cases of peritonitis. When the inflammation is at its commencement, and of an active character, the urine is commonly scanty and high-coloured. Dr. Abercrombie states that when the peritoneal covering of the kidneys is involved, there is almost total suppression; though there is some doubt as to whether this may not arise from the suppression, and peritonitis having a common cause, rather than from the suppression CAUSES. 339 being the effect of the inflammation. The character of the urine is important also,—as should it be albuminous, it would indicate that the peritonitis is probably the effect of renal disease; and should it contain a large quantity of lithates, it Avould indicate the likelihood of acute inflammatory action, with probably some hepatic complica- tion ; and should it be in large quantities, and of light specific gra- vity, it should suggest the existence of some form of hysteria simulating peritonitis. A knoAAdedge of the causes of peritonitis is essential to the diagno- sis and treatment of the disease in its various forms. It may occur as a primary affection from exposure to cold or excessive fatigue ; but this is its most uncommon form, so much so, that when Ave meet Avith Avhat appears to be a case of this kind, Ave must inquire most carefully into the probability of some other cause. It may also occur in its most violent and rapidly fatal, or sometimes in a circum- scribed and more insidious form, from perforation of some portion of the alimentary canal; this generally happens after there has been some evidence of disease likely to produce such perforation either in the stomach, the small, or the large intestines, though sometimes a chronic ulcer may suddenly open into the peritoneum Avithout any previous symptoms whatever. When perforation of the stomach takes place, it may arise from organic disease often of a malignant character, as Avas the case Avith Napoleon Buonaparte : or it may occur after protracted symptoms of dyspepsia: or it may take place Avithout any previous symptoms whatever; this is most common in young females, but it has been knoAvn to happen in both sexes, and in more advanced life. The peritonitis from this form of perforation is generally fatal in from twenty-four to forty-eight hours, as, from the suddenness Avith which it occurs, there is no time for the formation of adhesions to circum- scribe the extravasated contents of the stomach. AVhen the perfora- tion supervenes upon protracted disease with dyspeptic symptoms, the consequent extravasation is commonly circumscribed, and thus the fatal consequences may be delayed : in one instance of an elderly man, Avho had been long suffering from apparently intractable dys- pepsia, Avith great pain and distension immediately after taking food, several perforating ulcers were found in the stomach after death; but most of these opened into the portions of intestine betAveen which and the stomach adhesion had been established before the perforation occurred. Thus one communicated in this Avay with the duodenum, and two with the transverse colon; whilst one opened freely into a large sac or pouch, formed by thick fibrinous lymph effused upon the surfaces of the adjacent viscera. In another case, which occurred some years ago in Guy's Hospital, there Avere the pain and tenderness of circumscribed peritonitis in the left hypochon- drium, in an elderly female, who had before been in the hospital for what appeared to be chronic gastritis; but what Avas remarkable, symptoms of pleuritis speedily followed, and shortly after those of considerable pleuritic effusion, combined with which there were metallic tinkling and amphoric cough and voice, so distinctly marked 310 PERITONITIS. as to lead those who were unacquainted with the previous history of the case to believe that a pneumo-thorax existed. Inspection after death showed a large perforating ulcer of the stomach at the curvature through which the contents passed freely into a large pouch of false membrane, spread out upon the neighbouring viscera, the roof of which was formed by the diaphragm, through which the inflammation had extended by contiguity to the left pleura, giving rise to serous effusion in that cavity; the pouch before mentioned, being distended by flatus from the stomach, produced the amphoric * sounds by the succussion caused by the movements of the diaphragm in breathing, coughing, or speaking ; affording a curious instance of the auscultatory phenomena, which may be produced in the abdo- men. Peritonitis may also arise from perforating ulcers in the duode- num, jejunum, or ileum : those in the duodenum perhaps associated with a tendency to similar diseases in the stomach; thus in the first of the two cases just referred to there Avas communication by ulcera- tion between the portions of the duodenum which are adjacent to each other. Perforating ulcers are very rare in the jejunum, and when they do occur, are probably of a scrofulous character. They are more common in the ileum, in which, especially towards the loAver part, they are very apt to occur in fever, more particularly in that form which is characterised by a tendency to bowel irritation, and to which some have wished to restrict the term typhoid fever. These perforations are produced by the ulceration of the aggregate or solitary glands, so common in that disease, and Avhen they do take place, generally occur about the fourteenth day of the fever. The peritonitis, which is set up by the extravasation from perforating ulcers in fever, is almost ahvays fatal in about twenty-four hours; since, owing to the want of plastic poAver in such subjects, there is little chance of its being circumscribed by adhesions. Strumous ulceration may occur in any portion of the intestine, and give rise to extravasation, and the same thing may occur in phthisis and dysen- tery. The contents of the urinary bladder may also escape into the peritoneum, either from chronic disease of that organ, or from the effects of stricture, though the latter is rare ; and perforation of the full bladder by ulceration has also been knoAvn to take place, the contents of which may thus escape into the abdominal cavity, and give rise to peritonitis. There can be no doubt, also, that inflammation of the peritoneum, to a greater or less extent, may arise from that of the other lining of the intestines, independently of that form which has been described as being produced by ulceration and perforation. Thus acute inflam- mation of the mucous membrane may by mere continuity involve also the muscular and serous coats, and this is the more likely to happen when the former is excited by violent purgatives, such as some forms of quack medicines; thus more than one case has been Avitnessed arising from the use of Morison's pills. Peritonitis is more common in females than in males ; and proba- bly the chief reason of this being so is the frequency of peritonitis CAUSES. 341 arising from affections of the uterus and its appendages. It is very likely to arise after delivery, from imprudent exposure; and per- haps partial peritonitis, giving rise to adhesion between the uterus and adjacent viscera, is a very common consequence of parturition, and is evidenced by subsequent pains and impeded action of the bowels or bladder. There is also the more fatal disease, commonly known as puerperal peritonitis, which, however, is a specific disease, requiring a distinct notice. Disease or irritation of the ovaries is a cause of severe peritonitis more commonly than is generally known, or at least recognised by medical authors. In one instance a young married lady Avho had menstruated regularly, imprudently sat upon the grass at a pic-nic party about the time that catamenia might be expected to appear. A feAV days afterwards she Avas attacked with rigors, followed by severe pain in the left iliac fossa, where there was great tenderness; the pain gradually extended upwards, and to the right over the whole of the abdomen. To these symptoms succeeded sickness, obstinate constipation, a small, hard pulse, with paroxysms of intense suffering; in short, the patient was in a state resembling that of per- sons suffering from a foreign body in the appendix ceci, with the exception of the chief pain being referred to the left instead of the right side. Upon inspection after death there was found to be ex- tensive peritonitis, which appeared to have commenced from the serous coat of the left ovary, the ovary itself being large, generally hyperemic, and in one part containing a cyst about the size of a pea; but which was believed not to be an ovarian fcetation, of which a suspicion was entertained before death. Another instance, which was not fatal, was that of a young woman, a patient in the clinical ward at Guy's Hospital, in whom the symptoms very closely re- sembled those of a foreign body in the appendix; this occurred at the menstrual period, the catamenia being delayed. The disease yielded to the treatment most adapted to peritoneal inflammation in that situation; and after the action of the bowels had been restored, the catamenia appeared. If it be true, and instances might be mul- tiplied to prove that it probably is true, that peritoneal inflammation is a possible and not very improbable consequence of ovarian irrita- tion, the fact is important, not only in a pathological, but also in a practical and prophylactic point of view. Peritonitis may also arise from blood disease, and this is one of its most frequent causes. Thus rheumatic or gouty inflammation of the peritoneum is a possible though not very probable occurrence. It may also arise from the presence of bile in the blood ; but amongst all its causes there is perhaps none more frequent than uremia or retention of the urea in the blood, owing to disease of the kidneys. It may also arise from the presence in the system of various morbid poisons, as of the exanthemata; and there can be little doubt that the scarlatinous poison may affect the peritoneum, independently of the kidney disease, which is one of its common effects; the same remark applies still more to erysipelas. There is, however, one special form of peritonitis, belonging no doubt to the class of blood 342 PERITONITIS. diseases, which is of special importance from its fatality, and from its sometimes prevailing, to all appearance, as an epidemic: this is the disease commonly knoAvn as puerperal peritonitis. The inflammation begins in the peritoneal coat of the uterus, and extends thence over a large portion of the membrane; it generally commences a few days after parturition, but appears to be distinct from the simple or non- specific peritonitis, which not very unfrequently folloAvs that event, there being greater prostration; in fact, its symptoms from the first are of a typhoid character. It has just been stated that the disease is frequently epidemic, and Avhat is of more importance to be remem- bered, it is highly contagious; so much so, that it may be conveyed through the medium of a third person; and it is no uncommon thing for a medical man who has attended a patient so affected to com- municate it to the next woman Avhom he may deliver. The^know- ledge of this fact, and it is one almost universally admitted, renders it incumbent upon every medical man who has attended any one instance of it (as Dr. Watson pertinently insists), " to use the most diligent attention; he should even Avash his hands Avith some disin- fecting fluid—a weak solution of chlorine, for instance; he should avoid going in the same dress to any other of his midwifery patients; in short, he should take all those precautions, which, when the danger is understood, common sense will suggest, against his clothes or his body becoming a vehicle of contagion and death between one patient and another." We might even go further than this, and affirm that it is the duty of a medical man, who has attended cases of this disease, and finds that it is spreading, to relinquish, for a time, his midAvifery practice altogether. Another point of scarcely less practical import, is the known relation betAveen the poison of this disease and that of erysipelas; this is so firmly believed by many eminent obstetricians, that they take every possible pains to avoid being brought in contact with persons affected with the latter disease, lest they should infect their midwifery patients with the former. The same may be said, though perhaps not Avith equal certainty, of scarlatina. When peritonitis terminates fatally, it generally does so by death from syncope, or failure of the heart's action; the pulse becomes smaller and smaller, though generally to the last rather wiry (p. 74). This sinking is almost always preceded by a cessation of the pain, which has been by many authors referred to gangrene, which, how- ever, rarely occurs, though when it does, there is the same subsidence of pain. The diagnosis of peritonitis consists pretty much in a method of exclusion, namely, in the presence of acute pain recurring generally in paroxysms with great tenderness, and thoracic respiration, without the evidence of inflammation of any other tissue. Unless these symptoms present themselves in an hysterical female, in whom the neuralgic pains, Avhich closely simulate peritonitis, can only be dis- tinguished from that disease by a careful investigation of the pre- vious history and constitution of the patient—by the pulse wanting CAUSES. 343 hardness—and by pressure being sometimes well borne when the attention of the patient is diverted, as by engaging her in conversa- tion at the time of making the examination of the abdomen, we may infer that the disease is peritonitis. The peripheral pain and tender- ness excited by inflammation of the spinal chord will also closely simulate the symptoms of peritonitis, though upon careful examination they may generally be distinguished. AVhen the inflammation has extended to the muscular coat of the intestines, or that affecting the peritoneal coat of these organs is of sufficient intensity to arrest their peristaltic action, the symptoms Avill closely simulate those of strangu- lated hernia; and a careful investigation should be instituted into the probability of such a cause for them. Where there is much sickness there will be scanty urine, and a question might arise be- tween peritonitis and inflammation of the kidney; the state of the urine, the character of the pulse, and the sickness being, in the case of the kidneys, a more prominent symptom than the pain, or at all events than the tenderness, Avill greatly assist in the diagnosis. The prognosis of peritonitis, when we have ascertained its existence, is at all times doubtful, as it is essentially a dangerous disease, the vital powers often failing suddenly, and with but little previous warning. It is not, however, necessarily a fatal disease, as the inflam- mation may subside or yield to appropriate treatment at any period of its course, and eAren Avhen it has proceeded so far as to establish adhesions,- these are not necessarily dangerous, unless they cause obstruction to the passage of the contents of the hollow viscera. As the fatal termination of peritonitis is commonly by failure of the moving powers of the circulation, the prognosis must depend, in great measure, upon the vital powers of the patient; though these we cannot often accurately estimate: it must also be much influenced by what we can ascertain of the cause of this disease. When we can discover no assignable previous lesion as the cause of the inflamma- tion, we must regard the peritonitis as, per se, though a \rery dangerous, yet by no means necessarily fatal disease. The degree of danger will depend upon the probable extent of surface involved, also upon the part which appears to be most affected: thus, inflammation of the peritoneum near the diaphragm is more likely to be attended Avith that rapid sinking which is one of the chief dangers in this disease. Increasing quickness Avith diminished volume of the pulse is always a dangerous symptom; whilst an increasing volume, some approach to softness and elasticity, especially if the pulse, at the same time, become less frequent, is an almost certain sign of the subsidence of the inflammation. Sickness and diminished urine are unfavourable symptoms; and a moderate flow of urine, with gentle warm perspira- tion, favourable ; but a cold clammy sweat is fatal. AVhen we have reason to believe that the peritonitis is set up by perforation of any hollow viscus and extravasation of its contents, thai prognosis is, in the highest degree, unfavourable; yet even here, when the patient has survived more than forty-eight hours, we may reasonably hope that the extravasation is being circumscribed by adhesions. 344 PERITONITIS. Peritonitis arising from uterine or ovarian irritation or inflamma- tion, (provided it be not of a specific character, as in puerperal peri- tonitis,) is generally amenable to judicious treatment, though it may be fatal, as in the case already related. The peritonitis of blood diseases is dangerous pretty much in the proportion of those diseases themselves; that of gout and rheumatism being rare, though not without great danger when it does occur: that arising from uremia, as in Bright's disease, is not often the cause of death; indeed it is rare to find the peritoneum alone implicated, and this inflammation, when it does occur, which happens in a very great number of cases, though of an acute is not often of a very active character, the effusion being mainly serous; it is rather to be regarded as a consequence of a very dangerous disease, and also as adding, in no inconsiderable degree, to the danger, rather than as, upon its own account, very formidable. Of the scarlatinous peritonitis not much is at present known, but as far as we do know, there is reason to believe it to be highly dan- gerous, often speedily fatal, if not at all times necessarily so; and the same may perhaps be said of the erysipelatous peritonitis. The treatment of acute peritonitis, like the diagnosis and prognosis, must be guided by our estimate of the powers of the patient and our knowledge of its cause. When we can detect no primary lesion, or, in other words, when we believe the cause to be one of simple primary peritonitis, the first object of our treatment must be to reduce the inflammatory action, the second to keep at rest as much as possible the inflamed part, and the third to induce a moderate mercurial action. AVhere there is no such depression of the pulse as to lead to the apprehension of immediate sinking, blood may be drawn from the arm; and if the operation be followed by any increase in the volume of the pulse it may be safely repeated in a feAV hours. If by these measures we have in any degree diminished the hardness of the pulse, it will be more prudent not to repeat the venesection, but to apply from twenty to thirty leeches over the surface of the abdomen. The next indication, though apparently of almost a negative cha- racter, is of the utmost importance, namely, to obviate all disturbing cause which might irritate the inflamed part. For fulfilling this indication one obvious method is to abstain from the use of purga- tives, and there can be no more mischievous practice than the ex- hibition of such drugs in acute peritonitis; the chief reliance should be upon opium, which may be given in grain doses, repeated at intervals of about four hours. There need be no apprehension of the opium confining the bowels, as it is by no means desirable that they should act as long as active peritonitis exists; and when the inflammation has in some measure subsided, the probability is that the opium will act as an aperient. It is also worthy of remark that the opium will to some extent counteract the tendency to exhaustion produced by the bleeding, and that the bleeding will render^he patient more tolerant of the opium. With the opium mercury may be combined, but never in such doses as to affect the bowels. As a general rule a grain of calomel may be given with each grain of DIAGNOSIS AND PROGNOSIS. 345 opium, or if there be reason to apprehend irritability of the bowels, two grains of hydrarg. cum cret. may be used instead. It is also im- portant to keep the patient in the recumbent position, and he should not be allowed to get out of bed, or even to sit up for any purpose whatever. When the pain and tenderness are manifestly diminished, a blister may be applied, but this is only admissible after the more acute symptoms have subsided, not only upon the general principles already laid down, but because the superficial tenderness caused by the blister may interfere with our examination of the abdomen, and may mislead us as to the real seat of the pain. Upon the same prin- ciple that we avoid disturbing the intestines by purgatives, Ave should endeavour to keep the stomach as tranquil as possible; Ave should therefore forbid large draughts of anything, and endeavour to support the patient by giving from time to time about tAvo tablespoonfufs of barley-water, or, what is perhaps to be preferred, especially if there be any tendency to sickness, about the same quantity of milk and lime-water in equal parts. When there is sickness it will often be counteracted by the opium or calomel, but should this not succeed, about ten grains of calcined magnesia (Henry's is the best) with five minims of vinum opii in an ounce of Avater, may be given every four hours. The practice of administering effervescing draughts, and thereby suddenly distending the stomach by the rapid evolution of gas, is at best inconsistent. Sinapisms may also be applied under such circumstances to the scrobiculus cordis. The treatment of peritonitis from perforation of the stomach, or any other portion of the alimentary canal, is almost hopeless; yet as inspections after death show us that the consequent extravasation may be circumscribed by adhesions, and the fatal extension of the disease thus prevented, we must endeavour by all means to favour such a process. The great principle of treatment, then, in such a case, is rest. The patient should not only be kept quiet, but as far as possible motionless. Small quantities of bland fluid, not exceed- ing half an ounce at a time, should be given as nutriment (the milk and lime-water, for instance), and opium should be administered; one good effect will be that we shall be better able to maintain the quiet which is so indispensable. By acting upon these principles, a case of perforation of the stomach was actually saved under the care of Dr. Hughes and Mr. Ray of Dulwich, though the patient subsequently died of a similar disease. The peritonitic symptoms which not uncommonly follow parturi- tion, independently of the specific form of the disease constituting puerperal peritonitis, will generally yield to strict observance of rest, the application of about twelve leeches, followed by warm fomenta- tions, or the application of a warm linseed poultice, care being taken that the leech-bites do not continue to bleed too long after the appli- cation of the latter. As the peritonitis consequent upon ovarian irritation or inflam- mation may occur in every variety of intensity, it will require a corresponding variety of treatment. As it will in many cases be next to impossible to distinguish with certainty between neuralgic 346 PERITONITIS. and inflammatory pains, a middle course must often be adopted. For this purpose rest and an unstimulating diet should be enjoined, and a pill of one of the accompanying forms administered about three times daily, (F. 60.)* When menstruation is impending, the latter is to be preferred, the drops (F. 61)f being given in the intervals. In more severe and decided cases, where the tenderness is great, the pulse sharp, and the bowels confined, the treatment must be the same as in simple peritonitis, care being taken, however, not to carry depletion so far, the use of the lancet being rarely admissible. The caution about purgatives is also as applicable here as in other cases. When the inflammation has susided the bowels will generally act spontaneously. The treatment of peritonitis arising from uremia belongs perhaps mainly to that of disease Avhich gives rise to it: that arising in Bright's disease being generally of subacute character, very active depletion will rarely be required, but a few leeches may be applied to the abdo- men. Mercury, as is Avell known, is a most dangerous remedy in Bright's disease, and should therefore be rarely used. When admin- istered it should be withdraAvn upon the slightest indication of its specific effects, which must be most carefully looked for. Saline diaphoretics, as the liquor ammonie acet. or the citrate of potass (F. 62):}: are often beneficial; and if there be no sickness, antimony is the remedy upon Avhich we may place the most reliance. This may be given either in the form of the antimonial opiate pill (F. 26) or of three grains of James's powder with the same quantity of hyoscyamus three times a-day; the opium, however, must not be administered if the pupil be contracted, or if there be any of the symptoms of cere- bral affection, so common in uremia. When these latter symptoms are absent, the pulv. ipecac, co. in doses of three or four grains, three times a-day, Avill often be of service. In the peritonitis which some- times occurs almost contemporaneously with the invasion of scarla- tina, which is to be known in most cases only by its fatal result, we can of course do but little, the chief indications being for the use of stimulants. When, however, as is sometimes the case with the peri- toneum as well as Avith other serous membranes, it becomes inflamed * (60) R. Ext. Hyoscyam. gr. x. Hydr. cum Cret. gr. iv. Ft. Pil. iij.; one to be taken three times a-day. Or, R. Ext. Conii, gr. x. Hydr. cum Cret. gr. iv. Ft. Pil. iij.; one to be taken three times a-day. f (61) R. Liq. Potassae, 3 ii. Sp. iEth nit Tinct. Hoscyam. iia 3 iii. M. A small spoonful to be taken three times a-day in an ounce of barley-water. X (62) R. Pot. Bicarb. 9 i. Acidi Citrici, gr. xv. Sp. ;Eth. nit. gss. Syrupi Aurant. 3 ss. Aq. distillat. 3 x. Misce. For a draught, to be repeated three times a-day. TREATMENT. 347 towards the subsidence of the fever, independently of uremia (the signs of which should, hoAvever, always be carefully looked for), it must be treated upon the ordinary principles, though we must not forget that the patient has passed through a depressing disease, the poison of which is scarcely eliminated from the system; depletion must not, therefore, in ordinary cases be attempted, unless the pulse have considerable volume as well as sharpness, and the tenderness be intense. Calomel, Avith Dover's powder, or the antimony and opium and saline diaphoretics, must therefore constitute the staple of the treatment, the effect of the opium upon the brain being carefully watched. The same rules of treatment apply to the erysipelatous peritonitis. The treatment of puerperal peritonitis belongs more appropriately to the obstetrician; but it belongs also to the general physician to be aAvare of the principles upon which this treatment is to be conducted. The inflammation may be stated to be the effect of the localisation in the peritoneum of the influence of a specific morbid poison, in which respect it may be said to resemble the serous inflammations which occur in influenza. There is, however, a greater tolerance of bleed- ing in the latter than in the former disease, and in some epidemics this measure is well borne; but as a general rule it must be resorted to Avith much caution; and in estimating its expediency, we must be guided as well by the general epidemic character of the disease,— that is to say, by the tolerance of depletion evinced not only by other patients suffering from the same disease, but by the greater or less tolerance of similar measures evinced in all diseases which may hap- pen to be prevailing at the time—as by the particular condition of each individual patient. When, for instance, fevers with a tendency to prostration, especially exanthems, such as scarlatina or erysipelas, quickly assuming a typhoid character, are prevailing, the lancet should be almost entirely laid aside, and even leeches used with the greatest caution. As regards the indication to be drawn from the patient herself, Ave must look mainly to the pulse: if in the onset of the disease the pulse is hard without being very small, thatis to say, if the heart evince some power, and at the same time the inflamma- tory contractility of the pulse is well marked, blood may be drawn if there are none of the contra-indi cations from without which have just been alluded to. Next, if next, to bleeding in efficiency, and far beyond it in extent of applicability, is opium, which appears notonly to fulfil the indication of restraining the peristaltic action of the intes- tines, but also appears to have a direct effect upon the disease. In this, as in other forms of peritonitis, or perhaps even more so, purgatives should be carefully avoided; it has happened that the withdrawal of the opium, and administration of an aperient, has brought back the worst symptoms of the disease, Avhen they had to all appearance subsided. Of chronic peritonitis Dr. Abercrombie truly observed, that this insidious affection is more common than persons not familiar Avith pathological investigations are generally aware of. It is a disease of the utmost danger, yet often extremely obscure in its symptoms and, 348 CHRONIC PERITONITIS. can only be treated with any prospect of success by the greatest attention to its earliest indications. This chronic, or more properly speaking, subacute inflammation of the peritoneum, may arise from a variety of causes: thus, in many cases, it is the effect of previous acute peritonitis, where there is organisation of lymph of different degrees of plasticity, accompanied by serum, Avhich generally does not become absorbed; in which case we have green and puriform matter, and, here and there, lymph agglutinating the contents of the peritoneal cavity. Another form of the disease, and that which includes, perhaps, the greatest number of instances, is associated with tubercle; and is the local affection by which the tuberculous diathesis most frequently manifests itself in more advanced childhood and early youth. The liability to the deposition of tubercles in the abdomen, and espe- cially in the peritoneum, may be said, as regards age, to folloAV the tendency to such deposits in the encephalon, and to precede that in the chest. In such cases, the disease consists in the deposition of various forms of tuberculous matter on the surface of the peritoneum; in some instances there may be only the minute transparent miliary tubercle; in others again there may be associated with these, the flattened opaque white tubercle, lying apparently immediately under the surface of the membrane, without any inflammatory deposit upon it; in others again, and those especially in which the cause of death is to be referred to the peritoneal disease, there is every variety of tuberculous and inflammatory deposits, agglutinating and knotting together some parts of the intestines into such an inextricable mass, that it is often next to impossible to unravel them. In another form of the disease, to which the term chronic is per- haps more particularly applicable, there is thickening, contraction, and opacity of the membrane, with little or no deposition of lymph, but a large effusion of serum, constituting one form of ascites. The symptoms of chronic peritonitis are, as has just been observed, in a great number of cases very obscure, it being often next to impossible to assign with any exactness the period of its first inva- sion. At first there is commonly more or less pain, which is either constant, or occurring in paroxysms: this pain is in some cases referred to a particular part, at others it extends over the whole of the abdomen; there is generally increase of the pain upon pressure, and also upon motion, or upon assuming the erect position, or there may be no pain, but merely a dread of pressure. The abdomen is generally rather tumid, and upon the whole resonant upon percussion, though there may be here and there points of dulness; at times also what appears to be a solid mass may be detected in the abdomen by percussion and manipulation. In some cases, and these more advanced, the abdomen is flat, and the resonance defective: the abdo- minal muscles, especially the recti, are often strongly contracted, and give a feeling to the hand as of a nodulated mass beneath. In most cases there is vomiting at times in the course of the disease; some- times, it may be, from intestinal obstruction, sometimes from inter- current acute peritonitis in the upper part of the abdomen, and, some- SYMPTOMS. 349 times, in the tuberculous cases, from disease of the mesenteric glands, or enlargement of the glands in the neighborhood of the pylorus. The bowels are very irregular in their action, being in many cases irritable, though even where this is the case, they are liable to inter- vals of obstinate constipation; sometimes the first appearance of the disease dates from an attack of the latter: the action of the bowels is almost always attended with pain. In addition to these symptoms, which are more directly referable to the abdominal disease, Ave find others which belong more to the state of the system upon which it depends, or to which it has given rise. In those cases which are the sequele of acute peritonitis, there will not necessarily be any previous history of tuberculous or other cachexia, yet even here there will probably be some history of ante- cedent disorders Avhich may have given rise to the first peritonitis; since, as we have pointed out, primary or idiopathic peritonitis is an uncommon disease, and therefore in these cases there will probably be elicited some circumstances which would excite the suspicion of some affection of the abdominal viscera, such as has been pointed out as likely to excite peritonitis, and in addition there will have been subsequent derangement of the health, with, in all cases, more or less general emaciation, with sinking of the countenance. These remarks are perhaps specially applicable in the case of females, in whom the peritonitis has been produced by ovarian or uterine disease. In the most numerous class of cases, those namely which are of a tuberculous character, the general symptoms will be those of the strumous diathesis, such as have been pointed out Avhen treating of phthisis pulmonalis; indeed, this form of peritonitis, with its frequent accompaniments of strumous affection of the mucous membrane and the mesenteric glands, constitutes a modification of phthisis abdomi- nalis. Instances of this disease generally present themselves in young persons between the ages of ten and twenty, and Avhen in such sub- jects, we have pain and tenderness in the abdomen, with emaciation, and more especially if there be occasional flushings of heat, Avith a quick pulse, and tongue furred at the back and centre, with red edges; and if the boAvels be irritable, with intervals of constipation, Ave may generally infer the presence of chronic peritonitis of a tuber- culous character. In the chronic peritonitis to which we have alluded as presenting more the appearance of ascites, there are no very characteristic general symptoms; there will be emaciation, and generally con- siderable anxiety of countenance; the pulse for the most part quick, the bowels torpid, the urine scanty, and often depositing urates. The progress of chronic peritonitis is liable to great variations; but in the majority of instances, unless it be early arrested, its ten- dency is to a fatal termination. In such cases, under fa\Tourable circumstances and judicious management, the bowels will become regular, and the evacuations healthy, often after the removal of large accumulations of solid matter, when the tenderness may disappear, and nutrition being restored, the patient regains flesh. But even under these circumstances, there is great liability to relapse, for since 350 CHRONIC PERITONITIS. the previous accumulations had in all probability taken place through the contractility of portions of the intestines having been impaired by previous disease, there is a liability of its recurrence, and also a danger of fresh obstructions being established by the insidious pro- gress of chronic inflammatory action, and such cases require constant watching, and the greatest care for months after the disease has appa- rently subsided. If, on the other hand, the disease be not arrested, the tumescence and tenderness of the abdomen increase, with extreme pain, often referred to particular parts; the action of the bowels becomes more irregular and attended with greater distress, sickness may become urgent, and the patient sinks, either exhausted by inability to retain nourishment, or worn out by the continual suffering; or, life may terminate more suddenly from perforation of the intestine consequent upon obstruction. The progress of that class of cases to describe which the term phthisis abdominalis has been applied, is Arery similar, as regards the constitutional symptoms, to that of phthisis pulmonalis, but even in these, we sometimes find the disease rather unexpectedly to recede, the abdomen losing its tumescence, the bowels recovering their healthy action, the patient regaining his health and strength: some- times too, even when the swelling has continued, and fluctuation has been distinctly felt, and' hectic symptoms have been well marked, there has been an escape of pus through the ring of the external oblique muscle, or through the umbilicus, and the patient has eventually recovered. In by far the greater number of instances, however, Avhen the disease has been well marked, emaciation has increased, and the patient has died of exhaustion, unless previously cut off by any of the casualties before mentioned. In the chronic peritonitis, which has been described as assuming the form of ascites, the fluid is rarely absorbed, and the continued pressure on the abdominal viscera commonly produces death from emaciation and exhaustion; though even here it has sometimes hap- pened that the fluid has disappeared after a copious discharge of water, either by the bowels or the kidneys, or, in some cases, after an abundant flow of saliva. Since the symptoms of chronic peritonitis are so obscure and insi- dious, the diagnosis must, especially at the commencement, be diffi- cult ; and, although it may be true, as stated by Abercrombie, that when there is continued pain and tenderness in the abdomen, we may generally infer the existence of chronic peritonitis, there are diseases with which it may be confounded, amongst Avhich may be reckoned, tabes mesenterica, worms, infantile remittent fever, and phthisis pulmonalis. As regards the first of these, it rarely happens that chronic peritonitis runs its course without more or less complica- tion of mesenteric disease, and although it may be doubted whether the latter is ever the direct cause of the former, there can be no doubt that peritonitis often supervenes upon it; and for these reasons the diagnosis becomes of less practical importance, though the ten- derness of the abdomen would generally enable us to distinguish peritonitis from uncomplicated mesenteric disease. In the case of DIAGNOSIS. 351 worms and infantile remittent fever, though there may be pains in the abdomen, they may be readily distinguished from chronic peri- tonitis, both by the general symptoms and by manipulation of the abdomen. For a diagnosis between this disease and phthisis pulmo- nalis Ave'must again have recourse to a careful observation of the physical signs, since the constitutional ones are often so nearly iden- tical ; and here, too, we may remark, that the two affections are very often coincident: so much is this the case, that in young persons pre- senting some of the symptoms of chronic peritonitis, we should insti- tute an examination of the chest with a view to ascertain if there be any early signs of phthisis, as this discovery Avould tend to confirm our diagnosis in regard to the abdominal disease ; and the practical question will often be, not Avhether either of these diseases exist, but which is the more advanced of the two: and it is well to bear in mind, that, though the majority of cases of tuberculous peritonitis occur in young persons under the age of eighteen, most such sub- jects die with phthisis pulmonalis, though not of it; whereas, whilst the majority of cases of consumption occur aboAre the age of eighteen or even tAventy, many such subjects die with the disease which we have termed phthisis abdominalis, though not of- it. Inflammation of the mucous membrane of the intestines when uncomplicated with peritonitis, may be distinguished from the chronic form of that dis- ease by the absence of superficial tenderness, the form of the abdo- men, the character of the evacuations, and the defined pink flush on the cheeks. Besides the general distinctions between chronic peritonitis and the diseases just mentioned, there are other points bearing upon the diagnosis to which our attention ought to be directed. Thus, in examining the abdomen by the hand, what appear to be tumours may not unfrequently be detected; of these it Avould at first be impossible to say whether they are strumous or other masses, or accumulations in the intestines; and the only mode of ascertaining will be to administer a gentle laxative; as, for instance, three or four grains of grey powder to be folloAved in a few hours by a dessert- spoonful of castor oil, and to observe the character of the evacuations, and the effect upon the swelling. This may be repeated several times, as long, in fact, as any solid matter continues to be brought away, after Avhich it Avill often be found that the supposed tumour has disappeared. The removal of such swellings by these means is not, however, conclusive against the existence of chronic peritonitis, since, as has been pointed out, it may be the cause Avhich has rendered the intestines liable to such accumulations. Besides the general diagnosis of the presence of peritonitis by the signs which have already been detailed, Ave may often arrive at a greater degree of certainty, not only as to its existence, but also its character, extent, and situation, by careful manipulation, and even oscultation : thus, when exploring the abdomen by the hand and fin- gers—besides the deviations from its natural elasticity and the points of tenderness complained of by the patient, a certain crepitation is felt, under the fingers, which has been, not unaptly, compared to the 352 CHRONIC PERITONITIS. moving of greased surfaces one over the other;—this will indicate fresh or unorganised lymph, corresponding to the part where it is felt. Again, the application of the stethoscope will often detect, especially towards the margin of the ribs, a dry friction sound, or a soft crepitating one, not unlike that which has been termed mucous crepitation : the former of these is indicative of old fibrinous effusion, and the latter of recent and soft lymph. These phenomena will sometimes enable us to define the boundaries of the effused lymph with remarkable precision. The chronic peritonitis which constitutes one form of ascites, and which often presents no symptoms before the occurrence of the effu- sion, is to be distinguished from ovarian dropsy by the absence of those signs Avhich characterise the encysted form of the latter, though from hepatic dropsy the diagnosis is not so easy; it may, hoAvever, be inferred, from the absence of the symptoms and the previous his- tory which belongs to the latter, as well as from the greater hardness and more globular form of the abdomen. The prognosis of chronic peritonitis is, in the majority of cases, unfavourable, though we are not to conclude that it is at all times necessarily so. When the disease is the result of previous acute peritonitis, there is great danger from the liability to intestinal ob- struction, arising either from adhesions, from bands of false mem- brane pressing upon the intestines, or from the loss of contractility induced by the inflammation. Such cases may, however, under careful management, apparently recover, and the patient escape any serious inconvenience, though the possibility of his having at any time a dangerous attack of intestinal obstruction is not to be lost sight of, especially when a question arises as to the probable value of his life. These remarks apply, though not perhaps with equal force, to the case of females in Avhom the disease has ocurred from uterine or ovarian affection. Of strumous peritonitis, it may be said that the disease is only less dangerous than pulmonary consumption, and it is hard to give any reason Avhy it should be so at all, unless it be that the access of air in the lungs causes a softening of the tubercu- lated portion of the organ, and consequent destruction of the sur- rounding tissue, Avhich does not take place in the closed peritoneal sac. The occurrence, too, of symptoms of strumous peritonitis in young persons of phthisical families might be supposed to have an unfavourable bearing upon their prospects as regards their liability to phthisis at a maturer age. Yet, strange as it may appear, cases have occurred in which there have been well-marked signs of early phthisis pulmonalis coexisting Avith undoubted chronic peritonitis, where the development of the latter disease seemed to exert a revul- sive influence in arresting the progress of the former. This Avas unmistakeably the case in a patient to whom allusion has been already made, who recovered after the escape of a large quantity of puriform matter by the umbilicus, and in whom there Avere oscultatory signs of incipient, or, to speak more correctly, early phthisis. In the chronic serous peritonitis or peritonitic ascites, the prognosis is also unfavourable, though even here, as has been pointed TREATMENT. 353 out, the effusion may sometimes disappear after profuse watery dis- charges. The treatment of chronic peritonitis must be conducted Avith the greatest caution, the object being first to avoid all needless excite- ment of the peristaltic action, of the intestinal canal, which has the effect of aggravating the inflammatory action where it exists, and exciting it afresh where it has subsided;—secondly, to check any tendency to acute inflammation which may arise in the progress of the disease ;—and thirdly, to correct that condition of the constitu- tion upon which it so frequently depends. In the subacute disease, Avhich is a sequel of the acute, Ave must carefully look for any indi- cation of fresh inflammatory action arising in particular parts, and when this is the case, we must, where the powers of the patient admit, apply a few leeches over the affected part. After this blisters may be occasionally used, or stimulating liniment applied to the abdomen; hot fomentation or warm poultices of linseed meal will often give much relief when the pain is urgent. Our next object should be to reduce the tendency to chronic inflammatory action; this will, perhaps, be best affected, in the class of cases of Avhich we are now speaking, by the moderate and carefully regulated use of mercurial preparations: these are generally best combined with opium to prevent irritation of the bowels, and there is, perhaps, no better form than one grain to a grain and a-half of calomel with three or four of compound soap pill tAvice or thrice a-day, watching at the same time most carefully for the signs of the specific action of the mineral, in Avhich case it should be immediately Avithdrawn, or at all events, reduced to one dose in the day ; for the continuance of slight mercurial action is, perhaps, desirable in those cases in which emaciation and general exhaustion are not great, and we have good reason to believe that the disease is not of a tuberculous charac- ter. AVhen the bowels are sluggish, as they often are in this form of chronic peritonitis, the most gentle laxatives must be used; per- haps there are few better than the hydr. cum cret. and castor-oil, but should the bowels be obstinate, we must on no account attempt to force an action by strong purgatives. As a general rule in cases of this kind, those aperients which appear to soften the contents of the bowels, by promoting the secretion from its lining membrane, are to be preferred,, whilst those which act more by exciting the action of the muscular coat are to be avoided. AVhen the action of the bowels is torpid and there are occasional pains, the combination of hyoscyamus, liq. potasse, and sp. nit. eth. will be found very ser- viceable, and to this may be added a little pot. iodid., say tAvo grains to a dose, which will often promote the absorption of effused matter. The occasional use of soap enemata is also to be recommended. As the patient recovers, pure air and gentle exercise are incomparably the best tonics for restoring the tone and contractility of the muscu- lar coats of the intestines, as well as promoting absorption so far as it can be affected. In those cases in which, from the signs we have here pointed out, there is reason to believe the peritoneal inflammation to be of a 23 354 CHRONIC PERITONITIS. strumous character, we must be even more upon our guard to avoid depressing the powers of the patient, and especially cautious in the use of mercurials: when there is any great increase of tenderness, and reason to apprehend the supervention of acute inflammation, a few leeches may be applied to the part, and Ave may venture upon about a grain of calomel, or two or three of hydrarg. cum cret., with four or five of pulv. ipecac, co. night and morning; and Avhen the pulse is softened, and the skin cooler, a blister may be applied. At the same time with these remedies, Ave may also administer one of the accompanying mixtures (F. 62),* the former to be preferred if the urine be scanty. Should there be no symptoms of intercurrent acute peritonitis, or as soon as they have subsided, the iodide of potassium may be used with advantage, in doses of from a grain and a-half to three grains; and will be best given Avith the first mixture. At this period of the disease Ave must direct our attention as much to the strumous diathesis of the patient as to the local disease, and therefore diet and general mode of life become of the greatest consequence. In regard to diet, Ave must remember that we are probably exposed to disease in the mesenteric glands and the lymphatics, and that the stomach and bowels are prone to be either irritable or torpid in their action. At the same time we must endeavour to convey into the system the greatest amount of nutritious non-stimulating aliment that it is capable of receiving and assimilating. In promoting the recovery after the severer symptoms have sub- sided, or preventing their invasion, Avhere there is reason to appre- hend them, the importance of pure air and light are not, perhaps, sufficiently estimated. Children in AA'hom there exists any indica- tions of a strumous diathesis should, at all times, be kept in as pure an air as circumstances admit of; and not only should this be carried out by residence in the country in elevated situations, or by the sea- side, but also by their spending a large portion of their time in the open air. A moderately Avarm clothing, covering pretty uniformly the whole surface, is not only essential for the sake of equalising the circulation, but also enabling them to spend much time in the open air without risk. Exposure to the direct solar ray, unless the heat be great, or, at all events, the free admission of light, is no incon- siderable preventive to the establishment of strumous disease. In the chronic serous peritonitis or peritonitic ascites, we may use mercury somewhat more freely; the combination of squill and blue * (62) R. Liq. Potasste, 3 iii. Tinct. Ilyoscy. ^ iv. Sp. JEth" nit! 3 v. M. A small spoonful to be taken in a glass of barley-water. Or, R. Sodoe B'carb. gr. xiv. Tinct. liyoscy. rr^ xx.—xxx. Sp JEth. nit. 3 ss. Mist. Acac. giv. Sp. Pimentte, 3 ii. Aq. pime. A sufficient quantity to make a % iv. mixture, of which the third portion is to be taken at a time, and repeated thrice in the Jay. TREATMENT. 355 pill being in general the preferable form, or the following pill (F. 63)* may be administered three times daily, saline diuretics being given in the intervals, to which may be added from one to tAvo drachms of infusion of digitalis, provided the effect upon the pulse be carefully watched. Hydragogue cathartics in the form either of pulv. jalap co., of elaterium with bitart. of potass, being exhibited from time to time (F. 64).f Should the swelling continue, and the urine not be increased after the mouth has been slightly affected by the mercury, the iodide of potassium should be tried, which may be administered in the form prescribed above. As, however, these and all measures for promoting the removal of the fluid by absorption Avill, in many cases, prove unsuccessful, it will often be necessary to have recourse to paracentesis, though the operation is, under such circumstances, not without danger, OAving to the peritoneum being already in a state of chronic inflammation, and any considerable tenderness, sharpness of pulse, or other inflammatory-symptom, should be received as a contra-indication. When the operation is determined upon, it would be well to have recourse again to the mercury, until the mouth is slightly affected, when paracentesis may be performed. When the pulse is feeble, a small trochar should be used for this purpose, the abdomen carefully bandaged, and a grain of opium administered with a grain of calomel. After the patient has recovered from the immediate effect of the operation, diuretics with the iodide of potas- sium may be resumed. * (63) R. Pulv. Digitalis, gr. j. Pil. Hydrarg. gr. i. Pil. ScillEe co. gr. iij. Ft. Pil. f (64) R. Extract Elater. contriti, gr. J. Pot. Bitart. gr. xvj. Zingiberis contriti, gr. ij. M. To be well combined in the form of a powder. 356 SYMPTOMS OF ENTERITIS. XX. ENTERITIS AND OBSTRUCTED BOWELS. Enteritis is a term, the meaning of which, as used by different authors, it is not very easy to define. Some appear in speaking of it to contemplate inflammation of the mucous membrane, others that of the serous. Dr. AVatson, with his accustomed fondness for simplicity, interprets it as inflammation of the bowels, by which he means inflammation of the serous membrane, the muscular and areolar tissues, and the mucous membrane, of a portion of intestine: and this is the sense in which Ave purpose to apply it. It is very doubtful if this disease is ever a primary one: most authors speak of the inflammation as arising in the peritoneal coat, and extending from thence to the other tissues of the intestine; but Ave have seen that primary peritonitis is a very rare occurrence. Still, as enteritis is spoken of as a primary lesion by many authors of reputation, as it is one which Ave not uncommonly meet with as a consequence of some antecedent disease or irritation, as, above all, it is a disease of the greatest danger, proving fatal if not relieved in a short time, and requiring the most careful discrimination as to its diagnosis and treatment, it is necessary to be Avell acquainted with its nature and symptoms. Enteritis may commence with some very well marked pain, or extraordinary sensation in the abdomen: patients have more than once spoken to the author of the first symptom having been a sense of something having given Avay or becoming tAvisted or displaced. In some cases there are rigors. The pain, which is at first circum- scribed, rapidly becomes more and more intense, and extends over the Avhole abdomen. There may not be much tenderness at the commencement, but in a short time it becomes so severe that the slightest pressure, even that of the bed-clothes, cannot be borne. The pain in enteritis is incessant, though it is subject to paroxysms of aggravated intensity; in this respect it differs from that of colic, in Avhich the pain comes on in paroxysms, and entirely subsides in the intervals. It Avill sometimes happen that at the very commencement of the attack there will be copious relief of the bowels, after which they become obstinately constipated. Nausea and vomiting super- vene sooner or later, though the period at which this happens varies according to the seat of the disease. The vomiting is often highly offensive, having an odour of feces, and thence called stercoraceous, showing that the matter ejected has been brought up from the loAver part of the canal, though most probably not loAver than the ileum. The sufferings of the patient are most distressing; he lies on his back, with his knees draAvn up to relax the abdominal muscles. The res- piration is hurried and mostly thoracic; and the movements and position all evince an apprehension of pressure or disturbance of the DIAGNOSIS. 357 inflamed part; so that though there may be jactitation of the extremi- ties, the trunk is kept perfectly quiet. The countenance, as in peri- tonitis, is expressive of great distress. The symptoms are generally at the commencement those of inflammation of a serous membrane, which, from the implication of a mucous one, from its intensity, and often from its situation, speedily assumes a very depressing character. Accordingly, the pulse may be at first full and hard, but speedily losing the former character, whilst it retains its hardness, it becomes wiry, and as the disease advances, thready and almost imperceptible. If the inflammation do not subside, the distress and exhaustion of the patient increase, the pulse becomes smaller and smaller, and at last imperceptible, the skin clammy, and death takes place from failure, or rather depression of the heart's action. In some instances, the pain suddenly ceases some time before death: this used, as in the case of peritonitis, to be referred to gangrene, but that is not always found to have occurred; it is probably the effect of nervine exhaustion. The above constitute the essential symptoms of enteritis, and may be summed up as consisting of those of intense inflammation in the abdomen, to Avhich are added those of the Icesa partis functio, in the form of arrested action of the boAvel, and its consequences. There are, however, several which may be termed accidental symptoms, about which a good deal of discrepancy will be found in different authors; the explanation of Avhich is that these are referable to the cause of the inflammation, and the part of the intestine affected by it, both which may vary. Now a common, perhaps the most common cause of enteritis, is mechanical obstruction, of Avhich we shall presently speak more fully; and hence we have shrinking or swelling of the abdomen;—vomiting coming on among the first symptoms, or not till towards the close of the disease;—scanty and high-coloured, or abundant and pure urine, according as the obstruction is seated near the commencement, or the termination, of the canal. All these, then, have been enumerated amongst the symptoms of enteritis. If the occlusion have taken place in a portion of intestine near the yielding parts of the abdominal parietes, there will be generally a local tumescence; but if more deeply seated, there will be no appreciable swelling. In some instances, though these are not the most frequent, the inflammation appears to have arisen spontaneously, or at least inde- pendently of any mechanical cause. Where this has been the case, a portion of the bowel is dark, almost livid, having the peritoneal coats covered with flakes of lymph, and the mucous lining with sanious mucus, the intestine being at this part much dilated, though below it the canal is empty and firmly contracted; this contraction being the effect, and not the cause, of the obstruction above. In some of these cases we can, as we have said, assign no cause for the inflammation, though in many there can be little doubt that it has been set up in the following manner:—Irritation proceeding from some indigestible matter in the canal;—a strong purgative, to remove the cause of that irritation;—another purgative to overcome the obstinate constipation Avhich has resulted from the increased 358 OBSTRUCTED BOWEL. irritation induced by the first;—enteritis and its disastrous conse- quences. It is to this form of enteritis, occurring in the small intes- tine, that the term ileus, or iliac passion, has been applied. Another class of cases, in which the inflammation commences in the cecum and appendix vermiformis, are those in which a cherry-stone, a lump of hardened feces, or even a pill, has been found in the latter, though it is more than probable that there Avas some pre-existent disease to allow of its intrusion: in these the pain and tenderness commence in the region of the cecum, where there is also some tumefaction. Closely resembling these cases are those to be noticed presently, in which peritonitis and enteritis appear to have been set up by disease in the ovary. The diagnosis of enteritis from colic depends upon the tenderness; the pain of the latter being relieved by pressure, the persistence of the pain—the sickness—and the signs of acute inflammation. It is of course essential to ascertain that there is no hernia to be detected, and all the outlets should be most carefully examined. The treatment of enteritis rests upon the simple principles of sub- duing the inflammatory action by such measures as the strength will admit of, and keeping the inflamed part at rest. When the patient is seen early, and the pulse is moderately full, as Avell as hard, vene- section to the first signs of fainting is admissible; and it will often happen that this Avill be folloAved by a spontaneous action of the boAvels; leeches may also be applied to the seat of tenderness. Pur- gatives should on no account be given; but the patient must be put upon the use of calomel and opium in equal parts. The pain often renders the tolerance of opium great, so that eight or ten grains of each may often be given in the course of twenty-four hours. The occasional use of a soap enema is admissible. AVe must not forget the tendency to death by asthenia in this disease; and when the extremities become cold, or the pulse very feeble, Avine or brandy should be given. AVhen the action of the mercury begins to shoAV itself on the gums, it should be withdrawn, and the opium steadily persevered with. OBSTRUCTED BOWEL. By obstruction of the bowels is here intended that degree of con- stipation which resists the use of ordinary remedies; and although this obstruction may arise from such a variety of causes that it is impossible to classify it in any strictly pathological arrangement, yet it is a condition of such extreme importance in practice, and one the mismanagement of which is so eminently dangerous, that we proceed to speak of it as one disease, though the causes of it may be various; and though our treatment must be in a great measure guided by our discrimination in detecting the principal one. And therefore, before proceeding to describe the disease, we shall enumerate them. These causes may be either inflammatory, as in the case of perito- nitis or of enteritis; or obstruction may be the secondary effect of ITS HISTORY. 359 inflammation, as in the case—of the impeded peristaltic movement, from adhesion of one portion of bowel to another, or to some neigh- bouring viscus, or of constriction by a band of false membrane, or— of the diminished contractility of the muscular coat Avhich ensues upon and may continue after peritonitis or enteritis. It may also be produced by chronic disease, whether inflammatory or otherwise, causing contraction or thickening of the coats of the intestines;—or it may arise as a consequence of any of the above, the delay in the passage of the contents setting up a distension behind it; and this distension, of a coil of intestine for instance, may cause its displace- ment (as by rolling over), and a consequent tAvisting of the boAvel. The same thing may be produced, especially in the large intestines, and this, more especially about the sigmoid flexure, by habitual costiveness (induced in many instances by neglecting the calls of nature), the distended portion of the boAvel having been ascertained in one instance to have rolled tAvice over. Analogous to these cases of tAvisting and strangulation, are those with Avhich the surgeon is familiar, as arising from hernia, Avhich should ahvays be carefully searched for; but hernia may exist without being apparent exter- nally, as in the case of hernia at the obturator foramen, or a loop of intestine passing through some advantitious ring formed by .false membrane. Inflammatory action in the inner or mucous coat of the intestinal canal does not commonly produce obstruction, though it is to be remembered that dysentery causes a delay in the passage of foecal matter; and ulceration of the stomach, or duodenum, often produces considerable constipation. Ulceration of the bowel may also cause delay in the passage of its contents, in order,, seemingly, to alloAV time for the process of reparation. ^Obstruction again may also arise from the accumulation of hardened feces, generally in the colon, as a consequence of diminished contractility, either from inflammation or over-distension; and hardened feces, or the presence of a forcing body in the appendix vermiformis ceci, produces constipation of peculiar obstinacy and urgency of symptoms. Another cause of obstruction may be intus-susception, or the passing of a portion of intestine into that immediately below it, and its becoming invaginated therein. Besides these causes Ave may have others arising from a loss of natural irritability, or an insensibility to the natural stimulus, as in the effect of lesion of innervation; analogus to retention of urine from paralysis of the bladder. These cases commonly present themselves under someAvhat of the following circumstances: the patient, who may previously have enjoyed good health, has felt some sudden pain, sometimes as of a sense of falling or twisting in the abdomen, which in some instances is followed immediately by faintness or sickness, or both; in others there may be for a short time no unpleasant symptoms. The boAvels not acting, however, the patient often of his own accord takes a pur- gative, which he may even be induced to repeat. Either these medi- cines are rejected, or the patient suffers much from weight and dis- 360 OBSTRUCTED BOWEL. tension of the abdomen: in this condition, and becoming anxious at getting no relief of the boAvels, he seeks for medical advice. Again, in some cases there may have been previous tenderness in the abdo- men, Avith irregular action of the boAvels, before the supervention of these symptoms. In others, again, we may elicit a history of some former peritonitic attack; or again, there may haAre been no well- defined symptoms, but simply a cessation of the action of the bowels, and subsequent AA'eight and distension; or the distressing sensations may have come on speedily after partaking of some indigestible food. Such is the general history of obstructed boAArel; yet upon close inquiry we shall find very different and eA'en opposite symptoms in different cases. Our first business in cases of this kind is carefully to explore the abdomen, in order to ascertain if any external hernia exists. If this examination, which ought always to be most carefully conducted, reveals nothing of the kind, we proceed to ascertain, as far as pos- sible, the seat and character of the obstruction, by examination of the degree of tenderness of the abdomen or of any part of it, con- sidered in connection Avith the character of the pulse, the position of the patient, and the degree of pain caused by motion. Should a rather sharp and hard pulse, Avith considerable pain, aggravated by pressure or motion, induce us to believe that there is some peritoneal inflam- mation, we must not infer that such inflammation is the* primary cause of the obstruction, as the very existence of the obstruction may of itself give rise to inflammation, especially if active purgatives have been used. If, hoAvever, there be no sign of inflammatory action, we may conclude that the obstruction is caused either by accumulation in the bowel, by loss of contractile power, as in colic, or by twisting, intus-susception, or constriction by some bridle of false membrane. Our next examination should be as to the degree of tumescence of the abdomen, for in this respect we observe two opposite conditions; in the extreme case, for instance, of obstruction in the duodenum, the abdomen is flat or even sunken; in the opposite one, of obstruc- tion at the sigmoid flexure, we have a very tumid and resonant abdo- men; intermediate obstructions will give intermediate degrees of fulness. Sickness, again, is a very important symptom. When the obstruction is high up in the canal, sickness will be early and inces- sant; when it is in the colon there is no sickness, except what may be excited by irritating medicines, till the obstruction has lasted some days. In obstruction in the course of the lower part of the jejunum or ileum, Ave have early sickness, but not so immediate or so urgent as in the case of the duodenum. The condition of the urine is most important as regards the diagnosis of the seat of the obstruction; when the obstruction is high up, as in the duodenum, the quantity of urine is so small, or rather the suppression so complete, that cases of this kind have been mistaken, and that too by men of experience, for ischuria renalis; Avhereas, Avhen the stoppage has been very low down, as in the sigmoid flexure for instance, the urine is abundant and clear. In the first case the suppression of the urine may in a great measure be accounted for by the sickness; it may be observed, MODE OF INVESTIGATING. 361 however, that sickness as ordinarily observed, independent of me- chanical occlusion near the stomach, never suppresses the secretion so completely. In the case of obstruction in the descending colon, as there is no sickness, and as there is delay in the passage of its con- tents along the intestinal tube, there is abundant opportunity for absorption; and therefore, from the large quantity of fluid taken up by the veins, the quantity which passes out becomes large. There is another circumstance which deserves investigation when Ave Avould ascertain the character or seat of the obstruction, and that is the degree of contraction of the loAver boAvel as carefully explored by a bougie, or the oesophagus tube. AVhen sudden obstruction takes place in any part of the alimentary canal, it generally happens that the whole of the bowel beloAv this part speedily and even forcibly empties itself; and this perhaps applies more particularly to the small intestines, where obstructions, when they do occur, are generally from tAvisting, intus-susception, or acute inflammation, as enteritis. This not only produces the flatness of the abdomen above alluded to, but even a forcible contraction of the rectum, such as in one instance to have induced a doubt of the diagnosis of obstruction high up in the small intestines, from the fact that it AAras almost impossible to introduce the tube or even the finger in the rectum; so forcibly did the bowel contract through its Avhole course below the closure. And the same thing occurs in sudden occlusion, or sudden stoppage from inflammatory affection, in the large intestines: thus, in those unfor- tunate cases in Avhich this mischief ensues from the presence of a foreign body in the appendix ceci, the whole of the large intestines completely empty themselves, and afterwards no action takes place. When, however, the stoppage takes place from chronic thickening or contraction, or from malignant disease, occurrences Avhich are more likely to take place in the large intestines, the bowel often loses its contractility below as Avell as above the seat of obstruction; and, therefore, the rectum upon examination by the finger will often be found dilated; so that upon the introduction of the oesophagus tube it will often coil upon itself in the pouched bowel, which may lead to a belief that it has passed a considerable distance up the canal. This condition rather favours the supposition that the obstruction is produced by chronic or malignant disease, seated probably in the large intestine. The examination of the bowel with a bougie is not without danger; since the instrument passing readily through the dilated portion, may be brought too forcibly in contact with the side of the boAvel, just at the seat of the obstruction, near to which there is not uncommonly ulceration. Examination of the lumbar region is also important in determining the seat of obstruction: when it is in the small intestines, the cecum, or even the ascending colon, there will be no great fulness in the right loin—but if it be in the trans- verse or descending colon, we generally find a bulging in that region, which Avhen the obstruction is remote, (as in the descending colon or sigmoid flexure,) will generally be very resonant on percussion, from the accumulation of flatus; but if the stoppage be nearer, as in the transverse colon, it may be dull from the accumulation of fecal mat- 362 PROGNOSIS AND TREATMENT. ter. If upon similar examination the left loin also be found bulging, the obstruction is in the sigmoid flexure; and if there be also great resonance, it is probably at its termination in the rectum. It may not be amiss to observe that the sigmoid flexure may, under these circumstances, rise up above the crest of the ilium, and produce tumescence, with resonance, in the left lumbar region, which may cause it to be mistaken for the descending colon; a circumstance of no great practical importance as regards the diagnosis, but which deserves grave consideration when any operation is proposed to be performed in that region, with a vieAV to relieving the obstruc- tion. The prognosis of obstruction of this kind must of necessity depend upon its cause, and. it has generally been assumed that where the disease has been of such a nature that it Avould not yield to active purgatives, it was necessarily of a fatal character. The experience, however, of the last ten years has done much to correct this opinion; and though we must still view every such case with great apprehen- sion, we are not Avarranted in pronouncing it necessarily fatal. In reference, hoAvever, to this vieAV of the subject, the fact of much pur- gative medicine being in the intestines is not to be overlooked in forming our prognosis, and constitutes an unfavourable element. A variety of symptoms have been laid down by various authors as warranting an unfavourable prognosis. Amongst these we find nausea, vomiting, pain, tenderness and tumefaction of the abdomen, and high-coloured urine; and these are not without importance, though they never occur together, and, indeed, may be said to be incompatible with each other; and experience has shown us that as many as can co-exist may do so, and yet the patient recover. They show, however, either that the disease is high up in the alimentary canal, in which case it is, if not soon relieved, more speedily fatal; or that it is in the large intestines, and the nature of the obstruction such that the distension, perhaps inverted action, has been propa- gated high up the canal. The correct vieAV of the matter in the pre- sent state of our information is, that all such cases are dangerous; but unless Ave are certain as to the cause, which we never can be unless there be external hernia, or stricture can be detected by examination per anum, they are not hopeless. It is by no means certain that intus-susception is necessarily fatal unless aggravated by stimulating purgatives, and in the apparently no less desperate case of a foreign body in the appendix vermiformis, we have yet to learn that recovery or relief are impossible under appropriate treatment; more especially as we know that such bodies sometimes are expelled by ulceration through the walls of the abdomen. It may, hoAV- ever, be remembered, that as regards the prognosis of intestinal* ob- struction ; obstruction in the small intestines is fatal more speedily than that loAver down, and that the same remark applies to those depending upon inflammatory affections as compared with those resulting from chronic thickening: but that these latter, unless in a situation to be relieved by operation for artificial anus, are of all OBSTRUCTED BOWEL. 363 obstructions the most certainly fatal, not excepting even internal hernia. It is uoav generally admitted by all rational practitioners, that, after moderate purgatives have failed, it is advisable to adopt gentler measures and to rely chiefly on enemata, and not, in the words of Dr. Copland, " to prescribe medicines Avhich will irritate and invert the action of the upper part of the tube without ever reaching the seat of the obstruction." But it has not been so generally considered that they may produce serious mischief, even when they do not invert the action of the tube, and when they do reach the seat of the ob- struction ; for it must be evident that in cases of mechanical obstruc- tion purgatives must produce much irritation immediately above it, and increase the already existing evil of ulceration. In those cases, too, in Avhich the constipation is the effect of a conservative arrest, on the part of nature, of the peristaltic action of the intestines, the action of a strong purgative destroys the only chance of escape for the patient. A remarkable instance of this kind used to be related by the late Mr. Bransby Cooper. The patient, who had resided much in a hot climate, had previously suffered from attacks of constipation, which Mr. Cooper inferred, from his account, to have arisen in the manner just alluded to, in order to allow the closure by means of adhesion to a neighbouring viscus, or to the abdominal walls, of a perforating ulcer of the colon. A powerful purgative was however administered, contrary to the advice of Mr. Cooper, and produced fatal extravasation into the peritoneum. Seeing then that in cases of obstinate constipation no reliance can be placed on strong purga- tives, especially when administered by the mouth, and that much mischief may arise from the incautious use of such medicines, the question remains, what is the best course to be pursued ? Supposing for instance, that from the early severity of the symp- toms, from the sharp and Aviry pulse, and urgent vomiting and scanty urine, we have reason to believe that the cause is inflammation, affect- ing the serous or muscular coat of the intestines, or both, and that probably high up in the intestinal tube, the principles upon which Ave must act, are, the subduing the inflammatory action by general antiphlogistic measures, as far as they are admissible. Thus, for instance, Avhen the pulse is firm and the heart's action not depressed, \ a full bleeding will be of great assistance, and not unfrequently speed- ily folloAved by an action of the boAvels; and upon the same princi- ple local depletion may also be used with caution. The next, and perhaps more important principle, is to favour the subsidence of the inflammation by quieting as much as possible the inflamed or irri- tated part. For this purpose our chief reliance is upon opium. With the opium calomel may be indeed combined; but increased experience tends to shoAV that this latter remedy, so far from being the more important, must be used with great care; the calomel, indeed, has the advantage of softening the contents of the alimentary canal, and thereby facilitating their passage, and it sometimes hap- pens that a free action of the bowels takes place just as the effect of 364 TREATMENT. the mercury begins to show itself upon the system; but the mineral should be withdraAvn upon the first signs of ptyalism, and if there have been no effect upon the bowels the opium should be continued. The best rule by which to be guided under such circumstances is the pain. These cases are almost always attended Avith pain, and conse- quently require a considerable dose of opium to procure sleep; therefore, when the patient sleeps we may infer that he is sufficiently under its influence, and he should not be aroused to take it. In the intervals, however, the opium may be given in doses varying from one to two grains every three or four hours. A very convenient form for its administration is the pil. sap. co. of the Pharmacopoeia; and when it is thought desirable to use larger doses than one grain of opium, an additional quantity may be added to the pill, e. g. (F. 65).* This plan may be sometimes pursued for several days before any decided effect is produced; but at the end of that time free evac- uations will often ensue, so much so that the patient may be heard to complain that the pills are " too poAverful." When from the less urgency of the symptoms, from the free secretion of urine, and the gradually increasing size of the abdomen, Ave have reason to believe that the obstruction is in the lower part of the canal, and that it is probably of a mechanical rather than an inflammatory character, we must, as in all cases, first make the most careful examination, lest by any means the existence of hernia should be overlooked ; and having done this we may proceed to explore the bowel most carefully. If we cannot by the bougie or oesophagus tube reach the seat of the stricture, we must continue the opiate, and wash out the bowel from time to time with the stomach-pump; but if these means fail, or if there be evidence of stricture in the rectum, the question arises as to whether an operation should be performed. That it has suc- ceeded is true, but it has more often failed. Improved diagnosis and great surgical skill may increase the number of the successful cases; but in the meantime, we must, as Heberden said, in his day, of the operation for strangulated hernia, " have a dread of directing such a hazardous operation too soon, or such a painful one too late." * (65) R. Pil. Saponis co. gr. xvj. Opii, gr. ij—iv. Misce. Ft. Pil. iv. MUCO-ENTERITIS. 365 XXI. MUCO-ENTERITIS, TABES MESENTERICA, DIARRHCEA AND DYSENTERY. Like the mucous membrane of the stomach, that of the small intestines is liable to inflammation, both acute and chronic. To this disease Ave apply the term muco-enteritis, though some authors appear to have spoken of it under that of enteritis. This affection commences with a deep-seated pain, which is gene- rally about the right iliac region, which, by degrees, spreads itself towards the umbilicus, and over the whole of the abdomen. This pain is generally increased by moderately firm pressure, though there is nothing like the excessive tenderness of acute peritonitis. The bowels are often at the first constipated, but they shortly become relaxed, and sometimes they are so from the first; the evacuations consisting of thin mucous or serous matter, variously tinged Avith bile or fecal matter, and highly offensive. The action of the bowels is generally preceded and attended by much griping pain, and a con- siderable evolution of offensive flatus; there are also frequent aggra- vations of pain, from the passage of irritating gaseous or other matter through the inflamed portion of the intestine. The constitutional symptoms are not ordinarily of a very severe character; there' may be no well marked symptoms of the invasion of pyrexia, though in many cases there are chills alternating/with flushings of heat. The skin is commonly Avarm rather than hot, though the extremities are apt to be cold; it is also uncertain as to moisture, but in most cases moist and dry by turns. The countenance is commonly pale, though there is often at intervals a circumscribed flush on one or both cheeks. The pupils are apt to be rather dilated. The pulse is gene- rally accelerated, rather sharp, but compressible, the tongue coated with a Avhitish fur toAvards the centre, the tip and edges red, with elongated papille. The urine is scanty and high-coloured, sometimes turbid with urates. There is considerable thirst. In the majority of cases, the symptoms gradually subside after a few days. The thirst abates, the pain and tenderness become less, the diarrhcea ceases, and the evacuations resume their natural con- sistence. In some instances, on the other hand, generally occuring in subjects of feeble or strumous constitutions, the purging increases and becomes incessant; there is sickness, emaciation, extreme pros- tration, rapid flickering pulse, glazed tongue, and death from asthenia. These latter cases, hoAAever, are almost always complicated with disease of the mesenteric glands, and often Avith strumous peritonitis, constituting the tabes mesenterica to be presently noticed. In some instances, too, the inflammation extends to the muscular and peri- toneal coats, and assumes the form of enteritis. Perforation from ulceration may ensue, and fatal peritonitis be the result. 366 CHRONIC MUCO-ENTERITIS. The anatomical change connected with muco-enteritis is active congestion of the mucous membrane, shoAving itself in finely-arbor- escent injection of the vessels, most intense in. the valvule con- niventes. where there are here and there superficial ulcerations. There is also, as in bronchitis, inflammatory turgescence of the sub- mucous areolar tissue, and in very severe cases flakes of albuminous matter. The causes of muco-enteritis are—checked perspiration, irritating matters taken into the canal, as indigestible articles of food, shell-fish, stale vegetables, sunripe fruits, drastic purgatives, &c, and very cold drinks taken when the body is overheated. It some- times is a consequence of continued fever, and it frequently follows severe burns or scalds, and the retrocession of chronic diseases of the skin. Muco-enteritis may be distinguished from peritonitis by the absence of extreme tenderness, by the softer pulse, and the looseness of the boAvels, and by nearly the same symptoms from enteritis. From continued fever, of Avhich it is a frequent complication, it may be distinguished by the absence of the oppression and other symptoms of that disease. From dysentery, by the pain and tenderness not being limited to the course of the colon, by the absence of the tenesmus, and of the viscid slimy stools. The treatment of uncomplicated muco-enteritis should be exceed- ingly simple. Where there is much tenderness a few leeches may be applied to the abdomen, and if the boAvels have not been satis- factorily opened, about four grains of hydr. cum cret. may be given, and followed in about four hours by tAvo or three drachms of castor- oil, with as many minims of tincture of opium. Subsequently the carbonate of soda (F. 66)'* may be administered, and if the bowels are irritable four or five grains of pulv. ipecac, co. every night. If the skin be dry, and opium seem inadmissible, a few minims of vin. ipecac, added to the mixture, will encourage perspiration. The important part of the treatment consists hoAvever in the removal of all cause of irritation by the blandest diet. This should consist for some time of soft farinaceous food. Under the above plan of treatment, the acute muco-enteritis will commonly subside, unless the accidents of ulceration or the super- vention of enteritis occur. It may however, especially in delicate constitutions, pass on to the chronic form of the disease. Chronic muco-enteritis, besides being a sequel of the acute disease, may creep on in an insidious manner, often commencing with the symptoms of chronic gastritis, to which are gradually added those of muco-enteritis, in a less active though more protracted form. But though the symptoms may be less severe, the disease is more dan- gerous, the patient's strength gradually failing, and death ultimately taking place, it may be after a period of months or even years, often * (66) R. Sodse Bicarb. ►) ij. Mist. Acac. 3 iv. Ryrupi Aurant. 5 ij. Aq. Menth. pip. q. s.; to make a four ounce mixture, of which the one-third portion is to be given thrice a-day. PROGNOSIS AND TREATMENT. 367 under an apparent aggravation of his symptoms, though sometimes from the inability of the system to resist an attack of some ordinary malady. The anatomical changes produced by chronic muco-enteritis are, injection of the vessels of the mucous membrane of the intestines— ulceration, especially about the valvule conniventes—thickening and induration of the submucous areolar tissue—and sometimes, as a consequence, contraction of the calibre of the intestine. They are essentially those of inflammation of a mucous membrane, and it is remarkable that they are in the main confined to that membrane; the mucous glands not being, as in the case of continued fever, con- siderably enlarged, and ulceration of them being still more rare. The prognosis of continued chronic muco-enteritis is in the main unfavourable, though the fatal termination may be long delayed: and this fatal tendency depends not so much upon the severity of the disease as the circumstances under which it commonly occurs. We have already seen that inflammation of the lungs or bronchial mem- brane may occur in subjects in Avhom there is deficient power of repair, and consequently the disease assumes a disorganising cha- racter, and the result is the same as Avhen it is accompanied by the deposition of tubercle: and so it may be in the bowels; common inflammation may assume much the character of strumous. Thus common inflammation of the mucous membrane may be excited by causes similar to those Avhich induce the acute form of the disease, but from the enfeebled powers of the constitution repairs may not be effected. The treatment of chronic muco-enteritis must consist mainly in the removing every cause of excitement or irritation of the inflamed membrane. As the bowels are generally relaxed there Avill seldom be occassion for laxatives; but should they not act for more than thirty-six hours, and should the evacuations contain pieces of solid matter, two grains of hydr. cum cret. may be given, and afterAvards a tea-spoonful of castor-oil; or should there be no sickness the castor- oil with tincture of rhubarb, may be administered (F. 67).* The frequent use of mercury is most pernicious; but if the bowels be irritable, and the motions pale, a grain of hydr. cum cret. with three or four of Dover's powders, may be given at night. When there is much tenderness, Avith signs of active inflammation, a few leeches may be applied to the seat of the pain, and afterAvards a warm linseed poultice; provided always that the strength of the patient is sufficient to justify it. The soda with mucilage (F. 66) may also be employed, and if there be much diarrhcea the chalk mixture may be given occasionally. When the irritability of the boAvels is excessive, about four ounces of starch, with thirty minims of laudanum may be thrown *(67) R. OleiRicini, Tinct. Rhei, Si SI g iij. Mist. Acac. g iij. Tinct. Opii, ttl vj. Aq. Pimentae, 3 vij. M. A large spoonful or two to be given as a dose. 368 TABES MESENTERICA. into the rectum. The diet must be of the blandest and most soothing kind, consisting of soft farinaceous substances, a little plainly-dressed meat, if it do not cause uneasiness, and fowls or game, provided the latter be not high. The drink should be barley Avater or milk and lime-water; or if there be not much flatulence a draft of equal parts of milk and soda-Avater will often be found refreshing. AVhen there is much exhaustion a little arroAV-root Avith brandy may be taken. Tabes mesenterica, or, as it is sometimes more fitly called, phthisis abdominalis, consists essentially of strumous or tuberculous inflam- mation of all the tissues of the intestines, and of the mesenteric glands. This is a disease almost exclusively of infancy, childhood, or early youth. It may follow as a sequel of muco-enteritis, but otherwise the symptoms at its commencement are insidious and obscure. In the majority of instances there will have been previously-enlarged glands, tumid abdomen, or other signs of the strumous diathesis. The appetite of the child becomes capricious; there will often be an unwillingness to take food, alternating with an almost insatiable craving; the complexion of the child becomes doughy, though the cheeks may retain their colour for some time. He afterwards begins to lose flesh, and the abdomen becomes more tumid, Avhich is ren- dered more obvious by the emaciation of the extremities. There Avill be flushings of heat, more particularly towards evening, when there is often not uncommonly a bright, Avell-defined flush upon one or both cheeks. The bowels are irregular, the motions sometimes dry and friable, at others very relaxed, and almost ahvays pale. The urine is loaded with lithates, and often there is a stain of purpurine at the bottom of the vessel. The tongue is covered with a creamy coating, through Avhich the elongated papule are conspicuous; the breath is sourish and offensive. If the disease be not arrested in its earlier stages, the emaciation increases, the abdomen enlarges, and considerable effusion often takes place into the peritoneal cavity. There are frequent attacks of diarrhoea, pus or blood being sometimes present in the evacuations. Hectic increases, and the patient sinks from asthenia. The treatment of this disease, to be effective, must be preventive; and the indications which we must endeavour to fulfil, are, first, the correction of the strumous diathesis; and, secondly, to prevent the determination of that diathesis to the abdominal viscera. For this end, we must endeavour to prevent or counteract those circumstances Avhich have been pointed out (p. Ill) as tending to promote this diathesis, and in addition, the uses of the steel, Avine, and cod-liver oil, to the extent of a drachm of each three times a-day for a child of four years, may be had recourse to, the bowels being regulated as occasion may require. AVe have already pointed out that childhood is the period in Avhich those organs are in the state of greatest func- tional activity compared to the rest of the system, and therefore the phthisis of childhood is often abdominal. Now, although we cannot dispense with the functions of the alimentary canal and mesenteric glands, we may do much toAvards the rendering those functions the DIARRHffiA — VARIETIES. 369 cause of the least possible irritation to the organs themselves. Thus the diet should be of the simplest and the blandest character, as Avell as that which is the most readily digested and assimilated. Milk, as containing all the elements of nutrition in a fluid state, is peculiarly appropriate; but, in the earlier stages of the complaint, beef-tea, made according to Professor Liebig's recommendation, and even the gravy of roast meat, or the meat itself carefully cooked, are admissible, as are also light farinaceous articles of diet. AVhen there is any febrile excitement, the iron and codliver-oil must be suspended, and simple salines may be employed. In the more advanced cases, Avhere there is much abdominal tumescence, and even fluctuation, Ave may often derive much benefit from the iodide of potassium (F. 68).* AVe have already alluded to diarrhoea as produced by inflamma- tion or irritation of the mucous lining of the small intestines, but, independently of-this, it may arise from a variety of causes. Among the first of these may be reckoned the overloading of the stomach, and the taking of food which is indigestible. This is the diarrhcea crapulosa of Cullen, and proceeds from the excessive secre- tion poured out in consequence of the irritation set up by the quan- tity or quality of the ingesta. The symptoms of this form of diarrhcea are griping, flatulence, sometimes nausea, a foul tongue, acrid or rotten egg eructations, stools of unnatural appearance, very liquid, or even watery; there is little or no fever or acceleration of the pulse. Another cause of diarrhcea is mental emotion, especially fear, the effect of which in this way is proverbial. A high temperature, again, has the same effect, perhaps by stimulating in the first instance the liver, the increased secretion from which excites that from the small intestines; be that as it may, we certainly find diarrhcea most preva- lent in the hot months of summer and autumn. The treatment of diarrhoea must depend in a great measure upon our knoAvledge of its cause, though it must be regulated upon the principle of excluding every source of irritation. In the diarrhcea crapulosa, the purging will of itself generally remove the offending matters; though, if we are called at the com- mencement, Ave may favour the process by the administration of about a tea-spoonful of castor oil, or the combination of rhubarb and chalk (F. 58). After this a day or two's abstinence upon barley-water will complete the cure; though if the bowels continue irritable, it will be Avell to give a gentle opiate. In the case of diarrhoea from mental emotion, or that which arises apparently from season or external causes, the bland diet should be had recourse to, and if the diarrhoea do not speedily subside, a little chalk-mixture may be employed. If the diarrhcea persists, vege- * (68) R. Pot. Iodidi, gr. iij. Liq. Potassse, n\^. xxiv. Sp. JEth. nit. 3 j. Decoct. Sarsse. co. q. s.; to make a three ounce mixture. A table-spoonful of this may be given three times a-day to a child of three years old. 24 370 ENGLISH CHOLERA—DYSENTERY. table astringents, and the aromatic confection may be administered (F. 69).* It sometimes happens that the disease assumes a more severe character; the vomiting and purging being profuse, and much tinged with bile, are supposed by some to consist mainly of that secretion, though there can be little doubt that it is largely diluted, as well by the exhalations from the alimentary canal as by a great Aoav of mucous from the biliary passages. AVith the purgings are violent pains in the stomach and boAvels, cramps in the abdominal muscles and in the legs, depression and tendency to collapse, Avith cold extremities and a feeble pulse. The exhaustion and collapse has sometimes been so great that death from syncope has ensued. This is the English cholera, or sporadic cholera, generally more or less prevalent in the autumnal months; but differing widely from the fatal epidemic, or Asiatic cholera, from Avhich it may be distinguished by the evacua- tion being coloured, the urine not being suppressed, the tongue being warm, and, by the face and extremities, though showing signs of depressed circulation, not presenting the leaden colour and sodden feel of that fearful malady. The prognosis of the cholera of this country is upon the whole favourable, though persons of feeble powers sometimes give Avay under it. At the commencement of this disease, the best treatment is that recommended by Sydenham, and which is in principle that which has been so much insisted upon throughout this Avork, namely, the alloAV- ing of the subsidence of the irritation. Any attempt either to expel the offending matter by purgatives, as Avell as that of locking up the acrid discharges in the canal, must be injurious. He therefore recom- mends emollient drinks; of these we possess an admirable one in the form of arroAV-root. If, however, the vomiting and diarrhoea continue obstinate, and we are rarely called until they have done so for a few hours, the best and safest plan is to give an opiate, of which the best form is a grain of solid opium with a grain of calomel. This may be repeated in four or six hours, or even less if the sickness and vomiting continue. Some cretaceous mixture may also be given after every alternate evacua- tion (F. 70).f If the extremities become cold and the pulse feeble, wine in brandy and ammonia should be given; and diligent friction should be used to the abdomen and extremities, when the cramps are distressing. Dysentery is essential in an inflammation of the mucous membrane * (69) R. Confect. Aromat. gr. xv. Tinct. Cinnam. co. zj. Infus. Cusparise, 3 vij. M. To be repeated twice or thrice a-day. f (70) R. Confect. Aurant. 3 ij. \7in. Ipecac. 3 ss. Tinct. Opii, m . xx. Mist. Cretae, 3 iv. Aq. Cinnam. q. s.; to make a six ounce mixture, of which one ounce is to be given after every alternate evacuation. CAUSES AND TREATMENT. 371 of the large intestines, and its effects are morbid secretions from the membrane with excessive irritability of the canal. Consequently we have—griping pains in the abdomen, generally referred to the course of the large intestine,—excessive straining, and tenesmus,—slimy mucous stools, often tinged with blood. The acute form of this dis- ease is attended with the fever of mucous inflammation. AVhen the inflammation is in the descending colon and rectum, the stools are very scanty, and contain little fecal matter; when, on the other hand, it is nearer towards the cecum, there is more liquid fecal matter mingled with the blood and slime; the disease partakes, in fact, more of the character of diarrhcea, and has been termed dysen- teric diarrhoea. Dysentery is a very severe and often fatal disease in hot climates, and is one specially fatal to soldiers exposed to vicissitudes of weather in such situations. It is by no means so common now in England and the metropolis, as in the days of Sydenham, still, the wards of our hospitals present cases of acute dysentery, commenting in this country, though the majority are severe cases of the chronic disease in persons who have undergone the acute stage abroad. The symptoms of fever sometimes precede those of the local affec- tion, but more frequently the latter declare themselves the first. The fever is, at the commencement, that of active inflammation, but as it is also that of mucous inflammation in the abdomen, it soon assumes more of an asthenic character, and the pulse becomes compressible. Except the fever be great, the tongue may be natural. The pain is often severe, though not generally constant, and there is usually more or less tenderness along the course of the colon. One most distressing symptom is the frequent desire to go to stool, which is not relieved by obeying the call. Sometimes the matter discharged is white slime, but more frequently it is tinged with blood, constitut- ing what used to be commonly termed the bloody flux. Sometimes there is dysuria; and in very severe cases the stomach often sympa- thises, and there is vomiting. AVhilst these symptoms continue, the febrile condition is kept up, and assumes a low typhoid form, and the patient may ultimately sink from asthenia. The anatomical changes are essentially those of acute inflammation of the mucous membrane and sub-mucous areolar tissue, for a descrip- tion of which we would refer to the Avork of Drs. Jones and Sieve- king.* The muscular and peritoneal coats are rarely involved; but the whole internal surface of the large intestines may be often seen to be reduced as it were to a ragged mesh of disorganisation. The causes of this severe form of the disease appear to be exposure to vicissitudes of heat and cold, and wet, especially in hot climates, and in marshy localities. It is sometimes a sequel of ague, and cer- tainly infests the same districts. AVe have already shoAvn how dvsentery may lead to disease of the liver. But in hot climates more particularly, ague gives rise to congestion of the liver, which, * " Manual of Pathological Anatomy," Philadelphia edition, p. 494, et seq. 372 DYSENTERY. by obstructing the return of blood through the portal vein from the rectum and descending colon, therefore favours hyperemia of those parts, and consequently dysentery. The causes of dysentery are brought as it were to a focus amongst soldiers engaged in active ser- vice, in hot climates and marshy districts, and therefore it has not been unaptly called by Sir James M'Gregor, "the scourge of armies." Under such circumstances, too, it appear in some instances to have assumed a contagious character. The prognosis of the dysentery of hot climates must depend much on the character of the disease prevailing at the time. In this climate it is not often fatal, though it may be so in feeble constitutions, espe- cially in children, and in young persons of strumous diathesis, in whom there would appear to be a tendency to scrofulous diseases in the abdomen. In the severe form of the acute disease, the.plan recommended in the army has been, bleeding at the commencement, and immediately after twelve grains of Dover's powder every hour for three doses; diluent drinks are to be freely given, and sweating encouraged for eight hours; afterwards, three grains of calomel and one of opium every alternate night, and in the intervening days two drachms of Epsom salts in light broth. The bleeding was repeated if the pulse warranted it; Dover's powder given immediately afterwards as a sudorific. The above plan embodies the principle of subduing the general inflammatory action, and obviating the local irritation. AVhen the disease has assumed a more chronic form, in which case it has probably proceeded to ulceration, laxatives and opiates should be given alternately, and soothing enemata administered. In the dysenteries of this country bleeding is rarely required; and when the disease presents itself in a severe form there is generally too much depression to justify it. Leeches may be applied to the track of the colon, if the tenderness be great; or they may be, with much benefit, applied to the verge of the anus. Three grains of hydr. cum cret. may then be given, and two hours after that, half an ounce of castor oil, with about three minums of tincture of opium. Warm baths, hot fomentations tothe abdomen, and a feAV grains of Dover's powder night and morning should be employed; and if the disease continue, and the motions are pale, about two grains of the hydr. cum cret. may be added to Dover's powder. AVhen the febrile symptoms have subsided, the cusparia may be given as an astringent. In the severe forms of chronic dysentery, imported from abroad into the wards of our hos- pitals, the combination of copper and opium is a most useful astrin- gent (F. 71).* * (71) R. Cupri Sulphat. gr. ij. Opii, gr. iij. Ext. Glycrrhiz. q. s. Ft. Pil. vj.; one to be taken three times a-day. CHOLERA INFANTUM — SYMTOMS. 373 [CHOLEEA INFANTUM. This disease, the characteristic symptoms of which are vomiting and purging, with rapid and extreme emaciation, is an endemic of all the larger cities throughout the middle, southern, and a part of the Avestern portions of the United States, during the season of the great- est heat. So exclusively is it confined to this portion of the year, as to be familiarly denominated in many of our cities, the summer com- plaint of children. The disease is met with only in infants; and it is, perhaps, one of the most fatal to Avhich they are liable in this country. This results less from the actual malignancy of the disease, than from the con- continued action of the endemic cause—a heated and impure atmo- sphere—by which the disease is produced, from the influence of Avhich, in the majority of instances, it is scarcely possible to effect the removal of the infants, either before or after they are attacked. Cholera infantum occurs chiefly in children between four and twenty months of age—seldom earlier or later. If its second sum- mer is passed Avithout an attack, the infant is considered as being in little danger from the disease. The attack, in most cases, commences with profuse diarrhoea—the discharges being sometimes of a green or yelloAV colour, but more commonly colourless, or nearly so, and of a watery consistence, often intermixed with minute AA'hitish flocculi. The diarrhoea is very soon accompanied by great irritability of stomach, every thing swallowed being immediately rejected. In some cases the infant is, from the first, attacked Avith almost incessant vomiting and Avatery purging; the stools being small in quantity and forcibly expelled. More com- monly, however, they are large in quantity and passed Avithout the least effort. ■ From the very commencement of the attack the child exhibits great languor and prostration, and becomes rapidly and extremely emaciated. In most cases, the pulse is, at first, quick, frequent, small, and sometimes tense. The tongue is coated Avith a white, slimy mucus. The skin is unusually dry and harsh. The head and abdomen are hot, and the extremities either of their natural temperature, or more or less cold. There is intense thirst. Most commonly a degree of febrile reaction takes place toAvards evening. Some degree of abdo- minal pain is ahvays experienced, causing the child to be fretful, restless, to draw up its knees, and to utter, occasionally, acute screams. The pain is more severe in some cases than in others, the abdomen being tender to the slightest touch, and more or less tympanitic. In many cases the extreme irritability of the stomach soon ceases, the diarrhcea, however, continuing unabated, or the evacuations from the bowels increase in frequency but diminish in quantity. The irritability of the intestinal canal is often such as to cause whatever 374 CHOLERA INFANTUM. is taken into the stomach to be immediately discharged per anum, without having undergone the slightest change. Delirium occasionally sets in at an early period of the attack. The eyes of the patient become wild and injected—he tosses, incessantly, his head backAvards and forwards, and frequently attempts to bite or scratch his attendants. Although, in very violent cases, death, from extreme prostration, may occur Avithin twenty-four or forty-eight hours, the disease usually runs a protracted course. The child becomes more and more emaci- ated—the skin cool and clammy, shrivelled, and of a dark brownish hue. It is often covered with minute petechie. The eyes are lan- guid, glassy, and holloav, the countenance shrunken, the nose sharp and pointed, the lips thin, dry and shrivelled. The fauces becoming- dry, a difficulty in deglutition is experienced, and the child is induced to thrust his hand deep into his mouth as if to remove some offend- ing substance. The abdomen becomes more and more distended, and the hands and feet pallid, or of a leaden hue, and oedematous. The discharges from the bowels become dark coloured, and very offensive—resembling the washings of spoiled meat—or they are com- posed entirely of a small quantity of dark coloured mucus, mixed with food or drinks that have been taken into the stomach. The patient becomes more and more exhausted—rolls its head about Avhen aAvake, and utters constant short, plaintive, scarcely audible cries; or, he lies constantly in a state of partial stupor, with half closed eyelids, and so insensible to external impressions as to allow flies to alight on the half exposed eyeballs without his exhibit- ing the slightest consciousness of their presence. In the majority of the protracted cases, an eruption of very minute white vesicles occurs upon the breast and upper portion of the abdo- men. Frequently the brain becomes affected at an early period of the attack, and the patient dies with all the symptoms of acute hydro- cephalus. More commonly, however, he falls very gradually into a state of complete coma, death being not unfrequently preceded by convulsions. The pathological lesions in this disease vary according to the period at which death takes place. AVhen this occurs early in the attack, often the only morbid appearance to be detected is an extreme paleness of the mucous coat of the stomach and intestines, Avith more or less congestion of the liver. AVhere the disease has lasted for a longer period, increased redness in points or patches of the alimentary mucous membrane, is generally present. The red points have, in most cases, the appearance of minute extravasations of blood. They are sometimes isolated and spread over a large portion of the stomach and duodenum, or occur only in the small intestines. In other parts of the bowels they occur in patches, often slightly elevated, from a thickening of the mucous membrane. The patches vary in size, but are never very large. In other cases, Avith increased redness of some portions of the intestines, there is an extreme contraction of their caliber. Occasionally more CAUSES — PROGNOSIS. 375 or less softening of some portions of the mucous membrane of the stomach or intestines is met with, often unattended with the slightest trace of inflammation. The muciparous follicles of the intestines are in most instances enlarged, often inflamed, and occasionally ulcerated. The liver is very commonly enlarged, and more or less congested; the gall-bladder filled with dark green bile, or Avith a pale almost colourless fluid. In perhaps the majority of the more protracted cases, serous effu- sion is found upon the surface, at the base, or in the ventricles of the brain, accompanied, in some instances, with opacity and thicken- ing of the arachnoid membrane. In very protracted cases, softening of the brain, to a greater or less extent, is often present. Cholera infantum Avould appear to depend upon hyperemia of the mucous membrane of the alimentary canal, Avith a morbidly increased activity of function in its muciparous follicles—more or less inflam- mation being excited, in the course of the disease, either by the con- tinued action of the causes by which it Avas originally produced, or by accidental sources of irritation. The disease is the result exclusively of a heated, confined, and impure atmosphere. This acts primarily upon the skin and second- arily upon the mucous membrane of the digestive canal, at a period of life, Avhen from the process of dentition, and the development and activity, of its muciparous follicles, the membrane is strongly predis- posed to take on morbid action. The prevalence of cholera infantum, is ahvays in proportion to the heat of the summer, with Avhich it sets in and declines. It is, also, in a great measure confined to the larger and more crowded cities of the middle and southern states; and in these is chiefly prevalent and fatal among the children of those who inhabit small, ill-constructed houses, located in narrow, confined lanes, courts, and alleys, over- crowded in population, or in situations abounding with filth. AVhen it occurs in the country, which it seldom does, it is always in Ioav, damp, and otherAvise unhealthy localities. The process of dentition may be considered as among the most common predisposing, and errors in diet as a frequent exciting cause of the disease. The prognosis in cholera infantum will, in a great measure, depend upon the possibility of removing the patient from the influence of the endemic cause by which the disease has been produced and kept up, and the period of the attack at which such removal is effected. AVithout such removal it is very difficult in any instance to effect a per- manent cure, while in most cases, in the early stages of the disease, little else is required; even at a later period, its effects are always salutary, and has enabled the physician, by an appropriate treatment, to effect a cure under circumstances apparently the most unpromising. Even when a removal to a more airy and healthy situation cannot be effected, much benefit Avill be derived from carrying the patient frequently into the open air, in the nearest open and healthy situa- tion, in a carriage, or in the arms; daily rides into the country are ahvays of advantage; and still more so, Avhen the patient resides in 376 CHOLERA INFANTUM. the vicinity of a large river, daily trips upon the water in an open boat. AVhen in doors, the patient should occupy, both day and night, as large and airy a room as can be commanded, and this should be kept strictly clean, dry, and freely ventilated. His clothing should always be dry, clean, and while sufficient to guard from any sudden change in the temperature of the air, not too warm or heavy so as to overheat him. Fine soft flannel, or soft coarse muslin next the skin, will be adviseable in nearly every instance. The patient should sleep upon a mattress, or on a folded blanket, laid upon the sacking bottom or the floor of his crib, his body being defended by a light, loose covering. In all cases in which a child is attacked with the symptoms of cholera infantum, the gums should be at once examined, and if they be found hot, SAvollen or inflamed, they should be freely divided. The patient should be confined exclusively to the breast, or if Aveaned, to a diet of tapioca, pure arrow-root, or rice flour with milk, or plain beef, mutton, or chicken broth; and for drink, cold water in small portions at a time, gum water, or gum water with a slight addition of rennet whey; he should be immersed daily in a bath, Avarm or tepid, according as the temperature of the skin is deficient or increased, followed by frictions over the entire surface of the body with the hand or a soft dry cloth. These measures, with exposure to a pure, free atmosphere, will very generally, when commenced with at the onset of the attack, speedily arrest it. Should the diarrhoea, hoAvever, continue to be troublesome, one- sixth of a grain of calomel, in combination Avith a-half grain of ace- tate of lead, and three or four grains of prepared chalk, repeated every three hours, will ordinarily suspend it. To allay the irritability of the stomach which is so commonly pre- sent in the commencement of the attack, from a sixth to an eighth of a grain of calomel, rubbed up with a little dry sugar, and sprinkled upon the tongue, will in general succeed; if not, a drop or two of spirits of turpentine, or a solution of camphor in sulphuric ether, or a drop of creasote diffused in water may be tried. The acetate of lead in solution will often promptly allay the irritation of the stom- ach when everything else fails. Five grains of the acetate of lead, Avith the addition of five drops of diluted acetic acid, may be dis- solved in two ounces of pure water, and sweetened Avith a drachm of refined sugar, of which a teaspoonful may be given every hour until the vomiting ceases. AVhen the vomiting is violent and frequent, the application of a few leeches to the epigastrium will be found ser- viceable. In cases attended Avith pain, tenderness and tumefaction, with increased heat of the abdomen, leeches, in numbers proportioned to the age of the patient should be applied to the epigastrium, and fol- lowed by light emollient cataplasms or warm fomentations over the Avhole abdomen. The sixth of a grain of calomel rubbed up with two or three grains of prepared chalk and a third of a grain of hyoscyamus may be given every three hours. TREATMENT. 377 When symptoms of cerebral irritation present themselves—heat of the head, a wild injected state of the eyes, aversion from light, deli- rium, &c.—leeches are to be applied to the temples or behind the ears, cold lotions to the scalp, and some rubefacient embrocation to the lower extremities, or warm sinapised pediluvia employed. In all cases in which there is a tendency to disease of the brain, small blisters behind the ears, kept open by some stimulating dressing, will be found of advantage. When, after the morbid irritability of the stomach has subsided, frequent thin watery discharges from the bowels still continue, one of the best prescriptions will be found to be a combination of calomel, one-fourth of a grain, prepared chalk three grains, acetate of lead one grain, and extract of hyoscyamus one-third of a grain; to be repeated every three hours. As soon as the discharges from the bowels have become diminished in frequency, and more consistent in form, the common chalk mixture, with the addition of some light vegetable astringent, will generally confirm the cure. In the more chronic stage of the disease, anodyne injections com- posed of thin starch with the addition of a few drops of the tincture of opium, the administration by the mouth of some astringent as kino, decoction of dewberry root or the geranium maculatum, tinc- ture of galls, or tannin, with a well regulated diet, and exposure to a dry, cool, and pure atmosphere, Avill often effect the removal of the disease, under the most unpromising circumstances. The tartrate of iron in solution, or the persesquinitrate of iron will in these cases be often found beneficial. The sulphate of quinia in solution, with the addition of tannin, besides exerting a favourable impression upon the disordered condition of the bowels will, in many cases, at the same time, accelerate the patient's recovery by restoring strength to the system generally. In cases attended with thin, dark coloured, highly offensive dis- charges from the bowels, frequent griping pains, and a tympanitic con- dition of the abdomen, the best effects will be derived from the use of the following mixture: B. Mucil. g. acacie, 3 iij.; Sach. alb. pur. 3 iij.; Spir. terebinth. 3 ij.; Magnes. calc. gr. xv. Tinct. opii camph. Z ij. M. Dose, a teaspoonfull every three or four hours. AVhen there is great irritability of the bowels, 3 iij. of the tinct. kino or catechu may be advantageously added. Under the same circum- stances, pulverised charcoal will often be found to correct very promptly the morbid condition of the stools. It may be given in the following combination: R. Carb. ligni, 3 j. ad. 3 ij.; Pulv. rhei, 9 ij.; Ipecac, pulv. gr. iij.; Ext. hyoscyam. gr. iv. M. f. chart., No. xii.; one to be given every three or four hours. After the stomach and boAvels haAre resumed their natural condi- tion, the utmost care must be taken to prevent a relapse, by a proper regulation of the child's diet and clothing, and its exposure to a cool, free, and otherwise healthy atmosphere.—Editor.] 378 DISEASES OF THE KIDNEYS. XXII. DISEASES OF THE KIDNEYS. The urinary diseases which more particularly belong to the pro- vince of the physician are in general those in Avhich the secretion of the kidneys deviates from its healthy condition, either as to quantity or quality; independently of those mechanical causes Avhich interfere with its excretion from the bladder, the management of which falls more within the province of the surgeon. Now it must be borne in mind that for the secretion of healthy urine tAvo general conditions are essential. First, there must be a healthy and normal condition of the blood from Avhich the secretion is to be eliminated, and secondly, a healthy condition of the kidneys Avhich are to eliminate it. As regards the quantity of the urine, we have elsewhere explained the law, that in order to the due supply of water (upon which the quantity of the urine depends) there must be a ready absorption from the stomach and intestines through their respective veins, a free pas- sage through the portal vein and its branches in the liver, a free return through the vene cave hepatice to the ascending cava and right auricle and ventricle, a free passage through the pulmonic circulation to the left auricle, a free transit through the mitral valve and left ventricle, and thence through the aorta and renal arteries to the kidneys, and through these organs; and if obstruction to the circula- tion exist in any part of this circuit, we shall have the quantity of urine defective: and very scanty urine means nothing more than this; it points out that there is this cause somewhere, but it does not necessarily imply that there is mechanical obstruction; for, on the contrary it may arise altogether from a morbid impediment to some of those physiological actions which are essential to its transit through this course. When there is sickness, the fluid taken into the stomach being rejected before any absorption can take place, the urine is scanty, and the same is true when there is obstruction in the course of the small intestines. If, again, there be congestion or induration of the liver, the same result will ensue, and also if the fluid pass very rapidly through the intestines, as in severe diarrhcea, and still more when, instead of absorption, there is very rapid exhalation of fluid into the stomach and small intestines, as in the case of cholera, in the severest forms of Avhich there is absolutely no urine secreted. AVhen, again, there is obstructive disease about the right side of the heart, or in the cava near the entrance into the right auricle, and in the still more common case of obstruction to the pulmonic circulation from disease of the bronchial tubes or lungs; or, if there be disease of the mitral valve, causing either obstruction or regurgitation, the urine will be scanty; and also Avhen there has been disease of the aorta or CHANGES IN THE URINE. 379 its sigmoid valves of sufficiently long standing to impede the action of the left ventricle. We see then that the urine may be diminished in quantity from disease in any of these situations, independently of any affection of the kidneys themselves. AVith the kidneys the case is somewhat different. There may be disease of these organs without any diminution in the quantity of the urine, or even with an increased floAV of it. In those diseases again which interfere Avith tl^e capillary circulation throughout the system, in fever, for instance, the urine is scanty. Thus, if there be a free elimination of Avater by the malpighian bodies, the quantity of the urine Avill not be diminished, though the tubes may be diseased, provided that the disease be not such as to cause any mechanical impediment to the passage of fluid through them, in which case the change Avill be not in the quantity, but in the quality of the secre- tion ; but if the disease be such as to cause thickening or other obstruction of these tubes, or strangulation or disorganisation of the malpighian tufts, the secretion of urine will be impeded. As regards the changes in the quality of the urine, we may divide them into two great classes. I. Those in which the deviations from the healthy condition consist—of matters belonging to it in health, but altered in quantity,—or of substances which are not integrant ingredients of healthy urine, but are products of imperfect assimila- tion or digestion ; so that here we have two kinds of abnormal urine depending not so much upon the disease in the secreting organs as upon a morbid condition of the blood from Avhich the secretion is to be derived; of these, as they belong rather to lesion of the organs of digestion and assimilation, we shall speak elseAvhere. II. As regards the other class of morbid products in urine, those mainly in which the integrant ingredients of the blood are present, we find that unless they proceed from lesion of the urinary passages or bladder, they are the effect either of passive hemorrhage or of that large and impor- tant class of diseases which, for convenience sake as much as from the AArant of a better term by Avhich to express them, we include under the name of Bright's disease, after the illustrious physician to whose researches Ave are indebted for nearly all the knoAvledge we possess respecting them. In this form of abnormal urine we find tAvo remarkable conditions, both of primary importance in the clini- cal history of the disease of which we are treating: (1) The presence of some of the essential ingredients of the blood ; and (2) the abscence or defect of the natural ingredients of the urine. (1.) The presence of blood-matter in the urine is, Avhen it proceeds from the kidneys, a product of diseased action in those organs, and is to be received as probable evidence of such: but as that action is generally of an inflammatory character (acute, subacute, or chronic), it, like similar disease in other organs, interferes with their natural and healthy functions; that is to say, in this case, with the elimina- tion of those substances which ought to be carried out of the system by the kidneys—hence (2) the absence or defect of the natural solid contents of the urine. Some of these, the urea and uric acid more particularly, act as poisons when retained in the system, and exert 380 DISEASES OF THE KIDNEYS. their influence either directly upon the nervous centres, or more indirectly and slowly by producing inflammation or chronic changes * in the various tissues of the body; and further than this, the very abstraction of the blood-matter by the urine is itself a direct source of mischief, producing, when long continued, a deficiency in the natural elements of that fluid, which is the pabulum of the Avhole system. Of the ingredients of the blood, as in the original healthy blood, so also in the morbid secretion, which is derived from it, the albu- men is the most abundant of the soluble solid contents. The insolu- ble or red globules, though the most abundant in the blood, are not necessarily present in the albuminous urine, since, OAving to their inability to transude through the coats of the vessels, they can only find their way into the urine by more or less laceration of some of the minuter vessels. Indeed, as a general rule, we may say that the red globules, when present in this form of the morbid urine, are never so in a quantity proportionate (as compared to the blood) to the albumen, and that when present in the urine in such quantity, they indicate that the affection is more strictly of a hemorrhagic character, probably of a traumatic origin. As then the albumen is the prominent ingredient in such exuda- tion, it is important to be provided Avith a ready test for detecting its presence. Now it is well known that a simple solution of albu- men in pure water is rendered milky by the application of heat above 160° F., owing to the coagulation of the albumen at this temperature ; but the urine not being a simple fluid, but one Avhich may contain substances which prevent this coagulation, such as the alkalies and alkaline carbonates, which form with it albuminates soluble in boiling water, we have need of some other test not liable to this objection. Nitric acid is such a test, as it will throw down albumen when present even in a minute quantity, and of course pre- vents its combining with the alkalies. But nitric acid may throw down from the urine a precipitate which is not albumen; thus if there be a large quantity of urate of ammonia present, the nitric acid combines with the latter, and separates the uric acid, which gives to the urine a turbidity that by an unpractised eye is not very readily distinguished from albumen; this, however, is re-dissolved by heat. Heat is also liable to the objection, that it may produce a precipitate, which is not albumen : this ensues when the urine contains a large quantity of phosphates: such urine is generally alkaline, but not necessarily so; this precipitate, when it occurs, is immediately re-dis- solved by nitric acid. We see then that nitric acid and heat may both give precipitates which are not albumen, but that the precipitate which is thrown down by heat is re-dissolved by nitric acid if it be not albumen; and similarly that by nitric acid disappears by heat. Heat again is liable to the objection that it may give no precipitate though albumen be present: to this objection nitric acid is scarcely ever liable, though the addition of a few drops may give a precipi- tate, which is re-dissolved by a further addition, and this may even take place a second time if the acid be added guttatim; but the fur- TESTS FOR ALBUMEN IN THE URINE. 381 ther addition of acid produces a precipitate which neither itself nor the heat can re-dissolve. The two tests thus used in conjunction are therefore liable to little or no fallacy: the nitric acid alone is no doubt nearly sufficient for all cases; but if the urine be previously turbid by any of those sub- stances which are re-dissolved by heat, we cannot so Avell judge of the effect produced by acid. This difficulty would no doubt be obviated by previously filtering the urine, which ought to be done in every doubtful case. For bedside purposes the best method is to put first a small quantity, say about three drachms, into a clean test- tube, and if the urine be previously clear, and no precipitate comes down with nitric acid, there is, in all probability, no albumen present; but should any appear, boil the fluid in the tube over a spirit-lamp, and if this resist the heat, we may be sure that it is albumen. Should, hoAvever, no precipitate occur upon the addition of the acid, we may be almost equally sure that there is no albumen; but as it is well to verify even this test, let some of the urine be boiled in a clean tube, and then add the acid; if no precipitate occurs with either test, we may be nearly confident that there is no albumen, and if heat gives one which is re-dissolved by nitric acid it is phosphatic, and if there be none by heat, but nitric acid gives one, it is ablumen, as it comes down in the heated urine. It is commonly supposed that the phosphatic precipitate first takes place only in alkaline urine; this, however, is by no means univer- sally true, as has been shown by Dr. Eees: such urine, hoAvever, generally has a less decidedly acid reaction than healthy urine, or even the majority of cases of albuminous urine. It is remarkable that the hability to the opposite fallacy, namely, the presence of albumen without its giving a precipitate by heat, is also connected with alkaline urine; and, universally, when the urine is alkaline we are not to suppose that it is not albuminous because heat gives no precipitate, or rather we should place no reliance at all upon heat under such circumstances. It is not, however, as certainly true that when the urine is acid, albumen, if present, will be thrown down by heat, since • specimens of acid urine have been examined, though rarely, (and in carefully-cleaned tubes, too,) in which there has been no precipitate thrown down, although the heat has been continued for some time. Such urine has generally been of high specific gravity, and it is therefore probable that the albumen has been held in solution, by the ammonia resulting from the decomposition of the urea. It follows from this that heat is never to be used Avithout first ascertaining whether the urine is acid or alkaline, an examination which ought, under no circumstances to be omitted. For bedside purposes in private practice, and upon a first visit to a patient, when other tests may not be so readily procured, heat applied in the rough way of a spoon over a candle is a very convenient one, and a practised eye will generally recognise with tolerable certainty a precipitate of albumen thrown down in this way: but this should never preclude a more careful examination afterwards; and when there are other symptoms which indicate the probability of the urine being albu- 382 DISEASES OF THE KIDNEYS. minous, the absence of a precipitate by this test is never to be con- sidered as satisfactory. The fallibility of heat as a test for the presence of albumen, both positive and negative, probably accounts for the fables narrated of persons passing albuminous urine after a hearty meal of animal food, and when suffering under dyspeptic symptoms, produced by indigestible substances; such, for instance, as pastry. With regard to the latter, it must be remembered too that disordered stomach is one of the effects of renal disease, and may be present when many of the more prominent ones are Avanting. Persons under the influence of mercury are also said to pass albu- minous urine Avithout there being disease of the kidney; but as far as may be inferred from a very large number of observations made at Guy's Hospital, this is also an erroneous belief, though several such patients passed urine which gave the phosphatic precipitate with heat. Pregnant females not unfrequently pass albuminous urine, the albumen, in most cases, disappearing after delivery, and the patients doing well; but, as has been pointed out by Dr. Lever, care is re- quired in such cases, as there is a greater liability to puerperal con- vulsions, and other formidable nervine symptoms. A very delicate test for albumen is the addition of a solution of ferro-cyanide of potassium after acidulating the urine with a few drops of strong acetic acid. The methods of testing the urine for the presence of albumen have been dwelt upon at more length on account of their extreme import- ance, and the presence of albumen being the readiest test of the elimination of blood-matter by the kidneys. AVhen albumen is present, fibrine is so also, though it may escape detection; in most cases, however, it may be preceived in the urine, by the aid of the microscope, in the form of casts of the uriniferous tubes. Blood-cor- puscles may or may not be present; when they are they may be de- tected by the microscope, and their presence in great abundance is a sign of the disease being rather of a hemorrhagic character than the renal disease which we are now considering. Hematosine or hemato- globuline may find its way into the urine without any laceration of the vessels, by the disintegration of the corpuscles. It may be ob- served, however, in reference to this, that purpurine has often given to urine an appearance that has led even medical practitioners of experience to a belief that blood was present. When pus is present in the urine, its serum will of course render the latter albuminous; the pus will, however, be detected by the appearance of the pus-corpuscles under microscopic examination, as well as by the action of liquor-potasse applied to the sediment which subsides from the urine. Puriform urine is, however, by no means incompatible Avith Bright's disease. We now proceed to speak of that large class of diseases with which albuminous urine is commonly associated, though it may not be present in all cases; and we commence with acute nephritis as essen- tially belonging to it, though, perhaps, not ahvays included in the term Bright's disease; since the profession were not unacquainted with it before the appearance of the works of that physician, though NEPHRITIS. 383 for a more rational knoAvledge of its pathology we are mainly in- debted to him and his followers. NEPHEITIS. Although the kidneys, like other organs of the body, are liable both to acute and chronic inflammation, of Avhich the latter is incom- parably the more common, yet, as these, since the investigation of Dr. Bright, have generally been included under the term Bright's disease, we will, for the sake of convenience, restrict the term nephritis to the acute inflammation of the kidneys. By nephritis, then, we mean an acute inflammation of the kidney, which may be either idiopathic, or it may be the effect of some mechanical cause, as the presence of a calculus, or of some poison taken into the stomach, and thence absorbed into the circulation: of this we have instances in the effect of very poAverful diuretics, and also of acute poisoning by lead; tubercles, or the presence of strum- ous, or sometimes of fibrinous deposits, may also be either the causes or predisponents of inflammations. In the idiopathic inflammation, the kidney is generally somewhat enlarged, of a deep dusky red or chocolate colour throughout, and, when handled, softer and more lacerable than natural; in severe and fatal cases of this kind we often find minute points of suppuration through the organ, and puriform mucus oozing from the points of the infundibula. This inflammation may probably terminate by resolution, in Avhich case the symptoms subside, though in a large proportion of cases it proves fatal in its acute or earlier stage; or, it may lead to suppuration, one or more abscesses being formed in the organ, or sometimes the kidney is reduced to a mere sac of puriform matter. Acute nephritis may also pass into a chronic state, constituting one of the forms of Bright's disease. The diagnosis of nephritis is not Avithout its difficulties, and the same remark applies to other forms of renal irritation. Gastritis has many symptoms of nephritis; indeed sickness belongs as much to the latter as the former, and in both is the urine excessively scanty; but besides the unfrequency of pure gastritis, the urine when passed, though concentrated, is otherAvise healthy, and contains no blood- matter; whereas, in nephritis what little is excreted generally con- tains albumen. With regard to another affection however, namely, obstruction in the duodenum or upper part of the small intestines, the distinction is still more difficult, since, as in that case we may have no urine at all for three or four days, we can get no evidence from that source: this long-continued suppression should, however, incline us to look for its source rather in the intestines than in the kidneys. In this case, as also in that of the stomach, we must direct our attention to the seat and character of the pain; its lancinating character, its extension along the course of the ureters and down the thigh, or the numbness in the latter situation, together with retraction of the testicle, all indicate nephritic affection; but, on the other hand 384 DIAGNOSIS OF NEPHRITIS. these may be wanting, and it is not impossible that in occlusion of the duodenum, there may be spasms and cramps which may simulate the pain in the thigh and be attended with retraction of the testicle: this difficulty, it is true, is not a common one, but speaking from personal experience, it has occurred in several instances, and it has been a great difficulty when it has done so, though it does not seem to have attracted the attention of authors generally; it is, however, more readily solved, when the connection between intestinal obstruc- tion and scanty urine is remembered and understood. In colic the pain will often be apparently in the region of the kidneys or ureters, or both; but in that disease, owing to the obstruction being low in the bowels, the urine is abundant. This will prove that the disease is not nephritis, though it will not prove that the pains do not proceed from the presence of a calculus: but to that we shall pre- sently revert. In connection with the diagnosis of this disease, we may mention, that the testicle may not only be retracted and painful, but that it may also be actually inflamed; this fact, pointed out by Dr. Watson, in connection with nephritis, though it may not often afford much aid to our diagnosis, is most interesting as an instance of inflammation arising from irritation at one extremity of a nerve causing irritation or inflammation at other extremities of the same, or communicating nerves: in >other words, it is evidence of the reality of nervine inflammation. We have just been alluding to the irritation arising from a cal- culus, and this may often be attended with nephritis; indeed it is, perhaps, the most frequent cause of the acute form of that disease: but these pains may arise without inflammation, or with inflamma- tion confined to one kidney only; in the former case the disease is described as nephralgia, (some practitioners indeed speak of nephral- gia as an independent disease). In nephralgia the local symptoms are the same as in nephritis, but there is no fever; there will, how- ever, be sickness, and the urine may be abundant, or even excessive: it is here then, perhaps, that the greatest difficulty will arise in dis- tinguishing this disease from colic; but the lower bowels are not obstinately constipated, and the examination of the urine will, in the case of a uric-acid calculus, soon settle the question. In the case of an oxalate-of-lime calculus, the obscurity is greater, and can be de- cided only by a careful microscopic examination of the urine. Still it would be possible to multiply cases in which there has existed the greatest difficulty in distinguishing between diseases of the colon and irritation of the ureter, and the diagnosis is one that can be made only by minute investigation of such individual case, and of which it is impossible to include the whole details under any general rules. There is sometimes difficulty in distinguishing disease of the kidneys, whether nephritis or neuralgia, from that of the spinal column or the contents of the spinal canal. It is true, indeed, that both are often implicated at the same time, especially in the cases of suppurative disease of the kidney, described by Mr. Stanley; but in these cases the active nephritic symptoms are not generally present, and when the vertebre are diseased, examination of the spinous processes will TREATMENT. 385 almost ahvays detect either tenderness or laxation. The most valuable diagnostic sign in such cases is sickness: when the pain proceeds from irritation of the kidney, it will rarely be Avanting. The treatment of nephritis is in principle the same as that of all inflammations. AVe must endeavour to reduce the inflammatory action by such general antiphlogistic measures as the strength of the patient will tolerate; next we must use all means to exclude every cause of fresh excitement of the inflamed organ, and in very severe cases, and where the pulse and general condition of the patient war- rant it, blood may be draAvn from the arm. In the majority of cases, however, cupping from the loins is to be preferred, the quantity being of course regulated by the age and general condition of the patient. Even AAdiere the poAvers are feeble Ave may take tAvo or four ounces partly as a revulsive. As regards internal remedies we are somewhat at a loss, owing to the frequency of sickness. Calomel in small doses, in combination with opium, also in small doses, Avill some- times obviate this, but large quantities of mercury are uncalled for, and it is very probable that could Ave bring the system under its influence Ave should promote organic change in the kidneys. Opium also must be used with care, both on account of its tendency at first to confine the bowels, and the danger of its affecting the brain, already threatened by a narcotic poison. Diuretics, though sometimes sup- posed to be indicated by the diminished secretion of urine, are the most mischievous drugs that can be employed in acute nephritis. Antimony appears to be indicated as promoting the action of the skin, and thereby determining from the kidneys, instead of to them, like diuretics. The objection to its use is the tendency to sick- ness; it will not, hoAvever, be generally found that minute doses of antimonial medicines will aggravate sickness (they may indeed stop it), and the folloAving pill will generally be admissible (F. 72).* Should the opium be contraindicated by tendency to stupor or other form of cerebral affection, or should the tartar emetic appear to increase the sickness, Ave may use a combination of henbane with true James' powder (F. 73).f Saline medicines which do not act principally upon the kidneys, such as Liq. ammon. acet. and Liq. ammon. citrat., may be employed in small doses, and the action of the skin encouraged by large poultices to the loins, and by vapour-baths. If sickness be urgent, a feAV grains of calcined mag- nesia may be given in water. The diet should also be strictly anti- phlogistic, the aliment consisting mainly or entirely of farinaceous substances; animal broths being not only too stimulating to the system generally, but objectionable as solutions of azotised matter, the natural outlet for such substances being the kidneys, and there- * (72) R. Hydrarg. Chlorid. gr. ii. Opii, gr. i. Antim. Pot. Tart. gr. ss. Ft. Pil. vj.; one to be taken every three or four hours. f (73) R. Pulv. Jacobi veri, gr. iv. Ext. Hyoscyam. gr. v. Ft. Pil. ij. 25 336 BRIGHT'S DISEASE. fore such substances being in some degree stimulants to those organs Jellies, though not required in more acute stages, are not liable to the latter objection, which is hoAvever applicable to tea and coffee. It is needless to insist upon the necessity for perfect rest in acute nephritis, as the patient is generally far too ill to wish to do otherAvise than keep his bed; still it is a principle to be remembered in the treat- ment of the less acute stages, and also as bearing upon the manage- ment of kidney disease in general. In those cases in Avhich there is no fever, or which are in fact nephralgia from the presence of calculous matter, opium may be freely used ; and in such instances there Avill be less danger from its effect upon the brain, as the urine is commonly abundant, one kidney only being in the majority of cases implicated, or that being, for the time at least, sufficient for the purposes of depuration. Under such circumstances, too, gentle diuretics may also be sometimes used, Avith a vieAV of aiding the expulsion of the calculus from the pelvis of the kidney. For this purpose the citrate of ammonia with the potassio-tartrate of soda, in doses of about a scruple, Avith tinc- ture of hyoscyamus, warm-baths and poultice to the loins, Avill also give relief, as will also belladonna liniment or a belladonna plaster. BRIGHT'S DISEASE. We now proceed to the consideration of that class of diseases far more common than the acute nephritis, and which produce a very large proportion of the deaths arising from chronic disease. If all the fatal cases of heart disease and disease of the brain, originating from albuminuria, or Bright's disease, be taken fairly into the account, it Avill be found that this disease is second only to phthisis in the number of lives which it destroys. The anatomical changes Avhich occur in the kidney are almost as various as those which take place in the respiratory organs as sequele of the different forms of inflammation, acute and chronic; or they may be still more aptly but less familiarly compared to those Avhich occur in the liver, in AAdiich we find congestive inflammation of the ducts or catarrhal inflammation, cirrhosis or inflammation of the areolar tissue, with contraction, and fatty degeneration. Into the minute changes which constitute the varieties of Bright's kidney it is not our province very fully to enter, not because those changes are in themselves devoid of interest in a practical point of view, but because their description, belonging more to pathological anatomy, would refer the reader to the Pathological Anatomy of Doctors Jones and Sieve- king, p. 517 et seq. Philadelphia Edition. For practical purposes we would recognise six forms of Bright's kidney, though it is probable that the first three may be different stages of the same affection. 1. That Avhich commonly occurs in an acute form, and which has the nearest resemblance to an acute catarrhal affection : it is, in fact, if the expression may be used, a bronchitis of the kidney. Like ITS DIFFERENT FORMS. 387 analogous disease in other organs, it evinces the close sympathy between the skin and the internal mucous membranes, being that form Avhich is generally induced by affections of the skin or impres- sions upon it, as in scarlatina and the application of cold to the ex- ternal surface. The kidneys are large, SAvollen in fact, and dark from an increased quantity of blood, the tubes being in a condition of active hyperemia; the anatomical changes are very similar in appearance to those produced by the passive hyperemia from mecha- nical obstruction, forming the " coarse" kidney to be hereafter noticed. This form of diseased kidney is perhaps that with the pathological anatomy of Avhich we are the least acquainted, since the disease is rarely fatal, in this stage at least. In the commencement the urine is scanty, of a smoky appearance, as if soot had been stirred up in it, and of a specific gravity Ararying but little from the natural standard. It is highly albuminous, containing also red corpuscles, to Avhich its peculiar colour is OAving, and epithelial cells, which may be seen under the microscope. It is from this circumstance that it has obtained the name of acute desquamative nephritis. It is well to repeat that the urine is scanty, and that there is, therefore, defec- tive depuration of the blood, Avhich is also drained of its solid ingre- dients, though not to such an extent as in the next form of the disease. 2. There is the form of disease commonly known as the large white kidney, in which the organ is large, generally as much as double the natural size and weight. AVhen the tunic is peeled off, which it readily may be, the surface is presented, very pale, of a polished smoothness, and faintly marked with stellated vessels. The section of the organ when cut into presents to the naked eye a dingy white surface, almost homogeneous for a considerable depth from the surface of the organ, though near the pelvis the straight tubes are as strongly marked upon the pale ground. This appearance is found, upon microscopic examination, to be produced from the obli- teration of the tubuli by inflammatory deposit. Associated with this form of disease the urine is nearly about the quantity secreted in health, generally of the smoky appearance, noticed in connection with the preceding form, from the admixture of red corpuscles, very albuminous, and of light specific gravity. As the disease advances, the urine commonly becomes less in quantity and of lighter specific gravity. The remarkable circumstance in this form of .morbid urine is the concurrence of a large quantity of blood-matter, and the defi- ciency in the proper excretory matter of the urine. 3. The third form of disease is one which is now become almost obsolete amongst pathological anatomists, though it used to be re- garded as nearly synonymous Avith Bright's kidney, namely, the mottled kidney. This is large, and mottled with Avhite upon a coarse and rather dark ground; it is probably a state of transition from the first to the second form of the disease. The character of the urine secreted by kidneys thus affected is an intermediate one be- tAveen the last tAvo. It is at first of moderate quality and of specific gravity of about 1015. It afterAvards becomes of lighter specific 388 bright's disease. gravity, and if the case be watched throughout, it first undergoes an increase in quantity, and then begins again to diminish: the promi- nent characteristics of the urine approaching, as the disease advances, more nearly to those of the second form. It may here be remarked, that the three forms already described, differ probably more in degree than in the nature of the morbid change. There is, however, this distinction to be observed, that the first form is more commonly an acute affection, and one Avhich has therefore a greater tendency to recovery, but which, when fatal, proves so in a shorter period, presenting upon inspection the appear- ances which have been described ; it may therefore be asked, what is the evidence of its being capable of passing into the second ? To this it may be replied, that, in those cases, Avhich are not very fre- quent, that have commenced Avith the symptoms characteristic of the first form, and which have assumed subsequently a more chronic character, and ultimately proved fatal, the kidneys have been found to present the appearance of either the second or third. The next tAvo varieties Avhich we have to notice are also probably but different stages of the same disease, but essentially different from the three preceding, though an attempt has been made by Freirick to establish the identity of all; this question has, however, been ably investigated and decided in the negative, by Dr. AVilks, in an excellent paper in the Gruy's Hospital Reports for 1853, vol. viii. p. 232. 4. The fourth form then is one Avhich differs more in reality than in appearance from the second or large white kidney; the organ being, as in that form, " large, dense, and Avhite" (I use the words of Dr. Wilks in the paper alluded to above).—" It is, in fact, an entire fibrous metamorphosis of the kidney, differing from the latter (form 2) in this, that Avhereas the characteristic of that Avas a diseased con- dition of the tubes, Avhich were croAvded Avith exudation, in this, the section is smooth, uniform, and evidently consisting of one homoge- neous material; the deposit being in this case in the parenchyma, or areolar matrix of the organ, may be regarded in some measure as analogous to pneumonic induration. This form of diseased kidney is perhaps not of A'ery frequent occurrence, at least, not on the inspec- tion table, as it probabby passes on to the more frequent and fatal form to be next described. As far as Ave can A^enture an opinion, the urine Avhich is secreted is scanty, of Ioav specific gravity, contain- ing a small quantity of albumen, and very defective in urea and the other excretory matters." 5. The fifth form of Bright's kidney is that commonly known as the hard, granular, or contracted kidney. The kidneys are smaller than in health, generally about half the size; the surface of the organ is uneven and puckered, what in fact might be termed hobnailed, the tunic adherent, and the surface of the organ apt to be lacerated in the attempt to detach it. The essence of the disease being a degeneration, or atrophy of the secreting structure, which is in some parts so narrowed that the bases of the tubular cones almost reach the surface of the organ: there is no deposit in the tubes, but the degeneration consists of a large increase of fibrous tissue, which, by CHANGES IN THE BLOOD. 389 its subsequent contraction, strangulates and atrophies the secreting cells, much as in the case of advanced cirrhosis of the liver. The urine secreted by the kidneys in this form of disease, may or may not be albuminous; often it is not so; or when albumen is present, it is in very small quantities; it is, however, of very light specific gravity, sometimes as low as 100*5, and very scanty. The essential characteristic of this form of disease is a suppression of the excretion by the kidneys, of the natural solid ingredients of the urine. 6. The sixth form of this disease, is that Avhich Avas termed by the late Air. T. AV. King the " coarse kidney." The organ in this form is large, dark, not unlike that of the first form, being, in fact, in a state of hyperemia, the result, generally, of a certain amount of mechanical obstruction, arising from impediment to the circulation through the right heart. The pathology of this affection appears to consist in a passive hyperemia, upon Avhich has supervened some subacute inflammatory action, induced perhaps by a fresh attack of the original disease (chronic bronchitis for instance), or excited by the exposure to cold, or the impression upon the skin or other mucous surface Avhich produced that fresh attack. The urine in this form of the disease is always scanty, generally of high specific gravity, loaded Avith urates, and containing but a moderate quantity of albumen; when rendered turbid by lithates, it generally becomes clear upon the first application of heat, but as the heat is continued, it becomes again turbid from the deposition of albumen. AVe cannot quit the subject of Bright's kidney without some allusion to the fatty degeneration of the organ, to which for some time much importance Avas attached, it being supposed to constitute the primary and efficient cause of large numbers of cases. Further observation has, however, tended to show that fatty change is rather an effect, and a sign of previous disease, than any way concerned in the etiology of the disease itself; thus, for instance, we have seen that one of the sequels of inflammatory action may be fatty change, and accordingly the inflammatory exudation into the tubes, in the large Avhite kidney, may eventually become fatty; and in a similar manner, the small, granular kidney may be very fatty, though both these conditions may occur without any fatty deposit Avhatever. Such, then, are the general characters of the morbid changes, which constitute the fundamental lesion, in the large class of diseases which, for convenience' sake, we term Bright's disease: and such being the differences in the immediate effects of that disease (by which we mean the different modes in Avhich the urine is altered from the normal state), which effects become in their turn the potential causes of other diseases, we naturally expect that those other diseases must be of very different characters; and further, since the alteration in the quality of the urine is of such a nature as materially to influence that of the blood itself, Ave should also be led to expect that these secondary or remoter diseases might attack the system wherever the blood is distributed, or, in other words, that any part of the body may become affected. Of the changes in the blood itself, the first, and most obvious, is 390 BRIGHT'S DISEASE. the diminution in the solid ingredients—albumen and red globules, and after a time in the fibrine also. In all the first three forms of disease, in which the urine contains a large quantity of albumen, there is soon a notable deficiency of that substance in the blood, Avhich has the effect of reducing its specific gravity much beloAV the natural standard, sometimes as Ioav as 1015 or 1010. When, as is often the case, the red corpuscles are likcAvise present in the urine, they also speedily become defective in the blood; but in many instances, of the second form more particularly, in AAdiich the urine is highly albuminous, there are no red corpuscles, and in these there is no notable deficiency of red corpuscles until the disease has existed for a considerable time, after which the corpuscles as well as the alubmen become defective. The same thing nearly is the case Avith the fibrine, Avhich is not defective in quantity, but on the contrary is sometimes in excess at the commencement of the disease, and continues to be so even after a notable decrease in the albumen and red corpuscles; it is owing no doubt to this, that the blood when draAvn is often buffed, and sometimes cupped; later, hoAvever, in the progress of the disease, the fibrine also becomes defective, falling as low as 2 or 1| per mille. The other effect upon the blood, Avhich may be regarded as a potential cause of disease, is the retention in the blood of the excretory matters, urea, uric acid, &c. Owing to their non-elimination by the kidneys, these substances, more particularly the urea, from its greater abund- ance, may be readily detected in the blood; and so retained they act as poisons, or irritants upon the nervous system, the serous mem- branes, the coats of the arteries, and other tissues. The principal changes thus produced upon the blood may be summed up as a deficiency of albumen, red corpuscles, and, ultimately, of fibrine also, or, which amounts to nearly the same thing, a proportionate excess of water, and the presence of a large quantity of excretory matter. As a result of the change in the blood, Ave may first notice deopsy. This indeed was the symptom, or, as it was then considered, primary disease, which drew attention to the abnormal changes in the urine of which Ave have been speaking, and to their subsequent connection Avith disease of the kidney. This dropsy shows itself in the greatest degree in those cases in Avhich the urine is most albuminous, and the blood most abundant in water; and it is, no doubt, mainly owing to this cause; but, as serous effusion may be excited by irritation either of the general areolar tissue of the body, or of the closed sacs, we can readily believe that the presence of an irritating matter will produce the same effect. AVe have, therefore, tAvo causes at work, Avhich may be considered to co-operate in producing the effusion. This effusion is in greatest abundance in those cases in which there is the greatest drain from the blood, that is to say, in the first three forms of the disease, and in such cases it shows itself mostly in the form of general anasarca, though this may be accompanied by effusion into the serous cavities of the head, chest, or abdomen. It is, per- haps, in the more advanced stages of the second form of the disease, that, namely, of the large white kidneyi; in which we have a coincidence of the tAvo causes, a great drain of blood-matter—and a very defective MUCOUS INFLAMMATION AND HEART DISEASE. 391 elimination of urine-matter,—that Ave meet with the greatest amount of effusion, both general and into the serous cavities; the latter form of effusion being often of a highly-inflammatory character, and con- taining a considerable quantity of fibrinous or molecular lymph. In the fourth and fifth forms of the disease, especially the latter, in Avhich there is little or no albumen passing off by the urine, we may often have no dropsy, or scarcely any, though there may be sudden effusion of an inflammatory character, from the effect of the retained excretory matter in the blood. This, hoAvever, belongs more properly to the serous inflammations to be presently noticed. Before quitting the subject of dropsy, Ave may notice its tendency to affect the sub-mucous areolar tissue throughout the body; this effusion may, no doubt, like those last mentioned, be sometimes of an inflammatory character, and Avhere we have two causes in opera- tion, the one leading to dropsical effusion and the other exciting a degree of inflammation which may also induce similar exudation, it is difficult to draAV the line: but it may be of practical utility to bear in mind, both—that those effusions Avhich occur in such abundance in this disease, and Avhich we are prone to regard as mere exudations, may partake in some measure of the inflammatory character,—and also, that others which from their situation, as well as other pheno- mena attending them, may suggest to our minds the notion of inflam- matory affections, may, in reality, have much of the character of passive effusion. AVe particularly allude to the bronchial membrane, a sub- mucous effusion affecting which may, and often does produce, in con- nexion Avith diseased kidney, sibilant and other ronchi, which Ave are very prone to associate Avith more active bronchitis. Another form of sub-mucous effusion, Avhich is very common in all the varieties of this disease, is underneath the conjunctiva, producing the appearance of a watery eye; but when more closely regarded, it will be found that the appearance is not produced, as it seems to be, by a tear resting on the eyelid, but by an accumulation of fluid beneath the epithelium, which, gravitating towards the lower lid, causes the con- junctiva to overlap it, producing a kind of watery chemosis. This effusion is one of the most characteristic signs of renal disease, and has several times been observed in cases in which no other dropsical effusion whatever was to be detected, especially in those cases of the fourth and fifth forms of disease, in which there is a tendency to cerebral complication. AVhether this may have anything to do Avith disturbance of the cerebral circulation, or impending effusion, may be worth investigating. Another characteristic of the dropsy from the diseased kidney is, that when it assumes the form of general anasarca, it always affects the genitals, being particularly noticeable in the penis and scrotum, it also differs from the dropsy produced by disease in the liver, in its not being confined, even at the commencenient, to the loAver extremities, but affecting also the upper, as well as the face, where it particularly shows itself beneath the eyes. Purely renal anasarca differs from the purely cardiac in the absence of the lividity, and ■n 392 BRIGHT'S DISEASE. other signs of congestion, which almost always accompany the latter but in practice these causes of dropsy often concur. We have just spoken of the effusion under the mucous membranes as a form of dropsy; but Ave must add, that inflammations of these membranes are among the consequences of Bright's kidney; these we meet with in every form of the disease, though perhaps more particularly in the more advanced stages. Mucous inflammation shows itseif in the form of bronchitis, which is a very common effect of Bright's kidney. Dr. Wilks, in the paper above quoted, states it as his belief, founded upon most extensive observation, that it is the most common next to albuminous urine. Another shape in Avhich mucous inflammation or irritation pre- sents itself in Bright's kidney is in that of the gastro-intestinal mucous membrane, in the form of vomiting and diarrhcea, generally of a dysenteric character. The connection between inflammation of the kidneys and vomiting we have already pointed out; but inde- pendently of this, there appears to be an effort at a vicarious elimi- nation of the retained secretion by this membrane. Inflammation of serous membranes has been already alluded to, and it was one of the effects of Bright's kidneys which first attracted attention. It is very probable that the tAvo conditions of the blood, namely, the defect in the quantity of red corpuscles and the presence of excretory matter, concur in inducing this kind of inflammation, the former by causing a susceptibility of such inflammations, as we have seen (p. 60), and the latter by acting as a direct or efficient cause. That the presence of the urea in the blood is an efficient cause is evident from the fact, that urea is capable of exciting such inflammation: and that it is present in the effusions which take place into the serous cavities in this disease is well ascertained, it having been in different instances detected in every one of them. These inflammations are often of the most sudden and violent character,—an attack of pleuritis or pericarditis sometimes proving fatal in the course of twenty-four hours. The pleura and pericar- dium are the serous membranes most liable to become affected in this manner; and next in order are the arachnoid and peritoneum, the former perhaps the most frequently. It is true that affections of the encephalon frequently occur, but they depend probably upon another condition of the brain to be presently noticed. Another common consequence of the Bright's kidney is disease of the heart and large vessels. The excretory matters present in the blood appear to act as stimulants, inducing an inflammatory action in the endocardium and lining of the arteries, the consequence of which is thickening and puckering of the valves, and contraction of the orifices; the valves and endocardium on the left side being mainly affected. As an effect of this endocardial affection, either direct or through the narroAving of the orifices, that of the aorta especially, we find the left ventricle to become dilated, and, most commonly, at the same time hypertrophic, upon the principles already explained (p. 380). The chronic changes in the valves may also give rise, as in other forms of endocarditis, to obstruction or regurgitation, with their effects upon CEREBRAL AFFECTIONS. 393 the circulation. The action of the blood upon the lining of the arteries is of an analogous character, the membrane becoming opaque, and the other coats of the artery thickened and contracted, the effect of which is to cause irregularities in the circulation, espe- cially in the cerebral arteries, Avhich are particularly liable to these changes; thus either apoplexy may ensue from extravasation, or from sudden arrest of the circulation; or the circulation being only partially impeded, we have the more gradual effect of softening from imperfect nutrition. The substance of the lungs is not so frequently the subject of inflammation in Bright's disease as are the pleure and bronchial tubes. Still, in a considerable number of cases we find hepatisation and induration of the lungs, not to mention that the state which we commonly describe as oedema is often the effect of inflammatory action, the greater quantity of fluid in the blood in excess over that of plastic matter, inducing this form of effusion. The coincidence of pneumonia with albuminuria has been sufficiently common to sug- gest that it may be the cause of the latter; but the more advanced condition of the renal disease in all fatal cases of this kind, seems to answer the question in the negative. Besides the affections of the brain arising from the changes in the arteries, we have cerebral symptoms produced by the direct poisonous action of the retained secretion upon the nervous matter; this is, in fact, the most sudden as well as one of the most dangerous conditions of the toxemic condition, which plays so conspicuous a part in the phenomena of this disease. These affections are, either sudden con- vulsion, passing not unfrequently into coma, Avith a remarkable stridulous breathing; or, which is a very characteristic form of cere- bral affection, we have a state of "quiet stupor," to use the wrords of Dr. Addison, which may continue for a considerable time, out of Avhich the patient may recover if the elimination of the poison can be established; but if this do not take place, the stupor gradually assumes the form of most profound coma. These affections of the nervous system belong entirely, if we may so speak, to the aneccritic element of the disease; as shown by their presenting themselves in other affeqtions in which the uremia is induced by retained secretion, as in the retention of urine, and it may be in cholera, but in which there is no elimination of urine-matter by the urine. This state also appears to be a form of narcotism, resembling in many respects those induced by opium and by alcohol. The pupil is sometimes obedient to light, never dilated, and in many instances contracted. Another nervine affection often met with in Bright's disease, is the occurrence of cramp in the limbs, especially in the lower extremi- ties; the etiology of this affection is somewhat obscure, though its frequent occurrence is undoubted. It seems to take place most fre- quently in the earlier stages, so much so, that in many cases of some standing, the period of the commencement of the disease may be inferred from this symptom; it may possibly depend upon the great diminution in the quantity of the urine and consequent uremia, which often marks the commencement or more acute stage of the 391 bright's disease. disease. It is someAvhat remarkable that this is a prominent symp- tom in cholera, in Avhich likewise uremia exists in a remarkable degree. Having detailed the principal elements, so to speak, which make up this remarkable disease, we are in a position to treat of it as a Avhole. In the first three forms of diseased kidney Avhich we have described above, Ave have the first, Avhich is essentially acute, and the second and third, Avhich may be either a chronic form of the first, or have been from the commencement subacute or chronic affections. In cases of the first Ave have generally a history of exposure to the cold, or an attack of scarlatina; and about a fortnight afterAvards, there are observed chills, heats, thirst, a dry skin, and almost simul- taneously Avith these, puffin ess of the face, or oedema of the feet and ankles. About the same time the urine is observed to be very scanty, and often dark, though there may be frequent calls to void it. Upon examination the secretion is found to be such as has been described as belonging to the first form. The oedema in many cases rapidly extends, so that the Avhole of the surface of the body becomes highly anasarcous: and this anasarca commonly extends to other parts, so that we may have oedema of the lungs or epiglottis. There is also a great tendency to effusion into the serous cavities, especially the peritoneal, so that it is rare to find a case which has gone to this extent without some amount of ascites. It is often when the disease has just obtained this point, that we first see our patients, when we find them largely oedematous, the cheeks and eyelids much SAvollen, the conjunctiva overlapping the lower lid, the skin hot and dry, and the pulse sharp; if the disease do not subside or yield to treatment, the urine may become more abundant, but retain the same proportion of albumen; the countenance will become more bloated and doughy, the prolabia paler, the patient more unwieldy and distressed, and considerable dyspnoea is now.experienced; the pulse at this period is generally moderately full and sharp, though not very difficult of compression. If the disease still continue to advance, the oedema may extend from the areolar tissue at the root of the lungs to the lungs themselves, and become such as to cause death from apnoea; or the rima glottidis may become oedematous to such a degree as entirely to close the chink; or sudden effusion may take place in the chest or pericardium, by which life may be endangered; and the same thing may occur, though perhaps but rarely, on the surface or into the cavities of the brain; or there may be effusion into the air- cells, or the bronchial tubes become so swollen as to produce the ill effects of oedema of the substance of the lungs themselves. Death from direct uremic poisoning in this form is rare, that is to say, from its direct influences upon the nervous substance; but there may be sufficient uremia to produce serous inflammations which may be fatal. Still it is not saying too much to assert that when death takes place in the acute form of Bright's disease, it is more commonly from the effects of the effusion than from uremic poisoning. It more commonly happens that the disease assumes one of the HISTORY AND SYMPTOMS, 395 sub-acute or chronic forms 2 and 3. These occur either at more advanced stages of the first form, or they may commence insidiously, and preserve the chronic character throughout. AVhen this is the case, there may be scarce any symptoms to mark the commencement of the mischief. Sometimes there will be increased frequency of micturition, and the urine may be absolutely increased in quantity; often too it is of the smoky appearance, though there may be no deviation from the natural colour. Sometimes, too, there will be pain in the loins and across the epigastrium, or there may be cramps in the loAver extremities, especially at night. The next symptom Avill generally be oedema, commencing at the legs or ankles, but soon affecting the face, and often producing the appearance, of the conjunc- tiva already noticed, the countenance becoming, all this time, more and more bloated and anemic. The oedema may now extend rapidly, and the SAvollen, bloated aspect of the patient, Avhich when once seen cannot be readily mistaken, is highly characteristic of this form of the disease. It cannot, perhaps, be better described than in the words of a sailor in Guy's Hospital, the subject of it, who said he was com- pletely "water-logged;" and either oedema of the lungs or epiglottis, or effusion into any of the serous cavities, may suddenly take place; we may also at any time have active inflammation of the serous or bronchial membranes, or irritability of the stomach, or dysenteric diarrhcea may supervene. It is perhaps in this form of Bright's dis- eases that Ave most frequently have to encounter the active serous inflammation of uremia, which is apt to prove fatal, more particularly if it affect the pericardium; we may, too, have the sudden hwasion of cerebral symptoms, from the direct effect of uremic poisoning upon the brain; or we may have disease of the heart and arteries, from inflam- mation of the lining membrane, producing thickening and rigidity of the arteries generally, (which may often be felt most distinctly at the wrist,) and in the brain softening from defective nutrition, and extravasation; the obstruction of the circulation also induces hyper- trophy or dilatation, or both, of the left ventricle of the heart. In the most chronic form of the disease, which is generally that in which we find the fourth and fifth forms of the Bright's kidney, the symptoms are even more insidious; there may be no dropsy of any kind, though in most instances there is oedema of the feet and ankles, and slight puffiness under the eyes; in this form of the disease we may have the oedema beneath the conjunctiva producing the watery chemosis already described, even when there is no other dropsical swelling to be detected. This state of things may go on for a length of time, the patient not making much complaint or suspecting the presence of serious illness; until either from some accidental cause, inflammation within the chest, generally of the bronchial membranes, leads him to seek advice, when the true nature of his illness is detected; or what is even more common, the chronic change of the endocardium and arteries above described having been insidiously going on, he becomes the subject of palpitation and dyspnoea, from disease of the aorta or large arteries, when a careful inquiry leads to examination of the urine, which may, however, be found to contain 396 bright's disease. little or no albumen, but it will almost ahvays be of light specific gravity, or if not so, absolutely, it will be so, in proportion to the small quantity excreted, thus evidencing the scanty elimination of its normal solid ingredients. In other cases, again, the first evidence of disease may be the invasion of cerebral symptoms, either suddenly in the form of apoplexy, from extravasation, or by the arrest of circu- lation, from universal thickening and rigidity of the cerebral arteries, or we may have the sudden stupor or other cerebral disturbances pointed out by Dr. Addison as the direct effect of the retained secre- tion upon the nervous matter. (Guy's Hospital Reports, vol. iv. p. 1.) In this class of cases the chief cause of the symptoms is the retained secretion acting as an irritant or narcotic poison upon the organs of circulation, upon the serous and mucous membranes, or upon the nervous centres; it seems, too, at times, to act upon the extreme cir- culation, producing a degree of collapse with lividity, not very dissimilar in kind from cholera. This form of diseased kidney is often associated with the rheumatic or gouty diathesis, and may pro- bably be the effect of a chronic gouty inflammation of the kidney. The congestive form of Bright's kidney, if indeed it deserve the name, is essentially a secondary one, and the symptoms are mainly referable to the disease which produced it, that is to say, to obstructed pulmonic circulation, and consequent venous engorgment. Its exis- tence will, however, aggravate the effects of the primary disease; and when it supervenes upon an organ already diseased, as by either of the preceding forms, the consequences of retained secretion may be expected to declare themselves more rapidly. The diagnosis of Bright's kidney was for many years considered to be exceedingly simple; the presence of albumen in the urine, if there were no hemorrhage to account for it, being considered a suffi- cient sign of its existence, and its absence a certain proof of its non- existence : the discovery, however, by more extended clinical expe- rience, that albumen may not be found in the urine, however carefully tested, though the kidneys may be almost destroyed, as regards the performance of their most important offices, has shoAvn that we must look to other conditions either of the urine or of the system generally, to guide us. In the first three forms of disease Ave have less difficulty, as the urine is in them always albuminous ; and as in those cases the inflammation is mainly in the tubes, constituting a state of things analogous to bronchitis of the lung, we have gene- rally a desquamation of renal cells, which may be recognised under the microscope; and their presence has been regarded by Dr. G. Johnson as diagnostic of these forms of the disease: but this does not always hold true, since in many undoubted cases these cells are not to be found. The abundance of albumen, and the extent of dropsical effusion on the other hand, constitute more appreciable as well as more constant signs of this form of the disease. In the hard granular kidney there is more difficulty, as the urine may be free from albumen throughout; though even here, if it be repeatedly tested, a slight deposit of it may in most cases be at some time obtained; added to which, the secretion will be either very DIAGNOSIS AND CAUSES. 397 scanty or of exceedingly light specific gravity, and with but little urinous odour when boiled or treated with nitric acid, shoAving the exceedingly scanty elimination of urea. The causes of Bright's disease are in the first instance either expo- sure to cold, especiaUy when the skin is in a state of perspiration, and scarlatina; the acute form of the disease may also be induced by _ the injudicious use of substances having a powerful diuretic action. The second or more chronic form of the disease, no doubt, is often a consequence of the first, but it appears often to have crept on gradually without any acute stage, and to have been caused, as far as we can judge, by the more gradual operation of causes similar to those Avhich produce the first, more frequently repeated, though applied in less intensity. Amongst the stimulating causes by which this affection of the kidney may be induced, we may reckon the use of ardent spirits, more particularly gin; but it is probable that, how- ever prolific of disease in other ways, its direct agency, as a cause of renal disease has been much over-estimated; but there can be no doubt that intemperance, especially in the form of dram drinking, so common amongst the lower orders in large towns, not only, by the cachectic state which it induces, renders the individual more sus- ceptible at all times of the direct causes of the disease, but also the relaxed and enfeebled condition both of the nervous and vascular systems which succeeds the excitement produced by alcohol, greatly aggravates this susceptibility, and renders the subject of it at such times peculiarly liable to become affected by the slightest exposure. _ It is probable for these reasons that renal disease, more especially in this form, is so extensively prevalent in London and the other large toAvns in this kingdom. The causes AA'hich induce hard contracted kidney are still more obscure, owing in great measure to this form of renal disease differ- ing from the others not only in the nature of the degeneration, but also in the absence of all symptoms by Avhich the progress of the disease is marked, the first intimation of its existence being derived from that impaired function of the organ Avhich is the consequence of the morbid change, or from those still more remote consequences —the effect of that impaired function upon other parts of the system. It may be, no doubt, in many instances, associated with a gouty dia- thesis, but that this diathesis is its alone cause there is by no means satisfactory evidence. It is observed most frequently either in advanced life, or in those who have worked hard, or lived hard. The prognosis of this disease is, no doubt, in the main unfavoura- ble ; but in each particular case much must depend upon its probable character and previous duration. The first form of the disease is rarely fatal as such, the great danger being that it will pass on to the second stage or form. In early cases of scarlatinal dropsy we have every reason to believe that Ave still have the former condition to deal with, and, therefore, the prognosis is upon the Avhole favourable. In the non-scarlatinal cases, the difficulty is to ascertain whether we really have a very early case to deal with, or one of the more chronic forms of the Avhite or mottled kidney, in which the disease has been 398 BRIGHT'S DISEASE. for a long time insidiously making way, although the patient may have only just become aAvare of his illness. An appearance of the lips and countenance denoting a tolerable abundance of red blood, a specific gravity of the urine nearly approaching to the natural standard, and a Avell-marked history of the recent invasion of the disease, confirmed by evidence of previous good health, are fiwoura- ble symptoms; Avhilst a doubtful history of the commencement of the illness, and of the previous health of the patient, a very low specific gravity of the urine, and above all evidence of the secondary effects of uremia upon other organs, are unfavourable signs. In proportion as we are sure that the disease has passed from the stage of engorge- ment to that of disorganisation, in the same proportion may avc be certain that recovery is not to be expected, and in proportion as we have signs of advancing secondary disease from uremic poisoning, in the same proportion may we apprehend a speedy termination. In the cases of the hard contracted kidney, the ultimate prognosis is equally unfavourable, and the patient is at all times liable to sudden, and possibly fatal attacks of disease, either of the heart or encephalon, though it is to the latter that he is more especially liable. It is, however, true, nevertheless, that patients may go on under careful management, Avith this form of renal disease extending from late in the middle period of life to an advanced age. The treatment of this disease has been reckoned among the oppro- bria medicine; and undoubtedly a large number of cases are beyond the reach of any means Ave posses, as regards the removal of the lesion AArhich is the primary cause of the most serious symptoms; but this arises from our having to do not so much with the diseased action producing structural change as Avith the consequences of de- stroyed function resulting from a structural change already effected by that diseased action. Under Avhich circumstances it is no more a reproach to medicine that it cannot restore to its healthy and efficient condition a kidney that, as far as that part of its structure upon Avhich its action as such is concerned, has ceased to be a kidney; than it is to surgery that it cannot restore a limb already destroyed by disease or accident. In those cases, hoAvever, in which Ave have to combat the disease itself, and not the effects of those changes Avhich the disease has effected, art may yet do much. It is only, hoAvever, in the first form of Bright's disease that we are so favourably circum- stanced. In the case of the active congestion of the kidney there are two distinct indications to be fulfilled. In the first place Ave must en- deavour to subdue the inflammatory action by general treatment, and promote its subsidence in the affected organs by measures directed specially to them; and secondly, we must endeavour to obviate the effects upon different parts of the system of the impaired and per- verted function of a vital organ. In some acute cases, in the early stage, Avhen there is reason to believe that the health has been pre- viously good, as in the case of scarlatinal dropsy in a sound subject, blood has been often taken from the arm with benefit; but that this may be safe we must not only have the above conditions, but we CAUSES AND TREATMENT. 399 must have a sharp and firm pulse, a hot skin, and a complexion evi- dencing that the blood has not yet been materially impoverished by the drain through the kidneys. Such cases are indeed mostly con- fined to those occurring after scarlatina, OAving to the comparative infrequency of our seeing other cases at a sufficiently early stage. If, however, there be a sharp and tolerably firm pulse Avith hot skin, and there be any doubt as to the tolerance of general depletion, six or eight ounces of blood may be taken from the loins by cupping. As a general rule, however, where there is pallor, blood should not be _ abstracted. The next and most generally useful means of ful- filling this indication is antimony, which at once loAvers the action of the heart and large arteries, relieves congestion in the extreme circulation, and promotes the cutaneous secretion. It may be given either in the form of pill, with henbane (F. 7-1),* which will perhaps be best borne when the stomach is irritable, otherAvise it is best to use it in solution, beginning with a sixth or a quarter of a grain. In the commencement, a saline mixture, such as a solution of citrate of potass or acetate of ammonia, may be used as a vehicle; but when tie disease has lasted long enough to impoverish the blood, salines, which are spanemics, are to be avoided, though the acetate of am- monia is less liable to this objection than others. Gentle Avarmth should be at the same time employed to encourage perspiration, and to this end_ a linseed poultice applied across the loins will often be found serviceable. As in these cases the urine will generally be scanty, indeed in the acute stage it ahvays is so, and the system surcharged with fluid, showing itself in the form of great and general anasarca, the question arises, are Ave to employ diuretics? As a general rule, direct diu- retics should not be employed during the early stages of the inflam- matory form of Bright's disease any more than Ave should administer active purgatives in inflammation of the boAA'els. It will, hoAvever, often happen that under the guarded use of depletion Avhich has been enjoined, and of the antimonial medicines, the urine from having been very scanty and loaded Avith blood-matter will become much more abundant, and though still containing both red corpuscles and albumen, the proportion will be much less, and, by this healthy diu- resis, much of the redundant fluid may be carried out of the system Avithout further injury to the kidneys. But even Avhen this is going on we must endeavour to save those organs as much as possible by encouraging the escape of fluid through other outlets. AVith this object we must continue the diaphoretic treatment, and at the same time have recourse to moderate hydrogogues. For this purpose the compound jalap powder of the Pharmacopoeia is a most useful com- bination. Elaterium, though a most valuable hydrogogue, is to be avoided in this period of the disease, from its tendency to irritate the mucous lining of the intestinal canal. Jalap and calomel may also * (74) R. Antim. Pot. tart. gr. J. Extr. Hyoscy. gr. iv. Ft. Pil.; to be repeated every 4th or 6th hour. 400 bright's disease. be occasionally used Avith advantage in the early stages, particularly in scarlatinal dropsy in young subjects. AVhen the antimony has been continued for a few days, and no irritating or inconveniently depressing effects produced, it may be further increased, and its use continued until the action of the skin has been established and the pulse has become soft. In some cases, the scarlatinal ones more especially, Ave find the anasarca disappear and the urine lose its albumen under this plan of treatment, after which, by a more liberal diet, careful avoidance of cold, and gradual return to exercise in the open air—the importance of Avhich in maintaining the healthy action of the skin in the conva- lescence from the acute form of this disease, as well as in some periods of the chronic forms, is not sufficiently appreciated—the patient will gradually regain his colour and strength, and recovery may be even- tually completed, though the greatest care will for a long time be necessary, lest by any imprudent exposure or,repressed action of the skin the kidneys should be overstimulated and resume their diseased action. One of the great difficulties in the management of this form of the disease has been already alluded to, namely, irritability of the stomach, which is amongst the most prominent symptoms of inflam- matory affection of the kidneys, and is peculiarly embarrassing in such cases, as it prevents the use of the antimony, which is the remedy upon Avhich most reliance is to be placed. Under such circumstances the stomach should be as little disturbed as possible, the very least quantity of liquid, to allay thirst, should be alloAved, and if there be not extreme debility, recourse should be had to cupping at the loins; and should this be deemed inadmissible, the dry cupping may be employed; sinapisms should be at the same time applied to the pit of the stomach, and the functions of the skin may be promoted by vapour-baths. Should the bowels not be acting freely, an enema containing jalap (F. 75)* will also be a rational means of unloading the system of some of its superfluous Avater, and determining from the kidneys. By these means we may subdue the more active irrita- tion of the kidneys and relieve the consequent sickness, and thus prepare the Avay for the antimonial treatment. It sometimes happens, hoAvever, in the progress of these acute cases that we have the sudden supervention of head symptoms. When this occurs with very scanty urine, especially if that urine contain blood, leeches or cupping may be used over the loins; in adults the latter should be preferred, and unless there be dysenteric irritation the jalap and senna enema may be used. If the cerebral oppression continue, dry cupping at the neck may be employed, and if that fail a blister may be applied in the same situation, but in all the earlier cases of this disease it is better to avoid the use of such a remedy where it can safely be done, lest the lytta should irritate the kidneys by absorption into the circulation. (75) R. Pulv. Jalapas, 3 i. Iufus. Sennse co. fervent. ^ viij. Misce. Ft. Enema. TREATMENT. 401 The question has frequently been raised, as to how far this inflam- mation may, like several others, be subdued by mercury; experience answers that it seems but little amenable to such treatment; and, further, that there is conditions connected even with the earlier period that render mercury a dangerous remedy; first, because there is present, sooner or later, a deficiency of red corpuscles, Avhich is always aggravated by mercury; secondly, because, though there may be no great degree of pallor, or manifest signs of that state of the system which is usually admitted to contra-indicate mercury, the mouth and fauces often become suddenly and violently affected by it, Avhen this state of the kidneys exist, even in.so slight a degree that the intolerance of mercury is the first symptom AA'hich draAvs atten- tion to the state of the urine; and, lastly, because, in cases where the disease has probably been in an early stage, and the remedy has been very cautiously administered it has produced disorganising effects, Avhich can only be accounted for by the supposition that the presence in the blood of retained secretion greatly diminishes, or almost des- troys that vitality of the tissues by which the tendency to such effects is counteracted. This sometimes shoAVS itself in rapid gan- grene of the anasarcous extremities.* In the less acute, and more protracted form of this disease, namely, the large white and mottled kidney, Ave must still keep in vieAV the principle of relieving the circulation of the excess of fluid and the excretory matter Avhich it contains, Avith the least possible excitement of the kidneys. For this purpose, when there is no great debility, Ave may still have recourse to the antimony, especially if the skin be hot and dry. The hydrogogue cathartics may also be employed, either in the form of half a grain of elaterium with eight or ten of bitartrate of potass, or the elaterium may be administered, in very minute doses, say one-twelfth of a grain every three or four hours; but in either case we must guard carefully against its irritating effects upon the lining of the stomach and large intestines. In the more advanced stages we 'may, however, have recourse to gentle diuretics, as we use expectorants in chronic bronchitis. Of diuretics the safest will be the least stimulating, and therefore when there is no great feebleness in the action of the heart, digitalis in the form of infusion, in doses of from one to two drachms, may be employed, and Avith this may be combined the nitric ether. Salines are hardly admissible, not so much on account of their tendency to stimulate the kidneys as from their increasing the spanemia Avhich already exists; though this objection does not apply so much to the salts of ammonia, of which we may sometimes employ the acetate, or a draught con- taing the citric acid saturated with ammonia (F. 76).f * See Guy's Hospital Reports, Second Series, vol. i. p. 205. f (76) R. Acidi Citrici, Q j. Ammon. Sesquicarb. gr. xv. Sp. JEth. nit. 5 ss. Syrupi Aurant. % ss. * Aq. Purse vel Mist. Camphorae, £xi. Ft. Haust.; to be taken three times a-day. 26 402 .bright's disease. In this form of the disease, serous inflammations are very apt to arise; and there is some difficulty in subduing them owing to the intolerance of mercury. The best means will be cupping in small quantities, the application of blisters, the use of the antimony with digitalis, and purgatives, either in the shape of elaterium or com- pound jalap powder. In cases Avhere there is too much irritability of stomach for the former, and the latter has not acted sufficiently free, the draught of tartrate of potass, manna, and senna, will sometimes bring away a considerable quantity of fluid with but very little irrita- tion. The use of hydrogogues is indicated in this form of the disease by the tendency which exists to great serous effusion upon the occur- rence of slight inflammatory action, or even without, and this is peculiarly the case in the lungs and the bronchial membrane, and the areolar tissue about the glottis. AVhen this last occurrence takes place, which is indicated by dysp- noea, with a whistling respiration, in addition to the above remedies hot fomentation, or rather flannels wrung out of nearly boiling water, must be applied to the throat, and a blister to the back of the neck. Should these measures fail tracheotomy may be had recourse to. The oppression of the system by the universal dropsy, which gravi- tates more particularly into the scrotum and lower extremities, sug- gests the expediency of puncturing the surface to give it exit. This may occasionally be done with advantage, but the punctures or in- cisions should never be in the legs, owing to the great tendency to gangrene; sometimes the scrotum may be punctured, but as a general rule the thighs are to be preferred. The safest plan is to make a feAV small incisions with the point of a lancet, which will generally dis- charge sufficiently freely, though otherwise the puncturing needles may be employed, as recommended by Air. Hilton; but the greatest care must be taken to keep up the Avarmth of the part by the use of warm fomentations of flannel. AVhen, after we have succeeded in removing the dropsical effu- sions, and apparently arrested the disease, or, at all events, subdued the more urgent symptoms, the anemic conditions remain, kept up by the continued discharge of more or less blood-matter by the kid- neys, tonics appear to be indicated; and for this purpose preparations of iron have been recommended. Their use, however, requires the greatest caution, from the tendency to head affections. Perhaps the safest form in this disease is the tinct. ferri sesquichlor., which may be administered in doses not exceeding ten minims. As a general rule, however, iron is not a safe remedy; zinc will be found much more so, of Avhich the sulphate may be employed in doses of from one to five grains. The good effect of zinc as a tonic will often be apparent, and by its astringent properties it may be useful in restrain- ing the discharge of albumen; for this latter purpose gallic acid has been employed, and it is said with benefit. It is apparent from Avhat has already been said, that in these forms of the disease we have to deal more with its secondary effects than with the disease itself; yet if we can succeed in overcoming this, we TREATMENT. 403 may direct our attention more to the primary affection, not so much with the hope of its entire removal as with a view to checking the morbid action going on, and so preserving, for the longest possible time, the portion of the organs not irretrievably injured. AVhen we have the symptoms of an acute affection supervening upon a chronic, we must follow the plan of treatment already recommended for the acute cases; but when we have succeeded in subduing the urgent symptoms, and have, for a time at least, only the chronic kidney disease, as evidenced by albuminous urine, with but few other dis- orders to deal with, a system of diatetics and general mode of living must be folloAved, the chief object of which must be to throAV as little work, so to speak, as possible upon them. The action of the skin will now be best insured b}^ moderate exercise; warm clothing should indeed still be used, so as to aid exercise in inducing perspiration, and to prevent its too ready suppression. The diet should be light and unstimulating. It has been proposed to enjoin an abstinence from animal food on the ground of the redundance of azotised matter in the blood; but this plan has not generally been found successful, and in general meat or fish may be allowed once a day. A valuable article of diet also will be milk, when it suits the stomach; and the system may be further supported by farinaceous substances. Spirits and strong wines are to be avoided, but light malt liquor is admis- sible, as also an occasional glass of light wine. A most important aid towards recovery is removal to a warm climate; a voyage to India, round the Cape and back, or to the West Indies, has in several instances produced, to all appearance, a cure in cases which appeared to have advanced beyond the first stage. In the still more chronic cases of the small granular kidney, we must bear in mind that the chief dangers are those arising from the frequently sudden effects of uremic poisoning upon the brain, and the changes (also the effect of uremia) in the heart and arteries. In this form of the disease we must regulate the diet, and encourage the action of the skin much in the same manner as in the last, but we must alloAV but very gentle exercise; and it is doubtful if a warm climate would be desirable. The general tendency in this form of the disease may perhaps be not inaptly said to be, to premature senile changes, and therefore we must direct our attention to succouring the poAvers of the sj^stem by every possible means. The diet should be bland and nutritious, but not highly animalised, and, unless custom have induced the necessity, but little stimulants should be used. As this form of disease may be connected with a gouty diathesis, we must most carefully guard against the retrocession of gout, and if any symptoms show themselves in the extremities, they should be encouraged. AVhen there is any threatening of head affection we may apply blisters, or, if there be heat or throbbing, a little blood may be taken by cupping. Failure of the nervous power, as shoAvn by tremor or gradual paralysis, may be met by sulphate of zinc. AVhen the renal secretion is very deficient, gentle diuretics may be employed, amongst which the decoct, scopar. co. of the Pharmaco- 404 bright's disease. poeia, with nitric ether, may be given; it is, however, very difficult to get duretics of any kind to act. A steady action of the bowels must be maintained, and when there is no irritability of the large intestines, the compound decoct, of aloes with a little additional bicarb, of potass, and about ten grains of rhubarb, will act agreeably. If care be taken to relieve the kidneys by acting upon the skin, and to avoid all excitement either of the brain or the organs of circula- tion, life may be prolonged for several years; but such a patient is ahvays in jeopardy, and from the different forms of apoplexy to which he is liable, as he is also to sudden death from the heart. URINARY DEPOSITS AND DIABETES. 405 XXIII. URINARY DEPOSITS AND DIABETES. We have already spoken of the symptoms of. a stone, or calculus, as well as of gravel or sand in the kidneys, or passing thence through the ureter into the bladder, as regards the urinary organs; that is to say, as regards the mechanical irritation they produce, considered simply as foreign bodies, in which respect the different kinds of cal- culus matter pretty closely resemble each other ; but the case is far otherwise in regard to their chemical composition, and in great measure also as to their physical properties; and no less so in regard to the causes which produce them, and, consequently, the means which must be used for their prevention. AVhen, therefore, we have reason to suspect the presence of any such matters in the urinary organs, or even the tendency to them, we examine the chemical condition of the urine, not only once or twice, but often, with a view to ascertaining not its condition upon one occasion only but repeatedly, that we may be enabled to form an opinion of the habit or diathesis of the patient in this particular ; and a knowledge of this will enable us to reason not only forwards, to the probable character of any sediment or secretion which may be in the urinary organs either in esse or in posse, but backwards also to several antecedent conditions of the chylopoietic viscera which may have led to their formation. It is known to every one that fresh urine from a healthy person is generally more or less acid, though this may vary from a very decided reaction to almost neutrality, the acidity being the greatest in urine voided just before meals, and the least when digestion is going on. This is generally believed to depend, not upon the pre- sence of a pure acid but of super-salts of the alkaline or earthy bases which the urine contains. Now, although the stronger mineral acids, the sulphuric and the hydrochloric, are both present in the urine, those which we should naturally look for in a free state would be the uric (or lithic) and the phosphoric, not only from the great abund- ance of the former, but also because either would be liable to be set free, by the former entering more readily into combination Avith the alkaline and earthy bases which the urine contains: they do not, however, exist in a free state in the urine of health, but certain of the bases are not perfectly neutralised, and form super-salts Avith those acids; or, in other words, they form super-urates and super- phosphates. It is probably upon the presence of super-phosphate of soda that the acid reaction of the urine depends, since it is questionable whe- ther the super-urate is ordinarily present, though the urate of ammo- nia exists in great abundance, and is readily soluble in Avater, and in urine in its normal condition. Now this latter salt is, of course, 406 URIC ACID AND URATES. readily decomposed by the presence of any stronger acid than the uric, which, being insoluble, will of course be precipitated, and accor- dingly it comes down in the form either of an amphorous sediment, or of minute grains, resembling poAvdered cayenne pepper; for though uric acid may thus be rendered insoluble in the urine, it does not generally come down in the shape of crystals, since, as Dr. Bence Jones has taught us, the hydrochloric, which is the acid upon which excessive acidity of the urine mainly depends, does not imme- diately decompose urate of ammonia, the combination in which the uric acid exists in the urine, but renders it less soluble, throwing it down in the form of an amorphous powder. AVe have, then, two forms of uric acid deposits, the free crystalline uric acid itself, which can only appear when the urine contains a great excess of hydro- chloric acid,—and the urate of ammonia, showing itself in amorphous sediments, generally of a pinkish faAvn or drab-colour, redissolved by heating the urine, which the free lithic acid is not: but independ- ently of being of limited solubility in cool urine, which is normally acid, it may also make its appearance, being thrown down as shown by excess of acid from its being actually in greater quantity than in perfect health, either absolutely or in proportion to the quantity of fluid secreted. In the majority of instances, the precipitate is dependent upon both these causes. The immediate or chemical cause, then, of the depositions of uric acid, is excessive acidity in the urine. The probable cause of this acidity is to be found in the stomach, the acidity of which varies, as we have seen, inversely as to that of the urine. In cases of extreme irritability of this organ, there is, probably, during digestion, a rapid secretion of hydrochloric acid; during this process, the acidity of the urine would be diminished,»or Avould altogether disappear ; but after a reabsorption of the acid, the urine would become proportionally acid ; this shows the fallacy of observations upon the acidity of the urine made only once in twenty-four hours, since it is probable that at certain times in the day the urine of a person passing free uric acid may be alkaline. The chemical cause of the deposit of the non- crystallised sediment, the urate of ammonia, is either excess of acid or an unusually large quantity of the urates, often both causes com- bined. The morbid causes of this condition may be either gastric irritation, as in the case of the Uric acid crystals; gout or rheumatism, or other febrile disturbance; or a deficiency in the quantity of Avater proportionate to the solid contents of the urine, as in the case of obstruction to the portal circulation. In the two latter conditions the urates alone are precipitated, Avithout any crystals of uric acid; but in the former uric acid also is ahvays present if there be a con- siderable acidity of the urine. The diagnosis of these forms of disease must depend upon the examination of the deposits both by the microscope and chemically; the latter, however, when there is the least doubt, is the only means to be relied upon. The microscopic appearances of crystalline uric- acid present every combination of the rhombic prism, though these their causes and diagnosis. 407 » may arrange themselves into forms very likely to mislead* Uric acid is destroyed by heating it to a red heat in a platinum spoon, it burns in fact. When uric acid is treated with a little nitric acid, and then heated to dryness, it becomes of a deep red, which is always increased in intensity by the addition of vapour of ammonia. The urate of ammonia is, for the most part, thrown down as an amorphous sediment; as regards the test of burning, and of the addition of nitric acid, it comports itself like the uric acid; but there is this difference ;—that though both are dissolved by carbonate of potass, the utrate of ammonia evolves ammoniated fumes Avhen the solution is heated, which is not the case with uric acid; and what is still more to the purpose, urate of ammonia is readily dissolved by heating it in water, which is not the case with uric acid. This last test enables us to determine whether urine which obviously contains urate of ammonia, contains likewise uric acid, a question which may always be answered by heating the liquid, when if it becomes per- fectly clear the deposit is urate of ammonia, without uric acid. These two kinds of deposit of uric acid require different modes of treatment according to their cause. When the crystalline uric acid is present, either with or without the urates, the medicinal treatment must consist in the exhibition of alkalies, and the dietetic, in abstin- ence from acids and all substances likely to become so. For the first, the liquor potasse, carbonate of potass, saline draughts of citric acid and citrate of potass, and phosphate of soda may be employed; the carbonates of soda and magnesia are sometimes used, but the first is open to the objection, that the urate of soda is insoluble; and the latter, that it sometimes forms concretions in the alimentary canal. As regards the regimen, we must prohibit the use of vegetable acids, and enjoin a very moderate use of substances containing much starch or sugar, since they readily form a vegetable acid in the stomach. To promote the removal of acid by the skin, and the free evolution of carbonic acid by the lungs, is an indication of still greater mo- ment ; for this cause moderate exercise should be used. The deposit of the amorphous lithates, being dependent upon no great excess of acid in the urine, (when unaccompanied by free lithic acid,) should not be treated Avith alkaline remedies, at least not as a general rule, since we should rather turn our attention to the disease of which they may be symptomatic. AVhen the deposit occurs as the consequence of slight dyspeptic derangement, or excesses or irregu- larities in diet, a little additional liquid, as an extra glass of water or soda-water, or a gentle diuretic will, as Dr. Bence Jones observes, dissolve the urate of ammonia, by increasing the quantity of liquid in the urine: whilst we must look to a very moderate diet, and moderate exercise, for effecting a cure. But in those diseases in .Avhich (as we have pointed out) the urates come down through a defi- ciency of water to hold them in solution, owing to disease in the course of that circuit through which water passes from the intestines to the arterial system, diuretics, whether gentle or of a more poAverful kind, * Bird on Urinary Deposits. 408 PURPURINE. will have little or no effect, until we obviate the primary disease, if it be possible to do so, or if not, till we have in some degree relieved the circulation, by measures adapted to the particular affection. In connection Avith urate of ammonia Ave may allude to the re- markable colouring matter purpurine, which is sometimes present in considerable quantities, but never comes down as a deposit unless urate of ammonia be also present, which has the property of remov- ing the great mass of purpurine from the urine, and assuming thereby a purple tint.* Urate of ammonia, thus coloured, varies from a pinkish drab or faAvn colour to that of a rich carmine; so deep, indeed, is the colour that urine in Avhich it has been suspended has not unfrequently been supposed to be coloured with blood; so close, sometimes, is this resemblance, that it is necessary to satisfy ourselves of the absence of the latter by the appropriate tests. It also interferes so much Avith the solubility of the urate of am- monia with which it is united, that long continued boiling is necessary to effect its solution; a familiar instance of this is to be found in the pink stain or fur, as it is often called, Avhich adheres to the bottom of the utensil, and for the removal of which the house- maid is often obliged to have recourse to hot water and soda or potass. The brightness of the' colour when this deposit is collected in a filter, and the fact that alcohol will separate the purpurine from the urate of ammonia, by dissolving the former and leaving the urate, are sufficient characteristics. In examining urine highly coloured by purpurine, care is requisite to avoid confounding it with the muddy deposit of uric acid thrown doAvn by nitric acid Avith albumen. This property which purpurine possesses of precipitating urate of ammonia gives it considerable importance in reference to urinary calculi, which thereby receive strata of urate of ammonia which would otherwise have remained dissolved in the urine. It possesses also a further pathological importance from its indicating an impediment to the free secretion of bile by the liver, or perhaps more correctly the purpurine being a more highly carbonised substance than any in the urine, is the form in which that principle appears when the kidneys take on a supplementary action to the liver, and through the liver to the lungs. It does not, as Dr. Golding Bird remarks, universally occur in phthisis; and the reason of this is, that, as we have else- where pointed out, there may be great disorganisation of the lungs in phthisis, yet no considerable defect in the decarbonisation of the blood by these organs, OAving to the diminished quantity of the blood itself: but if the lungs have become rapidly obstructed, whether by phthisis, capillary bronchitis, or the various other diseases which we have shown to produce that effect, purpurine soon appears in the urine. Oxalate of lime is another deposit of frequent occurrence in the. urine, chiefly, perhaps, important from its tendency to form concre- tions in the kidneys and bladder. Dr. Bence Jones considers it of very little consequence in other respects, from its being found in the * Dr. Golding Bird, " Urinary Deposits, Philada. ed., p. 158. OXALATE OF LIME. 409 urine of persons in good health, as well as of those in very opposite states of disease. Dr. Golding Bird, on the contrary, regarded it as indicative of derangement of the general health, and therefore of great pathological importance, besides its tendency to form calculi of the most painful form. The truth will probably be eventually found to lie between these two opinions; the frequency of its occurrence, for which fact we are in the first instance indebted to Dr. Bird, is sufficient to awaken our attention to the importance of this form of deposit, whilst the fact of its being often found in the urine of healthy persons, proves that it does not necessarily indicate any great devia- tion from health, though it may point out to what form of diseased action the patient in question may be more particularly liable. There can be little doubt that a tendency to deposit oxalate of lime is associated with an excessive secretion of uric acid and urea from the kidneys, that it is often accompanied by great nervous irritability, languor, emaciation, hypochondriasis, and want of nervine and phy- sical energy, consequent upon a drain upon the system analogous to what may be seen in spermatorrhoea and in leucorrhoea in females. The diagnosis of this deposit is very simple; if the urine be allowed to stand in a tall glass for about* an hour, and the greater part of it decanted, the portion remaining at the bottom will be found under a half-inch glass to contain minute octohedral crystals. It is a remark- able fact that oxalate of lime has a great tendency to alternate in the same patient with uric acid or urate of ammonia. The treatment of the diathesis, if it may be so called, consists in attending carefully to the state of the skin and in regulating the diet. Good mutton once a day, or when the appetite admits of it and the patient requires support, a slice of cold mutton also at breakfast; moderate use of fruit, vegetables, avoidance of pastry, cocoa once a day in preference to tea or coffee; barley water or toast-water, or good water itself, for drink, unless the state of the patient seems urgently to call for stimulants, when a little weak brandy and water may be allowed. Nitric acid, or the nitro-hydrochloric extemporaneously prepared may be given, in a bitter infusion, twice or thrice a-day. The use, however, of the acids must be carefully watched, as they will after a time produce urate of ammonia in the urine; when this begins to be the case they must be discontinued. When there is anemia, tincture of sesquichloride of iron should be employed; when much nervous debility, sulphate of zinc. An excess of sulphates exists sometimes in the urine, though it does not show itself in the form of any deposit; the sulphates of soda and potass being always present, whatever be the condition of the urine; the sulphuric acid may, however, be precipitated, and its quantity ascertained, by adding a solution of chloride of barium, taking the precaution of adding a few drops of hydrochloric acid to ensure the solution of any phosphate of baryta that may be formed. Dr. Bence Jones gives the following summary of his observations on the occurrence of sulphates in the urine : 1. That the sulphates in the urine are much increased by food, whether it be animal or vegetable. 410 EXCESSES OF SULPHATES. 2. Exercise does not produce so marked an increase in the sul- phates. 3. Sulphuric acid, Avhen taken in large doses, increases the sul- phates in the urine, in small quantities it produces little or no effect. 4. Sulphur, when taken, increases the sulphates in the urine, and sulphates of soda or magnesia produce the greatest effect upon the quantity of sulphate in the urine. The phosphates, both alkaline and earthy, are liable to considera- ble variations as to the quantity in which they occur in the urine, and the latter are often precipitated,, producing deposits, and some- times forming calculi in the bladder. The fact, however, of their being precipitated is no proof of their being present in any unusual quantity, since they may exist in even an abnormal proportion, and remain dissolved; hence the term phosphatic diathesis, commonly applied to the state of the system in which the urine presents these deposits, is hardly applicable. The manner in which earthy phos- phates are thrown down from the urine is as follows: Phosphoric acid is Avhat is termed a tri-basic acid; it can only combine with three equivalents of an alkali or oxide (neither more or less); but these three equivalent* need not be of the same oxide or alkali; and one or two of these equivalents may be oxide of hydro- gen or water. Thus we have three phosphates of soda; one equiva- lent of the acid with two of water and one of soda; this, called acid phosphate of soda, having an acid reaction. Again we have another tri-basic salt, in which one equivalent of phosphoric acid is combined with one of water and two of soda; this is the common phosphate of 4 soda, which has a slightly alkaline reaction. Lastly, we have a third tri-basic phosphate of soda, consisting of one equivalent of the acid to. three equivalents of soda. This salt has a decidedly alkaline reaction; but all the salts are alike tri-basic. The first two exist in the urine, but more commonly the acid phosphate, which probably gives its alkaline reaction to that fluid; but neither of these is ever precipitated, whatever be the character of the urine, since they are highly soluble under all circumstances. The earthy phosphates in the urine are the phosphate of lime, which consists of one equivalent of phosphoric acid to three of lime, and according to Dr. Bence Jones ammonio-phosphate of magnesia. These phosphates are soluble only in a fluid having an acid reaction; and the solution of the acid phos- phate of soda is sufficient for this purpose; whilst, therefore, the urine is even slightly acidulated by this salt, there being no alkali or alkaline carbonate sufficient to neutralise it, the phosphates of magnesia and lime will not be thrown down; but urine which is alkalised from carbonate of ammonia, carbonate of soda, carbonate of potass, or the common phosphates of soda, being unable to dis- solve these phosphates, they therefore occur as a deposit; hence it appears that the so-called phosphatic diathesis, in which these preci- pitates occur, is really an alkaline one, since there is not necessarily any excess of phosphate present, in point of fact generally the reverse. For the method of ascertaining the amount of phosphates present, the student should consult Dr. Bence Jones' work on Animal Chemistry PHOSPHATES. 411 and the no less valuable one of the late Dr. Golding Bird on Urinary Deposits. The following conclusions, drawn by Dr. Bence Jones from a long series of observations, if of no other value, are most important as disproving a number of very prevalent errors upon the subject. 1. The variations of the earthy phosphates are so dependent on the earthy matter (lime and magnesia) present in the urine, that no deduction from them as to the nature or state of disease is probable. 2. Neither the earthy phosphates nor the alkaline phosphates are permanently increased in spinal diseases. 3. In fevers, and acute inflammations of fibrous, muscular, or car- tilaginous tissues, the total amount of earthy and alkaline phosphates is not increased. 4. In chronic diseases in which the nervous tissue is not affected, no deductions can be drawn. 5. Chronic cases of mania, melancholia, and general paralysis of the insane gave no results. 6. In chronic diseases of the brain, and in chronic and even acute diseases of the membranes, there is no increase in the total amount of alkaline and earthy phosphates. 7. In fractures of the skull, when any inflammation of the brain comes on, there is an increase of the total amount of phosphates. When there is no head symptoms, no increase of the phosphates is observed, even when other acute inflammations supervene. 8. In acute inflammation of the brain there is an excessive amount of phosphates in the urine. When the inflammation becomes chro- nic, no excess of phosphate can be shown to exist in the urine. 9. In some functional diseases of the brain an excessive amount of phosphates is observable; this ceases with delirium. Delirium tre- mens shows a remarkable deficiency in the amount of phosphates excreted, provided no food be taken. Where food can be taken, the diminution is not apparent. It appears that excess of phosphates in the urine is the effect of a few, though very few diseases; but it is not the cause of any, and therefore requires no directly remedial measures. With alkaline urine, however, the cases is different, since it is not only a sign of disease, but also by the phosphatic'deposits which it produces, is the cause of gravel and calculus. Now, we have stated that the carbonate of ammonia will cause these phosphatic deposits to occur in the urine, and carbonate of ammonia is a common cause of alkalescence of the urine; but whence comes the ammonia ? This, as is now well known, is produced by the decomposition of the urea —this urea, which is the principal solid ingredient of the urine, and is very prone to decomposition, forming carbonate of ammonia by combination with water, thus:— Urea = C2 H4 N2 02 Water = H4 04 C2 H8 N2 06=C2 04+N2 H3 0 =Carbonate of ammonia. 412 URINARY DEPOSITS. Healthy urine does not undergo this change till some considerable time after its excretion from the body; but in disease of the mucous lining of the bladder, ureters, or pelves of the kidneys, the unhealthy mucous, which is secreted, may act as a sort of ferment, inducing the change of urea into carbonate of ammonia; but independently of this, there are many morbid conditions, some of them lesions of innervation, and others generally dependent on a low degree of vital power, in which there is either a disposition in the urine speedily to undergo this change; or in the very act of secretion, the elements of urea arrange themselves, instead, into the form of carbonate of am- monia and Avater. The most familiar instance of this is that of alka- line (ammoniacal) urine, resulting from injuries to the back; this effect being produced, as Sir B. Brodie has pointed out, equally whether the injury is inflicted in the lumbar, the dorsal, or the cervical regions. The ammoniacal urine thus present in the bladder, no doubt proves in its turngan irritant to the mucous lining of that organ, which pours out an increased quantity of mucus; the mucus becomes, as it is termed, ropy, by the action of the alkali upon it, and thus the urine itself becomes ropy. This tough mucus is sometimes mixed up with earthy phosphates, which are deposited; and becomes a nidus for the formation of calculi. Besides, hoAvever, the alkalescence of the urine from carbonate of ammonia, it may also become alkaline from the presence of carbonate of potass or soda, this being the consequence of an increased secre- tion of acid in the stomach (probably through irritability of that organ), and this increased acidity at one extremity of the digestive process, so to speak, produces a corresponding alkalescence of the other. This alkalescence, however, is not constant, occurring almost exclusively during the process of digestion. AVe see then that the causes of the phosphatic deposits in the urine are complex. (1) They depend primarily upon one of these condi- tions, either an excess in the quantity of the earthy phosphates them- selves, or on the urine being alkaline; generally, as in the case of the urates, upon both of these conditions. (2) The alkalescency of the urine may have a tAvo-fold origin, either, that is to say, from carbon- ate of ammonia, produced by decomposition of the urea, or from car- bonate of a fixed alkali resulting from irritability of the stomach. (3) There may be several conditions favouring the decomposition of the urea, namely,—disease of the mucous lining of the bladder and urinary passages—lesion of innervation, as in the case of blows on the loins, and injuries to the spinal column—and general debility of constitution, from whatever cause arising, whereby a faulty assimila- tion is produced, and the urea formed in the extreme circulation tends more rapidly to degeneration to the lower substances in the scale of organisation, carbonate of ammonia and water. In regard to diagnosis there are two points to be determined; first, the diagnosis between phosphates and other forms of urinary deposit, and between phosphates the result of ammoniacal urine, and those throAvn down by fixed alkalies. The phosphates, which often form calculi in the bladder are, the phosphate of lime, and the phosphates CAUSES OF PHOSPHATES. 413 of ammonia and magnesia. They most commonly occur mixed in the same calculus, which is then termed the fusible calculus. The phosphate of lime occurs alone as a precipitate, chiefly from indiges- tion; the phosphates of ammonia and magnesia chiefly in conse- quence of diseased bladder, or of the other causes which have been pointed out as rendering the urine ammoniacal. Deposits of these salts are always Avhite, unless coloured with blood, soluble in dilute hydrochloric acid, and insoluble in ammonia or liquor potasse. The phosphate of lime, which, as we have observed, is generally precipi- tated with the ammonio-magnesian phosphate, is not so readily soluble in very dilute acids as the former, and therefore, when a mixed deposit of the phosphate of lime and triple phosphate occurs, the phosphate of lime is but sloAvly acted upon when digested in very dilute acetic acid, which readily dissolves the magnesian salt. When either the triple phosphate or the phosphate of lime is exposed to the flame of the blow-pipe it fuses Avith great difficulty, and not until the heat has been urged to the utmost. If, however, the phos- phate of lime is mixed Avith the triple phosphate in about equal pro- portions, they readily melt into a white enamel, constituting what has been spoken of above as the fusible calculus; by which property these mixed salts can be readily detected in concretions—a charac- teristic very available in the examination of gravel and calculi, as the two phosphates generally occur together* In short, the ammonio- magnesian phosphates are very readily soluble in dilute acetic acid; but the phosphate of lime very slowly so. Both are fused with extreme difficulty; but the mixture of the two, which is the more common deposit, is readily fusible. The physical appearance (says Dr. Bird)f presented by deposits of the earthy phosphates varies extremely; sometimes, especially when the triple salt forms the chief portion o*f the deposit, it falls to the bottom of the vessel as a white crystalline gravel. If but a small quantity of this substance be present, it may readily escape detection by remaining for a long time diffused through the urine; after a few hours repose, some of the crystals collect on the surface, forming an iridescent pellicle, reflecting coloured bands, like soap-bubbles or a thin layer of oil. The phosphates when very abundant will often present the appear- ance of thick mucus, from which they may be distinguished by their being readily dissolved by the addition of hydrochloric acid : when the pus or thick mucus, as not unfrequently happens, is mixed with the phosphates, the only means of detecting the latter is by placing a few drops of the urine between two plates of glass under the micro- scope, when the phosphatic crystals will be easily recognised. The microscopic characters are—(1.) Prisms exceedingly well defined, with the angles and edges remarkably sharp and perfect, the triangular prism predominating, though every variety of termination may be present; these consist of neutral triple phosphates. (2.) * Dr. Golding Bird on Urinary Deposits, Philada. edition, p. 222. •f Op. citat., p. 223. 414 URINARY DEPOSITS. Stellated crystals of the neutral triple phosphates, composed of acicu- lar prisms cohering at one end. These, though not unlike crystals of uric acid, in form, are always colourless, and never present the yellow orange of the last deposit. (3.) Penniform foliaceous crystals, of the basic salt of lesser portion, as generally taking place out of the body. (4.) The phosphate of lime occurs either as an amorphous powder, or in roundish particles. The next question is as to the different causes of the precipitation of the phosphates. When the urine is alkaline from fixed alkali, the cause is gastric derangement; when the urine is alkaline from carbonate of ammonia, the cause is metataxis of the elements of urea, and may depend either upon organic disease of the urinary organs, or upon general constitutional debility. The broad distinctions between the characters of these tAvo kinds of urine are these. That ammoniacal urine does not at first affect blue test paper, but that when the paper has dried it becomes red. This is not the case with urine alkaline from fixed alkali. In the former kind of urine the alkalescence is constant, in the latter vari- able. The former shows prismatic crystals under the microscope, the latter, when fresh, only granular deposit. In regard to the treatment of this class of disorders, we may first dispose of those cases in which the urine is alkaline, probably from fixed alkali, and the cause gastric irritation. The treatment of these belongs more properly to that of dyspepsia. They are generally attended with pains and distension after meals; the former being often of the character of cardialgia, and penetrating through betAveen the scapule, torpid bowels, and not uncommonly depression of spirits, languor, loss of appetite, and white tongue indented by the teeth. These cases often present an excess of urea, as well as a deposite of crystalline or amorphous phosphates. The treatment must be rather rational than chemical. Exercise and employment, or cheerful recreation, are amongst the best of remedies; to Avhich may be added, the conium and blue pill, tAvice a day, for a few days, and the compound gentian mixture, with 20 minims of aromatic spirit of ammonia, in the morning. The mer- curial should not, hoAvever, be continued for more than three or four days; but the aperient tonic may be persevered in. The bismuth with acid or with the conium may be used; but above all things moderate diet and exercise. The ammoniacal urine may be the result either of general debility, of disease or injury to the spine, or of disease of the bladder. In the first of these cases we must, as before, look mainly to the general condition of the patient, more especially to that of the nervous sys- tem. Such patients are often those Avho have undergone much Avear and tear of body or mind, or both, or Avho have injured their consti- tutions~by excesses. And here, as before, our treatment must be mainly directed to the general health, availing oursebves of the state of the urine, as a help to the knowledge of its condition. These cases are often attended with an excess of urea in the urine, the effect perhaps of an excessive Avaste of the tissues.' In them, as in the for- URINARY DEPOSITS. 415 mer cases, we must have recourse to the tonic aperient, or if the bowels be irritable we may employ the infusion of cascarilla or columba instead of the mixture of gentian and senna. If the tongue be coated, the pill of hydrarg. cum cret. and soda (F. 77)* may be used every second or third night, for a short time ; but any prolonged use of mercury is to be rigidly abstained from. And when the ner- vine depression has subsided sufficiently to enable us to dispense with the ammonia, the nitric or nitrohydrochloric acid may be given in the bitter infusion, and at the same time the nervous poAver may be improved, and the nervine irritability relieved by a combination of sulphate of zinc with extract of henbane, or extract of hop. The zinc may be first given in grain doses, three times a day; and the dose may be gradually increased to four or five. Moderate diet— mutton once a day, and tAvo or three glasses of sherry—avoidance of strong tea -or coffee; cocoa for breakfast where it agrees is to be given. In those cases, again, in which, with phosphatic sediment in the urine, there is a marasmus and much nervous debility, great anxiety of countenance, a red tongue, thirst, and symptoms in general closely allied to those of diabetes, and probably referable to shock or injury to the spine, and in which too the deposit is chiefly phosphate of lime, Ave must pursue the same tonic treatment, combining bismuth with the zinc; and besides this, endeavouring to allay the nervous irritability. For this purpose, Dr. Prout and Dr. Golding Bird con- cur in recommending opium, or what is better, the salts of morphia. Dr. Bird recommends from one-third of a grain to half a grain of the acetate to be given three or four times in the twenty-four hours, and persevered with for some weeks. In some cases the constitutional symptoms are not very urgent; for this reason the deposit attracts less attention, and the formation of a calculus may ensue. To obviate this, mineral acids have been pre- scribed, but it is doubtful if any of them, except the phosphoric, ever reach the urine, unless given in doses which are hardly safe. But the nitric, though it may not act chemically upon the secretion, often corrects its alkalescence, probably by its tonic action upon the stomach, and is less likely to cause irritation. In the last class of cases, in Avhich the urine is ammoniacal from mucus secreted by diseased bladder, our attention must be directed to the primary cause, and our remedies to obviating as much as possible every cause of irritation. The diet should be light and unstimulating, demulcent drinks may be employed, and the nitric or nitrohydrochloric acid administered; care must be, from time to time, taken to ascertain that the urine is really ammoniacal, and it must not be hastily presumed to be so merely by its odour. AVhen there is much restlessness and uneasiness opiates may be employed, and a suppository of ten grains of pil. sap. co. will often give great * (77) R. Hyd. cum Cret. Sodse Carb. exsic. aa gr. ij. Extr. Hyoscyam. gr. iv. Misce. Ft. Pil. ij. 416 DIABETES. relief. The washing out the bladder from time to time with warm water, should also be steadily persevered in. DIABETES. Diabetes is a disease about the true nature of which there was formerly, and still exists, much obscurity. Its cause used to be referred to the kidneys, it Avas thence transferred to the stomach; it then acquired a temporary occupation of the cerebellum; and is noAV, whether permanently or not, placed in the liver. Still, as the one prominent symptom is the remarkable change in the renal secretion, we have connected it with the urinary deposits. The invasion of diabetes is generally very gradual. The patient commonly feels weak and languid, and complains of thirst, and it may be that he notices that his urine is becoming very abundant; though in a very large proportion of cases, patients do not mention _ this symptom till questioned concerning it. Subsequently the patient loses flesh and strength, though his appetite is often good, sometimes excessive. He complains much of thirst, and of dryness of the fauces; the breath has a SAveetish odour, or, if the expression may be used, a sourish sweet one; the tongue is clammy, red, and raw-looking at the edges, with sometimes a whitish-brown streak down the middle. With the loss of bodily strength, that of the mind also fails. The patient loses the power of continued attention, becomes infirm of purpose, irritable, anxious, or desponding. The symptoms in the majority of cases slowly advance, and, after a period of months, or sometimes years, he gradually sinks exhausted; or phthisis rapidly develops itself, and speedily puts an end to his life. Sometimes there is sudden death. The one characteristic symptom is the presence of sugar in the urine; the prominent one, sooner or later, is the excessive quantity of that secretion; hence its name, diabetes, from 8iaj3an«o, "I pass through," though the connection between the excessive flow of urine, highly charged with sugar, and the other symptoms, is not at first sight very apparent. Into the extended investigation connected with this subject it is not our province to enter, we therefore content our- selves Avith a. very brief summary of the facts which have been ascertained. A considerable proportion of sugar is contained in the food we eat, but in addition to this, a larger quantity is produced by the trans- formation of the amylaceous substances which enter so largely into most articles of vegetable diet; which transformation is effected by the pancreatic secretion. This sugar is dissolved and taken up and conveyed by the veins from the intestines into the portal vein, dis- tributed through the liver, whence it is brought in the course of the circulation to the right ventricle; but in its passage through the liver it is found to have undergone a remarkable change: this hepatic sugar, or glucose, though isomerically the same, is noAV found to be capable of being oxidised in the lungs, so that it is made subservient ITS NATURE. 417 to the purposes of forming carbonic acid, in the generation of animal heat, and also, in all probability, of nourishing the non-nitrogenised tissues, fat, cartilage, &c. AVe say that the sugar has acquired the remarkable property of being thus changed in the lungs, for ordinary sugar will not be acted upon in the lungs, neither will that which has been changed in the liver, unless it be dissolved in perfect blood, that is to say, that if common sugar be exposed in the blood to the air in the lungs, it remains unchanged; and so with the sugar taken from the blood in the right ventricle, if the blood in which it is ex- posed to the air in the lungs have been deprived of its fibrine. So that tAvo things are essential. The action of the liver, and perfect blood for a solvent, in order that the sugar may be fitted for its pur- poses in the animal economy. Now, in diabetes, the sugar is un- changed in the liver, and therefore it remains unchanged in the lungs, the consequence of which is, that being unfitted for the purposes of nutrition or combustion, it remains in solution, and is eliminated from the blood by the kidneys, whose office it is to remove from the blood all soluble matters not capable of serving any further purpose in the system, which substances act as stimulants to those organs, and promote the flow of urine.* From Avhat has been just stated, it must be very easy to understand the subsequent phenomena of diabetes, namely, the failure of nutri- tion, the wasting, the hunger, the thirst, the profuse diuresis, the sugar in the urine, the saccharine smell of the breath; but of the nature of the lesion which prevents the healthy action of the liver upon the blood, we know nothing. It has indeed been ascertained, that sugar was present in the urine of animals in whom the fourth ventricle of the brain had been irritated, and hence it was supposed that there was the origin of the malady; but the observations of Dr. Pavey have shoAvn that the sugar has, under such circumstances, been duly acted upon in the liver, and that it is not diabetic or morbid sugar which has thus found its way into the general circulation, but only an excess of glycose, or sugar of the hepatic cave. The diagnosis of diabetes depends upon the detection of the sugar. This may be discovered as follow:—To a small quantity of the urine, in a test-tube, add about half its bulk of liquor potasse, then boil for about two minutes over a spirit-lamp. If sugar be present, the urine will assume a rich brown colour; this is a very convenient test for clinical purposes; but in some rare cases it may mislead: in all doubtful cases, the Trommer's test, of the sulphate of copper and liquor potasse should be employed. Another sign of diabetes is the high specific gravity of the urine, which may be as high as 1050, or more; whenever it is abundant, and 1030, or near it, we may suspect diabetes; but we are not to overlook the possibility of diabetes without very abundant urine; such cases have occurred, and perhaps are more liable than others to terminate suddenly. * For most of the above we are indebted to the researches of M. Bernard and Dr. Pavey. 418 TREATMENT OF DIABETES. The treatment of diabetes, from the secresy of the nature of the disease, must be obscure and unsatisfactory. The use of amylaceous and saccharine articles of food seems to be contraindicated, and they do, except in very small quantities, increase the flow of urine, and consequent emaciation. But patients will not, or rather cannot, endure the restrictions sometimes imposed. Most vegetables are objectionable, except the cruciferous plants; malt liquor is to be shunned ; bread, and potatoes, and turnips, sparingly used. Let the patient have tea or coffee, with plenty of milk, a rasher of bacon, and a little toasted bread. For dinner, beef or mutton, game or fish, with greens or spinach, and Italian maccaroni boiled in milk. Let him drink a little brandy and water. He may have some tea, with a little well-toasted bread in the evening ; and as he will want some supper, he may have a mutton-chop with maccaroni, or a mess of maccaroni and milk. Of medicines we know of none that have any direct control over the disease. Some years ago, the author recom- mended the use of ammonia in considerable doses, and although the chemical theory upon which that recommendation was based has since proved to be erroneous, the remedy has certainly been found useful by the late Dr. Golding Bird and others, as well as by the author. He has generally given the annexed form (F. 78).* The cod-liver oil may be given at the same time about twice a-day; rennet has been recommended, as has also pepsine, but the author has obtained no result from them. The fixed alkalies are not with- out good effect: and a course of liq. potasse and taraxacum certainly deserves a trial. AVhen the urine is very abundant, about three or four minims of laudanum may be added to each dose of the ammonia mixture; and about five grains of Dover's powder given at night will promote per- spiration. The patient should take moderate exercise, and his mind should be engaged either by a moderate attention to business, travel- ling, or light reading. As the boAvels are apt to be constipated, a little castor-oil may be given from time to time. * (78) R. Ammon. Sesquicarb. ^ ij. Infus. Cascarillae, ^ viij. Misce. From 3 ij to g i. to be taken every fourth or sixth hour. INFLAMMATORY DISEASES OF THE BRAIN. 419 XXIV. INFLAMMATOKY DISEASE OF THE ENCEPHALON. The contents of the cranium, like those of the other cavities of the body, are liable to attacks of inflammation, but it unfortunately happens that, important as are those affections, there are none of which the diagnosis is attended with greater difficulties. These inflam- mations have been by most authors included under the term phreni- tis, though some have restricted this term to inflammation of the membranes, commonly known as meningitis, whilst inflammation of the substance of the brain has been described as cerebritis, a barba- rous word for which, nevertheless, we are in want of a substitute. Whilst, hoAvever, it is highly convenient for the purposes of patholo- gical anatomy to restrict the terms meningitis and cerebritis to inflammation of the membranes and the cerebrum respectively, it is perhaps more expedient for the purposes of practical medicine to retain the term phrenitis in its original signification of inflammation of the encephalon; and the reason why we Avould do so is, that, not- withstanding the careful observations of Abercrombie and others, we are not as yet in a position to speak of the two diseases as capa- ble of separation in practice, however distinct they may be in their anatomical condition. By phrenitis then, or encephalitis, we wish to express a group of anatomical changes, which, as a group, are allied to a certain class of symptoms, but which symptoms cannot at present be individually connected with corresponding anatomical changes; just as we might have spoken of thoracic inflammation generally, before the introduction of auscultation, as including a variety of anatomical changes, and presenting a large group of symptoms Avhich Ave were unable upon the instant to connect seve- rally Avith the appropriate pathological changes. The inflammatory appearances to which we refer are— 1. Thickening or opacity of the arachnoid, effusion of lymph or pus between the layers of the arachnoid, or between the attached surface of that membrane and the pia mater. 2. Softening of the substance of the brain; the softened substance being sometimes of a red colour, constituting the ramollissement- rouge of the French authors, or it may be of a yellowish colour, sometimes from infiltration of puriform matter, at others from change in the red corpuscles of the blood. Effused blood may sometimes have been the cause of the disorganisation, but there is equal reason to believe that in many cases its presence has been the effect. Ano- ther form of softening is simple loss of cohesion without change of colour. 3. The formation of circumscribed abscess in the cerebral matter. 4. Induration, with increased vascularity of some portion of the cerebral matter. 420 SYMPTOMS OF PHRENITIS. The symptoms of phrenitis present almost as great variation as do the morbid appearances. In the best marked cases of inflammation Avithin the cranium Ave have, in the first place, fever of a decided character but not more violent than in some other forms of febrile disease, perhaps hardly so much so. This is followed by acute shooting pain in the head, sickness, intolerance of light and sound, generally with a contracted pupil, particularly in the most acute cases and Avhere the membranes are involved. The pulse is firm, not hard, often rather sharp, seldom peculiarly frequent, sometimes sloAver than natural. The skin rarely A'ery hot or dry. These may be regarded as the general symptoms of commencing inflammation within the cranium, Avhich, if not speedily removed, are generally folloAved by others, AAdiich indicate, Avith some degree of probability, though by no means Avith any approach to certainty, the particular tissue of the encephalon, or, it may be, the part of the brain involved. Thus there may be delirium often coming on in paroxysms, or partial and temporary loss of recollection, convulsions, strabismus, with dilatation of the pupils, sometimes of one only, or there may be increased contraction, some- times blindness more or less complete, partial paralysis, which is sometimes temporary. These symptoms are generally terminated by coma more or less profound. The pulse, which, at the superven- tion of the second series of symptoms, generally becomes slow, increases in frequency at the latter stages, and at last is generally characterised by extreme rapidity. The • bowels, especially at the commencement, are commonly torpid, and acted upon with great difficulty, and the urine scanty. The tongue at first is generally whitish, not exactly dry, but rather more so than in health. As a general rule it may be laid doAvn that convulsion is symp- tomatic of inflammation of the membranes rather than of the sub- stance of the brain, and paralysis, especially Avhen partial, belongs more to the latter affection. In inflammation of the membranes the pupils are more contracted, the intolerance of light and sound greater, the pulse quicker, and the fever generally of a more active charac- ter. In inflammation of the substance of the brain, on the other hand, Ave have as frequently dilated pupil, paralysis, sIoav pulse, and a greater tendency to typhoid symptoms. To the above rules there are certainly exceptions, and consequently, though there exists a great variety in the symptoms in different cases of encephalic inflam- mation, we are as yet unable to account for them by the particular tissue affected. Cerebral inflammation, especially of the membranes, may be ex- cited by the ordinary causes of inflammation, as, for instance, expo- sure to vicissitudes of temperature, and also to the direct solar ray in hot seasons or in hot climates. It may also be induced by Avhat- ever powerfully influences the circulation within the cranium, AAmether affecting the blood itself or its moving poAvers. Thus it may arise from mental anxiety or excitement, as Avell as from the excessive use of spirituous liquors. It may also be induced by pois- ons in the blood, whether generated in the system, as in uremia and • DIAGNOSIS. 421 some forms of jaundice, or derived from without, as those of the exanthemata. Disease of the arteries may also give rise to it, though not generally of an active character, and it may be brought on by delirium tremens and rheumatism. External injuries and disease of the bones of the head are among the most common causes of cerebral inflammation, and amongst these we may particularly notice disease of the petrous portion of the temporal bone from otitis. The diagnosis of phrenitis is highly important, but no less perplex- ing. It is, however, a great assistance to bear in mind that there are three diseases with Avhich it is more particularly liable to be confounded, namely, fever, either continued or eruptive, acute mania, and delirium tremens ; and, as Dr. Addison well remarks, the difficulty is the greater, as each of these diseases is apt to be accom- panied by more or less inflammation of the brain or its membranes. From ordinary fever it may commonly be distinguished by there being less oppression, and by the delirium being generally more vio- lent and earlier in its appearance, and by the pulse being sharp and more commonly irregular, and the skin less hot than in the com- mencement of fever; though, on the other hand, there do occur cases in Avhich the fever is more marked, and the local symptoms less severe than in well-defined cases of phrenitis, the pulse being soft and not irregular, and these cases certainly do for some days remain involved in the greatest obscurity until some more decided (though often partial) effects of cerebral lesion begin to shoAV themselves. Sickness, again, though a very general symptom of cerebral inflam- mation, is sometimes wanting, and, on the other hand, it is not un- common at the commencement of fever, especially the exanthemata. It is, hoAvever, fortunate that those cases which most resemble fever at the commencement are precisely those which are the least bene- fitted by active antiphlogistic measures. From delirium tremens the disease may generally be distinguished by the harder pulse and drier skin, the skin in phrenitis being less dry than in fever, but much less moist than in delirium tremens. The scanty urine and the Avhiter and drier tongue, will also greatly assist the diagnosis. From acute mania, phrenitis may be distinguished by the disorder being in the former almost entirely mental, Avith little or no evidence of derangement of the general health, with the exception of more or less disorder of the digestive functions. The delirium is also more apt to occur in paroxysms, in which, indeed, the pulse undergoes some acceleration, but seldom or ever to the same extent as in those forms of phrenitis which are attended by active delirium. From hysteria the diagnosis of this, like almost every other disease, may be difficult; and here, as in mania, we must be guided by the sharpness, frequency, and irregularity of the pulse, which are for the most part wanting in hysteria. The disturbances of the uterine func- tions must also be taken into account, though it must not be forgotten that suppressed menstruation may induce active phrenitis. The cephalalgia of dyspepsia may become so intense as to give rise to the suspicion of inflammation of the brain, but in the former there 422 PROGNOSIS. is more obvious disturbances of the digestive organs. The diagnosis, however, sometimes requires great care and attention to the symp- toms of phrenitis above noticed, and the more so, as in dyspepsia, though the pulse is rarely much accelerated, it may become irregular. Inflammation of the nervous centres may certainly give rise to pains very similar to those of rheumatism, and what is more, it is by no means impossible that it may actually give rise to such pains, accompanied by SAvellings closely resembling those of acute rheu- matism. The absence of these swellings will, in the majority of cases, assist us in our diagnosis; but when they do occur, which is but rarely, and perhaps more commonly in connection with disease of the spinal chord than of the brain, the diagnosis becomes in the highest degree obscure, until some decided symptoms of nervine lesion begin to manifest themselves. The prognosis of all forms of cerebral inflammation is essentially doubtful, and in the more insidious cases, and those especially which have been overlooked at the commencement, unfavourable. A considerable proportion, however, of severe cases, and those in which the symptoms are most clearly marked, recover under active antiphlogistic treatment. Of such measures the most important are bleeding and purging. In all well marked cases blood should be drawn in the first instance from the arm, according to the state of the pulse; and in the more doubtful cases, and where the pulse is soft, Ave should administer an active aperient; and unless there be decided contra-indications from the state of the pulse, apply cupping-glasses either to the nape of the neck or behind the ears. Nextj and perhaps hardly next in importance to abstraction of blood, is the energetic use of purgative medicines. The bowels in most cases of acute cere- bral inflammation are obstinately constipated, from a defect, possibly, of innervation; therefore, both to overcome this condition, to relieve the circulation, and it may be to produce a revulsion, active purga- tives are required. These remedies should be exhibited from the first, and need not interfere with the other depletory measures. Three or four grains of calomel, with twelve or sixteen of pil. coloc. co. should be administered just before or after the first bleeding, and this should be followed, in about three hours, by one of the more active cathartic draughts, and should this not operate speedily, the colocynth and calomel may be again administered, and if the bowels are not freely acted upon, a cathartic injection (F. 79).* After the action of the bowels has been established it should be freely main- tained by repeated doses of calomel, about two or three grains every four hours, and the mixture of magnesia, with the sulphate in the intervals; and the action of these may be further promoted by a tere- binthinate enema. The purgatives must be steadily continued until the symptoms subside, unless there be such exhaustion as to forbid their continuance; "for," says Dr. Abercrombie, "my own experience * (79) R. Pulv. Jalapse, 3 ij. Infus. Sennse co. Oct. ss. Decoct. Avenae, Oct. ss. Misce. Ft. Enema. TREATMENT OF PHRENITIS. 423 is that more recoveries from head affections of the most alarming aspect take place under the use of very strong purging than under any other mode of treatment." When not contraindicated by the irritability of the stomach, antimonials are of service, by diminishing the force of the circulation, and perhaps also by their action upon the capillaries. Under these circumstances we may in the mixture for the carbonate of magnesia substitute a small quantity of tartar-emetic as follows (F. 80).* At the commencement of the disease the powerful application of cold to the head is often of great service. This, in general, is best effected by means of ice in a bladder, and" should be persisted in as long as there is any disposition to undue heat of the scalp, or in- creased action of the carotid arteries. Its application also requires attention on the part of nurses and attendants, since if it be not steadily employed there is apt to supervene a reaction which may be injurious. The application of blisters, in the early stages of this, as of all other inflammations, is objectionable, but after the activity of the disease has subsided, and there is threatened coma, they may be used on the head and upper part of the spine. The generally very small quantity of the urinary secretion would seem to indicate the use of diuretics, and of these, the digitalis is perhaps the most appropriate, from its effect in controlling the action of the heart. To the use of mercury Ave have before alluded, but chiefly with reference to its pur- gative action, and doubtless it is upon this that its beneficial action mainly depends. There are, however, many practitioners of very high authority who rely much upon its specific action in this disease, and there can be no doubt that many cases have begun to improve just at the time that the gums Avere becoming tender, and to promote this object they recommend inunction, in addition to its internal administration. This is a practice of which it may be said, that it does not interfere with, but rather aids other modes of treatment; and that, if the patient survive long enough to be endangered by the effusion of lymph, or serum, it has a tendency to prevent these con- sequences; but when employed, it must not be in such a manner as to interfere with its purgative action, under the idea that its specific effect may be lost by its running off by the bowels, since Avhatever may be the benefits derived from the specific effects of mercury, they are—when there is undoubtedly active cerebral inflammation—second to those which may be obtained by relieving the circulation through the medium of the bowels, and as far as possible by the kidneys at the same time. On the other hand, too, it must be borne in mind, that the same principle for which we have contended in the treat- ment of pneumonia, applies also in the case of phrenitis, namely, that Avhen the inflammation is of low form, and the powers of the system reduced, so as to produce a tendency to disorganisation, this tendency * (80) H- Mag. Sulphat g iss. Antim. Pot. tart. gr. j. Aq. Menth. vir. § vj. M. A spoonful to be taken every fourth or sixth hour. 424 HYDROCEPHALUS. is much aggravated by mercurial action: and it is by no means im- proper in such cases, when the pulse is soft, the pupils dilated, and the skin perspirable, to administer stimulants, carefully, however, watching their effects; ammonia is that Avhich Ave should try first, if the bowels prove to be relaxed, and the urine not scanty, in com- bination with the infusion of serpentaria, and afterAvards wine may be allowed. We do not, however, mean to say that mercurial prepara- tions are in such cases to be entirely set aside, for the exhibition of a grain of calomel two or three times a-day, may have the effect of keeping up a sufficient secretion from the liver, but what we mean is, that it is not necessary or' expedient to push it to salivation. The acute hydrocephalus of children is a disease which combines all the variety of symptoms above stated, and many of the anatomical changes which have been there described, though it has received its name solely from the effusion of fluid into the ventricles, Avhich almost always takes place when it is sufficiently protracted; notwithstanding that it may prove fatal before any such effusion occurs. The appear- ances found on dissection are, in a great majority of instances, effusion of serum (with very little albumen) into the ventricles of the brain, with a dryness of the surface, sometimes explained by the closure by lymph of the opening into the fourth ventricle. These appearances, with the exception of the last, which is by no means constant, are not in themselves certain proofs of inflammatory action, "but as we find in a large proportion of cases which during life have presented the symptoms under consideration, the unequivocal marks of inflamma- tion co-existing with the effusion into the ventricles, and sometimes existing without it: and as we find also that the chief symptoms in those undoubtedly inflammatory, are just the same as those which present on dissection the effusion only, we can have no reasonable doubt that the effusion, when preceded by those symptoms, is to be regarded as an effect of a diseased action, either so truly inflammatory, or so nearly resembling inflammation, as to demand the same prac- tical consideration." This reasoning is not, however, entirely unexceptionable, since the majority of the symptoms are referable, mainly, to the disturbance or suppression of the functions of the brain; and since it is in accord- ance Avith the principles already laid down to believe that they would be nearly similar, whether that suppression or irritation arose from the effect of inflammatory action, or from structural change indepen- dent of such action, or even as a purely nervine disease, without any change whatever cognizable by our senses; unless, indeed, it can be shown that there are in all cases the symptoms Avhich belong, in general, to inflammation, independently of the part affected. And whether this be conceded or not, it must be admitted that cases of hydrocephalus present a great variety as regards the activity of the disease, and the signs of inflammatory fever; the most probable con- clusion seems therefore to be, that in the majority of cases the disease is of an inflammatory nature, though this inflammation is rarely of a very active or sthenic character, and arising generally in subjects of a tuberculous or strumous diathesis : but that in such subjects an SYMPTOMS AND CAUSES. 425 effusion passive, or nearly so, accompanied by softening of the cen- tral parts of the brain, may take place without any inflammatory action, or that of so low a character as hardly to deserve the name; and the appearances on dissection are often such as lead to the belief that some of these changes have preceded any of the inflammatory symptoms, and that the inflammation has occurred as a consequence, rather than a cause, as in the case of intercurrent pneumonia in tuberculated lungs. The symptoms of this disease are generally of an insidious charac- ter, in Avhich respect, it resembles diseases having their origin in some defect of the constitution, inducing a liability to a plastic, or caco-plastic deposits, rather than those of a truly inflammatory origin. A child, often of a strumous family, and generally with a large cranium, or of a very excitable or restless disposition, is observed to be more than usually irritable, turns from the light, and not unfrequently has an increased appetite for food; the bowels generally are confined, and the urine scanty; the child often appears languid, sometimes drowsy, and is disposed to lay its head on its mother's or nurse's lap; if old enough to make its feelings known, it complains of giddiness, or appears apprehensive of falling, and refers its uneasy feeling to the back of the head, Avhich is often drawn back- wards when the child lies down to sleep; the pulse is frequent, the breathing hurried, and the sleep is disturbed by starting or scream- ing. These symptoms, which constitute those of what may be termed the first, or premonitory period of the disease, are sometimes so slight as to be overlooked, though in some instances they are per- haps altogether wanting, and the pain in the head, with more active symptoms, comes on suddenly upon a state of apparent health, con- stituting what is commonly termed the second period of the disease. In the second period there is severe pain in the head, with scream- ing and knitting of the broAvs, intolerance of light and sound, with increased heat of scalp, Avith throbbing of the carotids. There is often strabismus, and the pupils are generally contracted, sometimes unequally so, and occasionally they may be dilated, though probably this latter condition belongs properly to the next period of the dis- ease. There may be sudden convulsions; the hearing is painfully acute; there is frequent vomiting; the bowels are obstinately con- fined, but the abdomen is flat; the urine scanty; there are, in the cheeks, alternations of vivid flushings and death-like paleness. There is generally great restlessness, and the child requires to be continually moved, or taken into the arms when awake; in sleep there is constant moaning and grinding of the teeth. At this period of the disease, we may have sudden and very great variations; thus, a day on which all the symptoms appear to have been much aggravated, may be followed by one in which they seem almost entirely to have subsided; but this appearance of improvement, or almost of recovery, is most fallacious, and may be followed by a day of still greater excitement, and this alternation may recur for a period of several days. It sometimes happens, too, that the pulse sinks suddenly to the natural standard, a change which is often pre- 426 ACUTE HYDROCEPHALUS. monitory of the supervention of the third period, or that of coma, the invasion of which is commonly gradual: it is interrupted by scream- ing, convulsions, rolling of the head, and jactitation of the limbs. The pupils, during this period, are almost ahvays dilated, and un- affected by light, the sight appears to be imperfect, and the cornea becomes dim; the pulse again becomes very quick, the teeth are clenched, the countenance loses all expressiveness, the evacuations are passed involuntarily and frequently; there is more or less par- afysis before the fatal termination, which is generally preceded by some severe convulsive attacks. We have already alluded to the fallaciousness of rapid apparent amendment in this disease; but on the other hand, we must not for- get that after the coma has been apparently established, and death seems from hour to hour imminent, the patient will pass gradually, or, in some cases, almost suddenly, into a state of permanent conva- lescence. The causes of hydrocephalus resolve themselves into two classes, the constitutional and the extraneous. The constitutional consist almost entirely in the scrofulous or strumous diathesis. Infancy and childhood being, as we have elsewhere pointed out (p. 112), the periods of life at Avhich this diathesis is most prone to manifest itself in the encephalon. In addition to the period of life and the stru- mous diathesis, the circumstance or condition which induces the greatest susceptibility of this disease is any more than ordinary activity or excitability of the brain; hence the remark not uncom- mon in families who have suffered from this fatal malady, that it is generally the most lively and intelligent children who have been carried off by it. These conditions may coexist to such a degree that the disease may appear to originate spontaneously, without any immediate cause. Yet it is most commonly induced, even in the predisposed, by some circumstance or accident disturbing the circulation generally, or par- ticularly any that excites or stimulates the brain, and thereby increases the activity of the cerebral circulation. Of these, the most frequent are exanthems or other febrile diseases (not to mention that the state of debility which follows them often increases the liability to hydro- cephalus, though it may not be sufficient to set it up of itself), teeth- ing gastric disturbances, and confined or disordered bowels. Mental excitement, and over-exertion of the intellectual faculties, as in exces- sive study, and the two great emulation which some of our schools, even for children, encourage, often induces or accelerates it. The diagnosis of hydrocephalus is often almost as obscure as it is important; in young girls it may be sometimes simulated by hys- teria, in those of both sexes by phrenitis, and in young children by infantile remittent. The diagnosis of hydrocephalus from those dis- eases with which it may be confounded, and which have their origin in the digestive organs, rests mainly upon the more decided reference of all the disorders, feelings, and actions to the head. Thus we have from the first irritability or drowsiness, knitting of the brows, aver- sion to light, disordered vision, or excessive sensibility to sound; to DIAGNOSIS AND PROGNOSIS. 427 which may be added, altered disposition, great irregularity, often slowness, in the pulse, costive bowels, but without tumescence of the abdomen, and scanty urine. In subjects approaching the period of life in A\rhich we should expect phrenitis rather than hydrocephalus, the question as to which class any particular case in question may belong is one rather of names than realities, since the forms of dis- ease may merge so insensibly into each other that it is next to impossible to draw the limit; but it is a real and vital question as to Avhether the case is one of the more active and sthenic inflammation to which the term phrenitis is more properly applied, or of the stru- mous and more disorganising hydrocephalus—a distinction not unlike that between pneumonia and phthisis. The age and diathesis of the patient, the greater or less rapidity of the disease, the contracted or passive pupil, the sharpness of the pulse, may help to decide whether the disease approaches to the more or less active affection. The prognosis of hydrocephalus is commonly stated to be gene- rally unfavourable. It would perhaps be nearer the truth to say that it is essentially so, and can only be said to be doubtful so long as the diagnosis is so likeAvise; and the reason is probably this:— that hydrocephalus being a disease almost always of a strumous or disorganising character, beginning in the central parts of the brain, Avhich Ave know admit of a much greater amount of injury being inflicted upon them Avithout their manifesting any well-marked signs of such injury, than do the more superficial parts of the organ; we can readily believe that disease of this character may have produced an almost irreparable amount of mischief before it could have extended itself to the surface, that is to say, before it could have manifested its most characteristic symptoms; and in a question of so much difficulty as that betAveen hydrocephalus and the more active though less certainly fatal disease of phrenitis, affecting chiefly the membranes, we may always give the patient the benefit of the doubt; though this doubt will be greatly lessened by a knowledge of family predisposition, or evident signs of the strumous diathesis; yet where the diagnosis is rendered pretty certain by the subsequent progress of the disease, we must not lightly be induced to give up our fears by delusive appearances of amendment, such as subsidence of the pulse to the natural standard, or the other remission of symptoms already alluded to. After what has been said of the prognosis of hydrocephalus, it need hardly be added that the result of almost every mode of treat- ment is far from satisfactory; and perhaps the best that can be said of any is that it is most successful in those cases of meningitis or phrenitis which most closely simulate true hydrocephalus. And a stronger proof of this need hardly be required than the efficacy often ascribed to mercury, which reason as well as experience teaches us is more probably injurious than beneficial in true hydrocephalus. Wherever, in fact, we have the family and individual history of previous liability, with the premonitory signs and characteristic mode of invasion of true hydrocephalus, by which we mean the central softening with effusion into the ventricles; in these we 428 ACUTE HYDROCEPHALUS. should expect a priori, and shall generally find, if we make the ex- periment, that the action of mercury- may be established, so far at least as to produce the green stools, which are the surest signs of its specific action in children, Avithout any corresponding effect upon the symptoms of the disease. Whereas, in more rapid and acute cases occurring in robust children whose antecedents are opposed to the belief in the existence of strumous disease, we may often find mercury a valuable adjunct to other remedies. The treatment of hydrocephalus must greatly depend upon the constitution of the patient, and the period and intensity of the dis- ease. When, as is more commonly the case, Ave are first called after the disease may be said to be established, and the inflammatory symptoms are Avell marked, we must attempt to subdue them by evacuants, bearing in mind, at the same time, the delicate constitu- tion, and in most cases tender age of the patient. Now it is well known that in many cases children bear depletion well; if the child be above the age of three years, blood may be taken from the arm to the amount of three ounces or upAvards, according to the age of the patient; in a severe case, according to Dr. Watson, we may apply three or four leeches to a child betAveen three and six months old; and six ounces may be taken from the arm of a child of from five to six years old. The same judicious physician observes, how- ever, that these quantities are to be regarded merely as approxima- tions, the true measure of the quantity of blood to be taken being, in all acute diseases, and more particularly in this, the effect Avhich it has at the time upon the system. Next to depletion, or rather equally with it, the most important measure is active purgation; for this purpose we shall certainly derive much help from mercury; two, three, or four grains of calomel, according to the age of the patient, and folloAved after three or four hours by an active purgative draught, will generally produce two or three full evacuations, provided the latter be retained; but as there is often much irritability of the stomach, we must not persist in administering it should it be rejected, but have recourse to cathartic enemata;—about one scruple of poAvdered jalap in five or six ounces of ordinary cathartic mixture, warmed, will answer well for this pur- pose in a child of five years old. When the bowels are acting freely, and we wish' merely for the revulsive action of the enema, the tur- pentine glyster may be preferred. In the second stage of the disease, when the inflammatory symp- toms are still active, and the head is hot, we have a most powerful remedy in the application of cold to the scalp. This may be most efficiently done by pouring cold water from a height of two or three feet upon the head; but this mode of its application is apt to be too depressing, and therefore an evaporating lotion, or what is still better, a bladder of pounded ice, is to be preferred. In the use of these, however, we must be guided by the temperature of the head, the cold application being removed when the cheeks become pale or cold. Care must also be taken that the application is constantly cold, as when evaporating lotions are allowed to dry there is often a reaction, TREATMENT. 429 and the scalp becomes hotter, and the circulation in the head more active than before its application; the ice-bladders, or the wet cloths, must therefore be constantly applied and carefully attended to, unless withdrawn for the reasons pointed out above. It is in the confirmed hydrocephalus that so much reliance is by many practitioners placed upon the action of mercury, and this confidence appears to be enter- tained by physicians of high authority; Avhereas, upon the other hand, there is equally high authority for regarding this remedy as useless otherAvise than as a purgative. It is probable, however, that mercury is less useful in proportion as the disease approaches to the true hydrocephalus, and that it is in the more rapid cases, with greater delirium, occurring in robust children, that Ave may hope for the greatest good from its use. When the bowels are, as is generally the case, torpid, the calomel may be used in doses of about two grains every four hours for a child of four years old. When there is any disposition to irritability of boAvels, which there sometimes is, after the first difficulty has been OA'ercome, the hydrarg. cum cret. is to be preferred. This may be given in doses of three grains; or the ac- companying form may be adopted (F. 81).* The effect of the con- tinued exhibition of the mercurial will be the passing of the charac- teristic dark-green evacuations, Avhich may be taken as evidence of the mercurial action, since young children are rarely salivated, though when that happens, there is much danger of sloughing of the cheeks. When the heat of the scalp and febrile excitement are sub- siding, and the patient if not improving appears to be passing into a state of coma, blisters may be applied to the nape of the neck, or behind the ears, and in those cases in which the action of mercury is thought desirable, the vesicated surface may be dressed with mer- curial ointment. It is at this period, too, that diuretics appear to be specially indicated. When the pulse is not very feeble, digitalis may be given in the form of effusion, in doses of from tAventy minims to a drachm, according to the age of the child; the combination of hydrarg. cum cret. with poAvered squill may also be used, in the pro- portion of about tAvo parts of the former to one of the latter, and this is perhaps a good form for the administration of mercury. Colchicum has also been highly extolled as almost infallible; but Avhen Ave have to deal Avith a disease nearly incurable, we are sure to hear of many infallible remedies. AVhen there is much irritability and restlessness towards the close of the disease, but no stertor, a moderate opiate Avill often be of great service; the best form is Dover's poAvder, in doses of two or three grains. AVhen there is much exhaustion wine may be administered, and that freely; its effects being carefully watched; and, undoubtedly, cases apparently desperate have recovered under the use of stimu- lants ; though it may well be questioned whether such cases Avere not rather those of fever, with head affection, than true hydrocephalus. * (81) R. Hydr. Chlorid. gr. ij. Hydr. cum. Cret. gr. xij. Sacchari purificat. ^ j- Misce. Of which gr. iij. to vj. are a dose ; to be repeated every third or fourth hour. 430 ACUTE HYDROCEPHALUS. If the disease in its Avorst and not least frequent form be thus certainly fatal, it is of the first importance to adopt all preventive measures; and as there can be no doubt of the close connection, not to say identity, between hydrocephalus and tuberculous disease of the encephalon, the principles upon which our prophylaxis is to rest must be the same as those laid down for the prevention of other tuberculous affections, namely—1. to counteract the tuberculous diathesis by attention to the general health. 2. To obviate the tendency of this diathesis to localise itself in the part particularly threatened, namely, the encephalon. For fulfilling the first indication we must apply, according to the age and circumstances of the patient, the principles already laid down. There can be no doubt that the great amount of the strumous disease amongst children in our large towns, arises no less from errors as to ventilation, light, food, clothing, and cleanliness, than from any here- ditary taint in the parents. Although some have been found to deny that strumous disease can be generated de novo in a child born of healthy parents, yet none can reasonably entertain a doubt, that though the parents may have no hereditary taint, yet if their health be deteriorated by the above causes, their children, who are also in most cases of necessity exposed to the same, will become in many instances the victims of scrofula, and therefore not only should rational prophylactic measures be enjoined, upon every opportunity, as regards the children themselves, but parents should be made aAvare that their own intemperance, improvidence, or neglect, may be visited upon their children in early death or ruined health. And this applies with equal force to all classes of society; the profligacy and intemperance, or the excitement and bad atmosphere of the count- ing-house or the gaming-table, on the part of the father, acting upon the health of the offspring no less than the confined workshop or the excesses of the gin-shop; and this applies to the self-indulgence or drudgery of dissipation on that of the mother, no less than to excessive labour, anxiety, privation, or spirit-drinking. The careful ventilation of sleeping apartments, as Avell as cleanli- ness, require care in all classes, as do also the most free admission possible of air, and solar light; the importance of this latter, as affect- ing the health of young children, being generally not sufficiently appreciated. The clothing of all children in this climate requires care, especially of those who, either from any family tendency or from locality, may be prone to strumous disease; it should be uni- form over the trunk especially, not heating, but composed of material of little conducting power of heat. As regards diet, where the mother is healthy, and has a good supply of milk, the child should be kept at the breast for a year; and when the supply begins to fall off before that time, the child should be fed Avith arroAV-root, or tops and bot- toms softened in milk, so as to be taken through a bottle; the feeding children with a boat or even a spoon before they have teeth being a practice that cannot be too strongly reprobated. Whilst great care is to be taken to avoid the effects of cold or TREATMENT. 431 damp, equal caution must be used to prevent the child becoming too susceptible of its influence, and for the purpose of hardening him against it there is no means more effectual than the use of the bath. Most children can bear a bath of the temperature of the room; but should the circulation be so feeble that there is no reaction after its use, the temperature of the water should be raised five or ten degrees above it. It is, however, with preventing the disease from localising itself in the encephalon that we are now mainly concerned; and here we must bear in mind the principle upon which we are to act, namely, the obviating all undue excitement of the organ threatened. To this end precautions should be taken from the first, and amongst the earliest of these should be the keeping of the head cool; the child should be early disencumbered of its cap, both by night and day; here we must, in some degree, qualify what has been said respecting light, since the excitement of a too-powerful light is to be carefully shunned Avhenever the child evinces the least susceptibility to cere- bral irritation. The same applies to loud noises, Avhich are at all times painful; and from the irritation and excitement Avhich they frequently induce, may bring on spasmodic affections; and, therefore, there is good reason to believe that they may promote that determi- nation to the head which favours development of tubercle in the encephalon. AVhen any tendency to tuberculosis is to be appre- hended, either from the constitution of the child or from his ante- cedents, we have reason to fear its development in the brain; and, therefore, AAre must guard against whatever strongly stimulates the sensorial nerves, excites the spirits, or promotes the too rapid or early development of the intellectual faculties. On these grounds we cannot too peremptorily forbid the tossing, and jumping, and halloo- ing to children in arms, often practised by heedless nurses or friends; neither can we too earnestly restrain the vanity or injudicious zeal of parents in urging children, with such a tendency (and be it remem- bered that such children have generally a precocity of intellect that almost holds out a temptation to doing so), to the exercise of their intellectual faculties, and the attainment of acquirements beyond their age, Avhich, if it does not hasten on a fatal malady, is often pro- ductive of a result opposite to that expected: the over-stimulated intellect, like the overgrown body, evincing in the man a feebleness, and want of power of sustained exertion, Avhich the inexperienced would hardly have anticipated from the early intelligence and unusual aptitude for learning of the child. At the same time that these negative precautions are enjoined we must not overlook the more direct ones of combatting the earliest manifestations of cerebral disorders. The state of the evacuations should be carefully watched, and when the bowels are sluggish, a moderate aperient should be, from time to time, administered. For this purpose a good form is the combination of rhubarb and hydrarg. cum cret. or calomel with jalap, which may be helped with from one to two drachms of castor- oil on the following morning. There is, perhaps, some ground for 432 ACUTE HYDROCEPHALUS. difference of opinion as to the use of iron in such cases, and expe- rience teaches us that, in general, it is too liable either to stimulate the circulation, or to induce congestion, to be a safe remedy; per- haps where there is pallor, the syrup of the iodide, in small doses, may be used; but iodide of potassium, combined Avith a vegetable tonic, would, in the majority of instances, be a more effectual as well as a safer medicine. The syrup of the iodide of zinc, as prepared by Mr. Davenport, will also be found a most useful medicine, combining at once the alterative properties of the iodine with the tonic but unstimulating ones of the zinc. The hydrocephalus, of which Ave have just been speaking, is upon the whole to be regarded as the effect of inflammatory action, though of a low character, and one belonging to a peculiar constitutional diathesis; but there is a form of hydrocephalus which is of a non- inflammatory character, and in its most exquisite form to be vieAved in the light of a simple dropsy of the brain, arising, in many cases, from obstructed circulation by occlusion of, or pressure upon, the sinuses, or from atrophy of the brain, 'through disease of the arteries. In the majority of instances, however, chronic hydrocephalus is the result of antecedent acute disease of the arachnoid, of that part more especially which lines the ventricles. In the greater proportion of cases, thirty-six out of fifty according to Dr. West, the disease had its origin before birth. The diagnosis of chronic hydrocephalus is self-evident. The prognosis is in the main decidedly unfavourable, though there have been many probably of a somewhat sub-acute character, in which there have been undoubted effusion, and that, too, of a con- siderable quantity, which has been much reduced by remedies, and probably in the end entirely removed. AVhen the sutures are open, the case is more favourable, both because the brain suffers less from the pressure, and also, because there is greater opportunity for the adaptation of the capacity of the calvarium to the altered amount of its contents. As this form of the disease is, like the acute, if not essentially and directly of a tuberculous character, at least most closely connected with the tuberculous diathesis, Ave must direct our dietetic and gene- ral treatment to obviating the constitutional tendency; at the same time Ave may also have recourse to occasional alterative doses of mercury (F. 82).* Care should be taken to insure its moderate ape- rient action, as it is very doubtful if there is any benefit to be derived from the direct action of the mercury upon the system. The remedy from Avhich, however, most good may be expected, is the iodide of potassium. This will best be used in combination with an alkali, to prevent the iodine being rendered irritating by the salt meeting with any free acid in the intestines; about a drachm of the annexed mix- * (82) R. Hydrarg. Chlor. gr. ij. Sodse Carb. exsic. gr. viij. Pulv. Cretae co. 9 j. M. From gr. vij. to xvi. to be taken every other or every third night. CEREBRO-SPINAL MENINGITIS. 433 ture may be given to a child of a year old (F. 83).* The absorption may, perhaps, be helped, from time to time, by the addition of a small quantity of infusion of digitalis, of which about fifteen minims may be given to a child of a year old ; but its use should not be continued for more than four or five days together. Blisters may also be applied behind the ears in children of a year old and upwards. A good rule for their use is to allow the plaster to remain on for one hour, and then remove it; and if there be no vesication at the end of an hour after its removal the same proceeding may be repeated. The general treatment and hygienic measures for the prevention of chronic hydrocephalus must be the same as those employed against the acute form of the disease. [CEREBRO-SPINAL MENINGITIS. Sporadic cases of inflammation affecting the meninges of the brain and medulla spinalis are occasionally met with, but it is from its frequent occurence as an epidemic in different portions of Europe and the United States, that cerebro-spinal meningitis has, of late years, attracted attention. The disease in many instances occurs suddenly, without any pre- monitory symptoms. In general, however, it is preceded by more or less of pain of the head, especially of the forehead, temples, or occiput. The pain is usually constant, but occasionally remittent, or even intermittent. Pain is, also, sometimes experienced in the back of the neck and along the course of the spine, with a sense of soreness in the limbs and joints. In a few cases the attack is pre- ceded by a sense of giddiness, with or without dimness of vision. In some instances the attack commences with a feeling of chilli- ness, succeeded by a slight increase in the heat of the surface, and pain, extending from between the shoulders to the occiput, with stiff- ness, to a greater or less extent, of the posterior cervical muscles. Or, the patient may be attacked by chilliness, pallor of countenance, coldness of the extremities, low moaning, or muttering delirium, quickly succeeded by restlessness, flushing of the face, a frequent pulse, a wild expression of the eyes, and a hot and dry skin. In other cases, the disease may be ushered in by a sense of lassitude and uneasiness, considerable prostration, and a dull heavy pain of the head, with more or less vertigo, especially when an attempt is made to assume the erect position; the eyes are languid and half-closed, the speech laborious and indistinct; occasionally the patient is sud- * (83) R. Pot. Iodidi, gr. iv. Sp. /Eth. Nit. 3 j. Liq. Potasste, n^ xxiv. Tinct. Hyoscy. 3 j. Syrupi Aurant. 3 ii. Aq. Purre, <]uant. suf. ; to make a two ounce mixture, of which from z j. to iv. are to be taken three times a-day. 28 434 CEREBRO-SPINAL MENINGITIS. denly attacked with deep coma, or Avith more or less stupor, attended by a sense of extreme debility, giddiness, dimness of sight, or double vision. Or, the attack may commence Avith severe pain of the abdomen, succeeded immediately by nausea, and perhaps vomiting. In violent attacks of this character, the extremities become, at the same time, cold and of a bluish colour, and the pulse is reduced to a mere thread. After a feAV hours, reaction, more or less perfect, ensues. Whatever may be the character of the initiatory symptoms, they are replaced, after a period of variable duration, by a state of violent agitation, or by a state of stupor more or less decided, with a slow occasionally full pulse, and dilated and immoveable pupils. AArhen in this condition, on touching any portion of the patient's body will sometimes cause him to emit a short plaintive cry; at others, the patient utters, from time to time, acute cries, and carries his hand frequently to his head. When spoken to, he Avill, in general, exhibit a degree of consciousness, by a motion of the head, by an attempt to articulate, or by opening his eyes for a moment. Pain, more or less intense, of the head and along the spine, is pre- sent in the early stage of nearly all cases. Pressure applied to the cervical portion of the spine Avill often produce pain of the head darting to the forehead, eyes, and temples, as Avell as pain at the top of the sternum; while pressure on the dorsal vertebras will cause pain at the middle of the sternum, or about the umbilicus, according as it is made higher or lower. The pain is frequently severe, and continues for some time after the pressure is removed. From an early period of the attack, delirium is very commonly present, often attended Avith contraction of the pupils, or, occasion- ally, with dilatation of one pupil and contraction of the other; some- times with ptosis of the eyelids, and ecchymosis under the eyes. Ordinarily, the delirium lasts but a short period, but quickly returns. The mind of the patient is in most, cases desponding and apprehen- sive. More or less intolerance of light and sound is present in the majo- rity of cases : in some it is to such an extent that the slightest ray of light or the least unusual sound is apt to excite' convulsive move- ments. In the first period of the attack, imperfect vision has been occasionally noticed; the patient seeing objects double, or only one-half of them, or they appear to him as if enveloped in a mist. The conjunctivae are often injected, and the eyes of a glittering and watery aspect. Insensibility of the eyes to light, and complete blindness of one or both eyes have been noticed as present in many cases. Violent inflammation of one or other eye has been described as of frequent occurrence in some epidemics. Partial or complete deafness is present in some cases ; in others a constant ringing in the ears is complained of from an early period of the attack. There is often present an exalted sensibility of the entire surface of the body, the patient Avincing upon the slightest touch, even of SYMPTOMS. 435 the bed-clothing, and refusing to change his position, from the pain consequent upon every attempt at motion. , In very violent cases, petechias occur upon the extremities and over the eyelids, within a few hours after the attack. An exanthe- matous eruption, also, occasionally makes its appearance. The respiration is sometimes irregular and laboured—a difficulty would appear to be experienced in some cases in expanding the lungs—with respiration chiefly through the nostrils. Stertorous respiration is not a frequent symptom. There is often continued irritability of the stomach, Avith insatia- ble thirst, and tenderness of the epigastrium upon pressure. Constipation and suspended secretions are common symptoms of the disease. The tongue is usually more or less coated with a pale ash, white or yellowish fur. In the more graA'e and malignant forms of the disease it has been observed to be broad and flabby—sometimes so enlarged as to impede articulation, and becoming indented around its edges by pressing upon the teeth. An increased flow of saliva is commonly present. During the period of excitement the pulse is usually full and fre- quent—from 120 to 140 in a minute—often, hoAvever, it is very slow—sinking, sometimes, to 48 or 50 in the minute. The pulse, however, has been observed to vary in the number of its beats at different periods of the day. The most striking characteristic of cerebro-spinal meningitis is presented by the condition of the muscular system. The muscles of the neck in particular become rigidly contracted, draAving back the head upon the vertebral column, and firmly fixing it in that position, so that the patient is unable to move it forwards; neither can this be done by the attendants Avith the employment of any justifiable force. The countenance at the same time assumes very much the tetanic expression. In some cases, the contraction is confined to the sterno- mastoid muscle of one or both sides; in others, again, it is the extensors that are principally affected, the head being retained permanently in its natural erect position. The rigidity is A'ery commonly observed in the muscles of the extremities also. The patient loses the poAver of moving his limbs and of assuming the erect posture. In some instances there is a quivering motion of the muscles of the face, Avith tremors of the hands, and embarrassment in the movements of the extremities, or spasmodic twitchings in the flexors of the limbs, with a disposition to a constant movement of the legs from side to side, alternately. In some epidemics, rigidity of all the spinal muscles was a common symptom—occasionally, the whole spine, from the occiput to the sacrum, being bent forcibly backwards, like a well-strung bow, so as to prevent the patient from lying flat upon his back. Contraction of the recti muscles of the abdomen is often present. In many cases there is a difficulty of prehension, it being with great difficulty that the patient can take and drink water from any vessel without assistance. In some cases involuntary twitchings of 436 CEREBRO-SPINAL MENINGITIS. » the muscles are produced whenever the patient attempts to move or seize any thing, as if he were under the influence of strychnia. In others, violent convulsions are induced the moment the inferior extremities are raised up, or merely touched. There is great irregularity as to the period when the tetanic symp- toms occur. They may set in as early as the first day of the attack, or not until after the lapse of several days. Cerebro-spinal meningitis, although it is, in general, marked by pain of the head, more or less intense, rachialgia, heat of the scalp, congestion of the conjunctivae, some degree of intolerance of light and noise, exalted sensibility of the cutaneous surface generally, tendency to coma, and a tetanic affection of the muscles of the neck and per- haps extremities, may, nevertheless, in many instances, present no symptoms of so decided a character as to lead us to suspect the exist- ence of serious disease of the brain and spinal marrow, until the laboured pulse, the dilated pupil, the profound coma, or the severe spasmodic or convulsive attacks indicate but too plainly the near approach of death. In other cases again, and these by no means of rare occurrence, symptoms of a most formidable character may present themselves at the very onset of the disease. Thus, the patient may be attacked at once with violent paroxysms of general convulsions, requiring manual restraint to protect him from injury; or he may suddenly, without any striking premonitory symptoms, sink into a state of coma almost apoplectic in its character, or, into a half unconscious condition, with constant moaning or plaintive cries, and grinding of the teeth. Intermissions of a periodic character are not uncommon in this disease. So complete, in some instances, will be the cessation of all the prominent symptoms as to lead to the hope of the speedy recovery of the patient, the fallacy of which is shown by the return of the symp- toms in perhaps a more aggravated form, on the following day. AVhen death is not early induced by the violence of the attack, the patient sinks, more or less rapidly, into a state of profound coma, his pulse becomes slow and labouring, his power of speech and degluti- tion entirely fail, his tongue becomes dry, and, together with the lips encrusted with dark sordes; his stools are passed involuntarily, Avhile his bladder becomes distended with urine, or allows it constantly to dribble away: death finally closes the scene, often preceded by para- lysis of one side of the body, or of one or other extremity. The duration of the disease is very variable. Death may occur within a few hours from the commencement of the attack. The generality of cases terminate about the fourth day; some, however, are prolonged over fourteen, twenty, or even fifty days. Conva- lescency is usually slow and lingering. Even after an apparently perfect recovery, secondary diseases are apt to occur, and sooner or later destroy the patient. The diagnosis in cerebro-spinal meningitis is somewhat obscure. There is no symptom or series of symptoms which can be considered as strictly pathognomonic. The disease is in general characterised by acute and fixed pain of the head, rachialgia; aversion from light; PROGNOSIS — ANATOMICAL LESIONS. 437 injection of the conjunctivae; increased sensibility of the surface; acute cries; low, muttering delirium or coma; pain and stiffness of the posterior cervical muscles, with permanent retraction of the head; often rigidity of the large extensors of the spine; spasmodic tremors or twitchings of the muscles, particularly of the face; tetanic convul- sions of the limbs. AVhen a disease, marked by several or all of the above symptoms, occurs as an epidemic, we may pretty confidently pronounce it to be cerebro-spinal meningitis. The prognosis is for the most part unfavourable—sporadic cases, it is true, frequently do well under an appropriate treatment, but in its epidemic form, it has terminated fatally in the great majority of cases. When the attack commences with great prostration, coma, and general symptoms of collapse, death often ensues in a few hours without the occurrence of reaction. Few cases recover after severe tetanic symp- toms make their appearance. Irregularity of respiration, difficulty of swalloAving, great enlargement of the tongue, extensive petechia), violent general convulsions, and deep, persistent coma are all unfa- vourable symptoms. The anatomical lesions detected in the bodies of those who have fallen victims to the disease are chiefly confined to the meninges of the brain and spinal marrow. The pia mater is deeply injected with blood, and the large vessels and sinuses of the brain remarkably turgid. The arachnoid is slightly opaque at different points, Avith its free surface generally dry and clammy. More or less serosity, either lactescent or turbid, yelloAvish, and often semi-gelatinous is found in many cases effused beneath the arachnoid. In others, drops, varying in size, of a yellowish colour and purulent appearance, are dissem- inated along the course of the vessels. More generally, patches, or bands of a consistent substance, of a yellowish or greenish colour, resembling concrete pus, are met with on the surface of the pia mater, at the upper and lateral portions of the hemispheres, but especially at the base of the brain, in the space corresponding to the circle of Willis; many of the cerebral nerves being, at their origin, imbeded in it. It passes over the infractuosities, rarely penetrating into them. In the spinal canal, this puriform matter extends along the anterior or posterior face of the medulla, and, occasionally, competely v#envelopes it, extending often to the extremity of the cauda equina; investing each of the spinal nerves at its source. In some cases true purulent collections are present. These morbid deposits are confined as in the cranium to the sub-arachnoid space. In a few cases inflammatory effusion is met with in the ventricles of the brain, with increased vascularity of the choroid plexus; more rarely the substance of the brain and spinal marrow is found softened to a greater or less extent. Sometimes on dividing the brain, besides the red points commonly present in cases of congestion and inflam- mation, there is observed an immense number of red vessels, contain- ing sometimes fluid, and at others, coagulated blood. Similar vessels are seen, also, upon removing the membranes, ramifying over the base of the brain, and also over the floor and walls of the ventricles. There is reason to believe that when the substance of the brain and 438 CERERRO-SPINAL MENINGITIS. spinal marrow is found affected it has become so secondarily, from the extension to it of disease primarily located in the meningeal envelopes. Whenever purulent effusion is detected on the spinal medulla, it is also met with on the brain; occasionally, however, it is confined entirely to the latter, from which circumstance it has been inferred that the inflammation in cerebro-spinal meningitis commences always in the encephalon, and from thence extends to the spinal meninges. The rapidity with which suppuration may occur in this disease is surprising. Cases are recorded in which pus was met with, although death had occurred in fifteen, thirty-six, and forty-eight hours from the onset of the disease. Slight redness of different portions of the gastro-intestinal mucous membrane is occasionally met Avith, in the form of patches, arborisa- tions, or dots. In some instances a diseased condition of the follicles, in others, thickening, or softening, to a greater or less extent, of portions of the mucous membrane of the stomach and ileum are pre- sent; while, in other cases, again, enlargement, and even ulceration of the agminated and solitary glands of the loAver portion of the ileum, with enlargement, reddening, or softening of the mesenteric glands, have been observed. These lesions of the digestive organs have almost invariably occurred in patients who survived the first few days of the attack, from this fact, and their infrequency, they can be vieAved only as the result of an accidental or secondary affection. In the post mortem examinations made at Versailles, in 1839, the left cavities of the heart were found to be almost entirely empty, Avhile those of the right side were filled with large fibrinous coagula, of a yellow colour and some consistence. The same thing was observed by the physicians in other parts of France, especially in cases in which the blood drawn during the life time of the patient Avas buffy and contained but little serosity. Dr. Ames, of Alabama, found the blood drawn from the arm, and by cups, to form large, loose coagula, in which all the red globules were rarely included. The serum separated slowly, and in small quantity. The colour Avas in general bright—in a few cases approaching to that of arterial blood. Of thirty cases, it was buffed in only four. It presented an excess of fibrine. In four analyses of the blood, procured in two cases at the first venesection, in one at the second, and in another at the third, M. Tourdes states, that the principal alteration detected Avas an increase of the red globules and of the fibrine, but especially of the former. As already remarked, it is chiefly from the occurrence of cerebro- spinal meningitis as an epidemic that the disease has of late years attracted the attention of physicians. These epidemic visitations are occasionally confined within very narrow limits, while, at others, as was the case in France, between the years 1837 and 1842, they spread successively over extensive regions. Their occurrence would appear to be altogether independent of any morbific agency referable to peculiarities of climate, season, or locality. Age, and to a certain extent sex, would appear to rank as predisposing causes of the dis- TREATMENT. 439 ease, whatever may be the nature of the epidemic agent by which it is produced. Its subjects, wherever it has so occurred, have been young persons of the male sex. In Ireland, boys under twelve years of age were those almost exclusively attacked. In Gibraltar, in the great majority of cases, it occurred in subjects—chiefly males —betAveen two and fifteen years. of age. In Tennessee, its principal victims were children between the ages of six and fifteen years. In Missouri, between ten and fifteen years. In San Augustine, Texas, the patients Avere generally under fifteen years; in but two or three instances did the disease attack those over eighteen years of age, and not in a single instance a female. In Alabama, however, the majority of those attacked—over fifty per cent.—Avere beyond tAventy years of age. Ffty-four per cent, were males. In Texas there was not an instance of the disease occurring among the negroes, who were pro- bably more exposed to morbific agencies than the whites. In regard to the treatment of cerebro-spinal meningitis, owing to the rapid march of the disease in the larger number of cases, there is little time left for the application of those remedies which its charac- ter, as indicated by the symptoms present during the life of the patient, and the lesions discovered upon dissection after death, Avould point out as the most appropriate. At the height of the epidemic, in those cases especially in Avhich the attack commences with symp- toms of extreme violence, as well as in those where symptoms indi- cative of extreme collapse are present at the very onset of the dis- ease, the most judicious and best directed plan of treatment will very generally fail to arrest a fatal termination. At the commencement of the attack, when symptoms of prostra- tion and of deep stupor are absent, as Avell as during the early period of the stage of excitement, there can be no doubt of the propriety and efficacy of direct depletion. In all cases, then, of the character just described, free bleeding from the arm should be resorted to without delay. The amount of blood to be draAvn is to be measured by the age and condition of the patient, and the effect produced. If a weak pulse rise, or a strong one retain its character during the flow of blood, this may be allowed to continue; but when the pulse becomes weak, a moisture breaks out upon the surface, and the face become pallid, indicating approach- ing syncope, the flow of blood should be at once arrested, even though we may be required to re-open the vein a few hours subse- quently, should the pulse again rise, and the face become once more flushed. We are not, however, to proportion our bleeding to the degree of restlessness and delirium with which the patient may be affected. These violent states of nervous erethism quickly exhaust the powers of life, and were a too copious venesection to be resorted to, a sudden and speedily fatal collapse would be liable to ensue. Subsequently to general bleeding, cups should be applied to the back of the neck, and along the spine, and leeches to the temples, to the neck, and behind the ears, and repeated at short intervals, so long as any indication for direct depletion remains. After the first bleeding an active mercurial cathartic should be 440 CEREBRO-SPINAL MENINGITIS. administered, and cold applied to the head by means of a bladder half filled with powdered ice, or cloths wet with iced Avater, or iced Avater and vinegar, the hair being first removed. At the same time the feet and legs should be immersed in hot water, followed by sina- pisms to the feet and ankles. In conjunction with direct depletion by the lancet, active purgation will unquestionably be found an efficient remedy, by producing a revulsion from the diseased organs. There are but few cases in which the presence of gastro-enteric inflammation will forbid the employment of purgatives. Tartar emetic, in divided doses, combined with the saline diapho- retics, will no doubt prove beneficial in the early period of the stage of excitement. In the epidemic which occurred at Vicksburg, Miss., Dr. Hicks gave it in combination with camphor, and, as he states, with the best effects* After blood-letting has been carried as far as it is thought prudent, under the circumstances of the case, especially if the patient falls into a state of coma, Avith feeble pulse and deficient reaction, blisters along the whole course of the spine will often be found of advantage. According to Dr. Ames, blisters to the upper portion of the spine very generally had the effect of removing or greatly relieving the cephalalgia, even when bleeding had failed to do so. In the malig- nant forms of the disease, the relief afforded by them was very great. Blisters to the scalp have been advised; we doubt, however, the pro- priety of their application to this part. In those cases where the attack commences with symptoms of collapse, or where such symptoms ensue after a transient and imper- fect reaction, the most powerful excitants, mustard, ammonia, or tur- pentine, aided by heat and friction, should, Avithout delay, be applied externally along the spine and to the extremities, and perseveringly employed, at short intervals, until the torpid sensibility is aroused. It is probable that, in these cases, the actual cautery, as employed by M. Eollet, will be found of advantage. He passes the iron, at a white heat, six, eight, or more times, at as many different points, along each side of the spinal processes. M. Rollet states that, in the worst cases, the first application of the actual cautery does not elicit from the patient any indication of sensibility, it is only at the third, fourth, or even fifth application that a slight muscular movement proves that pain is experienced. Some patients utter cries during the last applications, but immediately relapse again into a comatose condition. Should we succeed in establishing reaction, the patient must be carefully watched, and if it transcend the proper grade, resort should be immediately had to general and local blood-letting, to an extent proportioned to the violence of the symptoms, and the age and strength of the patient, at the same time, cold applications should be * R. Antimon. Tart. gr. ij. Pulv. Camphorae, 3 ij. Mucil. g. Acacise, 3 vj. M. Dose, a tablespoonful every two hours. TREATMENT. 441 made to the head, and the other means of keeping down excessive reaction employed. By several of the American writers on the disease, the early and free exhibition of mercury, both by the skin and mouth, with the view of producing promptly its specific action, is favourably spoken of. Dr. Ames, of Alabama, considers it a more efficient remedy than blood-letting, as weil in the promptness as in the permanence of its beneficial effects. The French physicians condemn mercurial frictions—more, how- ever, we suspect, from theoretical views, than from any actual expe- rience of their bad effects. It is proper to remark that, in many cases, mercury, even when its specific effects have been induced early in the attack, has failed to exert any perceptible influence in retarding the fatal march of the disease. The same remark, hoAvever, may be made in reference to every other remedy that has been resorted to in this disease. Sub- sequent to venesection and the employment of the other antiphlo- gistic remedies, the administration of opium has been recommended by several of the French physicians. Forget commenced its use between the fifth and seventh days of the disease, in the form of a syrup containing half a grain of opium as a dose for an adult. This he found to relieve the pain of the head, and to calm the delirium and muscular spasms. M. Chaufard states that the early employment of the most energetic antiphlogistic means failed in his hands to cure the disease, but he found it to be promptly arrested by opium given in large doses,—in many cases it Avas advantageously combined witty quinia. Before this plan was adopted, we are told, only one case was cured out of thirty, but afterwards the disease was even less fatal than in its sporadic form. M. Tourdes admits, with M. Chau- fard, the inefficacy of the usual antiphlogistic remedies, but cannot agree with all the latter has said in praise of the curative effects of opium. Dr. Ames, of Alabama, does not consider the latter as gene- rally safe in the more violent inflammatory cases, nor of any use in the congestive malignant cases. In the other forms of the disease, he speaks of it as a safe and very valuable remedy. At St. Augus- tine, Texas, we are informed by Dr. Roberts, that opium and mor- phia were tried in a few cases, but without any good result, they appeared rather to increase the stupor, without relieving the pain and restlessness. To produce a sedative effect, some of the French practitioners employed, subsequent to antiphlogistics and revulsives, the water of the cherry laurel and that of valerian combined with mucilage. M. Maihle recommends in preference, the distilled water of bitter almonds, as furnishing more definite proportions of hydrocyanic acid. Quinia is recommended as a most efficacious remedy in cerebro- spinal meningitis by certain of the French army physicians; by the majority, however, it is denounced as positively injurious. It was frequently employed by Dr. Ames in the graver forms of the disease, and sometimes with partial success. AVhen the disease was attended 442 CEREBRO-SPINAL MENINGITIS. by fever of a regular remittent form, he found it occasionally to arrest the paroxysms. In other forms of the disease, he found it, if not absolutely injurious, to afford not much encouragement for its repetition. Dr. Ames speaks highly of the effects of potass in this disease. It was given to children in doses of from three to five grains, every two hours. No case proved fatal in his practice, nor, so far as he could learn, in which the potass was freely and continuously em- ployed. In many cases, unattended with febrile symptoms, properly so called, under the use of -the remedy, the cephalalgia was speedily and permanently relieved, and in others, its administration Avas followed by a prompt reduction of arterial excitement, delirium, and the intense pain of the head. Etherial inspiration, it is said, was practised, with the best effects, by M. Basseron, physician-in-chief to the Military Hospital of Mus- tapha, in Algeria. During the period of excitement, cooling drinks should be allowed, and a strictly antiphlogistic diet enjoined. Absolute rest and quiet, Avith the seclusion of light, as far as it is consistent with due ventila- tion, are all important. In the comatose cases, and during the stage of collapse, care should be taken to prevent an accumulation of urine in the bladder. Convalescence from epidemic cerebro-spinal meningitis is usually protracted, and relapses are liable to occur from slight errors in diet and regimen, hence the greatest watchfulness is to be observed until the general health and strength of the patient are fully re-established. Dr. Hicks found the annexed prescription* to act as a most admi- rable tonic, after the violence of the disease had been subdued, for relieving the inertia of the nervous system that remained in every instance in which recovery took place. * R. Iod. Ferri, ^ j. Iod. Potass. ^ ij. Iodini, gr. viij. Syr. Sarsapar. ^ iv. M. Given in doses of a teaspoonful every four hours, in a little water. DELIRIUM TREMENS AND MANIA. 443 xxv, DELIRIUM TREMENS AND MANIA. Delirium tremens, or the mania apotu of the older authors, is a disease which we recognise, and can define only by its symptoms, since it belongs to that class of nervine affections, in which defect or derangement of the nervous power arises independently of any structural change cognisable to our senses. The Avhole of the symptoms in this affection, are essentially those of exhaustion, with that state of the nervine functions so commonly associated with it, and which is recognised, amongst medical men, as that of excessive irritability. This disease attacks exclusively those who have been subject to a long series of excessive nervine stimula- tion, accompanied by circumstances tending to derange the circula- tory and digestive organs. All these conditions are combined in repeated and continued alcoholic intoxication, and therefore it has been regarded as especially a drunkard's disease, and hence the synonyme mania a potu: this, however, though true of by far the greater number of instances, is not so universally. The disease generally commences, or is preceded, by more or less of febrile excitement, during which there is often a sense of horror of some impending calamity, or the patient entertains a suspicion of some plot laid against him; there is a continued movement of the eyes, as if in apprehension of some approaching danger; hurriedness and excitability of manner; a degree of tremulousness in the limbs, and the same is observed of the tongue when the patient is asked to protrude it. This excitement and tremulousness continue until to the dread of approaching danger are added hallucinations, and the patient believes that he sees persons or other objects approaching to do him mischief. In this state of excitement he will, unless carefully Avatched, elude the restraint of his friends, and walk or run hurriedly for long distances, as if endeavouring to escape pursuit. These hal- lucinations are accompanied by delirium, the patient generally assert- ing that he is in some other place, commonly, to all appearance, under the idea that he has been kidnapped or removed by stealth or force; and whilst suspicious of all about him, he is more especially so of his nearest relatives, and those in whom he is most used to trust; his talking is incoherent, generally, however, in accordance with his hallucinations, or about some disappointment or loss in business, or some subject which has caused him peculiar anxiety of mind. This last form of delirium is more particularly observable in those in whom the disease has been induced by some circumstances other than in- toxication. Sometimes, however, there is a degree of hilarity about the patient, and he will sing and be jocose at intervals. It is one of the peculiarities of this form of delirium, that a word will often bring him to a state of reason, though only for a very short time, after 444 DELIRIUM TREMENS. which he immediately recurs to his former delusions. With all this excitement, the pulse, though rapid, is very compressible, and the tongue is creamy and moist, the skin perspires freely, the urine is abundant, the bowels, though torpid, not obstinately constipated, and the pupils rather dilated, though obedient to the stimulus of light. If the disease be not checked by the appropriate treatment, the patient passes into a state of coma, or what is equally frequent, sub- sides rapidly from excitement to exhaustion, and sinks from gradual syncope. Another danger to be apprehended is the patient's de- stroying himself, either accidentally in his anxiety to escape from his imaginary danger, or by direct injury inflicted upon himself. The most common cause of delirium tremens is, as has been stated, intemperance, the disease generally commencing after a continuance of excessive drinking, wound up, perhaps, by an extraordinary de- bauch. Sometimes, too, the approach of the disease seems to cause an increased desire for stimulating drinks, this giving rise to some very great excess, the depression consequent upon which is the beginning of the attack. Sometimes it happens that, owing to a threatened attack of apoplexy, or some inflammatory affection, real or presumed, the patient is bled, or blood is lost by some accident incurred in a drunken fit; or it may be that the state of the liver, induced by alcohol, gives rise to an attack of haematemesis, and the loss of blood appears to be the immediate cause of the invasion of delirium tremens. It may be, too, that the sudden withdrawal of his accustomed stimulants brings it on when such stimulants have been forbidden, OAving to the patient being under treatment for disease or accident. Sometimes a drunkard in a fit of remorse determines to abstain entirely, and this too may induce the disease. Intemperance in the use of alcoholic drinks is not, however, the alone cause of delirium tremens, indeed it may be questioned whether it is ever, in the strictest sense of the word, a cause at all, since its effect is merely to induce a state of susceptibility to those influences which are the real cause, and to which intemperate habits render him peculiarly exposed; and many cases have occurred which seem to show that this susceptibility may be induced by long-continued excitement of the nervous system in other ways. The excessive attention to busi- ness, where that business is of an exciting kind, has, when the excite- ment has ceased or been abruptly brought to a close by some heavy reverse, been known to be followed by the symptoms of delirium tremens. Another instance is afforded bv the case of a young me- dical practitioner, of strictly temperate habits, who, whilst successfully but anxiously engaged in a rapidly-increasing practice, became the subject of severe erysipelas, upon the subsidence of which he had an attack of delirium, with all the most characteristic signs of delirium tremens. The diagnosis of delirium tremens, in its perfect form, is not dif- ficult: from phrenitis it maybe distinguished by the softer pulse, the moist tongue, perspiring skin, scanty urine, and by what is perhaps a still more important sign, the dilated pupil: from acute mania it is to be distinguished mainly by the character of the delirium, which is DIAGNOSIS-^-PROGNOSIS — TREATMENT. 445 never of the violent character which it assumes in the latter disease, and by the state of the pupil above alluded to; neither does delirium tremens assume the severe paroxysmal character. Whilst, however, we maintain that there is little difficulty in the diagnosis of delirium tremens, in its unmixed form, we would strongly inculcate, what the experience of all must confirm, that the majority of cases with which we have to do are not such; but that they seem to belong to an in- termediate condition, between phrenitis on the one hand, and delirium tremens on the other; and it is in appreciating the tendency which exists to either of these affections that the tact of the practitioner will be particularly tried. The history of the disease will not, on such occasions, be always found a sufficient guide; for not only may de- lirium tremens arise, though rarely, without intemperance, but what is more common, intemperance may induce either phrenitis or mania; it is, indeed, by their characteristic symptoms that we judge of the presence of either of these complications, and when the probability of such complication existing is fully appreciated, there will be no great difficulty in detecting it; thus, if with the delusion, and tremor of delirium tremens, we find a dry, or even not moist, tongue, a harsh skin, scanty urine, or a contracted pupil; or if the pulse be small and hard, rather than of the full, soft character belonging to delirium tremens, we must regard the case as complicated, and our prognosis and treatment must be regulated accordingly. On the other hand, with many of the constitutional symptoms of delirium tremens, we may have the furious and paroxysmal delirium of acute mania. The prognosis of delirium tremens must, it is obvious from what has been said, be doubtful. In a first attack, Avhere there are no complications and no very severe visceral disorder, the patient will generally do well. Where the symptoms of phrenitis are mixed up with those of delirium the danger is greater, nearly in the direct pro- portion of the amount of phrenitic symptoms. Those cases which arise from purely mental excitement independently of intemperance are specially dangerous. When we have to deal Avith a case of simple delirium tremens, our treatment must be simple and decided. The patient must be put to bed, carefully watched, and kept there by gentle means; the head may be shaved, or, if this be not done, the hair must be cut short; and where there is undue heat of scalp, a cold or evaporating lotion must be applied. We must first take care that the bowels are well cleared out, which will be best effected by half an ounce of castor oil, or some rhubarb and calomel; and when this has been done, we may put the patient upon the use of calomel and opium, a grain of eaeja being administered every three or four hours at the commencement, but should this not be sufficient to quiet the excitement, an extra dose of opium, in the form of half a drachm of the tincture, may be administered at night, and this may be repeated in the course of two hours, should rest not be obtained. Should this fail, and should there be no symptoms of the unfavorable action of the opium, as indicated by a dry skin, scanty urine, or, what is most important of all, a con- 446 DELIRIUM TREMENS. tracted pupil, the opium may be repeated on the following night in still larger doses; indeed, when we have a clear case of delirium tremens, we must measure the dose of opium not by quantity, but by its effects. In the more mixed cases, however, and they are not the least common, more caution is necessary, and it will be safest, after unloading the bowels, to commence our treatment with a combination of calomel, camphor, and henbane (F. 84);* and, if there be much restlessness, with a pupil inclined to be contracted, a full dose of hen- bane may be given at night in the form of tincture, adding to it some ammonia when the pulse is feeble (F. 85).f Cases of this kind some- times go on favourably under the above plan of treatment, but it sometimes happens, that under its influence the more phrenitic symp- toms subside, and the disease becomes one of decided delirium tremens, when a full dose of opium will be followed by the best re- sults. Another important question in the treatment of delirium tremens, is the extent to which alcoholic stimulants are to be em- ployed. As has been observed above, the immediate cause of the disease appears in some instances to be the withdraAval of such stimu- lants, and therefore their use is clearly indicated, and generally it will be best to employ that to which the patient has been most accustomed. It is, however, to be borne in mind, that alcohol is not the cure for this disease, its use being to obviate that state of the nervous system which supervenes in drunkards when the stimulating effects of drink have subsided, and Avhich may often be witnessed in the gin-drinker before he has had his morning-glass, and which favours the development of delirium tremens. The rules by Avhich we must be guided in its use are nearly the same as those which regulate the employment of opium, except that in this case, we must look more to the state of the circulation, Avhereas in the use of opium, we are guided more by that of the nervous system, a compressible pulse being our best indication for the administering of beer, Avine, or spirits. In those cases which are the result of mental excitement and anxi- ety, more caution is required, and Ave must be still more guarded in our use of opium: and alcholic stimulants will be less rarely admissi- ble. Under these circumstances, the combination of calomel and henbane will be. our best internal remedy, and the henbane may be further administered in the form of tincture, in the intervals, some- times with the addition of Liq. Ammon. Acetatis, if there be not free * (84) R. Hydrarg. Chlorid. Camphorae Rasae, aa gr. j. Ext. Hyoscy. gr. iij. Ft. Til.; to be taken every four hours, t (85) R. Camphorae, gr. ij. Ammon. Sesquicarb. gr. iv. Tinct. Hyoscy. Tinct. Lupuli, Syrupi Aurant. Mist. Acac. aa, g j. Mist. Camphorae, ^ j. Ft. Haust.; to be taken at bed time. ACUTE MANIA. 417 perspiration; and in such cases, after we see our way more clearly to the use of opium, Ave may endeavour to calm the nervous excite- ment, and, it may be, counteract the ill effects of opium, by the con- tinuance of the hyoscyamus. Here also, as in most cases, the best guide for the use of opium is the state of the pupil. MANIA. Acute mania is another form of purely nervine disease, in which the affection of the brain appears mainly, if not entirely, by its func- tional derangement; structural lesions when they occur being in most instances to be regarded in the light of effects, rather than causes. Though mania is characterised by attacks of furious deli- rium, coming on in paroxysms, it is sometimes, preceded more or less by constitutional disturbance, not of a febrile character, but affect- ing mainly the digestive organs; there is generally dyspepsia, and sometimes jaundice, for a considerable period. The principal changes hoAvever, are in the nervine functions; and it is, perhaps, characteristic of the disease, that this derangement is beyond all proportion to any bodily disorder. The first premonitory symptoms are often a change of manner and of tastes on the part of the patient, Avith considerable Avaywardness and capriciousness, he becomes unu- sually irrascible, or oppressed Avith anxieties about his temporal or spiritual Avelfare. His friends, though surprised and annoyed at this alteration, may entertain no serious apprehension, owing to the absence of much constitutional ailment, when suddenly he breaks out into a state of furious madness, and sometimes can be only for- cibly prevented doing some serious injury to himself or others. This state of violence may as suddenly subside into one of sullenness and moroseness, or he may even become for a time rational and tranquil, though this interval of remission will be again followed by v a recurrence of the madness. When the disease has thus manifested itself, the pulse is generally quick, sometimes full, the bowels torpid, the urine scanty, and the tongue white, and, as it advances, it becomes brown. The pupils are most commonly contracted, and there is extreme sleeplessness. These paroxysms of excitement, with inter- vals, may continue to follow each other, unless we can succed in sub- duing them, till the patient either sinks exhausted, or passes into a state of confirmed insanity. As regards the causes of this disease, there can be no doubt that some are born with a susceptibility to it, inherited, it may be, through either parent; and sometimes this susceptibility is such, that the mania is excited by almost unappreciable causes; and the tendency is much increased by an habitually torpid state of bowels, by de- rangement in the digestive organs, or of the liver or kidneys. The more immediate causes are generally either excessive mental exer- tion, excitement, depression, intemperance, or venereal excesses. The diagnosis of mania depends upon the character of the delirium, and the absence of constitutional or bodily disease in any degree com- 448 ACUTE MANIA. mensurate with the mental disturbance; by the former it may be distinguished from delirium tremens, and by the latter from phre- nitis. In mania, the delirium is more furious, and the delusions are more subjective than in delirium tremens, in which disease they are more of an objective character; whilst there is no attempt at violence to others, unless under an apprehension of danger; the tremor, also, of delirium tremens is wanting in mania. The prognosis of mania is, in a great degree, dependent upon the cause of the disease. Where there is hereditary tendency, the pro- bability of recovery is less than Avhere the disease has been induced, though it should be observed, that in the latter case, the immediate danger to the life of the patient is not less than in the former. The risk both of life and reason is also greater in a second than in a first attack, and the more frequent the recurrence, the less the chance of the removal of the disease. The treatment of the disease must consist, in the first instance, of endeavouring to subdue the excitement, both of the vascular and nervous systems; as the latter generally preponderates, our chief attention must be directed to it; though it must be confessed that our power over the nervous, is much less than over the circulatory organs. When there is decided heat of scalp, the pulse strong, and the constitution sound, blood should be taken, either from the arm, or by cupping at the nape of the neck. The head, also, should be immediately shaved, and cold lotions, or powdered ice in bladders, applied to the scalp; and, as the bowels are generally torpid, we must have recourse to active aperients; calomel and colocynth should be administered at once in full doses; and an active purgative draught shortly afterAvards. The enema with oil of turpentine has an addi- tional good effect, not only as a purgative, but also as a revulsive. Calomel and colocynth, or blue pill with scammony, or compound rhubarb pill, may also be continued twice or thrice daily; so as fairly to unload the bowels, and by keeping up a steady action of the intes- tinal canal, to stimulate the organs which pour their secretions into it, especially the liver. Should sleep not be procured after the above measures haAre been carried out, we must have recourse to anodynes, or rather to nervine sedatives, as opium is not admissible, as a general rule, in this disease. And here we may be allowed to remark, that hyoscyamus and conium are not to be regarded in the light of mild preparations of opium—though they are sometimes placed in the same category as though they might be used indiscriminately—for experience teaches us that the difference of their action is not so much one of degree, as of kind; and therefore when a powerful remedy is required, and full doses of opium seem to be contra-indi- cated, Ave must not evade the difficulty by having recourse to smaller doses, or less active preparations, the effect of which, as far as they have any effect, will be injurious, but employ hyoscyamus or conium in poAverful doses; the draught of the former (F. 80), will be found very useful, omitting the ammonia Avhen there is vascular excite- ment; as will also the camphor and hyoscyamus in the form of pills. TREATMENT. 449 The exhaustion which supervenes upon the repeated fits of excite- ment and which sometimes appears early, must be counteracted by stimulants, of which perhaps the safest will be ammonia; this may be given in infusion of serpentaria, and where the pulse is very feeble a few minims of compound spirit of aether may be added. At this period also counter-irritation is indicated, and blisters may be applied to the nape of the neck, or sinapisms to the feet. Throughout the whole of the treatment, the utmost vigilance is required to prevent the patient inflicting injury either upon himself or those about him; care must also be taken to exclude all objects as well as persons, which may be likely to cause excitement, either through his affections or antipathies; and on this account, friends whose sensibilities might be strongly excited should be forbidden to approach him. 29 450 APOPLEXY. XXVI. APOPLEXY AND PARALYSIS. The simplest definition that can be given of apoplexy is, that it is a sudden loss or suspension of the functions of animal life, those of organic life remaining intact, or at least impaired only, but ndt arrested. Thus when a person falls down senseless, but not in a state of syncope, the action of the heart not being greatly impeded, he is, said to be attacked with apoplexy, or for the sake of greater accuracy, with cerebral apoplexy. This definition, however, requires considerable qualification as well as extension, since it sometimes happens that, with the functions of animal life, those of organic life are also involved, and if it be to the extent of stopping them, the patient of course dies—it is a case of sudden death; but if upon examination there be found the appearance which is supposed to constitute xat i^ox^v, apoplexy (extravasation of blood), in the cranium or spinal canal, he is said to have died of apoplexy. It happens too, almost always, that the functions which hold a middle place betAveen animal and organic life, those, namely, of the nerves of respiration, are impeded, but not arrested. When the primary lesion is in the brain, the automatic or reflex motions in the extremities are not impaired, since the true spinal system is uninjured, and, accordingly, the lower extremities will be drawn up when the soles of the feet are irritated; but it may happen also that there will be sudden loss of power (though the case is rare) of some of the extremities, as of the legs, for instance, and Avith it the loss of the reflex or automatic motion; although at the same time the sensorial functions may be unimpaired. In this case the primary mischief is in the spinal canal, and the patient is said to have spinal apoplexy. Perhaps the most correct definition of apoplexy in general would be, that it is a sudden loss of function sustained by some portion of the brain or spinal cord. This again is liable to being misunder- stood, owing to a vagueness attaehed to the term apoplexy; for instance, when a person suddenly loses the poAver of one extremity or one side, he is said to have an attack of sudden paralysis or loss of power, but this is not commonly called apoplexy, unless it be found, or there be strong reasons for believing, that there is extrava- sation of blood; whereas, the sudden paralysis or loss of power may depend upon a variety of conditions of the nervous matter, of which extravasation of blood into its substance, or upon its surface, is only one. We see then that the obscurity which necessarily attaches to the pathology of the sudden and dangerous disease which is com- monly known as apoplexy, is further increased by the word com- monly employed to designate it not always being used in the same sense, a difficulty rendered still greater by its unfortunate adoption into the pathology of another region of the body by the phrase pul- ITS NATURE. 451 monary apoplexy, to express extravasation into the tissue of the lung. Apoplexy makes its attack in different ways; and Dr. Abercrom- bie has described three different modes of its invasion, in Avhich he has been followed by Dr. Watson; and although every particular case may not in all things agree with any one of the three, it will almost invariably do so in its more prominent features, so that the bearing its distinctions in mind will contribute much to a clearer apprehension of this most difficult part of our subject. In the first form of the attack the patient falls doAvn suddenly in a state of profound coma, " his face is generally flushed, his pulse full and not frequent, sometimes below the natural standard. In some of these cases convulsions occur, in others rigidity and contraction of the muscles of the limbs on one side only." Of persons so attacked some die in a short time, and a large quan- tity of blood is found extravasated; others die after a longer period, and serous effusion only, and of no great amount, is found; and in some that die early, no effusion of either blood or serum. Others recover altogether, and no ill effects remain; others, again, recover from the coma, but remain paralysed upon one side, or as it is termed hemiphlegic, or Avith defect of the power of speech, or of one of the senses. The paralysis may disappear after a few days, or it may continue for months, or years, or for life. If we endeavour to analyse this class of cases of apoplexy, which have been distinguished by Dr. Abercrombie as the primarily apop- lectic, we shall perceive that they consist of a sudden loss of the func- tions of animal life; Ave have a sudden or very rapid loss of the powers of the brain, and death, when it takes place, is by coma, or death from the brain. This may be caused by rapid effusion of blood pressing upon the brain and destroying its powers. In other cases, again, we have the same symptoms, but death after a longer inter- val, the coma becoming more and more profound; and in these cases a small amount of fluid only is found effused upon the surface of the brain, or into the ventricles. This effusion as such, is not suffi- cient in most cases to cause death, but in the majority of instances it is not probably the quantity of effusion, but its quality that is con- nected with the invasion of the coma. The serum contains urea, whence it is to be inferred that the same principle is circulating in vessels of the brain as well as throughout the system, OAving to uraemic poisoning from disease of the kidne}rs. Of the cases which recover from the coma some are permanently paralysed ; and there can be little doubt that in these there is perma- nent injury inflicted on the nervous matter by the extravasation of blood from rupture of a blood-vessel. But here it will be well to call to mind that this rupture is in most instances the effect of dis- ease of the vessel, and that the vessels of the brain are more liable to disease than those of almost any other part of the system ; and fur- ther, that such disease will often be, of itself, sufficient to produce sudden loss of power of that portion of the nervous matter through which the vessels ramify; that is to say, that disease of the cerebral 452 APOPLEXY. arteries (generally in the form of thickening of the tunics with depo- sit of oil globules, semi-cartilaginous matter, and sometimes calcare ous matter) may by simple disturbance of the circulation, produce a loss of consciousness or of power, that is to say, coma or paralysis, according to the extent and situation of the nervous substance in- A^olved. It will generally happen, hoAvever, that Avhen there is no further lesion the coma or paralysis will pass off, and the patient recover for a time at least. But we have still another source of obscurity and difficulty, these very lesions of the arteries, Avhich give rise to secondary lesion in the brain, are themselves often the result of an antecedent one, Avhich may of itself produce similar disturbance of the functions of the brain directly, and without the intervention of the disease of the arteries; since one effect of the uraemic poisoning from disease of the kidneys, or otherwise, is sudden coma; but disease of the arteries generally, and more especially those of the brain, is among the most common effects of uraemic poisoning. So that Ave may have two causes coexisting, either of Avhich may be sufficient to produce apop- lectic symptoms, both of which may have a common antecedent cause, but of which one—the disease of the arteries may be the effect of the other—the uraemic poisoning. There remains, hoAvever, another anatomical condition in which the apoplectic symptoms require to be accounted for, and that is apoplexy without any appreciable structural change whatever, the cases of simple apoplexy of Dr. Abercrombie ; but when Ave bear in mind what has been stated of the possibility of apoplectic symptoms being induced by diminished supply of blood, through disease of the arteries, and the probability too of this being overlooked in post- mortem examination ; and when we take into account the cases from direct uraemic poisoning, of which cause of cerebral disorder Dr. Abercrombie could have taken but little account, we no doubt greatly diminish the number of cases. If we endeavour to analyse the causes of apoplexy we find the immediate ones to consist of extravasation of blood into the substance of the brain upon its surface, or into the ventricles; pressure upon, or compression of the substance of the brain, by determination of blood, or an undue quantity sent to that organ ; disease of the arte- ries, generally of a large branch, intercepting or diminishing the supply of arterial blood to a large portion of one hemisphere, often producing or attended by softening of some portion of the nervous substance from impaired nutrition ; poisoning of the blood circulating in the brain, by retained secretion, as in the case of uraemia; and as a doubtful cause we may add, simple loss of poAver by the brain, or a portion of it, constituting the true simple apoplexy of Abercrom- bie ; but we regard this case as doubtful, since it is difficult to find unexceptionable instances from Avhich all the other causes have been eliminated. If we still further pursue the train of causation, Ave find that as the extravasation must have proceeded from ruptured vessels, so this rupture may have arisen in one of tAvo Avays—either the vessels may ITS PATHOLOGY. 453 have been subjected to an unusual amount of distension, or, in other words, the blood may have been too forcibly injected into them, or the vessels themselves may have been diseased. In the case of dis- tension, again, there is room for difference in the causes. 1. The injecting force of the left ventricle may have been excessive. This may, no doubt, arise from hypertrophy of the left ventricle; but there can be little doubt that too much importance is attached to this as a direct cause of sanguineous apoplexy, hoAvever frequently the two lesions may have been found to coexist. The truth being, as we have elseAvhere pointed out, that hypertrophy is generally the result of a conservative effort, either to compensate for the mechani- cal disadvantage of dilatation, in Avhich case there can be no increase in the force of the systole, or to counterbalance the obstruction pro- duced by disease of the valve or arteries. In the case of Aralvular obstruction the force of the systole indeed may be increased, but it is so only in proportion to the obstruction, and there is no increase in the force of the jet. In the case of regurgitation through the aortic valves, or disease of the large arteries, the conditions are different; for, as has been elseAvhere pointed out, the blood passes along them in jets rather than in a continuous stream, as may be perceived at the wrist by the so-called AArater-hammer, or splashing pulse, and each jet is more forcible in proportion as the continuity of the cur- rent is destroyed; and in such case a greater degree of violence is sustained by some of the remoter arteries than they are normally exposed to, and the result may be laceration. 2. On the other hand, we may have a delay in the return of the blood through the veins, arising from obstruction in the pulmonic circulation, whether pro- duced by diseases of the mitral valve, or the lungs, or air passages, especially the latter, as in the case of chronic bronchitis; but in such cases the obstructed circulation through the veins, though it must in time be propagated to the arteries, and does in some instances give rise to laceration and extravasation, yet when it is the cause of apop- lexy, it is so more commonly by means of pressure from engorge- ment of the vessels of the brain. Again, we may have disease of the arteries themselves: this may arise from several causes, the chief of Avhich are—advanced life, leading to ossific deposits, rigidity, and lacerability of the arteries generally, but more particularly those of the brain; hard labour, which produces a nearly similar effect; intemperance, and disease of the depurating organs, but more especially of the kidneys ; though the last mentioned cause, namely, renal disease, may be the effect of the previous one, [intemperance. Another form of disease of the cerebral arteries is aneurism, most often of the large, but sometimes of small branches, which may be sometimes seen Avithout any great amount of disease in the arteries generally. The next cause of apoplexy, namely, sanguineous engorgment, is one, the existence of which was for a long time denied by British pathologists; but the experiments of Dr. BurroAvs satisfactorily show that the arguments used to prove its impossibility are altogether incon- clusive. In connection with this cause of apoplexy we may notice 454 APOPLEXY. the frequently adduced one of serous effusion, constituting the serous apoplexy of some authors; it is, however, far from certain, and it is contrary to the analogy of the other serous membranes to believe, that the serum can be poured out with sufficient rapidity to produce apoplectic coma, independently of previous engorgement or uraemic poisoning, either of Avhich is sufficient to account for the attack. A common cause of this engorgement of the brain has been pointed out above—namely, obstruction to the return of the blood to the right heart, either caused by disease of that organ, or dyspnoea from disease of the lungs or air passages; but there can be little doubt that it may arise primarily, upon the principle of the old adage— uubi stimulus ibifluxus,v Avhether that stimulus be primary as regards the brain, as from mental emotion, or, it may be, gouty hyperaemia —or secondary, from irritation elsewhere, as in the case of the stomach, through the medium of the pneumogastric nerve. Disease of the arteries, intercepting the supply of blood to any considerable portion of the brain, is another cause. That by this means the func- tions of a considerable portion of the brain are suspended, is evident from many cases in which there has been sudden paralysis of the extremity which corresponds to the portion of the brain so affected, and the fact has been most ingeniously and elaborately established by Dr. Norman Chevers; but here we meet with an instance of the necessity for the most scrupulous care in endeavouring to trace the causation of the attack, since disease of the arteries may arise from uraemia, Avhich may of itself produce apoplexy, and render the vessels more liable to rupture—another cause of apoplexy. But there is still another cause, and that is softening of the brain, which may be the secondary effect of diseased arteries. It is true that this affection more commonly induces gradual paralysis than a sudden attack of apoplexy; but there can be little doubt that it sometimes induces the latter, Avhen situated in the central parts of the brain. Softening may take place, as we have seen, from active inflammation, which is, however, generally accompanied by symptoms of that affection, and is then of the character of the red or yellow softening; but it some- times, though very rarely, presents itself in the form of the white or non-inflammatory softening, as a primary lesion. The last cause of apoplexy, or apoplectic coma, which we have to notice is poisoned blood circulating in the brain: of this the most notable and frequent instance is that of which we have before spoken under the term uraemia. And next, if not equal to that in import- ance, is blood overcharged with carbon, which state may be either the direct effect of dyspnoea from pulmonic disease, or it may be a secondary effect of disease of the brain, paralysing the muscles con- cerned in respiration. But the same symptoms may arise from poisons introduced into the system by the mouth, as in the case of ordinary drunkenness, though the latter cases are not commonly regarded as apoplexy. We find then that there are a variety of causes Avhich may induce apoplexy, widely differing as to the anatomical changes with which they are found associated. But we believe that they all resolve ITS PATHOLOGY. 455 themselves into pressure, deficiency of supply of blood, solution of continuity, and poisoned blood. In regard to pressure it may be asked whether extravasation ever causes sufficient pressure to induce apoplexy ? Dr. Burrows gives some very good grounds for believing that it does not; but that the apoplectic coma and the extravasation are the joint effects of a com- mon cause, namely, hyperaemia. And there can be little doubt that in by far the greater number of cases of extravasation, his reasoning is conclusive—that the extravasation, though it causes paralysis, does not produce apoplectic coma; but in the second class of cases of Dr. Abercrombie, the cases not primarily apoplectic, it is difficult to account for the phenomena upon any other hypothesis than that which has been given, the quantity of blood extravasated becoming at length so great as to produce pressure upon the nervous fibre sufficient to induce apoplectic coma. The extravasation too, by pro- ducing laceration and division of the nervous substance, induces a suspension of the functions of the brain, which, when it involves the nerves of respiration, must amount to coma. It may perhaps be asked how it can happen that a person with a chronic disorder like the form of Bright's kidney, which is very apt to lead to coma, should so suddenly manifest the effects of a poison which must have been circulating in the system for a considerable time ? To this we can only reply, that the urea seems to be a cumu- lative poison, and that there is no more difficulty in believing the sudden effect of such a poison upon the brain than that of digitalis, which may have been taken for a considerable time, upon the heart. But after deducting these cases, there still remain others in which there is satisfactory evidence that no such condition either of the blood or vessels has existed, and that many of these are to be ex- plained by pressure from increased determination of the blood to the brain there can be no doubt, although some have denied the physical possibility of such a condition. Dr. Burrows has, however, not only shown that it is possible for the cranium to contain a greater quantity of blood at one time than another, but has proved it by experiment. Whether after all these deductions Ave have still to admit the occurrence of apoplexy from simple functional loss of power by the brain, independently of any of the above causes, may still be considered doubtful; its theoretical possibility may be admitted, but its actual occurrence is, to say the least, "not proven." The second class of cases of Dr. Abercrombie are those which he described as not primarily apoplectic—the coma not being the earliest symptom. The disease commences with sudden pain in the head— there is faintness, sickness, pallor, and the signs of syncope; the patient does not always fall, and commonly recovers in a short time from all giddiness and confusion, but does not lose the pains in the head. After a certain time, varying from a few minutes to several hours, he becomes very forgetful, confused, and gradually sinks into coma, from which he rarely ever recovers; sometimes in such cases there is paralysis, and now and then convulsion of one side, but more often there is neither. The cases of this class are more certainly 456 APOPLEXY. fatal than the more sudden primarily apoplectic ones. Upon a con- sideration of the symptoms we may preceive that they are to be explained by the rupture of a vessel, which gives a shock to the system, from which it in a short time recovers; but in the mean while blood is steadily escaping from the ruptured vessel, which by its increasing pressure destroys the functions of the brain, and we have death from coma. In some cases in which there has been a considerable interval between the recovery from the first shock and the invasion of the comatic symptoms, it has been conjectured by Dr. Abercrombie, and with good reason, that a clot has formed upon the orifice of the open vessel, which has checked the hemorrhage for a time, and thereby arrested the progress of the disease, but by the removal of the clot the haemorrhage has recurred, and the pressure and consequent coma have advanced. In the third class of cases, the paralytic—the symptoms resembling those of the "primarily apoplectic" as regards their suddenness, but differing in respect to their not involving the consciousness—there is no coma. In the subsequent progress of these cases there is con- siderable difference; in some the disease passes more or less quickly into apoplexy; and in some, on the other hand, the patient gradually recovers the use of the paralysed muscles; others again remain per- manently paralysed for the remainder of life; bereft, it may be, of the use of one side, or with one leg or one arm paralysed, or imper- fect speech, or loss of vision of one eye from amaurosis, or dropping of one eye-lid (ptosis). When these cases prove fatal, the appearances after death are, as in the primarily apoplectic, inconstant; and it is no more than we might expect that they should be so, the pathology of the two classes of cases being essentially the same, the difference being in the extent or part of the organ affected. Besides the immediate causes of apoplexy Avhich have been men- tioned above, there are several conditions which render any person liable to apoplectic attacks, some of which may be, indeed, said to be the immediate cause of the disease; among the first of these we may reckon hereditary predisposition. The recurrence of apoplexy in families is an observation too well attested to require to be insisted upon. Age is a most important agent in the production of apoplexy. It is true Ave sometimes meet with apoplexy in young persons, but after fifty the liability to it greatly increases, and a greater number of cases occur between the ages of fifty and sixty than in any other decennial period of human life. It is not, however, to be inferred from this that the liability to the disease begins to decrease after sixty, but only that the absolute number of persons living decreases; and if this be taken into the account it is found that the proportion of those who die of apoplexy between sixty and seventy is still greater than in the preceding decennial period, and the same of ages still more advanced. The results of statistical inquiries appear to be that the liability to apoplexy increases as age advances, but that about fifty it undergoes a considerable increase. Whether the apo- plexies in advanced life are generally those from disease of the arteries or from simple engorgement has not been estimated by any author^ but ITS REMOTE CAUSES. 457 it is probable that the former affection increases with increasing age, and with it, as a necessary consequence, the tendency to apoplexy and paralysis. The gouty diathesis is another predisposing condition; na- tural configuration and temperament is another; persons of a plethoric habit, corpulent, and with short necks, are more prone than others to this disease; but the most spare are not exempt from it. Here again Ave most likely meet with differences in the kind of apoplexy, that is to say, in its immediate cause, as it is probable that the apoplexy of the short-necked and plethoric is that of congestion (generally venous), Avhile the apoplexy of the spare is that of diseased arteries. Disease of the heart and respiratory organs, again, have been pointed out as predisposing to apoplexy; and, according to the arguments already adduced, it is probable that the apoplexy from disease of the mitral valve—of the right heart,—or that from pulmonic obstruction, from Avhatever cause arising, is the apoplexy of engorgement; and there is probably a considerable difference as regards the state of the circulation through the brain, as Avell as in other parts of the body, between disease of the aortic orifice, and that of the mitral valve with the cognate condition, which difference we have already pointed out (280 et seq). Another predisposing condition, or perhaps we should rather say the most frequent of all the primary causes of apoplexy, is Bright's kidney. The series of causation, indeed, by which it produces apo- plexy may be various; either it may ensue directly from the non- depurated blood, or through the heart disease, of which the renal affection is a most productive cause, or through the arteries, which are also very prone to become affected from the same source. The diagnosis of apoplexy as such is not difficult; the only diseases with which it is liable to be confounded are epilepsy and intoxication either by alcohol or opium. From the former it may be distinguished by the absence of the convulsions or other characteristic signs of epi- lepsy to be hereafter described. From intoxication the diagnosis is not ahvays so easy, since profound intoxication is a species of apo- plexy; the previous history will in most cases enable us to recognise intoxication, which for our credit's sake, as well as the safety of the patient, it is most important that we should not set down as apoplexy: but when a man is found in a condition supposed to be apoplectic, and can give no account of himself, we must observe carefully if there be any smell of alcohol or opium in the breath. It is to be remem- bered too that either alcohol or opium might induce apoplexy, but it would be safer, especially in the case of alcohol, to wait for its development; and in a doubtful case the use of the stomach pump would probably bring to light the true state of the case. The diagnosis of the true nature of the case, or, in other words, of the cerebral lesion upon which the apoplectic attack depends, requires much more consideration; and as upon it must depend the treatment to be pursued we shall consider the two subjects together. There has been no more prevalent or dangerous error, or which has more slowdy yielded to the increased accuracy of modern pathology, than, that all cases of apoplexy are to be met with active depletion 458 APOPLEXY. and other powerful antiphlogistic measures; whereas, from what we have seen, the apoplectic seizure may arise from such very different causes, and be connected with such very different conditions of the system, that it is obvious that the same remedies cannot be applicable to all. Let us first take as an instance an attack of the primarily apoplectic kind, which, from the suddenness of its invasion and the imminent danger of the patient, appears to require the most prompt treatment. Those cases which strictly agree with the description of Dr. Abercrombie, quoted above, in which the face is flushed and the pulse full and strong, are cases of active congestion of the brain, gene- rally with a strong left ventricje of the heart, arising either from that cause or simple increased determination of blood to the brain, aggra- vated probably by some unusual mental excitement, or the stimulus of excessive repletion. In such cases prompt and active depletion is the most appropriate remedy. A vein should be immediately opened and blood be allowed to flow until a decided impression is produced upon the pulse. The boAvels should also be freely acted upon with the least possible delay. For this purpose, when there is no very great difficulty in swallowing, a full dose of calomel, say ten grains, should be administered, which will best be effected by mixing it with a little sugar and butter, and placing it far back upon the tongue of the patient; but if he appear totally unable to swallow, which may be ascertained by introducing a tea-spoonful of liquid into the mouth, it will be better not to attempt to give the calomel, since it is apt to be rolled about in the mouth, and by producing soreness may increase the difficulty of deglutition without slrj adequate benefit. Under such circumstances about two drops of croton oil should be placed on the tongue, and in either case a purgative enema should be administered (F. 86).* But it very often happens that we do not find the concurrence of the above symptoms; full and strong pulse and the flushed face may be one or both of them wanting, in which case the apoplectic seizure may arise either from failure of the circula- tion from a feeble heart, or from diseased arteries, or from pulmonic obstruction, uraemia. Under such circumstances, nothing can be more judicious than the advice of Dr. Watson, adopted too by Dr. Burrows. " If the pulse be full, or hard, or thrilling, or if there be obvious external signs of plethora about the head, blood must be drawn. You are not to refrain from bleeding the apoplectic patient because he is pale if the pulse warrants it, nor may you omit taking blood if the face be turgid, although the pulse be small, for that smallness may depend upon organic disease of the heart. On the contrary, if the skin is pale and cold and the pulse flickering, you would probably insure your patient's death if you withdraw from the failing heart and blood-vessels a portion of their natural stimulus." Though even these directions must be received with some qualifica- tion, since there may be other causes besides disease of the heart, of which the chief are diseased cerebral arteries and uraemia, which * (86) R. Pulv. Jalapae, ajj. Infus. Sennae co. (callidi) ^ xii. Misce. Ft. Enema. DIAGNOSIS AND TREATMENT. 459 may produce apoplexy, in which case large bleedings would not be expedient. In the first place, however, it is most important, as Dr. Burrows has pointed out, to examine carefully the state of the heart, to which we would add that of the large vessels. Now the state of the pulse in diseases of the brain and upper part of the spinal cord is very per- plexing, and we have alluded to the influence of such as well as of cardiac affections in modifying the character of the pulse at the wrist, but when we know that there is cerebral disease, and apprehend that of the heart, the necessity for careful auscultation of the latter must be apparent. " If," says Dr. Burrows, " no cardiac disease be dis- covered, or if simple hypertrophy without notable valvular disease be .detected, depletion, both general and local, may be carried on so far as the cerebral symptoms appear to call for that kind of relief." But we would here recur to what we have stated as to the frequency of simple, i. e., primary hypertrophy (p. 272). A plethoric subject with full muscular development, and using much muscular exercise, may, indeed, especially after repletion, have an attack of apoplexy, and in such a case Ave should find all the conditions laid down by Dr. Wat- son as indicating depletion, which should be carried as far as the exigencies of the symptoms require, both in the way of bleeding and purging. But if we find hyperthrophy of the left ventricle without such condition and without valvular disease, we must refer it to one of the causes already assigned (p. 272), and regard it merely as a com- pensation for some other cause obstructing or impairing the force of the ventricular systole. If that cause exist in the left ventricle itself, in the way of fatty degeneration or the effects of carditis, the com- pensation Avill rarely be sufficient to counteract the obstructing cause, and we shall have practically a weak heart (which will generally be evidenced by more or less of dilatation). This will also appear in the feebleness of the pulse at the wrist, and still more in that of the pulsation of the carotids, which ought always to be most carefully explored. But, as we have pointed out, one very common cause of hypertro- phy is disease in the form of thickening of the tunics of the remoter branches of the arterial system; and such a state of things is very likely to be associated with apoplexy, if not to lead to it, and per- haps these cases constitute the greater number of those included in the term simple apoplexy. This cause of hypertrophy may generally be detected by the signs we have already given, especially by the tortuous and rigid radial or temporal artery, and by any evidence we may have of the existence of one of its frequent causes—visceral dis- ease, hard labour, hard living, and advanced age. Are we to bleed in such cases ? Now here we may have active congestion, attended or not by rupture of a vessel,—or a narroAved and diseased artery, obstructing the supply of blood; we, in fact, may have one of two opposite conditions. In the case of congestion we shall generally have the heart acting strongly and the pulse of considerable force, after making alloAvance for the thickened arterial tunics. Under such circumstances we believe that, except in very advanced life, we 460 APOPLEXY. may bleed moderately, more especially as in this condition of the sys- tem bleeding is generally well borne; and even if there be renal disease, which is not unlikely, it will not render the patient less able to bear one free venesection. But if Ave find hypertrophy with a feeble pulse, and still more, if the pulsations of the carotids are not strong, even though there may be no valvular disease, it is probable that there is some obstruction to the circulation Avhich the hypertro- phy is hardly sufficient to counteract, or that the hypertrophy is of the right ventricle, in neither of which cases is venesection expedient; and where there is reason to apprehend disease of a large artery of an obstructive character, diminishing the momentum of the blood throughout a considerable portion of the brain, depletion would be most mischievous. In cases of apoplexy from diseased arteries. there is generally pallor, probably from the patient being commonly of advanced age, and also from its frequent connection with renal disease; but if the pulse be full and but little compressible (and in saying this we must repeat the distinction betAveen a hard artery from thickened tunics and a firm pulse from a forcibly acting left ventricle with perfect valves), we may venture to bleed provided the extreme age of the patient do not contraindicate it; but if the pulse be compressible we should do wrong, although we may have evidence by auscultation of hypertrophy; still more, as in the absence of val- vular disease, and Avith a small pulse, it would be more than doubtful that the hypertrophy was of the left ventricle. As regards well-marked disease of the large arteries, we would lay it down as a rule that venesection should never be resorted to; but if there be considerable arterial action, cupping may be employed between the shoulders; but even this remedy must be employed with caution, since these are the cases in which we are most likely to have anaemia of a portion of the brain from obstructive arterial disease. J.n such cases, however, we shall almost always have hemiplegia. If there be regurgitation through the aortic valves, the thrilling pulse and forcible impulse of the heart, which will be generally hypertrophied, as well as dilated, should never tempt us to abstract blood by venesection, and if there be only obstruction in these valves without regurgitation, the same rule applies, since though there will probably be hypertrophy, this hypertrophy will not be more than sufficient to overcome the obstruction; in neither case, hoAvever, does apoplexy occur so much as the direct result of the hypertrophy as from the obstruction being propagated through the lungs to the right side of the heart, and bringing the circulation to the condition in which it is when there is disease of the mitral valve: in Avhich case the pulse, as we have before pointed out, is too feeble or irregular to suggest the idea of venesection; so that all the forms of valvular disease ordinarily met with, fall into the same category as regards the state of the cerebral circulation, and this last is similar to that produced by emphysema of the lungs, or dilatation of the tubes from chronic bronchitis; the similarity of which latter affection, as regards the circulation, to that produced by disease of the mitral valve we before pointed out (p. 282). In all these cases there will be evidence TREATMENT. 461 of extreme congestion, with forcible action of the heart; but a know- ledge of the mechanical disadvantage at which that organ is acting, should deter us from venesection, thought great relief will often be afforded by the free local abstraction of blood, by cupping either betAveen the shoulders, under the left mamma, or at the scorbiculis cordis. In all these cases, too, as we pointed out in disease of the heart producing venous congestion, much relief will be obtained by the free use of purgatives. Diuretics of a somewhat stimulating charac- ter will be found a valuable adjunct to the treatment, more particu- larly, as pointed out by Dr. BurroAvs, in cases proceeding from pul- monic obstruction: in those where the circulation is feeble the pur- gatives also should be of a somewhat stimulating character (F. 87),* and the enema should contain about an ounce of oil of turpentine. A blister should also be applied to the nape of the neck, and this, too, should be done in those cases Avhere even local depletion is not admissible. When there is dilatation of the chambers of the heart, or the circulation is very feeble, and the patient anaemic, we must not be deterred by the name of the disease from the use of stimu- lants, either in the form of ammonia, or it may be wine or brandy, especially if the extremities are cold and clammy, and the skin bedewed with perspiration; and these may often be required imme- diately after local depletion, in cases where the latter has been deemed necessary from the signs of excessive congestion. But the primary apoplectic cases include those in which there supervenes a sudden profound stupor, sometimes with convulsion, but more com- monly without it, in which there is no evident paralysis, and in Avhich there is reason, either from examination of the urine, or from other sources of information, to believe that there is albuminuria: when this is the case, and the coma is the direct effect of the urea upon the brain, as shown by the character of the stupor and the absence of any of the other lesions Avhich we have pointed out as inducing apoplexy; venesection is not indicated for the relief of the 'disease as such, but if there be increased arterial action, especially in the carotids, blood may be taken; it is however generally better to do so by cupping than by opening a vein; though if there be much hypertrophy of the heart, the latter is admissible. The boAvels must also be promptly acted upon, both by purgatives by the mouth and by enemata; for the former purpose not more than a single dose of calomel of about five grains is alloAvable, and that should not be repeated, on account of the great susceptibility of the system to the action of that mineral. The second class of cases (those not primarily apoplectic) may generally be recognised by the peculiar mode of invasion of the dis- ease ; and here unfortunately we can do but little, as the prognosis is in the highest degree unfavourable, the sudden pain generally indi- * (87) R. Pulv. Rhei, gr. x. Decoct. Aloes co. 5 ss. Infus. Sennao co. 3 j. Misce. Ft Haust ; to be repeated every third or fourth h^ur. 462 APOPLEXY. eating that a vessel of some size has given way in the brain, or on its surface, and the subequent coma is the result of the pressure pro- duced upon that organ. These are generally the cases of aneurism of one of the arteries of the brain already alluded to; and the ques- tion arises as to whether the coma is due directly to the pressure of the effused blood, or mediately to an anaemic condition of the brain Avhich that pressure must tend to produce. In the former case, it is desirable to diminish as much as possible the force of the heart's action; in the latter, the abstraction of blood would be injurious. The best guides under these circumstances are—the force of the heart's action, carefully distinguishing betAveen the stronger impulse with a rather deep sound, of a hypertrophic ventricle, and the heaving beat with clear sound of a dilated one;—the pulse at the wrist, taking especial notice of its being firm, perhaps sIoav, or on the other hand compressible and "splashing;"—the countenance Avhether congested or pallid. Of these perhaps the most important is the pulse, and if that be of the latter character, the depletion ought on no account to be had recourse to. If the patient be seen early, and the signs of oppression with strong cardiac action exist, the attempt should be made to check the mischief by venesection, carefully Avatching its effects upon the pulse. In the more intermediate condition, when the pulse is still firm, and the countenance turgid, blood may be taken from the nape of the neck by cupping, but Avhere there is the haemorrhagic pulse and pale countenance, we should rather have recourse to gentle stimulants. The treatment of the third class, or paralytic cases, must be regu- lated upon the same principles as those of the first, with the excep- tion that as we have not in the first instance to contend with the coma, there will not therefore be such urgent necessity for depletion; but we must be guided in its use by the same rules as in the pri- marily apoplectic cases, Avith the additional reason against venesec- tion that in the case of hyperaemia this has been already followed by extravasation, and therefore one great reason for the use of the lancet will have been removed; when therefore there are indications for1 the abstraction of blood in the condition of the heart, the pulse, or the countenance, or Avhen there is pain in the head over the mastoid process, or on the temple, on the opposite side to that which is par- alysed, we should prefer cupping from the nape of the neck. A con- siderable proportion of the cases of sudden paralysis, especially if it is partial, affecting, for instance, only one extremity, or the tongue or muscles of one eye, depend upon obstructed circulation from dis- ease of the arteries supplying the corresponding portions of the opposite side of the brain. To the diagnosis of this condition we may be led by the state of the temporal arteries, the age and habits of the patient, and the character of the urine. General depletion will here be scarcely ever required; but if the action of the heart be forcible, blood may be taken by cupping from the nape of the neck; and if there be signs of congestion, but with a doubtful state of the heart, considerable relief will be obtained by dry cupping. After this a blister may be applied, and a moderate dose of calomel admin- TREATMENT. 463 istered (when the urine is not albuminous), and the action of the bowels kept up by purgatives of a somewhat tonic character, such as the rhubarb and compound decoction of aloes. Sudden paralysis may sometimes ensue from softening of the brain, the suddenness of the attack depending probably upon the rapid extension of the disease to a set of fibres influencing the voluntary power of the affected muscles. This is generally associated Avith the arterial disease just specified, and will present no signs of increased vascular action, but often the opposite. Under such circumstances stimulants may be carefully administered, the bowels being kept freely open, but not purged, and a blister applied to the nape of the neck, and subsequently to the side of the head opposite to that on Avhich the paralysis exists. The paralysis may, as we have observed, be brought about by the extension of softening, but this extension may also reach the more central parts of the brain, and, by implica- ting the origin of the nerves of respiration, induce apoplectic coma; or the arterial disease which has lead to softening may also bring on apoplexy by the giving way of one of the diseased vessels. In either case of apoplexy supervening upon paralysis, the prognosis is highly unfavourable, and the treatment must be the same, and regulated upon the same principles as that of the second class of cases. After the " fit," as it is termed, of apoplexy has passed off, and more particularly in those cases where it is followed by hemiplegia, and probably attended by extravasation, inflammatory change takes place around the clot: and two or three days after the coma has sub- sided the patient complains of pain in the head, generally on the side opposite that which is paralysed ; the face becomes flushed, the scalp hot, the patient frowns, and sometimes squints; sometimes there is spasm of the arm or leg on the paralysed side, the arm being often drawn firmly across the chest; these muscular efforts being, as Dr- Burrows observes, an effect of the irritation produced by the clot in the cerebral substance around it; there is, at the same time, more or less pyrexia. Under these circumstances antiphlogistic measures are called for; but they should not be of a violent character. The patient should be cupped at the back of the neck, and salines with antimonials may be employed for a time, the bowels being kept freely open; after the skin has become cooler and moist, bichloride of mercury will often be of service ; a drachm of the solution may be ^iven three times a day, and the dose increased to a drachm and a half, or two drachms. A good form for its exhibition is the well- known one of Sir A. Cooper (F. 88).* Counter-irritation should be at the same time used. After, however, the inflammatory symptoms have passed away, and in some cases where none have existed, the paralysis continues, and sometimes the patient complains much of pain in the affected limbs; for the latter we cannot often do much, * (88) R. Liq. Hydr. Bichlorid. | ss. Tinct. Rhei, Tinct. Cinchonae, aa 3 ij. Misce. Of which 3 j. to iij. is to be taken in any proper vehicle. 464 APOPLEXY AND PARALYSIS. but some relief may be given by anodyne and gently stimulating liniments: as' regards either, we can do but little toAvards the remo- val of the primary lesion; yet where the paralysis is not perfect, and there seems to be some return of power, though it may take place slowly, we may help the progress of the patient by nervine tonics, of which the safest and most efficient is the sulphate of zinc, which may be given, beginning in doses of a grain, increased to four or five, three times a day. We have already alluded to apoplexy of the spinal marrow: that is to say,—sudden abolition of its proper functions. This may some- times arise from spinal hemorrhage, the symptoms of Avhichare sud- den pain in some part of the spinal cord, convulsions, and paralysis of those parts below the seat of the injury. Such cases are A'ery rare ; at least as observed by the morbid anatomist, the cases which he records being the fatal ones : but it is not improbable that slight extravasations do occassionally take place, and produce paralysis, which is recovered from. This paralysis of the lower extremities, commonly known by the term paraphlegia, may, however, arise from other causes, some of which are very obscure. The functions of the spinal cord may, besides extravasation, be arrested by softening, whether inflammatory or otherwise, by effusions or thickening, arising from inflammation of the membranes, or by pressure from tumours, or disease, or dis- placement of the vertebrae ; but in many cases there can be found no lesion to account for the paralysis, and we are driven to the conclu- sion that there is such a thing as loss of nervous power without any change in the nervous matter Avhich we are at present able to detect. In some cases the palsy comes on rather suddenly; the patient com- plains perhaps for a time of pains in some part of the spinal column, and then has suddenly an increase of this pain, with loss of power of the lower extremities. In the majority of cases, however, the disease creeps on far more insidiously; there is a feeling of diminished power and increased weight in the legs, which are apt to become colder than in health; there is tingling and numbness of the toes and feet, and a feeling of irritation as if by ants, which has received the name of formication: the difficulty of walking increases, and ulti- mately the patient loses altogether the power of doing so. The paralysis gradually extends in this way from below upwards, affects the bladder and rectum, and ultimately some of the organs still more essential to the maintenance of life, the patient sometimes dying of apncea from paralysis of the muscles of respiration. In some of these cases no structural changes can be found in either the brain or spinal cord; of such changes the commonest is softening. In the majority of instances the seat of the disease would appear to be rather in the brain and its prolongation into the spinal canal than in the true spinal marrow itself; since when the voluntary power is almost entirely annihilated, the reflex or excito-motory functions evince even a more than ordinary amount of susceptibility, the legs being often forcibly retracted when the feet have been irri- tated ; this circumstance has formerly led to the belief that patients PARAPLEGIA. 4&J were malingering, it having been assumed that if a person withdrew the foot from being tickled or pricked, and sometimes from even harsher irritation, he could move it at other times if he would. The lesion upon which paraplegia depends may be, as we have seen, various, and in some there is no appreciable structural lesion Avhatever, the disease being, in the strictest sense of the word, nervine, or depending upon failure of that poAver of which the nervous mat- ter as regards its physical constitution is the vehicle rather than the cause. In some instances, independently of those in which the disease originates in the nervous centres themselves, the loss of power is produced through injury inflicted directly upon the extremities of the motor nerves, as by exposure to cold; attacks of paraplegia sometimes come on after a person has left a warm room, and gone out upon coli ground with the feet and legs thinly covered, or when a person has been long sitting or standing with the legs and feet cold and wet; sometimes severe injury to the extremities of the nerves, probably of the sentient ones, has resulted in structural changes of the nervous centres, and subsequent paralysis, as in a case which occurred to the author in Guy's Hospital. Coexisting gastric irrita- tion has by some been thought a sufficient cause of paralysis of the lower extremities, and probably such is sometimes the case in chil- dren. The same has been said of disease of the kidneys, and certainly cases do occur of paraplegia coincident with strumous dis- organisation of those organs. It must be remembered that in most cases of paraplegia the urine is alkaline, though there is some obscu- rity as to the cause in such instances. Probably, however, this alkalescence has its being in a conservative effort of nature, large quantities of mucus (which is always alkaline) being formed to pro- tect the bladder from irritation by the retained urine. In such cases, too, the bladder presents all the appearances produced by chronic inflammation. In the treatment of paraplegia we must, in a great measure, be guided by the nature of the primary lesion as far as we are enabled to detect it. In those cases where the paraplegia has followed closely upon symptoms of inflammation of the cord and its mem- branes, we must employ local depletion, and antiphlogistic regimen, and a gentle mercurial course, though the latter should be used Avith extreme caution when we suspect that there may be softening of a non-inflammatory character. These cases again which are consequent upon exposure to cold are commonly of an inflammatory character, the immediate cause being often the pressure from effusion of fluid within the spinal canal, which effusion may have originated there, or have descended from the cranium. In the cases of which we are speaking the former is most probably the case, and here the abstrac- tion of a small amount of blood, followed by counter-irritation along the course of the spine, with a gentle mercurial course, should be first employed. A good form for the mercurial will be the Pil. hydrarg.; or if the bowels are not sluggish, the combination of hydr. cum cret. and pulv. ipecac, co., and subsequently iodide of potassium. When the debility continues, the sulphate of zinc may be used, as 30 ■i'36 FACIAL PARALYSIS. in the former cases, and electric sparks may be passed from the spine to the lower extremities, or an electro-magnetic current passed along the same course. Those cases which come on more gradually, and appear to depend sometimes upon adynamic softening, and at others seem to be unconnected Avith any structural change whatever, are even still less amenable to remedies than the preceding: where, / however, the structural lesion may have originated in inflammatory action or even excitement, the bichloride of mercury may be used in the form already recommended! Subsequently tonics should be used, of Avhich the best is the zinc, which may be pushed to doses of ten or twelve grains three times a day ; or the syrup of the iodide may be employed, commencing in doses of half a drachm, and in- creased to a drachm and a half, or tAvo drachms. In all these cases the bladder must be carefully attended to. Sometimes there is incontinence of urine, but at others retention ; and as we have before pointed out, the bladder is apt to become inflamed and irritated by the retained secretion, and, Avhat is more, the pelves of the kidneys distended, leading sometimes to disorganisation of these organs, or to a suppression of their functions, which tends greatly to aggravate any pre-existing nervine diseases. The urine should therefore be drawn off at least tAvice in the day when there is retention, and, if necessary, the bladder washed out with warm water. Besides the above, there are other forms of partial paralysis of the nerves, both of motion and sensation, frequently met with; the latter generally denominated ancesthesia. From a privative and aioOwoiiav, I perceive. Of the different forms of local paralysis, there is none more fre- quently met with, or of greater practical importance, than is that of one side of the face, generally known as facial paralysis, or paralysis of the portio dura, the muscles supplied by that portion of the seventh pair being generally, though not always, those which are exclusively affected: it is sometimes, too, known as Bell's paralysis, from the great physiologist Sir Charles Bell, to whose discoveries we are indebted for a knowledge of its true nature. With this facial para- lysis we may have facial anozsthesia, and it is well to consider the two together, though when the latter is superadded the affection is a far more serious one. We have before alluded to paralysis of the muscles of one side of the face as a part of hemiplegia, and whenever we meet with this form of paralysis, we must examine carefully Avhether either extremity or any other part is similarly affected, and if Ave find that it is not, Ave may be able to remove much serious apprehension that may be entertained by the patient or his friends. The facial palsy sometimes comes on very suddenly, the muscles of one side of the face becoming, as it were, powerless and sleeping, whilst those of the opposite side retain their wonted expressiveness. This want of symmetry is increased, too, by the mouth being drawn somewhat to the unaffected side. When, however, the patient speaks, or smiles, or weeps, the difference becomes still more striking, the unaffected muscles, no longer counterpoised by those Avhich should TREATMENT. 467 antagonise them on the opposite side, draw the mouth still more to the unaffected side; at the same time that the contrast between sleeping or waking, or between life and death, in the visage of the same person is at once ludicrous and distressing. Fortunately, the majority of these cases are more frightful to the uninitiated than really dangerous in the estimation of the experienced, provided that the paralysis be confined to the muscles supplied by the portio-dura. The paralysis of these muscles is rendered still more apparent by desiring the patient to blow or whistle, when the muscles of the paralysed cheek are puffed out like a foot-ball; or to close the eyes, when that of the paralysed side remains partially open, with the pupil drawn upwards; and whilst the brow of the sound side is some- what contracted by the action of the orbicularis oculi, that on the affected side remains smooth and undisturbed. With all this, how- ever, the power of the temporal and masseter muscles, Avhich are those of mastication, and supplied by the fifth nerve, remains unim- paired. Curiously differing from these cases are those of facial anaesthesia; here the fifth is the nerve involved, and the loss of sensation is in most cases perfect over one side of the face, terminat- ing, to a nicety, at the median line, so that even the most sensitive part, as the surface of the eye, may be touched without its being felt by the patient; the sense too of taste, as Avell as of feeling, of the half of the mouth is lost on the affected side. All this time, however, the power of voluntary motion is unimpaired as regards the acts of speaking, breathing, expression, and the like, and the symmetry of the visage is undisturbed; but in the act of mastication the case is different. When the patient attempts to perform it the temporal and masseter muscles are found to be powerless on the side Avhich has lost its feeling. We have just seen in striking contrast the effects of loss of their proper functions by the two nerves mainly supplying the muscles and other textures of the face and mouth, the fifth and the portio- dura. Now the cause of this loss of function may be seated either within the cranium, or along the course of the respective nerves. When the portio-dura alone is implicated, it is probable that this cause is either in the bony canal, in the temporal bone, or in that part of the nerve which lies in front of the ear. AVhen, on the other hand, it becomes apparent from the extent of the anaesthesia, and loss of poAver of the muscles of mastication that the Avhole of the fifth nerve on one side is affected; it foUoAvs from the more com- plicated origin, as well as distribution of that nerve, that the disease must be within the cranium, and therefore the prognosis becomes much more unfavourable (unless, indeed, one branch only of the fifth be implicated). The circumstances which may cause facial paralysis are of course exceedingly various, and it is only by careful examination of the course of the nerve that Ave can ascertain whether there be any tumour or other mechanical cause pressing upon the nerve and ob- structing its functions, or Avhether the patient have received any bloAV or other injury Avhich may have produced the same result. We 468 SPASMODIC DISEASES. must inquire also for any evidence of disease in the ear; but when all these causes have been eliminated, there remains the most frequent, which is exposure to a current of cold air; and Avhen there is a history of such an occurrence, and the case is one of simple facial paralysis, we may in most cases encourage our patient with the hope of perfect recovery. When, however, there has been any thickening of the sheath or parts around the nerve, Ave must expect more or less permanent deformity; but even here we may give the patient the comforting assurance that this is the extent of the mischief. When, from the history of the case, it appears that there has been a blow or exposure to cold, or other causes of inflammatory action, we must have recourse to either general or local depletion; the former being indicated Avhen there are the constitutional signs of inflammatory fever well marked. In other cases local abstraction of blood, as by cupping behind the ear, is to be preferred; apply fomen- tations to the ear, or, what Dr. Watson recommends as still better, direct a current of the steam of hot Avater against and into the ear. Mercury should also be administered so as slightly to touch the mouth, and afterwards, especially if there be thickening or indura- tion, iodide of potassium should be given. When there are signs of extensive disease in the petrous portion of the temporal bone, we cannot expect much benefit from any active treatment whatever. The cases of facial anaesthesia belong, as far as treatment is con- cerned, to the same class as other instances of loss of function of the nerves; such partial paralyses are, it is to be remembered, often amongst the first signs of softening of the brain, especially in persons whose nervine poAver has been impaired by intemperance or other excesses, fatigue of body, or mental anxiety, or too great intellectual exertion. In such instances, after using gentle measures to subdue any inflammatory excitement that may exist, but not unless we have good proof that it does exist, mercury in the form of bichloride may be employed; but in cases non-inflammatory, mercury, especially if it produce ptyalism, is most injurious. Iodine may, however, be employed in the form either of iodide of potassium, or iodide of zinc; but most reliance may be put upon a full course of sulphate of zinc. SPASMODIC DISEASES. Hitherto we have spoken either of structural changes producing diminution of the functions of the nervous substance, or total aboli- tion of it, or of those instances in which this poAver has appeared to be suspended or destroyed independently of any appreciable change in the nervous matter; but we have only incidentally alluded to that most remarkable condition, spasm. Spasm may be said to be the opposite of palsy; it is an excess of muscular force, and that, too, excited in a perverted and disorderly manner. There are two kinds of spasm, the one consisting of long-continued contraction of the affected muscles, which slowly and imperfectly relax, and then, after a time become again contracted; this is termed SPASM — ITS NATURE. 469 tonic spasm. In the other, which is termed clonic spasm, the con- tractions are sudden, violent, and repeated, the intervening relaxa- tion being, of course, equally sudden and repeated. In many instancbs antagonising muscles seem to be alternately affected, so that a limb is thrown into continued and forcible jactitation, during Avhat is termed a "fit" of this kind of spasm. We have before had occasion to remark, that the excito-motory functions may be in full activity, when those of voluntary motion are suspended, or destroyed by disease; and more than this, we often find the former increasing in activity in proportion as the latter become impaired; of this we have an instance in the case recorded by Dr. Watson, of a gentleman who at the commencement of an attack of paraplegia, found that when he attempted to scrape his foot on the scraper at the house-door, his leg and thigh were forcibly and Involuntarily flexed and drawn upwards. And we may observe that, independently of disease, the energy of these two func- tions seem to vary in an inverse proportion. Thus in infancy, when the voluntary poAver is as yet undeveloped, the excito-motory is in the fullest activity; and, although we may not observe any inconve- nient defect of excito-motory power, where the voluntary is in per- fection, yet we do not commonly find in the robust, vigorous man that liability to sudden movements of the voluntary muscles, inde- pendently of their natural stimulus, viz., volition, which is so fre- quent in the delicate female; he is not so " nervous" in fact. When, then, the voluntary power of the brain is least energetic, the volun- tary muscles, which in perfect health in the adult subject are mainly under its influence and but little subject to the true spinal system, become almost entirely under the control of the latter; and conse- quently, strong, muscular contortions are excited upon the applica- tion of the lightest stimuli, and Avhich are quite beyond the control of the Avill. Dr. Todd has not inaptly applied the term polarity to this power of the spinal chord of generating power within itself, to be communicated to the voluntary muscles; and if, we apply, as we not unreasonably might, the same term to the power of the brain of originating voluntary motor power, under the influence of volition, we might lay it down as an aphorism, the result of observation, that the polarity of the spinal cord varies in an inverse proportion to that of the brain. It is not by this meant, that the excito-motory functions can never become unduly susceptible unless there be antecedent diminution of the voluntary; nor that this excessive excitability may not exist as a primary affection, independently of disease elsewhere, but merely that it is most commonly observed in those states of the system when the voluntary power is the least; and further, that when the con- trolling influence of the latter is withdrawn, the former will be liable to be thrown into excessive action by ordinary causes of irritation; and that when any such cause, of a more than ordinary character, comes into operation, we shall have violent spasm. Neither must we lose sight of the fact, that the nervous centres, the one as well as the other, have the power of originating muscular contraction, and 470 SPASM — ITS NATURE. are liable to irritation from Avithin, as well as from without, and con- sequently, that excessive contraction, or spasm of the voluntary muscles, may be excited by irritation, or hyperaemia of those centres or the parts proceeding from them, as well as by irritation along the course of those proceeding to them, and hence inflammatory disease of the brain, or of the spinal cord, may be simulated, as regards the " loesa partis functio," by irritation from without; that is to say, by peripheral and centripetal irritation, acting upon nervous matter, either in itself morbidly susceptible, or, as in the case of the spinal cord, uncontrolled by a power Avhich is in a great measure antago- nistic to it: and thus similar symptoms may arise from opposite causes, and require opposite modes of treatment. If these principles are kept in vieAV, they will guide us to the explanation of much that otherwise appears anomalous in the diagnosis and treatment of spas- modic diseases. In speaking of these affections, we shall proceed in the reverse order to that pursued by most authors, and commence with those which are most obviously the result of peripheral irritation. The most familiar instances occur in the convulsions arising from gastric irritation and teething in children. Now, as regards both of these, we have all the conditions which we have just pointed out as favouring abnormal excitement of the excito-motory system. We have the period of infancy, in which that system of nerves has the predominance over the voluntary, and we have an irritating cause at the extremities of one or other set of spinal nerves; but most children "cut" their teeth without convul- sions; and all do not go into fits every time that the milk "dis- agrees," or that they overload their stomachs; accordingly we ordi- narily meet Avith these convulsions in children in whom, besides constitutional debility, generally of a strumous character, there is, in addition to a liability to gastric derangements from mesenteric dis- ease, a great susceptibility of the excito-motory system. If, from other causes, gastric irritation be set up, and there' be more thaD ordinary inflammation of the gums in dentition, such children will be apt to be convulsed, and the greater the "nervous irritability," the greater the liability to be affected, even by the slightest irritating cause. In the diagnosis of these affections, we must carefully remem- ber the distinction which we have just pointed out between the oppo- site conditions which may produce the same results, namely, con- vulsions—and by close examination of the general state of the sys- tem, and inquiry into the previous history, satisfy ourselves that those symptoms which indicate inflammatory disease are absent; and, in the case of children in whom dentition is going on, we may pretty safely infer that the irritation proceeding from that process is the cause of the convulsions. In the case of gastric irritation, the irritable state of bowels, the generally abundant, or, at all events, not scanty urine, the full pupil, and reddish tongue, the tumid abdo- men, the constantly quick pulse, and the absence of all the symptoms of inflammatory affections of the brain will point to the true nature of the case. CHOREA. 471 The causes of these forms of infantile convulsion will best suggest the indications for their treatment. When the source of irritation is dentition, the gums should be freely lanced, and this having been done, we must proceed to allay the irritation elsewhere. When the heat of the skin is but moderate, and the other signs of general fever are Avanting, we may put the child into a warm "bath, of the tempera- ture of 100°; but if there be apprehensions of febrile excitement, the bath should not be used, except by immersing only the legs and thighs; the bowels must be carefully attended to, and if there have been merely frequent tenesmus and expulsion of mucus, with but little faecal matter, a drachm of castor-oil may be given, and subsequently the combination of two or three grains of bicarbonate of soda, with two or three of tincture of hyoscyamus will be found a most efficient sedative to the nervous system. When the convulsions continue to recur, we may have recourse to an'injection of assafoetida; we must, however, carefully watch for any signs of cerebral excitement, as the irritation at the extremities of the nerves may, in children so predis- posed, set up inflammatory action in the encephalon. When this occurs, it must at its first appearance be properly met by the mea- sures already suggested. The same principles apply to convulsion arising from gastric irri- tation; the first object must be to remove all offending matters from the alimentary canal; for this purpose, from one to two grains of hydr. cum cret. according to the age of the child, may be given, and afterwards a teaspoonful of castor-oil; if, however, the bowels should- have been extremely irritable, and the motions loose and abundant, it will be better to combine the hydr. cum cret. with three or four grains of compound chalk powder, and if there be much diarrhoea, from one to two grains of compound ipecacuanha powder may be added, and the castor-oil may be given guarded with a minim, or even two, of laudanum. The warm bath up to the hips may also be here used with advantage, and, if the convulsions recur, an enema of four or five ounces of solution of assafoetida may be administered, which often affords great relief. Cases are not very rarely met with, in which' the laxative remedies above recommended have brought away a considerable quantity of scybalae resembling sheep's dung, to the great benefit of the patient. The soda and hyoscyamus, or simi- lar soothing measures, may also be subsequently used with advan- tage, and followed by the course of treatment before recommended for children prone to mesenteric and other strumous diseases in the abdomen. Chorea.—Chorea Sancti "Viti, or, as it is popularly termed, St. Vitus's dance, is another spasmodic affection; the spasm being of a clonic character. It derives its name from the movements, some- times simulating those of the dancer at festivals or solemn games, and the name of St. Vitus has been added, as to the relics of that saint was ascribed the power of curing this affection. The appearance of a person suffering from this disagreeable affection is too well known to require minute description. The disease is most common in young persons of either sex, though perhaps young girls are more 472 CHOREA — SYMPTOMS AND CAUSES. frequently affected than lads; it may, however, occur at almost any age. It is not very rare in children as young as six or seven; and there was once in Guy's Hospital a man of sixty who was the subject of chorea. The disease generally comes on gradually; the child is observed to drop things, or to be unable to hold its book or thread its needle, or is seen to be twitching one hand, for which it is often reproved as for a bad habit. The movement, hoAvever, extends generally over the side where it is first observed, and that side of the body, includ- ing often the muscles of the face, is in a state of incessant motion, which movement sometimes assumes a character of regularity or almost gracefulness, as in the salaam convulsion. Generally, however, the movements are of an irregular and hurried character, most dis- agreeable to witness ; the voluntary control over the affected limbs being, in a great measure, superseded, so that when the patient is told to grasp anything, he makes several attempts with the hand, frequently missing it, and at last seizing it convulsively. The con- tinual movements of the muscles of the face give to the countenance an expression almost idiotic, aggravated, possibly, by the diminution of voluntary energy. The speech is also imperfect; sometimes the power of articulation is entirely lost, the attempt to speak giving rise only to contortions of the mouth and tongue, attended with increased movements and an inarticulate sound. The disease does not, however, in all cases, come on thus gradu- ally, but it sometimes attacks a young person immediately after a sudden fright or poAverful emotion. The convulsions also become sometimes so violent and uncontrollable that the patient cannot lie safely in an ordinary bed, and it becomes necessary to place him in a cot, or use some means of protection at the sides. The movements too, though almost always affecting one side, may extend to the other; and if this be not the case, the muscles of the otherwise unaf- fected side are called into continual action to counteract those of the opposite side. Chorea, as must be apparent from what we have already stated, affects exclusively the muscles of voluntary motion, and those which, though not strictly such, are under the control of the will, as is the case with the muscles of respiration, the diaphragm being often implicated; and a case occurred under my care, of a girl in Guy's Hospital, in whom there appeared to be chorea of the diaphragm alone. There is no proof of the purely involuntary muscles being implicated; unless the curious fact, first pointed out by Dr. Addison, of the frequent occurrence of a systolic " bruit de soufflet" under the left nipple, be received as evidence of the muscular structure of the heart being affected; the obscurity, however, of the mechanism of this so-called mitral " bruit" together with the frequent connection of chorea with rheumatism, go far to invalidate this testimony. It is remarkable, too, that the choreal movements are entirely sus- pended during sleep. The diagnosis of chorea is sufficiently obvious. The cause of chorea is generally some strong emotion, or "other CAUSES AND TREATMENT. 473 impression upon the nervous system; in most cases fright is the active cause, in some a cut or bloAV, uoav and then depressing emo- tion. In a case which occurred lately, a boy of sixteen became the subject of chorea immediately upon hearing of the death of his father from cholera. The cause, however, which constitutes as it Avere, the essence of the disease, consists in an excessive susceptibility of the nerves of voluntary motion, so that the muscles are thrown into con- traction without the stimulus of volition, often in direct opposition to it, sometimes through stimuli conveyed from an extremity of an incident nerve ; sometimes it may be that the state of the nervous centre is such that muscular contractions are excited independently of any impression conveyed to it by the incident nerves. This state of the nervous system is in by far the greater number unconnected with any change in its substance appreciable by our senses, though it may sometimes be associated Avith structural change in the brain or spinal cord. We do, in fact, occasionally meet [with cases of chorea in Avhich there have been chronic effusion into the ventricles or on the surface of the brain, often the result of strumous disease, or in which strumous deposits upon the pia mater have pressed upon the substance of the brain. In some of these, the choreal have been the first active symptoms of cerebral disease, and it is not improba- ble that the presence of such disease may have been the means of impairing the functions of the nervous substance. These cases, how- ever, are so rare as to prove that the cause must be sought for else- where ; and although we have no appreciable lesion in any part of the system, we have that condition which is commonly described as a want of tone; the muscles are lax, the blood is often in an anaemic condition; and undoubtedly, strumous boys and girls, and those living in large towns, are those Avho are commonly the subjects of chorea. The prognosis of this disease is generally favourable, though in those cases in which there are signs of sub-acute encephalitis, stru- mous meningitis, or of other diseases within the cranium, it must be in accordance with such symptoms. The treatment of chorea is in general simple and successful. The objects to be followed are—to obviate aU causes of irritation or excitement,—to improve the gene- ral tone, and particularly that of the nervous system. When, therefore, the child or young person has been exposed to fright, or subject to irritation of any kind, all disturbing causes should be carefully guarded against, particularly the annoyance arising from evident imitation by other children. The bowels should be effectively cleared out, though irritation from purgatives should be avoided. AVith this view, the combination of calomel with scam- mony or jalap should be used every third or fourth night, and its action assisted, if necessary, with tartrate of potass and senna, or in delicate children the mixture alone may be employed. As regards tonics, we must be guided in our selection by the con- dition of the patient. Those Avhich are in general most efficient are —the preparations of zinc and iron, the combination of port wine with rhubarb, and the shoAver bath. 474 E PI L E J? S Y. In ordinary cases the exhibition of purgatives to keep the boAvels freely open, and the sulphate of zinc in doses gradually increased from a grain to twelve, fifteen, or twenty grains, or even more, Avill effect a cure. When, however, the sulphate has been used in these . large doses, its sudden discontinuance seems to be felt by the system, and a return of the symptoms ensues : the best rule, therefore, for its exhibition is as folloAvs:—the bowels being kept open, the sulphate of zinc should be given in doses commencing with a grain, and in the case of a child of about twelve years old the quantity should be increased by the addition of a grain to each dose daily until it either causes sickness or there is an obvious diminution of the cho- real movements. In the former case the dose should be diminished by at least one-half, and so continued for several days, with a vieAV to establishing a tolerance ; but if, on the other hand, there be a marked improvement, it should be no further increased, but con- tinued without alteration until either the improvement ceases—in which case it should be again gradually increased—or the disease has altogether subsided. Whenever the latter is the case, we ought to diminish the dose day by day, rather than discontinue it suddenly, as by following the latter course we have less reason to dread a relapse. In some cases, however, especially those in which there is considerable anaemia, the iron seems to have more control over the disease than has the zinc, though these cases are rather exceptional ones. AVhen such cases present themselves, and are apparent either from the anaemic condition above alluded to or from the failure of the zinc, we may administer either the ammonio-tartrate or the ammonio- citrate of iron in the usual doses, or the tinctura ferri comp. com- bined, when there is torpidity of the bowels, with the decoct, aloes co. (F. 89).* This form is particularly eligible for chorea occurring in connection with amenorrhoea. Epilepsy, or falling' sickness—the morbus comitialis of the Latin authors—differs from chorea in that the spasm, though like it clonic, recurs only at intervals, that is to say, in fits or paroxysms, and in the important fact that the proper functions of the brain are sus- pended, there being loss of consciousness. An attack of epilepsy is generally sudden in its invasion; the patient may have been but the instant before to all appearance in perfect health, when he suddenly utters a most terrific cry, and falls senseless and convulsed; he then, in the words of Dr. AVatson, "strains and struggles violently—his breathing is embarrassed or suspended—his face turgid and livid— he foams at the mouth—a choking sound is heard in the wind-pipe —he appears to be at the point of death by apnoea. But presently and by degrees these alarming phenomena diminish, and at length cease; the patient is left exhausted and comatose, but his life is no longer threatened, and in a short time he is to all appearance perfectly well. The same train of morbid phenomena recur, how- ever, again and again, at different and mostly at irregular intervals." * (89) R. Tinct. Ferri co. 5 v. Decoct. Aloes co. 3 iij. Ft. Haust.; to be taken three times a-day. PATHOLOGY. 475 The epileptic attack or fit in many cases comes on suddenly, as we have just observed, and without the slightest warning. But it is not very uncommon, on the other hand, for patients to have some pre- monitory symptom, Avith which they often become familiar, so as to become aware of the approach of the fit. In some instances there is vertigo, or confusion of intellect; sometimes there is unusual irrita- bility of temper, which may exist for several days previous to the fit; and in some cases there is an inordinate appetite for food—that not uncommon symptom of cerebral disturbance. Sometimes, again, there are symptoms recognisable by the attendants or friends of the patient, as imperfect articulation, slight distortion of the face, or squinting. But the most remarkable of the premonitory signs is the well knoAvn " aura epileptica," AAdiich consists of a feeling as of the passage of a current of air from some part of the body, generally one of the extremities, to the head, or sometimes to the pit of the sto- mach, and which is immediately followed by an epileptic fit. The true pathology of epilepsy is very obscure. If we look to the symptoms we find them to consist principally of a suspension of the proper functions of the brain—sensation, volition, con- sciousness—with violent clonic spasm; the muscles of respiration being always implicated, and the sphincters paralysed; the urine beihg generally voided during the fit, and the lower bowels being commonly emptied. It is not, however, so obvious whether these spasms arise from derangement in the brain itself, or in the true spinal or' excito-motory system; the fact of the natural functions of the brain being suspended does not preclude the possibility of the motor fibres exciting abnormal or violent muscular action, the more so since Ave knoAV that disease or injury of the brain will sometimes produce convulsions at the same time that it takes away the con- sciousness. . There is also reason to believe that disease of the spinal cord, or its membranes, is more apt to produce tonic spasm than con- vulsion; at the same time, we know that irritation in the course of the nerves will produce spasm, and that too of a clonic character; and from the analogy of other diseases, we should expect these move- ments to be the more violent and irregular when the controlling poAver of the sensorium is withdrawn and in abeyance; and, there- fore, it is not impossible that disease or irritation of a portion of the nervous matter constituting the cord may excite the spasms, and that they are more easily excited where the proper functions of the brain, as regards volition and consciousness, are impaired. It is to be borne in mind, too, that the spinal cord has a double function—one as an independent organ, and the other as a part or appendage of the brain; and, therefore, we may well believe that as regards the motor columns, or those proceeding from the brain, irritation in any part of their course might act as stimulants to the muscles to which they are distributed, and excite them to contraction; and the same thing may be true of the white matter itself; we therefore perceive that it is possible that it may be excited in any part of the nerves proceed- ing from the brain, as well as of the brain itself; but we also know that irritation at the extremities of the incident nerves, or along their 476 EPILEPSY. course, will produce irritation of the brain itself, and therefore we are driven to the conclusion that epilepsy may have its origin in any part of the cerebro-spinal system. Alorbid anatomy, again, does not throw any certain light upon either the nature or the seat of the lesion, upon Avhich epilepsy depends: it is true that in the bodies of those who have died in epi- leptic fits, and in whom there had been no other symptoms referable to the brain, congestion of the vessels in the substance and on the surface of the brain is generally found; but this congestion is in all probability the result of the mode of death, namely, apncea. Others, again, have had repeated attacks of epilepsy, and who, as commonly happens, have evinced some signs of diminution of the functions of the brain—as impaired intellect, or paralysis, or diminished muscular power, and have been inspected after death, which has occurred inde- pendently of an epileptic fit; and in some of them there have been found induration and dilatation of the blood-vessels, in others soften- ing with a similar dilatation; these changes affecting the Avhite matter; whilst the gray matter is sometimes altered in consistence, easily re- moved from the white matter, and adherent to the membranes; but these are precisely the changes observed in those who have had similar affections independently of epilepsy; and where the other symptoms of celebral disease have supervened, as they often do, upon repeated attacks of epilepsy, it is more reasonable to attribute the changes in the brain to the excitement and disturbed circulation attending the fits, than to suppose that the fits have been produced by what appears from the symptoms to have been a subsequent lesion. On the other hand, we sometimes find evidence of sources of irri- tation which must have been permanent, and in some instances con- genital, as thickening of the membrane, tubercles on the surface, spiculae of bone, or other alteration of the bones of the cranium. These no doubt may be what are termed "predisposing causes," or rather conditions increasing the liability to epilepsy. There have been various classifications of epilepsy, but we agree with Dr. Watson in regarding that which divides epilepsy into excen- tric, or proceeding from irritation external to the nervous centres, and centric, or induced by irritation within them, as the one most in accordance with our knowledge of the pathology of the disease; or if we might express the same idea in someAvhat different language— epdepsy may be centripetal, that is to say, excited by irritation at the extremities of the incident nerves, and proceeding through the cerebro-spinal axis, exciting convulsion by the reflected nerves; or proceeding direct from the nervous centre, the irritating cause being in that situation. The conditions Avhich predispose to epilepsy are, a peculiar con- formation of the head; conical, sometimes flattened, more commonly unsymmetrical as regards the two sides, or affected with chronic hydrocephalus. Scrofula also produces great liability to this disease, and it is no uncommon thing to meet with epilepsy in persons who have plain marks of scrofula upon them, or in a member of a family DIAGNOSIS — PROGNOSIS — TREATMENT. 477 of which others are obviously scrofulous. Like scrofula, too, epilepsy is often hereditary. Intemperance and excesses of all kinds also favour if they do not absolutely induce a liability to epilepsy, and of this class of causes of debility there is none more frequent or more effectual than the wretched habit of self-abuse. The essential causes of epilepsy are, we have said, involved in obscurity, but some occurrences certainly appear, in those who are susceptible, to act as causes. Amongst these we may enumerate strong mental emotion, particularly fright, repressed eruptions, par- ticularly about the head; and so will suppressed discharges, and, what may at first sight appear extraordinary, haemorrhage will also produce the same result. The sight of another person in an epileptic fit has been known to produce the disease in a person wit- nessing it, and a patient who has had previous fits is very likely to be thrown* into one by witnessing such a spectacle; and so likely is it to be induced by imitation that those who have feigned to be epi- leptic have been known eventually to become really so. The diagnosis of epilepsy is, in the majority of cases, not difficult; but there are three conditions from AA'hich it is important to distin- guish it—from apoplexy, from hysteria, and from no disease at all, that is to say, from malingering or feigning. In a case Avhere the previous history is known, or where we have been made acquainted with the circumstances of the attack, there is no great difficulty in distinguishing epilepsy from apoplexy; but if we are called to a person who has been found in a fit some caution is required in this respect. In the first place, it must be borne in mind that epilepsy may be apoplectic; that is to say, that the injury to the brain Avhich produced apoplexy may, at the same time, pro- duce epilepsy; in this case, there Avill be the signs of apoplexy super- added to those of epilepsy. The pulse will be either full and labour- ing or quick and feeble; the breathing will be slow and stertorous, not hurried and gasping and whistling, as in ordinary epilepsy; and in such cases it Avill generally happen that the convulsion is hemi- plegic; that is to say, affecting one side almost entirely. It must be remembered, too, that epilepsy is far more frequent in early life than is apoplexy. Hysteria may still more closely simulate epilepsy, and in some instances, perhaps, hysteria does give rise to true epilepsy; that is to say, the seat of irritation may be in the uterus or its appendages. In most cases however of hysteria, which simulate epilepsy, Ave may observe that the patient has sufficient consciousness not to injure her- self in her convulsions; she does not bite her tongue or bruise herself, and there is frequent screaming, whereas, although epilepsy begins with a cry, it is not repeated. The greatest difficulty, however, is Avith malingerers, if they are skil- ful ones. Here we have none of the differences pointed out in the last case. Pretenders rarely hurt themselves by their falls, though they may have resolution to bite the tongue. They generally, too, choose public situations or places, Avhich will serve to attract the attention of those whom they wish to deceive, for their performances, 478 EPILEPSY. but will rarely exhibit before a medical man. Their contortions are often more violent than those of real epileptics, and the more so the more they are watched; but though more violent the convulsions are not so forcible; the true epileptic exhibits a power during the fit far beyond what is natural. Epileptics during the fit are insensible to external impressions, and the pupils are not obedient to the stimulus of light, circumstances, the Tatter especially, which it is impossible to simulate. In epilepsy, again, the eyelids are partially open, and the eyeballs prominent and distorted, whereas the malingerer generally closes his eyes altogether. Various contrivances have been suggested for detecting impostors of this kind. A very ingenious one is that proposed by Dr. Watson, of expressing an intention in the patient's hearing of pouring boiling water upon him, and then proceeding to pour cold. The prognosis of epilepsy is in the general way unfavourable; it is less so before puberty than after, in females than in males. The changes which take place in the nervous and circulatory systems about the time of puberty may be hoped to be beneficial in those Avho have been thus afflicted, and particularly so in females; and even after puberty has been established, uterine derangements are so frequently a source of fits, which though they might perhaps be called hysterical are so perfectly epileptic in their character, that we cannot regard them as anything else, unless Ave are guided solely by a suspicion as to their origin; and as this must always be obscure, Ave may reasonably hope that in such subjects the disease is de- pendent upon a cause which is not necessarily permanent. As regards the form of disease itself, the centric is necessarily more incurable than the excentric, and the excentric is more hopeful in the inverse proportion of the time during Avhich it has lasted. The treatment of epilepsy during the fit must be directed to pre- venting the patient injuring himself, and obviating any immediate danger from the violence of the convulsion, the impediment to the respiration, and the disturbance of the circulation. For the former purpose it is necessary to place the patient in such a position as that he shall be least liable to strike himself against anything that will hurt him during the paroxysm; and if possible to thrust a piece of cork, or part of a silk handkerchief betAveen the teeth. Great watch- fulness should also be exercised over those who are liable to epilepsy, to prevent their placing themselves in a position in which a loss of poAver of supporting themselves would be peculiarly dangerous; as before a fire, by the water-side, or unattended in a great thoroughfare. The next object is to guard against any internal injury. Now it may be apprehended that epilepsy, from the obvious engorgement of the vessels of the head, may give rise to apoplexy, and that to prevent such a catastrophe it Avould be well to bleed the patient from the arm; but experience has shoAvn that this measure is a dangerous one; whether it be that you cannot greatly relieve the internal pressure in this Avay, whilst there is so much obstruction to the circulation owing to the suspended respiration, or whether it be that the effect of the abstraction of blood is to prolong the fit, and TREATMENT. 479 aggravate_ its violence, the result of bleeding during an epileptic fit, provided it be really such and not apoplectic, is that several persons so treated have died; whereas death from an epileptic fit is a compara- tively rare occurrence; and further than this the tendency to a re- currence of the fits is much increased by the depressing effects of blood- letting upon the system at large. But though this may not be done, Ave may apply cold to the head, and when the fit is long continued, and particularly if there be reason to believe that the bowels have not been freely relieved during the preceding tAventy-four hours, a stimulating clyster may be administered. The treatment between the fits is the most important, and must be directed towards removing the proclivity to the fits, and protecting the patient from their more obvious causes. In the first place, all those circumstances which tend to increase the liability should, if possible, be removed. We cannot indeed relieve the patient of his inherited liability to this dreadful malady, neither can we cure him of those habits, generally evil in themselves, Avhich aggravate, and in some cases even originate the liability; but we can warn him of their evil consequences, and point out the certain ruin to which he is hurrying himself. It is true, indeed, that our warnings will but too often be, like those of the teachers of morality and religion, listened to with attention, and their reasonableness acquiesced in, but disregarded or forgotten upon the first temptation; but whilst we find some who are increasing their susceptibility to epilepsy by vicious courses, we meet with others Avho are bringing about the same result by pursuits harmless, or even praiseworthy in themselves; and they also must be warned that what others may do with impunity they must not attempt, except at the peril of increased frequency or severity in the attacks. To use the graceful language of Dr. Watson, " The patient who is subject to epilepsy should live by rule, and be temperate in all things. His diet should be simple, nutritious, but not stimulating. He should renounce all strong liquor, and become, in the new-fangled and vulgar phrase, a tee- totaller. He should rise early and take regular exercise in the open air; keeping his head cool, and his extremities warm. He should avoid all mental excitement, and the fatiguing pursuit of what is called pleasure; all probable sources of sudden anger, surprise, alarm, or deep emotion of any kind; all striving and contention of the intellect. The student of whatever age and sort in whom epilepsy has declared itself, should shut his books; the man of business abandon or abridge his professional toil; at least they must be in- structed to abstain habitually, in their respective callings, from such application as would task and strain their powers, whether mental or bodily; and endeavours should be made to engage their thoughts, and interest their minds in less engrossing objects of attention." As regards more active measures, it is most important to keep up all the evacuations in their natural activity, or rather beyond it; and sometimes it may be well to set up some artificial discharge, especi- ally if the disease have supervened upon the suppression of any, whether natural, morbid, or artificial; but in doing this the general 480 EPILEPSY. health must be maintained at its full standard, and the tone of the system improved as far as can be without inducing plethora, or excitement. It is therefore necessary to have recourse to occasional purgatives to insure a free action of the bowels; and Avhere there has been suppression or diminution of any previous discharge, as from haemorrhoids, or former ulcers, a blister should be applied, from time to time, at the nape of the neck; and when the former discharge has been of long continuance a seton should be used. In females in whom there has been a cessation or diminution of the catamenia, aloetic purgatives should be employed, and where there is any ap- pearance of anaemia they may be combined with iron. The mist. ferri co. with decoct, aloes co. ansAvers this purpose admirably. When there is decided evidence of a plethoric condition, and the pulse is strong and hard, and previous attacks have been preceded by head-ache, with throbbing of the carotid and temporal arteries, with evident congestion of the superficial veins, blood may be ab- stracted with benefit; but even this will, in the majority of cases, be best done by cupping from the nape of the neck; Avhen these symp- toms are wanting we shall best obviate the tendency to local hyper- aemia by the use of tonics. Amongst these we must not omit those most important ones, air and water. Moderate exercise in the open country, where it can be effected, should always be employed, and the cold shower-bath, which may always be safely employed if it be followed by a gentle glow upon the surface. Of tonics the mineral ones seem to have the greatest control over the fits. Iron is not admissible when there is much head-ache, or when that symptom follows its use: copper is perhaps next to iron as a general tonic, and has perhaps more influence upon the nervous system. It may be given in the form of sulphate, in doses beginning at a fourth of a grain, and gradually increased to three or four grains, provided it produce no irritation in the stomach or bowels; it has frequently greatly prolonged the intervals between the fits, though in tAvo in- stances in which it was employed, the fits when they recurred did so with greater, and in one instance, fatal violence. Silver, in the form of nitrate or oxide, has been much praised as a remedy for epilepsy, and in the cases requiring tonics it is one of the best; it has however the disadvantage of sometimes rendering the skin black, or rather bluish, by the deposition, as it is supposed, of the oxide of the metal upon the rete-mucosum; certain however it is, that such an event has sometimes folloAved its use. Zinc is not liable to the same objec- tion, and from its superior efficacy as a nervine tonic, and its being less apt to cause determination to the head than any other of the mineral tonics, is upon the whole the most eligible. It may be given, as in chorea, in doses gradually increased from one grain to twenty or more, as far as the stomach will bear it; and when it has pro- duced a decided benefit, the dose should be reduced upon the de- scending scale. ASTHMA — ITS PATHOLOGY. 481 ASTHMA. In speaking of the diseases of the air-tubes and lungs, we have alluded to the paroxysms of dyspnoea which are often familiarly known by the name of asthma; but besides these there is the true asthma, with which little or no anatomical change is associated, and is probably of purely nervine or spasmodic character. An attack of asthma is generally preceded by signs of disorder of the digestive functions; there are flatulent distensions, headache, lassitude, depres- sion of spirits. Towards evening there may be weight and oppres- sion across the chest, with some difficulty of breathing, and perhaps in this state the patient retires to rest. The urgent dyspnoea gene- rally comes on after midnight, generally about tAvo or three o'clock in the morning, when the patient awakes with a feeling of constric- tion across his chest, and an inability to draw in his breath. He is compelled to rise, and sits bending forwards, with knees drawn up, labouring for breath, and often wheezing loudly, and complain- ing of a feeling of impending suffocation; he expresses an urgent desire for fresh air, and will go and open the window to get breath; and, what is characteristic, he rarely experiences any ill effects from so doing. The face is often livid from congestion, at other times pale and shrunken. There is generally much palpitation of the heart, with a feeble, and sometimes intermittent pulse, indicative of obstructed pulmonic circulation. If there be any urine voided, which there not uncommonly is at the commencement of a par- oxysm, it is copious, pale, and limpid, like that of an hysterical female. The boAvels, too, are often relaxed, with a spasmodic action. The fit lasts for several hours, and generally subsides toAvards morning, when the dyspnoea begins gradually to subside, the patient is enabled to breathe, speak, and cough with ease, and at last sinks into a quiet sleep. This is often preceded by a copious, thin, frothy expectoration. When this occurs the patient is said to have humid asthma, but sometimes there is none, when the case is said to be one of dry asthma. These paroxysms will sometimes recur for several nights in succession, the patient often saying in the intervals that he feels quite well, though there is generally apparent more or less difficulty in speaking. There are no anatomical changes found Avhich account for this disease; there may be emphysema of the cells of the lungs, and enlargement of the right side of the heart is not uncommon; both these, however, are often found without asthma; and though the former, when extensive, always gives rise to more or less dyspnoea, it is of a constant, rather than a paroxysmal character, and the latter is more probably an effect than a cause. The absence of all structural lesion in the chest, as well as the general spasmodic nature of the attack, the almost hysterical symp- toms, and 'the pale, limpid urine, all tend to show that asthma is a 31 482 COLIC. nervine affection, probably of a spasmodic character, the seat of the spasm being in the muscles that encircle the air-tubes. The circumstances Avhich excite the paroxysms shoAV that the spasm may have a centric or excentric origin, originating, in the former case, in the nervine centres, thus mental emotion will often bring on an attack; and as instances of the latter, we may adduce gastric irritation, the pneumo-gastric being in this case the incident nerve which conveys the impression to the centre. It is not there- fore surprising that bronchial irritation should be another cause, and that whatever produces a strong impression upon the bronchial membrane should induce an attack: thus, changes in temperature, or in the humidity of the atmosphere, will often bring one on; ^though different asthmatic subjects are variously affected in this way, an unusual degree of moisture bringing one on in some, whilst others rest best in low, damp situations. The susceptibility to asthma often arises from hereditary predisposition; it appears also to be induced by a lax habit of system, by gout, and by long-con- tinued dyspepsia. From the dyspnoea of emphysematous lung, or dilated tubes, as well as from that from disease of the heart and large arteries, • asthma may be distinguished by the absence of the physical signs of those diseases, and by the paroxysms generally coming on at night. The prognosis of asthma is in early attacks favourable; but a frequent repetition of them may exhaust the strength of the patient, and induce emphysema of the lungs, enlargement of the right heart, obstruction of the pulmonic circulation, and death from apncea. During an attack of asthma, if there be signs of great congestion about the head, a few ounces of blood may be taken by cupping betAveen the shoulder-blades; but as a general rule the abstraction of blood is to be avoided. A combination of the compound sulphuric aether, or chloric aether, with opium (F. 90),* gives much relief during the paroxysms; and a most efficient measure is the smoking of the leaves of strammonium, commonly known as herb-tobacco. In the intervals, every means should be used to improve the general health and the tone of the sj^stem; and that locality should be selected where the patient can breathe most freely. A course of sulphate of zinc, carried to the extent of about four grains three or four times a-day, should also be had recourse to. COLIC. Colic is a disease which, as regards the bowels, is in many respects analogous to asthma, as regards the lungs. Like the former, it pre- sents several of the symptoms of disordered function induced by inflammation, but it is not inflammatory in itself, and is unconnected * (90) R. Sp. Mth. co. n^ xx. vel ^theris Chlorici, n^ xv. Tinct. Opii, ttL xv. Mist Camphorae, ^ j. Misce. Ft. Haust. ; to be taken during the paroxysm. ITS PATHOLOGY. 483 with inflammation, unless the latter occur as an effect, or as an acci- dental complication. The symptoms of colic are, severe twisting pains in the abdomen, referred particularly to the umbilicus, the boAvels being obstinately confined; there is generally considerable flatulence, and often nausea. The pain is relieved by pressure, and the patient may often be seen to press his hands upon the abdomen for that purpose; the pulse and tongue are unaffected. The symptoms will often subside upon a free evacuation of the boAvels, but if that do not occur, the pains will be more severe and constant, the abdomen tender, and the case will pass into one of obstructed bowel, or of ileus or enteritis. As in the case of asthma, there are no anatomical changes con- nected with colic as such, the colon is found firmly contracted in one part, and largely distended in that immediately above or tergal to it; this appearance is commonly explained upon the hypothesis of spasm of the former part, and paralysis of the latter; and in ordinary cases this is probably the most satisfactory explanation, though it must be recollected, that if there be sudden stoppage of the bowels from any other cause, and the same may be true of paralysis, there will be contraction beyond it. The causes of simple colic are, cold applied to the surface, more particularly the abdomen and lower extremities, accumulations' of hardened matters, hysteria, spinal disease. It is in fact a nervine affection, in which the paralysis or irritation may originate from the spinal cord or the brain; or it may be excited by an impression upon the incident,nerves, as in case of cold to the surface, or irri- tating substances in the bowels itself. There is, however, one form of colic the history and symptoms of which clearly indicate its nervine origin, and that is Colica Pictonum, familiarly known as painters' colic, or Devonshire colic, or dry belly- ache of the West Indies, and in all cases it has been traced to the gra- dual introduction of lead into the system. In Devonshire it has often arisen from the use of cider, the common drink of the country people, which had been prepared in machinery in the joints of the several parts of Avhich lead had been employed, the acetic and malic acids of the apples having formed soluble salts with that metal. This disease commences Avith the same symptoms as the ordinary colic, but it does not end with them. It may be just after one of these attacks, or it may be during a second or a third, that one hand or both of them drop, as the workers in lead term it, so familiar are they with the fearful malady. About the same time with these symptoms another and very remarkable one presents itself, for the acquaintance with Avhich the profession is indebted to the late Dr. Burton of St. Thomas's Hospital. This is a bluish or purplish line along the edges of the gums. The immediate cause of the phenome- non is the deposition of sulphuret of lead, the sulphur being probably furnished by animal matters admitted into the "tartar" that forms on the teeth, or the sulpho-cyanic acid in the saliva; the lead is from the salt of that metal Avhich has entered the circulation. The palsy is the first amongst the nervine symptoms, but it is not 1 484 COLICA PICTONUM. the only one. Sometimes there are at the commencement pains in the head and sometimes cramps. In severe cases, generally those in which there has been several attacks of the colic, the paralysis extends to the lower extremities, and the sufferers become miserable cripples. Frequently there are at the same time pains in the limbs, often called rheumatic, but which close inquiry into the history of the case, aided by inspection of the gums, show to be lead-poisoning. The paralysed muscles waste, and the patient loses colour in the face and lips, one effect of lead being apparently that of diminishing the quantity of red corpuscles, and he either dies of general paralysis or is carried off by some visceral disease. The diagnosis of colic is not difficult. As long as it is only colic it may be distinguished from the other diseases of which we have spoken as interrupting the functions of the bowels by the absence of their characteristic symptoms; Avhen these present themselves it ceases to be colic. The prognosis of a first attack of colic is favourable ; recurrences of lead colic will sooner or later terminate as just described. Ordinary colic is best treated by calomel and opium, in doses of about a grain each, repeated every three hours for three times ; after which half an ounce of castor oil may be given and an enema of soap and water administered, or the patient may be put into a warm bath, and about a quart of the water thrown up into the bowels. If, how- ever, there be evident indication of inflammatory action, blood may be taken from the arm.- This, however, is a measure not to be wan- tonly practised in lead colic, since the abstraction of blood favours its absorption into the system, and promotes the anaemic character Avhich is one of the effects of the poison. The treatment of the paralysis is far more difficult. The best plan is to put the dropped hand on a splint; a blister may be applied to the arm, and on the excoriated surface there may be sprinkled about one-eighth of a grain of strychnine well mixed Avith ten grains of tragacanth poAvder. To eliminate the poison from the system various means have been suggested. Mercury has been recommended, but is worse than use less. Nitric acid has appeared to be beneficial, and of late the iodide of potassium has been used with much benefit. INTERMITTENT AND CONTINUED FEVERS. 485 XXVII. INTEEMITTENT AND CONTINUED FEVERS. When a person has been attacked with chilliness, or shivering, or lassitude, and this has been followed by increased heat of skin, acce- lerated pulse, pains in the limbs, coated tongue, loss of appetite, thirst, and general derangement of the functions of the system, he is said to be the subject of fever. This state, as we have seen, may be excited by inflammation exist- ing in any part of the system, and is then termed inflammatory fever; but, on the other hand, it may arise as a primary disease, independ- ently of any local affection, and is on that account called idiopathic fever. We have already seen, in treating of inflammation, that the character of the fever admits of considerable variations, sometimes marked by continued force and frequency of the pulse, evincing the truly inflammatory fever, and at others characterised by softer pulse, greater tendency to prostration, and failure of the moving powers of the circulation, constituting what has been termed typhus* fever : and it will generally be found that these idiopathic fevers are more or less of the latter character. It is not altogether to be overlooked that many distinguished phy- sicians, more especially on the continent, have maintained that all fevers have their origin in some local inflammation, and in proof of this, there has been adduced the almost constant occurrence of some change which might be ascribed to inflammation in the bodies of those who have died from them. If, however, this evidence be care- fully analysed, it will become apparent that there is no lesion, essen- tially characteristic of fever, which may not be explained by the congestion, arising from the impeded circulation in the extreme vessels, dependent, probably, upon an altered condition of the blood; or which may not be shown to be the result of an inflammation aris- ing in the progress of the fever; and consequently, if at all con- nected with the fever, in the way of causation, so connected as effect rather than as cause. Setting aside, then, the theory that ascribes all fevers to the effect of a local inflammation; both for the above reasons, and also upon the ground that nearly all physicians have found the practical neces- sity of recognising the existence of a state of pyrexia, that may be dis- tinguished, by its history and symptoms, from fever arising from a local inflammation, we proceed to state briefly the signs by which idiopathic fever in general may be distinguished. First of all we have the negative sign, that of the absence of all symptoms which indicate the existence of inflammation in any part; * By typhus we mean typhus, and by typhoid we mean typhoid, or fever resembling typhus. 486 CHARACTERS OF FEVER. and to this may be added the character of the fever, that it is always prone to the typhoid or sinking form; thus the puke is more readily compressed than in the inflammatory fever: the secretions generally are more vitiated, especially those about the mouth, which speedily become viscid and dark. The nervous system is generally more oppressed, there being early stupor or confusion, great weak- ness, with giddiness or vertigo, and a tendency to syncope on the slightest attempt at exertion. There are derangement of the exter- nal senses,—generally in the way of diminution,—as shown by the frequent tendency to deafness ; a failure rather than perversion of the intellectual faculties, as shown by the character of delirium, unat- tended with violence, generally approaching to stupor, and commonly described as low and muttering. There is an altered condition of the blood, which shows impaired vitality, sometimes losing entirely its poAver of coagulation, and at others showing signs of putrescency, giving rise to gangrene from slight irritation,—the red corpuscles, too, often breaking and allowing the effusion of the colouring matter through the serum or into the tissues, Avhence arise petechias, vibices, and passive haemorrhages. Over and above these symptoms of depression of the nervous power, and so-called putrescence of the blood and tissues, there is often a disposition to a defined inflammation of the skin, in many instances of a specific character, and appearing a certain time after the first invasion of the fever ; this belongs essentially to what are termed the exanthems or eruptive fevers, but is seldom altogether wanting in the ordinary continued fever. Another remarkable peculiarity by which idiopathic fever is dis- tinguished from that which attends local inflammation, is its tendency to spontaneous favourable termination. This tendency shows itself in a variety of ways, which forms, in fact, the basis of the division of fevers into three pretty generally recognised classes. In the first or intermitting form we have a perfect subsidence of the febrile symptoms after a cold and hot stage; this subsidence being attended by a copious spontaneous sweating, the fever returning after an interval of twenty-four, forty-eight, or seventy-two hours, and again subsiding, after running through the same course. In the second or remitting form of fever, there are distinct remis- sions of the symptoms, occurring, generally once in twenty-four hours, but not perfect subsidence of them. The continued fever, in which there is little or no abatement of the symptoms for several days,' when somethnes as early as the seventh and at others as late as the thirtieth, orTven fortieth, but most com monly about the twentieth day, or even earlier, a spontaneous subsi- dence of the symptoms takes place, sometimes very gradually, and at others almost suddenly, and attended by copious evacuations from the skin or kidneys. Another remarkable circumstance, and one peculiar to idiopathic fever, as opposed to that arising from local inflammation, is its ten- dency to become epidemic in districts or communities: thus showing that it arises not from general causes, like those which excite com- DIFFERENT FORMS OF FEVER. 487 mon inflammation, but is the eftect of some agencies which have a local or temporary operation. Of the local and temporary, we have good evidence of the existence of two, one or the other of which, or both conjoined, are the immediate causes of all idiopathic fevers ; namely, malaria or contagion. Of the existence of one form of malaria ; namely, that proceeding from the decomposition of vegetable matter, commonly known as the marsh miasm, there is little or no doubt, either in the minds of medical men or of the public generally; and this miasm is also acknowledged to be the alone cause of intermittent fevers or agues. This poison may possibly be generated accidentally, so as to effect only a particular individual or family; or from causes to be pre- sently noticed, its effects may not manifest themselves in an indivi- dual till after he has been for sometime removed from the sphere of its influence; but they are so commonly observed to prevail in marshy countries, that there is no doubt entertained of these effects being produced by a local cause, and the disease is said to be endemic (p. 22). Noav these endemic intermittent fevers are never communi- cated by personal intercourse to persons living beyond the district in which they prevail, and are also observed so constantly in marshy localities that there has been no controversy as to the origin of the morbific agency. Other forms of fever, are observed to prevail for a time in a com- munity, attacking large numbers in quick succession, and then subsiding, often reappearing in some neighbouring population, and in this manner sometimes traversing whole continents; these are said to be epidemic (p. 22). Concerning the origin of such diseases, there is much more doubt than in the case of the endemic. Some of them, of which the best instances are amongst the eruptive fevers, are so undoubtedly propagated by intercourse with subjects of the disease, that no doubt has ever been entertained by the experienced of the existence of contagion; but even with these there are obviously other conditions which regulate their extension through a population; so that although the existence of contagion as an immediate cause can- not be called in question, the agency of some other condition, in order that that cause may take effect, is hardly to be disproved. Other epidemics again attack a population so suddenly as scarcely to admit the supposition of their being propagated mainly by human intercourse, and thus we are constrained to recognise the possible existence of a malaria not depending upon local causes, but coming suddenly upon different districts. The question, then, of the origin of epidemic diseases becomes a much more complicated one than that of the endemic. The stating a disease to be contagious implies also that it arises from an animal poison; since it means that a person affected with a given disease is capable of generating in his own person a poison similar to that which first excited the disease in himself, and which is therefore capable under favourable circumstances of exciting a similar disease in another; and herein consists the difference between 488 • INTERMITTENT FEVER. such poison and poisons derived from the mineral and vegetable kingdoms. Setting aside, then, for the present the eruptive fevers, we may lay it down that there are some arising from the marsh miasm, and which are not communicated from person to person, but are endemic in certain localities; these are of the intermittent form; that there are others which are apt to affect a population for a time, the spread of which is favoured by filth and the presence of decomposing animal matter and Avhich are also rapidly propagated when a number of per- sons affected Avith them are crowded together, so as to leave no doubt that the specific poison exciting the disease may be generated or mul- tiplied Avithin the system; and these fevers are of the continued form. Enough has perhaps been already stated to make it apparent that the doctrine which would ascribe all fevers to the effect of a local inflammation is not founded on a comprehensive view of the facts, and the same may be said of that which would explain them solely upon the principle of a change in the blood, or disturbance of the nervous system. We shall be nearer the truth in stating—what indeed is not so much the enunciation of a theory as a summary of the facts observed in the progress of various forms of fever—that the morbific agent, after remaining for some time latent in the system, acts simultaneously upon the blood and its moving powers—upon the heart and upon the extreme circulation, i. e. upon the vital inter- action of the blood in the capillaries and the tissues,—upon the nervous system, and upon the functions of the secreting organs,— unless indeed these latter actions are to be included in the two former. But the peculiar action of the morbific cause upon all these parts of the system is a depressing one, and this depression is followed by an increased activity of the moving powers of the heart, without, however, restoring the healthy capillary circulation; and that this increased action is apt to be folloAved by a failure of the action of the heart and large vessels, threatening death from asthenia and syncope; though this latter mode of death may also arise from inflammations prolonging the fever, or inflicting injury upon some vital organ. INTERMITTENT FEVER. A paroxysm of ague or intermittent fever has generally been regarded as an epitome of a continued one, and for this reason most authors commence the subject of fevers with the consideration of intermittents. The first invasion of a paroxysm of intermittent fever, or ague, as it is commonly called in this country, is marked by those symptoms which have been already described as belonging to the commence- ment of the febrile state, but with great intensity. These are lassitude, pains in the limbs, giddiness, with a sense of weight or oppression about the epigastrium. The patient then begins to feel chilly, and have a sense of coldness down the back, the extremities become cold, AGUE — ITS DIFFERENT FORMS. 489 the fingers shrunken, and the nails blue, the skin is shrivelled, and the papillae become prominent, constituting what is commonly termed goose-skin, or more learnedly cutis anserina; and the countenance also is shrunken, the nose cold, the patient shivers, and his teeth chatter, and he is glad to draw close to the fire, or envelope himself in blankets. He not only is cold, but he feels cold, and acts accordingly The pulse is sometimes frequent, but always feeble; there is appa- rently a failure of the moving powers of the blood, which seems scarce to reach the surface. The tongue is white and dry; there is but little urine secreted, and the boAvels are confined: after this state of things has continued for a greater or less length of time, the heat of the surface begins to return, the patient has flushings of'heat and becomes warmer and warmer, and ultimately the whole surface is of a dry, burning heat; the shrivelled and livid extremities resume their natural colour, and even become turgid: he has at the same time intense thirst, restlessness, and severe headache; the urine is scanty, high-coloured and turbid, and the tongue furred and dry; the pulse frequent, full, and strong. After the second or hot stage has con- tinued for some time, another change comes over the patient; a mois- ture gradually appears upon the face and forehead, the harsh and hot skm becomes soft, and at last a copious sweat breaks out over the Avhole surface, affording him great relief. There is also a copious discharge of urine, Avhich however is still high-coloured, and the several functions of the system return to the condition in which they were before the commencement of the paroxysm. After a certain period of intermission, the paroxysm recurs, the time between the commencement of one paroxysm and the commencement of the next being termed the interval, and it is from the length of this interval that the different forms of intermitting fevers receive their names. Thus, when a paroxysm recurs daily, the ague or intermittent is said to be a quotidian; when every alternate day it is termed a tertian, the day on which the former paroxysm occurred being included and reckoned the first. When again the paroxysm recurs after an inter- val of three days, or on the fourth day, including that on which the former pa*roxysm occurred, it is termed a quartan. There are indeed other forms of intermittents in which the interval is longer, and which have been named quintans, sextans, septimans, &c, but these are not so regular in the recurrence of the paroxysms, which are apt to return at such uncertain intervals, as to lead to the belief that they are irregular varieties of the more ordinary forms of the disease. Sometimes, again, the paroxysms will recur daily, but with those on the alternate or tertian days corresponding to each other in severity, duration, character, or time of invasion. In these cases the patient is said to be affected with a double tertian; or again, there may be a paroxysm occurring on two consecutive days, leaving only one day of intermission; but in these cases those in the quartan days correspond in character with each other, and when this happens the disease is said to be a double quartan. Another form of double or even triple quartan is when the paroxysm observes the quartan days, but there are two or three paroxysms on each of those days. 490 AGUE. There is much Arariation in the duration of the paroxysm in differ- ent subjects, and even of the different paroxysms in the same case, as the time occupied by the whole paroxysm may vary from three to sixteen hours, the average being about four or five; the same also applies to the different stages of the paroxysm. The cold stage may pass off in less than an hour, or it may be prolonged for several, though about two hours may be said to be the average duration; and the same uncertainty attaches to the hot and sweating stages. It is, however, remarked as a general rule, that the longer the cold stage the shorter the paroxysm, and the shorter the interval the longer the paroxysm. Thus the quotidian has the shortest interval and shortest cold stage, but the longest paroxysm; the tertian a longer interval and longer cold stage, with a shorter paroxysm; and the quartan with the longest cold stage has the shortest paroxysms. Another curious rule, though one by no means without excep- tion, is, that the shorter the interval the earlier in the day does the poroxysm take place. Thus the quotidian paroxysm generally com- mences in the morning, the tertian about noon, and the quartan in the evening. The pathology of intermittent, as of all forms of fever, is neces- sarily obscure. We are aware from observation that during the cold stage there is great congestion or accumulation of blood in the great reservoirs, the liver, spleen, and large veins, a state of things which we know will arise when the action of the heart is very feeble; so that it is by no means certain that this internal congestion is anything beyond the immediate result of the diminished force of the moving powers of the blood. The cold stage has by many been regarded as the cause of the hot; but that it is so, further than that, in general, any state being at any time the effect of that which preceded, cannot be received as proved; since we find that there is no certain relation whatever between the intensity and duration of the cold stages and those of the hot. The hot skin, thirst, scanty urine, head- ache, &c, of the hot stage are perhaps to be explained by the difficult capillary circulation with the consequent increased force of the heart's action, and arrest of secretion, arising from the loss of the affinities between the blood and the tissues, and which we believe to be essen- tial to the febrile state. There is perhaps less difficulty in accounting for the sweating stage by the increased force and frequency of the heart's action, and gradually returning capillary circulation, though whether this perspiration is critical, and therefore by restoring the blood to its formal condition restores also the healthy relation be- tween the blood and the tissues, or whether this previous subsidence of the febrile action is the cause of a free capillary circulation, and consequently more copious secretion, is a question which will be answered according as the belief may happen to prevail that the miasm acts mainly upon the blood, or the nerves. It is unprofitable to theorise Avhere we know so little. It may, therefore, suffice to remark: that if it be assumed that the malarious poison acts purely by impression upon the nerves, without necessarily being taken into the circulation, the recurrence of the paroxysm PATHOLOGY. 491 must be accounted for solely by that hitherto unexplained tendency to periodicity, which is so remarkable in many of the animal func- tions ; but that we shall be quite unable to explain the circumstance of the morbific agency remaining, as it often does, long dormant in the system, until called into action by some favouring state of the system; whereas, if we assume the poison to be received into the circulation, and in virtue of its presence there to produce the pheno- mena of the disease, we shah frame a more plausible theory of inter- mittent fevers, referring the cold and congestive to the action of the poison destroying the affinity between the blood and the tissues in the capillary circulation, and thereby causing congestion of the internal organs; the hot stage again being the effect of the reaction from this state of congestion, Avhich induces the sweating stage, in Avhich the poison that has been accumulating in the system since the preceding paroxysm is eliminated from it, whereby the patient is restored to health, till an accumulation again takes place sufficient to produce a paroxysm. But in order to receive this explanation, we must also admit the possibility of the poison being generated in the system, since paroxysms will often continue to recur in those who are removed from the malarious atmosphere; and although we have no difficulty in believing this of poisons which are in the first in- stance of animal origin, we cannot readily admit it of those which are not so. v The alone cause of intermitting fever is miasm, of which we know nothing excepting its effects. This miasm emanates from marshy lands, and is supposed to be generated by the decomposition of vegetable matter. There is, however, reason for believing that it may be produced in certain soils when saturated with moisture, but in which there can be no vegetable decomposition taking place. As regards the propagation of the disease by human intercourse, it may be confidently asserted that in this climate it never is so; though under certain circumstances in hot climates the intermittent fevers may in many of their symptoms, as well as in the tendency to putrescency of the blood, approach more nearly to the lowest and most malignant forms of continued fevers, and excite a suspicion of their also acquiring that most important property of continued fevers, namely, that of spreading by contagion. Passing by, however, these exceptional cases, we proceed to ob- serve that the diffusion of this miasm is regulated by certain laws, both as regards the conditions external to those who are exposed to its influence, and their state of system at the time; these latter have been miscalled predisposing causes. As regards the laws which regulate the diffusion of the miasm: the most powerful agent is heat, the virulence of the miasm being nearly proportionate to its intensity—though occasionally epidemics of unusual virulence do occur which cannot be accounted for in this way—the poison does not readily diffuse itself through the atmos- phere, nor rise to any considerable height above the surface of the ground, the inhabitants of the upper stories of houses often enjoying a greater immunity than those beneath them. The malaria is more 492 AGUE. dangerous, and therefore more active, in the night than in the day time, and from this it has been inferred that though the heat of the sun's rays favours the evolution of the miasm, it afterwards dissipates it, though it is possible that the greater activity of the poison in the night may be owing to the presence of the dew. The poison is also wafted by the winds, being more virulent to the leeward than the windward of marshes, and apparently attracted and even stayed in its progress by trees, so much so that not only is the immediate vicinity of woods dangerous, but a number of trees intervening be- tween a marsh and a village appears to afford its inhabitants protec- tion. It is apparently neutralised by passing over the sea, and its virulence diminished by the cultivation of waste lands. As regards those exposed to its influence, it has been ascertained that the per- manent inhabitants of a malarious district are less susceptible of the effects of the poison in producing intermittent feA^er, though they appear to suffer from its agency in a more chronic form, being sallow, anaemic, and often affected Avith visceral disease. There are, again, certain conditions in the individual which render him more susceptible of the agency of the poison, and which have been therefore called predisposing causes of intermittent fever, though they were never known of themselves to give rise to any form of that disease. Thus it acts, like all other causes either of inflamma- tion or idiopathic fever, more powerfully upon those whose strength has been impaired by intemperance, fatigue, privation, excessive evacuations, or depressing mental emotions; whereas all agents, whether physical or mental, Avhich permanently strengthen the sys- tem, are the most efficacious in enabling it to resist its influence. Exposure to great heat or cold, the remaining in wet clothes or with damp feet, and standing upon damp ground, exposure to watery ex- halations, and especially to dew, are formidable adjuvants to the action of the malaria. In hot climates the Avhites are far more susceptible of the effects of malaria than the blacks. The poison when imbibed appears to lie latent for an indefinite time—in the agues of this country often for six or nine months; and it is remarkable that after its effects have for a time ceased to mani- fest themselves, or have not yet made their appearance, it will be called into action by any of those conditions of the system which constitute a susceptibility of its action. Besides the morbid changes in the liver and spleen, which are so frequent as to appear almost the necessary consequence of ague, if allowed to exist for any length of time, we have not unfrequently superadded some local affection, not so specific or uniform, the effect of the same cause, giving rise to what is termed complicated ague; such complications being generally seated in the head, the chest, or the abdomen.—Symptoms of congestion, irritation, or even inflamma- tion of the brain or its membranes have not unfrequently supervened in the progress of ague, giving rise to pains in the head, stupor, coma, delirium, or convulsion. Inflammatory affections of the chest, such as bronchitis, pleurisy, pneumonia, or even pericarditis, and present- PROGNOSIS AND DIAGNOSIS. 493 mL a T ™Ty Slgns of these affections, though in a somewhat mV3 leAf0rm' fre hable t0 occur in winter and the early spring — lhe abdominal complication is, however, the most common, and prevails most during the'summer and autumn: it may amount to no more than congestion of the mucous membrane of the canal as- sociated with depraved secretion from the liver, exciting sickness and moderate purging. In other cases, however, there is more decided inflammation either of the intestinal mucous membrane, of the liver or of the spleen. ' The prognosis of ague is to be considered first in reference to the immediate safety of the patient, and next to ultimate restoration to health. As regards the first question, there is little or no immediate clanger to be apprehended from agues occurring in persons whose constitutions are naturally sound, and have not been impaired by age, disease, or irregular habits; and this is still more the case if the disease be tertian or quartan, and occurring in the spring; but, on the other hand, where the constitution has been weakened by any of the above-mentioned causes, there is great danger of death from sinking under the general disturbance set up by the disease; and this is still more likely to ensue in the autumn, and'if the ague be a quotidian, or attended with disturbance in the alimentary canal. Upon the whole, however, it rarely happens that a person dies in this country, either in the paroxysm or during the continuance of the intermittent. As regards the second point, however, the prognosis is not so satisfactory, since it by no means follows, that because the paroxysms have ceased to recur, therefore a perfect cure has been effected, and the patient rendered safe from the ill effects of the ague and the miasm which excited it: for Ave knoAV that during the cold stage there is great congestion of the liver and spleen, of the latter more especially; so much so as in some instances to have caused death by rupture of the organ from over-distension. The effect of this frequent congestion is an induration of one or both of these organs, of the latter so frequently that the enlarged spleen is familiarly known by the name of "ague-cake;" and we know that the immediate effect of these indurations is obstruction to the passage of blood through the veins converging to the vena portae, and its remote consequences— diarrhoea, dysentery, and dropsy. We have reason to believe also that there is a connection between the action of the miasm and the sallow, bloodless aspect so often observed in those who have been the subject of intermittent; whether this anaemic condition be brought about through the agency of the diseased spleen, or whether both are to be regarded as the joint effects of the poison; and we know that such persons may have the visceral diseases consequent upon ague, even passing on to their fatal termination, without ever suffering a paroxysm of intermittent; showing that these results are to be ascribed rather to the action of the poison than the actual development of ague. Whilst, therefore, there is any enlargement of the spleen or liver, or any tendency to derangement of the ali- mentary canal, and whilst the patient continues weak and retains the sallow aspect, and until he has recovered his appetite and strength, 494 AGUE. we cannot regard him as altogether secure from the dangerous sequels of the disease. In general there is no great difficuly in the diagnosis of ague; the only disease with which it is liable to be confounded being hysteria, hectic and febrile paroxysms arising from certain local irritations; hysterical females occasionally experience attacks of shivering, fol- lowed sometimes by a hot and even a sweating stage; but these paroxysms are so irregular as to their recurrence and their progress, that the knowledge of their liability to recur, is sufficient to prevent their being mistaken for ague. Hectic fever often simulates a quotidian, and sometimes, though rarely, a tertian; but there is this difference, that in hectic the cold stage is very slight, sometimes altogether wanting; there is a liability to transient feverishness at all times, with a pallor of the countenance, displaced occasionally by a circumscribed flush, very different from the sallowness produced by the ague miasm. In hectic, too, the shivering, when it occurs, generally comes on towards evening, and the sweating in the morning; in this respect also differing from what has been before stated to be generally though not uniformly the case with regard to the time of invasion of a quotidian paroxysm. The existence of suppuration in some part, and the rapid emaciation, are additional diagnostic circumstances in hectic. Severe rigors, followed by heat and sweating, are also induced by stricture of the urethra, diseased prostate, and the passage of calculi along the gall-ducts or ureters; and these paroxysms, though irre- gular in the periods of their return, so closely simulate those of ague, that the possibility of the existence of one of these causes ought always to be carefully inquired into. In the treatment of intermittent, as of all idiopathic fever, we must bear in mind the tendency to spontaneous recovery, when the imme- diate cause of the disease has been eliminated; and therefore one of the first things to be done, where it is possible, is to remove the patient beyond the sphere of the malarious poison. It is also found by experience that anything producing a considerable impression upon the system at large, or strongly affecting the mind of the patient, will have the effect of preventing a paroxysm or greatly lessening its severity; for this purpose emetics have often been beneficially employed; the ordinary emetic* (F. 91) may be admin- istered, or half a drachm of sulphate of zinc given in the same way, before the time of the expected paroxysm. The application of a tour- niquet, so as to arrest a considerable portion of the circulation, has also not uncommonly prevented or diminished the paroxysm. And the same result has even been produced by swallowing some cob- web or a live frog. The treatment of ague may be divided into that during the paroxysms, and that in the interval; and upon the principles already laid down, we must perceive that the former can be merely pallia- * (91) R. Pulv. Ipecac. 9 j. Antim. Pot. Tart , gr. i. M. TREATMENT. 495 tive, and'that the latter should be directed towards removing or counteracting the cause of the paroxysm. During the cold stage the patient should be placed in a warm bed, with warm pans or bottles of water; he may be allowed the free use of warm drinks, and if he be not of a plethoric habit, moderate sti- mulants, as negus or white-wine whey, may be used in order to pro- mote reaction, and shorten the cold stage. It has been recommended to bleed during the cold stage, a practice eminently dangerous, and based upon the mistaken idea that the congestion in the internal organs is the cause and not the effect of the diminished force of the heart's action. In the hot stage the coverings should be diminished, and cooling drinks, as lemonade or common effervescing saline draughts, admi- nistered, or compound infusion of roses with a little nitre. It is during the hot stage that opium has been found particularly service- able, unless contra-indicated by well-marked local inflammation or congestion, TAventy or thirty minims may be administered, and will generally have the effect of speedily inducing a profuse perspiration. Bleeding in this stage, though it may give some temporary relief, is not to be recommended, since by impairing the powers of the patient it counteracts the treatment Avhich is to be adopted in the interval. In the sweating stage there is no occasion for any treatment beyond care to avoid checking the perspiration by premature expo- sure. It is, however, during the intermission that remedies are to be employed to eliminate the poison or counteract its effects, and pre- vent the return of the paroxysm; and for this purpose, more especi- ally the latter, tonics have been found most efficacious. Of these, the most important and most generally employed is Peruvian bark, or its alkaloid, the quinia in the form of one of its salts. There are tAvo ways of administering these drugs—the one is by giving a full dose shortly before the expected paroxysm, Avhen it Avill often have the effect of preventing its occurrence altogether. This practice is often recommended in the ague districts as curing the disease with the least possible expenditure of quinia or bark; it has, however, the disadvantage of the cure often not being permanent, the paroxysms returning after the omissions of several periods. When, however, we are particularly desirous of preventing the occurrence of a parox- ysm which is near at hand, twelve grains of sulphate of quinia may be administered, or, as some recommend, half an ounce of powdered bark, though the latter is more offensive to the patient. The most efficient means of counteracting the effect of the poison, is to 'administer the bark or quinia in divided doses, throughout the intermissions. The most convenient form is to give the sulphate in doses of from two to four grains every three hours, the dose being greater for a quartan than a quotidian. Some Avriters rather fanci- fully recommend two grains for a quotidian, three for a tertian, and four for a quartan; the dose may be increased should there be no complication contra-indicating it, and should the paroxysm not be delayed or mitigated. 496 AGUE. Another most important remedy, which has been known to suc- ceed when bark and quinia have failed in removing an ague, is, arsenic; the form in which it is most conveniently administered being four or five minims of the liq. pot. arsenit. of the Pharmaco- poea, three or four times a-day, as many of tincture of opium or a drachm of syrup of poppy being added, in order to prevent griping or irritation of the bowels ; but should the bowels by this means be confined, the use of a gentle laxative, such as about tAvo drachms of castor-oil, will be preferable to AvithdraAving the opiate. The dose of the arsenic may be cautiously increased. Should redness of the con- junctivae or other signs of an over-dose be perceived, the remedy should be immediately withdrawn, or the quantity diminished. Most authors recommend that the arsenic should be administered during the intermission; but Dr. Pereira states that he has repeat- edly used it with good effect during the paroxysm, and that it is not, like quinia, contra-indicated by the presence of inflammatory complication. Arsenic is a tasteless remedy, which is not unimportant in the treatment of ague in children, and is, moreover, a cheap one, which is no inconsiderable advantage when Ave consider the great scarcity and almost necessarily limited supply of quinia, and its consequent liability to adulteration; and take into account the numbers of a poor population who are frequently affected in ague districts. On the other hand, it must not be forgotten that arsenic is a poison, which quinia is not, and that although it has been stated to be a tonic, there is little ground for supposing it to be so, beyond the simple fact of its stopping the paroxysms of ague and periodic neuralgia. Other tonics have been recommended for the cure of ague, though none can bear comparison with the above as to their power over the disease; from the vegetable kingdom there are the Avillow bark and salicine; the cusparia bark, which contains cinchonia; the acorus, or calamus aromaticus; the gentian, &c.: and from the mineral, zinc and copper, the former of which has perhaps hardly been tried as fully as it deserves. But whatever be the remedy employed, it is to be remembered that the paroxysms after they have apparently ceased for a consider- able time, will often return; generally upon a day on which one would have taken place had there been no interruption to their recurrence; and therefore it is necessary to continue the remedy for some days after the disease has apparently subsided. There is no doubt that a loaded state of the boAvels, or congested condition of the liver, interferes Avith the beneficial effects of quinia or arsenic; and therefore it is often expedient to administer a moderate mercurial purgative before commencing the remedy to be employed in the intermission, Avhenever there is the least suspicion upon this point. An ingenious suggestion has lately been made, that quinia and arsenic act mainly as antidotes, counteracting the agency of the poison, but not removing it; and, therefore, that it Avould be most desirable to find some means of eliminating the poison from the sys- COMPLICATIONS — PREVENTIVE TREATMENT. 497 tern; for this purpose saline diuretics have been recommended, and particularly the acetate of potass. It does not appear, hoAvever, that this remedy can be relied on for preventing the paroxysm, though it did so in tAvo of several cases thus treated at Guy's. Where, £oav- ev^er, the order of the paroxysms had been broken by quinia, it cer- tainly seemed to promote convalescence. The treatment of complicated ague must, of course, depend mainly upon the nature of the complication. We have already noticed the tendency to congestion in the liver and spleen, which is in some degree induced in all Avho continue long Avithin the influence of the malaria, even should they not become actually the subjects of ague, but which is aggravated tenfold by the occurrence of paroxysms: therefore the occasional use of a mercurial purgative—e. g. three grains of calomel Avith tAvelve of rhubarb—is not only an almost necessary preliminary to the treatment of ague, but ought to be re- peated every second or third morning, in those who have been long exposed to the poison. When diarrhoea is present it will in general be restrained, and the state of the alvine evacuations corrected by two grains of the hydr. cum cret., with four of the pulv. ipecac, co., or eight of the pulv. cret. co., night and morning; accumulation in the intestines being guarded against by occasional doses of two drachms of castor-oil, or the combination of rhubarb and chalk, the lower bowels being emptied when necessary by injections of gruel; and it is to be observed that in all cases we shall gain nothing by the use of bark, but rather produce head-ache, thirst, and loaded tongue, if it be administered before these abdominal derangements have been removed; where there is much tenesmus Avith diarrhoea, the cusparia will be found a very useful preliminary to the exhibition of the bark. It is to be remembered too, that it is in such cases that the arsenic is peculiarly serviceable, not being likely to produce the same local irritation or general excitement that Ave may apprehend from the cinchona. The enlarged spleen, which is so common a complication or rather consequence of ague, will best be treated by moderate laxatives and local depletion, either by leeches or cupping-glasses; poultices and occasional blisterings, iodide of potassium, and occasionally quinia or bark, and by mercurial plaster, or the combination of equal parts of mercurial ointment and the compound iodide ointment, and, above all, by a rigid avoidance of exposure to the malarious influence. This latter precaution is indeed essential in all cases of convalesc- ence from ague, as is also the avoidance of damp atmosphere, getting the feet Avet, and all those circumstances which induce a chill to the system. Besides this, gentle tonics, as the infusion of calumba or cascarilla, or even a grain of the disulphate of quinia in infusion of orange-peel, with tAvo minims of diluted sulphuric acid, may be administered tAvice in the day. There is no disease in Avhich prophylactic treatment is of more importance than in ague, and this remark applies more particularly to those who have been affected by it, since such persons, not merely during comralescence, but even through life, evince a tendency to 32 498 REMITTENT FEVER. the disease far beyond what is observed in others who have not been so affected; and therefore, not only should they be specially careful to avoid a malarious locality, but all who either have had the fever or have been exposed to the influence of its causes, or are liable to such exposure, should be careful not to place themselves in those circumstances which have been pointed out as rendering them liable to their action. And those whose duties compel them, as it were, to set such circumstances at defiance, must use every precaution to coun- teract or diminish their agency; such, for instance, as never going out at night, or very early in the morning, unless compelled; and in the latter case not going out fasting; sleeping as far removed from the soil as possible; choosing, when it can be done, a situation screened by trees from that in which the poison seems most rife; avoiding all excesses, but living moderately well, or rather more generously than is the ordinary habit. Moderate doses of quinia, with the occasional use of a warm aperient, such as the compound decoction of aloes, is a useful safeguard for those who are travelling through an ague district, or temporarily residing in one. Eemittent fever arises, like intermittent, from malaria; and as met with in this climate is generally a modification of the latter, produced either by exposure to malaria in a concentrated or very active form, or by certain circumstances affecting the individual, and rendering him peculiarly susceptible of its action ; as cold, heat, or vicissitudes of temperature, or some source of irritation, generally in the liver or intestinal canal, which by tending to keep up the febrile state, pre- vents the complete apyrexia of an intermission. In some cases the invasion of a remittent is preceded by the ordi- nary premonitory signs of fever. It more commonly, however, com- mences rather suddenly, with chills, especially a feeling of coldness along the spine, sometimes actual rigors, depression of spirits, and anorexia, pain in the back and limbs, headache, or confusion of intellect. Febrile reaction then folloAvs, marked by dry heat, flush- ing, thirst, increased headache, hurried respiration, a frequent, full, and sometimes hard pulse, dry, white, and furred tongue. There is also at the commencement of the reaction a sense of weight about the epigastrium, with a feeling of constriction, and even pain, in- creased most commonly by pressure, and often attended with nausea, and perhaps vomiting—symptoms indicative of congestion about the praecordial region; the urine being scanty and high-coloured; and the stools, for the most part, of a dark bilious character. This state of active fever may continue for a very variable period ; sometimes not so long as eight hours, at others fourteen or sixteen, when the symptoms gradually subside, and a greater or less amount of perspiration ensues, much as the sweating supervenes upon the hot stages of regular intermittent. After this the patient feels much relieved, but is never altogether free from febrile excitement, and after an uncertain interval experiences a recurrence of the febrile symptoms, sometimes preceded by a cold stage which is scarcely perceptible ; at others by distinct chills, or even well-marked rigors. This fever admits of many degrees of severity ; from a chilliness CAUSES — DIAGNOSIS. 499 felt once in the twenty-four hours, followed by slight febrile reac- tion, to a fever in which the remissions are so slight as to assimilate the disease to severe continued fever. The cause of remittent fever has been already pointed out to be nearly the same with that of intermittent, the result being modified, either by a variety in the character of the miasm or the state of the subject, and it is, when the causes of both continued and intermittent fevers are in most active operation, and also when there is the great- est tendency to abdominal derangement, that remittent fevers are most commonly met with; namely, in the autumn and in places Avhere, besides the ordinary malaria, there are the effluvia emanating from sewers, stagnant ditches, and receptacles of decomposing animal and vegetable matter. So closely, indeed, does the remittent fever so excited often approach to typhus, that it may really become true typhus, and is, perhaps, under such circumstances, capable of repro- ducing itself by contagion. It is not difficult, neither is it perhaps a matter of much practical importance, to form a diagnosis between intermittent and Remittent fever; the greater difficulty, in some forms of remittent, is that which is of much more consequence to the safety of the patient—to distin- guish this disease from continued fever, to which, as we have seen, it may approach so nearly. It is, then, chiefly by inquiring into the history of the disease, and watching its progress, that we can hope to discriminate between the . two. If, for instance, the patient has been in a malarious district, if there be no maculae to be discovered on any part of the body, and if the case occurs in the autumn, or at a time when intermittents are prevailing, we may generally find that the fever has a miasmatic origin, and will probably evince a remitting character, a suspicion which will be brought almost to certainty if upon careful watching we discover that at some time there occurs a chilliness, followed by increased pyrexia, relieved by SAveating. On the other hand, as we shall presently see in continued fever, complicated with much gastric irritation, we often have that disease assuming the character of irreg- ular hectic, somewhat resembling remittent; from which, however, it may be distinguished by the character of the evacuations, the cir- cumscribed flush on the cheek, and the previous history of the disease. In autumnal seasons following unusually hot summers, remittent fever, occurring in patients of debilitated constitutions, or already labouring under visceral disease, may sometimes prove fatal; but in general, as it occurs in temperate climates, it is attended with little or no danger, beyond the remote consequences which attach to it as a form of ague ; indeed the remittent fever of such climates may be said to be dangerous only in proportion as the season and circum- stances under which they occur approach to those of intertropical countries, where there is a rapid production and decay of vegetable matter, and the system is rendered peculiarly susceptible of malari- ous poison, owing to the depressing influence of an almost vertical sun • and where the remittent fever is at all times a severe and often * 500 REMITTENT FEVER. fatal disease, but peculiarly dangerous to Europeans lately arrived from temperate climates. We have already spoken of the importance of the distinction be- tween continued and remittent feA^er, and towards assisting in the diagnosis, the treatment may often be made subservient. The first object in the use of remedies should be, Avhere the remission is obscure, to render it more distinct; and where it is tolerably so already, to convert it into an intermission. This will generally be effected by removing the irritating cause which has converted the intermission into a remission; therefore, the first thing to be done is, to explore carefully the abdomen, and if there be pain and tender- ness in the region of the liver, tenderness or flatulence of the bowels, our remedies should at once be directed to those organs. AVhere the tenderness of the spleen or liver is great, and there is tolerable firmness of the pulse, a small quantity of blood may be taken by cupping, or by a few leeches, from the region of the affected organ: but, as a general rule, unless the inflammatory symptoms be decided and severe, it is better to aAvait the effect of a moderate laxative, such as may have at the same time the effect of correcting the secretions into the intestinal canal. For this purpose, the best will be about five grains of hydr. cum cret., followed, in four hours, by three or four drachms of castor-oil; or if the oil would be likely to offend the stomach, the combination of calomel and rhubarb may be employed. When the bowels are very irritable, about two grains of hydr. cum cret. with six of pulv. « cret. co., may be given two or three times daily ; and if it be thought necessary to remove offending matter from the lower bowels, a pint of gruel may be given in the way of glyster. It will ordinarily happen, after the use of these remedies, that the remissions will be- come more distinct, or be converted into w^ell-marked intermissions. Indeed, it is no Arery uncommon occurrence for cases brought into the wards of our hospitals, closely resembling continued fever, to put on a distinctly remittent or intermittent form after the action of a laxative, such as has been recommended above; and as a general rule it will be by far the safest course to defer even local depletion till such means have been tried ; and with regard to general bleeding, although recommended as a preliminary measure by some of the older authors, it is certain that, unless there be evidence of active inflammation, with a hard and moderately full pulse, it is not well borne by patients such as now ordinarily present themselves with remittent fever. So important, on the other hand, are means for removing local irritation, that they will roften have the effect not only of establishing an intermission, but even of removing the fever altogether. Cases have already been mentioned in which the intermission appears to have been prevented, and the febrile state kept up, by impure air, and effluvia from decomposing animal matter, and it may be by the contagion of continued fever ; in such cases we often find the removal to a purer air, as from a confined dwelling to the ward of a hospital, speedily has the effect of bringing back the intermitting CONTINUED FEVER. 501 character. After the more active fever has been subdued, and the causes of local irritation removed, mucilaginous drinks and salines, as the liquor ammon. acetat. or citrate of potass, may be employed, under Avhich treatment the remissions will gradually develope them- selves into intermissions, and the disease may be treated as an inter- mittent ; though even before this, AArhen the remissions are considera- ble, and particularly in debilitated subjects, Ave may venture upon the use of the quinia, even Avhen a somewhat loaded tongue, with increased frequency of pulse, Avould, under other circumstances, contra-indicate its employment. CONTINUED FEVER. There are several forms of fever which, according to strict nosolo- gical arrangement, ought to come between the intermittent, the remit- tent, and the continued fever, yet as these three constitute, in a mea- sure, the typical forms of fever, or at all events those which are generally regarded as standards of comparison by medical men in this country (owing, perhaps, to their greater familiarity Avith them), we proceed at once to the consideration of continued fever, more for the sake of practical convenience, than in accordance with any sys- tem. As regards continued fever itself, it has been the custom to speak of varieties of this disease; and the same is common both Avith the profession and the public: thus we hear of typhus, putrid, bilious, nervous, and brain fevers; and more technically, if not more scien- tifically, of adynamic, atonic, mucous, gastro-enteritic, &c. Yet, not- withstanding that continued fever does assume these different phases, and notwithstanding that an attempt has of late been made with much ability to prove that there are at least two forms of it, arising from distinct poisons, it will be found most convenient for practical purposes to follow the course indicated by Dr. Watson, of including different forms under the general term of continued fever, and treat- ing of them as varieties or complications of that disease. An attack of continued fever does not always commence in the same way: in a large number of cases there is a previous drooping, or sinking of health, going on for days, or even weeks; the patient feels languid, indisposed for his ordinary employments or amuse- ments ; his appetite fails, his tongue becomes white or creamy, his bowels irregular, and his senses are often less acute; he is anxious, or drowsy, it may be, in the daytime, and his sleep is disturbed, and he wakes unrefreshed in the morning. In a large number of cases, however, these premonitory signs are altogether Avanting; the patient is more suddenly attacked; often there is at first, shivering, sickness, severe headache, or pain in the back, and in some cases the disease has commenced with syncope; there is also a state of general oppression, with the appearance of which every one must be acquainted who has made several visits to the bedside of a patient in this early stage of the disease; the tongue 502 CONTINUED FEVER. is either covered with a white fur, or there is a brownish streak, cleft in the middle, running along the dorsum; the pulse is commonly frequent, but compressible. This stage of oppression passes more or less quickly into a state of fully-developed fever. The skin becomes hot, often for a day or two pungently so, particularly in children; the pulse more frequent, fuller, and sharper, ranging generally from 100 to 120; the tongue is commonly injected at the tip and edges, furred towards the centre. with a disposition to become dry, and there is increased thirst and clamminess of the mouth. There is also increased oppression, and pain in the head, back, and limbs; and we see more fully marked the depressed and desponding, yet at the same time almost apathetic countenance, characteristic of continued fever; the conjunctivae are injected; there is also commonly a weight and tenderness on pressure at the epigastrium; the boAvels are, at this period, generally torpid, though sometimes irritable, and the urine is scanty and high-col- oured; there is restlessness, and sometimes delirium at night. It is often at this period of the fever, or it may be later, that an eruption shows itself, either in the form of lenticular, slightly elevated, rose-coloured papulae, or less elevated, and more irregularly shaped maculae, generally showing themselves first over the breast and abdo- men, or commencing first about the insertion of the pectoral muscles; though in slighter cases the eruption is altogether absent. In the milder cases, and Under careful treatment, and sometimes without any treatment at all, these symptoms will gradually subside, leaving the patient feeble, and generally with more or less loss of flesh; the convalescence commencing sometimes as soon as the tenth day, and in children even earlier, but in adults it is not generally fairly established before the end of the second, and sometimes the third week. Sometimes, however, the disease assumes a severer form, either suddenly, when the progress had hitherto appeared favourable, often without any assignable cause, but at other times from injudicious management; or it may from the first evince an almost malignant character. In a large number of those cases in which the fever unexpectedly assumes the severer type, the unfavourable symptoms generally show themselves from the seventh to the tenth day, or even later, about the time at which, in the milder ones, we may expect to see some signs of amendment,—the countenance becoming more anxious and shrunken, the tongue dryer, the fur, which had before been drab-coloured, becoming brownish, and assuming more the character of a coating, the pulse quicker and sharper, but at the same time more compressible; and the patient, who before might have lain indifferently on either side, remains in a supine position. The delirium which, if it existed before, was confined to occasional wandering on waking from sleep, becomes almost constant through the night, and sometimes continues during the day; or there may be stupor, from which the patient is with difficulty roused, though, when thoroughly so, he gives a short but pertinent answer, but soon SYMPTOMS. 503 relapses into his former stupid state, or begins to talk incoherently, and continues muttering to himself. The senses, especially those of sight and hearing, become more or less disordered; often there is apparent dimness of vision, but not unfrequently an obvious intolerance of light; the same is true also of hearing; there is frequently deafness, but on the other hand, intolerance of sound is not uncommon; and even as regards feeling, there is often an exaggerated sensibility to touch, though this is more common, perhaps, in the commencement of the disease, and is not confined to the severer cases. The debility continues to increase, showing itself, as regards the nervous system, by tremors, and twitching of the limbs and of the tongue, which sometimes is pro- truded with difficulty, and sometimes is quickly thrust forward and drawn back again for many times in succession. The tongue itself is red, clean, and glazed, or otherAvise of a yellowish brown, or even almost black [colour; the cheeks also become occasionally flushed, the bowels are generally loose, though at times there may be a ten- dency to constipation. This state of things may continue for even some two or three weeks, the pulse becoming smaller and more frequent, the tongue darker and dryer, the alvine evacuations passed unconsciously, and though the urine is retained, there may be at the same time a dribbling from the distended bladder; the pulse becomes more fre- quent and feeble, though it may almost to the last retain a certain degree of sharpness, or, though small, it has a slight back-stroke; and ultimately the patient sinks from asthenia. Or on the other hand, it may happen that the fever subsides; or in other words, the morbific influence of the poison upon the system ceases to operate; or the poison itself being eliminated, sometimes with copious evacua- tions, the capillary circulation is relieved, the secretions are restored, the tongue becomes less dry and cleaner, and the pulse soft, often full, and rather slow, and the patient, though in a state of great exhaustion and emaciation, begins slowly to recover. "In other cases, the change from the milder to the severer form of fever takes place more suddenly, and with signs of great nervous ex- citement, but at the same time of great debility. The patient becoming furiously delirious, the eyes red and fiery, the skin hot, and the counte- nance flushed; or there will be incoherent talking or muttering, the patient remaining for a time quiet, and then speaking rapidly and in a rambling way about his business, or whatever may be supposed to have been uppermost in his mind at the time of the attack; at other times he will moan piteously, or utter plaintive cries, there will be picking of the bed-clothes, tremor, or subsultus of the muscles, and the tongue will be protruded tremulously and with difficulty; the tongue itself being coated with a thick, pitchy mucus, which dries and cracks, and often causes great pain to the patient; this mucus adheres also to the teeth and lips, and seems to glue them together, extending also to the fauces, and probably likewise to the glottis, often exciting a teasing cough. The urine is very high coloured, and sometimes tinged with grumous, dark blood; the bowels are some- 504 CONTINUED FEVER. times confined, though at others relaxed, the stools loose, dark, and offensive. This state of things may continue for several days, the patient appearing all the time upon the verge of dissolution, after which a sIoav amendment commences almost imperceptibly, though, in a feAV cases, a sudden change takes place for the better on the supervention of a copious discharge from the skin, the bowels, or kidneys."* In a considerable proportion of cases, hoAvever, the prostration increases, the patient remains supine, and sinking lower and lower in his bed, continually muttering, but apparently insensible: some- times a sudden haemorrhage takes place, either from the bowels or by the uline, or the disorganised state of the red corpuscles allows the solution of the colouring matter in the serum, and its consequent transudation through the cutaneous vessels, producing purple or livid patches, and the patient ultimately sinks exhausted. In the forms of severe continued fever Avhich have just been de- scribed, the more dangerous symptoms have been supposed to super- vene upon those of the milder, but many cases are essentially of a severe and malignant character from the first; or speedily become so, either from the previous constitution of the patient, as when it has been impaired by exhausting diseases, fatigue, intemperance, venereal excesses, or protracted anxiety or distress of mind. It may be well here to observe, that, amongst the mental causes affecting the character of fever, there is reason for believing that a certain state of excitement induces a condition of the nervous system in which delirium, attended with exhaustion, supervenes early in the course of the disease, Avhich is prone to run its course with unusual celerity and violence. Cases of this kind occur most frequently amongst the more highly-educated classes. In other cases, again, either the poison producing the disease, is concentrated, or the patient rendered peculiarly susceptible to its agency by external circumstances, or its effects are aggravated by mismanagement. These are the cases commonly known as malignant, or putrid fever, and are most frequently met with in the confined habitations of the poor, especially in crowded cities, where, besides the depressing effects of noxious effluvia, we have the concentration of the poison from the croAvding of several infected persons in the same apartment, often in the same bed; superadded to which there is sometimes the perverse precaution of carefully excluding the air, sometimes the premature administration of stimulants, and now and then the no less pernicious misuse of depletion. Under such circum- stances, we have the effects of change, almost of decomposition of the blood, combined with irritation and speedy exhaustion of the nervous system; the former are shown by the early appearance of livid pete- chiae or vibices, and the excretion of dark blood from the bowels or bladder; and the latter by early delirium, speedily followed by coma or stupor. Such is the course of continued fever, vieAved irrespec- tively of the complications or local hyperaemias to which it very * " Elements of Medicine." Bright and Addison. COMPLICATIONS OF FEVER. 505 frequently gives rise, and without Avhich it may prove fatal by sinking or asthenia, apparently from failure of the moving powers of the circulation, brought about conjointly by the depressing agency of the poison upon the nervous system, and the loss of the healthy affinity between the blood and the tissues. The complications just alluded to are, however, particularly worthy of notice, as when they occur, which they very frequently do, they greatly affect the course of the disease, and ought proportionately to modify our prognosis, and also our treatment; and a further reason why they deserve to be carefully looked for upon all occasions is, that in certain epidemics particular complications appear to prevail, so that having observed cerebral complication to occur in several cases at the breaking out of an epidemic, we may be prepared to expect its recurrence in others. Fever with predominant cerebral complication.—One of the most dan- gerous and not the least frequent of the complications of continued fever, is lesion of the brain and its membranes. That the brain and nervous system is always one of the parts principally affected, Ave have already seen; though of the precise nature of this affection we may be said to be nearly ignorant, and are therefore justified, in the present state of our knoAvledge, in regarding it as the direct effect of the poison upon the nervous system; and there can be no doubt that death may ensue from this cause without any evidence of inflammation after death; and though preceded by much excitement, the symptoms during life are widely different from those which characterise true inflammation Avithin the cranium. Still, it is no less true that inflammation of the brain or its mem- branes, or of both, does frequently occur, as shown alike by the symptoms during life, and the results of dissection after death. There is intense pain in the head, with a sIoav, or oppressed pulse, which is speedily followed by great restlessness, incessant talking, and, though rarely, furious delirium, the pulse rising, and becoming frequent, and rather sharp, but generally compressible, the tongue broAvn and dry, and the skin hot; the eyes become suffused, and there is increased susceptibility to light and sound. This state of things may come on at any period of the fever, but when it shows itself early, is always of fearful omen; indeed, as a general rule, early delirium is a most unfavourable symptom in fever, more particularly in adults, since children may have a certain amount of wandering at almost any period of any febrile disease. The delirium under such circumstances is less violent than in ordinary inflammation of the brain, and indeed here, as in all cases of inflammation occurring in fever, the symptoms of languor and prostration supervene rapidly upon those of excitement; the tongue becomes brown and dry, the pulse, though frequent and sharp, is compressible, there is a dull, staring eye, feeble voice, subsultus tendinum, and, unless these symptoms subside, we have moaning and muttering, with feeble cries, the head being rolled about in evident distress; afterwards cold clammy sweats break out upon the surface, the urine and stools are passed unconsciously, the pulse becomes more 506 CONTINUED FEVER. and more feeble, and the patient either passes into a state of hopeless stupor, or sinks exhausted. The appearances after death are such as indicate inflammatory action, though hardly fully-developed inflam- mation. There is increased vascularity, as shown by the appearance of bloody points from divided vessels in the substance of the brain; and sometimes, though rarely, there is softening. As regards the membranes, there is increased injection of the pia mater, with sub- arachnoid effusion, the latter membrane being often opaque, and there may be effusion into the ventricles. In other cases, again, the poison seems to act more particularly upon the respiratory organs, especially the lungs and bronchial mem- brane, causing Congestion of a more or less active character, and subsequently inflammation of those organs. Complications of this class are more frequent in the winter months, but they may occur in fevers at all periods of the year. When the bronchial membrane is the tissue principally affected, there is, early in the disease, weight and oppression of the chest, dyspnce*a, often an appearance of conges- tion about the countenance, and sometimes a tendency to lividity of the extremities'; the tongue is generally dark at the edges, the pulse, which is sometimes sharp, is almost always quick and feeble; and there will in the commencement be, the dry, sibilant, or wheezing sound of congestion or turgescence of the bronchial membrane; this, in most cases, is followed by the expectoration, and other signs, of bronchitis; though it sometimes happens that the inflammation, if such it be, stops short at the stage of congestion, and subsides with the subsidence of the general fever. The complication of pneumonia is by no means unfrequent, per- haps less so than is commonly supposed, from the circumstance that, unless attended by bronchitis, it is often latent. The fact of pneu- monia being often latent is one of great importance generally, but it is especially so in reference to the treatment of fever, and for the discovery, or at all events for the distinct announcement of this fact, we are indebted to Dr. Addison; there being neither cough nor expectoration, and sometimes but little excitement of the respiration, often not more than we ordinarily meet with in fevers. It is only by auscultation that it can be detected, though, when deeply seated and uncomplicated, it may escape even this means of diagnosis. The post-mortem appearances are the same as those observed in the ordi- nary forms of pneumonia already described, with the exception, perhaps, that there is a greater tendency to the effusion of serum in the substance of the lung. Care is to be taken after death to dis- tinguish the hypostatic congestion occurring towards the termination of fever, sometimes during the last agony, from that produced by true pneumonia, and the same should be observed during life; for it not uncommonly happens that when a patient has for a long time been prostrate on his back, in a low form of fever, if he be raised, and the stethoscope applied to the back of the chest, the first few inspirations will be attended by a sound closely resembling the dry crepitation of early pneumonia; though after the repetition of several respirations it will cease. AFFECTION OF INTESTINES. 507 Perhaps the most frequent complication of continued fever, and one, which on that as well as other accounts, deserves most careful attention, is irritation and inflammation of the mucous membrane of the alimentary canal. That there is derangement in the upper part of this membrane is apparent from the state of the mouth, but it is not uncommon, especially at an advanced period, to see the tongue very red and morbidly clean, or even glazed; and at the same time, there may be_ great tenderness at the epigastrium, with nausea and vomiting, which last is not unfrequently a very troublesome symp- tom, indicating irritation or even inflammation of the mucous mem- brane of the stomach, which is sometimes found on inspection after death. The part of the intestinal mucous membrane, however, which is most frequently and peculiarly affected, is that belonging to about the lower third of the ileum. The whole of the lining membrane of the small intestines may indeed participate in the inflammation, and here and there spots of lymph may be seen upon its surface, but it is in the portion above-mentioned that the principal lesion is found. In this part of the canal there is often an increased vascularity over the whole of the surface, and in almost all cases irritation seems to be most intense in spots which appear, upon closer examination, to have been occupied by the small mucous glands of Peyer and Brun- ner, so that they are sometimes solitary, and sometimes as it were set in clusters. The ulceration is generally preceded by some effusion of lymph on the surface of the mucous gland, and, according to Vogel, the gland itself becomes the nidus of an interstitial deposit resembling scrofulous matter, Avhich he terms typhous deposit (p. 107). This matter breaks down, and involving the gland in its disintegration, an ulcer is formed by ulcerative absorption, though sometimes there may be sloughing of the membrane; sometimes, too, the peritoneal coat becomes involved; the escape of the contents of the canal, and consequent peritonitis, are the results. Another consequence of this ulceration may be the opening of one or more vessels of some size, from which haemorrhage to a considerable extent may ensue. Those ulcers are generally accompanied by injection and enlargement of the corresponding glands of the mesentery. This ulceration does not necessarily continue its process of destruction,' since we often find the parts where it has been situated in the different stages of repair and cicatrisation. The symptoms which arise from the above affection of the ileum are, deep-seated tenderness about the right iliac fossa, and irritability of bowels, the stools being very loose and of a yellow-ochry colour; sometimes, however, this complication exists without diarrhoea. The pulse is frequent, rather small, and very compressible. The tongue is red at the edges with elongated papillae, the centre generally brown and apt to become dry; sometimes it is glazed. The countenance is either pallid or there is a distinct patch of redness on the cheeks, Avhich disappears and recurs frequently in the day. The pupils are commonly dilated and the eyes bright; besides these symptoms, 508 CONTINUED FEVER. there is, to use the words of Dr. Addison, " a something in the aspect of the patient, and the general character of his symptoms, sufficient to apprise the attentive observer with tolerable certainty of the exist- ing complication. HoAvever mild the case, there is usually a certain degree of nervousness, tremulousness, or agitation about the patient, sometimes almost amounting to subsultus, and especially manifest on attempting to make any exertion; he is dull and drowsy, with some tendency to stupor, but may, nevertheless, always be roused to under- stand and answer questions, even during the night, when the mental aberration is most considerable." The patient may remain in this condition for several days, some- times for Aveeks, and the diarrhcea subsiding, the evacuations become more consistent, and he recovers; the convalescence being generally slow, and the patient very liable to relapse upon any error in diet, exposure, or undue exertion. In other cases, again, the diarrhoea continues, the stools are passed involuntarily, the prostration .and emaciation increase; there are frequent but irregular exacerbations, marked by the presence of the red patch aboAre noticed; there is excessive restlessness, with picking of the nose, lips, or bed-clothes, and the patient dies of asthenia; or it may be that before the exhaustion proceeds to this extent, perforation of the intestine takes place, and he is carried off by peritonitis. It is the above form of fever that is peculiarly exposed to the additional complications, if so they may be called, of bed-sores, pro- duced by continual pressure on one part, from inability of the patient to alter his position; the effects of this pressure in arresting the nutrition of the part being increased by the generally defective nutrition, dependent partly upon the febrile state, and in the present case particularly upon the diminished or arrested supply of chyle, owing to the obstruction of the lacteals; the sores sometimes com- mence in superficial ulcerations, produced by irritation of the fasces and urine where the evacuations are passed unconsciously. These bed-sores are in themselves a serious evil, being productive of all the exhaustion known to be attendant upon the well-known "cellular membranous inflammations," and which must tend greatly to aggra- vate the exhaustion produced by the fever; besides which they pro- long the febrile state, and deprive the patent of sleep by the pain and irritation which they occasion. Maculce in Fever.—Allusion has already been made to the erup- tions in continued fever, and they are deserving of closer observa- tion, since, if they do not in their different forms indicate essentially different species of fever, they certainly indicate a difference in the state of the circulation and of the system generally, which we ought never to overlook. There are two forms of maculae upon the dis- tinctive characters of which great stress has lately been laid as mark- ing different kinds of disease. The former, which we have spoken of as the rose-coloured rash, consisting of rose-coloured papillae, dis- appearing under pressure of the finger; irregularly scattered over the surface of the trunk, generally but few in number, though some- times, but very rarely, almost confluent. Each spot continues for MACULE IN FEVER. 509 about four days, but fresh spots are said to be continually appearing to the tAventy-first or twenty-second day of the fever; these have been described by Dr. Jenner as characterising a specific form of fever—the typhoid. The other form of rash, which has been supposed to indicate the true typhus, consists of mulberry-coloured spots, at first slightly elevated, and rendered much fainter, though not entirely disappear- ing when moderately pressed upon; but afterAvards they assume a more livid colour, and are not so much altered by pressure. These spots either fade into brownish stains and then vanish, or pass into decided petechias or small ecchemoses; each spot continuing from its first appearance to the termination of the disease. The general hue of the skin is, during the presence of this rash, rather dusky and mottled, constituting what has been termed the sub-cuticular rash* The question of the distinction of typhus and typhoid fever, as arising from distinct poisons, and distinguishable by eruption, is one that has been some years under discussion; thus Dr. Alison, writing at least as early as 1814, states that "An opinion has lately become rather prevalent that there are two kinds of fever, to which the names of typhus and typhoid fever have been given; of which the first, usually unconnected Avith any affection of the mucous mem- brane, is attended Avith the eruption, and is more contagious; the latter is necessarily connected with inflammation, going on to ulcera- tion, of the mucous membrane, is unattended Avith eruption, is more protracted and has little contagious property. This term typhoid fever is to be regarded as synonymous Avith gastro-enterite and dothen entente. If it be understood that the intestinal inflammation in this last case is of specific character, this doctrine can have no injurious results; but it is certain that some cases resulting from the contagion of the usual spotted typhus, sIioav all the symptoms and post-mortem appearances attributed to typhoid fever; and therefore it seems probable that the differences observed are only varieties depending upon constitution, and on the agency of other causes affecting the constitution, besides the existing cause of the disease."f The observations of Dr. Jenner are not indeed open to the practical objection of regarding any form of fever as synonymous with gastro- enteritis; yet it has not been disproved, or rather there is abundant evidence to prove, that there is truth in the remark of Dr. Alison, respecting the occurrence of theg astro-enteritic symptoms and post- mortem appearances, in cases which have undoubtedly been the true spotted typhus, both in their origin and in the character of the rash. The conclusions which it appears Ave may most legitimately draw from our present information upon this subject is, that in the fevers in Avhich the mulberry-coloured and livid spots are present, there is a greater tendency than in others to assume the low, sinking form, * For a very careful description of these rashes, see Dr. Jenner's paper in the thirty-thirl volume of the Medico-Chirurgical Transactions; Dr. Jenner, however, differs from most observers in stating that the mulberry rash totally disappears under pressure. f Alison's "Pathology and Practice," pp. 446-7. 510 CONTINUED FEVER. and perhaps a greater liability to head affections, but that never- theless there may and frequently does occur severe bowel irritation, with inflammation and ulceration of the lower portion of the ileum. Where there is the rose coloured rash, on the other hand, there is almost ahvays great bowel irritation, and not such early depression from the effects of the poison; but the frequency with which one form of the disease has been found to occur side by side with the other in many epidemics, though it may not have done so in all, and the almost imperceptible differences by which they appear to be distin- guished in some instances, seems at present to preclude the belief that they are specifically different. The Pulse in Fever.—Few of the phenomena of fever are more interesting or instructive than the state of the pulse; and it is by the indications which it affords, that we are enabled, more than by any other class of symptoms, to regulate our prognosis and our treat- ment. One of the effects of the poison being upon the blood, the mutual affinity betAveen that fluid and the tissues is weakened, and one of the moving powers of the circulation annulled or diminished, and consequently we find the heart labouring to overcome the ob- structed circulation; but in this instance we have not, in the ordi- nary fevers of this climate, the increased tonicity of the arteries which exist in inflammation (p. 71), and consequently the pulse is sharp and full, but never, except in inflammatory fever, hard. As the fever continues, the powers of the system, and consequently the contractility of the heart, failing, we have the pulse weaker and weaker, and at the same time as soft as at first, or even more so, from the diminishing tonicity of the arterial coats. Owing to the continued efforts of the heart and the persistent obstruction in the capillary circulation, there is not uncommonly a recoil to be felt, giving the sensation to the finger of a back stroke (p. 71). Another effect of the continuation of the obstruction to the extreme circula- tion, conjoined with the continually diminishing power of the heart, is, that the latter being unable to empty itself, and therefore con- tinually exposed to the presence of its natural stimulus, is inces- santly excited to contraction, the effect of which is great frequency of the pulse, which is often commensurate with its debility. With this stroke of the heart there may also be a tendency to the back stroke, and the result will be a kind of struggling or throbbing pulse, which is always a sign of imminent danger. When there is a subsidence of the fever, whether brought about or followed by anything like a critical discharge, or otherwise,— though it is to be observed that there is always a return of the secre- tions on its subsidence,—the healthy relations between the blood and the tissues gradually returning, the obstruction to the current is in some measure diminished; and therefore the pulse loses its sharp- ness, and the ventricles of the heart being better able to expel their blood, it becomes also slower: but the diminished contractility of the arteries continuing, with the generally exhausted state of the system, the pulse is soft and moderately full: and as the convalescence be- comes established, and the secretions abundant, the quantity of the DIAGNOSIS AND PROGNOSIS OF FEVER. 511 blood in the system being probably diminished, the left ventricle empties itself fully, but is slowly refilled. The force of its contrac- tion no doubt remains somewhat weakened, but the same is the case with the contractility of the arteries, so that they are equally balanced, and the result is a slow, very distinct, and moderately soft and full pulse. It may be well here to remark that the conditions of pulse which have been here somewhat theoretically referred to the different periods of fever, are fully borne out by experience; a quick and feeble pulse being that always met with in the advanced stages of continued fever, the pulse of convalescence being distinct and slow (sometimes below the healthy standard) and moderately soft and full. Upon these grounds, but still more upon almost universal experi- ence, the frequency of the pulse is of the greatest importance in fever; its not exceeding one hundred is in general a favourable sign, when it exceeds one hundred and twenty in adults the danger is great. The diagnosis of continued fever is not always so much a matter of course as is often supposed, as there are several diseases with which it may be confounded, though in the generality of cases it is un- doubtedly easy. The mode of the attack, the general oppression, with depression rather than excitement of the countenance, the fre- quent and compressible pulse, the vividly injected tongue, and in many cases the appearance of the eruptions, are sufficient to charac- terise the disease at once, not to mention the circumstance of a pre- vailing epidemic, or our knowledge of the sources of infection to which the patient may have been exposed. Cases of difficulty do, hoAve\rer, not very rarely arise, and this dif- ficulty results in the majority of instances from some local inflamma- tion, generally of a chronic character; such are deep-seated suppura- tion, or chronic or subacute disease of the large intestines, mesenteric glands, or peritoneum, Avhich will frequently give rise to symptoms nearly resembling those of mild continued fever, though upon closer observation the fever presents a more remitting character: whilst in the aged and persons of feeble constitutions acute inflammations will often assume the character of a more severe form of fever. Pneumonia, and in its most simple form, may in persons of all ages assume the character of severe continued fever, so much so that it is only by a careful exploration of the lungs, and not always even by this means, that its presence can be detected. And the same thing occurs in some cases also of acute diffused tuberculisation of the lungs. Puriform infection and poisoned wounds will also induce • fever of typhoid character. Prognosis of Continued Fever. The prognosis of continued fever in this country, in persons young and of sound constitution, is in general favourable; in very young persons the fever often subsides at the end of the eighth day; in those more advanced in life it is more doubtful, and even unfavourable. Persons above sixty are not often the subjects of continued fever, but of those Avhich are so the greater number do not recover. Dr. Alison states that the mortality in per- sons above forty is as high as one in two. It is to be remembered also that although fever is most common in the dwellings of the 512 CONTINUED FEVER. lower orders, and that in such abodes the mortality is the greatest, owing to want of ventilation, and often also of proper care and nour- ishment ; yet that when such persons are removed to more favoura- ble circumstances, as to the well-ventilated wards of our hospitals, they more frequently recover than do those Avho become the subjects of fever among the higher and more educated classes of society: the reason of this being probably that there is in the latter case a greater excitability of brain, and therefore a greater tendency to subsequent exhaustion of the nervous poAver, or what may be still worse, a greater liability' to inflammation of the brain or its membranes. Another circumstance to be taken into account is the general mor- tality in the prevailing epidemic, and more especially as it has occurred in the immediate locality. The previous impressions on the mind of the patient, again, are not to be overlooked, as it is always an unfavourable sign when he has at the commencement of the disease expressed a conviction that he shall not recover. For the same reason previous mental anxiety, or the having recently under- gone losses of friends or fortune, or other severe disappointment, have an unfavourable influence. As regards the general prognosis, we may also add that it should at all times be very guarded, for although mild continued fever Arery rarely proves fatal, still circumstances may arise in its progress which no human foresight can foretell or prevent, and therefore though it is very "true in fever, even of the severest form, thafr "Avhilst there is life there is hope," it is no less true, as is happily expressed by Dr. Addison, that "whilst there is fever there is danger." In young persons the milder form of this disease will often termi- nate favourably in eight or ten days, and in such subjects we may look for signs of its subsidence about that time:—namely, a dimin- ished frequency of the pulse, a softer and cooler skin with perhaps a little moisture upon it, the disappearance of the expression of languor and anxiety, a cleaner tongue, and an increased flow of urine, the return of sleep, and subsidence of all signs of irritation or disturb- ance about the brain. In the severe cases, which may be expected to run on for about three weeks, a rational prognosis is to be founded upon the considera- tion of the sources of danger, and the modes of fatal termination of fever; and the first symptoms of any of the conditions upon which they depend are to be regarded as dangerous. Iloiles of fatal termination of Fever.—A most important step to a correct prognosis, and sound practice, in fever is, the right apprecia- tion of its different modes of fatal termination. The earliest period at which fever may prove fatal, is in the stage of oppression from the first effects of the poison or morbific agent, upon the system, either by its depressing the action of the heart and arteries so as to cause death from syncope, or so greatly reducing the powers of the nervous matter as to produce fatal coma at the first invasion of the disease; though the cause of this coma may not be made apparent after death by the presence of any effusion or perceptible lesion in the brain. To the above may perhaps be added early death from the general FATAL TERMINATION OF FEVER. 513 arrest of the extreme circulation, or what Ave have before spoken of as capillary or peripheral syncope. These early terminations of fever are however not frequent, in this country especially, and consequently the real danger occurs at a more advanced period, and arises from more complicated causes. " It ap- pears manifestly owing," says Dr. Alison, " to a combination of the enfeebled state of the circulation, Avith peculiar derangement of the functions of individual organs, consequent on the attendant inflam- mations there. In consequence of this combination, Ave have three distinct fatal terminations of fever which are often blended together, but in some cases are quite separate and easily distinguished." (1.) The death by coma referable partly to the peculiar action of the cause of fever upon the brain, but partly also to increased determina- tion of blood thither, or inflammatory action there. (2.) The death by asphtjxia (apnoea), referable partly to the enfeebled state of the circulation, and partly to the Avant of poAver in the heart to propel the blood through the lungs, (and partly also to obstructed capillary circulation in these organs as a direct effect of the morbific agent,) but partly also to bronchitis and pneumonia. (3.) The death by mere asthenia—referable partly to the deleterious effects of the mor- bific cause upon the circulation, but frequently also in part to various local inflammations prolonging the febrile state, and especially to the inflammations and ulcerations of the mucous membranes of the intestines, which appear to have in this, as in other cases, a peculiar sedative, and what was formerly designated as a sympathetic effect, on the heart's action."* (1.) As regards death from coma or death from the brain, it is not at all common in the commencement of fever, though it may occur from the first affect of the poison upon the nervous system. It is more common, however, at a more advanced period; and generally, in the way of exhaustion coming on as a consequence of nervous excitement; and for this reason all symptoms which indicate early excitement are far more to be dreaded than those which show a sluggishness of the brain. Thus, early delirium, especially if it be of an active character, is amongst the worst signs in fever. Intole- rance of light is, for the same reason, unfavourable, and therefore a contracted pupil, which indicates a highly sensitive condition of the retina, is always Avorse than a moderately full or even dilated one. Deafness is not unfavourable, but intolerance of sound decidedly so. A persistent delirium is always more likely to be folloAved by coma than Avhere there are intervals of reason, and the delirium is a still worse sign Avhen the patient is continually talking upon the same subject, especially if that be one in connection Avith which there is reason to belieA^e that his mind may have been poAverfully affected. Continued sleeplessness is, in the same way, a far Avorse symptom than drowsiness, unless there be reason to apprehend that the latter be the result of effusion; in Avhich case, hoAvever, it Avill have been generally preceded by active excitement. Indeed, many of the more * Alison's " Outlines of Pathology Practice," p. 444. 33 511: FATAL TERMINATION OF FEVER. uneducated of the fever patients in our hospitals seem, as it were, almost to sleep through their fevers. Greatly increased heat of the scalp, and throbbing of the carotid arteries, are also unfavourable, as indeed are also signs of inflammation of the brain or its membranes. It is perhaps on this account that there is much truth in the observa- tion of Hippocrates, that convulsion occurring in the course of a fever is worse than fever supervening upon convulsions. Tremor of the limbs and tongue, inability to retain the faeces or urine, picking of the bed-clothes, and subsultus tendinum are among the symptoms of threatened death from coma. As regards the urine, hoAvever, the inability to empty the bladder is as likely to be the cause as the effect of the cerebral affection. (2.) Death from the lungs or death from apncea may ensue at any period of fever, and may take place almost at its onset from the effects of the morbific agent in obstructing the circulation of the blood through the capillaries of the lungs. This is not a very com- mon occurrence, and belongs to the congestive form of fever Avhen very severe. It is threatened Avhen there is early lividity, with a very small pulse, and shrunken, livid, cold extremities, with duski- ness of the lips and countenance, hurried and oppressed breathing, but without pain; with a skin generally cold, often moist, and scanty urine. Such cases, when they do occur, are always very dangerous. Death may also ensue in this manner when there is at the same time (as in the more advanced stages of the disease) a tendency to fatal termination by asthenia, owing to failure in the action of the right side of the heart. And on this account the symptoms of pulmonic congestion occurring in connection Avith those of sinking are most unfavourable. Death from apnoea may also take place from bron- chitis or pneumonia occurring as a complication of the fever; and the existence of either of these to any extent increases the clanger of the latter. Bronchitis often exists in the congestive form, accom- panied by sibilant respiration, and with no increase but even a dimi- nution in the secretion of the membrane, and therefore unattended by any mucous rattles, the pulse becoming feeble, the countenance, lips, and extremities congested, and sometimes livid. When the latter is the case there is great danger. The same condition may also arise from excessive secretion blocking up the tubes and pre- venting the aeration of the blood in the lungs, as in the case of asthenic bronchitis; and this is perhaps a fatal termination more common than that by congestion of the bronchial membrane; and for this reason very extensive mucous rattles, especially if pervading the small tubes, are unfavourable. This result may arise from pneu- monia, the presence of which, therefore, greatly adds to the danger , of fever. It must also be remembered that fever has a tendency to produce inflammation where it has formerly existed, and therefore that a previous attack of pneumonia, especially if it have left any consolidation or induration of the lung, greatly adds to the danger of fever. (3.) As regards the death by syncope or asthenia, it is by no means a common occurrence in the early stages of fever; still cases are to TREATMENT OF CONTINUED FEVER. 515 ■ be met with in which there appears to be considerable danger from the early failure of the moving powers of the circulation; the signs of Avhich are a very feeble and generally very quick pulse, with cold- ness and a tendency to lividity in the extremities; and it is also to be borne in mind that, in all periods of fever, death from syncope may occur from the neglect of proper precaution against such a possibility. It is, hoAveA^er, in the more advanced stages of the disease, gene- rally after the completion of the second Aveek, that death from the more protracted form of syncope, i. e., from asthenia, arising out of the combined effect of diminished, or rather arrested nutrition, and failing of the heart's action, is to be apprehended. The pulse becomes small, Aveak, and frequent, and very compressible; though in some cases, especially in persons advanced in life, it may appear mode- rately full, eA'en Avhen there is imminent sinking, owing to the obstruction in the extreme circulation and diminished contractility of the artery, by which the full impression of the systole, feeble though it may be, is conveyed to the finger. There may be failure of the extreme circulation, the temperature of the surface failing, the skin becoming covered Avith a clammy SAveat, and the extremities becoming cold and shrunken. It has also been stated that feebleness in the ventricular systole, by Avhich the first sound of the heart becomes less distinct than the second, is another sign of threat- ened death from asthenia. With the above symptoms there is also a dry, black, and chapped tongue, coated with black sordes, and similar incrustations upon the gums and teeth. The delirium char- acteristic of this condition is of the Ioav muttering character, arising, as it Avere, from failure in the cerebral circulation, and consequently indicating a state of things different from that which gives rise to the active delirium of inflammation or excitement of the brain, and from the coma which belongs to nervous exhaustion. The eruption, when there is any, will often shoAV signs of tendency to asthenia by assuming a livid colour; and another unfavourable symptom is the appearance of livid petechiae or vibices, to Avhich too there will often be added another unfavourable sign, namely, the passage of a large quantity of black blood by stool or urine. The patient at the same time sinks gradually to the bottom of the bed, and the stools and urine pass involuntarily. The pulse is no longer perceptible at the Avrist, and the heart's action becomes more and more feeble till it ceases altogether. The treatment of Continued Fever.—We believe that it Avill be found that the treatment of all forms of continued fever must be based upon the same principles, and therefore that there is more danger than advantage in dividing this disease into endless varieties, and appor- tioning to each its peculiar mode of treatment; since it will generally be found that the treatment most applicable to each will be best arrived at by the application of those general principles which have been established by an induction including all. Absolutely ignorant as we are of the proximate cause of continued fever Ave may nevertheless venture to affirm that there is no class of 516 TREATMENT OF FIRST STAGE. diseases in Avhich science has done more towards their successful management; for by a systematised knoAvledge avc become acquainted with the provisions of nature, by which the action of the morbific agent is rendered transient; and thence we are taught to look for its subsidence after a definite time; and consequently, to expect the recovery of the patient, provided that the functions necessary for the continuance of life can be maintained until that time, and also that no serious lesion is inflicted upon any vital organ. In the same manner, too, Ave become acquainted with the different modes in Avhich fever may be fatal, and thus we are enabled in some degree to anticipate and guard against such terminations; or, in the words of Cullen, to "obviate the tendency to death," and also to subdue, Avhere Ave cannot prevent, those local complications which may either be fatal by interfering Avith the functions of a vital organ, or, by pro- longing the febrile state, interfere Avith and obstruct the natural ten- dency to recoArery. It may here be asked—Is it possible to cut short the fever in its onset? We know that various remedies have been recommended, and are still frequently employed for this purpose, and that not Avithout apparent success; but Ave know also that such measures are often applied, and that very early, Avithout such a result; and further, that ephemeral fever is apt to occur under circumstances in which the continued feA'er might be apprehended, so that we see that the evidence in favour of the frequent success of remedies applied Avith this intention, rests upon rather slender grounds. At the same time, avc ought to state that the means generally employed are a moderate bleeding, followed by a combination of a purgative with an emetic; as a dose of tartar emetic followed by rhubarb and calomel, or a cathar- tic draught; and sometimes the tartar emetic, by first exciting per- spiration, and afterAvards acting upon the bowels, will be of itself sufficient for the purpose. It should be remembered, however, that bleeding is rarely a safe proceeding at the commencement or at any other period of fever, and that the same remark may apply in some cases to the tartarised antimony, as well as to active purgatiA^cs. As a general rule, howeArer, Avhen there is no great tendency to diar- rhoea, and the patient is seen early in the disease, the latter remedies may be used Avith a chantage, in a moderate degree; since, although they Avill not often cut short the disease, yet such evacuations tend rather to improve its subsequent progress, provided ahvays that there be not already any signs of exhaustion—for instance, by administering an emetic of ipecacuanha Avith a small quantity of the tartarised antimony; and AA'hen the bowels are not freely acted upon, four grains of hydr. cum cret., and four hours afterAvards two or three drachms of castor oil. Another means by which the fever may sometimes be arrested at its commencement is cold effusion; that is, pouring cold water over the Avhole surface, and then speedily drying the patient. After this has been done, it will not rarely happen that the surface becomes bedeAved with a moderate perspiration, the patient falls into a sleep, aud awakes with the skin cooler, and the fever much abated. This FEVER — BLEEDING. 517 is a practice, however, Avhich can only be pursued soon after the febrile reaction has set in, Avhen the surface, including the extremi- ties, is rather above than below the natural temperature, and the pulse moderately firm: for if it be applied after the fever has con- tinued for some days, or when there is any tendency to coldness of the extremities, or the pulse is compressible (conditions Avhich apply to the greater number of cases Avhen 'first seen by the medical prac- titioner) Ave might incur the risk of dangerous or even fatal syncope, or at all events, aggravate the tendency to internal congestions leading to some of those inflammatory complications which are amongst the chief dangers in fever. Among the means of subduing febrile action Avhich most readily suggest themselves is the abstraction of blood: but of this it cannot be said that it renders the subsequent progress of the fever more favourable; on the contrary, in the great majority of fevers in this country, it enhances the risk of subsequent death from asthenia, which is, perhaps, the greatest to be apprehended from uncom- plicated fever; and therefore, although it may be saying too much v to affirm that in no case ought blood to be taken from the arm in a case of fever, simply as such, yet it is far more safe to regard such a practice as an exception from the general rule. When indeed the pulse is full and frequent, and not compressible, provided also this fulness is real; with a hot skin, a ferrety eye, or other signs of cere- bral excitement, Wood may be drawn, the patient being placed in an erect or sitting posture, and the vein closed upon the first signs of syncope. The quantity of blood Avhich floAVS will be the sign of the propriety of the operation having been performed, and also of the tendency to any inflammatory complication. It is not here meant to deny that cases such as have just been described do not occur ever in this climate, but that cases are not to be assumed as such simply because they are fever, and because the febrile excitement is considerable. Blood-letting, too, Avhen applicable in fever (simply as such), is so only at the commencement of the febrile reaction, and in the greater number of cases the practitioner is not called in till this has existed some days; and then, unless there be some very urgent symptoms indicating its performance, the question of general bleeding is not to be entertained: nor indeed is the abstraction of blood in any way, simply with a vieAV to moderating the course of the fever: though local depletion, either by leeches or cupping, may be adopted with advantage, Avith a vieAV either to obviate the tendency to one of the modes of fatal termination which there may be reason to apprehend, or to relieve any particular organ which may appear to be specially affected. In the mean time those measures only must be adopted which Avill safely diminish the febrile action. Of these the first is Avhat has been termed the antiphlogistic regimen, or placing the patient upon such a plan as regards both diet and external circumstances as shall the most effectually preclude all excitement of the nervous and vas- cular systems; though even at this period of the disease Ave must 518 ANTIPHLOGISTIC REGIMEN. not lose sight of the principle, that we are endeavouring to avoid such excitement as much on account of the exhaustion by which it is generally followed, as from the immediate ill effects to be appre- hended from the excitement itself. The first thing then to be done is to prohibit all muscular exer- tion, and with this view the patient must be strictly confined to bed; all stimuli to the senses and to the feelings and intellect must be withdrawn. The room should therefore be darkened, or a A'ery moderate degree of light admitted. Sound should be excluded wrhere it can be done; all conversation and reading, and the access of more persons than absolutely necessary, forbidden. It is especi- ally desirable that all persons about the patient, whether medical attendant, friends, or nurses, should maintain a cheerful though quiet deportment. The diet at this time should be of the most unstimulating kind; milk and Avater, or thin barley Avater, with an occasional cup of tea, Avill generally be sufficient, as long as the febrile excitement is great. The temperature of the room should be moderate—about sixty in summer, and from fifty to fifty-five in Avinter, and there should be as free a circulation of air as is consistent Avith the comfort of the patient. The advantage arising from this is, that the accumulation about the patient of noxious effluvia from his own person may be thus obviated, and the poison in the system more quickly eliminated. There is, however, some difference of opinion upon this point. Dr. Alison observes, that the "disease frequently runs its course quite favourably in very foul and close air," and it certainly often appears when a patient has lain in a warm and close room during a considerable part of the disease that the change to cool and fresh air (particularly if accompanied with some muscular exertion) has an injurious effect, chiefly in bringing on a complication of inflammation. Now that many patients do well under the unfavourable circumstances of foul air and close apartments cannot be denied, but it will be found equally true that the rate of mortality is increased; and as regards the advantages of pure air, it has certainly appeared in many cases brought to Guy's hospital from some of the worst houses in London, that the change to a purer air has of itself a beneficial effect upon the progress of the disease; and even in certain beds, Avhich are the best placed for ventilation, the cases of fever are generally found to run their course most favourably. And certainly the cases do better when removed to one of the large general hospitals than Avhen taken to the fever hospital; where, notAvithstanding the most scientific ap- plication of every means of obviating it, there is a greater accumula- tion or concentration of the poison than in the general hospitals Avhere the patients are mixed almost indiscriminately, care only being taken not to allow a larger proportion than about ten per cent, of fevers in large and airy Avards. All this, hoAvever, does not impugn the cor- rectness of the remark of Dr. Alison just quoted, which shows the necessity for caution in effecting a removal. Another important precaution, for such it is to be regarded, rather than a direct curative measure, is the regulation of the bowels. We TREATMENT OF FEVER. 519 know that in many cases the greatest danger to be apprehended arises from irritability of bowels, and therefore all stimulating and drastic purgatives must be avoided; but the accumulation of morbid and decomposing faecal matter in the intestines being likely in itself to prove a source of irritation, it is necessary when there is not a mode- rate evacuation at least once in twenty-four hours, to relieve them by the hydr. cum cret. folloAved by castor-oil, as before recommended. When the above precautions are observed, the greater number of cases, in persons of sound constitution, will generally recover spon- taneously; the fever often beginning to subside in young subjects as soon as the eighth or tenth day; though in adults it will generally run on to the fourteenth or twenty-first. In these favourable cases active treatment cannot be too strongly deprecated, but there is one class of remedies Avhich have long been in use in the treatment of fevers, though it is perhaps only of late years that their virtue has been fully appreciated; and these are, what have been termed salines; that is to say solutions of the neutral salts or alkaline carbonates. They have generally been regarded as simple diapho- retics and diuretics, but they also tend to obviate that liability to capillary obstruction which is among the earliest effects of the morbific agent. It is possibly to their action upon the extreme cir- culation, that their effect upon the secretions is mainly to be at- tributed. The liq. ammon. acet., or the citrate of potass, which may be given either in the state of effervescence, or after that has sub- sided, are very useful and convenient salines; but they must be avoided when there is reason to apprehend bowel irritation; in such cases the bicarbonate of soda is to be preferred. When then Ave are called to a case of fever, some days, as most commonly happens, after the reaction has been fully established; after having satisfied ourselves that the disease is fever, and not one Avhich may by possibility be mistaken for it; our first duty is to inquire into its probable origin, and having done this to examine carefully as to the presence of maculae, and all other symptoms which might give a distinctive character to the disease (particularly in reference to any prevailing epidemic). Our next object must be to ascertain, as nearly as possible, the age of the fever. We should then proceed to search, as far as the condition of the patient allows, for any of the lesions liable to complicate the fever, and if none of these be found, we should direct our attention particularly to the bowels, and to the brain. If there have been no evacuation within the last tAventy-four hours, Ave should direct the hydr. cum cret. to be administered, followed by the castor-oil; if, however, there have been no alvine evacuation for a longer period, or if the medi- cine above recommended should fail in producing one, we should have recourse either to an enema, consisting of an ounce of castor- oil in a pint, of gruel, or to a common soap injection. These means Avill rarely fail, though in some forms of fever, where there is con- siderable head affection, the bowels will be very obstinate, in which case a full dose of calomel may be given, folloAved by more castor- oil and if necessary, a cathartic enema may be afterwards adminis- 520 TREATMENT OF FEVER. tered. This practice, hoAvever, belongs more to fever complicated Avith inflammation Avithin the cranium ; and as a general rule drastic purgatives should be carefully avoided. It may happen, on the oilier hand, that the bowels very early become irritable. AVhen this is the case, and it appears that the quantity passed has been small, and if there are pieces of solid matter in the evacuations, Ave may at first give tAvo grains (not more) of hydr. cum cret. and one or two drachms of castor-oil tAvo or three hours afterAvards, though it is not desirable that these medicines should produce more than two or three pretty free motions. After this, as also when Ave have good reason for believing that the boAvels have been sufficiently emptied at the commencement, Ave must at once have recourse to means for checking the diarrhcea; the pulv. cretae co. of the Pharmacopoeia, in doses of about ten grains, Avill often answer this purpose; or it may be given Avith about a drachm of tincture of catechu in cinnamon Avater : or the mist, cretae in doses of about half an ounce may be employed, Avith or Avithout about fifteen grains of the aromatic confection; though Avhen there is much tenderness of the epigastrium, or the tongue is red. it is better to omit the latter. A very useful means of checking diarrhcea is an enema consisting of about three ounces of starch (decoct, amyli of the Pharmacopoeia), and one ounce of syrup of poppies, or Avhat ansAvers nearly as well, about half a drachm of tincture of opium. The head also demands careful attention, and, even although there may be no particular cerebral complication, we often have delirium about the middle period of the fever, or even earlier. Where this delirium is active, and the pulse at all sharp, and the pupils con- tracted, and if there be also considerable heat of the scalp, and throb- bing of the carotids, a feAV leeches (i. e. from four to eight) may be applied to the temples; but we must be careful that the above con- ditions exist, as if this step be taken Avhen the pulse is compressible, or the pupils rather dilated, as is the case in the delirium which attends the gastric irritation, we shall increase rather than diminish the danger of our patient. The shaving of the scalp will ahvays be attended Avith relief, A\diere there is any tendency to delirium Avith increased heat about the head. When the excitement or delirium continues, we should apply a cold embrocation to the shaven scalp, provided the heat be consider- able. A convenient application is one part of rectified spirit Avith five of Avater; or a better may be prepared by mixing one part of spirit Avith tAvo of Avater, and two of vinegar; or two parts of liq. ammon. acetat. Avith one of dilute spirit. There is often much harm done from the slovenly Avay in Avhich cold is applied to the head; if it be done by means of a piece of linen soaked in the lotion, this should be frequently repeated so long as the head remains hot, for if this be neglected there is a reaction as soon as the linen becomes dry, or nearly so, and thus the determination to the head is increased. On the other hand, it should be remembered that cold applied in this Avay is a sedative of considerable efficacy, and that if it be persisted in after the head and face have got at ail below the natural tempera- TREATMENT OF FEVER. 521 ture, there may be a risk incurred of injuriously depressing the moving powers of the circulation. The state of the respiratory organs must at the same time be care- fully watched ; but here, except in cases of complication with actual inflammation of some of the thoracic viscera, there Avill rarely be occasion for active interference. In all cases of fever which are severe, there is more or less dyspnoea; and it will often be found, upon examination of the chest, that there are pretty extensive sibilus and ronchus, shoAAing congestion and turgescence of the mucous membrane both of the small and large tubes ; this, however, is not to be mistaken for active bronchitis, or to be treated as if it were such; the congestion being but the result of that general tendency to obstruction in the extreme circulation, Avhich is one of the effects of the morbific agent. A small quantity of ipecacuanha in one of the saline mixtures already mentioned, may be given with advantage in such cases ; provided the boAvels are not very irritable ; if they are so, the ipecac, may be added to the soda draught, or given with a little cretaceous mixture. A small quantity, as one grain, of hydr. cum cret., may also be given, AAith about three grains of ext, hyoscy- amus night and morning. If the irritation of the bronchial mem- branes continues after the skin becomes soft or moist, a blister applied over the sternum will often afford much relief. If none of the complications incident to fever make their appear- ance, Ave must carefully Avatch for symptoms indicating the approach of any of the fatal terminations. Noav, the death by coma as Avell as the death by apncea belong more to those cases in Avhich there is inflammatory complication of the brain or lungs, and the appropriate treatment will be further considered in speaking of that belonging to such complications ; it should, hoAvever, be borne in mind, that either of these modes of dying may occur as a direct effect of the morbific agent. In the former case this may be by its effect upon the brain ; under such circumstances, our remedies must be much less active than Avhen the same termination is threatened from active inflamma- tion of that organ; and it should be remembered also, that mere stupor from which the patient can be roused, requires but little treatment; and the same thing is applicable to an obtuseness of the senses of hearing and sight, such torpidity of the brain being in general a favourable symptom. Whereas, increased mental excita- bility or increased susceptibility of the above senses indicate an excitement Avhich is liable to be followed by a corresponding exhaus- tion of the nervous poAver, ending in death by coma. In the case of mere stupor but little treatment is required: the head should be kept cool, and Avhen necessary the cold lotion applied; and if the boAvels are sluggish, they should be stimulated by mode- rate purgatives, as the combination of rhubarb and calomel, or where they appear obstinate, five grains of the latter may be administered, and followed, in three or four hours, by half an ounce of castor-oil. AVhen, as is sometimes the case, the inaction of the boAvels is chiefly owinu- to the indolence or droAvsiness of the patient, a common enema of t>Tuel and salt, to Avhich may be added an ounce of castor-oil, 522 USE OF OPIUM IN FEVER. should be administered; or Avhere the bowel requires more active stimulation, it may be composed of about twelve ounces of compound infusion of senna with a drachm of powdered jalap. In some cases of cerebral oppression with torpid boAvels, a full dose of calomel, to the extent even of fifteen or tAventy grains, affords great relief; but it must only be employed Avhen there is no tenderness of the abdo- men or redness of the tongue, and where the motions which have been passed have been entirely solid and without mucus. In these, as in almost all cases of cerebral oppression, diuretics will be found useful, especially in the form of salines; indeed, the remedies just recommended need not interfere Avith the continuance of the saline treatment. Thus, the spirit of nitric aether may be added to either of the saline draughts; or it may be given with from five to ten grains of nitrate of potass. In other cases, again, we have to dread death by coma, from exhaustion of the nervous power consequent upon continued excite- ment. In such cases it is that the mode of death is not altogether unlike simple asthenia or gradual syncope, taking place simultane- ously Avith cerebral oppression; though the symptoms referable to the brain are the most conspicuous and embarrassing, as well as those to Avhich our treatment should be mainly directed. Here it is most important to allay the excitement, which may often depend upon the direct effect of the poison upon the brain, and appears to be the immediate effect of a state of that organ widely different from inflammation, but Avhich may sometimes be associated with a ten- dency to that condition. When the head is hot and the pulse sharp, a few leeches may be applied to the temples; but it will rarely be expedient to go further in the Avay of depletion. The head, too, should be shaved, and the cold lotion applied according to the cautions already given. The boAvels must also be attended to, and sufficient evacuations procured, if necessary, by moderate purgatives; though sometimes the chalk- mixture, or the starch and poppy clyster, may be required. Here, also, as in all cases of fever, the bladder must be carefully attended to. The best remedy, perhaps, for this condition of the nervous system (as long as the febrile excitement is considerable), is the henbane, which may be given where there is no tendency to diarrhoea, in com- bination with hydr. cum. cret., or a little camphor may be added (F. 92).* When there is much tremor, and the excitement increases at night, we may withhold the henbane during the day, but continu- ing the saline, try the effect of a full dose of the former at night. If, as commonly happens, the restlessness continues, the question arises / as to the procuring rest by means of a full dose of opium. This is one of the nicest points in the practice of physic, as the misapplica- tion of this drug under such circumstances is an error almost fatal, frequently altogether so. Opium must not be given when the heat * (92) R. Hydr. cum. Cret. gr. iss. Camphorte rasse, gr. ij. Ext. Hyoscy. gr. iij. Misce. Ft. Pil. i. TREATMENT OF FEVER — APNffiA. 523 of the scalp is considerable or the skin dry, or the urine scanty and loaded, or the pulse sharp, or the delirium violent; and above ail, when the pupil is contracted. When, hoAvever, the heat of the surface has been subdued, and the skin softened or rendered moist by the saline and other treatment just recommended—when the secretion of urine has been increased, the pulse softened, the tongue moistened, and the delirium has become more of a talkative, incoherent character, but Avithout violence, and, Avhich is indispensable in the administration of opium, if the pupils have become dilated, or even moderately full, we may, after several nights of restlessness, hope for refreshing sleep from a full dose of this drug or some one of its preparations. A con- venient form Avill be from half a grain to a grain of hydrochlorate or acetate of morphia (perhaps the former is to be preferred); of this half a grain may be given at night, and should the restlessness con- tinue Avithout contraction of the pupil, it may be repeated after two or three hours. When the first dose does not produce the desired effect, or Avhere the skin and tongue are moist, the urine abundant, and there are other reasons, either from the appearance and condi- tion of the patient, or from previous history, to believe that he has considerable tolerance of opiates, we may increase the dose, giving as much as one grain of the hydrochlorate, or its equivalent, one drachm of the liquor. Blistering the nape of the neck may also be of service in such cases; but it must not be done till the febrile heat has subsided, and the activity of the symptoms been in some measure subdued; nor in cases where there are livid maculae, with much depression and venous congestion, as there might be danger of sloughing. Upon the whole, it is a remedy more applicable to the case of stupor than of excitement. The use of Avine is an important consideration in this condition of fever; the mere presence of deli- rium is not to be regarded as in any way contra-indicating it, if the pulse is compressed and feeble, and the pupils not contracted; where, in fact, we have the symptoms of nervous excitement, with little poAver and no symptom of inflammation of the brain or its mem- branes, it may be as useful in preventing death by coma as that by asthenia. It may, perhaps, be thought that the doctrine to which we have throughout given a somewhat prominent position, namely—that the morbific agent in fever acts mainly upon the blood, and destroys its natural affinity for the tissues Avith AA'hich it is brought in contact in the course of the extreme circulation—is an opinion rather than an established law; but whether this be so or not, Ave believe that it is a fact, that in fever there is this loss, on the part of the blood, of its natural affinities, Avhich causes delay in the capillary circulation; and that this fact is independent of any opinions we may hold as to the blood being so affected; or as to its being secondarily influenced through the action of the poison upon the nervous system. This effect of the disease upon the extreme circulation often shows itself very formidably in the pulmonic circulation, threatening death from apncea; the lividity and venous congestion, Avith diminution of the arterial pulse, in some cases of this kind are very remarkable, 521 APNCEA — ASTHENIA. though death from this cause, independently of actual lesion of the lungs themselves, is not common, and in their treatment it will be important not to mistake the sibilant respiration intermixed Avith ronchus, Avhich may generally be heard (as the effect of the engorge- ment of the bronchial membrane) for acute bronchitis. In general, cases of this kind require little active treatment: a saline draught, consisting either of the citrate of potass draught, or that with liquor ammon. acet., with the the addition of about ten minims of ipecacu- anha wine, or from fifteen to tAventy of wine of potasso-tartrate of antimony, Avill generally have considerable effect upon this state of the circulation; Avhich Avill be aided by a moderate use of mercury, where it is not contra-indicated by irritability of boAvels; for this pur- pose from one to two grains of hydr. cum cret. may be given, Avith three of conium or hyoscyamus: when the skin has become some- Avhat moistened, a blister applied to the chest will promote the restoration of the pulmonic circulation. Death from asthenia or from gradual syncope is perhaps the most frequent of the fatal terminations of fever, and in some epidemics it is one against Avhich Ave must be prepared from the very commence- ment. On this account the pulse must be carefully watched, and as long as it remains sharp, and the skin hot and dry, and the urine scanty, the use of tonics and stimulants must be abstained from. But eAren in this condition of the patient beef-tea may be alloAved if it do not, as is sometimes the case, irritate the boAvels. The best form Avhere the stomach and bowels are irritable is Liebig's creatine soup. AVhen the pulse becomes more compressible, especially if the tongue begins to soften at the edges, we may, if there be increasing signs of prostration, administer a little diffusible stimulant; of this, that which may generally be employed Avith the greatest safety is the sesquicarbonate of ammonia, which will at first be best combined Avith the solution of acetate of ammonia, as we thus gain the aid of a saline in promoting the passage of the blood through the capillaries: indeed it is often syncope or asthenia commencing in the extreme vessels (ayhat we have ventured to term peripheral syncope) that we have to con- tend with; and consequently, although Ave may by stimulants main- tain for a time the action of the heart, Ave can do but little towards overcoming the obstruction that embarrassed it, so long as the cause of that obstruction continues. On this account Ave must persevere Avith the salines whilst the pulse retains any sharpness, or the back stroke already noticed. A convenient form for the combination of these remedies is the folioAving (F. 98).* The next point to determine, and it is one of no small difficulty and of extreme practical importance, is the administration of Avine. Noav as Avine is a direct stimulant to the heart and large vessels, and has but little influence over the extreme circulation except through * (93) R. Amnion. Sesquicarb. gr. iv. Liq. Ammon. Acet. 3 ii. Tinct. Serpentarise, %]. Infus. Serpentnr. - j. Misce. Ft. Haust. ; to be taken three times, or oftener, during the day. CHEST AFFECTION. 525 the heart, it is certainly highly desirable to delay its use until the ten- dency to capillary obstruction has passed away; or, in other Avords, un- til the fever itself has subsided, Avhich will generally be shoAvn by the pulse becoming sloAver and fuller, but at the same time soft and very compressible. When this is the case, although the tongue may be brown, the patient almost unconscious, andin the most abject state of prostration, Ave may confidently expect the greatest benefit from wine freely administered. It is not ahvays that the indications for its use are so clear, as in the Avorst cases Ave often find the central moving poAvers of the circulation to be sinking, Avhilst the febrile state and the consequent difficulty of the extreme circulation continue: under these perplexing circumstances, Ave must be guided by other con- ditions as well as by the pulse. Thus, in cases where Avine is most required, the patient generally lies prostrate upon his back and sink- ing loAver and lower in his bed, the countenance is sunken, the eyes holloAv, and the surface is inclined to cold at the extremities, though it may be hot about the trunk. If, however, this heat is attended with dampness, Ave may Avith more confidence administer AAune. The state of the pupils will often aid us, for in general, stimulants are better borne with a full than a contracted pupil. The tongue in such cases A\ill generally be broAvn from a crust of sordes, AA'hich also covers the teeth and gums. The state of pulse AA'hich affords the most certain indication for the use of wine has just been described, but as in the worst forms of fever Ave must not Avait for that Which may never show itself, Ave must consider feebleness and compressi- bility as themselves indications for the use of Avine, pro\rided the other signs of prostration are likeAvise present. A rule has been proposed by Dr. Stokes Avhich is certainly worth attending to, though it may not be at all times applicable; namely, that when the first sound of the heart is nearly lost and becomes much more feeble than the second, Avine is indicated. It Avill not be safe in all cases to wait for this symptom, but certainly AA'here it does occur, it is in general a sign that stimulants are required. As regards the quantity of wine to be given, it is impossible to lay down definite rules, as it must be giA^en according to its effects rather than by mea- sure. Where the signs of sinking are not very urgent Ave may begin with an ounce of sound port or sherry, Avliich may be diluted Avith an equal quantity of water, and given about four times in the tAventy- four hours, or even a less quantity may be ghren at shorter inteiwals. It will always be necessary to Avatch most carefully the effect of the wine, and if it cause increased heat of the head or actiATe delirium, or if the tongue become drier under its use, or the pulse more frequent and sharper, Avithout any increase of volume, it must be Avithdrawn: but, if the tongue become moister or the pulse less frequent or fuller, and especially if the patient should get some sleep or appear more tranquil, even though the depression become more alarming, its use must be continued and the quantity increased, and this must be done Avithout limit as long as the prostration continues, or the pulse appears to become more feeble. Sometimes ten, tAvelve, or more ounces must be given in the day, and in cases of extreme prostration, brandy and 526 COMPLICATED FEVER — HEAD AFFECTION. also ether must be given in addition; but such are almost despe- rate cases, though certainly where there has been a sIoav and com- pressible pulse, patients have sometimes been saved by the timely administration of the strongest stimulants. Complicated Fever. — The treatment of fever complicated with inflammation of the brain or its membranes is a matter of great nicety, owing to the difficulty of ascertaining with certainty how much of the cerebral disturbance is OAA'ing to inflammation, and hoAV much to the direct action of the morbific agent upon the brain. Where the symptoms plainly indicate that the former is the case, we must employ measures adapted to subdue that inflammation; though even here Ave must remember that depletion is not borne aa in simple inflammation of these organs. In doubtful cases the head should be shaved and cold applied to the scalp, according to the directions already given. The next question Avill be the use of depletion; and here we must be guided by the sharpness and hard- ness of the pulse, by the state of the secretions (the bowels being almost ahvays very difficult to act upon in cerebral inflammation, though rarely so in fever; urine also being scanty in the former case), by the tongue, which is more inclined to be Avhite the more the disease (in the early stages) assumes the character of inflamma- tion. We may also remark that when inflammation of the encephalon occurs in the course of mild continued fever, it has more of the char- acter of common inflammation, and therefore is more amenable to antiphlogistic measures, and more tolerant of them, than when it occurs almost at the first commencement of scarlet fever. In the former case blood may be drawn from the arm if the pulse will warrant it, and the patient may be cupped behind the ears or at the back of the neck, after an interval of twelve or twenty-four hours, and if there be no great heat of skin a blister may be applied. In the latter case it is rare that bleeding in any shape is admissible, especially if there be any eruption. The boAvels must be freely opened by moderate doses of calomel, the action of Avhich may be aided, if necessary, by a senna draught, and the calomel may be afterwards continued in doses of about tAvo grains every four hours until some of its specific effects are produced; or if the boAvels should be irritable mercurial inunction may be employed, or the blister may be dressed with mer- curial ointment. In whatever form, and at whatever period of the fever, the signs of inflammation of the encephalon, provided they really are such, show themselves, opium is inadmissible; useful though it is in cases of nervous excitability without inflammation; the great guide, in this matter is the pupil. A most important part of the treatment here, as in all cases, is obviating all excitement, and as much as possible all use of the organs suffering from inflammation, or threatened with it; and therefore light must be excluded, and the room kept as quiet as possible, and every cause of mental excitement guarded against; and forcible constraint must only be resorted to when necessary to prevent the patient inflicting an injury upon him- self or others. In fever complicated with chest affection the same principles of USE OF WINE IN FEVER. 527 treatment must be pursued. When Ave have evidence that the dis- ease really is fever, and where there is no reason for supposing the inflammation in the thorax to be a mere coincidence—as, for instance, the effect of exposure to any exciting cause of such inflammation after or shortly before the invasion of the fever—we are justified in believing that the local disease is the effect of the morbific agent upon that particular organ, and may consider it, much in the light of a specific inflammation, amenable to kws someAvhat different from those by Avhich common inflammation is regulated, and less tolerant of the antiphlogistic treatment applicable to the latter. In this case, too, we may reasonably expect that, if the local disease do not entirely subside, it will be very much mitigated when the general fever comes to an end. If, on the other hand, we have reason for believing that the local disease is the effect of some cause inde- pendent of the fever, we cannot entertain the same expectation of its spontaneous subsidence, and are therefore called upon to use more active measures for its suppression, and calculate upon a greater amount of tolerance of them. But it may be urged that the physical signs in both cases are the same, and in both Ave have the general symptoms of fever. The Avay to escape from this difficulty is to remember that it is the Avhole condition of the patient that we have to deal with, and not only the bronchitis, or pneumonia, or other local inflammation; and therefore Ave must be guided as to the use of depletory, and other antiphlogistic measures by the probability of their tolerance, as evinced by the greater or less degree of prostration, by the tongue, and, above all, by the pulse; and Avhere these, espe- cially the latter, do not indicate a toleration of depletion, we are not justified in having recourse to it on account of the inflammation, whatever reason we may have for supposing that it arises from ordi- nary rather than specific causes. Of the broncial congestion, threatening death by apnoea, and of the inexpediency of treating it as acute bronchitis, we have already spoken. Where, indeed, there are rattles as Aveli as the wheezing, and the skin is hot and the pulse sharp, if the tongue be furred as well as red at the edges, the saline, Avith the addition of antimonial or ipecacuanha wine may be administered (the latter is to be pre- ferred if the bowels are irritable), and the mercurial with henbane may be given as before recommended. When the dyspnoea is urgent, with pain referred to the sternum, and the pulse is such as to justify it, blood may be taken by the application of a few leeches over the sternum, or, Avhat is better, by cupping. Cases may indeed arise that require general bleeding, but they are exceedingly uncommon. When, as it is apt to do (more especially if depletion have been unadvisedly used), the bronchitis assumes the asthenic and suffoca- tive form already described (p. 98), it must be treated accordingly, and with even a greater amount of stimulants and support, than simple bronchitis. In many cases of fever we have pneumonia occurring as a compli- cation; and often in a form likely to escape detection, unless the chest be carefully examined. Xow the importance of the discovery 528 COMPLICATED FEVER. consists more in its foreAvarning us of the mode of death (that by apnoea which is most to be apprehended, than in suggesting any active measures for the subduing of the inflammation.—We are not, of course, here speaking of the diagnosis between primary pneu- monia and typhus fever, Avhich has been already explained.—When the primary disease is fever, and the'pnetimonia occurs in its pro- gress, it is probably OAving to the effect of the morbific agent upon the lung itself; and Avhen consolidation is the result, the deposit pro- ducing it may be of a nature analogous to that spoken of as the typhous deposit, occurring in the intestinal glands, and therefore not of a character to be improved by depletion: but, whether this be so or not, we must be guided in the use of remedies by the condition of the patient, and not be led to employ venesection because there is pneu- monia, unless there is evidence, from the pulse and other symptoms, of its probable tolerance. If the pulse be such as to justify the depletion, which it rarely is, we may hope, by the use of bleeding or cupping, either to put an end to the inflammation, or so far to arrest its progress as to allow time for the employment of the means already recommended for the treatment of that disease; but whilst this is admitted, the caution is again repeated, that the great danger lies in being hurried to the use of venesection through anxiety to save the patient from so formidable a complication of the fever: and a belief is expressed, Avhich increased experience tends to confirm—that the inflammatory complications of specific diseases will, more often than is commonly supposed, subside with the primary disease, and-—that local disorganisations have been in some cases caused by the lower- ing means employed. When bleeding from the arm is inadmissible, local depletion by cupping or leeches may sometimes be required; but even of these we would say that they are not to be used merely because there is local evidence of the pneumonia; we must also have some increase in the hardness as well as sharpness of the pulse. As regards the other means to be employed, amongst Avhich mer- cury is the chief, the same caution must be observed; that is, we must bear in mind that the inflammation is essentially liable to become disorganising, and, therefore, if the engorgement have led to consolidation, Ave must, when the patient is in a condition to allow of auscultation, examine from day to day; and if we find in the situ- ation Avhere the signs of the consolidation were observed, crepitation, whether moist or dry, the mercury should be withdrawn, or the quantity greatly reduced. The mercury may be combined with opium when the latter is not contra-indicated by any tendency to head affection, and, where there is not great debility, the tartarised antimony may be exhibited at the same time; though Avhen there is bowel irritation, the compound ipecacuanha should be preferred. The existence of pneumonia as a complication in fever, ought never to deter us from the use of support and stimulants Avhen Ave have evidence of failure of the powers of life, as evinced by the same symptoms as in simple fever—accompanied often by the plum- juice expectoration—and then the same means already recommended must be employed, with the addition sometimes of about fifteen TREATMENT OF FEVER. 529 minims_ of tincture of squills to the mixture of serpentaria and ammonia. The treatment of fever with bowel irritation is often most embar- rassing ; though the difficulty may perhaps be often avoided, where the case comes sufficiently early under our notice, by the rigorous exclusion of all the influences, whether in the form of medicine, or diet, or external circumstances, which tend to favour this complica- tion. On this account, all irritating purgatives should be avoided; amongst which must, as regards this disease, be included the saline ones, from their effect upon the secretion from the small intestines ; and, at the commencement of every fever, where a laxative is indi- cated, and there is reason to apprehend a possibility even of this complication, the safest that can be used is the hydr. cum cret., fol- lowed by the castor-oil, or where we are afraid of the latter offending the stomach, the hydr. cum cret. with rhubarb. The same precau- tion is necessary in regard to diet—it should from the first be of the most unirritating character; barley-water, milk and water, or even milk with bread, should constitute the whole, excepting perhaps a little tea. Milk,_wken not disagreeable to the patient, is perhaps the best article of diet in fever, until stimulants become necessary, and is to be preferred to the beef tea so much used in our hospitals, as being less likely to cause or increase diarrhoea. There can be little doubt that the tendency to diarrhcea is much increased by impure air, especially that loaded with effluvia from organic matter, and therefore ventilation and cleanliness are here of special importance. In cases of fever with bowel 'complication, we may allow of a lower temperature than in some other forms; as, for instance, chest-affec- tions. One great rule is to avoid officious practice": the best medicine will generally be found to be the bicarbonate of soda in peppermint water, with a little mucilage; when the bowels are much relaxed, a clyster should be administered of about two ounces of starch, Avith from half §, drachm to forty minims of laudanum, or an oiince of syrup of poppies. When the diarrhoea is excessive, chalk-mixture with some additional astringent, as a little tincture of catechu or about fifteen grains of extract of log-wood; though it is better, if possible, to prevent the diarrhoea by careful diet than to restrain it with astringents. When the powers of life appear to be failing, the serpentaria should be used with about fifteen grains of aromatic con- fection, and, if necessary, from three to five of sesqui-carbonate of ammonia; wine and brandy are not so early admissible in this as in the other complications ; but the former may be administered in arrow-root when the pulse becomes feeble and the tongue brown. When there is much irritability of stomach, which is not an uncom- mon occurrence, besides the application of sinapisms, the occasional use of a tea-spoonful of brandy in a wine-glass of soda-water will often give great relief. 34 530 ERUPTIVE FEVERS. XXVIII. ERUPTIVE FEVERS. The general laws of idiopathic fever are those of the exanthems. Of these, indeed, typhus "might be reckoned as one, excepting that the exanthems are generally more definite in their symptoms, course, and character, under every variety of climate, season, age, and habit of body: they are, in fact, the results of specific agents upon the system, producing respectively their specific effects, in every instance, similar in kind though varying in intensity. They are characterised each by its peculiar rash, efflorescence, or eruption, whence the terms exanthem (from t£av9so, effloresce-), and eruptive fevers. They have also each its period of incubation or interA'al betAveen exposure to the poison and invasion of the febrile symptoms; the period of erup- tive fever ; the period of maturation of the eruption; and in most, the secondary fever. The fevers to which this description applies are, small-pox, measles, scarlatina, the slight disease varicella or cow- pox ; probably also, the plague, and in most respects erysipelas. They have also the peculiarity that one attack protects the indi- vidual from a second of the same form of epidemic; this law does not, hoAvever, apply to plague, and is reversed in the case of erysipe- las. Individual exceptions also occur in all. In the cases of small-pox, measles, scarlatina, and plague, we have pretty certain evidence not only that the poison of these diseases is communicated by intercourse Avith those labouring under them; or in other Avords that they are contagious, but that they never arise from any other cause than this specific contagion, exhaled probably by the breath of persons affected by them, and also existing in the emanations from the surface of the bodies, as is shown by their com- municability by inoculation, and by their conveyance in clothes from affected persons; but also that as we now witness them they are never produced in any other way. This is not true in the case of erysipelas—though it is undoubtedly contagious — and has been questioned in regard to scarlatina ; though the occurrence of what are termed sporadic cases of the latter, or single cases, in which no such communication can be traced, may possibly be accounted for by the extreme subtlety of the poison. Notwithstanding that the cause of the majority of these diseases is contagion, this contagion is controlled by a variety of circumstances, affecting not only individuals but the whole population of any town or district, as is shoAvn by their spreading at times with great rapid- ity, and at times assuming a peculiar virulence. These epidemic influences are, no doubt, dependent in a great measure upon ob- scure atmosphere or telluric conditions; but they are also greatly aggravated by circumstances arising out of the habits and conditions of various populations: such are—the deficiency of ozone or alio- SMALL-POX. 531 tropic oxygen, existing in very densely populated districts,—the effluvia arising from defective drainage, and the filth in the dwellings of the masses,—the allowing noxious particles to accumulate, from the Avant of personal cleanliness, and the like. The pathology of these eruptive fevers may be summed up as the combination of an inflammation of the surface of a specific character, with a constitutional fever, of a typhoid type; but this local inflam- mation is not the cause of the fever, since in all cases it follows instead of preceding it. The internal inflammations also which occur are of a specific character in each respectively, and, therefore, to be regarded as the effects of the poison. The danger in these fevers depends not so much upon the extent of the external inflam- mation,—since it is so important a part of the pathology of some of them, that there is danger in arresting the course of it—as upon the internal inflammation, and also upon the affection of the general system, especially the depressing influence of the morbific agent upon the circulation. Small-pox is characterised by a tolerably uniform period of incu- bation, varying from seven to twelve days, and an eruptive fever of about forty-seven hours, a period of from seven to eight days from the appearance of the eruption to its completion, and, in severe cases, secondary fever of three or four days more. The fever of small-pox commences, like most others, with chilli- ness and languor, quickly folloAved by heat, with a dry skin, severe headache, and, in the majority of cases, an intense dull aching pain in the loins; sometimes nausea and vomiting, a hard frequent pulse, a Avhitish, furred, and rather dry tongue. These symptoms are not all present in every case at the commencement even of a severe attack. Much stress is laid by some authors upon the pains in the loins, and it is, perhaps, one of the most frequent concomitants of the eruptive fever; and its occurrence, when small-pox is at all pre- valent, should, to say the least, excite our suspicions. Sickness is another frequent symptom at this period, but not so common as the last-mentioned, and to say the least, it is not so constant in this as in the inflammatory fever of scarlatina. Some seArere cases commence Avith convulsions, and others, Avhich are still worse, with violent delirium or coma. After the fever has lasted, as before stated, about forty-eight hours, though the period admits of A'ariation of from thirty-six to sixty, the eruption begins to make its appearance. To this it is most important to pay close attention, as up to this period, our diagnosis betAveen small-pox and some other exanthems, can be only conjec- tural. It first appears at least thirty-six hours from the commence- ment of the fever (which is later than in scarlatina, but earlier than in measles), first of all in the face, in which respect also it differs from scarlatina, and consists, in the first instance, of minute elevated papulae, which feel to the finger, like small beads, or millet-seeds. These are often surrounded by an erythematous efflorescence, which, however, generally disappears after tAvo or three days. After the face the eruption generally appears in the wrists, the trunk, and last 532 VARIOLA DISCRETA. of all, in the lower extremities; and, in general, the last papulae do not show themselves till tAvo dajTs after the first; that is to say, that the eruption begins upon the third day of the fever, but fresh papula} do not cease to come out till the fifth. The papulae or pimples gra- dually enlarge, and ripen into pustules, shoAving a depression on their tops, on the second day. This appearance is important, as affording a distinction from the vesicles of varicella, in which the depression is not observed till later; the suppuration is complete on the eighth day of their appearance, when the pustules breaking, scabs or crusts begin to form, which fall off in four or five days more, the suppuration and incrustation observing the same order as to time in different parts of the body, as did the eruption of the pimples. This description of the progress of the pustules applies pretty exactly to all varieties of the disease. There is, however, a great difference in their number, and, in the same proportion, in the severity of the disease, the number of the pustules being, as a general rule, an exact measure of the extent to which the morbific poison has taken effect; and to which that highly sensitive and important structure, the skin, has been involved in the inflammation. In some cases there are but a few scattered over the body; in others, they are croAvded together in great numbers ; and that may be the case to such a degree, that there is not, as it were, room for them to remain separate, but they coalesce and run into one-another. This circumstance affords a means of distinction into tAvo important varieties. As long as the pustules are distinct, and retain individually their circular form (though they may be very numerous), the disease is called variola discreta, but Avhen they coalesce and unite into irregu- lar clusters, or patches of suppuration, it is termed variola confluens. In the variola discreta, or distinct small-pox, the eruption follows pretty accurately the course Avhich has been indicated, the pustules becoming turgid and globular from being filled with pus, but retain- ing their central depression, from the pus being deposited not so much immediately under the cuticle, as in the areolar tissue, by Avhich the summit of the pustule is, as it were, bound down to the cutis. As the pustules fill with pus, the parts most affected by them, as the face and wrists, become SAvollen, so much so that the eyes are sometimes completely closed; at the same time, there is often a feel- ing of tightness about the fauces, as if from swelling, and the salivary secretion is much increased. About the eighth day, a dark crust forms on the pustule, the cuticle cracks, and allows the escape of the pus, and the pustule gradually shrivels and dries, forming a scab, which, in a few days more, falls off, leaving a red skin, which does not disappear for several weeks, or a permanent depressed scar which remains for life. In this variety of small-pox the fever may be very severe at the commencement, but it subsides as soon as the eruption is complete, and recurs, after the maturation of the pustules, for three or four days in the severer cases, constituting the fever of maturation. It is by the appearance of the pustules in the face that we judge of the variety to which it belongs, according as they are distinct or confluent in that situation. Sometimes, Avhen the pustules are nume- CONFLUENT FORM. 533 rous, they touch without inosculating or uniting, when the pock is said to be cohering, constituting what is in truth a severe form of the distinct. The confluent form manifests throughout a greater intensity and virulence in the morbid poison. The eruptive fever is more violent, and the cerebral oppression and disturbance far greater; the fever, nevertheless, being of a more decidedly typhus character, the pulse being more feeble at the same time that it is more frequent, and the tongue more disposed to be brown; the eruptive fever is shorter, the pimples making their appearance earlier about the face, but not coming out with the same regularity as in the distinct form, accom- panied by a rash not unlike that of scarlatina, so much so as with shortened eruptive fever to give rise to some difficulty in the diag- nosis. Sometimes, too, the eruption is not unlike that of measles, but as regards the diagnosis from the latter disease, the shortness of the eruptive fever will proA^e an assistance. The pimples are also less regular in their development than in the distinct form, for, though the papulae soon lose all resemblance to that of either scarla- tina or measles, by filling with fluid at their summits; they have more the character of vesicles, containing a Avhitish fluid Avhich after- wards degenerates into a brownish colour, and do not plump up into true pustules: there is often all this time a livid appearance in the surface, betAveen the confluent pustules; the SAvelling of the limbs and salivation is also greater than in the other variety; sometimes there are spots of purpura. There is in this form of small-pox a re- mission rather than intermission upon the coming out of the erup- tion, and this remission is often but slight, and on the fifth or sixth day rigors occur, marking the fever of maturation; but about the eighth day of the rash, and the eleventh of the fever, being the time at which the maturation. is complete, there sets in the secondary fever, the intensity of which is the characteristic of the confluent disease. This is the most perilous period ,of the disorder; indeed, a large proportion of the fatal cases die from the tenth to the four- teenth day of the fever, rendering the second the most perilous Aveek. Some, indeed, die of this disease in the first week, the nervous sys- tem being overwhelmed by the disease, and the patient dying of syncope. In the second week, most deaths occur, the patients dying from apnoea, through affection of the air-passages; though subse- quent deaths take place, either from asthenia, owing to a want of power to recover from the depressive influence of the disease, or from the effects of some complication. The internal inflammations which accompany this disease are mostly those of mucuos membranes, the conjunctivae of the eyes and the lining of the fauces being commonly inflamed early in the dis- ease, that of the trachea and bronchia generally at a later period; a low form of pneumonia may also occur towards the termination. After the disease, especially in the severer cases, inflammations are apt to occur, which run quickly into suppurations, affecting especially the subcutaneous areolar tissue, and the eye, sometimes the joints, the pleurae, or the lungs: empyema is a common sequel. 534 SMALL-POX — PROGNOSIS. The prognosis of small-pox is mainly dependent upon the variety. Distinct small-pox is rarely fatal; in the coherent or semi-confluent form, the mortality is about one in ten; in the confluent one in two. The favourable circumstances are early and distinct eruptions, pre- viously good constitution, previous vaccination, the appearance of menstruation at the commencement in females, the swelling of the joints at the period of maturation. The unfavourable symptoms are, the fever assuming the form of typhus, the pustules becoming flat- tened or ichorous, the interstices livid, and sprinkled Avith petechias, the non-appearance of the swelling at the period of maturation or its sudden subsidence, sudden prostration, pallor, great anxiety and op- pression at the praecordia, coma, early delirium, syncope, severe affec- tion of the larnyx and trachea, subsequent suppurations, and inflam- mation of the lungs or pleurae. The danger of small-pox is very great in infancy, less in childhood and early youth, and in adults it increases with the age. In the milder cases but little treatment is required besides a cool apartment, good ventilation, light diet, attention to the bowels, mo- derate antiphlogistic treatment, as James's powder and salines, and watching for internal complications. In the severe cases the principle of our treatment must be the same, with some modifications, as those of the management of con- tinued fever. We must endeavour to control the febrile excitement, but we must bear in mind that there is a long and depressing process of disease to be gone through, and therefore we must husband the poAvers of the constitution. The heat of skin, headache, and throbbing pulse, in the commence- ment of the inflammatory fever, might seem to indicate bleeding; but experience has shown us that the amount of the eruption, which is the true measure of the violence of the disease, is not affected by it, and there is danger of giving a character of typhus to the fever. Gentler measures must, therefore, be had recourse to. In the first place, then, and before we can be certain of the precise character of the commencing fever, we must treat the patient much as in the com- mencement of common continued fever. If the bowels have not been * freely acted upon, we must insure their being well cleared out with an efficient but not irritating purgative, as the hydrarg. cum cret., followed by castor-oil, or the combination of rhubarb and calomel, and a saline draught should be administered every four or six hours; and when the skin is hot, a pill, as annexed (F. 94),* may be given at bed-time, and the same mode of treatment may be continued until the eruption is complete; but when the pulse is compressible, and the fever exhibits any tendency to typhus, we must give support freely, in the form of beef-tea, broth, and farinaceous substances. When there is delay in the appearance of the eruption, or it is of the vesicular character, gentle stimulants may be employed, when the * (F. 94) R. Pulv. Jacobi veri, gr. iv. Hydr. Chlorid. gr. iss. Ext. Hyoscy. gr. iv. Ft. Pil. ii. To be taken at bed time. TREATMENT. 535 liq. ammon. acet. with excess of ammonia may be administered; and as in cases of this kind there is only slight remission of the fever during the progress of the eruption, and the patient will often be very re'stless at night, we must endeavour to procure sleep by opiates, and these are more especially required about the fifth day of the eruption, unless they are contra-indicated by tendency to coma. The best form of opiate will be about half a grain of muriate of morphia in solution, or from twenty to thirty minims of laudanum. Whilst giving the opiate, Ave must ahvays be careful'to insure at least one moderate evacuation for the bowels daily. It is about this period that the powers of life may be expected to fail, and if the pulse be- come more compressible Ave must administer wine, and as a more efficient stimulant, it will be well to substitute the combination of serpenteria and ammonia for that abovementioned. In what has just been said we have pointed out the measures required in the more dangerous form of the disease, as it is in that only that any active interference is required, excepting during the eruptive fever, when the treatment will be the same in either case. In the distinct small-pox, after the eruption is completed, and in the severer cases even before, there is often considerable thirst with difficulty of de- glutition, acid drinks are grateful, and as good a form as any is the infus. rosae co. When the maturation is completed, there is often much irritation from the abraded surfaces; to allay this, equal parts of powdered starch and powdered calamine well rubbed together should be sprinkled upon them. It must be admitted that, as in continued fever so also in small- pox, although judicious treatment may obviate many perils that may arise from external or accidental causes, or may keep out of the way things absolutely hurtful, still it can do little or nothing towards controlling the disease itself; and therefore the only means of arrest- ing the mortality Avhich would otherwise ensue from this fearful malady is prevention. The plan first adopted for this purpose was giving the disease to a healthy person by means of inoculation, and it was found that thus given it was much milder than when received by ordinary con- tagion, or, as it is termed, "in the natural way;" thus inducing an immunity, at a diminished risk, from future attacks. This plan, which Avas first introduced into this country by the celebrated Lady Mary Wortley Montague, was for many years the only method of prevention used. Subsequently, it was discovered by the illustrious Jenner that a disease apparently similar, the variola vaccinia, may be communicated to man from the cow, and that although an incom- parably milder one than variola received from the human subject, it has nevertheless nearly, if not equally, the power of protecting the sub- ject from any future attack of variola. It may also be transferred from one human subject to another by inoculation, and retain the same protective power. Such are the two measures which have been adopted to guard against one of the most fearful scourges that have visited humanity. Of the former, it may be said that it was merely the submitting to a 536 VACCINATION. great evil to escape a greater; that though the inoculated disease was much milder than that from ordinary contagion, it was nevertheless not very unfrequently severe, and in some few instances fatal; and that it is open to the still stronger one that it keeps a pestilence alive in a community, since a person suffering from the inoculated small- pox can communicate the disease in its severe form to any unpro- tected subject. Upon these grounds the practice of inoculation for small-pox is forbidden by kw in almost every country in Europe; whereas, in most, the vaccine inoculation is more or less compulsory, in this country it is noAV rendered practically so. The small-pox from inoculation has therefore become a mere matter of history, whilst an acquaintance with the appearance and subsequent effects of the disease produced by vaccination has become still more necessary. When vaccination has been successfully performed, no results apparent to the naked eye show themselves till the third day, though by the aid of the microscope an efflorescence may be perceived round the puncture on the second. On the third day, however, the wound is red and elevated, and on the fifth, the cuticle is raised into a white vesicle, containing a minute quantity of a thin transparent fluid; the normal form of the vesicle is probably circular; but it may be of that shape or oval, according to the mode of making the incision. The vesicle may be said to be perfectly matured on the eighth day; its margin is turgid, and sensibly elevated above the surrounding skin;* its colour may be yelloAvish or pearly; at this time it may measure from a quarter to half an inch in diameter. Like the pus- tule of small-pox it has the central depression, and like it, it is cel- lular ; the lymph being contained in ten or twelve cells. About the time of the perfecting of the pustule, the redness which may hitherto have extended very little beyond its base, begins to spread and form what is termed the areola, which is a red border round the pustule, extending more and more till the eleventh day, when it begins to fade; in doing which it becomes livid, then gradually paler, leaving behind it a degree of hardness of the surface. About this time a broAvnish crust forms over the vesicle, which becomes harder and darker, and if not previously abraded, falls off about the twentieth day. Though the disease is so slight, and attended with but little constitutional disturbance, there is a certain amount of febrile dis- turbance about the eighth and ninth days, analogous to the secondary fever of small-pox, marking the affinity of the two diseases. For some years after the introduction of vaccination into this country there was, as might be expected, a great doubt, and more than doubt, in the minds of many, of its efficacy, whereas numbers received the evidence of its protective influence in the majority of cases, as proof of its effording a complete and permanent security in all. The truth, however, lies between the two extremes of opinion; vaccination does not afford perfect and permanent security through life to all upon whom it may be said to have been success- Gregory's Lectures on Eruptive Fevers. MODIFIED SMALL-POX. 537 fully performed, perhaps not to more than tAVO-thirds; but there are few, if any, of those so operated upon Avho do not enjoy a great immunity from the risks of small-pox, amounting almost to a cer- tainty of never being affected by that disease in its dangerous form. In many persons the protective influence shows itself not by pre- venting an attack of small-pox, but by so modifying it that the dis- ease is, as it were, cut short, and subsides before reaching the dan- gerous stages; to which it may be added, that the immunity, as regards a dangerous attack of small-pox, is, to say the least, as great as that conferred by a previous attack of small-pox itself. Certain it is, that fatal small-pox in the successfully vaccinated is almost unheard of, and it is equally certain that cases are upon record of persons dying from a second attack of small-pox. As, hoAvever, the legislature has practically decided the question between inoculation and vaccination, there remains a very important one, and that is, the duration, as well as the degree of security con- ferred by vaccination. There certainly occurred for several years after Jenner's discovery nothing to shake the confidence in the prac- tice of vaccination; but, in course of time, cases of small-pox of a modified form presented themselves in persons concerning AArhom there was satisfactory evidence of their having been duly vaccinated, and these cases became more frequent as there were more and more persons living who had been vaccinated ten, twenty, or more years previously. The history of these cases certainly favoured the belief that the protective power of vaccination diminished in the course of time, as numbers Avho were exposed to contagion in childhood with impunity, suffered from modified small-pox in after years. 'The author of the present work was himself exposed purposely to the contagion of small-pox, when an epidemic prevailed, and that by being on several occasions brought in contact with children suffering severely from it, and with perfect impunity (he being then about seven years old, and having been vaccinated in infancy), but when at the age of twenty -two, suffered from a severe attack of modified small-pox; and many cases have occurred under his notice of this form of small-pox in persons past the age of puberty, who had been vaccinated in infancy, though cases are not wanting of modified small-pox in childhood and early youth. The inference from all this is, that the protective power of vaccination, in any individual, is impaired by time, and that it is probably still further affected by the change which takes place in the system at the time of puberty. It is, therefore, to say the least, expedient to renew it, and perform re-vaccination about the age of sixteen or eighteen. The modified small-pox differs from the true in the character of the eruption, but still more in the duration and intensity of the fever; Dr. Watson mentions three distinct forms:— (1.) "The eruption sometimes approaches, in its character and course, very nearly to that of the ordinary small-pox; the pustules fill up, have the central depression, and ultimately crust over, and the face swells. But this course is performed in a shorter time than that of the ordinary disease; and the pustules are usually smaller. 538 MODIFIED SMALL-POX — CHICKEN-POX. This is the severest and least common form of the modified small- pox." (2.) "Sometimes the papulae shoAV a little fluid on their tops only, but never fairly suppurate or break, but the vesicles dry up, and hard prominences, Avith livid bases and horny summits, remain." (3.) "There are other cases in which a great part of the eruption consists of red pimples, which soon become livid, but contain, from first to last, no fluid Avhatever." In most cases all three varieties coexist; the pustules first appear- ing, those, namely, on the face and chest coming to maturity, whilst those which last appear, on the legs and feet, for instance, drying up, or merely presenting the red pimples. The difference, however, in the fever is still greater, and more important; the constitutional disturbance at the commencement, that is to say, the eruptive fever, may be at the first as seArere as in the ordinary small-pox; but just as the pustules are beginning to mature, the fever subsides, and the patient becomes convalescent, the disease appearing to be mysteriously arrested just at the time when in the unprotected it would become most severe and dangerous. To this we may add, that most threatening cases sometimes do occur in those who have been vaccinated, in which even the fever of maturation sets in; but, nevertheless, Avhen we are beginning to fear that the pro- tective power of vaccination may have been exhausted, the disease suddenly subsides; and this we must never despair of its doing at any time. The modified small-pox in general requires little or no treatment besides antiphlogistic regimen, cool air, and, if necessary, gentle lax- atives. Sometimes, indeed, the eruptive fever runs high, and appears to threaten the brain, and Avhen this is the case we may use depletory measures more boldly than in the unprotected, since the disease has not so long a course to run, but these should not be had recourse to without urgent necessity. The varicella, or chicken-pox, is in itself a disease of little import- ance, though it deserves notice from its resemblance to the milder forms of small-pox. It affects infants and young children almost exclusively. There is scarce any premonitory fever, so that the dis- ease is first announced by the eruption, which makes its appearance on the scalp, neck, breast, and shoulders, with but very few vesicles on the face; in which respect it differs most from small-pox. The eruption consists of perfectly transparent vesicles, of which fresh crops continue to appear for tAvo or three days in succession, the old ones beginning to shrivel about the third day, after which they become pearly and opaline, and leave small dry scabs, which crumble away, but sometimes leave shalloAv cicatrices. These, however, are probably the result of suppuration of vesicles which have been inflamed by rubbing. The important diagnosis of this disease is from small-pox, from which it may be distinguished by the absence, or very short dura- tion, of the eruptive fever, and by the truly vesicular character of the eruption, the vesicles being perfectly simple, consisting, in fact, MEASLES — PROGRESS. 539 of cuticle detached and raised by the fluid: the effect of which is, that the walls of the vesicles, not being kept down by any intervening areolar tissue, there is, during the first two days, no central depres- sion; it is therefore very important to watch the first appearance of new vesicles, as it is only by inspecting them within the first two days that we can be perfectly confident that the disease is not small- pox, as, after they have began to shrink, and after some have been irritated to suppuration by rubbing, it is next to impossible to say that the case is not one of either very mild, or modified, small-pox. The varicella has the characters of a distinct exanthem: it occcurs only once in the same person, spreads by contagion; it is not, however, communicable by inoculation, in which respect it presents a marked contrast to small-pox, which even in the modified and mildest form, can be reproduced in this way. Another important distinction is, that vaccination is no preventive to chicken-pox, and that the pre- vious occurrence of chicken-pox does not in any way interfere with the regular progress of the vaccine vesicle. It is needless to enter further into the question of the identity of small-pox and chicken- pox, since it has long been decided in the negative, though there may noAV and then be great difficulty in the diagnosis between the two; and there is a necessity that AAmen we meet with an equivocal eruption, we should enjoin the same precautionary measures as if the case were one of undoubted modified small-pox. _ The measles or rubeola, called often by the older nosologists mor- billi, is another exanthem, having a distinctive eruption, an eruptive and secondary fever, very rarely attacking the same person more than once. The period of incubation after exposure is about fourteen days; sometimes there is no apparent deviation from health during this time, at others, as Dr. Gregory points out, the patient is languid, and has ill-developed febrile symptoms for a greater or less portion of the time; so that there is apparently a greater want of uniformity in the premonitory fever of measles than of the other exanthems. In the morbilli regulares of Sydenham, the fever sets in in the ordinary way, with rigors, pain in the back and limbs, headache, &c, &c.; but what may be regarded as in a great measure characteristic is, that coincident with this, there are catarrhal symptoms, coryza, epiphora, sneezing, raAvness of the thorax and chest, and pains across the fore- head ; the pulse is quicker, and the tongue white; the eruption makes its appearance upon the fourth day. Dr. Gregory assigns seventy- two hours as the standard time; so that Ave may lay it down as a rule that this eruption is later in making its appearance than either of the cognate diseases, small-pox and scarlatina. The eruption begins on the face and neck, travels down to the loAver extremities, like the small-pox, the latest appearing about three days after the first. The papulae begin to fade three or four days after their appearance, so that the whole course of the eruption occupies six or seven. The eruption consists of small, scarcely-elevated papulae, not presenting the millet-seed sensation of small-pox to the fingers, but still percep- tibly raised, especially on the face, which is slightly swollen: they 510 MEASLES. coalesce into clusters, which often assume a crescentic, or horse-shoe form. The papulae eventually die aAvay in crust, which crumbles off in a fine powder. Quite unlike the scabs of small-pox or the des- quamation of scarlatina. The fever, as already described, is of an inflammatory character, more decidedly so than in the other exanthems, and the catarrhal inflammation Avhich accompanies it is sometimes severe; when the eruption makes its appearance, there is not uncommonly diarrhoea, showing the disposition of the disease to attack the. mucous mem- branes : at this time, too, the fever and catarrhal inflammation both become more severe, and continue until the eruption has covered the whole body, in which respect this disease presents a contrast to small- pox. Another remarkable point of difference is, that in measles the danger is mostly in an inverse proportion to the eruption; its chief source being apparently the inflammation of the mucous membrane, to which the eruption appears to act as a revulsive. In the gene- rality of cases the fever and inflammation both begin to decline Avhen the rasb begins to fade upon the face—that is to say, on the fourth day of the eruption; about this time, also, there is sometimes diar- rhoea, which seems to afford considerable relief. In the severer cases, however, the symptoms, both general and local, become increased in intensity at the subsidence of the eruption; the bronchitis extends into the smaller tubes; and to it is often added pneumonia, which may prove fatal in either by apnoea or exhaustion: in some cases, too, the fever assumes a typhoid form: sometimes there is exhausting dysenteric diarrhoea. It is not very uncommon for the eruption to recede suddenly (in some instances, as we have reason to believe, from imprudent exposure, but in others spontaneously),Avhen some of the unfavourable symptoms above described will manifest themselves. The diagnosis of the disease is not difficult, depending upon the character and duration of the eruptive fever, and the appearance and progress of the eruption. The eruption may be said to be the true characteristic, and without it we can never pronounce a case to be measles, though sometimes there is the true rubeolous rash, preceded by slight fever, but without any catarrhal symptoms appearing, when measles is prevailing epidemically—a disease which has been de- scribed under the term rubeola sine catarrho. This affection, however, bestows no immunity against the true disease, by which it is often quickly followed. The prognosis and treatment of measles are, as it were, corollaries to its history and progress. The most favourable signs are an abun- dant rash, persistent for the full period, fever of sthenic but not violent character, absence of pneumonia or capillary bronchitis, and the decline of the symptoms with the fading of the rash, with free spontaneous action of the boAvels at this time. The untoAvard events or signs are scanty eruption, and still more its sudden arrest or retro- cession; fever manifesting a tendency to typhus, capillary bronchitis, pneumonia, aggravation of the symptoms at the subsidence of the eruption, constituting a species of secondary fever. Independently, SCARLATINA. 541 hoAvever, of its immediate fatal results, measles often induces serious secondary consequences, or excites latent tendencies to constitutional diseases. The most frequent instance of this is the calling into activity any tendency to tuberculosis, when in children of this dia- thesis there ensue strumous enlargement of the glands, scrofulous affections of the eyes, joints, or other parts, tuberculous disease of the lungs or of the encephalon. In the milder forms of measles but little treatment is required: the patient should be kept moderately warm in bed, and a saline mixture administered of either acetate of ammo- nia or citrate of potass, with a few minims of antimonial wine, and tincture of hyoscyamus or conium; if the eruption should recede, the patient must be placed in a Avarm mustard bath. The great danger arises from the bronchitis or pneumonia. We must carefully watch ^ for the symptoms of these complications, and treat them according to their extent and intensity much as when they occur idiopathically. When these are detected early, moderate depletion may be had recourse to, and -will be Avell borne, and moderate doses of calomel A\ith Dover's poAArder, or antimony with opium, may be employed. Blisters may also be used when the more active symp- toms have been subdued, unless, as is often the case in scrofulous children, there is a liability to troublesome sores, when they had better be avoided; in such subjects, if blisters have become necessary, it is best to apply one, only for one or two hours, according to the age, and then remove it, and if at the end of an hour there is no vesi- cation, to repeat it; or after the blister has been applied for two or three hours, to remove it altogether, and apply a linseed poultice in its place. If typhoid symptoms should show themselves, the case must be treated as one of low fever, with the cautious use of ammo- nia and other stimulants. As the diarrhcea Avhich comes on upon the subsidence of the eruption is often sanatory, we must endeavour to induce it, should it not occur spontaneously, by gentle purgatives. Great care is required, in the after-management of measles, to preVent cold, by the use of Avarm clothing, and avoiding too early exposure out of doors. Another eruptive fever, of frequent occurrence, and in too many cases of a fatal tendency, is scarlatina, or scarlet fever. The former term is a corrupt word, which custom has sanctioned amongst nosolo- gists and professional men, and which it would be well if we could replace by the English noun, scarlet fever; but there is a difficulty in all reforms of this kind, and in this particular instance we are often induced to use the word "scarlatina" in accordance Avith the preju- dices of the vulgar, who, from its termination resembling that of a diminutive, are much less alarmed by the word than if we were to speak of scarlet fever. Hence, therefore, Ave adopt the mongrel word as a sort of euphemism for the English. Bv whatever name, however, it may be called, it is a most destruc- tive disease, and one the mortality from whicli appears to have been of late years increasing. Like the other exanthems, it has its period of incubation, its period of eruption, and its secondary fever. Be- sides this, as the scarlatinal poison, like others of a kindred nature, 542 SCARLATINA SIMPLEX. has a tendency to concentrate itself upon particular parts, inducing complications, which in many cases are to all appearance the natural consequence of the disease, and yet are not integrant portions of it, since it may run its course Avithout their happening. Scarlatina has most of the characteristics of a true exanthem; it is highly contagious, though, no doubt, the susceptibility of a Avhole population may be greatly influenced by atmospheric and other causes, and therefore it sometimes spreads with great rapidity, or, in other words, prevails epidemically: it rarely attacks a person a second time. It is particu- larly fatal to young persons. The susceptibility to the poison appears to be greatest from infancy to puberty, after which it appears gradu- ally to diminish as the subject groAvs older, ceasing entirely about forty; though some few instances do occur after that age. Women, hoAvever, in the puerperal state are very susceptible to it; at least, if they are not attacked oftener than others of the same age, the dis- ease in them is more likely to be fatal Avhen it does occur. Scarlatina then has a period of incubation of from ten to fourteen days, and during that time the patient commonly appears in his usual health. It makes its first invasion with ordinary signs of pyrexia, severe headache, and very commonly sickness, and on the second day an efflorescence is observed on the neck and breast. This extends upwards, generally towards the face, and dowmvards over the trunk and lower extremities : in the former situations the rash makes its appearance in large bright, red blotches, of indeter- minate form ; often nearly the Avhole surface is of this colour through- out: on the extremities it puts on more of a spotted appearance, Avhich it is possible to mistake for measles, though there are no true papulae, the cuticle not being elevated as in the last-mentioned dis- ease. During this period the pulse is sharp and frequent, the skin hot, the tongue coated, generally red at the edges, with very elon- gated papilke. In uncomplicated scarlatina, the rash keeps Avell out for from three to four days; it then begins to decline, and fades away altogether about the seventh; soon after this, desquamation of the cuticle commences in the form of scurf, from the face, neck, and trunk; but in large scales or rather sheets from the extremities; sometimes the whole cuticle of the hand has come away like a glove. The feArer has now, to all appearance, run its course, but it is evi- dent that even noAV the poison has not been entirely eliminated ; or, as others' would rather have it, the series of morbid phenomena is not complete; since even after this mild form of the disease, we not uncommonly find subsequent lesions of other organs, apparently the effect of the morbid poison locating itself in them. Such is the simple, uncomplicated scarlet fever, the scarlatina simplex of noso- logists. This exanthem, hoAvever, more commonly presents itself in a severer form, in which the morbid poison attacks the fauces and tonsil glands. In this, the scarlatina anginosa, the fever sets in much in the same manner as in the preceding, but is accompanied or shortly followed by a sense of stiffness about the muscles of the neck and throat; the characteristic tongue, with red edges and elongated I ANGINOSA — MALIGNA. 543 papila1, shows itself almost from the commencement, and upon look- ing at the fauces, we perceive the tonsils and uvula to be swollen. This SAvelling, and with it the general fever, continues to increase, and SAvallowing and deglutition become painful, and often the respira- tion is difficult, and the patient lies with the head rather thro-wn back. At the earlier period, the pulse is quick and sharp, but in most cases, readily compressible. The tonsils continue to enlarge, and there is often much stiffness of the jaAvs; so that it becomes very difficult to inspect the fauces, Avhich are commonly covered with apthous crusts. These crusts are often mistaken for ulceration, which, though not very common, does sometimes occur. The en- larged tonsils may be felt externally and the glands about the throat SAvell likeAvise. The pressure thus produced upon the large vessels no doubt promotes congestion in the brain; but, independently of this, there is sometimes early delirium, and as the disease advances, there may be tendency to coma. The inflammation about the throat extends often to the mucous membrane of the nostrils, and a sanious ichor floAVS from them; the lining membrane of the eustachian tube becomes likewise affected, and the inflammation spreads along it to the internal and external ear, and there is often an irritating dis- charge from the latter; the eye may also become affected in like manner, and sometimes the areolar tissue of the orbit. The mucous membrane of the larynx may also become the subject of inflamma- tion, producing sometimes death from suffocation, by the obstruction caused by the consequent SAvelling. The serous membranes, too, of the head and chest may likeAvise become implicated, and of these the tissues most likely to be affected are the arachnoid and the peri- cardium. Scarlatinal pericarditis is perhaps a more common affec- tion than most practitioners are aAvare of. It is about the fourth day of the fever, when the rash begins to decline, that these complications are most likely to ensue, and there- fore this may be regarded as a period of great danger, though in those cases in which there are no complications beyond that of the throat, there is great danger about the eighth day, when the febrile symptoms assume more the character of typhus, and the patient sometimes sinks under the depression produced by fever, aggravated, it may be, by the protracted suffering : but he will generally do well, as regards the immediate danger, if he survive the eighth or ninth day. # The last form of this diseased/which we have to notice, is the scar- latina maligna, than which a more fatal one is not to be found in the whole range of nosology, or,one which more speedily and entirely crushes the powers of life. In the scarlatina simplex, the amount or intensity of the poison appears to be small, and it is not even concen- trated in any single part; in the scarlatina anginosa there is danger OAvino- to the poison locating itself and setting up a specific inflam- mation in an important and susceptible part; but in this the inten- sity or virulence of the poison is such that all the forces of the sys- tem—the nervous poAver, and the action of the heart, as well as the vital affinities of the extreme circulation—appear to be destroyed, or 541 SCARLATINA MALIGNA. at least suspended, although in this form, as in the last, the poison exhibits a tendency to localise itself in the fauces. The initiatory fever of this malignant scarlatina differs from that of the other forms only in its greater intensity, and in its greater proneness to assume the character of typhus. There is great oppres- sion in the countenance, the eyes are suffused, the oppression about the praecordia and the general prostration are greater, and the pains in the back and stiffness in the muscles of the neck are more severe; the pulse is small and feeble, and the fauces, Avhen inspected, present a dusky-livid appearance. The eruption is generally late in making its appearance, and when it does, it is livid and often interspersed with spots of purpura. The poison, as before observed, early attacks the throat, which, upon inspection, is seen to be dusky, swollen, and livid. There is an offensive foetor in the breath, Avhich, when once observed, is again readily recognised; ashy sloughs form upon the tonsils, which ulcerate and sometimes become gangrenous. The voice is hoarse and the respiration performed with a difficulty almost like that of croup. The throat becomes clogged Avith a glairy phlegm, which the patient in vain endeaA^ours to expel, and the sanious ichor before mentioned streams from the nostrils, causing excoriation of the upper lip, and ulceration of the angles of the mouth. Delirium, sometimes of a low muttering kind, sets in early; in other cases there is a tendency to coma, and in others violent maniacal excitement seizes the patient suddenly. As has been before pointed out, the poison seems to destroy the natural vital affinities of the cir- culating fluid; and, as a consequence, general capillary congestion, shoAvs itself in the air-passages by Avheezing and urgent dyspnoea, and, in the alimentary canal, by irritable bowels and bloody stools. Sometimes the effects of this congestion are manifested by early collapse, the surface becoming cold, dusky, and shrunken, especially in the extremities, and the pulse at the wrist nearly imperceptible. Should the patient linger to the eighth or ninth day, there will gene- rally be then an aggravation of the fever, and the patient will die, either from sinking, or from apnoea OAving to congestion of the lungs, or from coma produced either simply by the effects of the poison upon the brain, or by the congestion produced by the pressure of the SAvollen glands upon the large veins in the neck, Avhich also tends greatly to aggravate the dyspnoea. It has been already stated that in this, the malignant form of scar- latina, the rash is generally late in making its appearance, but in some cases it never appears at all. Thus cases uoav and then appear of putrid sloughing of the throat, without any rash whatever, tending rapidly to death by sinking, and of Avhich it is at first very difficult to discover the origin. Subsequent cases of scarlatina, obviously traceable to communication with the patients so affected, leave no doubt as to the real nature of the disease. But this is not all; some- times young persons who have been in undoubted intercourse with others labouring under this disease, have died almost suddenly; in some instances, no cause for death could be found, upon careful MODES ON DEATH. 545 examination. Now, when we consider the rarity of sudden death in childhood (we do not mean infancy) and youth, and when we take into account also the acknoAvledged virulence of the poison of scar- latina, it is not too much to believe that it may have produced death by its direct influence upon the nervous or circulatory system. In other cases, again, death has taken place very speedily in young per- sons exposed to scarlatinous poison, and, upon examination, the cause has been found to be internal inflammation, often of a puriform char- acter. In one instance, a child, previously healthy, became collapsed, without much pain in the abdomen, but with apparent distress about the epigastrium, had some sickness, and died in a few hours. In this case, there was found peritonitis somewhat of a puriform character, involving the peritoneal surface of the duodenum and of a portion of the stomach and neighbouring viscera. Though scarlatina, in its severe forms, is so frequently fatal during the fever, the danger does not stop there, and therefore the sequels of the disease deserve attention. The most familiar of the sequels of scarlatina is the process of desquamation. This is itself a reparative process, being the mere falling off of the dead cuticle, to make room for the new; but till this process is completed, the susceptibility of the constitution is great, and the functions of so extensive and import- ant an organ as the skin, being liable to disturbance from changes of temperature, there is, as might be anticipated, a corresponding dan- ger of disease of the complementory organs—the kidneys,—hence, for want of caution at this time, we may have the scarlatinal dropsy, of which, for convenience' sake, we have spoken in connection with diseases of the kidneys. Dr. Gregory remarks, with truth, that when there has been serious anginose affection, the cellular membrane of the neck will often take on inflammation; erysipelatous redness of the neck, with great hard- ness and SAvelling are perceived; the cellular membrane sloughs; this sloughing, if extensive, brings life into hazard. This observa- tion is important, both for a caution in practice to be presently noticed, but also as an instance of the close affinity betAveen scarlatina and erysipelas. This tendency, to excite inflammation of the areolar tissue, does not, however, confine itself to that particular part, as it may also show itself in the same tissue elseAvhere; as, for instance, in the orbit. The ear, as Ave have remarked, often becomes inflamed during the fever, and the inflammation may assume a more chronic character, and continue after the subsidence of the former, becoming sometimes of a puriform nature, with a highly offensive odour, and leading to the destruction of the bones of the ear. The ulceration sometimes extends also to the petrous portion of the temporal bone, producing in some instances inflammation of the membranes, and in others abscess in the substance of the brain. It is remarked by Dr. Gregory, that scarlatina differs from measles, in that the former is accompanied and followed by phrenitis and dropsy, Avhile measles is by pneumonia. The same proposition might, perhaps, be enunciated in more general terms, by saying that scar- latina has a greater tendency to attack the serous membranes; pos- 35 546 SCARLATINA. sibly this may be dependent on the connection between scarlatina and Bright's kidney, in which there is so remarkable a liability to serous inflammation; it is evinced by another sequel of scarlatina not very generally noticed, arthritic inflammation resembling rheumatism. In whichever way we account for it, we certainly meet with inflam- mation of the serous membranes, sometimes without any albumen in the urine, sometimes with arthritic inflammation, and sometimes Avithout it; the proneness of the different serous membranes fol- lowing much the same order as in rheumatism; the pericardium becoming most frequently involved next to the pleurae and mem- branes of the brain, and, lastly, the peritoneum. Of the prognosis of scarlatina we need add little after what has been already stated, the diagnosis must also in the same Avay be tolerably apparent. We may, hoAvever, remark, that not only in the subsequent inflammation, but also in the appearance of the eruption, scarlatina will sometimes closely simulate erysipelas. The close affinity of these tAvo diseases has not perhaps generally received the attention which it merits. Like all virulent and dangerous diseases, scarlatina has had its share of "certain cures," but when these are tested by the truly malignant forms, they prove as certain failures. The scarlatina simplex is, as we have stated, a very mild disease, going on spontaneously to a favourable termination, and needing little treatment; in such cases, then, the "nimia medici diligentia" of Sydenham should be sedulously avoided. Even here, however, care should be taken to avoid over-exertion and exposure to cold, till the desquamation has been completed; since such cases do not appear to be more exempt from the invasion of scarlatinal dropsy than are the more severe. Dr. Gregory appositely remarks, that we may as sum- marily dispose of the treatment of the typhoid form of the disease, or scarlatina maligna: this in spite of all vaunted specifics, should be treated according to the dictates of common sense; that is to say, by support and stimulants, from the first evidence of the true character of the attack. Good beef tea should be early administered as freely as the patient can take it; and as the powers of life begin to fail, as shown by the dry brown tongue, black sordes about the mouth, dusky extremities, and feeble pulse, Avine should be given, not according to measure of ounces, but to its effects upon the circula- tion. Of medicines, strictly so called, ammonia is the best of stimu- lants. Some practitioners have imagined that it has an almost specific influence upon the disease; but Avhether that be so or not, its use in the malignant cases should never be omitted, provided the patient can swallow it. The best form for its exhibition is the mixture of serpentaria and ammonia (p. 519). AVhen the pulse becomes, as it sometimes does, nearly imperceptible at the wrist, ether may be added. It may be well, too, at the commencement of such cases. when the skin is hot over the Avhole surface, to add the liquor ammon, acet., in doses of one or two drachms, according to the age. As the ammonia is sometimes irritating to the fauces, so much so that it TREATMENT. 547 cannot be taken, we must then have recourse to other stimulants; the tincture of bark may then be used, and Avith it ether, in infusion or decoction of bark, and in such cases small doses of the chlorate of potass may be added. Some practitioners' place great reliance upon this salt, and certainly it is not undeserving of trial when the ammo- nia is found inadmissible; when that is not the case it should not supersede its use, though a solution of one drachm of the chlorate in a pint of Avater may be used for a drink, Avhich will be neither unplea- sant to. the patient, nor inconsistent Avith the exhibition of the am- monia. The great difficulty, however, is in the management of the inter- mediate cases, because here the result is more influenced by the treatment employed. In the invasion of the disease, the skin being hot, and the arterial excitement great, the obvious indication seems to be to lower them by decisive measures; but here, as in all specific fevers, Ave must remember that the poison is of a depressing character, and that the disease has a determinate course to run; for the latter reason, and still more from the test of experience, we may say that the abstraction of blood is, as a general rule, inexpedient; there may be cases in robust subjects, Avith a full, strong pulse, where it may be borne; such, however, are exceptional. Another means Avhich has been recommended to fulfil the abcwe indication, is the administration of an emetic at the onset, and this should be done then, if at all; but the success of the practice is doubtful. Vomiting often comes on spontaneously, and this sickness is certainly a general symptom in some very mild epidemics; still Dr. Gregory regards it as in itself unfavourable.—We should have some hesitation in adopt- ing the practice. There is, hoAvever, another safer means Of lowering the vascular excitement, and that is by a moderate but efficient pur- gative. We do not by this mean that purgatives are to be employed blindly, but that when Ave are sure that there is no tendency to diar- rhoea, and have reason to believe that the boAvels have not been freely acted upon within the preceding tAventy-four hours, a moderate dose of rhubarb and calomel, or of scammony and calomel, will be a safe remedy. The practice of cold affusion, as introduced by the late Dr. Currie, of Liverpool, is another of the means proposed for keeping doAvn the fever, and cooling the surface ; but though, in those cases to which it is applicable, it is a grateful and*efficient remedy, the number of such is very limited, and, unfortunately, does not include the most dan- gerous; "it is adapted," says Dr. Gregory, "for young persons Avith high anginose inflammation and a burning hot skin," but unfortu- nately, it is not applicable, on the one side, to cases of plethora, or on the other, to those of debility. The tepid sponging recommended as a substitute, is a useful auxiliary at a later period. The practice most applicable to those cases which require decided remedies, and can be benefited by them, will be, as Dr. Watson well observes, that which is proper for many cases of continued fever; it is one to Avhich the author has been driven, or rather Avhich he has 548 SEQUELS OF SCARLATINA. been compelled to fall back upon, after no inconsiderable experience of this distressing malady, and glad is he to find himself in accord- ance with that judicious and accomplished physician. The first thing to be done is to insure the free evacuation of the bowels, either in the manner above recommended, or by a moderate cathartic draught; put the patient in the best ventilated apartment at command, and remove all bed-hangings; without good ventilation yon can do nothing; keep the surface as cool as possible, by not allowing the patient to be overwhelmed with bedclothes. In the sinking cases, it is true, the extremities are apt to become cold, and this must be guarded against; but, as a general rule, let the cover- ings be light. Keep the head cool, and remove all superfluous hair; if there be delirium threatening, or head-affection, it must be shaved. The patient may then be put upon the use of the liquor ammon. acet.; and if the skin be very hot, it may be sponged with tepid vinegar and water. The acid gargles, as that of infusion of roses with sulphuric acid, are agreeable in mild cases, and cleanse the throat; but when there is any ulceration or excoriation, they cause pain; the gargle of mel rosae and bark will then be preferable; lime water with honey is also a useful cleansing gargle, or a mixture of chlorate of soda and water in the proportion of a drachm to a pint. But a most valuable means of checking the inflammation, is the applica- tion of the nitrate of silver, either in substance or in a strong solu- tion, to the uvula and tonsils, and around the fauces as far as it can be effected, and this may be repeated after twelve hours if possible. We must now watch carefully for the invasion of carebral symp- toms in the way of active delirium, and when these occur in mo- derately strong subjects Avith a firm pulse, a little blood may be abstracted by leeches; some writers recommend their being applied to the throat rather than to the temples, but against this practice in general, objections have already been stated: the best situation is, however, over the mastoid processes, where they are not likely to produce the same inconvenience, and where, should the bleeding be too profuse, which it is apt to be in scarlatina, especially with chil- dren, pressure can be conveniently applied. Our attention must still be directed to the throat, and as the disease advances, if the swelling continues, hot well-made linseed poultices should be applied externally. The bowels should throughout be carefully watched, as much with the vieAV of preventing costiveness as of checking diar- rhcea ; for the former purpose a moderate dose of castor-oil is the safest; for the latter a starch enema, with syrup of poppies, or, the chalk mixture with aromatic confection, may be given. The powers of life should noAV be carefully sustained: milk, or milk and water, and beef tea should be given as nourishment; and when the pulse begins to grow feeble, or even decidedly compressible, gentle stimu- lants must be employed. Of these the best is the sesquicarbonate of ammonia, which may be added in excess to the acetate. If the pros- tration still increase, the tongue become broAvn, and sordes begin to accumulate about the teeth, the serpentaria, with bark and ammonia, ERYSIPELAS. 549 may be used (F. 95).* About the same time, too, we may commence the cautious administration of wine, carefully watching its effects, and regulating its quantity accordingly. Of the management of scarlatinal dropsy we have spoken else- where ; we need therefore merely urge the necessity, in all cases, of using every precaution to prevent any chill to the surface, until the desquamation is entirely completed, which will not be till the end of three weeks, or sometimes more; and during this period the urine should be from time to time tested for albumen. It is in the fourth week that we most frequently meet with the dropsy, Avhich is in many cases preceded by headache, dyspnoea, or pains in the loins; in some very severe cases it is ushered in by convulsions; in others, however, it creeps on quite insidiously. The rheumatic sequels of scarlatina do not appear to have received the attention from authors which they deserve. Most practitioners must be familiar Avith the fact of arthritic swellings of a very trouble- some character occurring at the close of scarlatina, though many have doubted the identity of these with rheumatism; but not only have these arthritic swellings a close resemblance to that disease, but there is the same tendency to metastasis of the inflammation to the heart and pleurae. The treatment of those affections requires considerable caution, since after so depressing a disease as scarlatina the patient has rarely strength to endure the measures ordinarily adopted for the cure of acute rheumatism. When it is confined to the extemities, the treat- ment of the arthritic affection with the acetate and nitrate of potass, in the manner already pointed out, will best fulfil the indications; and when cardiac inflammation supervenes, the same practice may be continued, with the addition of moderate doses of calomel and opium ; as, for instance, a grain of calomel with half a grain of opium may be •administered every four hours; and if there be no great heat of skin, a blister may be applied to the region of the heart. Another disease of which it is most expedient to treat in connec- tion with this exanthem, is erysipelas, a disease about which there exists much difference of opinion upon almost every point, not only as regards the meaning and derivation of the term, but also as to noso- logy, its pathology, its origin and treatment. As regards its place in a system of nosology, that is now a matter of but little import- ance ; but we deem it expedient to treat of it in connection Avith the exanthemata, though reasons might be urged for placing it amongst the phlegmasia? ; the truth is, that it holds a middle place between the two, partaking, as we shall see, of the characters of both. Erysipelas has, according to some, a period of incubation of about * For instance— (F. 95) R. Ammon. Sesquicarb. gr. xviij. Tinct. Cinchonae co. 3 iv. Tinct. Serpentarise, 3 iij. Syrupi Aurantii, g iij. Infus. Serpentariae, q. s. to make a g iv. mixture of the one-sixth portion is to be given every fourth hour, to a child of ten years. 550 ERYSIPELAS. a week, though this does not seem to hold true of all cases. It sometimes begins without any previous signs of fever; this applies only to the mildest cases; in the more decided there is an eruptive fever, commencing with rigors, languor, pains in the limbs, fol- loAved by increased heat of skin, frequently sickness and vomiting, headache, thirst, restlessness, &c.; a white tongue, sharp pulse; with the fever there is often an inflammatory state of the fauces, of greater or less intensity. After a period, varying from tAventy-four to sixty hours, but generally about thirty, a redness appears most commonly upon the face, sometinir-s, though not so often, upon the legs, and still more rarely upon the trunk. The redness is soon fol- loAved by heat and tension of the part, and this redness, pain, heat, and SAvelling evince a disposition to spread to the surrounding parts (whence the name of the disease). When the eruption attacks the face, it is almost always the side of the nose, close to the inner angle of the eye, which is first affected. The SAvelling soon involves the whole of the eyelids, which assume a characteristic oedematous ap- pearance, and the eye is often closed; it then generally spreads over the whole face, and on to the scalp, sometimes extending down the throat or the back of the neck; in some instances it descends even to the extremities, and does not subside until it has invaded every part of the surface. The eruption of erysipelas appears to consist in an inflammation of the cutis, apparently differing but little from that set up by can- tharides or scalding Avater; the inflammation producing, as in the latter instances, an effusion of straw-coloured fluid (though, in some cases of a low type, this fluid may be a sanious ichor), which sepa- rates the cuticle from the custis vera, forming blebs or blisters of different sizes. These generally break and discharge their contents, and the raised cuticle dies off in scales, leaving a red or livid surface, according to the less or greater typhoid tendency in the patient; the whole process of desquamation being generally completed in a fort- night. The inflammation, however, in the severer cases is not con- fined to the skin, but extends to the subjacent areolar tissue, consti- tuting one of the severest forms of what used to be called " cellular membranous inflammation." In this inflammation there is, as might be anticipated, little or no plastic power, the effusion being at best but of the character of molecular lymph, and in a large number of cases puriform; and there being little or. no poAver to circumscribe the effused pus Avith plastic lymph, extensive and destructive gan- grene supervenes. Whilst all this mischief is going on upon the surface and in the areolar tissue, the constitution sympathises, as might be anticipated. In the milder cases, the fever gradually subsides without its assum- ing a Ioav type, or any dangerous complications arising, and the patient is convalescent in a few days. In the more severe, the tongue becomes brown, the pulse compressible, the eruption livid, and the patient is reduced to the condition of the loAvest typhus. The SAvelling of the face in such cases is often so great as entirely to obliterate the natural features, and give the patient a most frightful PROGRESS — CAUSES. 551 appearance. In this form of the disease the patient may die of exhaustion within a week, often about the fourth or fifth day. Besides the direct effect of this fever upon the system, there is another cause of depression in the puriform infection, from the dif- fuse suppurative inflammation, not to mention the probable depres- sing effect upon the nervous system of extensive inflammation of a part to which is distributed so abundant a supply of sentient extrem- ities of nerves, as is the case with the skin: but, besides these, there are apt to arise dangerous complications, the organ most likely to be so affected being the brain. Delirium, sometimes of a fierce charac- ter, at others having more that of delirium tremens, may suddenly set in, and the patient dies comatose about the eighth or ninth day. Some pathologists regard this as the effect of metastasis to the brain, and though Dr. Gregory regarded this proposition as untenable, there are facts in its favour, such, for instance, as the delirium super- vening upon the inflammation about the head being checked by cold applications, and its subsiding upon the use of external irritation. In these cases the brain presents no morbid appearance after death beyond mere engorgement of the vessels. The stomach is sometimes attacked, the symptoms being uncontrollable sickness, with a ten- dency to rapid exhaustion. There is in children a great liability to muco-enteritis AA'hen attacked by this disease. Erysipelas also attacks Jahe serous membranes much in the same way that scarlatina does; and another point in which it resembles that disease is its tendency to attack the throat. This it does in a still more dangerous manner, the inflammation extending often to the epiglottis and larynx, and causing death from apncea. The tendency of erysipelas to excite puerperal peritonitis has been already noticed, and it is remarkable that handling the affected peri- toneum in dissecting a subject that has died of the latter disease, is very likely, if there be any excoriation, to set up erysipelas of a formidable character. The cause of erysipelas is to this day rather an agitated question, though perhaps feAV Avill now be found hardy enough to deny that it may be propagated by contagion; or, on the other hand, that com- munication with an infected person is its alone cause. It is also miasmatic; that is to say, either excited, or its diffusion promoted, by some atmospheric or other epidemic influence, as in several sea- sons it spreads with unusual rapidity; though, Avhether this may arise from any specific poison pervading the atmosphere, or merely from the season being such as to induce a weakness of body in which there is less power of resisting the poison when applied to it, may admit of dispute. The spread of erysipelas is greatly facilitated by neglect of cleanliness, defective ventilation, and overcrowding of sick persons in the same apartment, as in the wards of an hospital; want of attention to these particulars favouring the development of Avhat has been termed hospital miasma, AA'hich is characterised by the extension of erysipelas and its kindred disease hospital gangrene. Erysipelas often attacks wounds and sores, and is therefore peculi- arly to be dreaded after accidents and operations. With regard to a • 552 ERYSIPELAS. poison so subtle and so easily conveyed as is that of erysipelas, it is difficult to give a positive ansAver to the folioAving queries:—Whe- ther it ever appears in its worst form in the wards of hospitals, &c, without being imported, and whether it spreads in such situations independently of any prevailing atmospheric or other epidemic influ- ence ? In regard to the first of these queries, it is highly probable that it may so arise, and that it would more frequently do so but for the great precautions that are now used. On the other hand, how- ever, the majority of cases that do occur at Guy's, particularly, may be traced to importation from without, and its extension in the medi- cal wards especially has been pretty effectually checked by the exclusion of such cases, and the speedy removal of any that may occur. We have already spoken of breach of surface (and of this class of causes there is none which is so likely to excite erysipelas as leech- bites) as inducing susceptibility, if not sometimes acting as the direct and immediate cause of erysipelas itself—exposure to cold is another. There is also a certain constitutional, and, apparently, congenital sus- ceptibility inherited by some persons, so that the slightest exposure to cold, the merest scratch, or the application of a single leech will induce erysipelas. This is often so slight an affection that it may well be doubted AAmether it is essentially the same disease, more par- ticularly as it rarely or never propagates itself by contagion; this, opinion, however, does not seem to be Avarranted upon other grounds; and, therefore, the inference to be drawn from such cases is, that in some persons it is very easy to generate erysipelas de novo, and that it is not capable of communication Avithout a certain amount of con- centration or intensity of the poison. The treatment of erysipelas is simple: it presents the same ques- tions for decision, and should be guided by the same principles, as that of continued fever. The milder cases require but little treat- ment ; attention to the bowels, saline draughts, with the addition of a little antimonial Avine, will generally be all that is required in the Avay of medicine: the patient should also be kept in bed till the inflammation has subsided, and precautions should be used against exposure to cold until the desquamation is complete. In the severe cases the same treatment should be used at the com- mencement : the patient should be put to bed, a gentle aperient, in shape either of rhubarb and calomel or hydrarg. cum cret. and castor- oil administered, and salines used. The best form will generally be the liq. ammon. acet., to which may be added sp. aeth. nit., and when there is any sharpness of the pulse, a few minims of antimonial wine. A question iioav arises as to any applications to the surface, and vari- ous modes of treatment have been recommended: in mild cases the best application will be the sprinkling of flour or starch over it; the latter is preferable; finely-powdered charcoal is, but for its blackness, an appropriate application. When the tension is great, especially about the face and scalp, the making a large number of minute punctures with the point of a lancet, and subsequently fomenting the parts so as to encourage the bleeding, is a very useful means of lower- TREATMENT. 553 ing the local inflammation, and often with it the constitutional fever. The long incisions which have favour with some practitioners can- not, however, be too emphatically condemned; cold applications should never be used to erysipelas of the face or scalp, but warm fomentations are often soothing when there is much tumefaction of the eyelids. As the disease proceeds, the question of the use of stimulants becomes the all-important one. In erysipelas we must generally endeavour to anticipate the prostration, and as soon as the pulse becomes compressible, the sesqui-carbonate of ammonia should be added in excess to the amount of about five grains: indeed in this disease, like scarlatina, the volatile alkali seems to have a peculiarly favourable effect. As the tongue becomes dry and sordes accumu- late upon the teeth, wine must be freely administered, as in the low forms of other fevers, and the serpentaria or bark should be used for the vehicle of the ammonia; a good form is the annexed (F. 96).* The bowels should be Avatched; they should not be allowed to become loaded; and if diarrhcea supervene, which it sometimes does, the enema of poppy and starch should be administered. Another important question will be the use of opium. Where there is restlessness at the earlier period of the disease, henbane may be used freely, and will often be effective, but in the more advanced periods, if there be much delirium, it will rarely have any effect: we must then have recourse to opium, provided the secretions are toler- ably free, the pulse not hard, and the pupil, when we can see it, not contracted; the nearer the character of the delirium approaches to that of delirium tremens, the more safely may we use opium or morphia. In all questionable cases the latter is to be preferred. When signs of phrenitis supervene, which they sometimes do, we must first inquire if there has been any retrocession of the eruption, about the head particularly; and if this appears to have been the case, we must apply a blister to the back of the neck. In cases where the very objectionable practice of applying cold to erysipelas on the head has been employed, a blister to the back of the' neck has in most instances brought back the eruption and saved the patient. When the stomach is the organ particularly affected and there is obstinate vomiting, a blister or sinapism should be applied to the pit of the stomach, and Henry's calcined magnesia may be gh'en, to the amount of about ten grains, with about three of dilute hydrocyanic acid in an ounce of vehicle; or if there be much depression, the brandy and soda-Avater, recommended in continued fever, may be employed. The erysipelas of new-born children oc- curring Avithin the month is ahvays a most dangerous disease, many obstetric practitioners regard it as almost certainly fatal. The best mode of treatment is warmth, and the use of ammonia. In severe cases, where there is no head-affection, the sesquichloride * (F. 96) R. Ammon. Sesquicarb. gr. v. Tinct. Cinchonte co. 3 iss. Decoct. Cinchonse, 3 ss. Infus. Serpentariae, ^ iv. Misce. Ft. haust. To be given every fourth hour. 554 YELLOW FEVER. of iron; in doses of about ten minims of the tincture three or four times a day, appears to be almost a specific. [THE YELLOW FEVER. The yellow fever is a disease bearing a close resemblance, in many of the features of its etiology and symptomatology, to the febrile dis- eases of acknowledged malarial origin, and yet differing from these, as well as from all other fevers, in many striking and important parti- culars. It would appear to be, in fact, as it has indeed been described, by several distinguished physicians, an affection sui generis —a specific fever. The occurrence of yelloAv fever is confined, strictly, within a certain geographical range, and limited by the atmospherical temperature of the climate and season—too great, as Avell as too low a degree of heat appearing to be alike inimical to its production. It is inva- riably arrested by the appearance of frost. The natives and permanent residents of the localities to which the disease is endemic are in a great measure exempt from its attacks, as is also the negro race. It is a fever of but one single paroxysm, terminating, in the great majority of cases, within seventy-two hours, and followed by an entire remission, succeeded either by complete convalescence, or, after longer or shorter interval, by a state of exhaustion, and a series of morbid phenomena eA'entuating, most commonly, in death. Persons Avho have once suffered an attack of the fever are gene- rally, though not invariably, exempt from a recurrence of the disease in future. Yellow feArer has received a variety of denominations, founded on the place from whence the disease is supposed to have been originally derived, on one or other of its characteristic symptoms or peculiari- ties, or its supposed pathological character. The term yellow fever, by AA'hich it is know to the large majority of English and American physicians, as it involves no hypothetical vieAvs in relation to its etiology or pathology, is perhaps, in the present state of medical opinion, as good a one as can be adopted. It is based upon the icteroid hue of the surface by which the disease is usually attended in some one or other of its stages. In its pathological character, and pathognomonic phenomena, yel- low fever is ahvays identically the same disease in Avhatever locality it may appear, as well as during its subsequent recurrences in the same locality. Nevertheless, it is liable to assume, in different places, at different periods, and often at the same place during the same season, various important modifications in its general characteristics—pro- ceeding, not from any specific difference in the nature of the disease, but from varying degrees of reaction—from a tendency to depression in the vital force—from the preponderance of certain symptoms, appertaining or not to the disease, and varying according to the greater or feAver number of vital organs involved, or from other causes; the A\diole depending on peculiarity of constitution, tempera- DESCRIPTION. 555 ment, habits, or state of health in those attacked; on a difference of intensity in the morbific agent, and on various contingencies result- ing from the nature of the localities at which the disease prevails, the degree of temperature, humidity, and other atmospherical phenomena. Hence, it folloAvs, that, in the examination of the disease no inva- riable concatenation of phenomena, succeeding each other in regular order, as the disease progresses towards a favourable or fatal termina- tion, are not to be expected in every case. "But a variety of groups of symptoms which, though linked together by certain phenomena—which, being pathognomonic of the disease, approximating to each other in several other respects, afford very strong evidence of their being all members of the same family —are yet sufficiently distinct in their general outline and their mode of progression, to justify their being made the subject of separate consideration. Certain of those groups of symptoms, or varieties of the same disease, prevail more generally in some regions than in others; thy are also more frequently encountered in some seasons than in others, in the same place; while in some epidemics, several or all the varieties are intermingled among the different individuals attacked; in others, the fever assumes much the same character in the majority of those affected. Such being the case, it is evident that the description of the disease as it affects one individual, or one set of individuals, will not necessarily apply to another case or group of cases. In some, the fever presents itself with marks of inflammatory action of greater or less intensity; in others, that action is almost or totally absent. In some, the pathognomonic symptoms are combined with an element of malignancy and putridity which imparts a totally different aspect to the disease. In a different set this element is absent, and replaced by one of a nervous character. In some in- stances, phenomena not characteristic or pathognomonic of the dis- ease, and depending on accidental complications, assume the predo- minance, and thereby impart still greater differences in the features of the case."* To meet these varying characteristics of the diseases at different places, and in different seasons, or in different individuals, the dis- ease has been divided into various forms. The division of all cases into the inflammatory, or those characterised by well marked reaction, and the congestive, in which this reaction is but faint or totally absent, would seem to be founded in nature. These general forms have been again subdivided, the first, into the mild, the violent, and the intense; the second, into the slight, the aggravated and the apoplectic. Under one or other of these divisions all the cases of yellow fever that pre- sent themselves may be, very conveniently, arranged. The attack of yelloAV fever usually occurs in the after or fore part of the day—sometimes during the night. It may commence abruptly Avithout premonitory symptoms of any kind. The patient may be struck down at once, as by a blow or by lightning, and sink immedi- ately into a state of coma. Sometimes the attack is preceded for several dav's by anorexia, general uneasiness, costiveness, flatulence, heat in * La Roche on Yellow Fever, Vol. I., p. 1-2. 556 YELLOW FEVER. the stomach, lowness of spirits, vertigo, pain of the head, with dull, watery, or brilliant, yellow or red eyes, &c. Very generally the attack is ushered in by a sense of chilliness, often alternating with glowing flushes of heat, or by a regular chill, amounting sometimes to a perfect rigor. On the other hand, in even severe and dangerous attacks, all symptoms of the kind may be absent. The alternation of chilliness and heat is seldom of any duration. It soon gives way to confirmed fever, which, though continued, is more intense in the latter part of the day and during the night, than during the other portion of the tAventy-four hours. In the more malignant forms of the disease there may occur but a slight reaction, or it may be entirely wanting; the pulse being feeble, soft, occa- sionally full, or scarcely to be felt—the patient sinking at once into a state of collapse, or of stupor, coma, and convulsions. When febrile reaction becomes fully developed, the pulse is gene- rally quick and tense, and during the exacerbation full and strong, though, occasionally soft, and from ninety to one hundred and twenty in a minute. In very malignant cases it is gaseous. There is a violent throbbing and beating of the temporal arteries and carotids. The skin is hot, dry, harsh, and pungent, or it may be dry, unctuous, or perspiring, flabby and cold, except over the centre of the body. The face is either highly flushed, pale, or purplish. The eyes decid- edly red, sometimes as though bloodshot, hot, and more or less painful, the patient experiencing a sensation as though grit or sand had been introduced beneath the eyelids. Often the ball of the eye resembles a mass of vessels distended with blood, it is, at the same time brilliant, shining, and Avatery, in some cases presenting somewhat the expres- sion peculiar to intoxication. Occasionally the condition described continues from the onset of the attack to the close of the stage of reaction, or it may only par- tially exist during the first or second days. Sometimes profuse per- spiration occurs and continues to the second or third day of the attack; at others, the temperature of the surface undergoes but little change, at others, again, the skin speedily becomes dry and cool, with complete torpor of its vessels, and an entire loss of irritability. The symptoms described are very generally attended with more or less intense pain, usually of the fore part of the head, and eyes, shooting from temple to temple, but occasionally confined to one side. This constitutes, in the majority of cases, one of the most dis- tressing symptoms throughout the entire stage of reaction. There is also pain, often of the most intense character, in the back, loins, and large joints—extending to the hips and down the thighs, or even lower. Cases occasionally occur, however, in which no such pains are experienced, or the pain in the back and limbs is dull and ob- scure, or that of the head is replaced by a sense of weight and stupefaction During this stage, the tongue is moist, covered with a thin, white, cottony fur, and most commonly red at the edges and apex; occa- sionally there is a soreness of the throat, sometimes even rendering deglutition difficult. SYMPTOMS. 557 At the very onset of the attack nausea or other uneasiness of the stomach, with or Avithout vomiting, is not unfrequently present. Generally the stomach is distended, often, but not always, painful upon pressure, and irritable, especially after taking any kind of drink or aliment—frequently affected with a sense of nausea and more or less propensity to reject its contents. These gastric symptoms are not, however, in general fully developed until from twelve to twenty- four hours from the commencement of the attack, or at the commence- ment of the second stage, when they become prominent. On the first or second day of the attack, sooner or later, the patient experiences a burning pain, or a sense of stricture, weight, distension, or oppression—sometimes overAvhelming—at the praecordia, Avhich feels as if tightly bound Avith a cord. Tenderness or pain is expe- rienced on pressure in most cases—often excessive. The irritability of the stomach augments and proves distressing—every thing saval- lowed is rejected, and even Avhen the stomach is undisturbed by drink or medicine its morbid contents are throAvn off spontaneously—con- sisting either of substances that have been swalloAved, mixed with clear, glazy mucus, or with matter of a sea-green colour and bitter taste. In mild cases, bilious vomiting sometimes occurs. The act of vomiting is often violent, and attended Avith retching and con- siderable distress and pains. There is, at the same time, conside- rable, though not often insatiable thirst. The desire for cold drinks is nevertheless generally extreme. The urine is commonly deficient in quantity, and of a dark red colour; often depositing a copious sediment. The boAvels are ordi- narily costive—sometimes obstinately so. AVhen stools are obtained the discharges are, at first, usually soft and feculent, seldom tinged Avith bile—occasionally they are of a drab colour. AVhen cathartics have not been given, the stools, in the course of the disease, become lighter coloured, and assume a starchy, cream-like or puruloid appearance, In a few cases they are Avatery, or even bloody, from the outset of the attack. The patient is affected with extreme restlessness and jactitation; moans, sighs, and shifts his position continually in search of ease. In the very few cases in which jactitation is absent, the patient some- times feels a disposition to rise from his bed, and Avalk about the room, his muscular strength remaining unimpaired to a degree unusual in febrile diseases. There is nevertheless, from the outset of the disease, and during its entire course, in numerous instances, universal debility. In very many cases the patient complains of feeling as though he were unable to expand his chest or inflate his lungs. Spasmodic pains about the chest are not unfrequent. Bespiration in some cases is laborious and hurried; in others, sIoav, and accompanied Avith deep and heavy sighing; in others, again, it is unaffected. The blood draAvn soon after the onset of the disease, and when there are symptoms of well marked reaction, and especially Avhen any local inflammation is present, is sometimes of a bright arterial hue, sizy, and even cupped, as in ordinary phlegmasias. In a very large num- 558 YELLOW FEVER. ber of cases, however, it presents neither cupping or buffy coat, and the coagulum is flabby and easily torn. AVhen the separation into crassamentum and serum takes place, in some cases the latter is of a natural colour; in others, it is of a yellow hue, or slightly tinged with red, and transparent; in other cases, again—more frequent in some epidemics than in others—the separation does not take place, the blood remaining for hours, or altogether the same as Avhen first draAvn. In a few cases, Avhen drawn later in the disease, or throughout its course in cases unattended A\ifh reaction, the blood is of a dark colour, void of all inflammatory indications, and not unfrequently as fluid as molasses; Avhile in other cases, again, it is smeared over with a pellicle of sizy lymp, at the same time that the part lying at the bottom of the vessel is dissolved. In the early stage of the in- flammatory form of yelloAV fever, the blood is very hot, and has a peculiar odour, which, according to some accurate observers, is sup- posed to furnish a sure indication of the true nature < >f the disease. At first, the patient attacked Avith yellow fever, is apprehensive and anxious to a distressing degree, as strongly expressed by his countenance. In very malignant cases there is an expression of apathy or one indicating a sense of horror or intense agon}-. In most cases, there is some confusion of intellect attended Avith constant pervigilium, though Avithout so much derangement of the reasoning faculties as to amount to decided delirium. In some cases, however, the latter symptom assumes a more marked character, the disturb- ance of the mind reaching to the degree constituting mania, attended Avith wild or fiery looks, and uncontrollable agitation of body. In other instances, there is a greater or less degree of stupor, through Avhich, as Dr. AVood remarks, when short of coma, the signs of dis- tress shoAV themselves as through a veil. In not a few cases, though particularly in young persons of both sexes, and in females at two different periods of life, hemorrhages take place from one or both nostrils, during the afternoon exacerbation. The stage of febrile reaction continues Avith little or no mitigation during a period varying from a few hours to tAvo, three, or more days—the duration being commonly in inverse ratio to the violence of the attack. Having run this course, the fever, with all the attend- ing symptoms, subsides, never more, or very seldom, to return—the disease being one of a single paroxysm—and is followed1 by a period of remission or metaptosis, during which the several organs of the system resume their normal functions. The patient feels himself able to set up, or even get out of bed. His eyes and face become tinged with yellow, or copious evacuations of bilious matter occur by stool, or a gentle or profuse perspiration sets in, or often, without any such critical signs, convalescence is established, and the patient speedily recovers. « This, however, is the course only of the most favourable cases. In the larger number, the period of remission which follows the first stage is only temporary, and is soon succeeded by other phenomena of a more formidable character. During the very period of de- ceitful calm, symptoms may be detected, denoting the existence of SYMPTOMS. 559 undiminished danger. The tenderness of the epigastrium is unre- lieved or even increased; the eyes and face usually acquire a yellow or orange colour, which gradually extends from the forehead to the face, neck, chest, and, finally, diffuses itself more or less generally over the Avhole surface. The urine also is found tinged with the same yellow hue. The pulse is sometimes slower than in health, and in bad cases the patient betrays a little heaviness of intellect or stupor. After a period, varying from a few hours to twenty-four or more, the symptoms just enumerated become aggravated, and others are added. In the majority of cases, the pulse remains natural, or slower than in health, and becomes still slower as the disease aclvances, until at length the pulsations are reduced to forty or thirty in a minute, being, at the same time, feeble and irregular. The heart, neverthe- less, even in the most malignant cases, often beating with consider- able energy, even after the pulse has ceased to be felt at the wrist, &c. The tongue becomes loaded—particularly in the centre—moist or dry, and. with or without redness of the edges. Thirst increases, and is often insatiable,—nausea and vomiting, with heat in the stomach, return, and become constant,—the matter ejected being mixed with streaks or flakes of a red or brownish colour. Eespiration quickens, or becomes embarrassed—the skin becomes cool, dry, and parched— the anxiety at the praecordia is now distressing, and attended with a sobbing kind of sighing, constant hiccough, and, occasionally, an expression of deep anguish and despair. The mind often remains clear and undisturbed. There is generally an extraordinary degree of apathy evinced—the countenance present- ing an expression of resignation or indifference as to the issue. Some- times the patient evinces a kind of cheerful delirium, imagining himself well; in other cases, Avithout delirium, he remains for a long time as if in a deep reverie, and when aroused, starts with surprise, and ansAArers in a hurried manner. Many, Avhile apparently in great dis- tress, declare that they are well. As the disease progresses, coma supervenes, from AA'hich the patient is aroused by vomiting or by dreams, and fancies himself perfectly restored to health—attempts to rise, but soon relapses into a state of insensibility. In many cases, debility is more or less considerable. In not a feAV, howeArer, the patient retains, to a late period, his mus- cular strength—to such an extent, indeed, that he will get out of bed and Avalk about his room, or even beyond that, if permitted. The physiognomony is peculiar and striking, conveying, as has been well remarked, an impression at once of the malignant and dangerous nature of the disease. Usually the foulness of the tonge increases, though it is not uncom- mon for it to become, after a short time, cleaner and moister than before. It is sometimes tremulous and protruded Avith difficulty; when the patient succeeds in showing it, he not unfrequently forgets to put it in again. It is broAvn and dry in the centre, or smooth, red and chapped, or white at the edges, Avith a black streak in the mid- dle. The gums, lips, teeth and nostrils are covered with sordes. 560 YELLOW FEVER. As the case advances, the vomiting becomes less frequent, while irritability of the stomach, which rejects everything introduced into it, continues undiminished. When vomiting does occur, however, there is an increase in the quantity of the matter ejected, and to the momentary relief of the patient. The matters ejected from the stomach are often thrown out forcibly and to a considerable dis- tance. From the condition just described, recovery not unfrequently takes place—generally by a gradual receding of the symptoms, but some- times by an evident-critical revolution—the pulse acquiring force and activity, the skin becoming warm and moist, the irritability of the stomach lessening and finally disappearing. In other cases the symptoms are of a still more formidable char- acter. The matter thrown up by vomiting consists of brown, black- ish, or chocolate flakes or particles, diffused in a colourless liquid, which, though at first slightly tinged by them, ultimately becomes black and opaque, resembling coffee grounds floating in a serous fluid. In some cases, grumous dissolved blood is thrown up. The matter vomited is acrid, often excoriating the throat, tongue and lips. Although fatal cases of yellow fever may occur unattended Avith vomiting of black matter, it is a common attendant upon the disease at the period indicated, and always portends the most imminent dan- ger, for, though some recover after its occurrence, the number is very limited. The abdomen is soft, seldom meteorised. The stools, when they occur, present the same character as the matter ejected from the stomach, or resemble tar or molasses, or they may consist of blood, more or less pure. The urine becomes natural in appearance, or of a dark colour, and limpid. It is often suppressed from deficiency of secretion, or simply retained. Sleep is interrupted, and attended generally with painful dreams. The face and breast become spotted as with ink. The jaundice—which though so common an attendant of the disease as to have given it its name, is nevertheless often, especialy in rapid cases, totally absent—becomes more diffused and of a deeper hue. The skin assuming often a deep, dusky yellow, or brown, ma- hogany, bronze or purple hue, imparting the idea of blood settled in a bruised part. The blood in the capillaries becomes stagnant, form- ing petechias, vibices, or large blotches, and accumulates in depend ing parts, and the extremities. In many cases it oozes from the nos- trils, tongue, gums, anus, eyes—from leech bites, blistered surfaces, and the punctures of the veins, and is, like all the blood in the vessels, dark coloured and dissolved. As the disease advances, these symptoms increase in intensity; hiccough sets in, and is soon constant and accompanied Avith the hip- pocratic countenance, difficulty of swallowing and slow and stertorous convulsive respiration. The pulse becomes small, feeble, intermittent, and finally fades aAvay. The alvine evacuations are highly offensive, of a cadaverous smell, and, like the urine—which, if at all secreted, assumes a blackish and bloody appearance—are avoided involun- tarily. Subsultus tendinum not unfrequently follows; so also gan- grenous spots, and, in a few cases, buboes, carbuncles, and eschars in SYMPTOMS. 561 various parts of the body Loss of speech, dimness of vision, insen- sibility, Ioav muttering delirium, and coma, at times supervene; but it is not unusual to find patients retaining their intellectual faculties unimpaired to the last. Battling in the throat, cold clammy sAveats, cadaverous and peculiarly offensive odour of body, cold respiration, are the immediate precursors of death, Avhich often occurs quietly, but, in other instances, in the midst of violent convulsions. The duration of the disease varies, according to the nature of the case, from three to nine days; sometimes it is shorter, at others longer; while, in cases of recovery, the convalescence is usually secure and rapid. In the foregoing account of the symptoms of yelloAV fever, considered in the aggregate, Avithout reference to the particular groups in Avhich they may present themselves, in the slight ephemeral to the most intense inflammatory grade, and in the several grades of the conges- tive form, we have folloAved very closely the admirable delineation of the disease given by Dr. La Boche in his late invaluable treatise on the yellow fever, using frequently his very Avords. FolioAving the author just referred to—and Ave know of no better guide—Ave shall noAV rapidly sketch the features of the disease as exhibited in the several grades of its inflammatory and congestive fevers. In the more intense grade of the inflammatory form, Ave have the initiatory chill—of a more or less decided character, followed by intense febrile action—a quick, frequent, strong and full pulse; hot, and usually dry, parched skin; violent throbbing of the temporal and carotid arteries; flushed face; red, blood-shot, brilliant, shining, Avatery eyes, with a sense of pain or soreness in the balls; sometimes tumid eyelids; intense pain in the supraorbital region, in the back, thighs, and legs; tongue usually crimson red at its edges and apex, and covered with white or yelloAV fur; a sense of anxiety, constriction and intense pain at the praecordia; nausea, succeeded by retching and vomiting, at first of the matters sav alio wed, mixed with a clear, glairy mucus—occasionally Avith a sea-green coloured substance of a bitter taste—now and then of pure bile—often distension of stomach, Avhich is sometimes painful on pressure, and generally irritable to an extreme degree, especially after the first twelve or twenty-four hours of the attack. The urine is deficient in quantity, high coloured and often sedimentitious. There is obstinate costiveness—the stools, Avhen obtained, being at first soft and feculent, sometimes tinged with bile; Avhen no cathartics are used, they become, subsequently, lighter coloured and of a starchy, cream-like appearance. There are considerable jactitation and restlessness, with moaning and sighing —and a disposition to rise from bed and walk about. The respira- tion is laborious and hurried. There is an anxious, gloomy, sad, or impatient expression of countenance. The patient experiences great apprehension—there is confusion of intellect, constant sleeplessness. Delirium, properly speaking, is generally absent; occasionally, how- ever it is present, even from an early period of the attack, reaching sometimes to a degree amounting to actual mania 36 562 YELLOW FEVER. The stage of reaction lasts* from a few hours, to two, three or more days—generally from sixty to seventy-two hours. It is succeeded by a remission of all the symptoms. The patient becomes at once cheer- ful, sits up or gets out of bed, and expresses a desire for food. The adnata of the eyes now usually assume a yelloAvish tinge. The remission, which is too generally a deceitful calm, may con- tinue from a few hours to twenty-four or thirty, and then gradually glide into the second stage. Prostration foUoAvs; the pulse be- comes rapid, irregular and depressed, or more generally, it is natural in frequency or even sloAver than in health. The tongue becomes loaded Avith a broAvn fur, having a darker streak along its middle, swollen, and moist, or, frequently, it is clean, with a slight pasty coat- ing, or it may be of a deep fiery red, and, occasionally, in an ad- vanced period, it is bloody, or dry, black, and chapped; Avith dark coloured sordes on the mouth, lips, gums, and nostrils. The respi- ration is quick and laborious; there is augmented and insatiable thirst; a distressing sense of anxiety at the praecorclia, accompanied, often, with hiccough and sighing. There is an augmentation, in many cases to an intolerable degree, of the pain at the epigastrium, which is aggravated during the vomiting that now occurs almost spontaneously—the contents of the stomach being forcibly ejected and to some distance—the matters discharged consist of broAvn, black- ish, or chocolate flakes or particles, diffused in a colourless fluid, and gradually acquire, in fatal cases, the characteristics of black vomit. ccasionally, involuntary discharges occur from theboAvels of a black, acrid, offensive matter, sometimes resembling tar or molasses, at others the stools consist of blood. A yelloAV tinge, Avhich appeared at first about the forehead and eyes, extends, subsequently, to the face, chest, and, finally, over the entire surface, gradually acquiring a deeper hue, the skin assuming a dusky, broAvn, mahogany, or bronze colour. The jaundiced hue of the skin is sometimes, how- ever, absent, or restricted to the adnata of the eyes, or appears only after death. The mind is often clear and undisturbed to the last— frequently the patient exhibits a degree of apathy, with an expres- sion of resignation and indifference. In other cases various modifi- cations of delirium are present. Frequently, there is more or less debility; in perhaps the majority of cases, however, the patient re- gains his muscular strength, if he had previously lost it, and retains it to the last. The body, in the progress of the disease, becomes cold and clammy ; the urine blackish or bloody, and is often passed in- voluntarily ; more generally it is suppressed or retained. Haemorr- hages of dark, dissolved blood, occur from all the natural outlets, and death, preceded by intolerance of light, petechia?, meteorism, singul- tus, eructation of offensive gas, subsultus tendinum, convulsions or coma, closes the scene. The rapidity of the fatal termination in this grade, is, in general proportioned to the violence of the inflammatory action of the second state, by which, in its higher degree, the vital organs may become rapidly overAvhelmed and disorganised, to a degree incompatible with the continuance of their functions. Kecoveries seldom occur in GRADES OF THE DISEASE. 563 this form and grade of the disease ; when they do, it is by a gradual amendment of the symptoms, or some critical movement taking place before the accession of black vomit. In the milder grade of the inflammatory form, the symptoms of the first stage are pretty much the same as in the morelintense grade, but_ less violent, rapid, and tumultuous. It is attended by more decided exacerbations and abatement of the fever—the abatement often approaches to an actual remission. It often extends to four or five days. The second period or that of remission is more perfect, and in many cases the harbinger of recovery—convalescence dating from the final subsidence of the fever—the disease terminating Avith bilious critical discharges by the bowels, a moisture over the skin, or diaphoresis, a copious emission of urine, or a haemorrhage from the nose—Avith or without jaundice—often without any evident crisis. In other cases, however, the remission is followed by many of the symptoms which mark the second stage of the preceding grade. These sometimes assume a character of great malignancj^, and if not ar- rested by art, or the recuperative efforts of nature, terminate in death. In other cases, they stop short of black vomit, and the patient is gra- dually restored to health. In others again, though in a very small number, recovery ensues, even after the supervention of the black vomit, and other usually fatal symptoms. The disease in this grade is evidently of a less malignant character, and within the range of re- medial agencies. The boAvels are acted upon without much difficulty by cathartics or enemata, the operation of which is productive of re- lief, the pain and affection of the head and other parts are under the control of proper depleting remedies, general and local, revulsives, &c; the gastric irritability, though obstinate, is not ahvays as un- controllable as in the more intense grade, and diaphoresis is generally easily obtained by external and internal means. In the ephemeral grade of the inflammatory form, although there are the same general features, the same outline of phenomena, as characterise the preceding grades, they are of a still milder and more manageable nature—and terminate, under proper and even mild treatment, sometimes in a single day. Occasionally, however, it continues from three to five days, Avhen, in some cases, it is attended with slight and imperfect remissions. The symptoms indicative of an open and Avell developed febrile paroxysm subside, sometimes, suddenly; at others, the crisis being- marked by increased alvine eAracuations, by diaphoresis, or epistaxis. In the aggraA*ated grade of the congestive form, the attack occurs suddenly. From the outset there is considerable prostration. In most cases, from an early period, there is giddiness, stupor, almost unconquerable disposition to sleep, loss of memory, and a desire to be left alone. There is a sense of weight and oppression, rather than of acute pain in the head. In a feAV cases, there is delirium, either transient, or ending in confirmed coma. The face is pale, purplish, or livid in color, Avith a stolid or apathetic expression of countenance—the patient being taciturn, and uttering no complaint. Sometimes there is entire insensibility, the eyes being Avide open, at 504 YELLOW FEVER. others there is an expression indicative of distress, horror, or even intense agony. There are obscure pains of the loins and extremities, and a feeling of helpless debility about the spine—most distressing at the sacrum— sometimes attended Avith a paralytic failure of the lower extremities. There is a dull, red, glassy, or drunken, idiotic look of the eyes, with, in some cases, a dilatation of the pupils, and sleepy movement. The skin is ahvays deficient in tone, dry, dense, or unctuous, or sometimes covered Avith, and as if melting in SAveat. It is generally cool—sometimes cold, except at the central portion of the body, which is hot; in some instances it is smooth and white, and occa- sionally loses, more or less completely, its sensibility and irritability. The pulse is sometimes accelerated, at others not more frequent than in health; sometimes full, at others small. It is ahvays Aveak, offering no resistance to the pressure of the finger; occasionally it is scarcely perceptible at the wrist, though at the same time the heart and carotids may be throbbing forcibly. As the disease advances, it diminishes in frequency, the beats not amounting, at times, to more than forty, or even thirty in a minute. In some cases it becomes intermittent. AVhen blood is draAvn, it is generally found black or discoloured, and seldom retains its natural character. There is tenderness of the epigastrium, tension of the hypochon- dria, Aveight and oppression at the praecordia. There is early irrita- bility of the stomach—and vomiting—the matter ejected rapidly assuming the character of black vomit. The discharges from the bowels are scanty—cream or clay-coloured, puruloid, or gelatinous —sometimes of a pea-green colour, or black and bloody. The respi- ration is laborious. The tongue, sometimes natural, is at others, first pasty, Avith patches of Avhite fur; its edges and apex being red. Occasionally, it appears as though seared with a hot iron. It is often tremulous, and Avhen the patient puts it out he often forgets to draAV it in again. It sometimes becomes dry, while the papillae are separated by deep fissures. There are, also, orthopnoea, sore throat, deep and interrupted sighs, haemorrhages of dissolved blood from one or more of the natural outlets, a yelloAV or bronze colo' r of the skin, suppression of urine, extreme restlessness, Ioav, mono- tonous Availing, and other symptoms indicative of the utmost danger, or the approach of death. In some cases, the leading symptom is an overwhelming oppres- sion at the praecordia, attended with sIoav, laboured respiration, deep sighs, and groans. In others, constant vomiting, and intense epigas- tric distress, quickly followed by black vomit and death; in oilier cases, again, the pulse is nearly natural, the tongue clean, and the stomach calm, but excessive restlessness, anxiety and distress ensue, soon followed by black vomit and fatal collapse. In some instances, the disease, though marked by the same train of phenomena, assumes, nevertheless, in its course, a less formidable character, stops short of the black vomit and other fatal symptoms, and proAres comparatively mild and manageable. As a general GRADES OF THE DISEASE. 565 rule, however, but very few of those attacked with this form of the disease recover. The adynamic or typhoid grade occurs in persons deficient in vital poAver, or under circumstances tending to foster or develope the typhoid diathesis. It is generally ushered in by a sense of chilliness, succeeded by one of burning heat, partially distributed over the body—affecting principally the under parts of the arms, and inner surface of the thighs. The circulation is depressed, the pulse being small and weak. The eyes have a dingy appearance. The head is severely painful, with confusion of thought and dimness of vision. The skin assumes an olive hue, and is covered with petechiae or vibices. Haemorrhage from the natural outlets, leech bites, &c, follow, as also excoriations about the nose, mouth, or other parts; 'gangrene of blistered surfaces, sometimes anthrax, buboes, and, more frequently, venous infiltration under the skin, or in the interstices of the muscles. The walking grade of yellow fever is so named from the fact that in it the organs of animal life remain almost unaffected. The patient most frequently sauntering about his room, or, at times, even walking in the streets for recreation or on business. In some instances he acknoAAdedges to a feeling of Aveakness, but, in others, he exhibits at intervals, or throughout, indications of considerable muscular strength. He complains of nothing, denies his being ill, amuses himself in reading or otherwise, and to a casual observer, appears to be slightly, if at all, indisposed. The pl^sician will be able, hoAvever, generally to observe that the patient exhibits an unusual expression of countenance—dull and listless. The eye is Avatery—the complexion almost of a' mahogany hue—the pulse exceedingly weak, or even totally absent. Black vomit overtakes him, even Avhile occupied as described, or very soon after, and death \ speedily ensues. In some of the cases of the apoplectic grade, the patient is struck doAvn suddenly, as if by lightning, Avith stupor or coma, and death, preceded by "convulsions, soon folloAvs: or, without the slightest premonition, he is instantly seized with vertigo and confusion of mind; accompanied with dull pain and fulness in the head—spas- modic pain and considerable debility in the legs—coldness, debility, and a sense of uneasiness in the spinal region—a pulse varying, in different cases, in fulness and frequency, but ahvays Aveak, and finally faltering,—a cold skin, sometimes dry and flabby, but gene- rally unctious or bedewed Avith cold perspiration—and irritability of stomach. The patient lies as if stunned, Avith dilated pupils and an expression of gloom on his countenance. An effort at reaction occasionally takes place—but scarcely ever leads to a favourable result. Afore generally, the patient becomes perfectly comatose, the eves assume a -dassy appearance, the pulse fades away, involuntary discharges and profuse haemorrhage supervene, and death soon ensues.* * La Roche on Yellow Fever, Vol. 1., p. 129, et seq. 566 YELLOW FEVER. " The yellow fever is far from pursuing, ahvays, everywhere, and under all circumstances, the even tenor of its course, Avithout expe- riencing more or less important modifications from other causes which may operate on the system in conjunction Avith, or antece- dently to, that by Avhich it is produced; Avhile the special morbid agent which gives rise to it, seldom fails to modify, to some extent— when it prevails extensively and with great virulence—other dis- eases arising from the impress of other causes. Hence arise, on the one hand, numerous complications of the fever with complaints of various kinds; in other words, cases in which, to the symptoms of the fever, are added others indicating the coexistence of some other disease, Avhich owes its origin to the operation of distinct causes; and, on the other hand, those modifications of prevailing complaints occasioned by an impress of the yellow fever cause, which, though not sufficiently powerful to produce the fever to its full extent,, is enough so to stamp those complaints with some of its features, and, in the language of Dr. Bush, to make them wear its livery."* In ■ proceeding to consider the pathological anatomy of yellow fever, Ave may remark in the outset, that cases occasionally present themselves, especially Avhen the disease has proved suddenly fatal or run a very rapid course, in Avhich no appreciable lesion in any of the organs or tissues can be discovered on dissection, or lesions of too slight a character to permit us to refer to them' any agency in the production of the phenomena of the disease, or its fatal termi- nation. In the great majority of cases, hoAvever, morbid changes, often considerable, are to be detected, by which the disease can usually be identified, while they throw more or less light on its pathology. The surface of the body in general presents a yellow colour, varying from a pale to a dark orange or broAvn. In many cases it has a greenish, or mahogany, or leaden hue, or even a purple or black aspect. The lighter shades of coloration, are usually observed in subjects carried off rapidly and by an inflammatory attack, the others in such as have fallen victims to attacks of a malignant or protracted character. Sometimes a pale yellow line, mingling Avith the other colours, can be traced from the nose to the pubes. The discoloration may be confined to the face or eyes, neck or chest, or extend over the entire surface. It is generally deeper on the face and trunk than on the extremities. It is more intense and general after than before death; it may even not have appeared previously. The scrotum, penis, fingers, toes, and ears, which, especially a short period before dissolution, are often very much discoloured from stagnation of blood, become, as do also the back and neck, of a dark purplish hue. These are cadaveric effects. Ecchymoses, in spots of different sizes or shape, round or in stripes, sometimes occupy the forehead, upper portion of the face, as also the trunk and extremities. These latter are the results of disease, and appear before death. The surface is, sometimes, also covered Avith minute * La Roche, op. citat. PATHOLOGICAL ANATOMY. 567 ecchymoidal spots, bearing some analogy to petechias, and increasing in number after death. In many cases the cellular membrane and fat are found to partake of the yelloAV colour of the skin. This occurs less frequently in malignant and congestive, than in ordinary cases of the disease. Extravasations of blood in the subcutaneous cellular membrane and between the interstices of the muscles, are not uncommon. In some cases, livid and gangrenous spots occur on portions of the body. The joints and muscles are generally rigid and stiff; and the latter, in those Avho have died of the malignant form of the disease are often of a dusky or dark hue. They are generally softened in texture and easily torn or broken down by pressure. Sometimes, especially after ordinary and inflammatory cases, they are but little, if at all changed in colour and firmness. They are occasionally pale as if they had been submitted to prolonged maceration. The face, in some cases, is tumefied, in others shrunken. The brain is often found entirely free from diseased changes. Traces of inflammation are occasionally, hoAvever, detected in it or its membranes, but ha\re no direct relationship to the yellow fever. In many cases, the pericranium, the sinuses, and the vessels of the brain are more or less gorged or congested with blood. In some the membranes alone, or together with the brain, are injected throughout or in patches; and in many, a fluid of a limpid or yellow colour, or mixed Avith blood, is effused in the ventricles, at the basis, or on the surface of the brain, or in its membranes. Nearly the same remarks may be made in reference to the lesions detected in the spinal marrow. When unequivocal traces of inflam- mation of this part or its membranes are present, these must be referred to some accidental complication, and not as forming an essential part of the disease. Many of the changes met with in the spinal marroAV after yellow fever, are probably to be referred to mere congestion, and the haemorrhagic tendency which constitutes a main characteristic of the disease. Various morbid appearances of the ganglia and ganglionic nerves have been described as occasionally met Avith after yellow fever. No one of these are invariably present—all of them are frequently absent —they often exist in subjects AArho have died of diseases having not the least resemblance to yellow fever; hence when present they are not to be vieAved as among the true anatomical characters of the latter. In general, the respiratory organs present no appearances indi- cating that they partake largely and necessarily in the diseased action of the system in yelloAV fever. The lungs are often found, at their posterior or lower portions, more or less gorged with dark coloured and altered blood. They are frequently in parts or through- out black, resembling a sponge; in substance sometimes firm and dense not unlike the substance of the spleen, or gorged with blood, black' and dissolved, and do not collapse upon the removal of the sternum. Not unfrequently their surface is covered Avith melsenic 568 YELLOW FEVER. patches or ecchymoses of from tAvo to five lines diameter, or masses of a black colour, impermeable to the air. The bronchial mucous membrane is in general free from disease; sometimes it is injected, or spotted Avith blood or even inflamed. The pleura is usually unaltered, the ecchymoid spots noticed upon it being situated in the cellular membrane beneath, or in the sub- stance of the lungs. In some cases the pleura has been found inflamed, or containing more or less effused serum of a yelloAvish, orange, or reddish colour, Avith or Avithout marks of inflammation. In a feAV, the fluid is of a sanguinolent character, and resembles, more or less closely, the black vomit. The substance of the heart, like that of other muscles, is sometimes of a dusky colour, and soft and more flabby than natural, and easily broken down by pressure between the fingers. In perhaps the greater number of instances, hoAvever, the organ retains its natural appearance. The pericardium, Avhich generally appears healthy, sometimes contains a notable, though not unusual quantity of serous fluid of a yelloAV or reddish colour. The endocardium, in some cases, is slightly red, apparently the effect of staining. In many others it is, as all the fibrous parts, the valves, &c, of a yellowish colour, which often extends into the aorta and the larger vessels. On the surface of the former, spots closely resembling petechiae, are sometimes ob- served. The cavities of the heart contain a greater or less quantity of blood, usually dark coloured, and for the most part grumous or fluid, Avith or without coagula of the same colour. In a large number of cases these cavities—especially the ventricles—contain albuminous concretions, varying in size and consistency, and of a transparent yellow colour, having the appearance of meat-jelly or fine amber. They penetrate sometimes into the aorta. The stomach is the organ most generally and seriously implicated in yelloAV fever—in it indications of disease are most frequently dis- covered after death. Externally it is sometimes of a yelloAV colour, but generally retains its normal appearance. It is usually found to contain more or less of matter similar in appearance to the black matter throAvn up by vomiting in the latter stages of the disease. This matter has been shoAvn by recent investigations to be blood— most probably diseased in character—poured out by the capillary vessels of the digestive mucous membrane, and still further changed by the action of the acid it meets Avith in the cavity of the stomach. In some cases, the contents of the stomach consist of blood more or less pure, Avith or Avithout coagula, and generally combined with a portion of glairy matter, and substances SAvalloAved a short time before death. In some instances, the mucous coat is smeared over with a dark, adhesive jelly-like substance, containing portions of blood/ tinder this substance, and sometimes when it does not exist, Ave find a layer of grayish matter not unlike a mixture of linseed meal. In a certain number of cases, the mucous coat, when cleansed from these various coatings, is found to present a normal appearance. In many instances it is even Avhiter than in its normal state, from the PATHOLOGICAL AX ATOMY. 569 effusion from its vessels, in all probability, of the blood with Avhich they had been loaded, in the form of black vomit. In the greater number of instances, however, the mucous membrane of the stomach is found more or less diseased, indicating that it had been the seat of inflamation more or less extended and of different grades of intensity. Thus the stomach is sometimes contracted, at others distended. The longitudinal rugae are enlarged. The sur- face has often a vermicular appearance, being corrugated and thrown into numerous folds. Its capillary vessels are injected to a greater or less extent Avith blood. It is reddened, presenting various shades, from a rose to an intense dark hue, or it may be leaden, livid, or even nearly black. The discolouration being either uniform in ap- pearance or in the form of arborisations—it may extend over the greater portion of the mucous coat, or be confined to the cardiac or pyloric orifices, and large curvature, presenting itself in patches dif- ferent in number and size in different cases. Streaks or spots of a purple colour, spread in various directions over both the altered and health}' parts. The spots, differing in size, have the appearance of ecchymoses. At other times, with or Avithout these, there are nu- merous small, dark red, or violet round spots, resembling petechiae, contrasting very decidedly with the rose hue of the mucous mem- brane upon which they are scattered. The lining membrane may, besides, present abrasions, or small depressions or pits, like holes or furroAvs, as though a portion of the tissue had been removed. It is frequently mammilated even to a remarkable degree, also, more or less considerably thickened and opaque. It is sometimes softened, and easily detached, especially about the great cul-de-sac. In a few cases it is ulcerated, or presents a gangrenous change. Sometimes, more especially after malignant or congestive attacks, an effusion is discovered under the mucous tissue. " These changes are not all found in the same cases, nor are they present at whatever period of the disease the patient may have suc- cumbed, or Avhatcver may have been the character and duration of the disease. In congestive or malignant cases, Ave find more or less injection of the capillaries—the redness generally of a dark hue. There are usually ecchymoses, and petechiae, but no thickening, softening, or similar changes. These, together Avith capillary injec- tion, are, as a general rule, met with after attacks of a different char- acter. In these, if death takes place on the second, third, or fourth day, the increased vascularity is noticed in bright reel or dark, dusky patches, more generally confined to the vicinity of the orifices, but sometimes extending to the greater part of the membrane. If the case has been protracted to a later period—to the sixth, seventh, eighth, or ninth day—a larger portion of the surface is found in- volved, and Ave may expect to find it of a leaden, livid, greenish, or mottled appearance, and presenting the marks of disorganisation al- ready noticed. In instances unattended Avith these changes, in which there is mere redness, with ecchymoid and petechial spots, these are probably not the effect of cadaveric changes for they are found im- mediately after death, and too soon to be attributed to such cause. 570 YELLOW FEVER. they must rather be referred to simple congestion. But Avhenever this redness is attended Avith thickening, or softening, or the mam- milated appearance of the membrane, Ave cannot but join in opinion with Louis in attributing these changes to an inflammatory condi- tion of the parts."* The appearances discovered in the oeso- phagus and intestines do not differ materially from those exhibited by the stomach. The intestines when the case has been rapid contain often bilious, yelloAV or ordinary excrementitial matter —at other times their contents are brown, black, thick or jelly- like, often of a tar-like appearance—or they may be fluid, of a red- dish or soot colour, or even consist of blood, more or less pure. Sometimes they are AA'hitish, „and often present the characteristics of the black vomit. The intestines, in a few instances, are con- tracted to a greater or less degree, and with more or less force. Extensive invaginations are occasionally observed. The duo- denum and upper portions of the jejunum are the parts most gene- rally affected, though in other cases, the lower portions of the ileum are more implicated than the latter. The glands of the intestines, especially those of Brunner, are occa- sionally found in a diseased or abnormal condition. The gall bladder is either empty, diminished in size—Avithered, as it were, or distended, with its usual amount of bile more or less natu- ral in quality—or its contents may be small in quantity, viscid, inspissated, or mixed Avith more mucus than common. It is either dark green, blackish-broAvn, or of an obscure red color, and of the con- sistence of tar. Not unfrequently the gall-bladder contains a quan- tity of thick viscous blood, grumous, tar-like, or ink-coloured, or of serum, and more rarely of pus. Its internal membrane is often spotted, or punctated, and sometimes largely injected with blood of a bright or obscure red or broAvn, or even dark colour. It is said often to present traces of unequivocal inflammation. The liver is usually of a light yelloAV, nankeen, fresh butter, straw, coffee and milk, gum yelloAV, buff, gamboge, light orange, or pista- chio colour. In some cases, this discolouration occupies the Avhole surface and pervades the entire parenchyma of the organ; Avhile, again, in others, it extends only partially over both, giving a marbled appearance—presenting throughout patches or regular striae, and alternating with others of a dark green colour. It is limited occa- sionally to a single lobe, usually the left. Becent observations would seem to shoAV that this discoloration is due to a fatty degeneration of the organ. "Frequently, however, as this peculiar coloration of the liver has been observed, it is far from being universally so; cases occurring in which the organ is found of a different hue—dark yelloAV, broAvn, red, purple, bluish, slate, chocolate, or livid. It has been described as of a brick colour, and compared to rhubarb, or to Peruvian bark. In other cases, again, it retains its natural appearance externally and internally, and is otherwise healthy. The parenchyma, when divided, is often found hard, dry, tough, and sometimes dry and brittle, and * La Roche on Yellow Fever. I. p. 398. CAUSES. 571 more or less devoid of blood; Avhile, in some cases, the viscus is more or less gorged Avith blood, and softer in texture than natural. In some cases, the biliary pores contain bile, but more frequently there is no indication of biliary secretion."* Though often more or less enlarged, and at other times shrunken, the liA^er seldom exhibits traces of inflammation, and, if these are dis- covered, they must be viewed simply as the effect of complications; Avhile the alteration in, or suppression of, the secretory function of that organ, may justly be referred to some cause different from that morbid state. The kidneys are not unfrequently found in a normal state, or with only trifling marks of having partaken of the disease. In other cases they are congested—filled, more or less, like other organs, with dark fluid blood, the mucous membrane of the pelvis and infundibulum being sometimes minutely spotted with blood, or ecchymoses; or they exhibit a morbid state, similar to that observed in Bright's dis- ease. In other cases they bear the marks of acute inflammation. The bladder is often contracted; sometimes its coats are thickened. The mucous coat is generally healthy, or only injected and dotted with small points, or ecchymosed. In some cases it is covered Avith a yellow mucus. The bladder is often empty, or nearly so—it may, -hoAvever, contain more or less urine, natural in appearance, bloody, or more or less bloody. Occasionally it contains black matter resem- bling that ejected from the stomach, or 'pure blood. The spleen is usually of a darker color than natural—sometimes somewhat enlarged, and friable. It is often .moderately softened, and generally engorged with dark currant-jelly-like blood. In some cases it is found unchanged. Xo prominent change has been detected in the pancreas. In some cases the penis is found covered Avith eschars; and the scrotum swollen and thickened—brown or black, as in senile gan- grene—sometimes Avith excoriations.f The yellow fever is a disease of hot climates and hot seasons. In every locality Avhere the disease prevails as an endemic, or in an epidemic form, the thermometer gives us an average heat of 80°, or thereabouts. In all these places, the disease shows itself only at the period of the year Avhen the heat is greatest—and usually with the most severity during seasons of the highest temperature, seldom attaining its greatest degree of intensity before the heat has continued at its maximum average for some time. Heat alone, however, is insufficient to produce the disease, for in climates and seasons of a higher and longer continued average temperature than that given above, it has not made its appearance. An excess or at least a certain degree of atmospherical humidity Avould also appear to be necessary to the development of yelloAV fever. The disease frequently occurs during rainy seasons, and is, ordinarily, encountered in damp localities, Avhere rain is common and falls abund- antly ; Avhere the soil, previously dry, has been rendered wet by copious *La Roche, on Yellow Fever. Vol. 1, p, 402. f Ibid. p. 386, et seq. 572 YELLOW FEVER. rain, freshets, overfloAvs, etc., or where the deAV point is high, and vesicular humidity generally or often noticed, or is considerable at the time. But facts innumerable go to show that humidity combined with heat, is not sufficient alone, for the production of fever. Some local cause capable, Avhen acted upon by heat, moisture, and perhaps other conditions of the atmosphere, the exact character and influence of which have not as yet been fully observed, of generating a special poison—by Avhich an infection of the surrounding atmosphere is produced ; which infected atmosphere when taken into the system— particularly in one especially predisposed to its morbific influence—the poison it contains enters the blood and is by it distributed throughout the body—impairing the vital properties of the blood itself, and pro- ducing a morbid impression upon the nervous centres—and in this manner deranging the functions of, and producing the morbid conditions Avhich avc detect in the several organs and tissues of the body. The variation in the character and extent of these lesions in different sub- jects depending on the difference of age, habits of body, and numerous other circumstances connected Avith the individual, on the degree and concentration and violence of the efficient cause; on the peculiar character of the epidemic constitution of the atmosphere, on the nature of the localities and numerous other modifying agencies. It would be impossible to enter here into the evidence of the- invariable origin of yellow feArer from a specific poison existing in the air of the localities where it prevails, and produced from causes there existing. That evidence is in our opinion conclusive, and irrefutable. In referring the production of the yellow fever, in every instance to a local malarial cause, we mean, also, to deny its propagation by contagion;—we are acquainted with no other disease of a strictly local origin ever evincing a contagious character or assuming such a character under any possible contingency. The facts, in evidence of the non-contagious character of yelloAV fever, are well authenti- cated and numerous—and sufficiently establish the correctness of the position. As a general rule, Ave use the Avords of Dr. La Boche, the disease may be regarded as one of Ioav, flat, and level localities, and as appertaining more especially to hot latitudes. It never sIioavs itself beyond a certain elevation, the limits of its altitudinal zone being even more restricted than those of ordinary paludial fevers. " The inability of the yelloAV fever to be generated at a high ele- vation above the level of the sea, depends in part on the greater elasticity and purity of the air, on a diminution of atmospheric pressure, and on a more thorough ventilation. But the main cause is the absence there of the degree of atmospheric heat, Avhich, as we have seen, is indispensably necessary for the elaboration of the morbific agent to which the disease is due. For the same reason, in part, though not exclusively, its geographical limits are restricted within certain bounds in a northern direction, Avhile, in a southern, the same effects are produced, as it would seem, by an excess of heat, and a variety of influences of a meteorological and telluric nature. Be the causes, hoAvever, Avhat they may, on one point there GEOGRAPHICAL RANGE. 573 can be no doubt—that the yellow fever has geographical limits, beyond Avhich it does not appear—and that Avithin those A^ery limits there are many places AA'here its usual apparent cause would seem to exist, but where, nevertheless, it has never shown itself, or has done so Arery seldom. The West Indian Islands, and part of the coast of South and North America, constitute its proper soil. From Brazil to Charleston, in one direction, and from Barbadoes to Tampico in another, the causes of the fever are in constant though unequal force, in regard to different seasons and localities. It prevails often, though not very generally, in some places more north than Charles- ton ; visits,-occasionally, the Atlantic cities of our Middle States, and has ascended as far as Boston, while in the Mississippi Valley it has prevailed as high as Memphis, perhaps Gallipolis, or even higher. In an eastern direction, but Avithin the same latitudes, it has extended to Cadiz, Xeres, Carthagenia, Malaga, Alicant, Seville, Barcelona, and other cities of the coast and the interior of Spain. It has prevailed several times at Gibraltar, once at Bocheford, once at Lisbon, and once at Leghorn. Hence, Ave find it embracing a considerable portion of the earth's surface. In its fullest latitudinal extension, it reaches to betAveen the tAventy-second and tAventy-third degrees south of the equator, and, on the other side, to the forty-second degree on the Atlantic coast, to the thirty-fifth degree on our Avestern Avaters, and to the 8.56° on the Pacific. Considered only in reference to its legitimate longitudinal boundaries, it stretches from about the sixtieth to the ninety-seventh degree of longitude east of Greenwich. Its true area includes the Caribbean and other islands called the West Indies, and Bahamas, the con- tiguous coast of Colombia and Guatimala and the extensive shores of the Aiexican Gulf, SAveeping from Cape Catoche on the west, to Cape Sable on the east, and running thence along the coast of America to AArihnington, (N. C.,) Norfolk, Baltimore, Philadelphia, New York, Boston, and intermediate towns: in some of which places it is an occasional, not annual, or even frequent visitor. " Until recently, the river Amazon, which divides Brazil from Guiana formed the boundary of the disease south of the equatorial line • for, although it is said to have prevailed at Olinda from 1687 to 1694, and to have shoAvn itself as far as Montevideo in the beginning of the present century, the latter circumstance is open to some doubt, while in Brazil, from the close of the seventeenth century to the middle of the present, the disease Avas not observed. Since 1850, it has invaded Kio Janeiro, Bahia, Pernambuco, and other places of that country. It is, in a great measure, a stranger to the Pacific, having prevailed but once at Panama, twice at Guay- aquil, .and once at Callao. It does not appear in the East Indies. It has never prevailed in China, Cochin China, Singapore, Siam, Ceylon ; it has prevailed occasionally on the African coast, Senegal, and the Gold coast, and has but three times, in the space of eighty- six years, shoAved itself in Cayenne. "Within those limits, it has, in some one or more places origi- nated and prevailed to a greater or less extent—occasionally or 574 YELLOW FEVER. frequently—either as an endemic, or as a mild or wide-spreading epidemic. Beyond these it never shoAvs itself; and though — whether north or south, east or west—it does not reach the point at Avhich common malarial fevers stop, it approximates to these diseases; so far, especially, as its northern or western extension is concerned, it being circumscribed within certain bounds; for they, too, have their limits. The effect in both instances is due to modifi- cations in the same morbific agencies* Acclimatisation is preventive of an attack of yellow fever. Thus, in places where the yellow fever is endemic—Avhere the climate is continuously warm, and the causes of the disease are more or less permanent, or frequently evolved—individuals accustomed by long and continued residence to the influence of the climate, and the agency of those causes, lose their susceptibility to an attack. But after a prolonged residence in cold and more salubrious localities, the indi- viduals thus protected lose, to a certain extent, their acclimatisation, and on their return to their former places of residence become once more liable to suffer from the disease. The children, too, of natives of, or those acclimatised to tropical regions, do not enjoy the same advantages in regard to protection, as their parents, but acquire them rapidly as they advance in age. The residents of some portions of tropical regions suffer to a certain extent from the disease, on remov- ing to another portion less salubrious. The protection of acclimati- sation is also, to some extent lost, by a long exemption of the locality from local sources of infection, or by the prevalence, during several successive summers, of a cooler and purer atmosphere than before. The most susceptible subjects of yellow fever are those Avho have recently arrived in infected localities, particularly the inhabitants of northern climates—the predisposition to an attack increasing Avith the degree of the northern latitude from which the stranger has arrived, and the shortness of the interval that has passed since he left the northern for the equatorial region. Even the inhabitants of situa- tions in the neighborhood of infected localities, but more elevated and salubrious, or of rural districts generally, though less prone to the disease than strangers from cold climates, are, nevertheless, liable to suffer when they venture in an infected place. As a general rule, an attack of the yellow fever exhausts the sus- ceptibility of the system to further attacks, or renders it less liable to be severely affected by the poison of the disease. Second attacks of yellow fever, in individuals who have passed through the disease, are somewhat rare; the immunity thus obtained is greater than that derived from simple acclimatisation. Second attacks constitute, there- fore, exceptions to a rule, and are perhaps but little more frequently met with than second attacks of other diseases through which the system usually passes but once. Individuals of the sanguine temperament—the robust, strong, and plethoric are those most prone to the disease—especially when their mode of living is calculated to keep up that temperament, or to bring * Op Citat.. Vol. I., p. 115, et seq. ' PREDISPOSITION. 575 out its elements in bolder relief. In times of unusually violent epi- demics, Avhen the fever spares none, individuals of all temperaments become alike its victims. As a general rule, females are less obnoxious to the impression of the poison productive of yellow fever than individuals of the other sex, and Avhen attacked have the disease in a milder form. The disease, usually, effects in preference individuals of adult age— sparing, to a greater or less extent, young children as well as persons advanced in life. " In all places, AArhether within the tropics or in temperate climates, in Avhich the yellow fever has manifested itself—sporadically or epi- demically—the negro race has manifested a greater or less suscepti- bility to the influence of those causes that give rise to the disease; every Avhere, however, that susceptibility is far inferior to that exhi- bited by the white race—the disease in the former spreading less extensively, and assuming usually a milder and more tractable cha- racter. In warm regions, the almost general exemption of the blacks is due, in some measure, to their being acclimatised to the country— a circumstance they share AAuth Creoles, and those who are inured to the climate; their more frequent liability to the disease in colder than in warmer regions, is due to the same cause which renders the white inhabitants, Avhether natives or long residents, more prone to the disease than Creoles—the want of acclimatisation. By losing, through means of expatriation, the poAver of resistance imparted by acclimatisation, they are placed much on the same footing as negroes of temperate climates, being no longer as surely exempt as they were before from the disease Avhen again they are exposed to its influence."* Fear, in common with all the depressing passions, are powerful predisposing causes of yelloAV fever. "Excessive joy, fits of anger, by stimulating the action of the heart and arteries, as well as the nervous system generally; strong emotions of any kind; despondency from pecuniary or other losses; disappointment from eAren trivial causes; intense mental application are no less to be deprecated, though producing their effects in a dif- ferent way; while the feeling of hope, courage, cheerfulness, as Avell as equanimity of temper, have the contrary tendency, of shielding the system from the morbid influence of the efficient cause of the disease, both by promoting the healthful play of the functions, and placing the happy possessor of them beyond the reach of the depressing passions. They prove powerful adjuvants of treatment."! Whilst sleep, especially in infected and exposed localities, must be viewed as a predisposing or exciting agent of the disease, the depri- vation of it—watchfulness from any cause—gives rise to the same effect. l- Intemperance in respect both to food and drink; the use, espe- cially when carried to excess, of aliments of an exciting and nutritious, as well as those of a crude and indigestible character; unripe or acid * La Roche, on Yellow Fever. Vol. 2, p. 64, f Ibid. 0i. citat. II., 74. 576 YELLOAV FEVER. fruit, perhaps still more particularly the use of ardent spirits, and, indeed, of stimulating liquors of any kind, have almost invariably exhibited a tendency to excite the development of the yelloAV fever. The danger arising from such indulgences has been fully recognised from the earliest period, and is recorded by almost every Avriter, ancient and modern, who has treated of the cause of the disease."* It is proper,- however, to remark, that a sudden change 1'rom a generous to an abstemious diet, will be apt to bring on an attack of the disease in individuals who might otherwise, in all probability, have escaped. A too rigid and abstemious diet is equally injurious. Immoderate evacuations; venereal excesses ; fatigue of body from whateA^er cause induced, as well as all other things calculated to debilitate the system, may be ranked among the predisposing and exciting causes of yellow fever. Butchers, Curriers, Tanners, Soap-boilers, Tallow-chandlers, Sca- vengers, and in general, all those Avho habitually breathe an umvhole- some atmosphere are far less liable to the disease than others differ- ently circumstanced. While, on the other hand, Cooks, Bakers, Black and AVhitesmiths, Hatters, Tailors, and Sugar-refiners, are re- puted to be particularly exposed to attacks of the disease. Among the more frequent exciting causes of yelloAV fever may be ranked exposure to cold in any way, especially when the body is heated or perspiring through the effect of exercise or otherwise, as also exposure to the coolness and chilliness of night air, to a shower of rain, &c, sleeping in the open air, or exposure in any manner to the night air—lying upon the ground, drinking large draughts of cold liquors, especially Avater. The suppression of any of then atural or of any artificial excretions, as also, the sudden diminution or removal of irritations to Avhich the system has become in some measure accustomed, issues, blisters, alvine eAracuations, ulcers, chronic cutaneous eruptions, etc., have been found to produce an injurious result, and prove the harbinger of an attack of the fever. The diagnosis of yelloAV fever, under ordinary circumstances and to one familiar Avith its phenomena and course as contrasted with those of other fevers endemic to the same localities and prevalent at a similar season of the year, is attended with little difficulty. There is not, howeA'er, a single symptom appertaining to the disease, when viewed by itself, or without regard to the degree of its frequency, that can, strictly speaking, be considered as really pathognomonic, each of its more prominent symptoms, is, at times, absent in cases of undoubted character, and each will be found to occur in other dis- eases but remotely connected with it. But as Dr. La Boche, very properly remarks, when vieAved in connection with each other— when found associated together, or when the greater number of them are present in the same case—especially when this assemblage is found to hold in a large number of individuals affected, the result is different. Under those circumstances, the peculiar jaundice described, varying * La Roche, Vol. 2, p. 77. PROGNOSIS — TREATMENT. 577 from the bright yelloAV to a dark mahogany or livid hue—the emis- sion from the stomach of the dark coffee-ground matter, so Avell knoAvn under the name of black vomit—the injected, brilliant, transparent, fiery, and glassy eye—the thin, slimy, white or moist, thick and dirty yelloAV fur, and clean, red edge and tip of the tongue—the super-orbit ar pain—the rachialgia—the single febrile paroxysm, and its sudden cessation at the end of some forty to seventy-two hours, more or less —the absence, from that period, of all fever—the progressive increase in the slowness and depression of the pulse—the gradual loss of cuta- neous heat—all these may be viewed, in their ensemble, as typical of the disease, and as its characteristic and pathognomonic phenomena. When they all occur together, or when only one or two fail to do so, the physician may be assured he has to deal with the yelloAV fever; and the certainty is enhanced Avhen the case in which they are observed presents itself at a period of the year, and under circumstances favour- able to the development of the disease. On the other hand, Avhen they are all, or for the most part, absent—the black vomit and jaun- dice particularly—we may, in the majority of cases, safely conclude that the disease is of a different kind, even Avhen circumstances are favourable to the development of the yellow fever cause* The prognosis in yelloAV fever is upon the whole unfavourable— under ordinary circumstances, and with the exception only of some epidemics of unusual mildness, the disease is of the most dangerous character, and the chances of recovery are slender. But little aid is afforded in enabling us to arrive at a correct prognosis by the presence or absence of signs Avhich in other diseases are of the highest value. Cases occur in which, Avhen everything would seem to indicate a favourable result, the patient has been carried off with great rapidity, while on the other hand, cases of recovery happen in Avhich, from the nature of the symptoms, a fatal termination might naturally have been anticipated. Dr. La Boche has presented in detail, and at great length, the various phenomena, the absence or occurrence of Avhich in a case of yellow fever may be considered as favourable or unfavour- able indications, and to the work of that gentleman we must refer for an account of all that the most accurate and repeated observations have taught us in reference to the prognosis of the disease. In the meantime we borrow from him the following general remarks. 1. As the yelloAV fever is more or less modified as to the degree of its prevalence, the severity of its attack, and the mortality it occasions, by certain peculiarities connected with the condition and habits of the patient, his age, sex, race, constitution, idyosyncracy, &c; it fol- lows as a necessary consequence, that Avhen it occurs under circum- stances the least favourable in the above respects, the prognosis will be equally unfavourable. " Hence we need not so much fear the issue in children, females, negroes or those who have already passed through the ordeal of the disease 'in natives of the warmer latitudes, or in those whose habits are temperate • while youth, a plethoric state, a sanguine constitution, * La Roche on Yellow Fever, II., 565. 37 578 YELLOW FEVER. high living, and intemperance, predispose to, Avhile a debauch, ex- cessive fatigue, or terror, a fit of anger, the intemperate use of venery, &c, often excite a severe attack, from which the chances of recovery are less to be anticipated." " Generally speaking, the more recently a stranger has arrived the more severe the attack. The same may be said of the remote cause itself, Avhich, in some seasons, is of such a degree of malignancy as to produce a disease, which, though apparently differing little from that of other periods, has a greater tendency to end fatally, and must, therefore, call for a very different prognosis. Again, the latter must be more guarded during the continuance of the same epidemic in different parts of an infected city—the symptoms appearing the same —inasmuch as the malignancy and fatal tendency of the fever differ in them. The same remark is applicable to the several periods of the same epidemic. In general the prognosis should be more guarded at the outset, as the disease is more apt then to terminate fatally. " 2. As a general rule, it may be said, that in yellow fever it is not so much the presence of good signs which we are to look for in order to form a favourable prognosis, as the absence of bad signs. For, what Avould be regarded as good signs in most other diseases, are of little or no avail in this, and many patients recover without having presented what may, strictly speaking, be called by that name; often after exhibiting some one or more of those Avhich experience, in many fatal cases, teaches us to look upon with suspicion; whereas, the appearance of any one of the decidedly bad signs, and still more a combination of them, must be viewed with fear, leading, as the}' very generally do, to a fatal termination. " 3. It is not less to be noted, that much more is' to be expected from a gradual amendment of the febrile and other symptoms than from a sudden disappearance of even the most unfavourable among these. From the latter change, indeed, the most disastrous results may in general be expected—followed, as it generally is, by delirium, coma, and other bad symptoms. The danger of the disease, great as it is, when the latter is uncomplicated with any other complaint, be- comes much more so, and calls for a more unfavourable prognosis, when to the phenomena Avhich reveal its existence, are superadded those indicating the coexistence of other disorders. ■ " 4. AVith the exception of the mildest or ephemeral forms of the disease, the danger to be apprehended is, generally speaking, propor- tionate to the shortness and rapidity of the case. When the disease extends to the seventh, ninth, or eleventh day, recovery may reason- ably be expected. The same favourable view may be taken from the prolonged duration of the stage of reaction—the danger in the subse- quent stage being proportioned to the shortness of the first, and the early supervention of the state of metaptosis. " 5. In cases marked by remissions, the disease, as we have seen, is of a milder character, and admits, therefore, of a much more favour- able prognosis, however severe the febrile reaction may be during the exacerbation. , " 6. Bigors, at the commencement of the attack, denote considerable TREATMENT. 579 danger, and are usually viewed as signs of fearful omen, the clanger being proportionate to their duration. The same may be said of chills, Avhen violent, long continued, and repeated." " 7. Considered in a general way, the yellow discoloration of the skin, which has given a name to the disease, is doubtless a sign of importance in a prognostic point of view; for, though not invariably observed in all fatal cases, it is much more frequently seen in these than in cases of recovery. Hence, generally speaking, the appearance of this symptom must be regarded as entitled to considerable atten- tion, and held Avith suspicion. "The appearance of jaundice at an early period of the disease may be viewed as a symptom of serious import, and as indicating a disease of dangerous, and even fatal character—the danger increasing in proportion to the deepness of the discoloration. AVhen, on the con- trary, it appears at a late period—after the sixth or seventh day—it loses the dangerous tendency in question, and, as we have seen, may even be said to assume the character of a critical sign. As regards the peculiar hue it presents: in many cases, and during certain epi- demics, the light yellow or lemon colour has proved more dangerous than the dark yellow; while in other seasons and localities, the reverse is said to have been the case. Jaundice is indicative of more danger when it assumes a greenish, violet, mahogany, or bronze hue, and particularly when the skin presents a mottled or party-coloured appearance, characterised by livid, olive, and ash-coloured patches of all sizes, and blending into each other. Greater apprehension is to be felt when the discoloration in question is rapidly and very extensively diffused over the body, than when it is limited in extent, and spreads slowly."* • In proceeding to a consideration of the treatment of yellow fever, we may remark, that this must be based upon the character assumed by the disease in its different visitations, and even in each separate case that presents itself. The same therapeutical measures are not adapted alike to the inflammatory and to the congestive forms of the fever. Nor will the same course of treatment tend to conduct to a favourable termination those cases, in Avhich, from the very onset, the disease assumes an unquestionably malignant or deadly aspect, and those the symptoms of which are so mild, that recovery will be sponta- neously, or with but slight aid from medicine—while it will be as little adapted to the cases intermediate between these two extremes— Avhere the object of the physician should be to apply in time those means best calculated to produce a favourable impression on the tram of morbid actions, and thereby arrest their dangerous tendencies. The treatment of yellow fever must be modified according to a variety of circumstances. As remarked by Dr. La Roche, " m encoun- tering this formidable disease, we must content ourselves with endea- vourmo- not to neutralise the poison circulating in the system, butto correctthe morbid effects it occasions on both solids .and fluids. W e must while watching carefully the course of the disease, prevent * Op. citat. I. p. 478, et seq. 580 YELLOW FEVER. undue mischief from being done, especially to organs essential to life. AVe must keep these organs in as healthy a condition as possible— restore, if possible, equilibrium in the play of the functions—reduce undue and dangerous excitement, general and local, and sustain the powers of life Avhen these threaten to become impaired, or are already reduced beyond the point of safety. But we are forced to confess that, beyond this, art is of little avail. The idea of curing the disease, or greatly abridging its course, is entitled to little confidence. To nature must be left the chief management of the case; time must be allowed for the elimination of the poison; and the physician must be impressed with the conviction that, in cases Avhere no marked organic mischief has been done, or is likely to occur, he must keep his hands off as much as possible, and restrict his agency to the employment only of such means as are strictly necessary to fulfil particular indi- cations. He must not attempt to do what is more safely done by the recuperative poAvers of the system, and rest assured that in these, and indeed in all instances, more danger is to be apprehended from too great than too little interference on the part of the medical attendant." When called to a case of yellow fever, a primary object of solicitude on the part of the physician, should "be, to guard as much as possible against all disturbing influences. He must see that the patient is confined effectually to his bed, and prevented from rising. He must give proper directions for the free ventilation of the apartment, and the preservation of cleanliness; while, Avhatever be the form the dis- ease assumes, he should proceed to the medical treatment of the case with the least delay possible. The great rapidity with AArhich the dangerous symptoms make their appearance, the little time afforded for preventing their onset, and the great importance of effecting that object—besides the difficulty of their removal when they do appear—render such promptness imperative. At the same time, a knoAvledge of the insidious and treacherous nature of the disease, the great difficulty of predicting whether symptoms indicative generally of a mild attack are not soon to be succeeded by those of an opposite kind, and whether changes calculated to make us hope for a favour- able issue are not to be followed—perhaps in a few hours—by others portending approaching death, should make him constantly attentive to the nature and succession of every phenomenon. Attention being paid to these details, the medical treatment will necessarily vary according to the particular form which the disease assumes. In the several varieties of the inflammatory form, recourse must be had to antiphlogistics, sedatives, and evacuants, graduating the energy of these to the degree of the violence of the reaction, the force of the circulation, the heat of the skin, and the extent of the local inflamations or congestions. Of the indispensable necessity of antiphlogistic and evacuant treatment, which in this, as in other feArers of kindred nature, consists in sanguine evacuations, sedatives —internal and external—and purgatives, there can be no doubt. It is based on the eAudent character of the complaint, and the sue- TREATMENT. 581 cess which has attended its application; and comes to us under the sanction of innumerable and high authorities* _ The foregoing remarks apply exclusively to the first stage of the inflammatory form of the disease; while to be productive of benefit they must be resorted to without loss of time—their success being proportionate to the earliness of their application. They are not, it is also to be recollected, as a general rule, to be used with the same freedom as in ordinary inflammations. Except Avhen there is inor- dinately high reaction—or Avhen important organs are seriously in- flamed or congested, and the patient is vigorous, plethoric, and young, and the recuperative poAvers of the system energetic, it Avould be safer to avoid the use of agents calculated to debilitate suddenly and considerably, and to trust to milder means. AVhile endeavour- ing to relieve inflammation or congestion, we should never lose sight of the imperative necessity of husbanding the strength of the patient, and of avoiding every thing calculated to depress the powers of life and foster the tendency to collapse. While general excitement, local inflamations and congestions, if they exist, are reduced by suitable depletion and sedatives, and the boAvels, Avhen costive, opened by mercurial and other purgatives, attention must be paid to tranquilize the stomach—and the physi- cian must Avatch the efforts of nature, and promote any critical move- ment she may indicate. Various means have been proposed and recommended to calm the stomach. Leeches or cups to the epigastrium in cases where they are admissible, have, occasionally, been found beneficial. Lime water by itself or combined with an equal quantity, or two-thirds of new milk, in doses of a wine glassful has been highly recommended; other means haA'e been also used with more or less success. Among these may be enumerated the carbonates of soda and potass, the saline mixture, the effervescent draught, yeast, calcined magnesia, porter, chalk mixture, liquor potassaj in barley Avater, carbonate of ammonia and hydriodate of potassium and spruce beer and essences. Of all remedies of the alkaline class, the chlorate of potass is entitled to most notice in this place, from the praise it has recently received from the high authority of Professor Frost, of Charleston. The nitrate of silver—small doses of creasote diffused in water— chloroform, in doses to the extent of even half a drachm, have likewise been recommended—they would all appear to us to be of doubtful propriety in the first stage at least of inflammatory cases. After the more decided inflammatory symptoms have been sub- dued, turpentine, combined Avith a portion of mucilage, in doses of ten drops every two hours, will often be found very speedily to check vomiting—under the same circumstances also, a blister or sinapism over the epigastrium will be found of service. The ascetate of lead, in doses of from grs. 2J or 3, every three or four hours, either in * La Roche, II., 635. 582 YELLOW FEVER. pills or simple solution, has been highly recommended, and will sometimes succeed in restraining the frequent retching and violent vomiting so characteristic of the disease. AVhen we have succeeded in checking the violence of the fever and in relieving Avhatever local irritation or congestion that may be present, and an intermis- sion has been obtained, " or," to use the language of Dr. La Boche, " when the latter or metaptosis has occurred at the regular time by the spontaneous subsidence of the febrile excitement, little remains to be done beyond keeping up the strength of the patient by mild tonics and light nourishment, and preventing, if possible, the onset of further and malignant symptoms, by the use of antiperiodic, tonic, and astringent remedies. But when the remission is incomplete, or is succeeded by a train of symptoms indicating a continuance and exasperation of the disease, another and different course must be pursued. The irritability of the stomach and the vomiting, as also the inflammation of that organ, if it occur, must be combated by seda- tives and antacids internally, emollients and revulsives externally; the cerebral organs, if implicated, must be attended to, and their irritation or congestion treated by ordinary means; the failing powers of the system must be sustained by nourishment, tonics, and stimuli, either by the stomach, if it will bear them, or, in the con- trary event, by the rectum; while the haemorrhagic tendency must be arrested by astringents or other suitable remedies. In the congestive form of the disease, when the reaction is defi- cient or altogether Avanting, recourse must be had to means calcu- lated to arouse and sustain the dormant energies of the system, and, at the same time, to relieve the sufferings of the overloaded organs. External stimulation, by means of rubefacients, hot baths, sinapisms, vesicatories, &c.; the internal use of stimuli, tonics, &c, by the stomach or boAvels, and, in the milder cases, stimulating and mer- curial cathartics, must be resorted to; and, whenever it can be done with safety, the congested vessels of important organs, and the inflammation of particular parts, which sometimes is combined with the congestion of others, must be relieved by general and topical bleeding. Local depletion, by cups or leeches, may be resorted to in many cases of yellow fever, where general depletion is not considered advisable; or for the relief of particular organs. The cups or leeches should be applied as near as possible to the part affected—on the epi- gastrium, when the stomach is to be relieved; on the temples, along the course of the jugular veins, inside the nostrils, or at the back of the neck, when the condition of the encephalon calls for assistance. As a general rule, local depletion should be resorted to at as early a period of the disease as possible. When practiced late, it is of no utility, and may even act disadvantageously, by increasing the pros- tration of the powers of life. Sudorifics are strongly recommended by many in the treatment of yelloAV fever in its earliest stage. The warm and vapor baths, or pediluvia of Avarm water, or warm water with mustard, aided by TREATMENT. 583 warm lemonade, or a warm infusion of some agreeable vegetable substance, have unquestionably been found, in many cases, when properly timed, to produce a general diaphoresis, from which very decided relief has been obtained. It is only at the very onset of the milder cases, however, that much benefit is to be expected from these sudorifics. In the more decided inflammatory forms, they cannot fail to prove prejudicial. From the irritable state of the stomach, there is little to be expected from the usual diaphoretics internally ad- ministered. The warm bath is particularly appropriate when, in the early stage, the reaction is imperfect, partial, or deficient—when, in a Avord, the disease assumes one of the grades of the congestive form. In such cases, a general bath of high temperature—not less than 100° —will tend to promote a return of heat to the surface, and diffuse it if unequally distributed, and at the same time revive the activity of the circulation. In general, the water may be used alone; but in the case of extreme collapse, its beneficial effects will be greatly enhanced by the addition of salt, spirits, or mustard. There are a number of means Avhich may be resorted to, in order to meet particular indications—to relieve pain and local inflammation. Pediluvia, Avarm or tepid, fomentations and cataplasms are generally used, and found useful. Warm frictions, either dry or with soap, with hot oil, whiskey, or stimulating lotions, or, again, with lemon juice, will also find a useful application. The latter means—frictions with lemon juice—constitute a main instrument of what is called the Cre- ole treatment, or that of the colored women of the West Indies, and is favorably spoken of by the medical writers of experience in tro- pical climates and this country* In the early period of the first stage of the fever, when the skin is hot and dry, cold water, applied over a considerable extent of the surface, either by sponging or affusion, has been found, at times, to exercise a beneficial influence, and by many physicians, is considered an important agent in the treatment of the disease. Such has been the case in tropical climates, and the results there obtained wall be found fully corroborated by those recorded in temperate latitudes. The same rule must be observed in the application of cold water in cases of yellow fever, as in other febrile diseases—namely, it should be resorted to, only when the skin is decidedly hot and dry, and the reaction well established. Under such a condition of things the application of the cold water is usually followed by a reduction of heat and of vascular action, as well as, also, in numerous cases, by a tendency to perspiration, a sensation of comfort, and an abatement of many unpleasant symptoms. The same effects, but in a less degree, will result from partial applications of cold water or cold pediluvia. When applied, on the contrary, under other circumstances, very opposite results will very generally follow. "If" as Dr. La Boche well remarks, "the skin be cool and the pulse depressed, the sedative effect of cold water will have a ten- * La Roche, Op. citat. 584 YELLOW FEVER. dency to aggravate the symptoms. Eeaction, in such cases, seldom occurs; the disease becomes more concentrated within the internal and important organs, and the prostration of the vital poAvers increases rapidly. AVhen the skin, instead of being dry, is Avarm, moist, and relaxed—Avhich, as seen, occurs sometimes in all epidem- ics, and very generally in others—the application of cold to the sur- face has a tendency to check the salutary condition, and Avill almost always sorely aggravate instead of benefiting the disease. JSTor are cold ablutions to be less avoided when the patient complains of chilliness or dyspnoea; or Avhen he labors under diarrhoea, or deep congestion, or well-marked inflammation of internal organs; or, again, Avhen he x is of weak constitution or of advanced age." " In cases attended with a moderate degree of temperature of the surface; or when, after depletion, or without, the skin exhibits a ten- dency to perspiration; when, again, the patient suffers from restless- ness or other nervous symptoms, or when the shock from cold Avater is unpleasant, the tepid bath, or ablution with water of slightly ele- vated temparature, or a sheet dipped in tepid water, is found highly advantageous " " In cases in which it is inconvenient or improper, for particular reasons, to have recourse to the hot or tepid bath—general or partial —the effect will often be obtained by means of the artificial vapor- bath, obtained by pouring water, either alone or mixed Avith vinegar, on hot bricks and introduced under the bed clothes." It is scarcely necessary to point out the importance of placing the patient in apartments, large, clean, dry, and well ventilated, and so situated as to secure for him the advantages of pure, cool, fresh air. Under all the circumstances of the disease, let Avhatever be its form, this is an all-important measure. The drinks of the patient should be cool and refreshing—in the first stage of the inflammatory' form of yellow fever, cold Avater is perhaps the best, taking care, hoAvever, that it be taken in mode- rate draughts, at short intervals, to avoid over distension or prostra- tion of ffie stomach. Where the stomach is irritable, and bears with difficulty the ingestion of Avater or other cool liquids, small portions of ice, held in the mouth and sloAvly swallowed, Avill often prove highly refreshing. "" A variety of drinks have been suggested, and in many cases .may be resorted to Avith advantage, as Aveak lemonade or orangeade, tamarind, currant jelly, and raAV-apple Avater; thin flaxseed, or gum water, plain or sweetened; iced carbonic acid Avater. " Under the use of cold and iced drinks, the irritation of the gastric mucous membrane," remarks Dr. La Eoche, "often subsides; the sense of heat and ardour at the epigastrium ; the nausea and vomiting; gas- tric haemorrhage, as well as the general excitement of the heart and arterial system, diminish; while the temperature of the skin is apt to lessen, and a disposition to perspiration not unfrequently mani- fests itself. "But, in all cases—even in those characterised by considerable thirst—care must be taken not to overload the stomach, as nausea TREATMENT. 585 and vomiting will almost inevitably be the result. The preferable plan is to direct the patient to drink often and to take but a small quantity at a time. Even in cases unattended Avith much thirst or irritability of the stomach, it is proper to enjoin the same rule of frequent and moderate drinking, for the double purpose of soothing the irritation of that organ, and guarding against awakening a dis- position to nausea and vomiting, which, as we have seen, are almost constant attendants on the disease, and require but a trifling cause to bring them on. " In cases characterised by symptoms different from those enume- rated, the drinks should be of a higher temperature; and Avhere there exists a tendency to perspiration, they should, the condition of the stomach alloAving, be taken Avarm and slightly aromatized. " In an advanced stage of the disease—when the poAvers of life are fading, the drinks should be of a stimulating and nourishing kind. Porter ancb water, weak punch, weak Avine-whey, claret, champagne, or hock wine, brandy and water, &c." AVhen the gastric irritability is so great as to forbid the admission of any thing into it, much benefit is often derived from the use of small and strongly purgative enemata. They act on the principle of revulsion—excite the peristaltic action of the tube downwards, and thus tend to quiet the stomach. In the advanced stage of the disease, especially when the stomach rejects every thing, stimulating and tonic substances, introduced by means of injections, sometimes prove serviceable. Blistering is not admissible in the early stage of the inflammatory form of yelloAV fever. At the commencement of the second stage— when symptoms of an unfavourable character are present, blisters to the ankles and other parts will often produce a favourable revulsive action, or prevent the depression of the vital poAvers. At a later period of the disease, when symptoms of prostration present them- selves, blisters, in conjunction with other stimulants and excitants, will not unfrequently contribute in arousing the sinking energies of the system. In the early period of the congestive form of yellow fever, blisters are adapted to aid in the restoration of action to the surface of the body, and in the excitation of the general circulation and nervous system. To relieve gastric distress, pain, nausea, and vomiting, m cases where the febrile excitement does not run high, or in the second stage of the disease, blisters to the epigastrium or spine will often prove serviceable. To relieve the headache, delirium, and stupor, attendant on the various stages of the disease, blisters to the nape of the neck, the occiput, or°the upper extremities, will, also, not unfrequently, be decidedly beneficial. So, likeAvise, pain in the region of the thorax, whether resulting from disease of the lungs or external muscles, as well as the tormenting rachialgia, is sometimes relieved by blisters to the affected parts. In order to obtain the effect desired from the application of 586 YELLLOW FEVER. blister; it is not ahvays necessary to produce vesication. By removing them so soon as they have produced a rubefacient effect, a revulsive action is obtained without risk of gangrene, soreness, or haemorrhage, while the effect may be renewed when it subsides too soon. Sinapisms may, in many cases, be usefully substituted for blisters, and should always be preferred when the urgency of the symptoms calls for a prompt and energetic treatment. They are particularly useful to tranquilise the stomach, and remove local pain; and, in congestive, as well as in the advanced stages of ordinary cases, to invite excitement to the surface, and arouse the failing power of the nervous and arterial systems. By some they are used early to coun- teract congestion. While all internal stimulants are strongly contra-indicated in the first stage of the inflammatory form of yellow fever, in cases in which from the onset the reaction is feeble and deficient — in some of the modifications of the congestive variety—they are sometimes required to arouse the energies of the vascular and nervous systems—even when bleeding and other means of deple- tion are employed to empty the congested organs. In not a feAV cases, however, of even the congestive form of yellow fever, the early use of stimulants is unnecessary and improper. It is chiefly in the advanced or sinking stage of the disease that they are admis- sible ; and they are here often required in very large doses. They are sometimes instrumental in sustaining the powers of life or mitigating particular symptoms, and thereby enabling the patient to outlive the disease. Nearly all the articles included in the class of stimulants have been recommended, capsicum, serpentaria, wine, brandy, ammonia, camphor, chloride of sodium, sulphuric ether, spirits of turpentine, etc. No one of these can be considered as specifically adapted to the disease; all have no doubt been found useful, and it is equally certain that all have equally failed. Opium, which is admissible, at an early period of the disease, only in the decidedly congestive form, when stimulating means are required to rouse the prostrated powers of life, has been recom- mended in the latter stage of ordinary cases to support the system— and, in combination with the other stimulants may, sometimes, be found useful. At this particular stage the cinchona bark, quinia, and the tinc- ture of the hydrochlorate of iron, have been recommended as tonics. The Peruvian bark, which has been suggested by some as an appropriate remedy even at the very onset of the fever, and by others at the close of the first stage or during the remission, is now, we believe, very generally considered as useless, or even mis- chievous, except during the last or sinking stage, when, probably, it may sometimes do good as well by its tonic as its astringent proper- ties. Of the sulphate of quinia, Avhich has supplanted the bark as a therapeutic agent, the same remarks may be made. Of late years the quinia has been recommended at the very onset TREATMENT. 587 of the attack, in large doses, with the view of at once cutting short the disease. In reference to the success of this abortive treatment of yellow fever, as it has been termed, we have been favoured with much discordant testimony, but none of sufficient weight and clearness to recommend it strongly to our notice. The muriated tincture of iron comes to us with such strong testi- mony in its favour as a remedy adapted to even the earlier stages of yellow fever, that it demands a further trial. / AVe have said nothing as yet of the mercurial treatment of yellow fever, so highly lauded for its superior efficacy by several physicians of high repute. It does not appear to us that any evidence has been adduced to prove that this plan of treatment has been more successful than others; while from the known effects of the mercury upon the blood, we should apprehend an increase of the very morbid condition of that fluid which, from an early period of the attack, constitutes so prominent a feature of yellow fever. From these considerations, and the uncertainty of our being able to place the system under its spe- cific effects—the probable failure, even when obtained, of their pro- ducing the desired result, and the time lost in waiting for those effects to develope themselves, we should be inclined to reject mercury from the list of the therapeutic agents adapted to the disease. In the management of a case of yellow fever, more perhaps than in one of any other disease, is it important to remove from the patient all impressions of a moral kind—to keep up his spirits and sustain his courage. His alarm and anxiety for the result of his case must by every means, if possible, be quelled, and the stimulus of hope constantly kept alive; unless this be done—remedies are of little avail. In the early stage of the inflammatory form of the disease, total abstinence from food should be enjoined, or only thin gum, rice, barley, or apple water allowed; or in the milder cases, arrow-root, sago, Indian, or oat-meal gruel, or the like, maybe allowed in small quantities, and at reasonable intervals. When the activity of the pulse has been reduced, and the skin softens and loses its excess of temperature; when the gastric irritation lessens also, and especially when the stage of metaptosis sets in with fair prospects of increasing amendment, the diet should be made more nourishing. Animal food, whether in the form of soup, carefully freed from fat, or in substance,, may be given, but with great circumspection; it may even be better to restrict the patient to farinaceous and vege- table articles. Thin rice and bread cream, arrow-root, sago, Indian mush, oat-meal gruel, slightly sweetened and aromatised, thin panada, weak coffee, tea, or chocolate, milk and barley-water, answer well, AA-hen given in small quantities at a time, and at short intervals. They are better suited than animal food to the existing condition of the digestive powers, which are often considerably impaired. AArine, and other spirituous liquors, except when the debility is unduly prominent, and all signs of inflammatory irritation have sub- sided must be avoided as unnecessary and often hurtful. Consider- able attention is also required as to the quantity in which food is 588 YELLOW FEVER. allowed—much mischief is often done by the patient indulging largely in even the most bland and proper articles. As a general rule, it is safer to give but a small portion of nourishment at a time, and gradually to increase the quantity. As febrile irritation and gastric irritability further subside, and the favourable crisis approaches, the food must be given at shorter inter- vals, and rendered more nourishing. It may now consist of the same articles prepared in a more generous manner, or of milk, stewed fruit, chicken or veal broth. When the debility is considerable, beef-tea, animal jelley, &c, may be allowed. This choice of aliments, graduated in the way mentioned, to the condition of the digestive powers and of the system at large, must be persevered in to the period of con- valescence. It is equally well suited when the disease, instead of progressively subsiding without the occurrence of bad symp- toms, passes to the third stage, or that of depression. AVhen, hoAV- ever, the disease assumes a malignant character, and symptoms of positive prostration call for tonics and stimulants, nourishing food, in the form of strong broths, essence of beef, animal jellies, administered often and in small bulk, may be tried as long as the stomach remains quiet, and it has sometimes proved advantageous. In congestive cases little or nothing can be done in the way of diet so long as reaction has not taken place. When reaction has been brought about, the diet must be regulated in the manner already ad- verted to. During convalescency, while the use of the remedies employed in the preceding stage, is to be gradually diminished, the patient must be allowed more and better food, but the transition to the diet of health must be gradual, and care must be taken to select none but light and nutritious articles, and to avoid indulging in these frequently, and especially overloading the stomach. For some clays, unless the debility be great, and all signs of gastric irritation completely sub- dued, the patient had better abstain from animal food, and limit him self to the use of eggs, bread, rice, bread and milk, panada, and oysters. As strength returns, and the functions of the stomach, acquire energy, he may be allowed chicken, veal, mutton, or beef broths, prepared Avith a large proportion of rice, barley, and other vegetables. Poultry, game, and fish may follow; and finally, the more substantial meats may be alloAved. But necessary and indispensable as this gradual return to the diet of health undoubtedly is, the physician does not ahvays find it pos- sible to enforce compliance; for there is often such a sudden revival of the appetite for animal food at the commencement of convalescence that it is difficult to restrain the patient within proper bounds. Cases not unfrequently occur, in which,'from feebleness and languor of the stomach, or a state of general debility, mild, and even strong tonics and stimulants are called for. Under these circumstances, the infusion of bitter plants, of Peruvian bark, of serpentaria, or the sul- phate of quinia, will prove serviceable; while malt liquors, wines— claret, sherry, madeira, hock—and even brandy and water, find a successful application. TREATMENT. 589 Haemorrhages occasionally occur during convalescence, which, as they indicate great debility of the system, and an atonic condition of the vessels, and tend to increase, by the loss of blood they occasion, the very cause on which they depend, must be checked with the least possible delay. In these cases, acids internally, and nitrate of silver, creasote, or the tincture of iron externally, cool air, as well as reme- dies calculated to impart tone to the system at large, are employed with advantage. Quiet and cheerfulness of mind must be secured, and sleep must be encouraged. They are essential to a rapid and complete reco- very. So long as debility is prominent, bodily exertions must be avoided; but, as soon as the strength admits of it, exercise, alter- nating Avith rest, and graduated to the condition of the patient— short, and frequently repeated—must be enjoined. The venereal act—to which, convalescents are prone-j-should be carefully avoided, as ahvays highly detrimental, and often, when indulged in to any excess, of fatal tendency. Great stress must, at the same time, be laid on cleanliness and free ventilation, but more particularly on change of locality, and removal from the infected to a pure and cool atmosphere. When circumstances will permit, and convalescence is long and tedious, a sea voyage, and a residence in a cold climate, must be recommended. Editor.] 590 EPIDEMICCHOLERA. XXIX. EPIDEA1IC CHOLEEA. Epidemic Cholera.—This disease, when it runs its full course, ter- minates in a state which is unquestionably one of fever, and as that fever is often attended by a characteristic eruption, it appears to approach more nearly to the eruptive fevers than to any other class of diseases, yet to avoid the imputation of theory, we have not con- nected it with any. In the larger proportion of cases, the development of this frightful disease is preceded by a premonitory stage, of which the symptoms are those of simple diarrhoea, though generally of a more than usually obstinate character. In some instances, too, the patient does not feel generally ill, and though, from the prevalence of the disease at the time, he may have some misgivings as to its true nature, he is will- ing to flatter himself, and eagerly assures his friends, that his diar- rhoea is of a healthy or conservative character. In others, again, there is, during this premonitory stage, more or less of a feeling of general illness; pains in the abdomen, and especially across the epi- gastrium ; coldness of the extremities, slight cramp in the calves of the legs, exhaustion, anxiety, and alarm. After these symptoms have continued, in some cases for several days, in others for only a few hours, the true choleraic symptoms declare themselves more or less quickly. Sometimes, on the other hand, the attack is fearfully sudden. The patient is seized without any previous warning, often about two o'clock in the morning, with a pain across the epigastrium, commonly at- tended with desire to go to stool; he does so, and passes a copious, often a bulky and healthy evacuation. This is ATery soon followed by another, and then another and another in rapid succession, the motions passing quickly into the true choleraic character, of a liquid resembling thin rice-water, sometimes even a limpid fluid, with just a few shreds of a Avhite substance suspended in it. AVith this purging there is commonly vomiting, the matter ejected from the stomach being the same in appearance as that passed from the bowels. Some- times the purging is so incessant, that the liquid streams from the patient without his having the power to restrain it. There are noAV severe cramps, commencing generaUy in the calves of the legs, and' extending to the abdomen and upper extremities, sometimes affecting even the muscles of the face, and not unfrequently, judging by the character of the pain, the diaphragm; there is also a total suppression of the urine, and, as may be inferred from the colourless appearance of the stools, of the bile also. There is urgent thirst; the patient is deathly cold to the touch, but complains much of heat; the skin streams with a cold perspiration; the extremities become shrunken and sodden, as if they had been long immersed in water; the hands SYMPTOMS., 591 and feet, and eventually the whole surface assumes a livid, leaden hue; the pulse becomes almost imperceptible at the wrist, sometimes quite so ; the tongue is white and cold, the breath like a stream of cold air, and the surface of the body exhales a cadaveric odour; there is incessant jactitation of the limbs, resembling that of exhaustion by haemorrhage. The cheeks are hollow, the countenance dark and dusky, and round the eyes, which are sunk in their orbits, there is a still darker circle. The voice is plaintive, and like a hoarse whisper, and startling the attendants by its unearthly sound. In many of the severest cases, the purging ceases after it has con- tinued for many hours, apparently because the system is thoroughly drained, and a state of most profound collapse may continue for many hours, when, if no reaction takes place, the patient dies. The mode of death is somewhat remarkable; the organic life seems to be the first extinct, after that the animal powers of voluntary motion, and lastly the intellect, which remains undisturbed till death. This appears to be, in fact, a manner of dying different from those Avhich we have hitherto noticed. It is not death from the heart, or death from the brain, but death beginning in the extreme of circula- tion, the heart, and lastly the brain failing in their functions from want of blood, the sujDply of which is cut off by the drain from the mucous surfaces and the skin; or it may be said to be death from the blood, Avhich when drawn is black and pitchy, from having been drained of its liquid. If the patient do not die in this stage, reaction, as it is termed, ensues, the pulse returns at the wrist, and ' the skin recovers its Avarmth; after a time, the secretions of bile and urine reappear, and the patient, exhausted indeed, and emaciated, but apparently free from disease, steadily, and sometimes Avith astonishing rapidity, regains his health. In a large number of cases, unfortunately it is not thus, but reaction leads to fever, and the fever is apparently of a specific character. After three or four days the patient begins to pass urine, generally of a dingy color; there is frequent vomiting of a green bilious fluid, and at the same time there are signs of stupor, or coma. The pulse is sharp, with a light back-stroke, _ and very compressible. Many—by far the greater number of patients thus affected, pass into a state of most profound coma, and so die. In the course of the consecutive fever just noticed, an exanthema- tons rash frequently makes its appearance, which has been described by Dr. Babington, who was the first to call attention to it: "After this" (the typhoid consecutive fever) "has existed several days, some red spots are observed about the Avrists and hands, and the face becomes tumid, as on the approach of erysipelas. If this occur in the evening, on the following morning the arms, the forehead, upto the roots of the hair, and the face generally, will be covered with laro-e elevated patches, of a bright-red color, more raised than mea- sles' and more defined than scarlatina, much resembling ndttle-rash, especially in the circumstance of their disappearance on pressure, and instant recurrence when that pressure is removed." Such are the more prominent features of this frightful malady, 592 EPIDEMIC CHOLERA. which we have been compelled to sketch thus brifly. Into the differ- ent opinions which have been entertained respecting its pathology, we cannot of course enter, but we submit that which seems to us most in accordance with general pathology, and the facts of the case. The morbid anatomy of cholera tells us little, as no appearances have been found, which in any Avay account for the symptoms. The most important are perhaps the capillary hyperaemia, the venous con- gestion, and the oedema of the mucous membrane of the stomach and small intestines, more especially of the duodenum. There is, too, another, to which we believe an exaggerated importance has been attached, namely, the distension of the gall-bladder Avith bile. The state of the intestinal membrane indicates the irritation that has been set up there, and this, too, seems to show that there has been an arrest of the capillary circulation, that arrest being followed, as we have elseAAdiere seen to be the case, by an exudation of the watery parts of the blood; that this is so is further shown by the oedema- tous condition of the sub-mucous areolar tissue. This seems to be the first link in the chain of diseased action which we are at present able to reach. But granting this, and that from hence the serosity of the blood is continually draining, the other phenomena follow as a matter of course; hence the thick tarry state of the blood, hence the suppression of urine (p. 35), hence the thirst (p. 78), hence the urea in the blood (p. 35), hence the suppression of bile (p. 35), hence the cramps (p. 393), hence the failure of the heart's action, of the cir- culation, and of animal heat; hence the uraemic poisoning, and subse- quent death by stupor or. coma. AAte Avould here remark that some importance has been attached to the gall-bladder being full; now it does by no means appear that this proceeds from any excessive secre- tion, it is merely, as Dr. Gull has remarked, such a condition as is common when the digestive function is long interrupted, and indi- cates rather a passive than an active state; but, as the same physician remarks, there are cases where the membrane of the ducts and gall- bladder is the seat of the cholera process. AAre believe that in many cases, the fulness of the gall-bladder is produced, not by pure, bile, but by choleraic effusion from its lining membrane, colored by bile Avhich had been already secreted. The seat, then, of the mischief is in the mucous membrane, beginning at the stomach and small intes- tines, and extending throughout its surface, so that the skin, which is one of its prolongations, is also similarly implicated, and further loss of fluid takes place from thence. AVe may here remark that a frequent and troublesome sequel of cholera is gastric irritation, some patients being subject to it for months and years afterAA'ards. In the consecutive fever, too, there is evidence of acute irritation of the gastro-intestinal mucous mem- brane. May not the rash have been an analogous affection of the skin? The diagnosis of cholera, Avhen established, is obvious. From the English cholera it maybe distinguished by the absence of bile in the ejected matters, by the A^oice, and by the tongue. AVhen there is ITS PATHOLOGY 593 premonitory diarrhoea, the signs of impending cholera are duskiness of the extremities, cold tongue, failing pulse. The prognosis of true epidemic cholera is in the main unfavour- able ; at the commencement of an epidemic of cholera, nine out of ten die. Upon an average, at least one half of the cases of developed cholera. Towards the termination of an epidemic the proportion of deaths becomes small. Of the causes of cholera we know but little; it may be said to pre- vail epidemically, though upon what this depends we know not, and this is not the place to enter into the nature of this epidemic influ- ence : it is but little controlled by climate; - it infests chiefly low situations, and the banks of rivers. Its spread is favoured by impu- rities in the air and water, and therefore by bad ventilation and drainage, and by neglect of personal cleanliness, and apparently by the defect of ozone in the atmosphere of large towns; by whatever, in fact, favours the spread of contagious diseases. Is it then conta- gious?—probably not highly so; but there can be no doubt that in many instances it has been conveyed by human intercourse. It affects mainly those in middle life, but no age is exempt. Debility may give some increased susceptibility, but the strongest and healthiest are not secure. There can beno"stronger proofs of the great fatality of this disease, than the variety of remedies which have been announced as of certain efficacy, and of which the worthlessness of most, and the pernicious- ness of some, have been found to be as certain. In the treatment of this disease all theories must be discarded. Many opinions which have been entertained as to its essence might at first sight appear as harm- less as they are weak, were it not that they have been made the grounds of the most pernicious treatment. Of this kind is the notion that a material poison has got into the blood which must be driven out of it that recovery may take place. Now we have pointed out the fact of the morbid action which takes place in the intestinal mucous membrane, and have traced its fatal consequences: the obvious indications must be to restrain this, and not to aggravate it. In the commencement of the disease check the diarrhoea. This is best done by opium and astringents. If there be moderate diarrhoea let the ordinary combination (F. 97)* be employed, and enjoin strict rest, that is confinement to bed, or, if not, to a couch; arrow-root and rice milk may be given, and if there be exhaustion let some brandy be added. If the diarrhcea increases, or if there be sickness, let a grain of calomel with one or two of opium, according to the urgency of the case, be given. If the choleraic symptoms appear to be setting in decidedly, give, in the first instance, half a drachm of compound chalk powder with opium, with half a drachm * (F. 97) R Confectionis Aromat. ^iiss. Tinct. Catechu, g j. Tinct. Opii, g ss—3 i. Mist. Cretae, ^ v. Aq. Cinnam. a sufficient quantity to make an Jviii mixture of which 3J is to be taken after each fluid stool. 38 594 EPIDEMIC CHOLERA. of sal volatile in cinnamon water; and if the diarrhcea be not checked, have recourse speedily to the calomel and opium. Many practitioners have a strong reliance upon calomel, and as it may help the capillary circulation, it is well to add it to the opium. The calomel and opium may be repeated, for the first three or four doses, every hour, and afterwards at longer intervals; but when collapse is setting in with- draw the opium. If the astringent mixture has no effect, about a scruple of the extract of logwood may be added to each dose, though it is liable to the objection that by discolouring the stools it may mis- lead us as to the character of any change taking place in the evacu- ations ; or the gallic acid may be employed. (F. 98)* A saturated solution of gallic acid to the amount of about four ounces may also be injected into the bowel. AVe do not, however, place very much reliance upon enemata, since they are seldom retained, and the chief irritation is high in the small intestines. Thirst is an urgent symp- tom, and though water can rarely be retained, the patient may be allowed to drink freely, though not in large quantities at a time. AVhen the pulse begins to fail, about a tablespoonful of brandy may be added to each tumbler of water. AVhen the sickness is urgent, about four minims of dilute hydrocyanic acid, with half a drachm of compound spirit of ammonia, may be given in water every two or three hours. The latter is also a valuable adjunct to the diarrhoea mixture when there is much exhaustion. The placing a small piece of ice in the mouth often helps to check the sickness, and is a great comfort to the patient. The measures which we have recommended are intended to carry out the principle of averting the diseased action from the organ or tissue Avhere that action is productive of the greatest mischief; and we would apply the same rule to the skin, which is similarly affected with the mucous membrane. The surface is exceedingly cold, and therefore it has been attempted to raise the temperature by great artificial heat; but this is as possible as it would be to warm a snow-ball without melting it. Any great heat and a load of blankets distresses the poor sufferer, and therefore it is best to con- sult his feelings in regard to clothes and temperature, though the apartment should be always carefully ventilated. AVe would not, however, by this, mean to forbid the application of large .sinapisms to the abdomen, which may have the effect of stimulating the capil- lary circulation; they are most beneficial at the commencement of the attack. AVhen the collapse takes place we believe that we can do but little. Some practitioners have great reliance upon repeated small doses of calomel, but we must not forget, that scarce any medicines can be taken into the system when it is in this condition. AVe have * (F. 98) R Acid Gallici, ^ss, Tinct. Catechu,'J j. Tinct. Opii, gss. An distillat. a sufficient quantity to make a ,^vi. mix- ture of which the one-sixth portion is to be taken every two hours. The laudanum must however be Withdrawn when the collapse sets in. TREATMENT. 595 generally been in the habit of giving about five grains of chlorate of potass with eight or ten of carbonate of soda in an ounce of vehicle every two hours, and a grain of calomel in the interval. If the pa- tient survive the collapse there is not uncommonly a distressing sickness with vomiting of green bilious matter. AVe have found the best remedy to be about five grains of calcined magnesia in half an ounce of water every hour and a half or two hours. After the sickness has subsided the chlorate of potass appears to act as a di- uretic, and helps to restore the capillary circulation. The secondary fever was, however, upon the whole, a most intractable disease, and even when the secretion of bile and urine appeared to be healthily restored many passed into a state of coma. The urine which was at first secreted was generally albuminous, but its becoming healthy did not insure an escape from the comatose symptoms. * 596 INFLUENZA AND HOOPING COUGH. XXX. INFLUENZA AND HOOPING-COUGH. Influenza or epidemic catarrh is a disease which requires only a short notice, although it is among the most fatal of epidemics; but we have already anticipated much that is to be said respecting its treatment. It has been termed epidemic catarrh, from the affection which is its most frequent attendant, but we believe that the morbid influence* merely locates itself most commonly in the mucous membrane of the fauces and air passages, but it often affects other tissues as well. Influenza makes its attack generally with the symptoms of fever of an adynamic character. These are chills, rigours, extreme lan- guor and depression, afterwards reaction, which is, however, feeble. The tongue is covered with a creamy mucus ; the pulse quickened, rather sharp, but always compressible; the skin is rarely very hot. In some cases, after reaction sets in, which may be in a few hours, the patient breaks out into a free perspiration, and if he be prudent and avoid exertion and exposure, the attack passes off. In most, hc%ever, there is severe catarrh, extending far into the bronchial tubes; and when neglected or when occurring in debilitated sub- jects, leading to fatal bronchitis, or peripneumonia notha. In some cases the lung becomes inflamed, in others the pleura, in others the pericardium or endocardium. In some instances, again, the ence- phalon is attacked, and there are some of the symptoms of phrenitis. Cynanche is also a common complication of influenza; so are some- times diarrhcea, dysentery, erysipelas, and a low form of arthritis. Influenza may be distinguished from common catarrh by the extreme debility; from mild fever by the extreme prostration, and in many cases by the appearance of an herpetic eruption around the mouth; from ordinary attacks of the inflammation which are apt to complicate it; by the tongue, the low form of the inflammation, and by the prevalence of the disease at the time. During the prevalence of an epidemic of influenza, an attack of that disease is always to be regarded with apprehension ; though in young and healthy subjects it is rarely fatal, unless some serious complication arises; but unless great care be taken, it is very probable that some such will occur. In old and feeble persons the prognosis is always doubtful; and if there be much tendency to chest-disease, unfavourable. In mild cases the best treatment is that of common catarrh. Where there is considerable depression, ammonia should be added to the saline, and a few grains of Dover's powder given at night, the * We are afraid of the term poison, lest it should suggest the attempt at some barsh method of eliminating it. HOOPING COUGH. 597 bowels being, of course, attended to. The treatment of the several complications must be that of those diseases themselves, with the qualification that the tendency is to asthenia, and that very feAV patients who are bled recover. And what is remarkable, in the in- fluenza of 1847, loss of blood was often followed by furious delirium. HOOPING-COUGH. This is an epidemic paroxysmal cough, mostly affecting children, the character of which is too generally known to need much descrip- tion. It generally begins with slight cough and difficulty of breath- ing, though often with but little signs of pyrexia; the cough by degrees assuming the well known " whoop," and being followed by expectoration of a quantity of mucus, and in many cases by sickness, after which the child will appear well, and express a desire for food, most of which is rejected after the next paroxysm. Sometimes, however, when the paroxysm has been a severe one, he is left languid and powerless. The disease may continue for weeks, or months, or for a year. The popular notion is that it lasts till the May following its invasion. Though children are the most frequently attacked by this disease, elderly and even old people have been often known to suffer from it. It perhaps depends upon a specific poison, and one attack generally insures an immunity for the remainder of life. It is generally believed to be contagious, and probably is so in some de- gree ; but it is certainly influenced by some epidemic temperament. 3 The danger of the disease consists in its liability to be compli- cated with severe bronchitis and pneumonia; and its remote ill effect, its proneness to induce dilated tubes or air cells. The treatment of hooping-cough, as long as it is simply such, should not be meddlesome; as it is a nursery disease there are many nursery remedies, of which the most harmless is the best. Bland nutritious diet, and a uniform temperature, are indispensable. Medical superintendence is also necessary to watch for the occur- rence of the complications, which must be treated upon general principles. The combination of the conium mixture (F. 23) with a little dilute hydrocyanic acid; two drachms of the mixture with one minim of the acid may be given to a child of four years old three times a day. After a time, if there be no fever, the ipecacuanha may be withdrawn, and the affection being spasmodic, zinc may be given, in doses of a quarter of a gram, in the intervals. Change of air, if possible to the sea-side, will generally complete the cure. 598 diseases of adolescence and puberty. XXXI. DISEASES OF ADOLESCENCE AND PUBERTY. The different periods of life are each more particularly obnoxious to different diseases, and this is peculiarly the case with regard to youth and adolescence. AVe do not by this allude so much to the structural diseases of the sexual organs, the discussion of which, as regards the female, belongs more to the works of the obstetrician, and as regards the male, to those of the surgeon; but to changes which take place in the relative proportions of 'the different parts of the body, at the period of puberty, which may be termed that of the transition from childhood, to manhood or womanhood. To this we have already alluded in reference to the development of tubercle. One great change which takes place at this time is in the relative size of the extremities and the trunk, and of the chest and the abdomen; and the reason of this is, that as the extremities acquire their full proportionate development, there must be an increase in the quantity of blood sent to the right heart directly through the cavse, as compared with that which finds its way by the more circuitous route through the portal system; at the same time there must be a demand for a greater activity in the decarbonising action of the lungs. This is remarkably shown as regards the latter by the observations of Andral and Gavarret, from which it appeared that in the male there was at the period of puberty a rapid increase in the volume of carbonic acid daily evolved by the lungs, that afterwards it continued slowly to increase till perfect manhood, and about the age of forty- five began to decline. Now the inference from this as regards the male subject is obviously this—that if the lungs themselves be un- sound, or if there be any causes impeding their development, as nar- rowing of the air passages, contraction of the chest from old pleuritic adhesions, or the effect of pericardial adhesion acting immediately through the impediment which it affords to respiratory movements; or if there be obstructions to the pulmonic circulation, either from disease of the mitral valve or dilated bronchial tubes, or the effects of old bronchitis, it will be at this period that the effects of such defective development may be expected to show themselves, (see Guy's Hospital Reports, 1st series, vol. vi., pp. 1, and 467,) and they will consist mainly either in disorganisation of the lungs, or enlarge- ment of the right heart, engorgement of the liver, ascites, and general dropsy. In the female, the progress of the activity of the respiratory func- tions is still more remarkable. In the girl it goes on increasing, as in the boy, to the age of puberty; but when menstruation is esta- blished, instead of a further and more rapid increase, as in the male at the same age, the increase in the daily evolution of carbonic acid AMENORRHEA. 599 is arrested; but should the catamenia be checked, there will be an increase in the evolution of carbonic acid until they are restored. AVe perceive, then, the important connection between the uterine functions and the organs of respiration, and also that if there exist any of those circumstances which have just been enumerated as pre- venting the development of the latter, an irregularity in the former must tend greatly to aggravate the ill effects which may be antici- pated. And that such is the case is confirmed by experience, cases having occurred in which, from early rheumatism and carditis, there had been narrowing of the mitral valve, menstruation became esta- blished, and the pulmonic obstruction was relieved, and the patient has gone on in tolerable health till the age when that function might be expected to cease, and then the dyspnoea, engorgement of heart and liver, and subsequent dropsy, quickly followed. Independently, however, of structural lesion, there appears in the female to be sometimes a want of power in the system to establish the catamenial function; in other cases, again, it is arrested when so established. Hence we have two varieties of amenorrhoea, which are termed in the former case emansio mensium, and in the latter suppressio men- sium; but there is besides another distinction of equal or even greater practical importance, and that is between amenorrhoea with anaemia, and amenorrhoea in a plethoric subject. The former is termed amenorrhoea with chlorosis, and the latter simple amenorrhoea. Amenorrhoea with chlorosis, when appearing in the form of emansio mensium, is characterised by delayed development of the mammae and general anaemia; with suppressio mensium there may be full development. Amenorrhoea with chlorosis, then, is associated with anaemia, and is probably its effect; the feeble powers of the system, as evinced by the deficiency of red corpuscles not being adequate to the supply of blood for the purpose. These cases are characterised by the white lips and white cheeks, with sometimes a sallow, greenish hue, the pearly conjunctivae, the dark areola round the eyes. There are com- monly dyspnoea and palpitation; there is an anaemic murmur in the ascending aorta, plainest, according to Dr. Hughes, where that vessel overlies the pulmonic artery. There is general weakness and inability for exertion, and the legs and feet are commonly oedematous towards night; the nervous system is highly susceptible, and such patients are morbidly timid, and often hysterical. As an additional cause of weakness, there is often leucorrhoea. This form of amenorrhoea is most common in towns, and is no doubt much favoured by the want of pure air and sunshine. It must obviously be unreasonable to attempt to relieve such cases by any measures calculated directly to induce or restore the uterine functions, since their non-performance is often a conservative precau- tion on the part of nature, to save the power of the system. Iron, indeed, has the reputation of being emmenagogue; but it is because it is tonic, and promotes the formation of red corpuscles, and the strength and material being given, the function is performed. The 600 HYSTERIA. iron may be exhibited in the form either of ammonio-citrate or ammonio-tartrate, or the compound iron mixture of the Pharmacopoeia. The two former are the least offensive, and are not so apt to induce head-ache. They may be given in solution, and as the boAvels are generally costive, some aperient pill should be given every night or every alternate night. For the latter reason an excellent form is the combination of the iron mixture with the compound decoction of aloes. AVhere there is much leucorrhcea, the solution of alum and zinc should be used as an injection per vaginam. In the cases of amenorrhoea without chlorosis, the cause of the non- performance of the function is probably dependent upon congestion. The subjects are generally florid, stout, full-bosomed girls, who, never- theless, have often a feeble circulation. Exercise, free purging, the application of a feAV leeches to the groins or to the inside of the thighs, when the period comes round, are the best remedies. Many practitioners have faith in the madder and hellebore as emmenagogues. Hysteria is another affection closely connected with uterine derange- ment in females, it is from thence that it derives its name. To de- scribe its various phases, would exceed our limits; there is no disease Avhich it may not simulate, but it should be "I remembered that there is none which it may not mask. The well-known hysteric fits are perhaps the effect of excessive polarity of the spinal cord, that of the brain being diminished; such a state of things is more apt to exist in the female than the male, especially if there be a tendency to chloro- sis; and when we consider the vast supply of nerves distributed to the uterus, we cannot be surprised at the ready excitement of spasm or convulsion from irritation of that organ. Another remarkable phenomena in hysteria is a strange perversion of the moral feelings, evincing its presence in fondness for simulation. Thus delicate fe- males will not only feign disease of the bladder, rectum, or uterus, but even some which may subject them to painful operations. Some- times, again, there is a species of delirium, of which one of the most remarkable characteristics is that young females, often young ladies, will use obscene expressions, and sometimes sing songs with which we could hardly believe that they were acquainted. In the management of hysteria we must look first to the natural functions, and especially those of the bowels and the uterus, and there are few better remedies during the paroxysm, than cold effusion. In the intervals of the paroxysms, the valerianate of zinc, in doses commencing at about a grain, and gradually increased, will often have the effect of preventing them. In the hysteric mania the combination of camphor and henbane, and the occasional use of assofcetida injections, will be very service- able. After the maniacal excitement has subsided, the valerianate, or sulphate of zinc may be employed; but more important than these are moderate exercise for the body, and rational employment for the mind. AVe have already hinted that in several spasmodic diseases the automatic functions are in undue action, whilst the voluntary power is in abeyance; and this is the case in hysteria; but beyond this, there is an increase in the emotional susceptibilities, and dimi- HYSTERIA. 601 nution in the controlling power of the reason. To subdue the former, and strengthen the latter, should therefore be a leading object. For this reason, moderate intellectual exercise is to be encouraged; but the stimulus of much that is termed light literature is to be discoun- tenanced. Rational society is to be sought, but dissipation shunned. Religion, in its truest sense, is as healthful, as sentimental religionism is pernicious. INDEX. Abscess, 56. Acid, phosphoric, in urine, 410. ----uric, 405. Adolescence, diseases of, 597. Ague, 485. Albumen in the urine, tests for, 380. ----of the blood, changes in, 33. Amenorrhoea, 498.. Anaemia, 30. Anaesthesia, 466. Antimony, tartarized, action of, 99, ----in pneumonia, 199. Anorexia, cause of, 326. Aortitis, 288, et seq. Aorta, aneurism of, 289. ----------diagnosis of, 292. ----------treatment of, 292. Aortic valves, disease of, 261, 280. --------treatment of, 361. Apnoea, death from, 26. Apoplexy, 450. ----different forms of, 451. ----pathology of, 452. ----its remote causes, 456. ----its diagnosis and treatment, 457, et seq. Appetite, loss of, 78. Ascites from chronic peritonitis, 352, 355. ----hepatic, 290. --------treatment of, 304. Asthenia, death from, 82. Asthma, 481. Auscultation, 129, et seq. Biliary calculi, 309. Blood, changes in, 30. ----coagulation of, 32. ----foreign ingredients in, 36. ----effects of retained secretion on, 34. ----• buffy coat, 32. ----inflamed, 60. Blood-letting, topical, 86. Bleeding, effects of, 88. ____indications for, 88, et seq. Bowels, inflammation of, 356. ----obstruction of, 358. Brain, disease of arteries of, 453. •=— congestion of vessels of, 453. ----inflammatory diseases of, 419. ----disease of, from affection of kid- neys, 393. Bright's disease, different forms of, 386. Bronchitis, acute, symptoms of, 168. --------character of expectoration in, 171. --------modes of fatal termination of, 172, et seq. --------diagnosis of, 174. --------prognosis of, 176. --------treatment of, 177, et seq. ----chronic, 181. --------its treatment, 184. Bronchial tubes, dilated, cause of, 182. et seq. Bronchophony, pneumonic, 135, 191. Broncho-pneumonia, 224. Broncho-Pleuro-pneumonia, 226. Buffy coat, 32. Calculus in the ureter, 384. Cancer of stomach, 320. Carditis, 255. Catarrh, 164. ----treatment of, 167. ----prevention of, 167. ----epidemic, 595. Cerebral inflammation, 419. Cerebro-spinal meningitis, 433. Changes, elementary, 29. Chicken-pox, 538. Child-crowing, 154. Chlorosis, 498. Chorea, 471. Cholera, English, 370. ----epidemic, 590. ----infantum, 373. Circulation, derangements of, 36. Cirrhosis of liver, 301. Colchicum, use of, in rheumatism, 118, 119. Cold, use of, 100. Colica pictonum, 483. Colic, 482. ----painter's, 483. > 604 INDEX. Coma, death from, 27. Congestion, active, 36. ----passive, 38. ----mechanical, 39, 43. ----treatment of, 39. Constipation, obstinate, its causes, 359. ----diagnosis of, 360. Convulsions, infantile, 471. Corpuscles, blood, changes in, 30. Counter-irritants, use of, 104. Crepitatio redux, 192. Crepitation, moist, 192. ----pneumonic, 189. Croup, 150. ----premonitory signs of, 150. ----symptoms of, 152. ----varieties of, 153, 154. ----spasmodic, 154. ----diagnosis of, 156. ----treatment of, 159. ----catarrhal, 154. ----mucous, 154. ----spasmodic, 154. Cynanche, 138. ----treatment of, 140. Death, modes of, 24. ----from coma, 24. ----from syncope, 25. ----modes of, an inflammation, 82. Delirium tremens, 443. ----its causes, 444. Deposits, typhous, 106. ----scrofulous, 107. ----urinary, 405. Diabetes, 416. Diaphoretics, use of, 98. Diathesis, tuberculous, 110. Diarrhcea, 369. ----varieties of, 369. Digitalis, action of, 100. Disease, general signs of, 65. ----causes of, 18. ----endemic, 22, ----epidemic, 22. ----hereditary, tendency to, 19. Diuretics, use of, 96. Dropsy, 290, 325, 352, 390. ----of the brain, 424. Dysentery, 370. Dyspepsia, 326. ----treatment of. 331. ----symptoms of, 326. Effusion, inflammatory, 50. ----pleuritic, signs of, 211. ----diagnosis of, 214. Empyema, 207. Encenhalon, inflammatory diseases of, 419. Encephalitis, 419. Endemic diseases, 22. Endocarditis, 259. ----anatomical changes in, 259. ----signs of, 259, 260. ----causes of, 263. ----diagnosis of, 264. ----fatal termination of, 265. ----treatment of, 265. ----chronic, 270. Enteritis, 356. Epidemic diseases, 22. Epilepsy, 474, et seq. ----its pathology, 475. ----causes and diagnosis, 476. ----treatment of, 478. Erysipelas, 549. ----causes of, 551. ----treatment, 552. Fever, inflammatory, 61. ----hectic, 62. ----eruptive, 530, et seq. ----intermittent, 485, 488. Fever, intermittent, causes of, 487. ---------complicated, 497. ---------treatment, 494. ----remittent, 498. ■----continued, 485, 501. ---------its symptoms, 501. ---------varieties of, 503. ---------complications of, 504. ----muculae in, 508. ----pulse in, 510. ----prognosis, 512. ----modes of death in, 512. ----treatment of, 515. ----use of wine in, 524. ----complicated, treatment of, 527. ----yellow, 554. Fibrine, changes in quantity and quality of, 30. G-all Ducts, inflammation of, 305. ---------treatment of, 306. Gall-stones, 309, 310. Gangrene, 59. Gastritis, acute, symptoms of, 315. ---------cause of, 315. ---------diagnosis of, 316. ---------treatment of, 317. ----chronic, 318. ----terminations of, 318. ----causes of, 318. ■—— treatment of, 319. Glottis, oedema of, 147. Gout, acute, 122. ----chronic, 123. of, j----treatment of, 126. j Gouty diathesis, 123. INDEX. 605 HEMATEMESIS, 322. Haemoptysis, 232, 236, 241. ----treatment of, 250. Heart, diseases of the, 255. ----hypertrophy of, 271. ----dilatation of, 271. ----hypertrophy of, true, 272. ----hypertrophy and dilatation of, 273, 280. ----hypertrophy of, false, 274. ----fatty degeneration of, 274. ----hypertrophy of, false, diagnosis, 276. ----disease of, from affection of kidneys, 392. Heartburn, 335. Hectic fever, 62. Hepatitis, 297. Hepatization, pneumonic, 190. ----grey, treatment of, 201. Hooping cough, 596. Hunger, its nature, 78. ----as a sign of disease, 78. Hydrocephalus, acute, 424. ---------its symptoms, 425. ---------its causes, 426. ---------its diagnosis, 426. ---------its treatment, 428. ----chronic, 432. Hyperaemia, active, 36. ----. passive, 38. Hysteria, 599. Ileus, 358. Indigestion, 326. Inflammation, 44, et seq. ----description of, 44. ----state of vessels in, 45. ----nerves in, 48. ----consequences of, 48, 49. ----blood in, 46, 60. ----signs of, 65. ----effusions of, 50. ----metastasis of, 49. ----resolution of, 49. ----its fatal terminations, 82, et seq. ____principles of treatment of, 82, et ----blood-letting in, 86, et seq. ----gouty, 121. ----rheumatic, 115. Inflammatory lymph, 52. ----process, review of, 63. Influenza, 595. Intestine, obstruction of, diagnosis, l Jaundice, 307. ----symptoms of, 308. ----causes of, 309. ----a fatal form of, 311. ____treatment of, 312. Kidneys, diseases of, 378, et seq. ----acute inflammation of, 383. ----Bright's disease of, different forms of, 386. ----affection of heart in, 390. —------brain in, 393. ---------lungs in, 392. ----spasmodic affection in, 393. ----changes of blood in, 390. ----Bright's disease of, its history and symptoms, 394. ---------its dignosis, 395. ---------its causes, 397. ---------its treatment, 398, et seq. Laryngismus stridulous, 154. Laryngophony, 135. Laryngitis, 142. ----acute, treatment of, 144. ----chronic, 148. Lemon-juice, use of, in rheumatism, 119. ■« Leucorrhoea, 488. Lime, oxalate of, 408. ----phosphate of, 409. Lithates, deposits of, 407. Lithic acid deposits, 407. Liver, diseases of, 293. ----congestion of, 293. ----gangrene of, 300. ----inflammation of, 297. ----inflammation of, suppurative, 297. ---------abscess of, 297. ----diagnosis of, 299. ----adhesive inflammation of, 300. ----cirrhosis of, 501. ---------pathology of, 301. ----inflammation of veins of, 304. ----inflammation of ducts of, 305. Lung, gangrene of, 192. ----malignant disease of, 242. Lymph, fibrinous, 50, 51. ----corpuscular, 51, 52. ----inflammatory, 52, 53. Mania, acute, 447. Mania-a-potu, 443. Measles, 539. Medicine defined, 17. Melaena, 324. Meningitis, cerebro-spinal, 433, Mercury in inflammation, 101. ----in pneumonia, 199. ----action of, 101. Metastasis, 49. Mitral valve, disease of, 262, 280. ----treatment of, 287. Muco enteritis, acute, 365. _________chronic. 366. 606 INDEX. Nerves, in inflammation, 48. Nephralgia, 384. Nephritis, acute, 383. ----treatment of, 385. ----diagnosis of, 384. Oesophagitis, 313. (Esophagus, diseases of, 313. ----stricture of, 313. Opium, its use in fever, 522. Ovaries, irritation of, 341. Oxalate of lime, 408. Pain, as a sign of disease, 65. Painter's colic, 483. Palsy, lead, 483. Paracentesis, 222. Paralysis, facial, 466. ----its causes and treatment, 460, etseq. Paraplegia, 464. Pectoriloquy, 135. Peritoneum, disease of, 336. Peritonitis, chronic, 347. ----tuberculous, 348. ----chronic, diagnosis, 350. ----its diagnosis and prognosis, 342, 343. ----fatal termination of, 342. ----puerperal, 345. ----acute, its treatment, 344. ----chronic, its treatment, 353. ----subacute, 353. ---- acute, 336. ---------its pathology, 336. ---------its symptoms, 337. ---------its causes, 339. Pericarditis, acute, 255. ----chronic, symptoms and treatment of, 269. ----fatal termination of, 265. Pericarditis, treatment of, 266. Peripneumonia notha, 224, Pertussis, 596. Phosphates in urine, 411. Phosphatic deposits, diagnosis of, 412. --------microscopic characters of, 413. Phosphates, causes of deposition of, in the urine, 414. Phrenitis, symptoms, 420. ----diagnosis of, 421. ----treatment of, 422. Phthisis, 227. ----anatomical changes in, 227. ----varieties of, 230. ----stages of, 230. ----complications of. 236. ----acute, 238. ----fatal termination of, 240. ----diagnosis of, 241. ----treatment of, 243. Phthisis, abdominal, 368. Plethora, 30. Pleuritis, 205. ----treatment of, 220. ----pathology of, 205. ----causes of, 215. —— symptoms of, 207. ----prognosis of, 218. Pleuro-pneumonia, 225. Pneumonia, pathology of, 186. ----anatomical changes in, 186. ----its symptoms, 188. ----diagnosis of, 193. ----prognosis of, 194. ----fatal terminations of, 196. ----causes of, 197. ----treatment of, 198. ----treatment in second stage, 200. ----typhoid, 203. ----in complication with fever, 527. ----in children, 194. Pneumonia notha, 224. Pneumothorax, 216. Poisons, effects of, 27, 28. Predisposing causes of disease, 18. Puberty, diseases of, 597. Pulse, conditions requisite for a healthv, 68, 69. ■----irregular, 69. ----feeble, 69, 71. ----splashing. 69. ----thrilling, 70. ----circumstances which affect it, 71. ----effect of nervous influence of, 72. ----frequency of, 72, 73. ----characters of, 73. ----its force or feebleness, 74. Purgatives, use of, 95. Puriform infection, fatal, 83. Purpurine, 408. Pyrosis, 329, 335. Rattles, mucous, causes and varieties of, 171. Resolution of inflammation, 49. Rheumatism, acute, 115. ----subacute, 116. ----diagnosis of, 117. ----treatment of, 117, et seq. Ronchus, nature and cause of, 134, 170. Rubeola, 539. Scarlatina, 541. ----simplex, 542. ----anginosa, 542. ----maligna, 543. ----treatment, 546. Scrofulous deposit, 107. Secretions, retained, effects of, 33, 34. INDEX. 607 Sedatives in inflammation, 98. Sibilus, nature and cause of, 133, 170. Small pox, 531. ----distinct, 532. ----confluent, 533. ----modified, 537. Svncope, death from, 25. Spaiiiemia, 30. Spasm, its nature and causes, 4(18. Sporadic diseases, 20. Stomach, diseases of, 315. ----malignant disease of, 320. --------causes of, 321. --------treatment of, 322. Sugar, tests for, in urine, 417. Sulphates in urine, 409. Summer complaint, 373. Suppuration, 55, 56. Symptoms of disease, secondary, 68. --------general, 68, 69. Syncope, death from, 25, 82. Tabes Mesenterica. 368. Tenderness, as a sign of disease. 66. Thirst, its cause, 77. ----as a symptom of disease, 78. Tongue, signs afforded by, 75. Tonsillitis, 13s. Tubercle, 107. ----origin of, 108. ----development of, 108. —— laws which regulate deposition 112. Tuberculous deposit, 107. ----diathesis, 108. Typhoid Fever, 509. Typhous deposit, 106. Typhus Fever, 485, 509. Ulceration, 58. ----fatal termination of, 83, 84. Urates, deposits of, 406. Urinary deposits, 405. Uric acid, deposits of, 405. 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The young practitioner will find it invaluable, while those who have had most experience will yet find something to learn, and much to commend, in a book which shows so much patimt observation, practical skill, and sound sense.—British and Fo- reign Med. Jievitw. We commend it to our readers as the best practi- cal treatise on the subject which has yet appeared. —London Lancet. ARNOTT (NEILL), M. D. ELEMENTS OF PHYSICS; or Natural Philosophy, General and Medical. Written for universal use, in plain or non-technical language. A new edition, by Isaac Hays, M. D. Complete in one octavo volume, leather, of 484 pages, with about two hundred illustra- tions. $2 50. BENNETT (HENRY), M. D. A PRACTICAL TREATISE ON INFLAMMATION OF THE UTERUS, ITS CERVIX AND APPENDAGES, and on its connection with Uterine Disease. Fourth American from the third and revised London edition. To which is added (July, 1856), aBEviEw of the Present State of Uterine Pathology. In one neat octavo volume, extra cloth, of 500 pages, with wood-cuts. $2 00. The addition of the "Review" presents the most recent aspects of the questions discussed in thi* well-known work, bringing it down to the latest moment. This edition has been carefully revised and altered, , When, a few years back, the first edition of the and various additions have been made, which render present work was published the subject was oneal- ^moreromnlete and, if possible, more worthy of most entirely unknown to the obstetrical celebrities t J hi-h.appreciation in which it is held by the I of the day ; and even now we have reason to know medical profession throughout the world. A copy j that the bulk of the profession are not fully alive to »)miild be in the possession of every physician— the importance and frequency of the disease of which Charleston Med. Journal and Review. it takes cognizance, l'he present edition is so much ^nariesion. iM.t,u,. o enlarged, altered, and unproved, that it can scarcely We are firmly of opinion that in proportion as a COnS1dered the same work.—Dr. Ranking'* Ab- knowledge of uterine diseases becomes more appre- r-jated this work will be proportionally established as a text-book in the profession.—The Lancet. | Also, just ready, by the same author, and for sale separate, A REVIEW OF THE PRESENT STATE OF UTERINE PATHOLOGY. 1 small vol. 8vo. '50 cents, in flexible cloth. T„\his little work, which can be had either in connection with the "Practical Treatise," or seSrate the author presents his lale»t views with regard to the various doctrines which have re- cently been brought forward on this interesting question, under the following heads :- r„ip t Preliminary. II. Sketch of Uterine Pathology. III. Objections. IV. The Leucorrhoea Theory-the Syphilis Theory-the Ovarian Theory. V. The Displacement Theory. Vi. Summary. 4 BLANCHARD & LEA'S MEDICAL BROWN (ISAAC BAKER), Surgeon-Accoucheur to St. Mary's Hospital, &c. ON SOME DISEASES OF WOMEN ADMITTING OF SURGICAL TREAT- MENT. With handsome illustrations. One vol. 8vo., extra cloth. (Now Ready.) St CO. Mr. Brown has earned for himself a high reputa- I and merit the careful attention of every surgeon- tion in the operative treatment of sundry diseases accoucheur.—Association Journal. and injuries to whichfemales.arei peculiarly-subject hesitation in recommending this book We can truly say of his work.that it .s an important f , j f „ eons 6who mRke addition to obstetrical literature The operative complaints a part of their study and practice. suggestions and contrivances which Mr. Brown de- * _ ... ,,' , , T-..-«»i scribes, exhibit much practical sagacity and skill, I -Dublin Quarterly Journal. BENNETT (J. HUGHES), M.D., F. R. S. E., Professor of Clinical Medicine in the University of Edinburgh, &c. THE PATHOLOGY AND TREATMENT OF PULMONARY TUBERCU- LOSIS, and on the Local Medication of Pharyngeal and Laryngeal Diseases frequently mistaken for or associated with, Phthisis. In one handsome octavo volume, extra cloth, with beautiful wood-cuts. pp. 130. (Lately Iss?ied.) ?1 25. BUDD (GEORGE), M. D., F. R. S., Professor of Medicine in King's College, London. ON DISEASES OF THE LIVER. Second American, from the second and enlarged London edition. In one very handsome octavo volume, extra cloth, with four beauti- fully colored plates, and numerous wood-cuts. pp. 468. $3 00. For many years, Dr. Budd's work must be the I the subject has been taken up by so able and experi- authovity of the ureat mass of British practitioners enced a physician.—British and Foreign Medico- on the hepatic diseases; and it is satisfactory that I Chirurgical Review. BY the same author. (Now Ready.) ON THE ORGANIC DISEASES AND FUNCTIONAL DISORDERS OF THE STOMACH. In one neat octavo volume, extra cloth. $150. A new work, 1856. While special treatises have been multiplying upon almost all the different classes of diseases, there has long been felt the want of an authoritative work on the disorders of the stomach, which con- stitute, perhaps, a larger proportion of the daily practice of the physician than any other class of maladies. To supply this want has been the object of the author, and his reputation is an ample s-uarantee of the value of his labors. From the high position occupied by Dr. Budd as a teacher, a writer, and a practitioner, it is almost needless to state that the present book may. be con- sulted with great advantage. It is written in aa easy style, the subjects are well arranged, and the practi- cal precepts, both of diagnosis and treatment, denote the character of a thoughtful and experienced phy- sician.—London Med. Times and Gazette, Dec. 1^55. BIRD (GOLDING), A. M., M. D., &c. URINARY DEPOSITS: THEIR DIAGNOSIS, PATHOLOGY, AND THERAPEUTICAL INDICATIONS. A new and enlarged American, from the last improved London edition. With over sixty illustrations. In one royal 12mo. vol, extra cloth, pp.372. $L 30. It can scarcely be necessary for us to say anything of the merits of this well-known Treatise, which so admirably brings into practical application the re yarding the physiology and pathology of the uri- nary secretion, which have contributed so much to the increase of our diagnostic powers, and to the extension and satisfactory employment of our thera- peutic resources. In the preparation of this new edition of his work, it is obvious that Dr. Golding suits of those microscopical and chemical researches Bird has spared no pains to render it a faithful repre sentation of the present state of scientific knowledge on the subject it emb races.— The British and Foreign Medico-Chirurgical Review. BY THE SAME At'THOR. ELEMENTS OF NATURAL PHILOSOPHY; being an Experimental Intro duction to the Physical Sciences. Illustrated with nearly four hundred wood-cuts. From the third London edition. In one neat volume, royal 12mo., extra cloth, pp.402. $125. BILLING'S PRINCIPLES OF MEDICINE.— Second American, from the Fifth and Improved London edition. In one handsome octavo volume, extra cloth. 250 pages. SI 25. BLAKISTOX'S PRACTICAL OBSERVATIONS ON CERTAIN DISEASES OF THE CHEST, and on the Principles of Auscultation. In one vol., cloth, 8vo pp.3S4. $1 25. BURROWS ON DISORDERS OF THE CERE- URAL CIRCULATION, and on the Connection between the Affections of the Brain and Diseases of the Heart. In one 8vo. vol.-, extra cloth, with colored plates, pp. 216. SI 25. BEALE ON THE LAWS OF HEALTH IN RE- LATION TO MIND AND BODY. A Series of Lettf rs from an old Practitioner to a Patient. In one volume, royal 12mo., extra cloth, pp. 290. 80 cents. BUSHNAN'S PHYSIOLOGY OF ANIMAL AND VEGETABLE LIFE ; a Popular Treatise on the Functions and Phenomena of Organic Life. In one handsome royal 12mo. volume, extra cloth, with over 100 illustrations, pp. 2*1. SO cents. BUCKLER ON THE ETIOLOGY, PATHOLOGY, AND TREATMENT OF FIBRO-BRONCIIl- T1S AND RHEUMATIC PNEUMONIA. In one Svo. volume, extra cloth, pp.150. $1 25. BLOOD AND URINE (MANUALS ON). BY JOHN WILLIAM GRIFFITH. G. OWEN REESE, AND ALFRED MARKWICK. One thick volume, royal 12mo., extra cloth, with plates, pp. 460. 551 25. BRODIE'S CLINICAL LECTURES ON SUR- GERY. 1 vol. 8vo., cloth. 350 pp. SI 25. AND SCIENTIFIC PUBLICATIONS. 5 BARLOW (GEORGE H.), M. D. Physician to Guy's Hospital, London, &c. A MANUAL OF THE PRACTICE OF MEDICINE. With Additions by D. F. Condie, M. D., author of " A Practical Treatise on Diseases of Children," &c. In one hand- some octavo volume, leather, of over bOO pages. (^4 new work, just ready, 1856.) $2 75. The position of the author as physician to Guy's Hospital and other large public institutions, is a sufficient guarantee of the extent and value of the experience which is here systematically re- corded and condensed. His aim throughout has been to produce a practical work, on which the student can rely as a guide, and to which the practitioner can refer with confidence. The additions by the editor comprise chapters on Cerebro-spinal Meningitis, Cholera Infantum, and Yellow Fever, besides numerous notes wherever the diseases or practice of this country seemed to render them necessary or desirable. AVe most emphatically commend it to the attention i will be found hardly less useful to the experienced of the profession, as deserving their confidence—a physician. The American editor has added to the depository of practical knowledge, from which they i work three chapters—on Cholera Infantum, Yellow Fever, and Cerebro-spinal Meningitis. These addi- tions, the two first of which are indispensable to a work on practice destined for the profession in this country, are executed with great judgment and fi- delity, by Dr. Condie, who has also succeeded hap- pily in imitating the conciseness and clearness of style which are such agreeable characteristics of the original book.—Boston Med. and Surg. Journal, Feb. 1856. We have looked through this volume with very great satisfaction: it is written in an easy and plea- sant style, and the short though lucid expositions of disease, clearness of description, and soundness of precept will make it a welcome visitor in the library of every practitioner. It combines the simplicity of old Cui.len, with the elegance of Watson, and al- though not so copious as other works we might men- may draw wiih great benefit.—Cincinnati Med. Ob- server, Mar 1856. The student has long been in want of a good ele- mentary work on the Practice of Medicine. In Dr. Barlow's Manual that want is supplied; and we have no question that it will at once he installed as the favorite text-book in all Medical Schools.— Medical Times and Gazette. We recommend Dr. Barlow's Manual in the warm- est manner as a most valuable vade-mecum. We have had frequent occasion to consult it, and have found it clear, concise, practical, and sound. It is eminently a practical work, containing all that is essential, and avoiding useless theoretical discus- sion. The work supplies what has been for some time wantiig, a manual of practice based upon mo- dern discoveries in pathology and rational views of treatment of disease. It is especially intended for j tion, it will, nevertheless, become a standard autho- the use of students and junior practitioners, but it | rity.—American Lancet, Mar. 1856. BARTLETT (ELISHA), M. D. THE HISTORY, DIAGNOSIS, AND TREATMENT OF THE FEVERS OF THE UNITED STATES. A new and revised edition. By Alo.nzo Clark, M. D , Prof. of Physiology and Pathology in the N. Y. Coll of Physicians and Surgeons, &c. In one octavo volume, of six hundred pages, extra cloth. (Nearly Ready.) The masterly and elegant treatise by Dr. Bartlett i and as such cordially recommend it to the medical is invaluable to the American student and practi- tioner.—Dr. Holmes's Report to the Nat. Med. Asso- ciation. We regard it, from the examination we have made of it, the best work on fevers extant in our language, public.—St. Louis Medical and Surgical Journal. Take it altogether, it is the most complete history of our fevers which has yet been published, and every practitioner should avail himself of its con- tents.—The Western Lancet. BOWMAN (JOHN E.), M.D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Second Ame- rican, from the third and revised English Edition. In one neat volume, royal 12mo., extra cloth, with numerous illustrations, pp. 288. (Noiv Ready, 1856.) $1 25. Presenting, in a condensed and convenient form, at a very low price, the applications of Chemistry to the practical purposes of Clinical Medicine, this work supplies a want which has long been felt bv the physician. The numerous editions which have been called for both in England and this country, sufficiently attest the success with which the author has carried out his plan. BY THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANA- LiTSIS. With numafous illustrations. In one neat vol., royal 12mo., extra cloth, pp.350. $125. CURLING (T. B.), F. R.S., Surgeon to the London Hospital, President of the Hunterian Society, &c. A PRACTICAL TREATISE ON DISEASES OF THE TESTIS, SPERMA- TIC CORD AND SCROTUM. Second American, from the second and enlarged English edi- tion. In one handsome octavo volume, extra cloth, with numerous illustrations, pp. 420. (Now Ready, 1856.) $2 00. In the revised English edition, of which this is a reprint, the author, for want of space, omitted the Anatomical Introduction. By a more condensed style of printing, room ha< been found in the present volume to retain this important portion without rendering the work inconveniently large. Some of the notes of the former American editor have also been incorporated, and a number of new illustrations introduced. With these improvements, and the thorough revision which it has enjoyed at the hands of the author, it will be found fully worthy to retain the authoritative position which it has acquired with regard to this class of affections. We now take farewell, for the present, of this ex- cellent treatise, placing it on our book shelves by the side of Cooper on Fractures and Dislocations, and other similar standard and valuable works— Asso. Med. Journal, Jan. 1856. We shall not devote any further space to the work .,„,i»r notice, as it is so well known to the profession already. We can only say that it should be in the library of every practical surgeon. The present edi- tion is much improved, contains numerous wood- cuts, and several accounts of cases illustrating the various diseases of the testicles.—Med. Times and Gazette, Feb. 135b. c BLANCHARD & LEA'S MEDICAL CARPENTER (WILLIAM B.), M. D., F. R. S., &c, Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief applications to Psychology, Pathology, Therapeutics, Hygiene, and Forensic Medicine. A new American, from the' last and revised London edition. With nearly three hundred illustrations. Edited, with addi- tions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the Pennsyl- vania Medical College, lV'c. In one very large and beautiful octavo volume, of about nine hundred large pages, handsomely printed and strongly bound in leather, with raised bands. (Just Issued, 1856 ) S4 ■'] 00. Dr.Druitt's researches into the literature of his subject have been not only extensive, but well di- rected ; the most discordant authors are fairly and impartially quoted, and, while due credit is given to each, their respective merits are weighed with an unprejudiced hand. The grain of wheat is pre- served, and the chafF is unmercifully stripped off. The arrangement is simple and philosophical, and the style, though clear and interesting, is so precise, that the book contains more information condensed into a few words than any other surgical work with which we are acquainted.—London Medical Times and Gazette. No work, in our opinion, equals it in presenting so much valuable surgical matter in so small a compass.—St. Louis Med. and Surgical Journal. Druitt's Surgery is too well known to the Ameri- can medical profession to require its announcement anywhere. Probably no work of the kind has ever been more cordially received and extensively circu- lated than this The fact that it comprehends in a comparatively small compass, all the essential ele- ments of theoretical and practical Surgery—that it is found to contain reliable and authentic informa- tion on the nature and treatment of nearly all surgi- cal affections—is a sufficient reason for the liberal patronage it has obtained. The editor, Dr. F. W. Sargent, has contributed much to enhance the value of the work, by such American improvements as are calculated more perfectly to adapt it to our own views and practice in this country. It abounds everywhere with spirited and life-like illustrations, which to the young surgeon, especially, are of no minor consideration. Every medical man frequently needs just such a work as this, for immediate refer- ence in moments of sudden emergency, when he has not time to consult more elaborate treatises.—The Ohio Medical and Surgical Journal. The author has evidently ransacked every stand- ard treatise of ancient and modern times, and all that is really practically useful at the bedside will be found in a form at once clear, distinct, and interest- ing.—Edinburgh Monthly Medical Journal. Druitt's work, condensed, systematic, lucid, and practical as it is, beyond most works on Surgery accessible to the American student, has had much currency in this country, and under its present au- spices promises to rise to yet higher favor.—The Western Journal of Medicine and Surgery. The most accurate and ample resume of the pre- sent state of Surgery that we areacquainted with.— Dublin Medical Journal. A better book on the principles and practice of Surgery as now understood in England and America, has not been given to the profession.—Boston Medi- cal and Surgical Journal. An unsurpassable compendium, not only of Sur- gical, but of Medical Practice.—London Medical Gazette. This work merits our warmest commendations, and we strongly recommend it to young surgeons as an admirable digest of the principles and practice of modern Surgery.—Medical Gazette. It may be said with truth that the work of Mr. Druitt affords a complete, though brief and con- densed view, of the entire field of modern surgery. We know of no work on the same subject having the appearance of a manual, which includes so many topics of interest to the surgeon ; and the terse man- ner in which each has been treated evinces a most enviable quality of mind on the part of the author, who seems to have an innate power of searching out and grasping the leading facts and features of the most elaborate productions of the pen. It is a useful handbook for the practitioner, and we should deem a teacher of surgery unpardonable who did not recommend it to his pupils. In our own opinion, it is admirably adapted to the wants of the student.— Provincial Medical and Surgical Journal. DUNGLISON, FORBES, TWEEDIE, AND CONOLLY. THE CYCLOPAEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia Medica, and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, &c. &c. In four large super-royal octavo volumes, of 3254 double-columned pages, strongly and handsomely bound, with raised bands. $12 00. * * This work contains no less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians, rendering it a complete library of reference for the country practitioner The Medical ami Surgical Journal For reference, it is above all price to every prac e most complete work on Practical Medicine | titioner Tl ,f or, at least, in our language.-Buffalo from a hasty ,„'/ aJj. Surzical Journal. quaintance d titioner.—Western Lancet. One of the most valuable medical publications of the day__as a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for readv and frequent reference, one in which modern English medicine is exhibited in the most advantageous light.—Medical Examiner. We rejoice that this work is to be placed within the reach of the profession in this country, it being unquestionably one of very great value to the prac- This estimate of it has not been formed examination, but after an intimate ac- derived from frequent consultation of it during the past nine or ten years. The editors are practitioners of established reputation, and the list of contributors embraces many of the most eminent professors and teachers of London, Edinburgh, Dub- lin, and Glasgow. It is, indeed, the great merit of this work that the principal articles have been fur- nished by practitioners who have not only devoted especial attention to the diseases about which they have written, but have also enjoyed opportunities for an extensive practical acquaintance with them, and whose reputation carries the assurance of their competency justly to appreciate the opinions of others, while it stamps their own doctrines with high and just authority.—American Medical Journ. DEVVEES'S COMPREHENSIVE SYSTEM OF MIDWIFERY. Illustrated by occasional cases and many engravings. Twelfth edition, with the author's last improvements and corrections In one octavo volume, extra cloth, of 600 pages. S>3 20. riKWFE^S TREATISE ON THE PHYSICAL AND MEDICAL TREATMENT OF CHILD- REN T'-nth edition. In one volume, octavo, extra cloth, 518 pages. $2 80. DFWEES'S TREATISE ON THE DISEASES OF FEMALES. Tenth edition. In one volume, octavo, extra cloth, 532 pages, with plates. S3 00. DANA ON ZOOPHYTES AND CORALS. In one volume, imperial quarto, extra cloth, with wood- cuts. SI5 00. Also, AN ATLAS, in one volume, imperial folio, with sixty-one magnificent colored plates. Bound in half morocco. $30 00. DE LA BECHE'S GEOLOGICAL OBSERVER. In one very large and handsome octavo volume, ex- tra cloth, of 700 pages, with 300 wood-cuts. 94 CO. FRICK ON RENAL AFFECTIONS; their Ding- nosis and Pathology. With illustrations. One volume, royal 12mo., extra cloth. 75 cents 12 BLANCHARD & LEA'S MEDICAL DUNGLISON (ROBLEY), M.D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. MEDICAL LEXICON; a Dictionary of Medical Science, containing a concise Explanation of the various Subjects and Terms of Physiology, Pathology, Hygiene, Therapeutics, Pharmacology, Obstetrics, Medical Jurisprudence, &c. With the French and other Synonymes; Notices of Climate and of celebrated Mineral Waters; Formulae for various Officinal, Empirical, and Dietetic Preparations, etc. Thirteenth edition, revi-ed. is now ready. In one very thick octavo volume, of over nine hundred large double-columned pages, strongly bound in leather, with raised bands. $4 00. Every successive edition of this work bears the marks of the industry of the author, and of his determination to keep it fully on a level with the most advanced state of medical science. Thus nearly fifteen thousand words have been added to it within the last few vears. As a complete Medica] Dictionary, therefore, embracing over FIFTY THOUSAND DEFINITIONS, in all the branches of the science, it is presented as meriting a continuance of the great favor and popularity which have carried it, within no very long space of time, to a thirteenth edition. Every precaution has been taken in the preparation of the present volume, to render its mecha- nical execution and typographical accuracy worthy of its extended reputation and universal use. The very extensive additions have been accommodated, without materially increasing the bulk of the volume by the employment of a small but exceedingly clear type, cast for this purpose. The press has been watched with great care, and every effort used to insure the verbal accuracy so ne- cessary to a work of this nature. The whole is printed on fine white paper ; and, while thus exhi- biting in every respect so great an improvement over former issues, it is presented at the original exceedingly low price. We welcome it cordially; it is an admirable work, and indispensable to all literary medical men. The labor which has been bestowed upon it is something prodigious. The work, however, has now been done, and we are happy in the thought that no hu- man being will have again to undertake the same gigantic task. Revised and corrected from time to time, Dr. Dunglison's " Medical Lexicon" will last for centuries.—British and Foreign Med.-Chirurg. Review. The fact that this excellent and learned work has passed through eight editions, and that a ninth is rendered necessary by the demands of the public, affords a sufficient evidence of the general apprecia- tion of Dr. Dunglison's labors by the medical pro- fession in England and America. It is a book which will be of great service to the student, in teaching him the meaning of all the technical terms used in medicine, and will be of no less use to the practi- tioner who desires to keep himself on a level with the advance of medical science.—London Medical Times and Gazette. In taking leave of our author, we feel compelled to confess that his work bears evidence of almost incredible labor having been bestowed upon its com- position.—Edinburgh Journal of Med. Science. A miracle of labor and industry in one who has written able and voluminous works on nearly every branch of medical science. There could be no more useful book to the student or practitioner, in the present advancing age, than one in which would be found, in addition to the ordinary meaning and deri- vation of medical terms—so many of which are of modern introduction—concise descriptions of their explanation and employment; and all this and much more is contained in the volume before us. It is therefore almost as indispensable to the other learned professions as to our own. In fact, to all who may have occasion to ascertain the meaning of any word belonging to the many branches of medicine. From a careful examination of the present edition, we can vouch for its accuracy, and for its being brought quite up to thedate of publication ; the author states in his preface that hehasadded to it aboutfour thou- sand terms, which are not to be found in the prece- ding one. — Dublin Quarterly Journal of Medical Sciences. On the appearance of the last edition of this valuable work, we directed the attention of our readers to its peculiar merits; and we need do little more than state, in reference to the present reissue, that, notwithstanding the large additions previously made to it, no fewer than four thou- sand terms, not to be found in the preceding edi- tion, are contained in the vohime before us.— Whilst it is a wonderful monument of its author's erudition and industry, it is also a work of great practical utility, as we can testify from our own experience; for we keep it constantly within our reach, and make very frequent reference to it, nearly always finding in it the information we seek. —British and Foreign Med.-Chirurg. Review. It has the rare merit that it certainly has no rival in the English language for accuracy and extent of references. The terms generally include short physiological and pathological descriptions, so that, as the author justly observes, the reader does not possess in this work a mere dictionary, but a book, whicli, while it instructs him in medical etymo- logy, furnishes him with a large amount of useful information. The author's labors have been pro- perly appreciated by his own countrymen ; and we can only confirm their judgment, by recommending this most useful volume to the notice of our cisat- lantic readers. No medical library will be complete without it.—London Med. Gazette. It is certainly more complete and comprehensive than any with which we are acquainted in the English language. Few, in fact, could be found better qualified than Dr. Dunglison for the produc- tion of such a work. Learned, industrious, per- severing, and accurate, he brings to the task all the peculiar talents necessary for its successful performance; while, at the same time, his fami- liarity with the writings of the ancient and modern " masters of our art," renders him skilful to note the exact usage of the several terms of science, and the various modifications which medical term- inology has undergone with the change of theo- ries or the progress of improvement. — American Journal of the Medical Sciences. One of the most complete and copious known to the cultivators of medical science.—Boston Med. Journal. The most comprehensive and best English Dic- tionary of medical terms extant.—Buffalo Medical Journal. « BY THE SAME AUTHOR. THE PRACTICE OF MEDICINE. A Treatise on Special Pathology and The- rapeutics. Third Edition. In two large octavo volumes, leather, of 1,500 pages. $6 25. Upon every topic embraced in the work the latest information will be found carefully posted up.— Medical Examiner. ferings of the race. Journal. -Boston Medical and Surgical It is certainly the most complete treatise of which The student of medicine will find, in these two we haveany knowledge.- Western Journal ofMedi- elegant volumes, a mine of facts, a gathering of \ cine,and Surgery. precepts and advice from the world of experience, that will nerve him with courage, and faithfully One of the most elaborate treatises of the kind direct him in his efforts to relieve the physical suf- I we have.—Southern Med. and Surg. Journal. AND SCIENTIFIC PUBLICATIONS. 13 DUNGL1SON (ROBLEY), M. D., Professor of Institutes of Medicine in the Jefferson Medical College, Philadelphia. HUMAN PHYSIOLOGY. Eighth edition. Thoroughly revised and exten- sively modified and enlarged, with five hundred and thirty-two illustrations. In two large and handsomely printed octavo volumes, leather, of about 1500 pages. (Just Ready, 1856.) $7 00. In revising this work for its eighth appearance, the author has spared no labor to render it worthy a continuance of the very great favor which has been extended to it by the profession. The whole contents have been rearranged, and to a great extent remodelled ; the investigations which of late years have been so numerous and so important, have been carefully examined and incorpjrated, and the work in every respect has been brought up to a level with the present state of the subject. The object of the author has been to render it a concise but comprehensive treatise, containing the whole body of physiological science, to which the student and man of science can at all times refer with the certainty of finding whatever they are in search of, fully presented in all its aspects; and on no former edition has the author bestowed more labor to secure this result. A similar improvement will be found in the typographical execution of the volumes, which, in this respect, are superior to their predecessors. A large number of additional wood-cuts have been introduced, and the series of illustrations has been greatly modified by the substitution of many new ones for such as were not deemed satisfactory. By an enlargement of the page, these very considerable additions have been accommodated without increasing the size of the volumes to an extent to render them unwieldy. It has long since taken rank as one of the medi- cal classics of our language. To say that it is by far the best text-book of physiology ever published in this country, is but echoing the general testi- mony of the profession.—N. Y. Journal of Medicine. should be without it. It is the completest work on Physiology in the English language, and is highly creditable to the author and publishers.—Canadian Medical Journal. The most complete and satisfactory system of Physiology in the English language.—Amer. Med. Journal. The best work of the kind in the English lan- guage.—Silliman's Journal. The most full and complete system of Physiology There is no single book we would recommend to the student or physician, with greater confidence than the present, because in it will be found a mir- ror of almost every standard physiological work of the day. We most cordially recommend the work to every member of the profession, and no student I in our language.—Western Lancet BY THE SAME AUTHOR. GENERAL THERAPEUTICS AND MATERIA MEDICA; adapted for a Medical Text-book. Fifth edition, much improved. With one hundred and eighty-seven illus- trations. In two large and handsomely printed octavo vols., leather, of about 1100 pages. $0 00. In this work of Dr. Dunglison, we recognize the | As a text-book for students, for whom it is par- same untiring industry in the collection and em- ticularly designed, we know of none superior to bodying of facts on the several subjects of which he , it.—St. Louis Medical and Surgical Journal. treats, that has heretofore distinguished him, and we cheerfully point to these volumes, as two of the most interesting that we know of. In noticing the additions to this, the fourth edition, there is very little in the periodical or annual literature of the profession, published in the interval which has elapsed since the issue of the first, that has escaped the careful search of the author. Asa book for reference, it is invaluable.—Charleston Med. Jour- nal and Review. It may be said to be the work now upon the sub- jects upon which it treats.— Western Lancet. It purports to be a new edition, but it is rather a new book, so greatly has it been improved, both in the amount and quality of the matter which it contains.—N. O. Medical and Surgical Journal. We bespeak for this edition, trom the profession, an increase of patronage over any of its former ones, on account of its increased merit.— N. Y. Journal of Medicine. We consider this work unequalled.—Boston Med. and Surg. Journal. BY the same author. (A new Edition.) NEW REMEDIES, WITH FORMULAE FOR THEIR PREPARATION AND ADMINISTRATION. Seventh edition, with extensive Additions. In one very large octavo volume, leather, of 770 pages. (Just Ready, May, 1856.) $3 75. Another edition of the " New Remedies" having been called for, the author has endeavored to add everything of moment that has appeared since the publication of the last edition. The chief remedial means which have obtained a place, for the first time, in this volume, either owin°- to their having been recently introduced into pharmacology, or to their having received novel applications—and which, consequently, belong to the category of "New Remedies"—are the fol- Aptol Caffein, Carbazotic acid, Cauterization and catheterism of the larynx and trachea, Cedron, Cerium' Chloride of bromine, Chloride of iron, Chloride of sodium, Cinchonicine, Cod-liver olein, Congelation, Eau de Pagliari, Galvanic cautery, Hydriodic ether, Hyposulphite of soda and silver, Inunction, Iodide of sodium, Nickel, Permanganate of potassa, Phosphate of lime, Pumpkin, Quinidia, Rennet Saccharine carbonate of iron and manganese, Santonin, Tellurium, and Traumaticine. The articles treated of in the former editions will be found to have undergone considerable ex- pansion in this, in order that the author might be enabled to introduce, as far as practicable, the results of the subsequent experience of others, as well as of his own observation and reflection; and to make the work still more deserving of the extended circulation with which the preceding editions have been favored by the profession. By an enlargement of the page, the numerous addi- tions have been incorporated without greatly increasing the bulk of the volume.— Preface. One of the most useful of the author's works.— Southern Medical and Surgical Journal. This elaborate and useful volume should be found in every medical library, for as a book of re- ference, for physicians, it is unsurpassed by any other work in existence, and the double index for diseases and for remedies, will be found greatly to enhance its value.—New York Med. Gazette. The great learning of the author, and his remark- able industry in pushing his researches into every source whence information is derivable, has enabled him to throw together an extensive mass of facts and statements, accompanied by full reference to authorities; which last feature renders the work practically valuable to investigators who desire to examine the original papers.—The Amer lean Journal of Pharmacy. 14 BLANCHARD cfe LEA'S MEDICAL ERICHSEN (JOHN), Professor of Surgery in University College, London, &,c. THE SCIENCE AND ART OF SURGERY; being a Treatise on Suroical Injuries, Diseases, and Operations. Edited by John H. Brinton, M. D. Illustrated with three hundred and eleven engravings on wood. In one large and handsome octavo volume, of over nine hundred closely printed pages, leather, raised bands. $-1 25. rarely encounter cases requiring surgical manage- ment.—Stethoscope. Embracing, as will be perceived, the whole surgi- cal domain, and each division of itself almost com- plete and perfect, each chapter full and explicit, each subject faithfully exhibited, we can only express our estimate of it in the aggregate. AVe consider it an excellent contribution "to surgery, as probably the besi single volume now extant on the subject, and with great pleasure we add it to our textbooks — Nashville Journal of Medicine and Surgery. Prof. Erichsen's work, for its size, has not been surpassed; his nine hundred and eight pages, pro- fusely illustrated, are rich in physiological, patholo- gical, and operative suggestions, doctrines, details, and processes; and will prove a reliable resource for information, both to physician and snraeon, in the hour of peril —N. 0. Med. and Surg Journal. We are acquainted with no other work wherein so much good sense, sound principle, and practical It is, in our humble judgment, decidedly the best book of the kind in the English language. Strange that just such books are notoftener produced by pub lie teachers of surgery in this country and Great •Jrilain Indeed, it is a matter of great astonishment. hut no less true than astonishing, that of the many works on surgery republished in this country within the last fifteen or twenty years as text-books for medical students, this is the only one that even ap- proximates to the fulfilment of the peculiar wants of young men just entering upon the study of this branch of ihe profession.— Western Jour, of Med. and Surgery. lis value is greatly enhanced by a very copious well arranged index. We regard this as one of the most valuable contributions to modern surgery. To one entering his noviiiaie of practice, we regard it the most serviceable guide which he can consult. He will find a fulness of detail leading him through every slep of the operation, and not deserting him until the final issue of the case is decided For the same, rea- son we recommend it to those whose routine of prac lice lies in such parts of the country that they must inferences, stamp every page.— American Lancet ELLIS (BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions, derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. To which is added an Appendix, on the Endermic use of Medicines, and on the use of Ether and Chloroform. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Tenth edition, revised and much extended by Robert P. Thomas, M. D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one neat octavo volume, extra cloth, of 296 pages. (Lately Issued.) $1 75. After an examination of the new matter and the alterations, we believe the reputation of the work built up by the author, and the late distinguished editor, will continue to flourish under the auspices of the present editor, who has the industry and accu- racy, and, we would say, conscientiousness requi- site for the responsible task.—Am. Jour, of Pharm. It will prove particularly useful to students and young practitioners, as the most important prescrip- tions employed in modern practice, which lie scat- tered through our medical literature, are here col- lected and conveniently arranged for reference.— Charleston Med. Journal and Review. FOWNES (GEORGE), PH. D., &c. ELEMENTARY CHEMISTRY; Theoretical and Practical. With numerous illustrations. A new American, from the last and revised London edition. Edited, with Addi- tions, by Robert Bridges, M. D. In one large royal 12mo. volume, of over 550 pages, with 181 wood-cuts. (Lately Issued.) In leather, $1 50; extra cloth, $1 35. AVe know of no better text-book, especially in the difficult department of organic chemistry, upon which it is particularly full and satisfactory. We would recommend it to preceptors as a capita] " office book" for their students who are beginners in Chemistry. It is copiously illustrated with ex- cellent wood-cuts, and altogether admirably "got up."—N J. Medical Reporter. A standard manual, which has long enjoyed the reputation of embodying much knowledge in a small space. The author hasachieved the difficult task of condensation with masterly tact. His book is con- cise without being dry, and brief without being too dogmatical or general.— Virginia Med. and Surgical Journal. The work of Dr. Fownes has long been before the public, and its merits have been fully appreci- ated as the best text-book on chemistry now in existence. We do not, of course, place it in a rank superior to the works of Brande, Graham, Turner, Gregory, or Gmelin, but we say that, as a work for students, it is preferable to any of them.—Lon- don Journal of Medicine. A work well adapted to the wants of the student. It is an excellent exposition of the chief doctrines and facts of modern chemistry. The size of the work, and still more the condensed yet perspicuous style in which it is written, absolve it from the charges very properly urged against most manuals termed popular.—Edinburgh Journal of Medical Science. FERGUSSON (WILLIAM), F. R.S., Professor of Surgery in King's College, London, &c. A SYSTEM OF PRACTICAL SURGERY. Fourth American, from the third and enlarged London edition. In one large and beautifully printed octavo volume, of about 700 pages, with 393 handsome illustrations, leather. $3 00. The most important subjects in connection with practical surgery which have been more recently brought under the notice of, and discussed by, the surgeons of Great Britain, are fully and dispassion- ately considered by Mr. Fergusson, and that which was before wanting has now been supplied^ so that we can now look upon it as a work on practical sur- gery instead of one on operative surgery alone. Medical Times and Gazette. No work was ever written which more nearly comprehended the necessities of the student and practitioner, and was more carefully arranged to that single purpose than this.—N. Y. Med. Journal. The addition of many new pages makes this work more than ever indispensable to the student and prac- titioner.—Ranking's Abstract. Among the numerous works upon surgery pub- lished of late years, we know of none we value more highly than the one before us. It is perhaps the very best we have for a text-book and for ordi- nary reference, being concise and eminently practi- cal.—Southern Med. and Surg. Journal. AND SCIENTIFIC PUBLICATIONS. 15 FLINT (AUSTIN), M. D., Professor of the Theory and Practice of Medicine in the University of Louisville, &c. (An Important New Work.) PHYSICAL EXPLORATION AND DIAGNOSIS OF DISEASES AFFECT- ING THE RESPIRATORY ORGANS. In one large and handsome octavo volume, extra cloth, 630 pages. (Now Ready.) $3 00. The author has aimed in the present work to supply a vacancy in medical literature, viz: '-'a work limited to diseases affecting the respiratory organs, treating inextenso and almost exclusively ofthe principles and practice of physical exploration, as applied to the diagnosis of those affections." The intricacy and importance ofthe subject demand a fuller and more detailed exposition than has been accorded to it in any volume as yet accessible to the American profession ; while the high re- putation which the author has acquired by his researches in kindred topics sufficiently manifests his ability to render the present work a text-book of great practical utility for the student, and a source to which the practitioner can at all time« refer with certainty. A very condensed summary of the contents is subjoined. INTRODUCTION. Section I. Preliminary points pertaining to the Ana- tomy and Physiology of the Respiratory Appara- tus. Section II. Topographical Divisions of the Chest. PART I. Physical Exploration of the Chest. Chap. I. Definitions—Different Methods of Explora- tions—General Remarks. Chap. II. Percussion. Chap. III. Auscultation. Chap. IV. Inspection. Chap. V. Mensuration. Chap. VI. Palpation. Chap. VII. Succussion. Chap. VIII. Recapitu- latory Enumeration of the Physical Signs fur- nished by the several methods of Exploration. Chap. IX. Correlation of Physical Signs. CONTENTS. PART II. Diagnosis of Diseases Affecting the Respira- tory Organs. Chap. I. Bronchitis, Pulmonary or Bronchial Ca- tarrh. Chap. II. Dilatation and Contraction of the Bronchial Tubes—Pertussis—Asthma. Chap. III. Pneumonitis—Imperfect Expansion (Atelec- tasis) and Collapse. Chap. IV. Emphysema. Chap. V. Pulmonary Tuberculosis — Bronchial Phthisis. Chap. VI. Pulmonary CEdema— Gan- grene of the Lungs—Pulmonary Apoplexy—Can- cer of the Lungs—Cancer in the Mediastinum. Chap. VII. Acute Pleuritis—Chronic Pleuritis— Empyema—Hydrothorax—Pneumothorax—Pneu- mo-hydrothorax--Pleuralgia--Diaphragmatic Her- nia. Chap. VIII. Diseases affecting the Trachea and Larynx—Foreign Bodies in the Air-passages. Appendix. On the Pitch of the Whispering Souille over Pulmonary Excavations. GRAHAM (THOMAS), F. R. S., Professor of Chemistry in University College, London, &c. THE ELEMENTS OF CHEMISTRY. Including the application of the Science to the Arts. With numerous illustrations. With Notes and Additions, by Robert Bridges, M. D., &c. iftrc. Second American, from the second and enlarged London edition. PART I. (Lately Issued) large 8vo., 430 pages, 185 illustrations. SI 50. PART II. (Preparing) to match. GRIFFITH (ROBERT E.), M. D., &c. A UNIVERSAL FORMULARY, containing the methods of Preparing and Ad- ministering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceu- tists. Second Edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M.D. Professor of Materia Medica in the Philadelphia College of Pharmacy. In one larg-e and handsome octavo volume, extra cloth, of over 600 pages, double columns. (Just Issued.) S3 00; or bound in sheep, S3 25. It was a work requiri-ng much perseverance, and when published was looked upon as by far the best work of its kind that had is=ued from the American press. Prof Thomas has certainly " improved." as well as added othis Formulary, and has rendered it additionally deserving of the confidence of pharma- ceutists and physicians— Am. Journal ofPharmacy. We are happy to announce a new and improved edition of this, one ofthe most valuable and useful works that have emanated from an American pen. It would do credit to any country, and will be found of daily usefulness to practitioners of medicine; it is better adapted to their purposes than the dispensalo tits—Southern Med. and Surg. Journal. A new edition of this well-known work, edited by R P Thomas, M D., affords occasion for renewing our commendation of so useful a handbook, which ought to be universally studied by medical men of every class, and made use of by way of reference by office pupils, as a standard authority. It has been much enlarged, and now condenses a vast amount of needful and necessary knowledge in small com- n„« The more of such books the better for the pro- fession and the public- N. Y. Med. Gazette. It is one ofthe most useful books a country practi- tioner can possibly have in his possession.—Medical Chronicle. The amount of useful, every-day matter, for a prac- ticing physician, is really immense.— Boston Med. and Surg. Journal. This is a work of six hundred and fifty one pages, embracing all on the subject of preparing and admi- nistering medicines that can be desired by the physi- cian and pharmaceutist — Western Lancet. In short, it is a full and complete work of the kind and should he in the hands of every physician and apothecary. O. Med. and Surg. Journal We predict a great sale for this work, and we espe- ciallv recommend it to all medical teachers.—Rich- mond Stethoscope. This edition of Dr. Griffith's work has been irreatly improved by the revision and ample additions of Dr. Thomas, and is now, we believe, one of the most complete works of its kind in any language. The additions amount to about, sevenly pages, and no effort has been spared to include in ihem all the re- cent improvements which have, been published in medical journals, and systematic treatises. A. work of this kind appears to us indispensable to the physi- cian, and there is none we can more cordially recom- mend.— N. Y. Journal of Medicine. BY THE SAME AUTHOR. MEDICAL BOTANY; or, a Description of all the more important Plants used in Medicine and of their Properties, Uses, and Modes of Administration. In one large octavo volume, extra cloth, of 704 pages, handsomely printed, with nearly 350 illustrations on wood. $3 00. 1(5 BLANCHARD & LEA'S MEDICAL GROSS (SAMUEL D.), M. D., Professor of Surgery in the Jefferson Medical College of Philadelphia, &c. A PRACTICAL TREATISE ON THE DISEASES, INJURIES, AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLATSID, AND THE URETHRA. Second Edition, revised and much enlarged, with one hundred and eighty- four illustrations. In one large and very handsome octavo volume, of over nine hundred pages. (Just Issued.) In leather, raised bands, S5 25; extra cloth, $4 75. The author has availed himself of the opportunity afforded by a call for a new edition of this work, to thoroughly revise and render it in every respect worthy, so far as in his power, ofthe very flattering reception whicb has been accorded to it by the profession. The new matter thus added amounts to almost one-third ofthe original work, while the number of illustrations has been nearly doubled. These additions pervade every portion of the work, which thus has rather the aspect of a new treatise than a new edition. In its present improved form, therefore, it may confidently be presented as a complete and reliable storehouse of information on this important class of diseases, and as in every way fitted to maintain the position which it has acquired in Europe and in this country, as the standard of authority on the subjects treated of. A volume replete with truths and principles ofthe provements, it will probably remain one of the most valuable works on this subject so long as the science of medicine shall exist.—Boston Med. and Surg. Journal. Dr. Gross has brought all his learning, experi- ence, tact, and judgment to the task, and has pro- duced a work worthy of his high reputation. AVe feel perfectly safe in recommending it to our read- ers as a monograph unequalled in interest and practical value by any other on the subject in our language.—Western Journal of Med. and Surg. Whoever will peruse the vast amount of valuable practical information it contains, and which we have been unable even to notice, will, we think, agree with us, that there is no work in the English language which can make any just pretensions to be its equal.—N. Y. Journal of Medicine. utmost value in the investigation of these diseases.- American Medical Journal. On the appearance of the first edition of this work, the leading English medical review predicted that it would have a " permanent place in the literature of surgery worthy to rank with the best works of the present age." This prediction has been amply ful- filled. Dr. Gross's treatise has been found to sup- ply completely the want which has been felt ever since the elevation of surgery to the rank of a science, of a good practical treatise on the diseases of the bladder and its accessory organs. Philosophical in its design, methodical in its arrangement, ample and sound in its practical details, it may in truth be said to leave scarcely anything to be desired on so im- portant a subject, and with the additions and modi- fications resulting from future discoveries and im- by the same author. (Just Issued). A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PAS- SAGES. In one handsome octavo volume, extra cloth, with illustrations, pp. 468. S'2 75. A very elaborate work. It is a complete summary conclude by recommending it to our readers, fully of the whole subject, and will be a useful book of j persuaded that its perusal will afford them much reference.—British and Foreign Medico-Chirurg. I practical information well conveyed, evidently de- Review. j rived from considerable experience and deduced from A highly valuable book of reference on a most im- I aTn ample collection of facts. — Dublin Quarterly portant subject in the practice of medicine. We ! Journal, May, 1855. BY the same author. (Preparing.) A SYSTEM OF SURGERY; Diagnostic, Pathological, Therapeutic, and Opera- tive. With very numerous engravings on wood. BY THE SAME AUTHOR. ELEMENTS OF PATHOLOGICAL ANATOMY; illustrated by colored En- gravings, and two hundred and fifty wood-cuts. Second edition, thoroughly revised and greatly enlarged. In one very large and handsome imperial octavo volume, leather, raised bands, pp. 822. S-3 75. GLUGE (GOTTLIEB), M. D., Professor of Physiology and Pathological Anatomy in the University of Brussels, &c. AN ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylva- nia. In one volume, very large imperial quarto, extra cloth, with 320 figures, plain and colored, on twelve copperplates. S5 00. GARDNER'S MEDICAL CHEMISTRY, for the use of Students and the Profession. In one royal limn, vol , ex. cloth, pp. 390, with illustrations. SI 00. HARRISON'S ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM. In one octavo volume, leather, 292 pages. $1 50. HUGHES' CUNICAL INTRODUCTION TO THE PRACTICE OF AUSCULTATION AND OTHER MODES OF PHYSICAL DIAGNOSIS, IN DISEASES OF THE LUNGS AND HEART. Second American, from the second London edition. 1 vol. royal l'2mo., ex. cloth, pp. 304. SI 00. HAMILTON (FRANK H.), M. D., Professor of Surgery, in Buffulo Medical College, &c. A TREATISE ON FRACTURES AND DISLOCATIONS. In one handsome octavo volume, with numerous illustrations. (Preparing.) The numerous improvements which this important branch of surgery has received from the skill and ingenuity of American surgeons, renders particularly appropriate and valuable a complete and systematic original work on the subject. The es>ays which Professor Hamilton has published on kindred topics are already widely and favorably known, and give earnest that his forthcoming work will prove indispensable, both as a text-book for the student, and as a guide for the practitioner. AND SCIENTIFIC PUBLICATIONS. 17 HOBLYN (RICHARD D.), M. D. A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. By Richard D. Hoblyn, A. M , etc A new American from the last London edition. Revised, with numerous Additions, by Isaac Hays, M. D., editor of the "American Journal of the Medical Sciences." In one large royal 12mo. volume, leather, of over 500 double columned pages. (Now Ready, 1856.) Si 50. The great care bestowed on the revision of this work, and the extensive additions made to it by the editor, have caused the delay in its appearance. While carefully excluding obsolete words, it has been his aim to render it a complete manual of definitions, in which the student of medicine or of its allied sciences might feel assured of being able to find concise explanations of all terms occur- ring in his course of reading. The amount ofthe additions thus made, may be estimated from the fact that the present edition contains fully one-third more matter than the last, the number of pages haying been increased by over one hundred, notwithstanding an enlargement of the size ofthe page, while at the same time it has been kept at the former exceedingly low price. nor desire to procure a larger work. — American Lancet. If the frequency with which we have referred to this volume since its reception from the puhlisher, two or three weeks ago, be any criterion for the future, the binding will soon have to be renewed, even with careful handling. "We find that Dr. Hays has done the profession great service by his careful and industrious labors. The Dictionary has thus become eminently suited to our medical brethren in this country. The additions by Dr. Hays are in brackets, and we believe there is not a single page but bears these insignia; in every instance which we have thus far noticed, the additions are really needed and ex- ceedingly valuable. We heartily commend the work to all who wish to be au courant in medical termi- nology.— Boston Med. and Surg. Journal. To both practitioner and student, we recommend this dictionary as being convenient in size, accurate in definition, and sufficiently full and complete for ordinary consultation.—Charleston Med. Journ. and Review. Admirably calculated to meet the wants of the practitioner or student, who has neither the means Hoblyn has always been a favorite dictionary, and in its present enlarged and improved form will give greater satisfaction than ever. The American editor, Dr. Hays, has made many very valuable additions. —N.J. Med. Reporter. To supply the want of the medical reader arising from this cause, we know of no dictionary better arranged and adapted than the one bearing the above title. It is not encumbered with the obsolete terms of a bygone age, but it contains all that are now in use ; embracing every department of medical science down to the very latest date. The volume is of a convenient size to be used by the medical student, and yet large enough to make a respectable appear- ance in^the library of a physician.—Western Lancet. Hoblyn's Dictionary has long been a favorite with us. It is the best book of definitions we have, and ought always to be upon the student's table.— Southern Med. and Surg. Journal. HUNTER (JOHN). TREATISE ON THE VENEREAL DISEASE. With copious Additions, by Dr. Ph. Ricord, Surgeon to the Venereal Hospital of Paris. Edited, with additional Notes, by F. J. Bumstead, M. D. In one octavo volume, with plates. $3 25. HP See Ricord. Also, HUNTER'S COMPLETE WORKS, with Memoir, Notes, &c. &c. In four neat octavo volumes, leather, with plates. S10 00. HORNER (WILLIAM E.), M. D., Professor of Anatomy in the University of Pennsylvania. SPECIAL ANATOMY AND HISTOLOGY. Eighth edition. Extensively revised and modified. In two large octavo volumes, extra cloth, of more than one thousand pages, handsomely printed, with over three hundred illustrations. S6 00. This edition enjoyed a thorough and laborious revision on the part of the author shortly before his death, with the view of bringing it fully up to the existing state of knowledge on the subject of general and special anatomy. To adapt it more perfectly to the wants ofthe student, he introduced a large number of additional wood-engravings, illustrative ofthe objects described, while the pub- lishers have endeavored to render the mechanical execution of the work worthy of its extended reputation. JONES (T. WHARTON), F. R. S., Professor of Ophthalmic Medicine and Surgery in University College, London, &c. THE PRINCIPLES AND PRACTICE OF OPHTHALMIC MEDICINE AND SURGERY. With one hundred and ten illustrations. Second American from the second and revised London edition, with additions by Edward Hartshorne, M. D., Surgeon to Wills' Hospital^ fa. In one large, handsome royal 12mo. volume, extra cloth, of 500 pages. (Now Ready.)' SI 50. The thorough revisions which this work has undergone at the hands of both author and editor have brought Tt thoroughly up to the present state of the subject, and have rendered it complete, without detracting from its character as a manual, or deviating from its original object of affording a digest of the present condition of ophthalmic science for study and reference by those whose leisure does not admit of their perusing the larger works of Mackenzie or Lawrence. By an en- largement of the «ize of the page, the numerous additions to this edition have been accommodated without increasing the bulk of the volume, and at the very low price at which it is offered, a con- tinuance of the favor which it has hitherto received is confidently expected. ly wrought up. and digested in the author's mind, as to come forth with the freshness and impressive- ness of an original production. We entertain little doubt that this book will become what its author hoped it might become, a manual for daily reference and consultation by the student and the general prac- titioner. The work is marked by that correctness, clearness, and precision of style which distinguish nil the productions of the learned author.—British and For. Med. Review. We are confident that the reader will find, on perusal, that the execution of the work amply fulfils the promise of the preface, and sustains, in every point, the already h gh reputation of the author as an ophthalmic surgeon as well as a physiologis and pathologist. The book is evidently the result of much labor and research, and has been written with the greatest care and attention; it possesses that best quality which a general work, like a sys- tem or manual can show, viz : the quality of having all the materials whencesoever derived, so thorough- 18 BLANCHARD & LEA'S MEDICAL JONES (C. HAND FIELD), F. R. S., &. EDWARD H. SIEVEKING, M.D., Assistant Physicians and Lecturers in St. Mary's Hospital, London. A MANUAL OF PATHOLOGICAL ANATOMY. First American Edition, Revised. With three hundred and ninety-seven handsome wood engravings. In one large and beautiful octavo volume of nearly 750 pages, leather. (Lately Issued.) S3 75. As a concise text-book, containing, in a condensed authors have not attempted to intrude new views on form, a complete outline of what is known in the I their professional brethren, but simply to lay before domain of Pathological Anatomy, it is perhaps the them, what has long been wanted, an outline of the best work in the English language. Its great merit ! present condition of pathological anatomy. In this consists in its completeness and brevity, and in this respect it supplies a great desideratum in our lite- rature. Heretofore the student of pathology was obliged toglean from a great number of monographs, and the field was so extensive that but few cultivated it with any degree of success. The authors of the present work have sought to corrrct this defect by placing before the reader a summary of ascertained facts, together with the opinions ofthe most eminent pathologists both of the Old and New World. As a simple work of reference, therefore, it is of great value to the student of pathological anatomy, and should be in every physician's library.—Western Lancet. We urge upon our readers and the profession gene- rally the importance of informing themselves in re- gard to modern views of pathology, and recommend to them to procure the work before us as the best means of obtaining this information.—Stethoscope. In offering the above titled work to the public, the they have been completely successful. The work is one of the best compilations which we have ever perused. The opinions and discoveries of all the leading pathologists and physiologists are engrossed, so that by reading any subject treated in the book you have a synopsis of the views of the most ap- proved authors.—Charleston Medical Journal and Review. We have no hesitation in recommending it as worthy of careful and thorough study by every mem- ber of the profession, old or young.—N. W. Med. and Surg. Journal. From the casual examination we have given we are inclined to regard it as a text-book, plain, ra- tional, and intelligible, such a book as the practical man needs for daily reference. For this reason it will be likely to be largely useful, as it suits itself to those busy men who have little time for minute investigation, and prefer a summary to an elaborate treatise.—Buffalo Medical Journal. KIRKES (WILLIAM SENHOUSE), M. D., Demonstrator of Morbid Anafcimy at St. Bartholomew's Hospital, &c.j and JAMES PAGET, F. R. S., Lecturer on General Anatomy and Physiology in St. Bartholomew's Hospital. A MANUAL OF PHYSIOLOGY. Second American, from the second and improved London edition. With one hundred and sixty-five illustrations. In one large and handsome royal 12mo. volume, leather, pp. 550. S2 00. In the present edition, the Manual of Physiology has been brought up to the actual condition of the science, and fully sustains the reputation which it has already so deservedly attained. We consider the work of MM. Kirkes and Paget to constitute one of the very best handbooks of Physiology we possess —presenting just such an outline of the science, com- prising an account of its leading facts and generally admitted principles, as the student requires during his attendance upon a course of lectures, or for re- ference whilst preparing for examination.— Am. Medical Journal. We need only say, that, without entering into dis- cussions of unsettled questions, it contains all the recent improvements in this department of medical science. For the student beginning this study, and the practitioner who has but leisure to refresh his memory, this book is invaluable, as it contains all that it is important to know, without special details, which are read with interest only by those who would make a specialty, or desire to possess a criti- cal knowledge of the subject.—Charleston Medical Journal. One of the best treatises that can be put into the hands ofthe student.—London Medical Gazette. Particularly adapted to those who desire to pos- sess a concise digest of the facts of Human Physi- ology.—British and Foreign Med.-Chirurg. Review. We conscientiously recommend it as an admira- ble " Handbook of Physiology."—London Journal of Medicine. KNAPP'S TECHNOLOGY ; or, Chemistry applied to the Arts and to Manufactures. Edited, with numerous Notes and Additions, by Dr. Edmund Ronalds and Dr. Thomas Richardson. First American edition, with Notes and Additions, by Prof. Walter R. Joiixson. In two handsome octavo volumes, extra cloth, printed and illus- trated in the highest style of art, with about 500 wood-engravings. $6 00. LALLEMAND ON THE CAUSES, SYMPTOMS, AND TREATMENT OF SPERMATORRHOEA. Translated and edited by Henry J. McDougal. In one. volume, octavo, extra cloth, 320 pages. Second American edition. SI 75. LUDLOW'S MANUAL OF EXAMINATIONS upon Anatomy and Physiology, Surgery, Practice of Medicine, Chemistry, Obstetrics, Materia Me- dica, Pharmacy, and Therapeutics. Designed for Students of Medicine throughout the United States. A new edition, revised and improved. In one la'ge royal 12mo. volume, with several hundred illus- trations. (Preparing.) LEES CLINICAL MIDWIFERY. In one royal 12mo. volume, extra cloth, of 238 pages. 75 cents. LISTON S LECTURES ON THE OPERATIONS OF SURGERY. Edited, with numerous Addi- tions and Alterations, by T. D. Mutter, M. D. In one large and handsome octavo volume, leather, of 506 pages, with 216 wood-cuts. 553 00. LARDNER (DIONYSIUS), D. C. L., &c. HANDBOOKS OF NATURAL PHILOSOPHY AND ASTRONOMY. Revised, with numerous Additions, by the American editor. First Course, containing Mecha- nics, Hydrostatics, Hydraulics, Pneumatics, Sound, and Optics. In one large royal 12mo. volume, of 750 pages, with 424 wood-cuts. $1 75. Second Course, containing Heat, Electricity, Magnetism, and Galvanism, one volume, large royal 12mo., of 450 pages, with 250 illustrations. SI 25. Third Course (now ready), containing Meteorology and Astronomy, in one large volume, royal 12mo. of nearly eight hundred pages, with thirty-seven plates and two hundred wood-cuts. $2 00. The whole complete in three volumes, of about two thousand large pages, with over one thousand figures on steel and wood. $5 00. Any volume sold separate, strongly bound in leather. The various sciences treated in this work will be found brought thoroughly up to the latest period. AND SCIENTIFIC PUBLICATIONS. 19 LEHMANN (C. G.) PHYSIOLOGICAL CHEMISTRY. Translated from the second edition by George E. Day, M. D., F. R. S., &c, edited by R. E. Rogers, M. D., Professor of Chemistry in the Aledical Department of the University of Pennsylvania, with illustrations selected from tunke's Atlas of Physiological Chemistry, and an Appendix of plates. Complete in two large and handsome octavo volumes, extra cloth, containing 1200 pages, with nearly two hundred illus- trations. (Now Ready.) $6 00. This great work, universally acknowledged as the most complete and authoritative exposition of the principles and details of Zoochemistry, in its passage through the press, has received from Professor Rogers such care as was necessary to present it in a correct and reliable form. To such a work additions were deemed superfluous, but several years having elapsed between the appear- ance in Germany of the first and last volume, the latter contained a supplement, embodying nume- i'ous corrections and additions resulting from the advance ofthe science. These have all been incor- porated in the text in their appropriate places, while the subjects have been still further elucidated by the insertion of illustrations from the Atlas of Dr. Otto Funke. With the view of supplying the student with the means of convenient comparison, a large number of wood-cuts, from works on kindred subjects, have also been added in the form of an Appendix of Plates. The work is, therefore, pre- sented as in every way worthy the attention of all who desire to be familiar with the modern facts and doctrines of Physiological Science. The most important contribution as yet made to Physiological Chemistry.—Am. Journal Med. Sci- ences, Jan. 1856. The present volumes belong to the small class of medical literature which comprises elaborate works of the highest order of merit.—Montreal Med. Chron- icle, Jan. 1856. The work of Lehmann stands unrivalled as the most comprehensive book of reference and informa- tion extant on every branch of the subject on which it treats.—Edinburgh Monthly Journal of Medical Science. All teachers must possess it, and every intelligent physician oujht to do likewise.—Southern Med. and Surg. Journal, Dec. 1855. by the same author. (Now Ready, 18560 MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Samuel Jackson, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania. With illustrations on wood. In one very handsome octavo volume, extra c'oth, of 336 pages. 52 25. The original of this work, though but lately issued by its distinguished author, has already assumed the highest position, as presenting in their latest development the modern doctrines and discoveries in the chemistry of life. The numerous additions by the translator, and the Introduc- tion by Professor Jackson will render its physiological aspect more complete than designed by the author, and will adapt it for use as a text-book of physiology, presenting more thoroughly than has yet been attempted, the modifications arising from the vast impulse which organic chemistry has received within a few years past. From Prof. Jackson's Introductory Essay. In adopting the handbook of Dr. Lehmann as a manual of Organic Chemistry for the use of the students of the University, and in recommending his original work of Physiological Chemistry for their more mature studies, the high value of his researches, and the great weight of his autho- rity in that important department of medical science are fully recognized. The present volume will be a very convenient one I densed form, the positive facts of Physiological for students, as offering a brief epitome of the more Chemistry.—Am. Journal Med. Sciences, April, 1850. elaborate work, and as containing, in a very con- | LAWRENCE (W.), F. R. S., &c. A TREATISE ON DISEASES OF THE EYE. A new edition, edited, with numerous additions, and 243 illustrations, by Isaac Hays, M. D., Surgeon to Will's Hospi- tal, &c. In one very large and handsome octavo volume, of 950 pages, strongly bound in leather with raised bands. $5 00. This work is so universally recognized as the standard authority on the subject, that the pub- lishers in presenting this new edition have only to remark that in its preparation the editor has carefully revised every portion, introducing additions and illustrations wherever the advance of science has rendered them necessary or desirable, constituting it a complete and thorough exponent of the most advanced state ofthe subject. This admirable treatise-the safest guide and most octavo pages—has enabled both author and editor to comprehensive work of reference, which is within do justice to all the details of this subject, and con- the reach ofthe profession.—Stethoscope. dense in this single volume the present state of our knowledge of the whole science in this department, This standard text-book on the department of whereby its practical value cannot be excelled. We which it treats, has not been superseded, by any or < heartily commend it, especially as a book of refer- all of the numerous publications on the subject [ ence, indispensable in every medical library. The heretofore issued. Nor with the multiplied improve- additions of the American editor very greatly en- ments of Dr. Hays, the American editor, is it at all hance the value ofthe work, exhibiting the learning likely that this great work will cease to merit the and experience of Dr. Hays, in the light in which he confidence and preference of students or practition- | ought to be held, as a standard authority on all sub- ers. Its ample extent—nearly one thousand large | jects appertaining to this specialty.—N.Y. Med. Gaz. Already well known and appreciated by the scien- tific world, Professor I.ehmann's great work re- quires no laudatory sentences, as, under a new garb, it is now presented to us. The little space at our command would ill suffice to set forth even a small portion of its excellences. To all whose studies or professional duties render the'revelations of Physio- logical Chemistry at once interesting and essential, these volumes will be indispensable. Highly com- plimented by European reviewers, sought for with avidity by scholars of every nation, and admirably written throughout, it is sure to win a welcome and to be thoroughly studied.—Boston Med. and Surg. Journal, Dec. 1855. 20 BLANCHARD & LEA'S MEDICAL LA ROCHE (R.), M. D., &c. YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeutical Relations. Including a Sketch of the Disease as it has occurred in Philadelphia from 1699 to 1854, with an examination of the connections between it and the fevers known under the same name in other parts of temperate as well as in tropical regions. In two large and handsome octavo volumes of nearly 1500 pages, extra cloth. (Now Ready.) §7 00. The publishers are happy in being able at length to present to the profession this great work, which they are assured will be regarded as an honor to the medical literature of the country. As the result of many vears of personal observation and study, as embodying an intelligent resume of all that has been written regarding the disease, and as exhausting the subject in all its various aspects, these volumes must at once take Ihe position of the standard authority and work of refer- ence on the many important questions brought into consideration. erection of this towering monument to his own fame, and to the glory of the medical literature of his own country. It is destined to remain the great autho- From Professor S. H. Dickson, Charleston, S. C., September 18, 1855. A monument of intelligent and well applied re- search, almost without example. It is, indeed, in itself, a large library, and is destined to constitute the special resort as a book of reference, in the subject of which it treats, to all future time. We have not time at present, engaged as we are, by day and by night, in the work of combating this very disease, now prevailing in out city, to do more than give this cursory notice of what we consider as undoubtedly the most able and erudite medical publication our country has yet produced But in view of the startling fact, that this, the most malig- nant and unmanageable disease of modern times, has for several years been prevailing in our country to a greater extent than ever before; that it is no longer confined to either large or small cities, but penetrates country villages, plantations, and farm- houses; that it is treated with scarcely better suc- cess now than thirty or forty years ago; that there is vast mischief done by ignorant pretenders to know- ledge in regard to the disease, and in view of the pro- bability that a majority of southern physicians will be called upon to treat the disease, we trust that this able and comprehensive treatise will he very gene- rally read in the south.—Memphis Med. Recorder. This is decidedly the great American medical work of theday—a full, complete, and systematic treatise, unequalled by any other upon the all-important sub- ject of Yellow Fever. The laborious, indefatigable, and learned author has devoted to it many years of arduous research and careful study, and the result is such as will jreflect the highest honor upon the author and our country.—Southern Med. and Surg. Journal. The genius and scholarship of this great physician rity upon the subject, of Yellow Fever The student and physician will find in these volumes a r£sumA of the sum total of the knowledge of the world upon the awful scourge which they so elaborately discuss. The style is so soft and so pure as to refresh and in- vigorate the mind while absorbing the thoughts of the gifted author, while the publishers have suc- ceeded in bringing the externals into a most felicitous harmony with the inspiration that dwells within. Take it all in all, it is a book we have often dreamed of, but dreamed not that it would ever meet our waking eye as a tangible reality.—Nashville Journal of Medicine. We deem it fortunate that the splendid work of Dr. La Roche should have been issued from the press at this particular time. The want of a reliable di- gest of all that is known in relation to this frightful malady has long been felt—a want very satisfactorily met in the work before us. We deem it but faint praise to say that Dr. La Rtche has succeeded in presenting the profession with an able and complete monograph, one which will find its way into every well ordered library.— Va. Stethoscope. Although we have no doubt that controversial treatises on the mode of origin and propagation of the fever in question will, as heretofore, occasionally appear, yet it must be some time before another sys- tematic work can arise in the face of so admirable and carefully executed a one as the present. It is a mine of information, quite an encyclopaedia of refer- ences, and risunu of knowledge relative to what has been recorded upon the subject.—London Lancet. A miracle of industry and research, constituting a complete library of reference on the disease of could not have been better employed than in the \ which it treats.—Dublin Quarterly Journal BY THE SAME AUTHOR. PNEUMONIA; its Supposed Connection, Pathological and Etiological, with Au- tumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome octavo volume, extra cloth, of 500 pages. $3 00. A more simple, clear, and forcible exposition of I This work should be carefully studied by Southern the groundless nature and dangerous tendency of | physicians, embodying as it does the reflections of certain pathological and etiological heresies, has I an original thinker and close observer on a subject seldom been presented to our notice.—N. Y. Journal peculiarly their own.— Virginia Med. and Surgical of Medicine and Collateral Science. J Journal. MULLER (PROFESSOR J.), M. D. PRINCIPLES OF PHYSICS AND METEOROLOGY. Edited, with Addi- tions, by R. Eglesfeld Griffith, M. D. In one large and handsome octavo volume, extra cloth, with 550 wood-cuts, and two colored plates, pp. 636. $3 50. The Physics of Muller is a work superb, complete, I tion to the scientific records of this country may be unique: the greatest want known to English Science | duly estimated by the fact that the cost of the origi- could not have been better supplied. The work is I nal drawings and engravings alone has exceeded the of surpassing interest. The value of this contribu- | sum of £2,000.—Lancet. MAYNE'S DISPENSATORY AND THERA- PEUTICAL REMEMBRANCER. Comprising the entire lists of Materia Medica, with every Practical Formula contained in the three British Pharmacopoeias. With relative Tables subjoined, illustrating, by upwards of six hundred and sixty examples, the Extemporaneous Forms and Com- binations suitable for the different Medicines. Edited, with the addition of the Formula? of the United States Pharmacopoeia, by R. Eglesfeld Griffith, M. D. Inonel'imo volume, extra cloth, of 300 large pages. 75 cents. MATTEUCCUS LECTURES ON THE PHYSI- CAL PHENOMENA OF LIVING BEINGS. Edited by J. Pereiea,M.D. In one neat royal 12mo. volume, extra cloth, with cuts, 3s8 pages. St 00. MALGAIGNE'S OPERATIVE SURGERY, based on Normal and Pathological Anatomy. Trans- lated from the French by Frederick Brittan, A.B.,M.D. With numerous illustrations on wood. In one handsome octavo volume, extra cloth, of nearly six hundred pages. S- 25. AND SCIENTIFIC PUBLICATIONS. 21 MEIGS (CHARLES D.)-, M. D., Professor of Obstetrics, &c. in the Jefferson Medical College, Philadelphia. OBSTETRICS: THE SCIENCE AND THE ART. Second edition, revised and improved. With one hundred and thirty-one illustrations. In one beautifully printed octavo volume, leather, of seven hundred and fifty-two large pages. $3 75. The rapid demand for a second edition of this work is a sufficient evidence that it has supplied a desideratum ofthe profession, notwithstanding the numerous treatises on the same subject which have appeared within the last few years. Adopting a system of his own, the author has combined the leading principles of his interesting and difficult subject, with a thorough exposition of its rules of practice, presenting the results of long and extensive experience and of familiar acquaintance with all the modern writers on this department of medicine. As an American Treatise on Mid- wifery, which has at once assumed the position of a classic, it possesses peculiar claims to the at- tention and study of the practitioner and student, while the numerous alterations and revisions which it has undergone in the present edition are shown by the great enlargement of the work, which is not only increased as to the size of the page, but also in the number. by the same author. (Lately Issued.) WOMAN: HER DISEASES AND THEIR REMEDIES. A Series of Leo- tures to his Class. Third and Improved edition. In one large and beautifully printed octavo volume, leather. pp. 672. 5?3 GO. The gratifying appreciation of his labors, as evinced by the exhaustion of two large impressions of this work within a few years, has not been lost upon the author, who has endeavored in every way to render it worthy of the favor with which it has been received. The opportunity thus afforded for a second revision has been improved, and the work is now presented as in every way superior to its predecessors, additions and alterations having been made whenever the advance of science has rendered them desirable. The typographical execution of the work will also be found to have undergone a similar improvement, and the work is now confidently presented as in every way worthy the position it has acquired as the standard American text-book on the Diseases of Females. It contains a vast amount of practical knowledge, by one who has accurately observed and retained the. experience of many years, and who tells the re- sult in a free, familiar, and pleasant manner.—Dub- lin Quarterly Journal. There is an off-hand fervor, a glow, and a warm- heartedness infecting the effort of Dr. Meigs, which is entirely captivating, and which absolutely hur- ries the reader through from beginning to end. Be- sides, the book teems with solid instruction, and it shows the very highest evidence of ability, viz., the clearness with which the information is pre- sented. We know of no better test of one's under- standing a subject than the evidence of the power of lucidly explaining it. The most elementary, as well as the obscurest subjects, under the pencil of Prof. Meigs, are isolated and made to stand out in by the same author. (Lately Published.) ON THE NATURE, SIGNS, AND TREATMENT OF CHILDBED FEVER. In a Series of Letters addressed to the Students of his Class. In one handsome octavo volume, extra cloth, of 365 pages. 52 50. such bold relief, as to produce distinct impressions upon the mind and memory ofthe reader. — The Charleston Med. Journal. Professor Meigs has enlarged and amended this great work, for such it unquestionably is, having passed the ordeal of criticism at home and abroad, but been improved thereby ; for in this new edition the author has introduced real improvements, and increased the value and utility of the book im- measurably. It presents so many novel, bright, and sparkling thoughts; such an exuberance of new ideas on almost every page, that we confess our- selves to have become enamored with the book and its author; and cannot withhold our congratu- lations from our Philadelphia confreres, that such a teacher is in their service.—N. Y. Med. Gazette. This book will add more to his fame than either of those which bear his name. Indeed we doubt whether any material improvement will be made on the teachings of this volume for a century to come, since it is so eminently practical, and based on pro- found knowledge of the science and consummate skill in the art of healing, and ratified by an ample and extensive experience, such as few men have the industry or good fortune to acquire.—N. Y. Med. Gazette. The instructive and interesting author of this work, whose previous labors in the department of medicine which he so sedulously cultivates, have placed his countrymen under deep and abiding obli- gations, again challenges their admiration in the fresh and vigorous, attractive and racy pages before us. It is a delectable book. * # # This treatise upon child-bed fevers will have an extensive sale, being destined, as it deserves, to find a place in the library of every practitioner who scorns to lag in the rear of his brethren.—Nashville Journal of Medi- cine and Surgery. BY THE SAME author ; WITH colored plates. (Lately Published.) A TREATISE ON ACUTE AND CHRONIC DISEASES OF THE NECK OF THE UTERUS. With numerous plates, drawn and colored from nature in the highest style of art. In one handsome octavo volume, extra cloth. $4 50. The object ofthe author in this work has been to present in a small compass the practical results of his Ion"- experience in this important and distressing class of diseases. The great changes intro- duced into practice, and the accessions to our knowledge on the subject, within the last few years, resulting from the use of the metroscope, brings within the ordinary practice of every physician numerous cases which were formerly regarded as incurable, and renders of great value a work like the present combining practical directions for diagnosis and treatment with an ample series of illus- trations, copied accurately from colored drawings made by the author, after nature. t BY THE SAME AUTHOR. OBSERVATIONS ON CERTAIN OF THE DISEASES OF YOUNG CHILDREN. In one handsome octavo volume, extra cloth, of 214 pages. $1 75. 22 BLANCHARD & LEA'S MEDICAL MACLISE (JOSEPH), SURGEON. SURGICAL ANATOMY. Forming one volume, very large imperial quarto. With sixty-eight large and splendid Plates, drawn in the best style and beautifully colored. Con- taining one hundred and ninety Figures, many of them the size of life. Together with copious and explanatory letter-pre^s. Strongly and handsomely bound in extra cloth, being one of the cheapest and best executed Surgical works as yet issued in this country. $ 11 00. * + * The size of this work prevtnts its transmission through the post-office as a whole, but those who desire to have copies forwarded by mail, can receive them in five parts, done up in stout wrappers. Price §9 00. One of the greatest artistic triumphs of the age in Surgical Anatomy.—British American Medical Journal. Too much cannot be said in its praise; indeed, we have not language to do it justice.—Ohio Medi- cal and Surgical Journal, The most admirable surgical atlas we have seen. To the practitioner deprived of demonstrative dis- sections upon the human subject, it is an invaluable companion.—N. J. Medical Reporter. The most accurately engraved and beautifully colored plates we have ever seen in an American book—one of the best and cheapest surgical works ever published.—Buffalo Medical Journal. It is very rare that so elegantly printed, so well illustrated, and so useful a work, is offered at so moderate a price.—Charleston Medical Journal. Its plates can boast a superiority which places them almost beyond the reach of competition.—Medi- cal Examiner. Every practitioner, we think, should have a work of this kind within reach.—Southern Medical and Surgical Journal. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given.—Boston Medical and Surgical Journal. Asa surgical anatomist, Mr. Maclise has proba- bly no superior.—British and Foreign Medico-Chi- rurgical Review. i Of great value to the student engaged in dissect- ing, and to the surgeon at a distance from the means of keeping up his anatomical knowledge.—Medical Times. The mechanical execution cannot be excelled— Transylvania Medical Journal. A work which has no parallel in point of accu- racy and cheapness in the English language.—N. Y. Journal of Medicine. To all engaged in the study or practice of their profession, such a work is almost indispensable.— Dublin Quarterly Medical Journal. No practitioner whose means will admit should fail to possess it.—Ranking's Abstract. Country practitioners'will find these plates of im- mense value__N. Y. Medical Gazette. AVe are extremely gratified to announce to the profession the completion of this truly magnificent work, which, as a whole, certainly stands unri- valled, both for accuracy of drawing, beauty of coloring, and all the requisite explanations of the subject in hand.—The New Orleans Medical and Surgical Journal. This is by far the ablest work on Surgical Ana- tomy that has come under our observation. We know of no other work that would justify a stu- dent, in any degree, for neglect of actual dissec- tion. In those sudden emergencies that so often arise, and which require the instantaneous command of minute anatomical knowledge, a work of this kind keeps the details ofthe dissecting-room perpetually fresh in the memory.—The Western Journal of Medi- cine and Surgery. B@?*" The very low price at which, this work is furnished, and the beauty of its execution, require an extended sale to compensate the publishers for the heavy expenses incurred. MOHR (FRANCIS) PH.D., AND RED WOOD (TH EOPH I LUS). PRACTICAL PHARMACY. Comprising the Arrangements, Apparatus, and Manipulations of the Pharmaceutical Shop and Laboratory. Edited, with extensive Additions, by Prof. William Procter, of the Philadelphia College of Pharmacy. In one handsomely printed octavo volume, extra cloth, of 570 pages, with over 500 engravings on wood. S>2 75. MACKENZIE (W.), M.D., Surgeon Oculist in Scotland in ordinary to Her Majesty, &.c. &c. A PRACTICAL TREATISE ON DISEASES AND INJURIES OF THE EYE. To which is prefixed an Anatomical Introduction explanatory of a Horizontal Section ol the Human Eyeball, by Thomas Wharton Jones, F. R. S. From the Fourth Revised and En- larged London Edition. With Notes and Additions by Addinell Hewson, M. D., Surgeon to Wills Hospital, &c. &c. In one very large and handsome octavo volume, leather, raised bands, with plates and numerous wood-cuts. (Now Ready.) $5 25. The treatise of Dr. Mackenzie indisputably holds the first place, and forms, in respect of learning and research, an Encyclopaedia unequalled in extent by any other work ofthe kind, either English or foreign. —Dixon on Diseases ofthe Eye. Few modern books on any department of medicine or surgery have met with such extended circulation, or have procured for their authors a like amount of European celebrity. The immense research which it displayed, the thorough acquaintance with the subject, practically as well as theoretically, and the able manner in which the author's stores of learning and experience were rendered available for general use, at once procured for the first edition, as well on the continent as in this country, that high position as a standard work which each successive edition has more firmly established, in spite of the attrac- tions of several rivals of no mean ability. This, the fourth edition, has been in a great measure re-writ- ten ; new matter, to the extent of one hundred and fifty pages, has been added, and in several instances formerly expressed opinions have been modified in accordance with the advances in the science which have been made of late years. Nothing worthy of repetition upon any branch of the subject appears to have escaped the author's notice. We consider it the duty of every one who has the love of his profes- sion and the welfare of his patient at heart, to make himself familiar with this the most complete work in the English language upon the diseases of the eye. —Med. Times and Gazette. The fourth edition of this standard work will no doubt be as fully appreciated as the three former edi- tions. It is unnecessary to say a word in its praise, for the verdict has already been passed upon it by the most competent judges, and " Mackenzie on the Eye" has justly obtained a reputation which it is no figure of speech to call world-wide.—British and Foreign Medico-Chirurgical Review. This new edition of Dr. Mackenzie's celebrated treatise on diseases of the eye, is truly a miracle of industry and learning. We need scarcely say that he has entirely exhausted the subject of his specialty. —Dublin Quarterly Journal. AND SCIENTIFIC PUBLICATIONS. 23 MILLER (JAMES), F. R. S. E., Professor of Surgery in the University of Edinburgh, &c. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume, leather, of 700 pages, with two hundred and forty exquisite illustrations on wood. (Now Ready, 1850.) f 3 75. The extended reputation enjoyed by this work will be fully maintained by the present edition. lhoroughly revised bv the author, it will be found a clear and compendious exposition of surgical science in its most advanced condition. In connection with the recently issued third edition of the author's " Practice of Surgery," it forms a very complete system of Surgery in all its branches. The work of Mr. Miller is too well and too favor aWy known among us, as one. of our best text-books, t> lender any further notice of it necessary than the fcfnouneement of a new edition, the fourth in our country, a proof of its extensive circulation among us. As a concise and reliable exposition of the sci- ence of modern surgery, it stands deservedly high__ we know not its superior__Boston Med. and Surg. Journal, May, 1856. The works of Professor Miller are so well known to the profession, that it is unnecessary for us say anything in relation to their general merits. The present edition of his "Principles," however, de serves a special notice, from the number, variety, and faithfulness of its illustrations. The wood-cuts are beautifully executed, and many of them are new and exceedingly instructive, particularly those illus- trating mortification, diseased and fractured bones, and the varieties of aneurism.—Western Lancet, May, 1856. This edition is far superior, both in the abundance and quality of its material, to any of the preceding. We hope it will be extensively read, and the sound principles which are herein taught treasured up for future application. The work takes rank with Watson's Practice of Physic; it certainly does not fall behind that great work in soundness of princi- ple or depth of reasoning and research. No physi- cian who values his reputation, or seeks the interests of his clients, can acquit himself before his God and the world without making himself familiar with the sound and philosophical views developed in the fore- going book.—New Orleans Med. and Surg. Journal. ■ Without doubt the ablest exposition of the prin- ciples of that branch of the healing art in any lan- guage. This opinion, deliberately formed after a careful study of the first edition, we have had no cause to change on examining the second. This edition has undergone thorough revision by the au- thor; many expressions have been modified, and a mass of newmatter introduced. The book isgotup in the finest style, and is an evidence of the progress of typography in our country.—Charleston Medical Journal and Review. We recommend it to both student and practitioner, feeling assured that as it now comes to us, it pre- sents the most satisfactory exposition of the modern doctrines of the principles of surgery to be found in any volume in any language.—N. Y. Journal of Medicine. by the same author. (Lately Published.) THE PRACTICE OF SURGERY. Third American from the second Edin- burgh edition. Edited, with Additions, by F. W. Sargent, M. D , one of the Surgeons to Will's Hospital, &c. Illustrated by three hundred and nineteen engravings on wood. In one large octavo volume, leather, of over 700 pages. $3 75. No encomium of ours could add to the popularity of Miller's Surgery. Its reputation in this country is unsurpassed by that of any other work, and, when taken in connection with the author's Principles of Surgery, constitutes a whole, without reference to which no conscientious surgeon would be willing to practice his art. The additions, by Dr. Sargent, have materially enhanced the value of the work.— Southern Medical and Surgical Journal. It is seldom that two volumes have ever made so profound an impression in so short a time as the " Principles" and the " Practice" of Surgery by Mr. Miller—or so richly merited the reputation they have acquired. The author is an eminently sensi- ble, practical, and well-informed man, who knows exactly what he is talking about and exactly how to talk it.—Kentucky Medical Recorder. By the almost unanimous voice of the profession, his works, both on the principles and practice of surgery have been assigned the highest rank. If we were limited to but one work on surgery, that one should be Miller's, as we regard it as superior to all others.—St. Louis Med. and Surg. Journal. The author, distinguished alike as a practitioner and writer, has in this and his " Principles," pre- sented to the profession one of the most complete and reliable systems of Surgery extant. His style of writing is original, impressive, and engaging, ener- getic, concise, and lucid. Few have the faculty of condensing so much in small space, and at the same time so persistently holding the attention; indeed, he appears to make the very process of condensation a means of eliminating attractions. Whether as a text-book for students or a book of reference for practitioners, it cannot be too strongly recommend- ed.—Southern Journal of Med. and Phys. Sciences. NEILL (JOHN), M. D., Professor of Surgery in the Pennsylvania Medical College, &c. OUTLINES OF THE ARTERIES. With short Descriptions. Designed for the Use of Medical Students. With handsome colored plates. Second and improved edition. In one octavo volume, extra cloth. $1 25. OUTLINES OF THE NERVES. With short Descriptions. Designed for the Use of Medical Students. With handsome plates. Second and improved edition. In one octavo volume, extra cloth. $1 23. OUTLINES OF THE VETNS AND LYMPHATICS. With short Descrip- tions. Designed for the Use of Medical Students. With handsome colored plates. In one octavo volume, extra cloth. SI 25. ALSO-__The three works done up in one handsome volume, half bound, with numerous plates, pre- senting a complete view ofthe Circulatory, Nervous, and Lymphatic Systems. $3 25. This book should be in the hand of every medical student. It is cheap, portable, and precisely the thino- needed in studying an important, though diffi- cult^part of Anatomy. — Boston Med. and Surg. Journal. We recommend every student of medicine to pur- chase a copy of this work, as a labor-saving ma- chine, admirably adapted to refresh the memory, with knowledge gained by lectures, dissections, and the reading of larger works.- Medicine. -N. Y. Journal of This work is from the pen of a Philadelphia ana- tomist, whose familiar knowledge of the subject has been aided by the press, the result of which is a vo- lume of great beauty and excellence. Its fine exe- cution commends it to the student of Anatomy. It requires no other recommendations.—Western Journ. of Medicine and Surgery. 24 BLANCHARD & LEA'S MEDICAL NEILL (JOHN), M. D., Surgeon to the Pennsylvania Hospital, &c; and FRANCIS GURNEY SMITH, M.D., Professor of Institutes of Medicine in the Pennsylvania Medical College. AN ANALYTICAL COMPENDIUM OF THE VARIOUS BRANCHES OF MEDICAL SCIENCE ; for the Use and Examination of Students. A new edition, revised and improved. In one very large and handsomely printed royal 12mo. volume, of about one thousand pages, with three hundred and seventy-four illustrations on wood. Strongly bound in leather, with raised bands. (Now Ready, 1856.) $3 00. The very flattering reception which has been accorded to this work, and the high estimate placed upon it by the profession, as evinced by the constant and increasing demand which has rapidly .ex- hausted two large editions, have stimulated the authors to render the volume in its present revi: ^ i more worthy of the success which has attended it. It has accordingly been thoroughly examine' 7 and such errors as had on former occasions escaped observation have been corrected, and whatever additions were necessary to maintain it on a level with the advance of science have been introduced. The extended series of illustrations has been still further increased and much improved, while, by a slight enlargement ofthe page, these various additions have been incorporated without increasing the bulk of the volume. The work is, therefore, again presented as eminently worthy of the favor with which it has hitherto been received. As a book for daily reference by the student requiring a guide to his more elaborate text-books, as a manual for preceptors desiring to stimulate their students by frequent and accurate examination, or as a source from which the practitioners of older date may easily and cheaply acquire a knowledge ofthe changes and improvement in professional science, its reputation is permanently established. In the rapid course of lectures, where work for the students is heavy, and review necessary for an examination, a compend is not only valuable, but it is almost a sine qua non. The one before us is, in most of the divisions, the most unexceptionable o£ all books of the kind that we know of. The newest and soundest doctrines and the latest im- provements and discoveries are explicitly, though concisely, laid before the student. Of course it is useless for us to recommend it to all last course students, but there is a class to whom we very sincerely commend this cheap book as worth its weight in silver — that class is the graduates in medicine of more than ten years' standing, who have not studied medicine since. They will perhaps find out from it that the science is not exactly now what it was when they left it off.—The Stethoscope AVe recommend it to our readers as the best work of the kind with which we are acquainted.—Med. Examiner, April, 1856. Having made free use of this volume in our ex- aminations of pupils, we can speak from experi- ence in recommending it as an admirable compend for students, and as especially useful to preceptors who examine their pupils. It will save the teacher much labor by enabling him readily to recall all of the points upon which his pupils should be ex- amined. A work of this sort should be in the hands of every one who takes pupils into his office with a view of examining them; and this is unquestionably the best of its class.—Transylvania Med. Journal. &C. NELIGAN (J. MOORE), M. D., M. R. I. A.. (A splendid work. Now Ready.) ATLAS OF CUTANEOUS DISEASES. In one beautiful quarto volume, extra cloth, with splendid colored plates, presenting nearly one hundred elaborate representations of disease. $4 50. This beautiful volume is intended as a complete and accurate representation of all the varieties of Diseases of the Skin. While it can be consulted in conjunction with any work on Practice, it has especial reference to the author's " Treatise on Diseases ofthe Skin," so favorably received by the profession some years since. The publishers feel justified in saying that no more beautifully exe- cuted plates have ever been presented to the profession of this country. The diagnosis of eruptive disease, however, under all circumstances, is very difficult. Nevertheless Dr. Neligan has certainly, "as far as possible," given a faithful and accurate representation of this class of diseases, and there can be no doubt that these plates will be of great use to the stfudent and practitioner in drawing a diagnosis as to the class, order, and species to which the particular case may belong. While looking over the "Atlas" we have been induced to examine also the " Practical Trea- tise." This was published in 1852, and we are in- clined to consider it a very superior work, combin- ing accurate verbal description, with sound views of the pathology and treatment of eruptive diseases. —Glasgow Medical Journal. The profession owes its thanks to the publishers of Neligan's Atlas of Cutaneous Diseases, for they have BY THE SAME AUTHOR. A PRACTICAL TREATISE ON DISEASES OF THE SKIN neat royal 12mo. volume, extra cloth, of 334 pages. $1 00. We must say he bears off the palm for clearness, conciseness, and rigid plainness of expression. This style enables him to compress much in a single sen- tence, without in any degree injuring the sense, but, on the contrary, making it more comprehensive and impressive. By far the largest proportion of the volume, is devoted to therapeutic considerations. Not merely are full details of treatment and formulae given at the close of each section, but an entire placed within its reach and at a moderate cost a most accurate and well delineated series of plates illus- trating the eruptive disorders. These plates are all drawn from the life, and in many of them the daguer- reotype has been employed with great success. Such works as these are especially useful to country prac- titioners, who have not an opportunity of seeing the rarer forms of cutaneous disease, and hence need the aid of illustrations to give them the requisite infor- mation on the subject. With these plates at hand, the inexperienced practitioner is enabled to discri- minate with much accuracy, and he is thus, com- paratively speaking, put on an equal footing with those who have had the opportunity of visiting the large hospitals of Europe and America.— Va. Med. Journal, June, 1856. In one chapter is devoted to " those general points in thera- peutics which are specially applicable to this class of affections." The present work forms a favorable contrast to the voluminous and disputed details of many of its predecessors, and will, we feel assured, be admirably conducive to facilitating the study of the student, and improving the practice of the prac- titioner.—Dublin Quarterly Journ. of Med. Science. fi@" The two volumes will be sent by mail on receipt of Five Dollars. OWEN ON THE DIFFERENT FORMS OF i THE SKELETON, AND OF THE TEETH. One vol. royal 12mo., extra cloth, with numerous illustrations. (Just Issued.) $1 25. ms. (Just Issu, AND SCIENTIFIC PUBLICATIONS. 25 (Now Complete?} PEREIRA (JONATHAN), M. D., F. R. S., AND-L. S. THE ELEMENTS OF MATERIA MEDICA AND THERAPEUTICS. Third American edition, enlarged and improved by the author; including Notices of most of the Medicinal Substances in use in the civilized world, and forming an Encyclopaedia of Materia Medica. Edited, with Additions, by Joseph Carson, M. D., Professor of Materia Medica and Pharmacy in the University of Pennsylvania. In two very large octavo volumes of 2100 pages, on small type, with about 500 illustrations on stone and wood, strongly bound in leather, with raised bands. SO 00. Gentlemen who have the first volume are recommended to complete their copies without delay. The first volume will no longer be sold separate. Price of Vol. II. §?5 00. >1- > ,.Vhen we remember that Philology, Natural His ifty, Botany, Chemistry, Physics, and the Micro- scope, are all brought forward to elucidate the sub- ject, one cannot fail to see that the reader has here a work worthy of the name of an encyclopaedia of Materia Medica. Our own opinion of its merits is that of its editors, and also that of the whole profes- sion, both of this and foreign countries—namely, " that in copiousness of details, in extent, variety, and accuracy of information, and in lucid explana- tion of difficult and recondite subjects, it surpasses all other works on Materia Medica hitherto pub- lished." We cannot close this notice without allud- ing to the special additions of the American editor, which pertain to the prominent vegetable produc- tions of this country, and to the directions of the United States Pharmacopoeia, in connection with all the articles contained in the volume which are re- ferred toby it. The illustrationshavebeenincreased, and this edition by Dr. Carson cannot well be re- garded in any other light than that of a treasure which should be found in the library of every physi- cian.—New York Journal of Medical and Collateral Science. The third edition of his "Elements of Materia Medica, although completed under the supervision of others, is by far the most elaborate treatise in the English language, and will, while medical literature is cherished, continue a monument alike honorable to his genius, as to his learning and industry.— American Journal of Pharmacy. The work, in its present shape, forms the most comprehensive and complete treatise on materia medica extant in the English language. — Dr. Pereira has been at great pains to introduce into his work, not only all the information on the natural, chemical, and commercial history of medi- cines, which might be serviceable to the physician and surgeon, but whatever might enable his read- ers to understand thoroughly the mode of prepar- ing and manufacturing various articles employed either for preparing medicines, or for certain pur- poses in the arts connected with materia medica and the practice of medicine. The accounts of the physiological and therapeutic effects of remedies are given with great clearness and accuracy, and in a j manner calculated to interest as well as instruct the | reader.—Edinburgh Medical and Surgical Journal. PEASELEE (E. R.), M. D., Professor of Anatomy and Physiology in Dartmouth College, ice. HUMAN HISTOLOGY, in its applications to Physiology and General Pathology; designed as a Text-Book for Medical Students. With numerous illustrations. In one handsome royal 12mo. volume. (Preparing.) The subject of this work is one, the growing importance of which, as the basis of Anatomy and Physiology, demands for it a separate volume. The book will therefore supply an acknowledged deficiency" in medical text-books, while the name ofthe author, and his experience as a teacher for the last thirteen years, is a guarantee that it will be thoroughly adapted to the use ofthe student. PIRRIE (WILLIAM), F. R. S. E., Professor of Surgery in the University of Aberdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill M. D. Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hospital, &c.' In one very handsome octavo volume, leather, of" 780 pages, with 316 illustrations. $3 75. We know of no other surgical work of a reason- able size, wherein there is so much theory and prac- tice, or where subjects are more soundly or clearly taught.—The Stethoscope. There is scarcely a disease of the bones or soft parts, fracture, or dislocation, that is not illustrated by accurate wood-engravings. Then, again, every instrument employed by the surgeon is thus repre- sented. These engravings are not only correct, but really beautiful, showing the astonishing degree of perfection to which the art of wood-engraving has arrived. Prof. Pirrie, in the work before us, has elaborately discussed the principles of surgery, and a safe and effectual practice predicated upon them. Perhaps no work upon this subject heretofore issued is so full upon the science of the art of surgery.— Nashville Journal of Medicine and Surgery. One of the best treatises on surgery in the English language.—Canada Med. Journal. Our impression is, that, as a manual for students, Pirrie's is the best work extant.—Western Med. and Surg. Journal. PANCOAST (J.), M. D., Professor of Anatomy in the Jefferson Medical College, Philadelphia, &c. OPERATIVE SURGERY; or, A Description and Demonstration of the various Processes of the Art; including all the New Operations, and exhibiting the State of Surgical Science in its present advanced condition. Complete in one royal 4to. volume, extra cloth, of 380 pages of letter-press description and eighty large 4to. plates, comprising 486 illustrations. Second edition, improved. $10 00. This excellent work is constructed on the model of the French Surgical Works by Velpeau and Mal- gaigne; and, so far as the English langmage is con- eerned, we are proud as an American to say that, of its kind it has no superior.—N. Y. Journal of Medicine. PARKER (LANGSTON), Surgeon to the Queen's Hospital, Birmingham. THE MODERN TREATMENT OF SYPHILITIC DISEASES, BOTH PRI- MARY AND SECONDARY; comprising the Treatment of Constitutional and Confirmed Syphi- lishv a safe and successful method. With numerous Cases, Formula?, and Clinical Observa- tions From the Third and entirely rewritten London edition. In one neat octavo volume, extra cloth, of 316 pages. (Just Issued.) SI 75. 26 BLANCHARD & LEA'S MEDICAL PARRISH (EDWARD), Lecturer on Practical Pharmacy and Materia Medica in the Pennsylvania Academy of Medicine, &c. AN INTRODUCTION TO PRACTICAL PHARMACY. Designed as a Text- Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many For- mulae and Prescriptions. In one handsome octavo volume, extra cloth, of 550 pages, with 243 Illustrations. (Now Ready, 1S56.) $2 75. ■$ This work, while necessary to the educated pharmaceutist, will also be found of the greatest importance to those practitioners who, residing at a distance from apothecaries, are called upon to dispense as well as to prescribe. The author has not only given a thorough outline of the principles of pharmacy and itsgeneral processes, but has also presented their special applications in the details of preparing all the different classes of medicines, illustrated with numerous engravings of apparajivj and implements, which, in all cases, are of the simplest description. Under the different hea\rfs are contained many tables and syllabi of classes of medicines, presenting the remedies of the United States Pharmacopoeia, together with many new ones, so arranged as to render their relations of easy comprehension, and embodying all the more important formulae of the Pharmacopoeia, as well as many others from the practice of distinguished physicians, not hitherto in print. Especial notice has been taken of the numerous important remedies recently obtained from our indigenous flora, and their composition and preparation pointed out. The long experience of the author as a teacher of pharmacy has rendered him familiar with the wants of students, and entirely competent to supply them. He has accordingly descended to those minutiae which so often interpose difficulties in the way ofthe young practitioner, who has hitherto had no practical guide to point out the modes of overcoming them. To both the country practitioner and the city apo- thecary this work of Mr. Parrish is a godsend. A careful study of its contents will give the young graduate a familiarity with the value and mode of administering his prescriptions, which wi.l be of as much use to his patient as to himself.— Va. Med. Journal. Mr. Parrish has rendered a very acceptable service to the practitioner and student, by furnishing this book, which contains the leading facts and principles of the science of Pharmacy, conveniently arranged for study, and with special reference to those features of the subject which possess an especial practical in- terest to the physician. It furnishes the student, at the commencement of his studies, with that infor- mation which is of the greatest importance in ini- tiating him into the domain of Chemistry and Materia Medica; it familiarizes him with the compounding of drugs, and supplies those minutia; which hut few practitioners can impart. The junior practitioner will, also, find this volume replete with instruction. —Charleston Med. Journal and Review, Mar. 1856. A careful examination of this work enables us to speak of it in the highest terms, as being the best treatise on practical pharmacy with which we are acquainted, and an invaluahle vade-mecum, not only to the apothecary and to those practitioners who are accustomed to prepare their own medicines, but to every medical man and medical student. Through- out the work are interspersed valuable tables, useful formulae, and practical hints, and the whole is illus- trated by a large number of excellent wood-engrav- ings.—Boston Med. and Surg. Journal. This is altogether one ofthe most useful books we have seen. It is just what we have long felt to be needed by apothecaries, students, and practitioners of medicine, most of win m in this country have to put up their own prescriptions. It bears, upon every page, the impress of practical knowledge, conveyed in a plain common sense manner, and adapted to the comprehension of all who may read it. No detail has been omitted, however trivial it may seem, al- though really important to the dispenser of medicine. —Southern Med. and Surg. Journal. PHYSICIAN'S DAILY RECORD FOR 1857. COMPRISING A REGISTER OF VISITS, ENGAGEMENTS, AND CASES. Together with Tables of Doses, Weights and Measures, Poisons and Antidotes, and other Memo- randa for Clinical Reference. A neat volume, for the Pocket. (Preparing.) For 25 patients, flexible cloth, 50 cents ; leather, tucks, 75 cents. For 50 " " 75 " « « $1 00. The object of this little volume is to afford the physician a convenient means of recording and arranging his daily practice, and of registering under every day and for every patient what visits have been paid, so that they can readily and expeditiously be charged for collection, besides keep- ing such memoranda of cases and treatment as may be deemed desirable for future reference; thus at once enabling him to regulate his business, and to preserve and accumulate the record of his clinical experience. Space is also furnished for such memoranda as are most likely to be re- quired in a physician's daily avocations ; while a portion of the work comprises in a condensed form such information as is likely to prove convenient for reference at the bedside. The copies in leather have pockets for loose memoranda, prescription papers, &c. The very low price at which it is offered places it within the reach of every practitioner, in the expectation that all will avail themselves of the great advantages which it offers. RICORD (P.), M. D., A TREATISE ON THE VENEREAL DISEASE. By John Hunter, F. R. S. With copious Additions, by Ph. Ricord, M. D. Edited, with Notes, by Freeman J. Bumstead, M. D. In one handsome octavo volume, extra cloth, of 520 pages, with plates. $3 25. secretaries, sometimes accredited and sometimes not. In the notes to Hunter, the master substitutes him- self for his interpreters, and gives his original thoughts to the world in a lucid and perfectly intelligible man- ner. In conclusion we can say that this is incon- testablythe best treatise on syphilis with which we are acquainted, and, as we do not often employ the phrase, we may be excused for expressing the hope that it may find a place in the library of every phj- sician.— Virginia Med. and Surg. Journal. BY THE SAME AUTHOR. Every one will recognize the attractiveness and value which this work derives from thus presen'ing the opinions of these two masters side by side. But, it must he admitted, what has made the fortune of the book, is the fact that it contains the "most com- plete embodiment of the veritable doctrines of the Hopital du Midi," which has ever been made public. The doctrinal ideas of M. Ricord, ideas which, if not universally adopted, are incontesiably dominant, have heretofore only heen interpreted by more or less skilful ILLUSTRATIONS OF SYPHILITIC DISEASE. Translated by Thomas F. Betton, M.D. With fifty large quarto colored plates. In one large quarto volume, extra cloth. $15 00. LETTERS ON SYPHILIS, addressed to the Chief Editor of the Union Medicale. Translated by W. P. Lattimore, M.D. In one neat octavo vol- ume, of 270 pages, extra cloth. $2 00. AND SCIENTIFIC PUBLICATIONS. 27 RAMSBOTHAM (FRANCIS H.), M.D. THE PRINCIPLES AND PRACTICE OF OBSTETRIC MEDICINE AND SURGERY, in reference to the Process of Parturition. A new and enlarged edition, thoroughly revised by the Author. With Additions by W. V. Keating, M. D. In one large and handsome imperial octavo volume, of 650 pages, strongly bound in leather, with raised bands; with sixty- four beautiful Plates, and numerous Wood-cuts in the text, containing in all nearly two hundred large and beautiful figures. (Lately Issued, 1856.) $5 00. In calling the attention of the profession to the new edition of this standard work, the publishers would remark that no efforts have been spared to secure for it a continuance and extension of the remarkable favor with which it has been received. The last London issue, which was considera- bly enlarged, has received a further revision from the author, especially for this country. Its pas- sage through the press here has been supervised by Dr. Keating, who has made numerous addi- tMijS with a view of presenting more fully whatever was necessary to adapt it thoroughly to .jfirlerican modes of practice. In its mechanical execution, a like superiority over former editions will be found. From Prof. Hodge, of the University of Pa. To the American public, it is most valuable, from its intrinsic undoubted excellence, and as being the best authorized exponent of British Midwifery. Its circulation will, 1 trust, be extensive throughout our country. The publishers have shown their appreciation of cine and Surgery to our library, and confidently recommend it to our readers, with the assurance that it will not disappoint their most sanguine ex- pectations.— Western Lancet. It is unnecessary to say anything in regard to the utility of this work. It is already appreciated in our country for the value of the matter, the clearness of its style, and the fulness of its illustrations. To the to be more highly recommended to students, and we physiciarl!s library it is indispensahle, while to the could wish to see it in the hands of every practitioner, stu(jeut as a text-book, from which to extract the the merits of this work and secured its success by the truly elegant style in which they have brought it out. excelling themselves in its production, espe- cially in its plates. It is dedicated to Prof. Meigs, and has the emphatic endorsement of Prof. Hodge, as the best exponent of British Midwifery. We know of no text-book which deserves in all respects for they will find it invaluable for reference.—Med Gazette. But once in a long time some brilliant genius rears his head above the horizon of science, and illumi- nates and purifies every department that he investi- gates ; and his works become types, by which innu- merable imitators mode] their feeble productions. Such a genius we find in the younger Ramsbotham, and such a type we find in the work now before us. The binding, paper, type, the engravings and wood material for laying the foundation of an education on obstetrical science, it has no superior.—Ohio Med. and Surg. Journal. \Ve will only add that the student will learn from it all he need to know, and the. practitioner will find it, as a book of reference, surpassed by none other.— Stethoscope. The character and merits of Dr. RamsbothanTs work are so well known and thoroughly established, cuts are all so excellent as to make this book one of that comment is unnecessary and praise superfluous. the finest specimens of the art of printing that have ! The illustrations, which are numerous and accurate, given such a world-wide reputation to its enter-I are executed in the highest style of art. We cannot prising and liberal puhlishers. We welcome Rams- too highly recommend the work to our readers.—St. botham's Principles and Practice of Obstetric Medi- I Louis Med. and Surg. Journal. ROKITANSKY (CARD, M.D., Curator of the Imperial Pathological Museum, and Professor at the University of Vienna, &c. A MANUAL OF PATHOLOGICAL ANATOMY. Four volumes, octavo, bound in two, extra cloth, of about 1200 pages. (Now Ready.) $o 50 Vol. I.—Manual of General Pathological Anatomy. Translated by W. E. Swai.ve. Vol II.—Pathological Anatomy of the Abdominal Viscera. Translated by Edward Sieveking, m!d. Vol. III.—Pathological Anatomy ofthe Bones, Cartilages, Muscles, and Skin, Cellular and Fibrous Tissue, Serous and Mucous Membrane, and Nervous System. Translated by C. H. Moore. V01. iv.__Pathological Anatomy of the Organs of Respiration and Circulation. Translated by G. E. Day. To render this lar^e and important work more easy of reference, and at the same time less cum- brous and costly, the four volumes have been arranged in two, retaining, however, the separate paging, &c. The publishers feel much pleasure in presenting to the profession of the United States the great work of Prof. Rokitansky, which is universally referred to as the standard of authority by the pa- thologists of all nations. Under the auspices of the Sydenham Society of London, the combined laborVf four translators has at length overcome the almost insuperable difficulties which have so loii°- prevented the appearance of the work in an English dress, while the additions made from various papers and essays ofthe author present his views on all the topics embraced, in their latest published form. To a work so widely known, eulogy is unnecessary, and the publishers would merely state that it i- said to conlain the results of not less than thirty thousand post-mortem examinations made by the author, diligently compared, generalized, and wrought into one com- plete and harmonious system. so charged his text with valuable truths, that any attempt of a reviewer to epitomize is at once para- lyzed, and must end in a failure.— Western Lancet. As this is the highest source of knowledge upon the important subject of which it treats, no real student can afford to be without it. The American publishers have entitled themselves to the thanks of the profession of their country, for this timeous and beautiful edition.—Nashville Journal of Medicine. As a book of reference, therefore, this work must prove of inestimable value, and we cannot too highly recommend it to the profession.— Charleston Med. Journal and Review, Jan. 1856. This book is a necessity to every practitioner.— Am. Med. Monthly. The profession is too well acquainted with the re- putation of Rokitansky's work to need our assur- ance that this is one of the most profound, thorough, and valuable books ever issued from the medical nress It is sui generis, and has no standard of com- parison. It is only nece.-sary to announce that it is issued in a form as cheap as is compatible with its size and preservation, and its sale follows as a matter of course. No library can be called com- plete without it.—Buffalo Med. Journal. An attempt to give our readers any adequate idea of the vast amount of instruction accumulated in these volumes, would be feeble and hopeless. The effort of the distinguished author to concentrate in a small space his great fund of knowledge, has 28 BLANCHARD & LEA'S MEDICAL RIGBY'S SYSTEM OF MIDWIFERY. With Notes and Additional Illustra- tions. Second American Edition. One volume octavo, extra cloth, 422 pages. ?2 50. ROYLE'S MATERIA MEDICA AND THERAPEUTICS; including the Preparations of the Pharmacopoeias of London, Edinburgh, Dublin, and of the United States. With many new medicines. Edited by Joseph Carson, M. D. With ninety-eight illustrations. In one large octavo volume, extra cloth, of about 700 pages. $3 00. SMITH (HENRY H.), Professor of Surgery in the University of Pennsylvania, &c. MINOR SURGERY; or, Hints on the Every-day Duties of the Surgeon. Illus- trated by two hundred and forty-seven illustrations. Third and enlarged edition. In one ha^C some royal 12mo. volume, pp. 456. In leather, $2 25; extra cloth, $2 00. And a capital little book it is. . . Minor Surgery, we repeat, is really Major Surgery, and anything which teaches it is worth having. So we cordially recommend this little book of Dr. Smith's.—Med.- Chir. Review. This beautiful little work has been compiled with a view to the wants of the profession in the matter of bandaging; &c, and well and ably has the author performed his labors. Well adapted to give the requisite information on the subjects of which it treats.—Medical Examiner. The directions are plain, and illustrated through- out with clear engravings.—London Lancet. One of the best works they can consult on the subject of which it treats.—Southern Journal of Medicine and Pharmacy. BY THE SAME AUTHOR, AND HORNER (WILLIAM E.), M.D., Late Professor of Anatomy in the University of Pennsylvania. AN ANATOMICAL ATLAS, illustrative of the Structure of the Human Body. In one volume, large imperial octavo, extra cloth, with about six hundred and fifty beautiful figures. $3 00. A work such as the present is therefore highly useful to the student, and we commend this one to their attention.—American Journal of Medical Sciences. No operator, however eminent, need hesitate to consult this unpretending yet excellent book. Those who are young in the business would find Dr. Smith's treatise a necessary companion, after once under- standing its true character.—Boston Med. and Surg. Journal. No young practitioner should be without this little volume; and we venture to assert, that it maybe consulted by the senior members of the profession with more real benefit, than the more voluminous works.— Western Lancet. These figures are well selected, and present a complete and accurate representation of that won- derful fabric, the human body. The plan of this Atlas, which renders it so peculiarly convenient for the student, and its superb artistical execution, have been already pointed out. We must congratu- late the student upon the completion of this Atlas, as it is the most convenient work of the kind that has yet appeared ; and we must add, the very beau- tiful manner in which it is " got up" is so creditable to the country as to be flattering to our national pride.—American Medical Journal. SARGENT (F. W.), M. D. ON BANDAGING AND OTHER OPERATIONS OF MINOR SURGERY. Second edition, enlarged. One handsome royal 12mo. vol., of nearly 400 pages, with 182 wood- cuts. (Now Ready, 1856.) Extra cloth, $1 40 ; leather, $1 50. This very useful little work has long been a favor- ite with practitioners and students. The recent call for a new edition has induced its author to make numerous important additions. A slight alteration in the size of the page has enabled him to introduce the new matter, to the extent of some fifty pages of the former edition-, at the same time that his volume is rendered still more compact than its less compre- hensive predecessor. A double gain in thus effected, which, in a vade-mecum of this kind, is a material improvement.—Am. Medical Journal. Sargent's Minor Surgery has always been popular, and deservedly so. It furnishes that knowledge ofthe most frequently requisite performances of surgical art which cannot be entirely'understood by attend- ing clinical lectures. The art of bandaging, which is regularly taught in Europe, is very frequently overlooked by teachers in this country; the student and junior practitioner, therefore, may often require that knowledge which this little volume so tersely and happily supplies. It is neatly printed and copi- ously illustrated by the enterprisingjjublishers, and should be possessed by all who desire to be thorough- ly conversant with the details of this branch of our art.—Charleston Med. Journ. and Review, March, 1856. A work that has been so long and favorably known to the profession as Dr. Sargent's Minor Surgery, needs no commendation from us. We would remark, however, in this connection, that minor surgery sel- dom gets that attention in our schools that its im- portance deserves. Our larger works are also very defective in their teaching on these small practical points. This little book will supply the void which all must feel who have not studied i'ts pages.—West- ern Lancet, March, 1856. We confess our indebtedness to this little volume on many occasions, and can warmly recommend it to our readers, as it is not above the consideration of the oldest and most experienced.—American Lan- cet, March, 1856. SKEY'S OPERATIVE SURGERY. In one very handsome octavo volume, extra cloth, of over 650 pages, with about one hundred wood-cuts. S3 25. STANLEY'S TREATISE ON DISEASES OF THE BONES. In one volume, octavo, extra cloth, 286 pages. 61 50. SOLLY ON THE HUMAN BRAIN; its Structure, Physiology, and Diseases. From the Second and much enlarged London edition. In one octavo volume, extra cloth, of 500 pages, with 120 wood- cuts. $2 00. SIMON'S GENERAL PATHOLOGY, as conduc- ive to the Establishment of Rational Principles for the prevention and Cure of Disease. In one neat octavo volume, extra cloth, of 212 pages. $1 25. STILLE (ALFRED), M. D. PRINCIPLES OF GENERAL AND SPECIAL THERAPEUTICS. handsome octavo. (Preparing.) In AND SCIENTIFIC PUBLICATIONS. 29 SHARPEY (WILLIAM), M.D., JONES QUAIN, M.D., AND RICHARD QUAIN, F. R. S., &c. HUMAN ANATOMY. Revised, with Notes and Additions, by Joseph Leidy, M. D., Professor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, leather, of about thirteen hundred pages. Beautifully illustrated with over five hundred engravings on wood. $6 00. It is indeed a work calculated to make an era in anatomical study, by placing before the student every department of his science, with a view to the relative importance of each ; and so skilfully have the different parts been interwoven, that no one who makes this work the basis of his studies, vi/,1 hereafter have any excuse for neglecting or ■njaervaluing any important particulars connected •rith the structure of the human frame; and whether the bias of his mind lead him in a more especial manner to surgery, physic, or physiology, he will find here a work at once so comprehensive and practical as to defend him from exclusiveness on the one hand, and pedantry on the other.— Journal and Retrospect of the Medical Sciences. We have no hesitation in recommending this trea- tise on anatomy as the most complete on that sub- ject in the English language; and the only one, perhaps, in any language, which brings the state of knowledge forward to the most recent disco- veries.— The Edinburgh Med. and Surg. Journal. SMITH (W. TYLER), M.D., Physician Accoucheur to St. Mary's Hospital, &c. ON PARTURITION, AND THE PRINCIPLES AND PRACTICE OF OBSTETRICS. In one royal 12mo. volume, extra cloth, of 400 pages. $1 25. by the same author.—(Just Issued.) A PRACTICAL TREATISE ON THE PATHOLOGY AND TREATMENT OF LEUCORRIKEA. With numerous illustrations. In one very handsome octavo volume, extra cloth, of about 250 pages. $1 50. We decide this book to be one of the most useful monographs which has appeared in this country. What was before unutterable confusion in regard to its subject has now the order, regularity, and har- mony of a most beautiful science. Dr. Smith has placed the whoie profession directly, and mankind indirectly, under abiding obligations. — Nashville Journ. of Medicine. We hail the appearance of this practical and in- valuable work, therefore, as a real acquisition to our medical literature.—Medical Gazette. SIBSON (FRANCIS), M. D., Physician to St. Mary's Hospital. MEDICAL ANATOMY. Illustrating the Form, Structure, and Position of the Internal Organs in Health and Disease. In large imperial quarto, with splendid colored plates. To match "Maclise's Surgical Anatomy." Part I. (Preparing.) SCHOEDLER (FRIEDRICH), PH.D., Professor of the Natural Sciences at Worms, &c. THE BOOK OF NATURE; an Elementary Introduction to the Sciences of Physics, Astronomy, Chemistry, Mineralogy, Geology, Botany, Zoology, and Physiology. First American edition, with a Glossary and other Additions and Improvements; from the second English edition. Translated from the sixth German edition, by Henry Medlock, F. C. S., &c. In one thick volume, small octavo, extra cloth, of about seven hundred pages, with 679 illustra- tions on wood. Suitable for the higher Schools and private students. (Now Ready.) $1 80. TANNER (T. H.), M. D., Physician to the Hospital for Women, &c. A MANUAL OF CLINICAL MEDICINE AND PHYSICAL DIAGNOSIS. To which is added The Code of Ethics of the American Medical Association. In one neat volume, small 12mo. Price in extra cloth, 87$ cents; flexible style, for the pocket, 80 cents. (Lately Published.) In this admirable little work the author's object has been to give the young practitioner that kind of information which enables him to make practical application of the knowledge acquired by his studies, and which is not to be found in the text-books. Such a manual has been much wanted, as it fills a void which has long been felt, but which there has hitherto been no attempt to supply. That the author has succeeded in his endeavor, is sufficiently shown by the unusually favorable reception which the work has already received, although only just published. Dr. Tanner has, in a happy and successful manner,! practitioners, it has only to be seen, to win for itself indicated the leading particulars to which, in the clinical study of a case of disease, the attention of the physician is to be directed, the value and import ofthe various abnormal phenomena detected, and the several instrumental and accessory means which maybe called into requisition to facilitate diagnosis and increase its certainty.—Am. Journal of Med. Sciences. In this small work is collected a fund of such in- formation as the student at the commencement, and even durin°- the continuance of his studies, is often sadly troubled to know where to look for.—Montreal Med. Chronicle. i place upon the shelves of every medical library. Nor will it be " shelved" long at a time; if we. mis- take not, it will be found, in the best sense of the homely but expressive word, " handy." The style is admirably clear, while it is so sententious as not to burden the memory. The arrangement is, to our mind, unexceptionable. The work, in short, de- serves the heartiest commendation.—Boston Med. and Surg Journal We cordially recommend every young practitioner who wishes to reap the greatest possible benefit from his observation of disease to mak* this book his daily companion.—New Hampshire Journal of Medi- cine. As a convenient and suggestive book of reference, The. work is an honor to its writer, and must ob- tain a wide circulation by its intrinsic merit alone. It seems to us that but slight effort on the part of the weaccord it our hearty praise —Va. Med. and Sur publishers will be requisite to exhaust even a large I Journal. edition. Suited alike to the wants of students and 30 BLANCHARD & LEA'S MEDICAL TAYLOR (ALFRED S.), M. D., F. R. S., Lecturer on Medical Jurisprudence and Chemistry in Guy's Hospital MEDICAL JURISPRUDENCE. Fourth American, from the fifth improved and enlarged English Edition. With Notes and References to American Decisions, by Edward Ha.rtshor.ne, M. D. In one large octavo volume, leather, of over seven hundred pases (Just Ready, June, 1856.) $3 00. l <= \ This standard work has lately received a very thorough revision at the hands ofthe author, who has introduced whatever was necessary to render it complete and satisfactory in carrying out the objects in view. Tlie editor has likewise used every exertion to make it equally thorough with regard to all matters relating to the practice of this country. In doing this, he has carefully ex- amined all that has appeared on the subject since the publication ofthe last edition, and has incorpo- rated all the new information thus presented. The work has thus been considerably increased in size, notwithstanding which, it has been kept at its former very moderate price, and in every respetc*. it will be found worthy of a continuance of the remarkable favor which has carried it through s(r\ many editions on both sides of the Atlantic. A few notices of the former editions are appended. We know of no work on Medical Jurisprudence which contains in the same space anything like the same amount of valuable matter.—N. Y. Journal of Medicine. No work upon the subject can be put into the hands of students either of law or medicine which will engage them more closely or profitably; and none could be offered to the busy practitioner of either calling, for the purpose of casual or hasty reference, that would he more likely to afford the aid desired. We therefore recommend it as the best and safest manual for daily use.—American Journal of Medical Sciences. So well is this work known to the members both of the medical and legal professions, and so highly is it appreciated by them, that it cannot be necessary for us to say a word in its commendation; its having already reached a fourth edition being the best pos- sible testimony in its favor. The author has ob- viously subjected the entire work to a very careful revision.—Brit, and Foreign Med. Chirurg. Review. This work of Dr. Taylor's is generally acknow- ledged to be one of the ablest extant on the subject of medical jurisprudence. It is certainly one ofthe apper most attractive books that we have met with;; sup- plying so much both to inierest and instruct, that we do not hesitate to affirm that after having once commenced its perusal, few could be prevailed upon to desist before completing it. In the last London edition, all the newly observed and accurately re- corded facts have been inserted, including much that is recent of Chemical, Microscopical, and Patholo- gical research, besides papers on numerous subjects never before published .-Charleston Medical Journal and Review. It is not excess of praise to say that the volume before us is the very best treatise extant on Medical Jurisprudence. In saying this, we do not wish to be understood as detracting from the merits of the excellent works of Beck, Ryan, Traill, Guy, and others; but in interest and value we think it must be conceded that Taylor is superior to anything that has preceded it. The author is already well known to the profession by his valuable treatise on Poisons; and. the present volume will add materially to his high reputation for accurate and extensive know- ledge and discriminating judgment.—JV. W. Medical ana Surgical Journal. BY THE SAME AUTHOR. ON POISONS, IN RELATION TO MEDICAL JURISPRUDENCE AND MEDICINE. Edited, with Notes and Additions, by R. E. Griffith, M. D. In one large octavo volume, leather, of 688 pages. $3 00 TODD (R. B.), M. D., AND BOWMAN (WILLIAM), F. R. S. PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With numerous handsome wood-cuts. Parts I, II, and III, in one octavo volume, 552 pages. $2 50. Part IV will complete the work. The first portion of Part IV, with numerous original illustrations, was published in the Medical News and Library for 1853, and the completion will be issued immediately on its appearance in London. Those who have subscribed since the appearance of the preceding portion of the work can have the three parts by mail, on remittance of $2 50 to the publishers. WATSON (THOMAS), M.D., &.c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Third American edition, revised, with Additions, by D. Francis Condie, M.D., author of a In one octavo volume, of nearly eleven hundred $3 25. Confessedly one of the very best works on the principles and practice of physic in the English or any other language.—Med. Examiner. Asa text-book it has no equal; as a compendium of pathology and practice no superior.—New York Annalist. We know of no work better calculated for being placed in the hands of the student, and for a text- book; on every important point the author seems to have posted up his knowledge to the day___ Amer. Med. Journal. One of the most practically useful books that ever was presented to the. student. — JV. Y. Med. Journal. ■ Treatise on the Diseases of Children," &c large pages, strongly bound with raised bands. To say that it is the very best work on the sub- ject now extant, is but to echo the sentiment of the medical press throughout the country. — JV. O. Medical Journal. Ofthe text-books recently republished Watson is very justly the principal favorite.—Holmes's Rep. to Nat. Med. Assoc. By universal consent the work ranks among the very best text-books in our language.—Illinois and Indiana Med. Journal. Regarded on all hands as one of the very best, if not the very best, systematic treatise on practical medicine extant.—St. Louis Med. Journal. WHAT TO OBSERVE AT THE BEDSIDE AND AFTER DEATH, IN MEDICAL CASES. Published under the authority of the London Society for Medical Observation. A new American, from the second and revised London edition. In one very handsome volume, royal 12mo., extra cloth. (Just Issued.) $ 1 00. To the observer who prefers accuracy to blunders and precision to carelessness, this little book is in- valuable.—JV. H. Journal of Medicine. One of the finest aids to a young practitioner we have ever seen.—Peninsular Journal of Medicine. AND SCIENTIFIC PUBLICATIONS. 31 WILSON (ERASMUS), M.D., F. R. S., Lecturer on Anatomy, London. A SYSTEM OF HUMAN ANATOMY, General and Special. Fourth Ameri- can, from the last English edition. Edited by Paul B. Goddard, A. M., M. D. With two hun- dred and fifty illustrations. Beautifully printed, in one large octavo volume, leather, of nearly six hundred pages. S3 00. In many, if not all the Colleges of the Union, it has become a standard text-book. This, of itself, is sufficiently expressive of its value. A work very desirable to the student; one, the possession of which will greatly facilitate his progress in the Btndy of Practical Anatomy.—New York Journal of Medicine. It offers to the student all the assistance that can be expected from such a work.—Medical Examiner. The most complete and convenient manual for the student we possess.—American Journal of Medical Science. In every respect, this work as an anatomical guide for the student and practitioner, merits our warmest and most decided praise.—London Medical Gazette. ' 'Its author ranks with the highest on Anatomy.— Southern Medical and Surgical Journal. by the same author. (Now Ready.) THE DISSECTOR'S MANUAL; or, Practical and Surgical Anatomy. Third American, from the last revised and enlarged English edition. Modified and rearranged, by William Hunt, M. D., Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, leather, of 532 pages, with 154 illustrations. §2 00. The modifications and additions which this work has received in passing recently through the author's hands, is sufficiently indicated by the fact that it is enlarged by more than one hundred pages, notwithstanding that it is printed in smaller type, and wiih a greatly enlarged page. So com- plete has the author rendered it, that the editor has found but little to do, except in rearranging it to suit the mode of dissection practised in this country, and in introducing a large number of additional illustrations. Of ihese, many new ones have been engraved expressly for the work, and the series throughout will be found greatly enhanced in value. The typographical execution ofthe volume has undergone a like improvement, and in every ret-pect the work is presented as merit- ing an increase of the favor which it has hitherto enjoyed as a sound practical guide to the study of anatomy. It remains only to add, that after a careful exami- I ing very superior claims, well calculated to facilitate nation, we have no hesitation in recommending this | their studies, and render their labor less irksome, by work to the notice of those for whom it has been I constantly keeping before them definite objects of expressly written—the students—asaguideposstss- | interest.— The Lancet. BY THE SAME AUTHOR. ON DISEASES OF THE SKIN. Third American, from the third London edition. In one neat octavo volume, of about five hundred pages, extra cloth. $1 75. The " Diseases of the Skin," by Mr. Erasmus I in that department of medical literature.—Medico- Wilson, may now be regarded as the standard work | Chirurgical Review. BY THE SAME AUTHOR. ON CONSTITUTIONAL AND HEREDITARY SYPHILIS, AND ON SYPHILITIC ERUPTIONS. In one small octavo volume, extra cloth, beautifully printed, with four exquisite colored plates, presenting more than thirty varieties of syphilitic eruptions. S2 i5. by the same author. (Just Issued.) HEALTHY SKIN; A Popular Treatise on the Skin and Hair, their Preserva- tion and Management. Second American, from the fourth London edition. One neat volume, royal 12mo., extra cloth, of about 300 pages, with numerous illustrations. SI 00 ; paper cover, 75 cents. WHITEHEAD (JAMES), F. R. C. S., &c. THE CAUSES AND TREATMENT OF ABORTION AND STERILITY; being the Result of an Extended Practical Inquiry into the Physiological and Morbid Conditions . of the Uterus. Second American Edition. In one volume, octavo, extra cloth, pp. 368. §175. WALSHE (W. H.), M. D., Professor ofthe Principles and Practice of Medicine in University College, London. DISEASES OF THE HEART, LUNGS, AND APPENDAGES; their Symptoms and Treatment. In one handsome volume, extra cloth, large royal 12ino., 512 pages. Sl 50. We consider this as the ablest work in the En- I the author being the first stethoscopist of the day.— glish language, on the subject of which it treats; | Charleston Medical Journal. WILDE (W. R.), Surgeon to St. Mark's Ophthalmic and Aural Hospital, Dublin. AURAL SURGERY, AND THE NATURE AND TREATMENT OF DIS- EASES OF THE EAR. In one handsome octavo volume, extra cloth, of 476 pages, with illustrations. $2 80. This work certainly contains more information on laws, and amenable to the same general methods of the subject to which it is devoted than any other treatment as other morbid processes. The work is with which we are acquainted. We feel grateful lo not written to supply the cravings of popular patrou- the author for his manful effort to rescue this depart- age, but it is wholly addressed to the profession, and mentof surgery from the hands of the empirics who bears on every page the impress of the reflections nearly monopolize it. We think he has successfully of a sagacious and practical surgeon.—I'd. Surg, and shown lhat aural diseases are not beyond the re- Med. Journal. sources of art; that they are governed by the same 32 BLANCHARD & LEA'S SCIENTIFIC PUBLICATIONS. WEST (CHARLES), M. D., Accoucheur to and Lecturer on Midwifery at St. Bartholomew's Hospital, Physician to the Hospital for Sick Children, &c. LECTURES ON THE DISEASES OF INFANCY AND CHILDHOOD. Second American, from the Second and Enlarged London edition. In one volume, octavo, extra cloth, of nearly five hundred pages. (Just Issued.) $2 00. ligation by this able, thorough, and finished work upon a subject which almost daily taxes to the ut- We take leave of Dr. West with great respect for his attainments, a due appreciation of his acute powers of observation, and a deep sense of obliga- tion for this valuable contribution to our profes- sional literature. His book is undoubtedly in many respects the best we possess on diseases of children. Dublin Quarterly Journal of Medical Science. Dr. West has placed the profession under deep ob- most the skill of the general practitioner. He has with singular felicity threaded his way through all the tortuous labyrinths of the difficult subjecthe has undertaken to elucidate, and has in many of the darkest corners left a light, which will neve;r « extinguished.—Nashville Medical Journal. by the same author. (Nearly Ready.) Publishing in the "Medical News and Library," for 1856. LECTURES ON THE DISEASES OF WOMEN. In two parts. Part I. 8vo. of about 300 pages, comprising the Diseases of the Uterus. Part II. (Preparing), will contain Diseases of the Ovaries, and of all the parts connected with the Uterus ; of the Bladder, Vagina, and External Organs. The object of the author in this work is to present a complete but succinct treatise on Female Di>eases, embodying the results of his experience during the last ten years at St. Bartholomew's and the Midwifery Hospitals, as well as in private practice. The characteristics which have se- cured to his former works so favorable a reception, cannot fail to render the present volume a standard authority on its important subject. To show the general scope ofthe work, an outline of the Contents of Part I. is subjoined. Lectures I, II.—Introductory—Symptoms—Examination of Symptoms—Modes of Examina- tions. Lectures III., IV., V—Disorders of Menstruation, Amenorrhoea, Menorrhagia, Dys- menorrhea. Lectures VI., VII, VIII.—Inflammation of the Uterus, Hypertrophy, Acute Inflammation, Chronic Inflammation, Ulceration ofthe Os Uteri, Cervical Leueorrhoea. Lectures IX., X., XL, XII, XIII.—Mis placement of the Uterus, Prolapsus, Anleversion, Retrover- sion, Inversion. Lectures XIV., XV., XVI, XVII.—Uterine Tumors and Outgrowths, Mucous, Fibro-cellular, and Glandular Polypi, Mucous Cysts, Fibrinous Polypi, Fibrous Tumors, Fibrous Polypi, Fatty Tumors, Tubercular Diseases. Lectures XVIII., XIX., XX.—Cancer of the Uterus. Part II. will receive an equally extended treatment, rendering the whole an admirable text-book for the student, and a reliable work for reference by the practitioner. by the same author. (Just Issued) AN ENQUIRY INTO THE PATHOLOGICAL IMPORTANCE OF ULCER- ATION OF THE OS UTERI. In one neat octavo volume, extra cloth. $1 00. WILLIAMS (C. J. B.), M. D., F. R. S., Professor of Clinical Medicine in University College, London, &c. PRINCIPLES OF MEDICINE; comprising General Pathology and Therapeu- tics, and a brief general view of Etiology, Nosology, Semeiology, Diagnosis, Prognosis, and Hygienics. Edited, with Additions, by Meredith Clymer, M. D. Fourth American, from the last and enlarged London edition. In one octavo volume, leather, of 476 pages. !?2 50. Few books have proved more useful, or met with The best exposition in our language, or, we be- lieve, in any language, of rational medicine, in its present improved and rapidly improving state.— British and Foreign Medico-Chirurg. Review. a more ready sale than this, and no practitioner should regard his library as complete without it. —Ohio Med. and Surg. Journal. YOUATT (WILLIAM), V. S. THE HORSE. A new edition, with numerous illustrations; together with a general history ofthe Horse; a Dissertation on the American Trotting Horse; how Trained and Jockeyed; an Account of his Remarkable Performances; and an Essay on the Ass and the Mule. By J. S. Skinner, formerly Assistant Postmaster-General, and Editor of the Turf Register. One large octavo volume, extra cloth. $1 50. The attention of all who keep horses is requested to this handsome and complete edition of a work which is recognized as the standard authority on all matters connected with veterinary medi- cine. The very low price at which it is now offered, free by mail, places it within the reach of every one. BY THE SAME AUTHOR. THE DOG. Edited by E. J. Lewis, M.D. With numerous and beautiful illustrations. In one very handsome volume, crown 8vo., crimson cloth, gilt. $1 25. ILLUSTRATED MEDICAL CATALOGUE. BLANCHARD & LEA have lately issued a Catalogue of their Medical, Surgical, and Sci- entific Publications, containing descriptions of the works, with Notices of the Press, and specimens of the Illustrations, making a very handsome pamphlet of sixty-four large octavo pages. Copies will be sent by mail, and the postage paid, on application to the Publishers, by inclosuog six cents in postage stamps. O 'JUKI 3-1316 r " fe^*2tiSDa NATIONAL LIBRARY OF MEDICINE NLM D3277fl0b 1 ' ' .-.'/ Vv!'i'--'^-''*:,!t;';,'i''V. ', ,W. - - '' '■'■ • '■ ■'StC'v* '*t-&'fA ■ .'.:■ •,-, ■■■.•,,.'7;."*......■• •••••••' ■■■: :■ ■ 'a* ^■■•^•■^:':^^pf ■■ -• ;■ .-■ ■■■: " ^^'-vi-H^^ . . ' " ' ' * . ;V... «■* v* ■■ * 1 v*- ■* ' Ji* 1. *•••■■ • >.Li; ,•,'•'■ MiWv^'Wffl • - •' ■!, ■ ■ *?■ r .^IvlaA'w.^ ,;. .".'.•.w.;S-->r.*-^ '■■■■ ,,VT^>W# ■ .. „..•*..•■' ^>^,-^$k$hpi_ ''£r?r.~r ^-^rri^/^^^'^li?*SSi? -t •": ■A^:-^jg|ggiM NLM032778061